INTRODUCTION
Intravenous infusion therapy is the most common invasive medical procedure for hospitalized patients. Nurses are responsible for managing intravenous infusion therapy, so they must have sufficient competency to safely administer intravenous infusion therapy [1]. Intravenous infusion therapy education should be differentiated in content and method according to the period of time it is provided. In addition, nurses must become accustomed to correct intravenous infusion therapy through periodic continuing education [2].
A study investigating the importance and level of performance of intravenous infusion therapy among nurses suggested the need for clear guidelines and evidence-based knowledge on intravenous infusion therapy [1]. The Hospital Nurses Association has developed guidelines related to ‘intravenous infusion therapy’ as a field of evidence-based clinical nursing practice guidelines [3] and recommends that healthcare organizations utilize them. Intravenous infusion therapy is a core nursing skill for new nurses to improve their work efficiency in clinical practice and provide quality nursing care to clients [2]. In addition, the Korean Accreditation Board Of Nursing Education (KABONE)[4] has designated ‘intravenous fluid infusion’ as a core nursing skill with a skill difficulty level of ‘high’. Core nursing skills refer to important skills that must be learned and achieved in the nursing school curriculum. The skill of ‘intravenous fluid infusion’ is a relatively low performance confidence item not only for new nurses [5] but also for nursing students [6], and therefore, improvement strategies such as reeducation for nursing students from the completion of fundamental nursing practice curriculum to the time of graduation are needed [6,7]. ‘Intravenous fluid infusion’ consists of explaining the goals and procedures for administering fluids, preparing supplies and inserting a vascular catheter, administering fluids according to prescription, adjusting the volume and rate of infusion, and record. This skill focuses on inserting intravenous lines and infusing fluids [4]. However, in clinical practice, intravenous infusion therapy was not included in the core nursing skills, including not only venous catheter insertion nursing, but also complication management and nursing for each situation related to venous catheters. Accordingly, if comprehensive nursing education in management areas, including intravenous insertion nursing, can be provided to nursing students and the effectiveness of this can be confirmed, it will be a useful alternative in terms of introductory education to be provided to new graduate nurses in clinical practice.
The peer teaching method is divided into two types, ‘peer teaching between peers’ and ‘peer teaching between seniors and juniors’, depending on the age of the participant. In the peer teaching between seniors and juniors, peer teaching is older and peer teaching is due to the difference in experience. It refers to a form of helping learners by demonstrating their abilities [8]. When a senior with a lot of experience and knowledge educates juniors as a fellow instructor, seniors and juniors can experience growing together in a cooperative atmosphere, so it is considered an effective method for training core nursing skills [9].
Looking at research on peer teaching in core nursing skills training, research is underway to determine the effect of applying peer teaching among peers [10-12], but research on peer teaching between seniors and juniors includes studies on the experiences of senior peer instructors [9]. As a result of applying peer teaching between seniors and juniors, the effects on clinical performance and critical thinking in vital sign measurement, simple catheterization, and hypodermic injection techniques were confirmed [11]. However, there is a lack of research confirming the effectiveness of peer teaching between seniors and juniors using an experimental design including a control group.
It has been reported that the self-directed learning ability of nursing students is highly related to clinical performance ability as students take initiative in their own learning and engage in education [13], so strategies to improve self-directed learning ability in nursing education are prioritized. In addition, nursing students’ confidence in performing skills affects clinical performance ability [14], and skill performance ability is highly correlated with performance confidence [15]. Therefore, performance confidence in core nursing skills education various efforts are being made to increase performance and improve performance, such as using autonomous practice and simulation programs [16,17].
