1. Shihabuddin, Courtney DNP, RN
  2. Karl, Joyce DNP, RN
  3. Momeyer, Mary Alice DNP, RN

Article Content

Peer-assisted learning (PAL) is a method in which students help each other learn, as well as learn themselves by teaching. Through PAL, students acquire knowledge and skill through active help and support processes.1 Alternative terms for PAL commonly include "peer teaching," "peer mentoring," and "peer support." A variation type is "near-peer learning," which is defined as a student from the same educational program teaching a student at a lower level within the program.2 Faculty can use PAL as a specific teaching strategy for active learning assignments. It also can be informally initiated or generated by students themselves, who realize the benefits of working together, for example, in the formation of study groups.


The effectiveness of PAL has been established for clinical teaching in medicine and other allied health disciplines; however, there is limited, concrete evidence of learning outcomes in this literature. In the last decade, there has been an increase in interest of using PAL as a collaborative model for practice placements for nursing students. Studies have been primarily limited to undergraduate students and not focused on the provider level in graduate nursing. While there is mutual agreement on the benefits of PAL, most studies recognize a lack of measurable learning outcomes.3


The Assignment: Strategy

Challenged by the abrupt disruptions in the learning environment due to the COVID-19 pandemic, graduate nursing faculty pivoted to provide students with alternative opportunities to support clinical learning, as recommended by the American Association of Colleges of Nursing in 2020.4 In an advanced assessment course, nurse practitioner (NP) students needed opportunity and direction to continue learning history and physical assessment techniques. In the same specialty track, NP clinical practicum students in their final semester prior to graduation needed to further build their skills in clinical reasoning, formulating differential diagnoses, and developing comprehensive management plans.


Faculty in both courses collaborated to create a structured, virtual assignment that required involvement of all students in both courses. Although both courses were previously conducted as synchronous sessions in the face-to-face classroom, near-peer learning provided an opportunity for learners to continue in a virtual environment while receiving the support from their peers who they identified with most.


The Assignment: Design

The following exemplar illustrates the PAL teaching methodology used as the basis for design of the active learning assignment. Case studies simulated real-life patient scenarios. The objective-structured clinical examination (OSCE) strategy was used with preassigned small groups for reciprocal learning on a virtual platform (Zoom), simulating a telehealth clinical encounter. Additional evidence-based teaching-learning techniques were used, including small group learning interactions, demonstration of telehealth assessment techniques, and students' self-reflection of the overall experience.


Specific assignment objectives for the advanced assessment students were to develop focused history taking and assessment skills and acquire focused physical examination skills while using a virtual platform. In the virtual laboratory setting, assessment students took turns in the role of the NP, conducting a history and demonstrating the physical examination for each of the cases. The assessment students were able to practice and refine assessment skills based on individualized, real-time feedback from practicum student facilitators. Assessment findings were documented in a clinical summary submission.


Objectives for the clinical practicum student group were to build diagnostic reasoning and patient management skills as well as demonstrate mastery of clinical course content. It was anticipated that these students would identify an increase in self-confidence as they realized their own progress since taking the assessment course themselves the year prior. A shared objective for both student groups in this near-peer assignment was to experience an interactive learning exercise that incorporated sharing and socialization for mutual benefits.


Steps of the Assignment

Each clinical practicum student was required to facilitate at least 1 virtual advanced assessment laboratory session. Prior to the laboratory session, practicum students created case studies based on faculty-guided chief complaints and demographic characteristics. Cases were developed according to an outline and included the elements of a patient history, physical examination, and potential differential diagnoses. To further demonstrate critical thinking, clinical reasoning, and clinical judgment as an NP provider, practicum students also developed comprehensive treatment, follow-up, and patient education plans for the working diagnoses.


The scheduled laboratory portion of the assignment included 2 main live-interactive components. Practicum students served as both the standardized patient and facilitator for assessment students who worked through a case in the NP role focused on history taking and physical examination. As the case scenarios were completed, dedicated discussion time allowed for real-time verbal feedback among all those involved. Following the laboratory session, practicum students formally critiqued the assessment students' written clinical summary and provided feedback using a faculty-developed rubric. This feedback was shared with each assessment student after faculty review. Finally, the clinical practicum students submitted a reflection to describe their learning, as well as the assignment's benefits and challenges.


Faculty evaluated the overall performance of both student groups during the laboratory sessions as satisfactory or unsatisfactory based on the observation of students' efforts and engagement. There were no other objective criteria used to evaluate the laboratory performance. Faculty provided feedback on the assignment's written components using a defined rubric.



Outcomes were measured using a simple Likert scale survey to evaluate the perceptions of both groups of students. Survey comments and final student reflections provided qualitative feedback. The students reported unanimously that the peer-facilitated assignment was a valuable experience overall in terms of learning, with gains in knowledge, skills, support, and confidence.


Assessment students at the brink of their clinical practicum identified that being paired with practicum learners helped them better understand the real-world context of their upcoming NP clinical practicum experience. One student highlighted:


It was helpful to have someone who was close to where we were at in the program to help guide us and teach us as they were actively in the clinical setting that we would soon be in. I felt like they were able to relate to our nerves/feelings/worries about clinical and learning assessments and could put our minds at ease a little bit.


Practicum students valued the exercise as an opportunity to apply knowledge and demonstrate clinical reasoning. One student's summative comments was as follows: "Developing cases helped improve critical thinking and application of advanced assessment skills while formulating differential diagnoses and integrating appropriate clinical practice guidelines."


Both groups of students reported the online interaction and socialization with peers were an added benefit. Faculty concurred that each of the assignment objectives was met. The use of this near-peer learning activity as an interactive learning experience provided an opportunity for nurse educators to improve learner confidence while developing students' clinical competence.



Adapting to the virtual environment for clinical interactions posed challenges. Faculty needed to adapt educational strategies for clinical competency in the evolving health care environment, meeting both cohorts' learning needs. In addition to the clinical focus, instruction on telehealth as a method to conduct a simulated patient encounter was required. Other logistical challenges included coordination of efforts, scheduling interactive laboratory time, and communication among all participants. Some students had issues with time management, scheduling, and internet connectivity, including freezing screens or loss of internet connection. Despite these challenges, students reported a positive experience with this near-peer learning activity.



The incorporation of PAL and near-peer learning is a valuable tool for nursing educators to consider and possibly integrate into curricula. Although this exemplar was developed in response to the COVID-19 pandemic, this strategy has positive impact, both in the virtual learning environment and in face-to-face clinical education. Further efforts are needed to identify resulting learning outcomes.




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2. Henderson S, Needham J, van de Mortel T. Clinical facilitators' experience of near peer learning in Australian undergraduate nursing students: a qualitative study. Nurse Educ Today. 2020;95:104602. doi:10.1016/j.nedt.2020.104602 [Context Link]


3. Markowski M, Bower H, Essex R, Yearley C. Peer learning and collaborative placement models in health care: a systematic review and qualitative synthesis of the literature. J Clin Nurs. 2021;30(11/12):1519-1541. doi:10.1111/jocn.15661 [Context Link]


4. Statement regarding nurse practitioner students and direct care clinical hours. 2020. Accessed September 21, 2021.[Context Link]