One of the challenges of clinical nursing education is to teach critical thinking and prioritization of care beyond the basic task accomplishment that occupies the minds of most students. Nurse educators try to meet these challenges by asking questions of students within the clinical setting, giving feedback on written work, and formal testing through case studies rather than traditional multiple choice methods. Though these methods are valuable, their common drawback is in trying to teach critical thinking and prioritization second-hand. All of these methods require critical thinking either after the point of patient care (i.e., asking questions, written work evaluation) or in a nonclinical setting (i.e., case study testing). In addition, they leave out the equally important aspects in nursing care of teaching and management skills. Yet critical thinking and prioritization are both skills that are more readily taught and solidly remembered when experienced first-hand, while teaching and management skills are invaluable to any nurse.
A strategy in clinical teaching that may prove useful in developing all of these areas is that of peer leadership. Peer leadership is simultaneous peer teaching and peer supervision. A detailed description of the peer leadership implementation is included in the Methods section.
Loving's (1993) model of Competence Validation provided the theoretical framework for this study. Competence validation is "the process by which the student's identity as a competent beginning nurse is established" (p. 417). Peer leadership is supported by this model in two ways. First, Loving's model differentiates between extrinsic and intrinsic learning environments, with the former being primarily evaluative of student performance and the latter being the student's internal motivation to acquire skills and knowledge to continue learning. In traditional student-instructor models of clinical teaching, the environment is usually extrinsic. Peer leadership validates intrinsic motivation by allowing the student the opportunity to develop the knowledge and skills necessary to learn clinical judgment in a non-evaluative experience.
Secondly, peer leadership facilitates autonomy from the instructor. Peer leaders are encouraged to lead their fellow students by brainstorming ideas and solutions independent from the instructor. Loving states, "When students independently experience success in patientcentered nursing care, their belief in themselves as competent nurses is enhanced" (p. 420). Because peer leadership encourages both creativity and experimentation, it is believed that peer leadership will lead to the successful outcome of cognitive flexibility. Cognitive flexibility is "the ability to identify information appropriate to problem solution and the ability to synthesize that information in a way appropriate for patient problem solution" (p. 419).
Ammon and Schroll (1988) reported that students who completed a peer leadership experience described "A heightened sense of responsibility... a broader viewpoint;" (p. 86) an increase in confidence level; and growth in organization, interpersonal relationships, and insight into their leadership styles.
Components of peer leadership have also been described in the literature as peer teaching (Cason, Cason, & Bartnik, 1977; Iwasiw & Goldenberg, 1993), peer evaluation (Erikson, 1987; Burnside, 1971), and peer collaboration (Flynn, Marcus, & Schmadl, 1981; Gerace & Sibilano, 1984).
In a study of peer teaching, Cason and colleagues (1977) reported that learners (first-semester students) improved in direct client care and teaching skills, while peer teachers stated increased opportunity to concentrate on comprehensive care and practice teaching skills with other students. Iwasiw and Goldenberg (1993) found in an experimental study that students who had peer teachers achieved significantly higher cognitive scores (i.e., measuring knowledge of purpose and procedure) on a surgical dressing change task than did controls. In addition, subjects' preference for peer teaching was rated equal to or higher than their preference for instructor teaching.
In studies using peer evaluation, students have stated a decreased level of anxiety; positive feelings of helping and collaboration; and gains in experience, performance evaluations, and accountability when evaluated by their peers instead of their instructor (Erikson, 1987). In addition, students have reported increased confidence in teaching ability, ability to give and receive criticism, peer collaboration, and communication skills (Burnside, 1971).
Peer leadership has been studied in terms of peer collaboration. Flynn and colleagues (1981) reported benefits of increased achievement of client outcomes, increased accountability through group problem solving, and increased confidence and ability to present pertinent data and plans at the bedside when using peer review conferences at the patient's bedside. Peer collaboration was also studied by Gerace and Sibilano (1984) with junior students reporting an appreciation for the expertise, skills, and support from their senior colleagues, while senior students gained self-confidence in initiating and following through on collaborative relationships (Gerace & Sibilano, 1984).
Although the literature describes several benefits to the peer leadership experiences (whether in teaching, evaluation, or collaboration), in most cases these benefits are anecdotally reported by the researcher after informal discussions or clinical conference setting discussions. In no studies were students asked to formally define what they had learned or what they perceived to be the benefits of peer leadership experiences. The purpose of this study was to describe what junior baccalaureate nursing students see as the benefits of a specific peer leadership experience on a medical-surgical unit.
