The study examined various methods of peer learning and their effectiveness in undergraduate nursing education. Using a specifically developed search strategy, healthcare databases were systematically searched for peer-reviewed articles, with studies involving peer learning and students in undergraduate general nursing courses (in both clinical and theoretical settings) being included. The studies were published in English between 2001 and 2010. Both study selection and quality analysis were undertaken independently by two researchers using published guidelines and data was thematically analyzed to answer the research questions. Eighteen studies comprising various research methods were included. The variety of terms used for peer learning and variations between study designs and assessment measures affected the reliability of the study. The outcome measures showing improvement in either an objective effect or subjective assessment were considered a positive result with sixteen studies demonstrating positive aspects to peer learning including increased confidence, competence, and a decrease in anxiety. We conclude that peer learning is a rapidly developing aspect of nursing education which has been shown to develop students’ skills in communication, critical thinking, and self-confidence. Peer learning was shown to be as effective as the conventional classroom lecture method in teaching undergraduate nursing students.
Nursing education studies have often focused on traditional teaching methods such as classroom lecture learning, a behaviourism-based teaching method based on passive learning [
Peer learning has been used in education to address critical thinking, psychomotor skills, cognitive development, clinical skills, and academic gains [
The Oxford Dictionary (2009) defines a “peer” as someone of the same age or someone who was attending the same university. The term “peer” can also refer to people who have equivalent skills or a commonality of experiences [
Operational terms as shown in Table
Operational definitions.
Term | Definition |
---|---|
Peer | A person with a comparable or slightly higher level of knowledge and experience to the learner. A person of any age can be a peer, that is, a third year student tutoring a first year student but the peer must be an undergraduate nursing student. |
Peer learning | Gaining, refining, or improving knowledge from interaction with a peer as defined previously. |
Mentor | A peer, who supports, guides, and educates a learner. |
Undergraduate nursing student | A nursing student at any stage of study prior to registration. |
Sources: [
The literature search was undertaken using the PICO algorithm of Participant, Intervention, Comparison, and Outcome and guidelines from The Cochrane Handbook [ participant—undergraduate nursing students, intervention—peer learning, comparison—classroom lecture learning, outcome—improvement in theory results or results of practical assessment or personal feelings relating to comfort, confidence, or competence.
A systematic literature search of multiple databases and search engines was undertaken using the keywords and the search strategy described in the following. The keywords used were student nurse, undergraduate nurse, peer learning, peer tutoring, peer mentoring, education, and opinion leaders. Also used were variations and truncations of these words, for example, peer education, nurse education, and problem-based learning. Each of the key words was searched for individually and then in combination with all others.
In addition, a number of key nursing journals such as Journal of Advanced Nursing and Journal of Nursing Education were hand-searched between the years 2000 and 2010. Snowballing, identifying suitable articles from the references of the selected studies, was then conducted to locate further studies.
Studies with all levels of evidence that met the criteria were included because studies in peer learning tended towards quasiexperimental, observational, or case study designs which are all lower on the hierarchy of evidence [
Two reviewers conducted a quality analysis of each study using quality criteria for qualitative and quantitative studies of the Critical Skills Appraisal Programme (CASP) [
Data were extracted and summarized in separate tables: quantitative studies (Table
Summary of included studies.
