Nursing students may not have the opportunity to interact with students in other levels of the program due to course and clinical schedules, as well as work and personal obligations. By including senior-level nursing students in the teaching process, it can provide benefits to both groups of students (Williams & Reddy, 2016). Junior-level students can obtain feedback on their clinical skills within a supportive, structured learning environment, whereas the senior-level students can use their knowledge base and clinical skills, as well as developing their ability to function as a mentor and role model (de Menezes & Premnath, 2016; Khaw & Raw, 2016). In near-peer teaching, there is at least 1 year of difference between the groups of students. In a systematic review of 26 articles, near-peer teaching was helpful in learning cognitive and psychomotor clinical skills (Irvine, Williams, & McKenna, 2017). According to McKenna and Williams (2017), near-peer teaching can assist students to understand course requirements and decrease anxiety about clinical experiences.
One method of implementing near-peer teaching into a nursing curricula is through the use of simulation. Intraprofessional simulation experiences with junior and senior nursing students can improve teamwork and communication skills while providing mentoring opportunities for lower level students (Boothby, Gropelli, & Succheralli, 2019). Kirkpatrick et al. (2018) found that intraprofessional simulation was beneficial in the areas of leadership, skills development, intraprofessional communication, and role identification and collaboration. In another study, common themes that emerged when nursing students participated in intraprofessional simulation included Role Recognition and Differentiation, Professional Solidarity, and Adaptation to the Team Environment (Leonard, Shuhaibar, & Chen, 2010).
Using students who are at a higher level within the program to serve as simulated patients and provide feedback to lower level students through the debriefing process can be beneficial to both groups of students (Sarmasoglu, Dinç, & Elçin, 2016). The debriefing process offered the senior students face-to-face time to review and analyze the strengths and weaknesses of the junior-level students' performance on a one-to-one basis. This feedback was conducted immediately after the assessment was completed. The group debriefing actively engaged students through reflection and questioning. In addition, the students were assisted in applying theory to practice. When senior-level nursing students served in the role of patients for junior-level nursing students, students responded positively about the experience and it provided the upper level students experience with leadership, mentoring, and teaching (Bryant, 2017; Owen & Ward-Smith, 2014). The purpose of this project was to allow students to participate in a simulation integrating content from the first semester, while allowing the senior students to discuss community resources with the junior students and provide peer feedback.
This study was conducted at a baccalaureate nursing (BSN) program at a rural, public university during consecutive fall and spring semesters. The research study was approved by the institution's institutional review board. The methodology used was a cross-sectional standard pretest–posttest design collecting self-reported changes in skill, perception, and attitudes. Second-semester senior students enrolled in the Population-Focused Nursing and Healthcare Policy course were recruited to be simulated patients for first-semester junior students in the Health Assessment course from the fall and spring semesters. All first-semester junior students were required to participate in the patient simulation as part of their clinical experience. The second-semester senior students also participated as part of their clinical hours. The senior students were educated on the scenarios and their role as simulated patients before the simulation using a podcast and in-person instruction. Furthermore, these students were required to review relevant assessment techniques prior to the simulation to ensure they were adequately prepared to provide accurate feedback to the junior-level students. Senior students received training and orientation on maintaining confidentiality through Health Insurance Portability and Accountability Act learning modules and the university's policy statement on Family Educational Rights and Privacy Act.
During the near-peer simulation, the junior students were required to obtain a focused history and perform a focused physical assessment, administer simulated medications based on provider orders, and educate the simulated patient on the treatment plan. Prior to the simulation experience, the junior-level students had received classroom instruction along with the opportunity to practice in the laboratory setting related to the body systems incorporated in the case scenarios. The senior students were oriented to the scenarios by one of the junior-level instructors prior to the simulation and were taught how to give effective feedback. The simulation rubric was provided to the senior students to make them aware of the expectations of the junior students. The senior students were advised to identify strengths and areas needing improvement. There were five different scenarios, including influenza, urinary tract infection, gastroesophageal reflux disorder, palpitations, and diarrhea. The scenarios were leveled for the junior nursing students and included content that had previously been taught. Each junior student was randomly assigned to one of the scenarios. Each scenario involved a patient who was uninsured and presenting to the emergency department for care. The duration of each simulation was 25 minutes. After this time, the senior students were allotted 3 minutes for constructive feedback on assessment performance and 2 minutes for discussion of community resources for patients without insurance. Faculty provided additional input on student performance during this time in case the senior students failed to address each aspect of the simulation. Faculty facilitated a debriefing session for the entire group of junior and senior students after the simulated patient experience.
All students were asked to complete an anonymous, optional online survey after the simulation experience. The survey was adapted with permission from Owen and Ward-Smith (2014). Both the junior and senior students completed the survey with 10 perception questions that were graded on a 5-point Likert scale (1 = strongly agree and 5 = strongly disagree). In addition, six open-ended questions for the junior students and seven open-ended questions for the senior students were included to collect qualitative data.
