A peer-instruction model has been used for several years in a nurse anesthetist curriculum to use simulation resources and anesthesia faculty efficiently. In this program, second-year nurse anesthetist students, designated as peer instructors, are paired one-to-one with novice first-year students, designated as peer learners, during an introductory nurse anesthetist course using a high-fidelity patient simulator (HFPS). This collaborative, student-to-student, peer-instruction teaching strategy was instituted to help first-year students integrate the fundamental concepts of the nurse anesthetist by using a narrative pedagogy among peers. Leonard, Shuhaibar, and Chen (2010) found that providing students with opportunities to interact with other students at advanced levels in a nursing program facilitated student engagement and excited them to progress to the next level of practice.
Feedback from first- and second-year nurse anesthetist students regarding the peer-instruction model used in this nurse anesthetist program has been positive. The peer-instruction model has decreased the number of faculty members required to run the simulation by two. However, to date, there has been no study to evaluate whether a peer-instruction model facilitates learning in first-year nurse anesthetist students compared with first-year students who received faculty instruction using an HFPS. Evidence is needed to support the use of this model in nurse anesthetist education. This pilot study was undertaken to examine learning outcomes associated with peer instruction among first-year nurse anesthetist students.
Teaching strategies using a HFPS are common components in undergraduate and graduate nursing programs (Weaver, 2011). First-year nurse anesthetist students receive didactic instruction about fundamental concepts of nursing anesthesia, and they participate in task-trainer workshops to learn psychomotor skills. Integration of these knowledge skills are instructed using clinical scenarios and an HFPS. During these introductory scenarios, students have many questions and a high level of anxiety, which makes the preparation of first-year students for the scenario and the debriefing sessions protracted processes for faculty. Using simulation as a teaching strategy in nurse anesthetist education can be limited by available faculty (Hotchkiss, Biddle, & Fallacaro, 2002; O’Donnell, Fletcher, Dixon, & Palmer, 1998). The overall nursing shortage, the relative lack of nurse anesthetist faculty members, and the small number of students who can be educated at one time using an HFPS can impede nurse anesthetist programs from using available simulator resources (Harlow & Sportsman, 2007; Jordan & Maree, 1998; Starnes-Ott & Kremer, 2007).
Peer instruction is a student-to-student collaborative teaching strategy that capitalizes on students’ perceptions of their peers and maximizes the benefits of cognitive congruence between peers (Lockspeiser, O’Sullivan, Teherani, & Muller, 2008; Ten Cate & Durning, 2007). Students perceive their peers as having more time to devote to instructing a fellow student and thus are better able to pass on tips and hints in an informal way. Students also find their peers less intimidating and more approachable than faculty members (Roberts, 2008; Ten Cate & Durning, 2007). Damon and Phelps (1989) asserted that a peer-instruction environment can better facilitate the students’ ability to ask questions, express opinions, and risk untested speculations, all of which contribute to learning.
Peer instruction has demonstrated multiple benefits in varied educational settings. In nursing education, peer instruction has been applied in the classroom, the laboratory, and the clinical area. Students in both the instructor role and the learner role have reported positive outcomes and perceptions of the experience (Evans & Cuffe, 2009; Knobe et al., 2010; Lockspeiser et al., 2008). The benefits of student-to-student instruction include augmented learning (Loke & Chow, 2007; Secomb, 2008); enhanced communication (Giuliodori, Lujan, & DiCarlo, 2006); development of collaborative relationships and collaborative skills (Sprengel & Job, 2004); improved independence and self-confidence (Loke & Chow, 2007; Secomb, 2008); more individualized instruction time in a one-to-one, student-to-teacher ratio (Iwasiw & Goldenberg, 1993); and decreased student anxiety (Owens & Walden, 2001; Yates, Cunningham, Moyle, & Wollin, 1997). Peer instruction has also been shown to promote cognitive gain (Cortright, Collins, & DiCarlo, 2005; DeClute & Ladyshewsky, 1993; Eisen, 2001; Giuliodori et al., 2006; Lockspeiser et al., 2008; Slavin, 1983), as well as critical thinking, problem solving, and decision-making skills (Bos, 1998; Cortright et al., 2005), and students are able to assess their own learning and guide their own educational experience (Boud, Cohen, & Sampson, 1999). Therefore, peer instruction as a teaching strategy may effectively convey knowledge from student to student, but more significant, it may also teach students how to learn. In addition, Solomon and Crowe (2001) reported student enjoyment of the teaching role, which emerged as a theme. Knobe et al. (2010) found that peer instructors benefited the most from a peer-instruction program due to the reinforcement of the learning process that occurred as a result of teaching others.