Author | Design | Intervention and comparison | Country and setting |
---|---|---|---|
Broscious and Saunders (2001) [ |
Mixed method |
Peer coaching | Junior and senior year students: Christopher Newport University in USA |
Christiansen and Bell (2010) [ |
Qualitative |
Peer learning | UK University preregistration nursing course |
Christiansen and Jensen (2008) [ |
Qualitative |
Role playing | Third year student nurses in Norway |
Cooke and Moyle (2002) [ |
Qualitative—case studies | PBL versus CLL | Second year students at university in Australia |
Daley et al. (2008) [ |
Qualitative |
Peer tutoring | Ohio State University, College of Nursing Students |
Feingold et al. (2008) |
Mixed methods |
Team learning | First year student nurses: university in South Western USA |
Goldsmith et al. (2006) [ |
Mixed method |
Peer learning | First/third year students: Clinical Practice Unit (CPU) of a nursing school in Australia |
Higgins (2004) [ |
Quantitative |
Peer tutoring versus nonpeer tutored | Medical-surgical undergraduate nursing course: Texas, USA |
Hughes et al. (2003) [ |
Quantitative |
Peer group experience versus nonpeer group experience | Baccalaureate school of nursing in USA |
Horne et al. (2007) [ |
Qualitative |
Enquiry-based learning | Second year students at a higher education setting in the UK |
Lin et al. (2010) [ |
Quantitative |
Peer tutoring. PBL method in class versus CLL | Nursing ethics classes: university in Taiwan |
Loke and Chow (2007) [ |
Qualitative |
Cooperative learning | Second/third year student nurses: university in Hong Kong |
Morris and Turnbull (2004) [ |
Qualitative evaluation |
Peer tutoring | 3-year undergraduate nursing course in the UK |
Ozturk et al. (2008) [ |
Qualitative |
PBL versus CLL | Fourth year undergraduate student nurses from two universities in Izmir, Turkey |
Rideout et al. (2002) [ |
Quantitative survey |
PBL versus CLL | Baccalaureate school of nursing and CLL programme in Canada |
Roberts (2008) [ |
Qualitative |
Informal peer learning | Undergraduate students over a three-year course in a range of acute settings including intensive care, general surgical, rehabilitation, and medical wards in the UK |
Siu et al. (2005) [ |
Quantitative |
PBL versus CLL | Two universities in Ontario, Canada |
Tiwari et al. (2006) [ |
Mixed methods |
PBL versus CLL | First year student nurses: university in Hong Kong |
PBL: problem-based learning, CLL: classroom lecture learning.
Quantitative studies.
Author/year | Aims | Sample/method | Power calculation/software/analysis tool used | Outcomes | Generalization and confounding factors | Further research |
---|---|---|---|---|---|---|
Higgins (2004) [ |
To determine relationship between academic performance, retention, and participation in a peer-tutoring programme. | Purposive sample: 26 at-risk students were offered peer tutoring |
(i) Power calculation not given. |
Significant relationship between academic performance/retention and participation in a peer-tutoring programme. Attrition rate decreased from 12% to 3%. | Difficult to generalize—no randomization; those who sought peer tutoring may be more motivated to pass. Small sample limited the finding. | Other nursing programs should duplicate peer tutoring for at-risk students in their courses |
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Hughes et al. (2003) [ |
To investigate effect of an informal peer group experience on baccalaureate nursing students. | Convenience sampling |
Insufficient power to detect group differences; multiple tools assessed, anxiety, depression, professional socialization, and general self-efficacy. | No significant differences between groups, but increased depression (mean 0.83, SD 0.55) and anxiety (mean 2.40, SD 0.81). | Restricted to two universities. |
Need for longitudinal study on nursing at varying stages in course |
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Lin et al. (2010) [ |
To compare the educational results of peer tutor problem-based learning and conventional teaching in nursing ethics education. | Convenience sampling |
No power calculation done. Nursing Ethical Discrimination Ability Scale; Learning Satisfaction Survey. Internal consistency reached 0.8 and split-halves reliability was 0.76. | Both methods effective for teaching ethics with PBL ( |
Only one university. Limited training of peers, no evaluation of how peers did their job. Teaching materials/teachers may have influenced result. Students used to CLL may prefer this. | Method needs further validation. |
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Ozturk et al. (2008) [ |
To compare effects of PBL and traditional education on senior undergraduate nursing students’ critical thinking dispositions. | Convenience sampling: |
Power calculation not given. California Critical Thinking Disposition Inventory. Independent |
PBL group showed higher levels of critical thinking than control group ( |
Two universities, voluntary participation, but good response rates. Generalization could be made with reservations as corroborate previous studies. | Alluded to development of a tool to measure critical thinking that is more specific to nursing. |
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Rideout et |
To compare graduate baccalaureate students in a PBL curriculum with others in a CLL programme. | Convenience sampling: |
No power calculation given. |
No differences in final exam results ( |
Restricted to two universities. | Future studies to be longitudinal in design and relying less on self-report measures. |
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Siu et al. (2005) [ |
To evaluate if nursing students enrolled in PBL programme had higher perceptions of empowerment than those in conventional learning lecture (CLL). | Convenience sampling: |
No power calculation given. Conditions for Learning Effectiveness Questionnaire (CLEQ). Psychological Empowerment Scale, Teaching-Learning Strategies Questionnaire, Clinical Problem-Solving Scale. ANCOVA; Spearman's Rho applied. | PBL experienced greater structural empowerment ( |
Sample from only two universities. Self-selection and self-reporting questionnaires were a potential problem. | Need for longitudinal investigation and replication with samples from several nursing programs. |
Qualitative studies.
