Nurse Educator

Nurse Educator Vol. 40, No. 2, pp. 105-108 Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.

Peer Coaching An Overlooked Resource Linda Smith McQuiston, PhD, RN & Kimberly Hanna, PhD, RN, MSN, CNL The authors present an innovative pedagogical approach to peer coaching using senior leadership and junior medical/surgical nursing students within the acute care clinical setting. The collaboration among faculty, staff, and students developed awareness of thinking critically, reasoning, and using effective clinical judgment. Through the use of Lasater’s Clinical Judgment Rubric, student reflections provided insight to the program’s effectiveness and use of alternative clinical experiences. Keywords: clinical experience; clinical judgment; critical thinking; nursing student; pedagogy; peer coaching

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urse educators search for innovative pedagogical methods for teaching students how to think critically, reason, and make effective clinical judgments. Clinical practice and leadership development are areas in which these skills are essential. The peer coaching program described in this article was designed to enable senior nursing students to apply leadership skills such as delegation, time management, and collaboration, leading to increased critical thinking, clinical reasoning, and clinical judgment.

Local Problem The first year of clinical experience can be challenging for students and faculty. Faculty are confronted with managing clinical learning for students with a limited skill set and knowledge base, as well as dealing with time constraints and student numbers in the clinical setting. At the other end of the continuum, graduating seniors are expected to demonstrate leadership skills within the clinical setting. In the early semesters of the nursing program, students have limited opportunities to manage the care of more than 1 patient and patients with multiple problems. Delegating and leading others in the care of patients are other essential skills for practice, but opportunities to do so may be scarce. Students at the end

Author Affiliations: Assistant Professor (Dr McQuiston), College of Nursing, Health, and Human Services, Indiana State University, Terre Haute; Associate Professor (Dr Hanna), Whitson-Hestor School of Nursing, Tennessee Technological University, Cookeville. This project, conducted at Whitson-Hester School of Nursing, Tennessee Technological University, was funded in part by a faculty research grant from Tennessee Technological University. The first author was a participant in the 2013 NLN Scholarly Writing Retreat sponsored by Pocket Nurse and the NLN Foundation for Nursing Education. The authors declare no conflicts of interest. Correspondence: Dr McQuiston, College of Nursing, Health, and Human Services, Nursing Building, 749 Chestnut St, Terre Haute, Indiana 47809 ([email protected]). Accepted for publication: September 13, 2014 Published ahead of print: October 27, 2014 DOI: 10.1097/NNE.0000000000000103

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of their program need to transfer classroom knowledge into actual leadership situations such as in the areas of multiple patient assignments, working with and delegating to other members of the health care team, and problem solving issues related to patient care.

Intended Improvement The questions for the faculty were as follows: (1) How can faculty improve supervision of beginning clinical students and provide leadership experiences for the senior students? (2) Could the experiences of both of these groups be improved by bringing them together in a clinical setting? (3) Could graduating senior nursing students enhance the newer students’ understanding of patient conditions, pathophysiology, and the connection between knowledge gained in the didactic portion of their education? The answers to the above questions resulted in the development of an alternative teaching strategy for use in the clinical setting: peer coaching. The intended purpose was to enhance the leadership competence of graduating seniors while helping novice nursing students develop fundamental clinical and decision-making skills. Peer coaching can also provide faculty members with greater access to their beginning students.

Rationale for Peer Coaching It is important to note that peer coaching is not the same as mentoring. According to Hubbard and colleagues,1 mentoring is a method of advising, intended to augment personal and professional growth and development. Coaching has a different meaning and implies leading a team.1-4 Peer coaching describes a collaborative relationship between an experienced individual and a willing participant.5-8 The concept has been used to describe a nurse coaching a patient,7 an experienced RN precepting a new nurse,9,10 and peer tutoring between students.2,11-13 The peer coaching model used in this project builds on the principles of active learning based on the constructivist paradigm: (1) mental sorting of information, (2) cognitive Volume 40 & Number 2 & March/April 2015

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growth, (3) organization of learned knowledge, (4) association with known experiences, and (5) active participation.14 These 5 principles served as a foundation for the development of the peer coaching program. Greater access to an array of resources, in this case leadership students, in the clinical environment fosters recognition of inconsistencies between didactic learning and skills, thus helping to close the educationpractice gap.1,2,15

