Clinical experiences can be stressful and intimidating for nursing students, particularly those enrolled in medical-surgical nursing courses. 1,2 For nurse educators, providing opportunities for clinical practice is challenging as well. Several factors contribute to this clinical environment. Larger classes may be admitted to programs in an effort to ease the nursing shortage. Many beginning nursing students are young and have had no prior college course-work or healthcare-related work. Additionally, there is an increasing shortage of nursing faculty to provide students with quality learning experiences in the clinical setting. Hospitalized patients are more acutely ill. The end result is larger groups of students caring for more complicated patients with fewer clinical faculty. One approach to overcome these obstacles is peer mentoring using different levels of nursing students during initial clinical experiences. The authors discuss how this teaching strategy was implemented.
Although much has been written on the role of mentoring for practicing nurses, little has been documented on the value of peer mentoring for nursing students, particularly early in the curriculum with freshmen and sophomore students. Peer mentoring is described as providing support in a nonevaluative environment. 3 Active participation, mutual support, and cooperative learning are components of peer mentoring, but are more frequently used to describe phenomenon in the traditional classroom environment rather than the clinical setting.
In order for learning to occur, key elements must include participants who are actively involved and engaged in the learning process. As active participants, peer mentoring engages both the mentor and the student being mentored. By being actively involved in one’s own clinical learning, students recognize the relevance of these clinical skills to their own development as a future nurse. Additionally, peer feedback in the clinical setting may help develop collaborative skills, improve communication skills, and assist in developing professional responsibility. 4
Others have used peer instruction within the school’s skills lab to provide a supportive and nonthreatening learning environment. 5 Owens and Walden 5 report assigning a senior baccalaureate nursing student as a peer instructor to supervise students in a foundations course and other nursing students during skills practice sessions. The senior nursing student also served as a mentor and counselor to other students.
Becker and Neuwirth 6 document benefits of peer mentoring in a study involving senior-level nursing students as teaching assistants for beginning students in the clinical setting. Benefits were found to include decreased student anxiety, increased hands-on learning opportunities, increased faculty’s perception of patient safety, providing positive role modeling, and promoting collegiality among the students. Likewise, Glass and Walter 7 reported the peer mentoring process in nursing education provides a nurturing climate for both personal and professional growth. Outcomes of the peer mentoring experience include shared learning, caring, friendship, and a commitment to each other’s growth. The development of collaborative skills was also documented.
Peer Mentoring Strategy
The peer mentoring teaching strategy was designed to lessen freshmen anxiety associated with their initial clinical experience and to introduce them to the role of the student nurse in the clinical setting. Thirty freshmen nursing students, enrolled in a foundations course in a baccalaureate program at a rural Midwest comprehensive state university, participated in the peer mentoring experience. Twenty-three of the students were either 18 or 19 years of age, while 7 students were 20 years of age or older. Only 4 of the 30 students had prior healthcare-related work experience.
For their initial clinical experience, freshmen were paired with sophomore-level peer mentors enrolled in a medical-surgical nursing course. The experience also served to introduce the concept of peer mentoring to these sophomore students. The authors implemented clinical peer mentoring as a result of a curricular revision. Second-semester freshmen are now being placed in this beginning foundations course earlier in the curriculum. This change necessitated clinical placement of students who are less familiar with the nurses’ role in the clinical setting. While the intent of this assignment was to reduce anxiety for the beginning student, peer mentoring proved to be mutually beneficial for both groups of students. Freshmen reported reduced anxiety as a result of peer mentoring, while sophomores stated that peer mentoring boosted self-confidence and made them realize how much more they had progressed since having taken the foundations course.
Developing the Peer Mentoring Experience
Preparing the Freshmen Students
We believe that the degree to which peer mentoring is successful for the beginning and the upper-level students lies in the extent of preparation of both groups. Faculty teaching the foundations course prepared the freshmen to work with peer mentors. Clinical expectations and objectives were discussed with the freshmen prior to the experience and included:
- perform basic nursing skills previously learned in the nursing lab
- review client chart while in the hospital and complete client clinical form, paying particular attention to charting, chart organization, and medical terminology
- observe the sophomore student’s role in the clinical setting, and their interaction with the clients, other students, and nursing faculty
- observe interactions and communications between different members of the healthcare team.
The role of the peer mentor is explained, including the importance of how to work with and how to ask for help from their mentor in order to successfully complete their clinical objectives. Students are reassured that nursing faculty will be readily available during the clinical experience. The week prior to the experience, students were oriented to the clinical site. Further, freshmen are encouraged to consider qualities that will promote a positive learning experience (eg, being receptive to the mentor’s input; a willingness to ask for help, advice, and guidance; a motivation to learn; being self-aware; a commitment to becoming a nurse; taking the initiative to actively participate in the learning experience).