Author/year | Aims | Participant selection | Assessment measures | Outcomes | Suggested research |
---|---|---|---|---|---|
Christiansen and Bell (2010) [ |
To explore impact of peer learning initiative to facilitate mutually supportive learning between student nurses. | Purposively selected. |
Focus group interviews. Narrative date analyzed thematically. Data collected over 18 months with 3 cohorts of students. | Active support from peers can reduce negative feelings experienced by first year student nurses. It assists coping and decreases attrition rates. Peers benefited by gaining confidence and increased readiness for registered practice. | Explore impact of peer learning on mentors in the workplace. |
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Christiansen and Jensen (2008) [ |
To explore classroom-based peer learning enabling students to cultivate their modes of expression. | Voluntary selection from 288 students doing third year communication course; 16 students took part in role play and 8 in focus group interview. | Observations and focus groups. | Provide tools that can be used in clinical practice. Students learnt from each other and appreciated being able to experience different roles. | Further study on students emotional learning during periods of clinical practice. |
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Cooke and Moyle (2002) [ |
To explore and evaluate the use of PBL over a one-month period in programme that uses CLL. | 130 students—100 responded to questionnaire. | Open ended questionnaire. | Gave more control over learning and added responsibility, promoting independent, self-directed learning. PBL was enjoyable. | None mentioned. |
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Daley et al., (2008) [ |
To evaluate a peer-tutoring approach to teaching designed to meet needs of two different levels of students. | All first year and some senior students in a leadership and management course. | Observations, conferences, focus groups, and journals. Multiple levels of evaluation. | Assignment of higher acuity patients to first years. Confidence of weaker students increased. Better understanding of role of team member, improvement in cognitive and motor skills, increased comfort in asking questions/discussing concepts, and awareness of a future role as mentor. | Additional work and formal evaluation of programme. |
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Horne et al. (2007) [ |
To evaluate student and facilitator perspectives of hybrid model of problem-based learning. | All 121 second year students and 15 facilitators. | Focus group interviews and use of Fourth Generation Evaluation (nominal group technique). | PBL aided development of independent learning skills, self-awareness, and confidence skills. Improved interpersonal/communication skills but depended on group collaboration and concerns about teamwork and group dynamics. | Further study of effectiveness for large groups of students >100. |
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Loke and Chow (2007) [ |
To facilitate the development of “cooperative learning” among nursing students through peer tutoring. | Voluntary selection of 14 third year students as tutors and 16 second year-students as tutees. | Focus groups and individual interviews at half way and end of 10-week tutoring period. | Positives included enhancement of deep learning, critical thinking, problem solving, communication skills, confidence in own learning, and time management. Negatives included participants being late or feeling of not having adequate knowledge to share with one another and mismatched personalities. | Further studies to examine peer-tutoring effects on students in all years. |
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Morris and Turnbull (2004) [ |
To explore viability and value of using student nurses as teachers in inquiry-based nursing curriculum. | A purposive sample of 240 student nurses (36%) participated in interviews. | Focus group interviews, field notes, interviews audio-taped, transcribed, and analyzed using thematic analysis. | Student nurses were uncomfortable with this method and thought it mostly inappropriate, although it may be appropriate in some circumstances. Use of parallel resource sessions in a nonfacilitated forum is problematic. Participants did not think that skills were transferable. | Further research required on the use of students as teachers. |
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Roberts (2008) [ |
To explore if students learn from each other and how, when/where this takes place. | Voluntary selection of 15 students. | Audio-taped conversations of students and field notes; thematic analysis. | Friendships are important to learning. Peer learning in clinical practice is informal and considered part of the job. It helped students to ask questions and contribute to the ward. Students were approachable and had more time for teaching. Students valued peers in clinical setting helping each other to cope with demands of clinical practice. | Replicate study with other groups of students in different locations and branches of nursing. |
Initially, 1813 studies were screened using the aforementioned criteria and 18 studies were selected for review. A flow chart (Figure
Flow chart of the systematic review selection process.