Nursing education aims to develop nurses who can perform nursing care in various situations by improving clinical performance along with nursing expertise [18]. Therefore, if there is a teaching and learning strategy that improves self-directed learning ability, skill performance, and skill performance confidence, which are related to clinical performance of nursing students, it will be very useful for core nursing skills education. Therefore, this study will confirm the effectiveness of peer teaching between seniors and juniors in practical education on evidence-based intravenous infusion therapy for nursing students. In addition, we aim to provide basic data on efficient teaching and learning strategies for intravenous infusion therapy, which is frequently used and highly important in clinical practice.
This study aimed to test the following hypotheses to confirm the effect of evidence-based intravenous infusion therapy practical training using peer teaching between seniors and juniors on nursing students’ skill performance ability, self-confidence, and self-directed learning ability.
• Hypothesis 1. The experimental group that participated in practical training using peer teaching between seniors and juniors will have higher self-confidence in performing intravenous infusion therapy techniques than the control group that participated in simple practical training.
• Hypothesis 2. The experimental group that participated in practical training using peer teaching between seniors and juniors will have a higher skill performance ability than the control group that participated in simple practical training.
• Hypothesis 3. The experimental group that participated in practical training using peer teaching between seniors and juniors will have higher self-directed learning ability than the control group that participated in simple practical training.
METHODS
1. Study Design
This was a quasi-experimental study with before/after design to verify effects of a evidence-based intravenous infusion therapy practice education applying senior-junior peer teaching on nursing students.
2. Participants
Participants of this study were students at two universities in Suwon and Incheon, South Korea - who took a course in the ‘Fundamental Nursing’ curriculum including theory about an intravenous infusion therapy. The inclusion criteria are as follows. Sophomores who were scheduled to practice core nursing skills were recruited. Study participants had not conducted intravenous infusion therapy training before. In the recruitment process, the researcher explained the purpose and ethical matters of this study to subjects who showed intention to participate. In the case of participating in this study based on sufficient understanding, confidentiality related to the subject and the fact that it could be withdrawn at any time without disadvantage during participation in the study were fully explained and a written consent was obtained. In addition, it was stated and explained that participation in this study and survey data collected were not related to their grades. Collected names were given numbers to protect personal privacy and confidentiality. Research consent forms and questionnaires of the students who participated in the study were stored in lockers of the researcher. The effect size was set to .60 based on the results of a previous study [10] to set the target subject population, the sample size of the study. Using the G*power program 3.1.9 and with a power (1-β) of .80, a significant level of .05, an effect size of 0.60, and a two-tailed independent t-test resulted in a sample size of 36 people per group. Considering the dropout rate (10%), the subjects recruited were 40 in the experimental group from one university, and 40 in the control group from the other university, selected through a convenience recruitment method. Initially, a total of 80 people participated. However, four participants did not respond to the follow-up. Therefore, 37 participants in the experimental group and 39 participants in the control group were included in the final analysis.
3. Procedure
1) Learner needs analysis
To analyze learner needs, a survey was conducted among third-year students who had completed fundamental nursing practice the year before. The survey was a self-reported, five-item survey with multiple responses. Thirty-one students responded to the survey, and the results showed that out of a total of 18 skills, the most important skills were intravenous fluid infusion (87.1%), transfusion therapy (48.4%), vital signs (29%), intradermal injections (29%), and suction (25.8%). The most difficult skills were intravenous fluid infusion (93.5%), transfusion therapy (83.9%), indwelling catheterization (77.4%), intradermal injection (38.7%), and evacuation enema aspiration (35.5%). Therefore, the most important and difficult intravenous fluid infusion skills were selected as the participants of practical training according to the students’ needs. In addition, when asked who they preferred to demonstrate the skill, the following were the order of preference: teaching assistant (58.1%), professor (45.2%), senior (32.3%), self-study (32.3%), and peer (22.6%).
However, if we exclude teaching assistants and practical training assistants who are already supervising and guiding in existing training, it was found that they prefer training with seniors who already have practical experience or through self-study. The appropriate learning media for skill training were practice guidelines (74.2%), videos (67.7%), PPT lecture materials (25.8%), and fundamental nursing textbooks (6.5%). Through this, it was found that skill practice using videos as well as practice guidelines was necessary.