Preparing the Sophomore Students
Prior to the experience, faculty teaching the medical surgical course also prepared their sophomore students to make them aware of the qualities necessary to be good mentors in order to reflect these traits when interacting with freshmen students. These qualities include being genuine, generous of self, self-confident, competent, and open to the peer mentor relationship. In addition, faculty discussed the above clinical expectations and objectives of the students they would be mentoring. How to best help their students reach their objectives, issues that have arisen in prior semesters, and the importance of being a good role model are discussed. Orientation to the role of mentor included not only sharing objectives for the intended experience, but also an overview of the clinical preparation form to be completed by the freshmen and clinical skills that they may assist the student to perform. Should problems or questions arise during this experience, students are assured that faculty for both courses would be available. These expectations equip the peer mentor with the ability to better work with the freshman student.
Initial Clinical Experience
During the clinical experience, each freshman was assigned to a sophomore student enrolled in the medical-surgical course. The faculty member teaching the foundations course had previously taught the sophomores and, therefore, was able to pair students based on known characteristics rather than using a random assigning process. The sophomore student prepared for clinical the previous evening which included an in-depth clinical preparation form completed on an assigned client. The freshman student then worked with the sophomore student throughout that day, completing a less-involved clinical preparation form with the guidance of the mentor and faculty, assisting with the client’s morning care and procedures, observing the mentor preparing and administering medications, charting, and making rounds with physicians and other collaborating disciplines. Freshmen received firsthand information from another student’s perspective on what could be expected during future clinical experiences in upcoming courses.
Both faculty, 1 from the foundations course and 1 from the medical surgical nursing course, were on the unit to serve as resources for both groups of students. Also available to the students were the 2 graduate assistants from the master’s program who served as assistant instructors the entire semester. During this experience, students were able to observe faculty interacting with other faculty and with students in a professional clinical setting.
Evaluation of Peer Mentoring
Initially, freshmen were surveyed prior to their first clinical experience to determine their perceived level of anxiety specific to various clinical situations. Using the Clinical Experience Assessment Form developed by Kleehammer, Hart, and Keck, 1 this 16-item Likert scale measures various situations in the clinical setting that may be perceived as producing anxiety. Items cover such aspects as communications, procedures, patient care, initial clinical experience on a unit, and interacting with healthcare providers and instructors. Scoring with the Likert format ranged from a 5 (strongly agree) to 1 (strongly disagree). According to the form’s developers, 1 a Cronback alpha reliability coefficient was determined as a measure of internal consistence (r = 0.82). Additionally, factor item analysis suggested that all items on this assessment form measured 1 concept—anxiety.
The form was administered in a classroom setting to the 30 freshmen 2 weeks prior to their first clinical experience in the hospital. Students were aware that they would have a sophomore medical-surgical student assigned to them the morning of their first clinical experience. Mean scores >3.0 on the 5-point Likert scale of the anxiety assessment form were considered indicative of anxiety. Means ranged from a low of 2.1 for “being late” (not causing much anxiety) to the clinical area to 4.1 for “fear of making mistakes” (causing a greater degree of anxiety). Eight of the 16 items were rated by the freshmen students as being anxiety producing. The means for these 8 items ranged from 3.1 to 4.1. Table 1 presents all items including the 8 items that were rated as anxiety-producing situations.
Although students indicated anticipation of their “initial clinical experience on a unit” caused anxiety with a mean of 3.1, faculty had expected the self-ratings to be higher. Speculatively, this lower-than-anticipated score may have been due to the students’ awareness that they would be assigned with a sophomore student, thus reducing their perceived anxiety level. With half of the 16 items identified by freshmen as causing anxiety, a student’s first clinical experience on a particular unit is indeed stressful.
In an overview comparing results with data collected by Kleehammer, Hart, & Keck 1 using junior and senior subjects, 7 of the same items were also identified as being anxiety-producing. In the prior study, “patient teaching” was not included in the list of most anxiety-producing situations. “Fear of being late” was listed as causing a great deal of stress in the first study, yet not in this more recent pilot study. It is important to note that in both studies, despite whether the student was at the beginning or near the end of the curriculum, students reported that their initial clinical experience on a unit, being observed and evaluation by faculty, talking to physicians, performing procedures and using hospital equipment, and fear of making mistakes were viewed as the most anxiety-producing situations.
Following the experience, both levels of students were asked to evaluate the experience. The Clinical Experience Evaluation Forms were used to determine the perceived benefits of peer mentoring to students being mentored and as well as to students serving as mentors. These forms were developed by the authors teaching in the 2 participating courses. The Clinical Experience Evaluation Forms consist of a 10-item Likert scale designed to measure the value of working with another student in the clinical setting. Though no reliability or validity testing was conducted, statements on these forms were derived from a review of the literature, a combined 25 years authors’ teaching experience, and comments from nursing students. Items cover such areas as confidence level, the benefit of prior clinical laboratory experiences and team-work, student workload, and peer support. Scoring with the Likert scale format ranged from 5 (strongly agree) to 1 (strongly disagree).
An overwhelmingly positive response was received from both groups of students. Responses to the Clinical Experience Evaluation forms are presented in Tables 2 and 3, freshmen and sophomore, respectively. Of the original 30 freshmen, 28 participated in the peer mentoring evaluation. Freshmen rated the peer mentoring experience with a mean score of 4.49 (range, 3.20-5.00). The 24 participating sophomores rated the peer mentoring experience with a mean score of 4.60 (range, 3.60-5.00). The students were also encouraged to include comments or suggestions regarding this experience. Examples of the comments follow.