Description of Program The peer coaching program was developed and introduced within an existing leadership course. Seniors were advised that their role would be to assist clinical faculty members with orienting, guiding, and delegating to junior nursing students. The goals were to promote communication and teamwork for incoming junior nursing students during their first clinical experience in a medical-surgical setting and to implement leadership skills learned in the course. Peer coaches would be considered experienced facilitators, with the expectation that they would establish a collaborative relationship with novice nursing students. Senior nursing students enrolled in the leadership course were given the option to use 12 to 48 hours of their clinical experience as a coach for junior students. Seniors were given an introduction to the program, role responsibilities, and dates for participation. No extra points or credits were given for their participation. Those who chose to participate signed a confidentiality agreement concerning both the facility and junior students within the clinical group. Volunteering senior students were then assigned a faculty member to contact about scheduling the clinical time for each group of junior nursing students. Senior peer coaches met with faculty members before the clinical experience to discuss the program learning objectives as well as junior student skills and knowledge levels. Senior nursing students met with the junior students during their preplanning time to assist with activities such as how to read a patient’s chart, navigate the computer-based health record, and complete assigned paperwork. Faculty members were not necessarily present during the preplanning phase of the clinical experience. On the day of the clinical experience, each senior student (peer coach) accompanied faculty members as they briefed students on their assignments for the day. The peer coach was then assigned to 2 or 3 students within the group. Faculty members were present at all times when junior students and peer coaches were on the nursing units, with the exception of preplanning (data collection), which did not entail any patient contact. Peer coaches assisted the junior students with (1) initial and focused patient assessments, (2) time management, (3) synthesis of data, (4) prioritization, and (5) identification of medications before administration. Junior students were not permitted to administer medications without direct supervision of clinical faculty. Ultimately, peer coach assignments included assisting with the care of 3 to 4 patients alongside the junior nursing student through collaboration, delegation, and prioritization of care duties. Peer coaches were required to participate in postconference activities for reflection and debriefing. Faculty members collaborated on junior students’ achievements and 106

accomplishments experienced with direct patient care. Many of the peer coaches presented during postconferences on topics such as intravenous solutions, interpretation of laboratory results, and electrocardiogram essentials. A typical peer coach experience included the peer coach meeting with students during preplanning day, ensuring that key elements of patient care would be addressed by the student, such as expected patient outcomes, possible complications to assess, and time management for subsequent day of clinical experience. The peer coach assessed each of the patients assigned to his/her team with the corresponding junior students during the clinical experience. Once assessments were completed, the peer coach reviewed medications, laboratory results, and recent vital signs and addressed time management.

Goals and Objectives Goals established by leadership faculty for both peer coaches and junior students included enhancing student critical thinking, clinical judgment, clinical reasoning, and application of knowledge leading to collegiality, delegation, and professionalism. The objectives were to (1) identify and use knowledge related to client needs and health care delivery systems; (2) exhibit responsibility and accountability in the leadership and management of professional nursing care; (3) identify, develop, and implement major roles of the nurse as a caregiver, coordinator of care, and member of a profession; and (4) develop the leadership role in coordinating and delivering nursing services. Benner et al15 recognized that clinical experiences for both the novice and experienced nursing student require an ongoing conversation with faculty to build on evidence-based care interventions, clinical judgment, and critical thinking skills. Positive active learning environments promote knowledge retention, open communication, and collegiality and encourage professionalism.1,2,4,13,15 Uses for peer coaching could include all areas of nursing education: didactic, clinical, simulation, and laboratory experiences.