2) Development
The senior tutors for this study were third-year students who understood the purpose of the study and agreed to participate voluntarily. A total of 9 volunteers were recruited, with 4∼5 juniors assigned to each senior. The seniors were given prior training in intravenous infusion therapy. Specifically, they received 1 hour of lecture and 8 hours of practice on intravenous infusion therapy, and during the practice time, they received individualized guidance to check and feedback on the skill performance of all seniors. After the individualized instruction, the seniors’ skill performance was evaluated, and all of them were rated as ‘excellent’. Senior participants were students who were enrolled in their third year, had completed fundamental nursing practice courses, and whose grades were in the top 30% of the course, and who agreed to participate voluntarily. A total of nine volunteers were recruited, and each senior was assigned four to five juniors. Seniors received 1 hour of lecture and 8 hours of practical training (2 sessions of 4 hours each). In the lecture, the seniors acquired various theoretical knowledge related to intravenous fluid therapy. During the four hours of practical training, the researcher coached every senior individually to check skill performance and provide feedback. In addition, all the seniors reflected on each other's skill performance and gave feedback to discuss skill accuracy and consistency in teaching. Two iterations of the exercise were planned, reflecting research that shows confidence in skill performance improves with repeated practice [7]. These efforts were made to minimize bias in skill among senior participants. After providing training for the seniors, the researcher directly assessed their performance of intravenous fluid infusion skills, and all students scored above 90 on average.
3) Intervention
The intervention in this study was conducted separately from classes and during free time when there were no regular classes. Each group consisted of 40 people, and the participants were divided into a total of 4 groups, 2 groups in the experimental group (20 participants per group) and 2 groups in the control group (20 participants per group) based on previous research [10], and practical training was provided to each group. The groups were separated by the school to eliminate the spread of the experiment effect. Both groups were provided with the same one-hour theoretical education lectured by the same researcher. Theoretical education provided through lectures included selection of peripheral blood vessel sites, efficient venous congestion methods, catheter insertion techniques, management of complications, venous tube fixation, and normal saline injection methods. The intravenous infusion therapy surgical procedure followed the intravenous infusion therapy protocol included in the evidence-based clinical nursing practice guidelines presented by the Hospital Nurses Association [3].
After 1 hour of theoretical training, the experimental group was provided with practical training led by a senior. The first session of practical training led by a senior consisted of watching a video of core intravenous therapy techniques, followed by a demonstration of the technique by a senior and practice on a mannequin model for each student. The second session consisted of mannequin model practice for each student and question/ answer session. The third session was operated with a demonstration of senior skills on venous congestion method practice, IV line fixation method, Saline lock method, and intravenous fluid therapy management, and mannequin model practice for each student. The fourth session consisted of individual skill demonstrations under the supervision of a senior. Each session was 2 hours for a total of 8 hours. On the other hand, the control group performed self-practice while supervised by a lab assistant after 1 hour of theoretical training. Self-practice was conducted four times every two hours for a total of eight hours. Before and after the intervention, the students’ skill performance ability was video-taped to measure the performance of both the experimental and control group participants by one researcher.
4) Qualitative evaluation
To assess learner satisfaction in the experimental group, we conducted a qualitative evaluation of 37 participants immediately after the intervention ended. In the subjective evaluation of the teaching method, ‘the skill process was memorable at every step because the senior directly explained each step and watched from the side’, ‘it was an opportunity to comfortably ask the senior a trivial question’, ‘a small number of people per senior’ ‘It was good to be assigned and receive close 1:1 guidance’, ‘It was good to be told in detail about trial and error and know-how’, ‘I gained confidence from the encouragement of my senior’, ‘It was an opportunity to get various information other than skills from my senior.’, ‘It was good that the senior spoke at a similar level to us.’ On the other hand, there are also comments that say, ‘It is unfortunate that there were differences among seniors.’