Participants were undergraduate nursing students from first to final year. In line with nursing demography the majority of participants were females. Participant numbers and study duration varied, for example, 15 students over a three-year period [
Of these studies, eight used a qualitative method, six utilized a quantitative method, and four used mixed methods (see Table
The analysis tools and tests used were presented (see Tables
Mixed method studies.
Year/author/ | Aims | Setting | Participant selection | Assessment measures | Outcomes | Generalizations and limitations | Suggested research |
---|---|---|---|---|---|---|---|
Broscious and Saunders (2001) [ |
To implement a strategy to reduce student anxiety during their first clinical experience. | Junior/senior year students in university in USA | 20 senior students and 25 junior students. Convenience sample of all students in year. | Group interview and Likert scale survey: scale had statements presented as description of student experiences. | On 5-point Likert scale (only means reported) students reported decreased sense of anxiety (mean 4.29), increasing confidence (mean 4.08), improved organization (mean 3.91), and perception of being a member of the team (mean 3.83). Senior students practiced leadership skill (mean 4.53), established priorities (mean 4.4), and developed plan of care (4.4). Reiterated amount learnt by senior. Impact of coach decreased in subsequent clinical session. | Small sample and voluntary selection limits generalization. | Further study by modifying and different sites and larger sample. |
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Feingold et al. (2008) |
To evaluate student perception of team learning and effect on class interaction and engagement. | First year student nurses at a university in south-western USA | First year students in course. Convenience sample: for interview—10%, |
Observation and interviews (Qualitative). STROBE classroom observation tool (Quantitative). | Team learning promoted student engagement and was predominantly interactive. Over 305 minutes, most students were engaged/on task for 84% of time, with 70% of time being learner to learner engagement and further 8% of time being used for self-engagement. Main behaviour was learner to learner engagement. Recognized benefit of discussion of problems. | The concept could be generalized. Small sample may not be representative of first year students (nonrandom, self-selected). | Further study to help refine team learning process and to guide implementation of interactive learning strategies. |
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Goldsmith |
To explore impact of peer learning on anxiety of first year student nurses when undertaking clinical skills assessments. | First/3rd year students in Clinical Practice Unit (CPU) in Australia (Conducted over two years and two campuses) | First/3rd year students in 2-year time frame. First year cohort of 187; 3rd year: 178. | Portfolio submission as 3rd year, clinical skills assessment for first year students. Both groups completed questionnaires. | Learning enhanced by experience. |
Only two campuses of one university. Late development of assessment tool with not all students given opportunity to complete questionnaire. Voluntary completion of questionnaire which may not have been representative. | Not reported. |
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Tiwari et al. (2006) [ |
To compare effects of problem-based learning and lecturing approaches on development of students’ critical thinking. | First year student nurses in one university in Hong Kong | All 79 students in first year randomly assigned to control and intervention groups. PBL = 40, CLL = 39. Selection by ballot. | Multivariate regression, 1 and 2 sample |
No significant difference between groups at initial testing ( |
Only one university and a small sample. Results may have been influenced by how lectures were conducted. Use of self-reporting tool. | Monitoring of groups critical thinking in subsequent years. |
Experimental studies with the highest level of evidence, that is, random controlled trials (RCTs), were not a common method of evaluating peer learning as they may not reproduce the true situation in an educational setting [
Eight studies used a comparison group [
Peer learning encouraged independent study, critical thinking, and problem solving skills. It could give students a sense of autonomy when they accepted responsibility for their own education. Peer learning was associated with increased levels of knowledge in a number of areas such as problem solving and communication [
One negative aspect was related to anxiety levels. Group learning showed an increase in anxiety in both control and intervention groups [
In addition to decreasing anxiety [
Four studies [
Peer learning was utilized in multiple situations from teaching ethics [
The purpose of this research was to ascertain whether undergraduate nursing students benefit from peer learning. Sixteen of eighteen studies demonstrated positive aspects to peer learning with outcome measures showing improvement in either an objective effect or a subjective assessment (such as a self-rated increase in student confidence). Furthermore, learning from peers was shown to be acceptable to most students. Much of the research into peer learning concentrated on formal peer learning with the evidence supporting the concept that peer learning may be an equally, if not more, effective method of delivering information in undergraduate nursing education.