Evaluation The Lasater Clinical Judgment Rubric (LCJR) was used as a tool for self-evaluation by both senior and junior nursing students.16 The LCJR is based on Tanner’s Clinical Judgment Model17 and provided peer coaches and novice students the opportunity for self-evaluation related to 4 dimensions: noticing, interpreting, responding, and reflecting. For this project, peer coaches and novice junior students were asked to evaluate their experiences related to expanded dimensions within the rubric: observations; recognize deviations from normal; seek information; prioritize data; make sense of data; remain calm and confident; exhibit clear communication skills; have a well-planned clinical day; and demonstrate technical skills related to patient care, a commitment to improvement, the ability to evaluate others’ performance, and self-assessment.16

Methods The LCJR was introduced to the senior nursing students before their engagement in the peer coaching program during their orientation phase and again at the end of program participation. Junior nursing students were given the LCJR at

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the end of the program, as an indicator of their own clinical judgment, clinical reasoning, and critical thinking skills on completion of their first medical/surgical rotation. The LCJR ranked student perception of their clinical outcomes ranging from excellent to poor.16 In addition, both experienced and novice students were given the opportunity to write comments related to the experience.

Outcomes Students were asked to rank their clinical development as beginners, developing, accomplished, or exemplary nursing care providers with regard to Lasater’s dimensions of noticing (observation, deviations, and seeking), interpreting (prioritizing and discernment of data), responding (calmness, confidence, communication, flexibility, and skillfulness), and reflecting (self-assessment and improvement).16 Students, both juniors and seniors, rated their overall performance at the end of the clinical rotation as either exemplary or accomplished in all 4 dimensions, with an average of 88.4% in the fall semester and 99.2% in the spring semester. In the fall, students ranked themselves highest (93.7%) in the dimension of effective reflecting, evaluation/self-analysis (92.1%), and commitment to improvement (95.3%). The lowest ranked dimension for students was in effective interpreting, which included prioritizing data (76.2%) and making sense of data (85.7%). Students participating in the spring semester ranked themselves highest in 2 dimensions: effective interpreting (100%) and effective reflecting (100%). The lowest dimension was effective responding (98.4%), which involved calmness and confidence (95.7%), clear communication (100%), flexibility and well-planned interventions (97.9%), and being skillful (100%). Senior and junior nursing students (in both semesters) noted that at the end of the program, they felt they were able to regularly notice patient changes from normal (91.8%), interpret data successfully related to patient disease or condition (88.1%), respond calmly and confidently to changes (83%), communicate clearly (96.8%), and establish interventions appropriate to patient needs and condition (93.4%). Students in both groups commented that peer coaching improved their clinical judgment to exemplary or accomplished levels on completion of the program. Graduating senior nursing students described the experience as being beneficial and humbling and validating their choice of career. Several senior students commented on the amount of knowledge they had retained over the course of their education and clinical experiences and their ability to share this information to incoming junior students. Both groups of students noted that they reflected on and evaluated their own performance related to patient care. Novice nursing students reported that having a more experienced student decreased their anxiety, thus facilitating the learning process. Faculty also benefited from using peer coaches as they were provided more time and attention for one-to-one interactions, as well as guidance of specific skills in the clinical setting. Strengths Senior students emphasized that interactions with junior students mandated precise language without assumption of previous knowledge, increasing the need for clear and conNurse Educator

cise communication. Both groups indicated that working together assisted in the integration of didactic information into direct patient care. Additional comments from junior nursing students stressed that experienced students were willing to share knowledge, collaborate, and promote positive outcomes within the clinical environment. Peer coaching placed the senior student in a leadership role. As senior nursing students coached and interacted with the junior students, there were opportunities for refining and demonstrating leadership responsibilities through role modeling, teamwork, promotion of positive patient outcomes, and reflection.2 Peer coaching offered senior students leadership opportunities such as delegation, prioritization, team-building, and role-modeling. They also were able to assist novice students with unit orientation, assessment skills, performance of therapeutic interventions, and addressing patient safety issues. Experienced and novice nurses had the opportunity to improve time management skills. Both groups stated that working together in the clinical area encouraged a mutual respect and development of teamwork. Students commented that peer coaching was valuable in developing skills and in their professional growth as a nurse. Comments from students in other peer coaching experiences reviewed echoed these sentiments.18-21

Limitations Limitations included time, organizational, clinical placement, and scheduling constraints; orientation to and development of the coaching role; clarifying clinical faculty expectations; and team-building resistance. Organizing and placing students in appropriate clinical settings and gaining knowledge of their clinical skills and experiences can be time consuming. Scheduling can be an issue if senior nursing students have classes on days when novice nursing students are in clinical practice. A detailed orientation was needed to develop the peer coaching role. Orienting faculty to their role in peer coaching program was difficult because of scheduling conflicts. Individual contacts were made with each clinical educator to explain the role and student placement rather than orienting faculty as a group. There also was some resistance to team-building participation in the program by experienced nursing students.