Freshmen Group Comments
I really enjoyed the experience and felt having another student there was a great idea.
The other student was really nice and made me feel more at ease.
I hope I can be a mentor next year, and hope I know as much as the sophomore students by then.
Sophomore Group Comments
It was good to work with a freshman because I felt like I have come a long way and it was a good confidence booster for me. Hopefully it also helped to make the freshman a little less nervous about clinical.
I think as a freshman, this would have helped me better understand nursing and what the job is actually about.
It really, really helped boost my self-confidence.
I realized after working with the freshmen how much I have actually learned since I was in that beginning course.
Freshmen were also required to write a 25-point Clinical Experience Evaluation paper. In this paper students were asked to provide a summary of the skills they observed or performed in the clinical setting. They also reflected and compared this experience with working in the nursing lab. Additionally, students were encouraged to reflect on advantages and disadvantages of working with their mentor. The clinical preparation form, completed during the experience, was required to be attached to the evaluation paper and was included as part of their grade.
The most common theme addressed in the clinical evaluation paper was the realization that clients are real people in contrast to working with mannequins in the lab. This realization, which seems obvious, has heightened students’ awareness of the seriousness of nurses’ role and the importance of being competent and knowledgeable when caring for real people. Students also wrote that the experience sparked their interest even more in becoming a nurse and increased their enthusiasm for future clinical learning. Though a posttest measuring anxiety was not administered, many students reported that having a mentor reduced their level of anxiety during the initial clinical experience.
Although the group contained 30 freshmen, it was divided into smaller groups of 7 or 8 students. Pairing the 2 levels of students allowed for smaller numbers of students in the clinical setting. These groups were taken into the hospital over a period of 4 clinical days. Though neither clients nor their families expressed concern with additional numbers of students, staff commented on how crowded the floor was with 14 or 16 students rather than the usual 7 or 8. Also, instead of the usual faculty member and a graduate assistant, during this experience there were 2 faculty and 2 graduate assistants. However, with each pair of students functioning as one, the number of students on the unit did not seem overwhelming.
Due to the constraints of time, freshmen enrolled in this 2-hour foundations course are only scheduled in the clinical setting once per semester and for only 4 hours. Conflicts with other university courses prevent students from staying longer during their 1-day experience, which would necessitate missing other scheduled classes. Likewise, having no prior knowledge to the type of clinical problems faced by the client and possible procedures hampered the freshmen students’ ability to gain further experience.
Several of the freshmen commented that they had been paired with a quiet or timid student and, therefore, their experience was not as good in comparison with some of their classmates. Sophomores lacking assertiveness, confidence, or with less knowledge, were found to be poor mentors. Likewise, several of the sophomore students commented that their student lacked motivation or initiative. One mentor was distressed that the student she was mentoring was not interested in finding information in the chart but, instead, wanted to copy information from the mentor’s clinical preparation tool. Comments such as these were used in positive debriefing postconference discussions revolving around the concept of mentorship in nursing, both in finding a good mentor and being a good mentor. Care was taken to remind students of confidentiality issues and discuss the concept behind the comments rather than discussing individual students.
Faculty in both courses have encouraged the continuation of this learning experience. Sophomore-level faculty envision students entering their course having been better prepared and knowing more what will be expected of them. By using similar clinical preparation tools, students can move more easily from simple to complex preparation and reasoning. Having the freshmen and sophomore students meet at the clinical site the afternoon prior to the experience has been discussed to improve interaction between the 2 students and assist the freshmen student in clinical preparation. The hospital library would be available and convenient to assist both students in preparing for the following day’s experience.
Although peer mentoring involved only 1 clinical experience for the freshmen student, this assignment can have both short- and long-term benefits for students and faculty. Short-term benefits for both groups of students include verbalizing less anxiety, less confusion, and a more positive environment for learning to occur. Peer mentoring encourages greater student responsibility and promotes active learning. Because neither the mentoring student nor the student being mentored wants to be perceived by the other as being incompetent or lacking the necessary knowledge, preparation prior to clinical experience improves. An increase in student interaction at various levels in the curriculum has been noted following the peer mentoring experience. Long-term benefits derived from such an experience may be that these students seek mentors early in their nursing careers. Later in their careers, nurses who had positive mentoring experiences as students may be more willing to serve as mentors to those entering the profession. In addition, peer mentoring may foster collegial relationships early in the students’ professional social development.
With diminishing resources available for educating nursing students, efficient and effective strategies need to be devised to address time constraints within the curriculum, faculty workload, and varied learning needs of students. Teaching approaches, such as incorporating the concept of peer mentoring, will infuse excitement in the educational process both for nurse educators and students, help meet the learning needs of various levels of students, and possibly build stronger collegial relationships for the future.
The authors acknowledge Dr A. Louise Hart for her continued encouragement for this project and for the use of the anxiety assessment tool that she helped develop.