Participation in the simulation experience included 138 students during the fall and spring semesters collectively (28 seniors and 110 juniors), with 17 second-semester seniors completing the postsurvey (17/28 = 60.71% response rate) and 92 first-semester juniors completing the postsurvey (92/110 = 83.64% response rate). A total of 109 junior and senior students completed the immediate postsurvey after the simulation experience. Most of the students were women (87.2%, n = 95) and White/Caucasian (61.5%, n = 67), and the largest age group was between the ages of 18 and 25 years (85.3%, n = 93). For the 10 survey questions, the mean score was 2.14, which best reflected the agree response (a 5-point Likert scale was used with 1 = strongly agree and 5 = strongly disagree). More than half of all responses (69%) from both junior and senior students best reflected the agree or strongly agree categories. The highest level of agreement from junior and senior students was observed with the statement “the simulation provided a variety of ways to learn” (mean = 2.03), with almost three quarters (73%) indicating agree or strongly agree.
Directed content analysis of the open-ended survey questions revealed five themes: Improved Confidence in Assessment Skills, Communication, Connecting Nursing Content, Peer Feedback and Interaction, and Awareness of Community Resources.
Improved Confidence in Assessment Skills. Both junior and senior nursing students felt the simulation experience gave them the opportunity to improve their health assessment skills. A junior student stated the experience assisted in “building up my confidence in doing my physical assessment.” A second junior student said that the most useful part of the simulation was “going through the assessment to practice for the final check off.” A senior student reported that “This experience allowed me to review my assessment skills and to teach someone younger than me.” Another senior student stated, “I think this really helped me gain confidence as a senior II because I was able to teach someone else the skills I know.”
Communication. The junior nursing students felt that assessing someone other than their laboratory partner was helpful in developing their communication skills. One student stated, “Being able to communicate with others other than our own classmates” was useful. Junior nursing students stated they gained “improved patient/caregiver communication” from the simulation, and they learned how to “build rapport and ask appropriate questions.” A senior student felt that this experience assisted the junior students to “to talk to patients using simple terms, gave them a chance to practice patient education, and more.”
Connecting Nursing Content. The simulation incorporated health assessment, fundamentals, and pharmacology, so students had to demonstrate multiple skills during the scenario. One junior student felt that the most useful part of the simulation was “being graded/checked off on how well we could do a physical assessment and how well we knew the medications/how to give them was more helpful than just practicing on our own.” A senior student said that the simulation allows the junior students to “connect Health Assessment and Pharmacology together instead of them being separate entities.” One senior said that the junior nursing students were able to “see the whole picture” in this simulation.
Peer Feedback and Interaction. The junior nursing students valued the peer feedback and opportunity to interact with the senior nursing students. One junior student stated, “It was good to get feedback from them—opportunities to interact with upperclassmen are not readily available.” A junior student reported that the senior nursing students were “very helpful and gave great advice.” A senior student stated, “I liked the debriefing because it allowed me to personally get to know the Junior 1s.” A senior student felt that “sharing knowledge as upperclassmen” was the useful part of the simulation.
Awareness of Community Resources. A senior student stated, “This provided the opportunity for our senior 2 class to teach the junior 1 students about the resources” in the community. Another student learned that it is important to assess “each patient's individual needs (e.g., lack of insurance, no transportation).”
It is important for collaboration among nursing students to begin during the formative years of the socialization process that occurs in nursing programs in order to promote improved patient safety in the practice arena (Robert Wood Johnson Foundation, 2011). However, scheduling and other barriers often prohibit activities that could foster collaboration during nursing programs. Near-peer experiences may prove easier to orchestrate and can pave the way for intraprofessional opportunities to further promote positive patient outcomes, while providing learning and social benefits to students. The majority of students who participated in this activity felt that the near-peer learning simulation was a positive experience, which improved their assessment and communication skills. The junior nursing students found the feedback from and interactions with the senior nursing students to be beneficial, similar to the findings of Owen and Ward-Smith (2014). In addition, the senior students felt that they benefitted from teaching the junior students about health assessment because it provided an opportunity to review content, which is similar to the findings of Sarmasoglu et al. (2016). The simulation allowed junior students to connect content between three of the nursing courses they were concurrently taking: Health Assessment, Pharmacology, and Fundamentals. The junior students also gained knowledge about community resources from the senior students, which may be useful to the junior students as they are beginning their clinical rotations.
A limitation to this study is that it occurred over two semesters at one university. Replication at other universities over a longer time frame may be useful. Several students reported that the medication administration station needed to be changed due to the backlog of students. In future simulation experiences, each simulation room may have its own medication administration area.
Near-peer learning can be a useful, low-cost teaching strategy that can provide benefits to both levels of nursing students, including peer feedback, intraprofessional student interactions, improved assessment and communication skills, and review of content. This innovative strategy promotes active learning and is extremely useful for students who learn kinesthetically. Future studies could incorporate undergraduate and graduate nursing students, along with students studying within other health care-related disciplines. Providing opportunities for multiple simulations per semester with senior and junior nursing students may also prove to be beneficial.
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