This study was a descriptive study using content analysis. Peer leaders were junior baccalaureate nursing students on a surgical unit at a large. Midwest teaching hospital. Students were assigned to be peer leaders for 1 specific clinical day during the 6-week rotation, though they voluntarily chose the day they would like to be peer leader. For groups larger than six members, names were drawn to establish who would have the peer leadership opportunity. Twelve students completed the peer leadership experience over 12 weeks of the semester. Each student received the same printed set of instructions describing their responsibilities as peer leader.
One day prior to the student clinical day, the peer leader completed preparatory work for each of the students' assigned patients. This included: history of the patient's condition; the basic pathophysiology behind each disease; a focused physical assessment for each patient to aid in recognizing possible complications; and knowledge of pertinent nursing diagnoses and technical skills. In addition, the peer leader was responsible for organizing the day on paper in a systematic way that could be used on the next clinical day. Some students chose to do this via a check list of tasks, while others listed what they hoped to be doing each hour of the day.
On the clinical day itself, the peer leader had several responsibilities. These included:
* Collection of specific, numeric information from other students. This included such things as vital signs, intravenous fluid rates and solutions, intake and output, and lab values. The peer leader and students were to collaborate to differentiate normal from abnormal assessment findings, relevant from irrelevant findings in relationship to a particular diagnosis, and consistency of their numeric findings with what they would expect given the physical status and overall disease process of a patient. Peer leaders were responsible for validating findings and decisions with the clinical instructor.
* Continuous monitoring of patient condition. The peer leader and student could decide together if the patient was experiencing physical or psychosocial complications of the disease process and decide what needed to be done. The peer leader was then responsible for informing the instructor of the patient's condition and plan of care on a regular basis.
* Assisting fellow students with specific tasks and nursing skills. This involved both routine tasks (e.g., bed making, ambulation) and more complex tasks (e.g., dressing changes, tracheotomy care). If the peer leader was unfamiliar with performing a certain task, the instructor taught the peer leader what to do and then allowed the peer leader to teach the student.
* Checking completeness of student's paperwork (e.g., bedside flow charting, laboratory values, and SOAP [subjective, objective, assessment, and plans] notes). The peer leader was responsible for reminding students to do their paperwork, as well as determining when it was incomplete to the best of their knowledge.
* Coordinating coverage of patients when students went to lunch or were off the unit.
* Informing students of learning opportunities and ensuring that students spent maximal time in learning or patient care activities rather than being preoccupied with paperwork or talking amongst themselves.
After completing their clinical time, each peer leader was asked to complete a written self-evaluation. Peer leaders were instructed, in part, to "describe your strengths and areas for improvement. Describe what you learned and what you would do differently if given another opportunity." Students were strongly encouraged to be both direct and honest in their evaluations.
The written self-evaluations of the peer leaders were analyzed by the researcher and categorized inductively into a list of perceived benefits of the peer leadership experience. Quotes from these self-evaluations follow each list item for the purpose of defining each benefit more clearly.
Practice in Prioritization of Nursing Care. Peer leaders had the chance to practice prioritization in the authentic nursing situation of caring for multiple patients. To learn effective prioritization, it is necessary that the student be busy and in the position of making difficult choices among patient needs. The peer leadership experience offers a chance to practice this skill prior to graduation. Students gave evidence of this benefit in their evaluations.
* It was good practice in keeping track of several patients and students at once and really munies the real world of nursing.
* It was always easy for me to see what had to be done when I had one patient, but when I was dealing with so many things at one time, it was hard to know what to do first.
* I always thought I was really organized, but with so many things happening and changing so fast, I found myself being forgetful and confused.
* I have a haxd time finding a way to 'do it all' without neglecting any aspects of patient care.
Enhancement of Critical Thinking Skills. Critical thinking skills are very difficult to define. Students had a difficult time knowing how to show that they were practicing critical thinking. Their selfevaluations had beginning descriptions of critical thinking skills.
* I failed to ask students the right questione when they gave me pieces of information on their patients. When I asked you (the clinical instructor) about pieces of data, you told me the questions I should ask. Then I was more able to ask better questions over the day and began to evaluate things myself.
* I talked to people about lab values and how they fit with the patient's diagnosis.
* I tried to help other students see where they could fit in important nursing assessments and interventions that they had missed.
