Dr. Yoo is Professor, Ajou University College of Nursing, Suwon, and Dr. Chae is Assistant Professor, Seoul National University College of Nursing, Jongro-gu, Seoul, Republic of Korea. At the time this manuscript was written, Dr. Chae was Assistant Professor, Ajou University College of Nursing, Suwon, Republic of Korea.
This study was developed from a study that was funded by the Korea Research Foundation Grant funded by the Korean Government (MOEHRD)/(KRF-2008-531-E00079).
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Sun-Mi Chae, PhD, APRN, BC, CPNP-PC, Assistant Professor, Seoul National University College of Nursing, 28 Yeongeon-dong, Jongro-gu, Seoul, Republic of Korea; e-mail: firstname.lastname@example.org.
Communication skills are core nursing skills for nurses. Building a trusting relationship with a patient is based on good communication skills, which include both verbal and nonverbal skills, such as respect, care, and concern (Makoul, Krupt, & Chang, 2007). Effective communication skills help nurses alleviate symptoms, restore health, and decrease the risk of medical incidents in patients while improving their own job satisfaction (Rosenweig, Clifton, & Arnold, 2007). They also provide a foundation for the development of the nursing profession and contribute to facilitating multidisciplinary collaboration with other members of the health care team (Zick, Granieri, & Makoul, 2007).
Both patients and nurses experience communication difficulties with each other. Patients express low satisfaction at communication with nurses due to the one-way conversation style of nurses and a lack of or inappropriate information about the patients during the communication (Ammentorp, Sabroe, Kofoed, & Mainz, 2007; Yoo, Yoo, Park, Lee, & Hong, 2003). Recent graduates reported that communication in a hospital was the most difficult part of nursing practice (Pellico, Brewer, & Kovner, 2009). A study on the communication of nursing students found that nursing students felt pressured about communication with patients and were not properly prepared to effectively communicate with their patients (Jones, 2007). Hence, communication skills should be emphasized and the students should develop these skills during their time in college to utilize the skills properly in clinical practice.
Skill development requires two kinds of knowledge—theoretical and procedural—that students can acquire from lectures and through practice in a laboratory setting, respectively (Bonner, 2007). To obtain communication skills, both types of knowledge are necessary. However, in most nursing schools only theoretical communication skills have been taught and evaluated through lectures and written tests. Therefore, a new method of nursing education should be developed to help nursing students attain both kinds of communication skills.
Learning communication skills should include support to the students to make behavioral changes through identification and self-reflection on their own problems. Critical feedback from their peers may help students to become more open to critique and stimulate them to address their problems and inappropriate behavior (Hanley & Higgins, 2005). The peer review process is effective for learning and evaluation (Goldsmith, Stewart, & Ferguson, 2006; McMillan & Cameron, 2006; Topping, 2001). It activates cognitive functions of both the students who are evaluating and those who are being evaluated. The evaluators can acquire analytical and critical thinking skills, problem solving ability, and a flexible attitude, whereas the students being evaluated can develop self-directed learning based on the results of the peer review.
According to Vygosky (1986), interaction among students with different levels of knowledge and understanding can induce cognitive conflicts that activate their cognitive system. The peer review process not only measures the outcomes of learning, but it also presents a new learning method that stimulates the active participation of the learners (Dannefer et al., 2005). Feedback from peers motivates students to study, encourages their cognitive activities, and improves their academic achievement (Caris-Verhallen, Kerkstra, Bensing, & Grypdonck, 2000; Mukohara et al., 2004). Previous studies demonstrate that the peer review method is effective and can be applied to students with any level of education, such as elementary students and adults (Parkin, 2006; Perez & Dabis, 2003; Stocks et al., 2007; Topping, 2001). However, the effects of peer review on learning communication skills among nursing students have received little research attention. Therefore, the purpose of this study was to investigate the effects of peer review on communication skills and learning motivation among nursing students.
This is a quantitative research study with a non-equivalent control, pretest–posttest design in which the intervention group received the peer review intervention. The participants were sophomore students taking a course in fundamental nursing in the fall 2008 semester at a nursing college in South Korea. Their grade point averages were used to assign them to one of the two groups; those with even numbers on the grade point average ranks were assigned to the intervention group and those with odd numbers were assigned to the control group. The intervention group had 24 students and the control group had 23. The purpose and procedures of the study were fully explained to the students and their agreement to participate in the study was obtained before data collection began. There was no attrition throughout the study.
The students were taught theory on communication skills for 3 hours in class and for 2 hours in the practice laboratory setting in September 2008. All of the students took a performance test on communication skills 4 weeks after the theory class as a pretest measurement. Their learning motivation was also measured. Standardized patients were used for the test, and they played the role of patients being admitted to a hospital. The communication between patients and students was videotaped for 15 minutes while they interviewed the patients to take an admission history.
A week after the pretest, the students in the intervention group were called and given information on the peer review. The same instrument used to measure communication skills in the pretest was used in the peer review. The faculty demonstrated how to evaluate other students using the tool before the peer review discussion. Small groups of four students were formed for the peer review. The students took turns receiving feedback from three other students after watching his or her videotaped performance. Each student evaluation took approximately 20 minutes. The faculty monitored the peer review discussions in a central control room to ensure the students delivered the correct information. Textbooks and other resources were available in the room for the use of feedback.
Meanwhile, the students in the control group completed a self-evaluation after watching a videotape of their own performance instead of using peer review. Then, for the posttests, communication skills and learning motivation were measured again using other standardized patients in both groups 9 weeks after the evaluation.
This study was conducted after obtaining approval from the institutional review board at the researcher’s institute. The study purpose was explained to all students, who voluntarily gave written informed consent. The students in the control group experienced the peer review process after the study was completed.
