Using peer feedback to enhance nursing students’ reflective abilities, clinical competencies, and sense of empowerment: a mixed-methods study

Debriefing in simulation-based learning aims to improve learners’ performance, correct their mistakes and enhance their clinical judgement and reasoning skills. Through reflection and feedback, instructors aim to bridge the gap between learning and experience (Kang and Yu, 2018, Lee et al., 2020). Beyond passively receiving comments from instructors on one’s performance and areas for improvement, the modern understanding of feedback refers to a process where learners internalize information from numerous sources to refine their performance or learning processes (Carless and Boud, 2018). However, students have reported receiving insufficient feedback and/or dissatisfaction with the quality and amount of feedback received (Alfehaid et al., 2018, Paterson et al., 2020, Wong and Shorey, 2022). With growing student populations and limited student-instructor interaction, receiving constructive and adequate feedback as desired by students occurs less often, impeding the development of future nurses (Alfehaid et al., 2018, O’Brien et al., 2019, Paterson et al., 2020, Wong and Shorey, 2022). Studies reported that the faculty did not explain how students could improve their performance and in future assessments, with only brief comments such as “good” without justifying what they did well (Henderson et al., 2019, Killingback et al., 2020, Paterson et al., 2020). There were also inconsistencies in quantity, quality and content of feedback from different lecturers (Killingback et al., 2020). Some highlighted a lack of time and large classes were barriers to detailed and personalized faculty feedback (Alfehaid et al., 2018, Henderson et al., 2019). In clinical settings, nursing students also found that there was a lack of individualized, consistent and adequate feedback from clinical staff, which adversely affected skill development as students lacked the opportunity and understanding on how they could improve their performance based on a set of standardized expectations from instructors (Nuuyoma, 2021, O’Brien et al., 2019, Wong and Shorey, 2022). Feedback is traditionally teacher-centered and shifting control of feedback to students via peer feedback could be a useful solution.

In peer feedback activities, at least one learner observes and provide feedback to another, typically during structured tasks similar to assessments or desired learning competencies (Hoo et al., 2020, Tripodi et al., 2021). Peer feedback has been integrated into the curricula in many educational disciplines. It has been used in the peer review of written assignments in higher education (Morris et al., 2021), problem-based or team-based learning in medical schools (Lerchenfeldt et al., 2019), simulations and summative assessments such as the Objective Structured Clinical Examination in nursing schools (Wong and Shorey, 2022). Effectiveness of peer feedback could be attributed to how peers convey feedback that is comprehended more easily by learners (Loda et al., 2019). Nursing students also found that peer feedback provided benefits that cannot be found through faculty feedback, such as critical thinking, consistency in assessment standards, adequate and immediate feedback (Wong and Shorey, 2022).

Peer tutors play an increasingly important role in higher education to supplement faculty teaching (Abbot et al., 2018). Peer tutors may possess superior or similar level of knowledge compared to the student being helped, and from a similar or different year of study (Topping, 2015, Zhang et al., 2022a). Peer tutoring places a strong emphasis on curriculum material with specific instructions on how peer tutors and students interact, with participants receiving general and/or specialized training. Structured learning materials or structured interactive behaviors applicable to any relevant topic may be provided as well (Topping, 2015). The goal of peer tutoring is to help both peer tutor and the student being helped understand the material better (Topping, 2015). In nursing education, peer tutors have been utilized during skill-based learning, clinical placements, simulations (Choi et al., 2021) and for providing academic support for students in need (Hawkins et al., 2022, Kim et al., 2021). Both the peer tutor and the student being helped benefit from peer tutoring, as they acquire knowledge and skills through active learning processes (Topping, 2015).

Peer-assisted learning is a popular teaching pedagogy and well-researched area in health professions education (Brierley et al., 2022, Khapre et al., 2021, Lerchenfeldt et al., 2019, Zhang and Maconochie, 2022). A recent meta-analysis found that near-peer teaching (peers of different academic levels) was significantly more effective than faculty-led teaching in improving learners’ procedural skills, while effectiveness of horizontal peer teaching (peers of similar academic levels) was comparable to faculty-led teaching (Zhang et al., 2022a). Healthcare students described peer-assisted learning to be a positive learning environment and felt more prepared for future assessments. Peer tutors also reported that it improved their teaching skills and knowledge (Hernández Coliñir et al., 2022). However, learners were also concerned about quality of peer feedback as peers may have limited knowledge and feedback experience (Wong and Shorey, 2022, Zhang et al., 2022b, Zhang and Maconochie, 2022). Previous reviews emphasized the need for peer tutor training to equippeer tutors with teaching skills and providing effective peer feedback, as peer tutors may feel confused and anxious when doing so without preparation (Burgess et al., 2016, Lerchenfeldt et al., 2019, Wong and Shorey, 2022).

While peer feedback is commonly provided verbally, a video component can be added, known as peer video feedback. Peer video feedback refers to the use of a recorded video to aid in peer feedback processes, which can be implemented in numerous ways (Zhang et al., 2022b). For example, students’ performance of a clinical skill such as a simulated patient interview, could be videorecorded, and later evaluated by peers online through video annotation (by adding qualitative comments at specific timepoints) (Lai et al., 2020) or rated using validated checklists (Lai et al., 2020, McGann et al., 2021, Sadowski et al., 2020). Peer video feedback can also be provided verbally and in-person by reviewing the recorded video with peers immediately after the students’ performance (Herrmann-Werner et al., 2019, Lehmann et al., 2018, Sheahan et al., 2019). Peer video feedback can improve technical and non-technical skills, and provides reliable evidence on performance, thus overcoming limitations of direct observation during peer verbal feedback, which can be affected by recall bias and inattention (Epstein et al., 2020, Zhang et al., 2022b). However, some studies found that verbal feedback assisted by video review was not superior to verbal feedback alone (Gamboa et al., 2018, Lehmann et al., 2018). Findings on the effectiveness of peer video feedback thus remains mixed.

Peer video feedback and peer feedback are not well-established in nursing education, and peer tutors’ perspectives in conducting peer feedback have been rarely examined (Wong and Shorey, 2022, Zhang et al., 2022b). Numerous factors affect the effectiveness and learning experiences of peer tutors and students in peer-assisted learning, such as the group size, formality of settings (formative or summative assessments), education distance (near-peer or horizontal peer tutoring), training of peer tutors and the type of curriculum content covered (Burgess and McGregor, 2018, Ten Cate and Durning, 2007, Topping, 2015, Zhang et al., 2022a). Previous research cautioned that although findings on the effects of peer-assisted learning were usually positive, new peer-assisted learning interventions need to be evaluated and monitored closely for such interventions to succeed and to ensure that they address the needs of peer tutors and students (Burgess et al., 2020, Topping and Ehly, 2001). More studies are thus needed to investigate the effective elements of peer video and verbal feedback, including peer tutors’ perspectives of peer tutor training and conducting peer feedback in nursing education. In this study, we defined peer video feedback as in-person verbal feedback assisted with video review.

The aims of this study are to:

1)

Compare the effectiveness of peer video feedback, peer verbal feedback versus faculty feedback in enhancing nursing students’ reflective abilities and clinical competency of a nursing skill following simulated practice

2)

Investigate the impact of a structured peer feedback framework on peer tutors’ feedback practices and sense of empowerment

3)

Explore peer tutors’ perspectives and experiences of conducting peer feedback

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