Teaching clinical skills to nursing students to ensure patient safety is an important aspect of nursing education in the United States and other countries. Nurse educators are challenged to develop innovative methods for teaching clinical skills to ensure competence at the bedside.1 However, teaching nursing skills to students is a complex process requiring the integration of 3 domains of learning: affective (emotional), cognitive (thinking), and psychomotor (kinesthetic).2,3 Recently, there has been considerable debate about the most effective ways to teach nursing skills, but unfortunately, there is little empirical evidence on how best to teach those skills to prelicensure nursing students.4 In addition, little is known about students' preferred learning styles for nursing skills acquisition.
Background
The literature suggests that students perform better and have greater motivation when innovative teaching methods are used than when traditional methods are used.5-9 According to McQuiston and Hanna,10 learning occurs not only through hierarchical relationships but also through peer relationships or peer coaching. Thus, peer student learning is 1 way to support students in achieving learning objectives for course work.11 Hunt and Ellison12 found that peer learning provided mentorship between students that promoted socialization and decreased anxiety for learning skills in the laboratory. Furthermore, Roberts13 found that students valued learning from peers and often used peers to cope with the demands of clinical practice. However, few studies have compared learning outcomes from the new methods to those from more traditional methods.5,6,8
Therefore, we used the Objective Structured Clinical Evaluation (OSCE) method for setting up stations to assess nursing students' competence in basic nursing skills. The OSCE is an approach for assessing clinical competence in which students rotate through short (5-10-minute) simulated patient scenarios in which 1 student is the examiner and 1 student is the examinee.14 The OSCE method has been found effective for teaching health care skills and evaluating competence at the bedside for both undergraduate and graduate students.15 In the past, the OSCE method has been used to teach health assessment, clinical skills, and counseling competence among nursing and medical students.16 However, few studies have examined nursing students' assessment of the peer learning process using the OSCE method.
This study evaluated the peer-student validation (PSV) approach, which is based on the OSCE method for student learning and evaluation of clinical skills among nursing students. The PSV approach encourages students to reflect on and assess their learning. The aim of the study was to compare nursing student satisfaction with the PSV method of learning basic skills and traditional learning method in a skills laboratory course.
Methods
Research Design
The study was conducted at a southern university in the United States. We compared the PSV group (n = 41) with the traditional method group (n = 46) using a posttest survey to examine differences in the students' perceptions of their learning experience using the 2 instructional methods (PSV and traditional). The traditional skills course was offered in the spring semester, and the faculty members evaluated students' skills. The PSV skills course was offered to a new group of students the following fall semester, using peer evaluation for nursing skills. The PSV course and the traditional course were taught by different faculty members.
After students had completed the 15-week skills course, they were asked to volunteer to participate in the study and complete a survey on their demographics, perceptions of the learning experience, and evaluation of nursing skills. Inclusion criteria were age 18 years or older and enrollment in the second semester of the junior year in the nursing program. The study was approved by the university's institutional review board.
Sample
The sample for this study included only students who were enrolled in a 4-year baccalaureate program in nursing. Fifty students in the PSV group and 50 students in the traditional group were approached to take the survey. Of the 100 students, 13 declined (9 in the PSV group and 4 in the traditional group). The 87 remaining students (41 in the PSV group and 46 in the traditional group) in the study signed the informed consent form.
Procedure
Five skill sets were incorporated into 3 learning modules that were completed during a weekly 3-hour laboratory using low-fidelity task manikins. The 3 modules included content related to (a) parental administration (subcutaneous, intramuscular, and intradermal injections), (b) intravenous (IV) initiation and phlebotomy (IV insertion, infusion rate, IV piggyback medication administration, IV flush, and obtaining blood samples), and (c) tracheostomy care (tracheostomy dressing change, suctioning, and pulse oximetry). In addition, students were taught medical terminology and medication calculations. A detailed protocol for each skill was provided to the students at the beginning of the course. Modules were completed in 15 weeks, and students were evaluated on subcutaneous injections, intramuscular injections, IV therapy, tracheostomy care, and tracheostomy suctioning. Two faculty members taught all traditional sections, and 2 other faculty taught the PSV group using the PSV protocol. Lastly, the students were asked to communicate with the low-fidelity task manikins as if they were talking to a patient in the clinical setting.