Conclusion Future implications for peer coaching opportunities include recruiting an experienced nursing student to coach a novice nurse in the areas of simulation, academic, and National Council Licensure Examination for Registered Nurses (NCLEX-RN) enrichment. Peer coaching in the simulation laboratory would provide an opportunity for experienced nursing students to coach beginning students through a simulated scenario and event. Academic peer coaches could assist students with current nursing course activities and provide tutoring. Graduates could mentor students through the NCLEX process and support them as they transition into practice.

References 1. Hubbard C, Halcomb K, Foley B, Roberts B. Mentoring: a nurse educator survey. Teach Learn Nurs. 2010;5(4):139-142. 2. Dennison S. Peer mentoring: untapped potential. J Nurs Educ. 2010;49(6):340-342. Volume 40 & Number 2 & March/April 2015

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3. Sandahl SS. Collaborative testing as a learning strategy in nursing education: a review of the literature. Nurs Educ Perspect. 2009; 30(3):171-175. 4. Zerwekh J, Zerwekh-Garneau A. Nursing Today. 7th ed. St Louis, MO: Elsevier; 2012. 5. Bensfield L, Solari-Twadell PA, Sommer S. The use of peer leadership to teach fundamental nursing skills. Nurse Educ. 2008; 33(4):155-158. 6. Broscious SK, Saunders DJ. Peer coaching. Nurse Educ. 2001; 26(5):212-214. 7. Donner G, Wheeler MM. Coaching in Nursing: An Introduction. Indianapolis, IN: Sigma Theta Tau International; 2009. 8. Hunt CW, Ellison KJ. Enhancing faculty resources through peer mentoring. Nurse Educ. 2010;35(5):192-196. 9. Myers S, Reidy P, French B, McHale J, Chisholm M, Griffin M. Safety concerns of hospital-based new-to-practice registered nurses and their preceptors. J Contin Educ Nurs. 2010;41(4): 163-171. 10. Sorensen HA, Yankech LR. Precepting in the fast lane: improving critical thinking in new graduate nurses. J Contin Educ Nurs. 2008;39(5):208-216. 11. Ketola J. An analysis of a mentoring program for baccalaureate nursing students: does the past still influence the present? Nurs Forum. 2009;44(4):245-255.

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12. Harmer BM, Huffman J, Johnson B. Clinical peer mentoring: partnering BSN seniors and sophomores on a dedicated education unit. Nurse Educ. 2011;36(5):197-202. 13. Robinson E, Niemer L. A peer mentor tutor program for academic success in nursing. Nurs Educ Perspect. 2010;31(5):286-289. 14. Bruner J, Vygotsky L, Feuerstein R. Constructivist theories. 2008. Available at http://mennta.hi.is/starfolk/solrunb/construc.htm. Accessed January 30, 2011. 15. Benner P, Sutphen M, Leonard V, Day L. Educating Nurses: A Call for Radical Transformation. San Francisco, CA: JosseyBass; 2010. 16. Lasater K. Clinical judgment development: Using simulation to create an assessment rubric. J Nurs Educ. 2007;46(11):496-503. 17. Tanner CA. Thinking like a nurse: a research-based model of clinical judgment in nursing. J Nurs Educ. 2006;45(6):204-211. 18. Kovnatska O. Say yes to mentoring! Strateg Finance. 2014;95(11): 47-51. 19. Maynard L. Using clinical peer coaching for patient safety. AORN J. 2012;96(2):203-205. 20. Anderson G, Hair C, Todero C. Nurse residency programs: an evidence-based review of theory, process, and outcomes. J Prof Nurs. 2012;28(4):203-212. 21. Van Oosten E, Kram K. Coaching for change. Acad Manage Learn Educ. 2014;13(2):295-298.

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Nurse Educator

Peer coaching: an overlooked resource.

The authors present an innovative pedagogical approach to peer coaching using senior leadership and junior medical/surgical nursing students within th...
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