The documented disadvantages of peer instruction are reported with less frequency. Students who did not prefer student-to-student instruction cited reasons that included the pairing of students with mismatched learning styles (Giuliodori et al., 2006; Secomb, 2008), unproductive competition between students (DeClute & Ladyshewsky, 1993), and a perceived inequality of teaching by a peer teacher compared with that by a faculty instructor (Iwasiw & Goldenberg, 1993; Knobe et al., 2010; Secomb, 2008). Knobe et al. (2010) explained that a significant limitation of a peer-teaching model is that peer learners tend to doubt the equivalence of competency between peer instructors and faculty instructors.
Purpose of the Study
The primary purpose of this pilot study was to determine whether there was a difference in learning outcomes between first-year nurse anesthetist students who were instructed by a peer-instruction model using an HFPS versus those who received faculty instruction. The secondary purpose was to examine the perceptions of all first- and second-year nurse anesthetist students regarding the use of a peer-instruction model.
Dr. Stephen Billett’s situational learning theory (1996) served as the theoretical framework to inform this study. Billet’s theory—the context of a learning environment influences the individual construction of knowledge so that when knowledge is acquired in an authentic situation, it will be more readily transferred or applied to a similar circumstance—is applicable to learning with an HFPS. The situational learning theory also explains how a shared understanding between peers may help form the conceptual links that contribute to knowledge development in a realistic context, such as when an HFPS is used (Billet, 1996).
The institutional review board of the affiliate hospital and the affiliate university both approved this prospective, posttest-only, true experimental pilot study. To answer the first research question, a convenience sample cohort of first-year nurse anesthetist students (n = 22) was invited to participate. Each participant provided written consent, and random assignment to the control or intervention group was completed.
Detailed clinical scenarios, learning objectives, and a detailed explanation about the peer-instruction model were provided to all first- and second-year nurse anesthetist students. The intervention group (n = 11) received peer instruction on one instruction day, and the control group (n = 11) received faculty instruction on a subsequent day using an HFPS. The clinical scenarios were the same for both groups. Two clinical scenarios were used on each instruction day, one in the morning session and one in the afternoon session.
In the morning of the simulation instruction day for the peer-instruction group, two pairs of peer instructor and peer learner student dyads (four students total) first reviewed the clinical scenario together in a practice area equipped with a manikin. First-year students were encouraged to practice the scenario with their peer instructors, and second-year students were directed to encourage questions and engage the first-year students in a mutual dialogue about each scenario, using the simulation objectives as a guide. The first-year students then participated in the clinical scenario using an HFPS and were subsequently debriefed. The second clinical scenario was practiced, performed, and debriefed in the same fashion in the afternoon session. The procedure for the faculty-instruction group was the same, except a faculty member replaced the peer instructors.
On a subsequent day, each first-year student (n = 22) demonstrated a clinical scenario similar to one of the scenarios reviewed on the instruction day. Learning outcomes were evaluated for each first-year student by two Certified Registered Nurse Anesthetist (CRNA) raters who were masked to the group assignments.
A 25-item Rapid Sequence Induction Checklist (RSIC) evaluation instrument (Morgan, Cleave-Hogg, Guest, & Herold, 2001) was used to assess learning outcomes of first-year nurse anesthetist students. The RSIC instrument was created and tested by Morgan et al. (2001) in a study that examined the validity and reliability of undergraduate performance assessments using an anesthesia simulator. Morgan et al. reported interrater reliability between paired raters using the RSIC to be 0.86. Content validity was confirmed on the instrument by a consensus of faculty experts who compared evaluation criteria to the course objectives.
Two CRNA raters were trained on the use of the evaluation instrument and practiced scoring on three separate demonstrations of the clinical scenario. The interrater reliability coefficient was 1.0 when no item was omitted by the demonstrator, 1.0 when two items were omitted, and 0.96 when five items were omitted. Each of the instrument’s 25 items was scored as 1 = performed or 0 = not performed; the range of possible scores was 0 to 25.
To answer the second research question, all 22 first-year and 24 second-year nurse anesthetist students were invited to anonymously and voluntarily complete a student satisfaction and course evaluation survey following the completion of the 10-week introductory nurse anesthetist course. The faculty instruction group of the first-year students was not paired with their peer instructors for the instruction day of the study, but they participated in the same number of simulations during the course and were paired with their peer instructors for the remaining 8 weeks of the course.
Two versions of the student satisfaction and course evaluation surveys exist, which include Likert scale questions and open-ended questions. One version of the survey was specific to first-year students as peer learners; the second version was specific to second-year students as peer instructors.