PSV Group
The PSV group received no lecture; instead, students completed online learning modules and participated in simulated practice with peers every other week; this group was taught by 2 faculty members and 1 teaching assistant. The PSV students independently completed 3 online, self-paced learning modules that included the 5 designated skills and dose calculation and medical terminology quizzes. In addition, they were required to attend a 1-hour open laboratory twice weekly to practice skills. During the 3-hour faculty-facilitated laboratory practice sessions, students rotated through simulated patient scenarios, learning modules, and group case studies that included viewing equipment related to the nursing skills.
Evaluation occurred the week after completion of each online learning session: 1 student served as the examiner and another student was the examinee. During the evaluation, students were not allowed to talk to one another; a debriefing session was conducted at the end of the evaluation. An evaluation rubric used by the examiner specified the performance criteria and the level for carrying out each task. Performance was rated from 1 to 5, in which 1 was the poorest performance and 5 indicated that the student had performed all tasks correctly. Students had to obtain a 5 on all tasks during the PSV evaluation. The faculty members observed the evaluation process between the 2 students and signed a form stating that the student had successfully passed the skill. If a student did not meet the criteria for passing the nursing skill, the student was required to attend open laboratory to practice for 1 week and was subsequently reevaluated by the open laboratory instructor.
Traditional Learning Group
The traditional group received face-to-face lectures and reading assignments covering the same content received by PSV students over the same time frame, and with the same accompanying laboratory time. As with the PSV group, the skills evaluated for clinical competence were subcutaneous injections, intramuscular injections, IV therapy, tracheostomy care, and tracheostomy suctioning.
The course was taught by 2 faculty who met with the students each week in the laboratory, lectured on the skills content, and demonstrated to students how to perform the skill. During this structured laboratory time, no individual student practice time was allocated. Students were expected to attend open laboratory (1 hour) to practice the nursing skills. As with the PSV group, open laboratory was available for practice of the nursing skills and attendance was encouraged, but not monitored. During open laboratory time, students used a low fidelity task manikin (non-computerized) to practice nursing skills. The skills evaluation for the traditional group was done by the faculty using a 1:1 method for the skill demonstration check-off. Faculty used the same evaluation rubric used with the PSV group. The time required for the 1:1 student skills evaluation was 20 minutes per student.
PSV Survey
The survey used to obtain self-assessment of the peer method included 10 items in 3 subscales: Evaluation Method, Satisfaction With the Teaching Method, and Lab Environment. Two additional questions asked the student's preference for learning skills and return demonstration of skills. The Evaluation Method subscale used a Likert scale ranging from 0 (not helpful) to 5 (very helpful). The Satisfaction subscale used a Likert scale ranging from 1 (completely satisfied) to 5 (completely dissatisfied), except for 1 item pertaining to time to practice nursing skills in the laboratory. This item used a Likert scale ranging from 0 (perfect time) to 5 (no time) to better discriminate for laboratory time. The Lab Environment subscale used a scale ranging from 0 (no stress) to 5 (most stress). In addition, 3 demographic questions were asked pertaining to age, gender, and education.
Content validity was assessed by a panel of 4 experts. Principal components analysis was used with a varimax rotation and converged in 5 iterations. The factor structures for coefficients are shown in the Table, Supplemental Digital Content 1, http://links.lww.com/NE/A217. The 3 factors explained 59.3% of the variance. The survey had a Cronbach's [alpha] of .66. The Evaluation Method subscale had a Cronbach's [alpha] of .74, the Satisfaction subscale had a Cronbach's [alpha] of .58, and the subscale of Lab Environment had a Cronbach's [alpha] of .59. Nursing faculty members were not present in the room when students completed the survey.
Results
The students' mean age was 23.9 +/- 4.8 years in the PSV group and 23.7 +/- 4.4 years in the traditional group. Most students in both groups (94% PSV group and 90% traditional group) were women. A previous bachelor's degree was reported by 80% of the PSV group and 88% of the traditional group. No significant differences were observed for demographics between groups. Also, both groups in the study had a 100% pass rate for the course and were able to perform the nursing skills accurately.