Peer learning can be utilized to pass information to large groups of students with less faculty member involvement. At a time when there is pressure to train more nurses and minimize costs [
Regardless of any decrease in active involvement by lecturers, the need for student supervision remains important. If peers are not knowledgeable or do not have the appropriate skills, then they cannot accurately pass information onto another student. The learning of inaccurate information could potentially cause issues for students when these inaccuracies were demonstrated in exams and on clinical placements. Without supervision, learning may not be effective as shown in an earlier study by Parkin [
Peer learning may result in information being more readily accepted by a student as individuals often turn to others who have similar experiences, for advice and guidance. This could decrease anxiety associated with learning due to familiarity of the peer with the student’s issues. As noted in the results, anxiety may occur when individuals are exposed to new concepts, whether they are novice or proficient learners [
Further, social interaction and collaboration between peer and student may have contributed to an increased learning curve and acquisition of further knowledge than would have occurred if students were studying independently. This was illustrated in this paper with students who had been in danger of failing and had received peer tutoring [
Student satisfaction may play a part in scholastic achievement through acceptance of an active learning method such as peer learning. Four studies investigating this component [
Peer learning may also be more successful when peers are close in experience or stage of training as it provides a more relaxed, less intimidating, more “user friendly” learning experience than sessions conducted by registered nurses. Prior to the current study, El Ansari and Oskrochi [
There is, however, a different perspective. Whilst peer learning has been used for years and might be becoming the norm, students may not be fully familiar with it and therefore be apprehensive about what it offers. Some students reported anxiety and apprehension when taking part in peer learning which was linked to feeling responsible for another’s education [
Finally, this paper raises issues around the confusing terminology used to refer to peer learning. As mentioned, multiple terms such as peer teaching, peer mentoring, and peer coaching were used interchangeably with debate about whether they meant the same thing or referred to subtle differences in meaning. A clearer definition of each of the terms is needed to increase the rigor of nursing education research, as was also raised by Secomb [
Some limitations of this study were recognized. Only studies published in English were included. Despite a rigorous search strategy, some relevant articles may have been omitted owing to the search terms used. The mix of study designs and various methods of reporting meant that direct comparison between studies was limited. Some studies were location- or topic-specific, and some studies collected data using indirect outcome measures. However, the collection and review of the diverse papers that were selected offered the best option for determining the overall impact of peer learning in education of nursing students.
Peer learning: learning from others who possess a similar level of knowledge, is becoming a part of nursing education. This study showed that undergraduate nursing students could benefit from peer learning, with an increase in confidence and competence and a decrease in anxiety. Their peers also gained skills to prepare them for their role as a registered nurse. Conduct of peer learning within the curriculum was shown to require adequate academic supervision to be effective. It was difficult to ascertain the most effective learning methods because of the inherent variation between study methodologies, terminology, subjects, and settings. Inconsistency terminology was identified as a problem that should be addressed in order to provide clarity in future research.
Further research is needed to fully investigate peer learning with the use of larger samples, various targeted curricula, courses, and locations to increase the validity of studies. The cost effectiveness of peer learning should be further investigated and compared to that of CLL to ascertain how this option could impact nursing education in terms of resources, time management, and effectiveness.