4. Measures
1) Self-confidence
In this study, it refers to the degree of subjective belief in one's knowledge and practical skills to perform intravenous fluid infusion as measured by a 5-point likert scale developed by Han, Cho, and Won [19]. The scores range from 29 points to 145 points. The higher scores indicate better self-confidence. In this study, Cronbach's ⍺ was .98.
2) Skill performance ability
In this study, skill performance for intravenous therapy was measured by scoring the performance of a total of 29 performance items on a 3-point scale of ‘excellent,’ ‘average,’ and ‘poor’ based on the ‘Intravenous Fluid Infusion’ performance protocol developed by KABONE [4]. If the item was performed perfectly, it was evaluated as excellent; if it was performed but practice was needed, it was evaluated as average; if the item was not performed, it was evaluated as poor. The scores range from 29 points to 87 points. The higher scores indicate better skill performance ability. In this study, Cronbach's ⍺ was .96.
3) Self-directed learning ability
A 45-item instrument developed by the Korea Educational Development Institute was used to measure self-directed learning ability in this study [20]. It consists of three subscales: learning planning (20 items), learning execution (15 items), and learning evaluation (10 items), and is a 5-point Likert scale. Scores range from 45 to 225, with neg-ative items reverse-coded so that higher scores indicate better self-directed learning ability. The reliability at the time of tool development was .93, with Cronbach's ⍺ of .89 for learning planning, .78 for learning execution, and .69 for learning evaluation. In this study, Cronbach's ⍺ was .92, and the subscales were .85 for learning planning, .80 for learning execution, and .82 for learning evaluation.
5. Data Collection
The data collection period was from September 4, 2023, to September 15, 2023. This study was conducted with the approval of the Institutional Review Board of the University in Gyeonggi-do to protect the ethical aspects of study participants (2307-045-03). It was explained that all interventions and surveys were for research purposes only and would not be used for grading. A simultaneous presurvey was conducted for each group, followed by a post-survey for each group at the time the intervention was deliv-ered to the experimental and control groups. The intervention was administered by the co-researchers them-selves, and questionnaires were distributed, collected, and evaluated. Written informed consent was obtained from the participants and they were informed that the data collected would remain anonymous and that they could with-draw from the study at any time. All participants were provided with a gift.
6. Data Analysis
The collected data were analyzed using the SPSS/WIN 28.0 program. The dependent variables and the general characteristics of the participants were analyzed using descriptive statistics. The Shapiro-Wilk test was used to verify the dependent variable's normality. Differences between the experimental group and the control group were analyzed by χ2test, independent t-test to verify prior homogeneity and hypothesis.
RESULTS
1. Homogeneities between Experimental Group and Control Group
As a result of conducting the Shapiro-Wilk test before confirming homogeneity, it was confirmed that the significance probability of the dependent variable was above .05 and was normally distributed. Regarding general characteristics of study subjects, there were 17 males and 59 fe-males (t=0.16, p=.786). As a result of confirming the fundamental nursing grade score before the study, homogeneity was secured between the two groups (t=-0.96, p= .340). As a result of comparing prior major satisfaction (t=-1.89, p=.063), prior self-confidence (t=0.05, p=.959), prior intravenous therapy skills performance (t=1.59, p= .117), and total self-directed learning ability (t=-1.62, p= .109) between the two groups, there was no significant difference in total scores. These results are summarized in Table 1.
Table 1.
Homogeneity Testing Between Experimental and Control Groups (N=76)
2. Testing of Hypothesis
As a result of analyzing collected data to test hypothesis 1, the control group's self-confidence difference between after and before score was −0.36±24.16 and the experimental group's self-confidence difference between after and before score was 20.78±17.81. As a result of testing differences between the two groups, the average score of the experimental group was significantly higher than that of the control group (t=4.36, p<.001). Thus, Hypothesis 1 was supported.