Subscale: Evaluation Method
The Evaluation Method subscale was used to determine whether the PSV was helpful for retaining information needed for communicating with patients in a clinical setting. No differences were found between the 2 groups in their self-assessment of retention of information and in their confidence level (Table). However, the PSV group assessed their communication with patients in the clinical setting as significantly better than the traditional group did (P < .04). In addition, students in the PSV group were more satisfied with their comfort (P < .01) in evaluating their partner; the traditional group only evaluated their partner during practice time and the faculty member conducted the final evaluation.
Subscale: Satisfaction Scale
The Satisfaction subscale was used to assess level of satisfaction with the method of teaching performance of the skill in the clinical environment, organization of content, and the time in the laboratory. Significant differences were also found between the groups in assessment of the organization of content in skills laboratory and in evaluations. The PSV group were more satisfied with the organization of the skill laboratory content than the traditional group were (P < .04). In addition, the PSV group were more satisfied with the amount of time for practicing nursing skills (P < .01) (Table).
Subscale: Lab Environment
The Lab Environment subscale was used to assess the level of stress and perceptions of the laboratory environment. No differences were found between the groups in scores on the Lab Environment subscale. Both groups rated their stress level for the evaluation as neutral and viewed their evaluation method as nonthreatening.
Preference Questions
Seventy percent of the PSV group preferred learning modules, compared with 44% of the traditional group (t = 2.99, P < .06). Most of the PSV group (80%) preferred the peer-student evaluation to the instructor method (t = 7.34, P < .01) of evaluating skills in the laboratory (Table).
Discussion
The data from this study suggest that the PSV method improved students' perceived ability to communicate in the clinical setting. This finding is similar to the finding of Aebersold and colleagues17 that when active learning modules were used to teach nursing skills to undergraduate students, the students reported greater satisfaction with patient communication in the clinical setting. Chuang et al18 also found that when students used computer-assisted learning to acquire nursing skills, they reported that they had more time to learn at their own pace.
Both the PSV and traditional groups preferred learning modules and lectures to assigned readings. Both groups indicated that assigned reading was the least favorite of 3 choices (lecture, assigned readings, and learning modules). The PSV group members were more satisfied with the organization of skills content and the time spent in the laboratory for practicing skills than the traditional group members were. Their satisfaction with the organization of content may reflect the fact that the PSV method provided a more structured format for receiving information about skills and practicing those skills.
Students said that the PSV method also made them feel more comfortable in evaluating their partner's skill performance. The PSV students were more satisfied than the traditional group with peer learning, and they perceived greater improvements in communicating with patients in the clinical settings. However, the traditional group did not work with their peers and had no peer evaluations. Himes and Ravert19 also found that prelicensure nursing students responded positively to teaching psychomotor skills using peer coaching and scripted case studies. In their study, peer learning helped students gain insight and knowledge about nurses' roles and attitudes while performing psychomotor skills. Similarly, Eldarir et al20 found that when nursing students used the OSCE method for practicing maternity nursing skills, they reported an increase in satisfaction with decision making and an increase in satisfaction in knowledge of translating theory to practice.
The study reported here used convenience sampling, which limits the generalizability of the results. Another important factor to consider is that the mean age of both groups was 23 years, and most of the students had completed a bachelor's degree in another field of study. However, these students were enrolled in a traditional registered nurse prelicensure program, not an accelerated program. Nevertheless, their previous education and age could help explain why the students preferred learning modules to assigned readings and lectures. Finally, the PSV group did not have a faculty member evaluating their skills during the examination period. However, 2 faculty members were present in the room during the PSV examination period to help rotate the students through the various stations.
Despite these limitations, the study provides evidence that students using the PSV method were satisfied with the time to practice nursing skills, the organization of course content, their self-confidence, and their communication with patients. Future research should consider evaluating faculty satisfaction with teaching nursing skills using traditional methods or the PSV method.
Conclusions
The PSV method promotes more active involvement of students in their learning, while allowing nurse educators to facilitate learning. This study suggests that offering the PSV method in the skills laboratory early in the curriculum for prelicensure nursing students could result in improved satisfaction with communication skills and higher confidence levels for performing nursing skills.
References