Descriptive statistics were used to describe the sample and compare the two groups of students by demographic characteristics. Frequency data were obtained on age, gender, ethnicity, previous number of years of intensive care unit experience, and previous use of patient simulation. The groups were similar in all categories.
The power analysis showed that a sample size of 66 students was needed to achieve statistical power of 0.80 and a medium effect size of 0.50 for parametric statistical analysis (t test) using Cohen’s power tables for a two-level group with one dependent variable (learning outcomes). The available sample for this study was a cohort of 22 first-year nurse anesthetist students in a nurse anesthetist program that routinely uses a peer-instruction model. A larger sample was unavailable because implementing a new teaching strategy in another nurse anesthetist program was not possible.
A nonparametric statistic, the Mann-Whitney U test, compared the median scores of the two groups by ranking the averaged scores and comparing the group median score to the median of the two groups combined (Burns & Grove, 2009). A nonparametric statistic was used secondary to the small sample size and an inability to ensure normal data distributions (Huck, 2008). Raw scores for each student were calculated as a sum of items performed correctly. Scores of the two raters were averaged, then all of the average scores were combined in a table and ranked, with the lowest score assigned a rank of 1. Ranks were averaged for repeated scores (Burns & Grove, 2009). The U statistic was calculated using the Mann-Whitney U test and was assessed for statistical significance with an alpha level set at p < 0.05 using SPSS® version 18.0 software.
No statistically significant difference in learning outcomes was found between groups of first-year nurse anesthetist students who received faculty instruction and those who received peer instruction using the HFPS, as assessed by CRNA raters using the RSIC, U = 56.5; p = 0.792. The faculty instruction group (control group) had an average rank of 11.14, whereas the peer instruction group (intervention group) had an average rank of 11.86. The interrater reliability between trained CRNA raters evaluating first-year nurse anesthetist student learning outcomes on the RSIC in this study was r = 0.68 using the Pearson correlation coefficient (SPSS 18.0 software) and the Microsoft Excel® Statistical Tool to calculate the correlation coefficient.
Feedback from first- and second-year students was collected on the student satisfaction and course evaluation surveys, and was mostly positive regarding peer instruction using an HFPS. Responses were consistent with previous cohorts of nurse anesthetist students and the literature describing other applications of peer-based education. Student responses to open-ended questions were analyzed by content analysis for emerging themes. Themes were summarized and compared with reviewed literature in terms of advantages and disadvantages of the peer-instruction teaching strategy.
The majority of first-year student responses were agree or strongly agree to 10 Likert scale questions. The internal reliability of the Likert scale data for first-year students was demonstrated by a Cronbach’s alpha of 0.82 (using SPSS version 18.0 software). The advantages of the peer-instruction model cited by first-year nurse anesthetist students were organized into three main thematic categories: knowledge and skill development, empathy exhibited by peer instructors, and an environment conducive to learning. One third of the first-year students stated that their second-year peer instructors were knowledgeable and that they appreciated the didactic and clinical information shared by their peer instructors. First-year students stated that the time provided to practice cases with their peer instructors using a simulator was beneficial and decreased their anxiety. First-year students reported that their peer instructors were empathetic, encouraged questions, and facilitated their ability to think critically. An interesting comment shared by a first-year student was that his or her peer preceptor had the time to share a wide range of didactic information with him or her that was beyond the specifics of the simulated scenario.
Most of the disadvantages indicated by first-year students were related to the design and implementation of the simulation activity and schedule, rather than disadvantages specific to the peer-instruction model used. A disadvantage specific to the peer-instruction model identified by two students was that peer instructors were inconsistent and that some were better than others at providing feedback and explaining concepts. Seven students (approximately one third) suggested that faculty members or peer instructors should demonstrate the scenario using the HFPS before each simulation experience to help clarify expectations for new students.
All second-year students responded to Likert scale questions with positive responses (agree or strongly agree), with the exception of one student’s response on two questions as undecided. The internal reliability of the Likert scale data for second-year students was demonstrated by a Cronbach’s alpha of 0.78 (using SPSS version 18.0 software). The advantages of the peer-instruction model cited by second-year students were organized into three major thematic categories: knowledge and skill reinforcement, facilitation of teaching ability, and collaboration with classmates. Second-year students cited an increase in confidence in their didactic knowledge and clinical skills as a major strength of instructing a first-year student using an HFPS. Second-year students also stated that peer instruction reinforced the enormous amount of information they learned during their first year in the nurse anesthetist program. A second-year student indicated that explaining concepts aloud to first-year students in a way they could understand provided an opportunity for the second-year student to critically think about and process what he or she had previously learned. Second-year students reported that the peer-instructor role provided them with an opportunity to learn how to teach first-year students by formulating rationales for various aspects of the simulated scenarios and answer questions in a clear and concise manner. One student added, “[It was a] great opportunity to discuss anesthetic approaches with classmates [who are rotating to different clinical sites].”