As a result of analyzing the collected data to test hypothesis 2, the control group's intravenous therapy skills performance difference between after and before score was 26.77±6.26 and the experimental group's intravenous therapy skills performance difference between after and before score was 32.41±3.88. As a result of testing differences between the two groups, the average score of the experimental group was significantly higher than that of the control group (t=4.74, p<.001). Thus, Hypothesis 2 was supported.
As a result of analyzing the collected data to test hypothesis 3, the control group's total self-directed learning ability difference between after and before score was 0.09 ±0.23 and the experimental group's total self-directed learning ability difference between after and before score was 0.26±0.41. As a result of testing differences between the two groups, the average score of the experimental group was significantly higher than that of the control group (t=2.25, p=.027). Among the self-directed learning ability questions, characteristics of ability to effort attribution (t=3.04, p=.003) was significantly higher in the experimental group except for the characteristics of ability to desire to learn (t=1.47, p=.147), characteristics of ability to learning objectives (t=0.71, p=.484), characteristics of ability to identify resources (t=0.06, p=.955), characteristics of ability to engage in self-care (t=0.95, p=.348), characteristics of ability to learning strategy (t=1.34, p=.186), characteristics of ability to sustain execution (t=1.83, p=.072), and characteristics of ability to self-reflection (t=1.81, p=.074). Thus, Hypothesis 3 was supported (Table 2).
Table 2.
Comparison of Self-Confidence, Skills Performance Ability, and Self-directed Learning Ability between the Experimental and Control Groups (N=76)
DISCUSSION
This study was conducted to verify the effect of evidence-based intravenous infusion therapy practical training using peer teaching between seniors and juniors on self-confidence, the skill performance ability, and self-directed learning ability of nursing students. Prior to practical training, we investigated learners’ needs and attempted to select and apply the most difficult skills.
The results of this study showed that peer teaching between seniors and juniors was effective in improving nursing students’ confidence in performing skills. This result was consistent with previous studies showing that, as a result of applying peer teaching between seniors and juniors, self-confidence increased statistically significantly when the difficulty level of core nursing skills was medium or higher [10,19,21]. It is believed that peer teaching between seniors and juniors provided close guidance to the nursing students and contributed to increasing their confidence in performing intravenous therapy by providing them with repeated practice experiences based on specific, individualized feedback on skill items. Han et al. [19] reported that self-confidence was significantly higher among those who experienced simulation or clinical practice, but fundamental nursing practice experience alone did not increase self-confidence. This study contributed to the evidence that the application of peer teaching between seniors and juniors positively affects self-confidence in intravenous infusion.
In addition, peer teaching between seniors and juniors was found to be effective in improving the technical performance of nursing students. Lee and Kang [11] reported that as a result of applying peer teaching between seniors and juniors in core nursing skills to nursing students improved clinical performance and improved basic nursing performance, which is similar to the results of this study. Kim [21] reported that there was a difference in performance before and after applying peer teaching between seniors and juniors in the case of skills with a difficulty level of ‘medium’ or higher, and Yoo et al. [10] also found that the experimental group that applied the peer tutoring method performed better than the control group when the difficulty level of the skill was ‘high’. So the peer teaching between seniors and juniors is effective for more difficult skills. In addition, it can be considered a useful method when the number of components of a skill is large, or when the skill includes items that are difficult to correct due to incorrect habituation, and when specific guidance from a senior is possible. We propose to apply peer teaching to various core nursing skills in the future to explore efficient teaching and learning strategies that take into account the difficulty of the skills.