Enhancement of Technical Skills. This researcher hypothesized that peer leaders would not have the opportunity to improve their technical skills because they were not providing direct patient care. However, this area was an unexpected benefit that the students listed. Observation of skills may decrease the level of anxiety associated with technical skill performance (Meisenhelder, 1993). In addition, the students' descriptions of technical skill enhancement perhaps support Doheny's (1993) ideas on the benefits of mental practice as an approach to teaching motor skills.
* I learned how to do a lot of skills this week that I wouldn't have otherwise. I learned about PCAs, epidurals, central line dressing changes, and how to measure central venous pressure.
* It was perfect for me to be able to watch other people do skills [sic) while I watched. There was not pressure for me to do it myself, but I still learned it.
* I watched lots of things that I hadn't seen before- a dressing change, an IV tubing change, and CVP monitoring.
Realization of Peers as a Resource. In traditional instructor-student clinical models of teaching, it is easy for both students and instructors to assume that the instructor is the sole possessor of knowledge and that clinical time is one means of imparting "the answers" to the students. In their self-evaluations, students realized the benefits of peer leadership in overcoming these misconceptions.
* I think we're learning the value of teamwork by doing this, and accept the responsibilities and roles of our coworkers.
* We have really improved working together as a team, and I think patient care has directly benefited from this.
* We're realizing that it isn't necessary to run to the instructor every time we have questions. The peer leader or one of the other students is likely to know the answer too.
* It was important for me to observe that each student faced the same 'fear of the unknown,' and how experience can help overcome those fears.
Development of Managerial Skills. In an increasingly cost-conscious health care system, nurses are being asked to be managers in a variety of ways. Registered nurses typically delegate responsibilities to nursing assistants or licensed practical nurses, serve as charge nurses and mentors, perform peer evaluations for review and advancement, and conduct cost analyses of nursing care. Strong communication and administrative skills are a necessary component of these functions. Peer leadership laid the groundwork of these skills in asking students to manage the care of their peers.
* I found myself being very supportive of each student. I helped with interventions and with locating resources.
* I worked on keeping a positive attitude when the day wasn't going very well.
* I was conscious of wanting to avoid being perceived as bossy.
* I have the tendency to take over something instead of taking the time to talk someone else through it.
* I had to learn to check up on people without nagging or seeming like I would do better than they would.
Nursing students often do not get the opportunity to practice the skills they need as nurses prior to graduation. Peer leadership is one teaching method that provided alternative learning opportunities to a group of junior baccalaureate nursing students. Despite its small sample size, this study was able to describe and categorize what these nursing students perceived to be the benefits of a peer leadership experience. These descriptions of students' perceptions support the idea that a peer leadership experience contributes to an intrinsic learning environment and cognitive flexibility as described by Loving (1993).
This descriptive study was performed with only 12 nursing students, and larger sample sizes are recommended for further study. In addition, it is difficult to conclude that the benefits listed in this article directly resulted from the peer leadership experience and were not a product of a particular teaching style of the instructor. The implementation of a control group study using the same clinical instructor is recommended to define these relationships more clearly.
- Amman, K.J., & Schroll, N.M. (1988). The junior student as peer leader. Nursing Outlook, 36(2), 85-86.
- Burnside, I.M. (1971). Peer supervision: A method of teaching. Journal of Nursing Education, 10(3), 15-22.
- Cason, CL., Cason, G.J., & Bartnik, D.A. (1977). Peer instruction in professional nurse education: A qualitative case study. Journal of Nursing Education, 16(1), 10-18.
- Doheny, M.O. (1993). Mental practice: An alternative approach to teaching motor skills. Journal of Nursing Education, 32(6), 260-263.
- Erikson, G.P. (1987). Peer evaluation as a teaching-learning strategy in baccalaureate education for community health nursing. Journal of Nursing Education, 26(5), 204-206.
- Flynn, J.P., Marcus, M.T., & Schmadl, J.C. (1981). Peer review: A successful teaching strategy in baccalaureate education. Journal of Nursing Education, 20(4), 28-32.
- Gerace, L., & Sibilano, H. (1984). Preparing students for peer collaboration: A clinical teaching model. Journal of Nursing Education, 23(5). 206-209.
- Iwasiw, CL., & Goldenberg, D. (1993). Peer teaching among nursing students in the clinical area: Effects on student learning. Journal of Advanced Nursing, 18, 659-668.
- Loving, G.L. (1993). Competence validation and cognitive flexibility: A theoretical model grounded in nursing education. Journal of Nursing Education, 32(9), 415-421.
- Meisenhelder, J.B. (1993). Anxiety: A block to clinical learning. Nursing Education, 12(6), 27-30.