The only disadvantage cited by two second-year nurse anesthetist students specific to the peer-instruction model was that some peer instructors did not facilitate the fidelity of the simulations as well as others and that some second-year students were more interested than others in teaching the first-year students. The frequent suggestion by first-year students to have the scenarios demonstrated using the HFPS to allay anxiety and to give an example of the performance of a scenario was echoed by several second-year students.
A limitation of our study was the small sample size, which required the use of a nonparametric statistic and limited statistical power. The study also evaluated each first-year student’s demonstration of one scenario on one occasion, which limits the generalizability of the results. The finding that the groups did not demonstrate differences in learning outcomes suggests the effectiveness of this teaching strategy to promote learning while decreasing the number of faculty members that are used. This study confirmed that learning outcomes were the same between groups, and the number of faculty members used decreased from four to two. The faculty member who facilitates the scenario practice and answers questions is not needed when using the peer-instruction model. In addition, the faculty member who prompts the new students during the scenario, provides cues when necessary to continue the scenario, and leads the debriefing discussion after the scenario is not needed, as these roles are performed by the peer instructors in this model. No other studies were identified in the literature that compared learning outcomes between groups using a peer-instruction model.
Qualitative data collected from first- and second-year nurse anesthetist students were favorable, with few disadvantages cited, and they were consistent with implementation of peer-learning models in other educational settings. This teaching strategy provided students with an opportunity to interact with more advanced students and fostered intraprofessional interaction between students, which both levels of students enjoyed. Both levels of students reported that the peer-instruction teaching model either developed or reinforced their knowledge and skills, and the collaboration with classmates was enjoyable, as well as facilitated an environment conducive to learning where the stress and anxiety of many first-year students was decreased.
The peer-instruction model shows promise as a cost-effective approach to nurse anesthetist education using an HFPS. This pilot study will be replicated in the future with an increased sample size to increase statistical power. Strategies to increase interrater reliability between trained CRNA raters will be used. Replication of the study with similar and with different nursing student populations in other nursing programs, including undergraduate students, would add to the body of knowledge about peer instruction as a learner-centered teaching strategy. Exploration about how to pair peer learners with peer instructors or how to better facilitate learning in both groups of students is warranted, as well as further exploration of teaching strategies that foster intraprofessional interaction between students to maximize learning outcomes such as student-to-student dialogue and other educational pedagogies.
- Billett, S. (1996). Situated learning: Bridging sociocultural and cognitive theorising. Learning and Instruction, 6, 263–280 doi:10.1016/0959-4752(96)00006-0 [CrossRef] .
- Bos, S. (1998). Perceived benefits of peer leadership as described by junior baccalaureate nursing students. Journal of Nursing Education, 37, 189–191.
- Boud, D., Cohen, R. & Sampson, J. (1999). Peer learning and assessment. Assessment & Evaluation in Higher Education, 24, 413–426 doi:10.1080/0260293990240405 [CrossRef] .
- Burns, N. & Grove, S.K. (2009). The practice of nursing research: Appraisal, synthesis, and generation of evidence (6th ed.). Philadelphia, PA: Saunders.
- Cortright, R.N., Collins, H.L. & DiCarlo, S.E. (2005). Peer instruction enhanced meaningful learning: Ability to solve novel problems. Advances in Physiology Education, 29, 107–111 doi:10.1152/advan.00060.2004 [CrossRef] .
- Damon, W. & Phelps, E. (1989). Critical distinctions among three approaches to peer education. International Journal of Educational Research, 13, 9–19 doi:10.1016/0883-0355(89)90013-X [CrossRef] .
- DeClute, J. & Ladyshewsky, R. (1993). Enhancing clinical competence using a collaborative clinical education model. Physical Therapy, 73, 683–689.
- Eisen, M. (2001). Peer-based professional development viewed through the lens of transformative learning. Holistic Nursing Practice, 16, 30–42.
- Evans, D.J. & Cuffe, T. (2009). Near-peer teaching in anatomy: An approach for deeper learning. Anatomical Sciences Education, 2, 227–233 doi:10.1002/ase.110 [CrossRef] .
- Giuliodori, M.J., Lujan, H.L. & DiCarlo, S.E. (2006). Peer instruction enhanced student performance on qualitative problem-solving questions. Advances in Physiology Education, 30, 168–173. doi:10.1152/advan.00013.2006 [CrossRef]
- Harlow, K.C. & Sportsman, S. (2007). An economic analysis of patient simulators clinical training in nursing education. Nursing Economic$, 25, 24–29, 3.