Communication Assessment Tool. Communication skills were measured using the Communication Assessment Tool developed by Makoul et al. (2007). It consists of 15 items representing verbal and nonverbal communication, such as caring attitudes and respect for patients during the communication. One item was excluded as being inappropriate to the study, and another was revised to make it more suitable to Korean culture. The instrument was translated into Korean and then back-translated into English to confirm its accuracy. Each item was measured with a 5-point Likert-type scale and included the process of introduction, problem identification, offering information, understanding, and closing. Cronbach’s alpha of the Communication Assessment Tool was 0.83 in this study.
Learning Motivation. The learning motivation scale used a 5-point Likert-type scale and consisted of 12 items with 4 sub-scales: attention, relation, confidence, and satisfaction (Keller, 1983). This study used the Korean version of the scale (Jang, 1996). A higher score indicated higher learning motivation. Cronbach’s alpha was 0.75 in the study.
Experience of Peer Review. Open-ended questions were posed to the students in the intervention group asking about their opinions of the peer review, including its strengths and weaknesses. The content of their statements was classified by similar themes and the frequency of each theme was calculated.
SPSS version 13.0 software was used to analyze the collected data. Descriptive statistics, an independent t test, and a paired t test were used.
Before the intervention, the communication skills in the intervention and control groups were 34.17±8.55 and 36.30±5.60, and the scores for learning motivation were 106.54±10.27 and 106.65±9.69, respectively. There was no significant difference in communication skills (t = 1.018, p = 0.315) or learning motivation (t = 0.038, p = 0.970) between the two groups.
After the intervention, communication skills in the intervention group (46.54±4.72) were significantly higher than in the control group (37.83±6.25) (t = −5.411, p < 0.001). Learning motivation was also significantly higher in the intervention group (121.08±6.02) than in the control group (105.70±9.27) (t = −6.777, p < 0.001). Although communication skills tended to increase after the intervention in both groups, this increase was statistically significant only in the intervention group (t = −5.808, p < 0.001). Learning motivation also increased significantly in the intervention group (t = −5.432, p < 0.001), but there was a slight, but not significant, decrease in the control group (t = 0.363, p = 0.72).
After the intervention, 10 of the 14 items on communication skills were significantly different between the two groups. In the intervention group, the item with the highest score was “Use open questions” (3.63±0.88), followed by “Encourage the patient to ask questions” (3.58±0.78) and “Treat the patient with respect” (3.58±0.72).
In the intervention group, 67% answered that peer review was helpful in identifying problems in communication with the patient, 54% felt more comfortable with peer evaluation compared with evaluation by instructors, and 41% recognized peer review as interesting work. However, negative student feedback about peer review included 20% who were embarrassed because they were evaluated by their classmates, 13% who thought peer review was not objective because they evaluated their own friends, and 13% who stated that the time spent on the peer review was too long.
Education on communication skills needs to focus on enhancing both knowledge and skills so that the students modify their attitudes and behaviors while gaining knowledge and are able to perform the role of good communicators. The study results indicate that the peer review method of learning was effective to improve the communication skills of nursing students. The students using the peer review process were able to reflect on their own communication skills while evaluating their classmates. These results support other studies on the effects of peer preview. Goldsmith et al. (2006) reported that nursing students were able to identify the weakness of their performance by watching a trial performance of the classmates during the peer review process. McMillan and Cameron (2006) also found that physicians who were evaluated by peers adjusted their mistakes after the videotaped peer review. Peer review has also been shown to cultivate clinical reasoning skills (Secomb, 2008) and comprehensive thinking (Zick et al., 2007) on the part of the students, and thus may reinforce therapeutic communication skills. Therefore, the peer review is a practical method to improve communication skills.
The peer review method increased the students’ interest in the topic and learning motivation. Evaluating classmates on the basis of what was learned can trigger the interests of students in learning and let them enjoy the pleasure of working with peers. The result is consistent with prior studies. In a study of physical therapist students, approximately all students reported that peer review was attractive and worthwhile (Currens & Bithell, 2003). Secomb (2008) demonstrated that working with other students during the peer review process led the students to act independently and voluntarily, thereby enhancing their leadership activities and self-esteem. Hence, the peer review method will contribute to achieving learning objectives by enhancing the students’ motivation, interest in learning, and collaboration with others.
Good communication skills include respect for a patient (Makoul et al., 2007). The students using peer review showed more respect during the communication process than did their counterparts. Because patients tend to seek advice from nurses who have a caring attitude (Caris-Verhallen et al., 2000), students with good communication skills will develop a high quality relationship with their patients. Therapeutic communication skills are necessary for data collection or patient problem identification and enable nurses to move from thoughts to action in clinical practice (Makoul, 2006). Peer review can provide students with opportunities to learn nonverbal communication through observing the performance of their classmates so that they learn actual behaviors and attitudes (Zick et al., 2007). Although participation in peer review delivered good experiences to the majority of the students, a minority expressed their concerns about the objectivity of the evaluation and some emotional discomfort with it. Other studies reported similar results (Parkin, 2006; Secomb, 2008).
An effective method of teaching and learning can help learners to develop knowledge within the system of their own cognition. To achieve this goal, this study examined the effects of peer review on communication skills and learning motivation among nursing students. Peer reviewers in this study were able to use self-reflection to modify their own weaknesses or problems in communication with a patient. This result suggests that self-reflection during the peer review triggers changes in their attitudes, as well as critical thinking. From the study results, it is recommended that video-based peer review should be considered for students with difficulties in communication as an effective learning method to improve their communication skills. Further research is also needed to identify the effects of peer review in other aspects of nursing education that involve practical skills, such as health assessment.
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