The results of this study showed that the peer teaching between seniors and juniors was effective in improving the self-directed learning ability of nursing students. In particular, there were significant differences between the groups in the effort factor of the outcomes belonging to the learning assessment. If we analyze the reasons for this, it is believed that the practice under the supervision of a senior assigned to each group made more training and effort than the autonomous practice under the supervision of a single teaching assistant, and it was found that the peer teaching between seniors and juniors was an effective teaching method for repetitive training, which is important in skill practice education. Jung [22] found statistically significant improvements in all areas of self-directed learning skills of learning planning, learning execution, and learning evaluation as a result of using peer teaching between seniors and juniors in the classroom, with the largest increase in learning planning. This is due to the fact that the students focused on identifying the learning needs of their classmates and setting goals with consideration for their peers while applying peer teaching. In addition, the nature of the class made the students focus on identifying resources for learning through the lecture and question-and-answer process. In the future, it is necessary to apply peer teaching to various Theoretical and practical subjects in nursing to identify the optimal teaching and learning strategies for each subject.
The results of the qualitative evaluation of the experimental group were as follows. The feedback from the experimental group was that they received specific and close guidance on the skill process, were able to ask questions in a relaxed atmosphere, and had the opportunity to listen to the know-how in detail on a similar level, which is consistent with the study by Kang and Seo [9], who reported that peer tutoring is a learning method that allows students to cooperate and complement each other in a relaxed atmosphere and with a good understanding of each other's positions. Lee and Kang [11] also reported that senior peer tutors can improve learning by reducing peer learners’ tension and stress compared to professor-led instruction due to the empathy that comes from being in the same student's shoes, which is consistent with this study. Park and Choi [6] emphasized that complicated nursing skills, such as intravenous fluid infusion, are not easy to master through simple repetitive practice, and through studies by Yoon and Park [23] and Yeom and Choi [7], core nursing skills It is reported that reeducation improves nursing students’ skill performance ability and performance confidence, which is similar to the results of this study. Therefore, to increase the clinical adaptability of nursing students after graduation and foster competent nurses, reeducation of core nursing skills is essential, and in this case, peer learning between seniors and juniors can be considered as a self-directed learning strategy. In this study, the selection of peer tutors as senior students was considered to overcome the limitation that peer tutoring is time-consuming because the level of students is similar among peers. Intravenous fluid therapy is a skill that needs to be retrained repeatedly until graduation, not just at the end of the fundamental nursing practice course [6,7]. The results of this study were similar to those of Kang [9], who found that ‘peer teaching between seniors and juniors are beneficial for juniors, but they can also contribute to improving skill performance ability and self-confidence for seniors who are instructors, thus creating a win-win experience for both seniors and juniors. However, there is a limitation in that it is difficult to match the learning time between the third who have to participate in clinical practice and sophomores, so operational strategies such as peer learning between seniors and juniors should be im-plemented as soon as the course starts. In addition, the third and fourth grades have a pattern of matching learning time with immersive doubling classes. Since repeated training is inevitable due to the nature of the skill, we propose peer mentoring in the third and fourth years. In addition, in this study, more than 8 hours of pre-learning time was spent to improve the skill confidence of seniors. In the future, strategies to realistically reduce the amount of teaching time for seniors by utilizing video recording, on-line learning, etc. can increase the utilization of nursing education. So teaching and learning designs that can expand the application of peer teaching between seniors and juniors to core nursing skills training, such as self-practice or club activities, can be considered, and we suggest fur-ther research on various self-directed learning strategies that can be practically useful in applying peer teaching between seniors and juniors.
CONCLUSION
This study applied the peer teaching method between seniors and juniors to practical training in evidence-based intravenous infusion therapy, and as a result, it was confirmed that it was effective in improving the self-confidence, skill performance ability, and self-directed learning ability of nursing students. Peer teaching between seniors and juniors is considered to be a teaching method that can be used in practical nursing education, and in terms of nursing education, it can be considered as a teaching and learning strategy other than the existing instructor-led lecture class.
We propose several follow-up studies to identify the best educational strategies and operation methods for each subject by utilizing peer teaching between seniors and juniors in future nursing theory and practice education.
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