- Hotchkiss, M.A., Biddle, C. & Fallacaro, M. (2002). Assessing the authenticity of the human simulation experience in anesthesiology. AANA Journal, 70, 470–473.
- Huck, S.W. (2008). Reading statistics and research (5th ed.). New York, NY: Pearson Education.
- Iwasiw, C.L. & Goldenberg, D. (1993). Peer teaching among nursing students in the clinical area: Effects on student learning. Journal of Advanced Nursing, 18, 659–668 doi:10.1046/j.1365-2648.1993.18040659.x [CrossRef] .
- Jordan, L. & Maree, S. (1998). Challenges facing the education of nurse anesthetists. AANA Journal, 56, 305–307.
- Knobe, M., Münker, R., Sellei, R.M., Holschen, M., Mooij, S.C., Schmidt-Rohlfing, B. & Pape, H. (2010). Peer teaching: A randomised controlled trial using student-teachers to teach musculoskeletal ultrasound. Medical Education, 44, 148–155 doi:10.1111/j.1365-2923.2009.03557.x [CrossRef] .
- Leonard, B., Shuhaibar, E.L. & Chen, R. (2010). Nursing student perceptions of intraprofessional team education using high-fidelity simulation. Journal of Nursing Education, 49, 628–631 doi:10.3928/01484834-20100730-06 [CrossRef] .
- Lockspeiser, T.M., O’Sullivan, P., Teherani, A. & Muller, J. (2008). Understanding the experience of being taught by peers: The value of social and cognitive congruence. Advances in Health Science Education: Theory and Practice, 13, 361–372 doi:10.1007/s10459-006-9049-8 [CrossRef] .
- Loke, A. & Chow, F. (2007). Learning partnership—The experience of peer tutoring among nursing students: A qualitative study. International Journal of Nursing Studies, 44, 237–244 doi:10.1016/j.ijnurstu.2005.11.028 [CrossRef] .
- Morgan, P.J., Cleave-Hogg, D.M., Guest, C.B. & Herold, J. (2001). Validity and reliability of undergraduate performance assessments in an anesthesia simulator. Canadian Journal of Anaesthesia, 48, 225–233 doi:10.1007/BF03019750 [CrossRef] .
- O’Donnell, J., Fletcher, J, Dixon, B. & Palmer, L. (1998). Planning and implementing an anesthesia crisis resource management course for student nurse anesthetists. CRNA: The Clinical Formum for Nurse Anesthetists, 9, 50–58.
- Owens, L.D. & Walden, D.J. (2001). Peer instruction in the learning laboratory: A strategy to decrease student anxiety. Journal of Nursing Education, 40, 375–377.
- Roberts, D. (2008). Learning in clinical practice: The importance of peers. Nursing Standard, 23(12), 35–41.
- Secomb, J. (2008). A systematic review of peer teaching and learning in clinical education. Journal of Clinical Nursing, 17, 703–716 doi:10.1111/j.1365-2702.2007.01954.x [CrossRef] .
- Slavin, R.E. (1983). When does cooperative learning increase student achievement?Psychological Bulletin, 94, 429–445 doi:10.1037/0033-2909.94.3.429 [CrossRef] .
- Solomon, P. & Crowe, J. (2001). Perceptions of student peer tutors in a problem-based learning programme. Medical Teacher, 23, 181–186 doi:10.1080/01421590020031101 [CrossRef] .
- Sprengel, A.D. & Job, L. (2004). Reducing student anxiety by using clinical peer mentoring with beginning nursing students. Nurse Educator, 29, 246–250 doi:10.1097/00006223-200411000-00010 [CrossRef] .
- Starnes-Ott, K. & Kremer, M.J. (2007). Recruitment and retention of nurse anesthesia faculty: Issues and strategies. AANA Journal, 75, 13–16.
- Ten Cate, O. & Durning, S. (2007). Dimensions and psychology of peer teaching in medical education. Medical Teacher, 29, 546–552 doi:10.1080/01421590701583816 [CrossRef] .
- Weaver, A. (2011). High-fidelity patient simulation in nursing education: An integrative review. Nursing Education Perspectives, 32, 37–40 doi:10.5480/1536-5026-32.1.37 [CrossRef] .
- Yates, P., Cunningham, J., Moyle, W. & Wollin, J. (1997). Peer mentorship in clinical education: Outcomes of a pilot programme for first year students. Nurse Education Today, 17, 508–514 doi:10.1016/S0260-6917(97)80013-5 [CrossRef] .