Three perspectives on peer learning: a qualitative study of undergraduate nursing students’ clinical placement

Introduction

Peer learning is an evidence-based pedagogical supervision model that has gained increasing recognition internationally (1–7). The model is rooted in a sociocultural perspective of learning, in which students are active participants who construct knowledge within a social community (8). Peer learning involves collaborative learning, where students learn and receive supervision together (1–5).

According to Markowski et al.’s (7) systematic review, this type of learning can be structured in various ways. Our study focuses on peer learning among undergraduate nursing students from the same course, who together take responsibility for their own learning, collaborate, learn from each other, actively seek knowledge, guide each other, and jointly reflect on and discuss different learning situations to acquire both practical and theoretical knowledge (3, 6, 9).

Previous studies indicate that peer learning supports students’ professional, cognitive and social development, and helps them develop skills in clinical practice (4, 7, 10). Research also suggests that peer learning promotes undergraduate nursing students’ independence when they work together on nursing care (9, 11–14) and prepares them for the transition to qualified registered nurses (7). It can also give them a greater sense of security in new clinical contexts and when facing unfamiliar clinical challenges (2). They adapt more quickly to the routines of the clinical setting (1) and provide each other with both professional and emotional support (10), which in turn can reduce stress, concerns and the challenges they encounter during clinical placement (2, 5, 7). 

Supervisors in peer learning aim to create a safe learning environment for undergraduate nursing students (1, 10), promote independence and collaborative learning (10, 12), and encourage a supervisory culture that underpins the method (12). In Norway, some clinical placements have been structured with undergraduate nursing students learning together in pairs (11, 15, 16). The goal is for clinical placement institutions to accommodate more students and help address the shortage of placements (17). The extent to which peer learning, grounded in educational theory (6–8), is used as the basis for supervision varies. In Norway, the method has been studied in different contexts, such as hospitals (13, 18, 19) and nursing homes (11). The studies focus on undergraduate nursing students’ perspectives when they are in the same year of study (11, 13), and both undergraduate nursing students’ and supervisors’ perspectives when students are from different years (18, 19). 

This focus aligns with international studies (1, 2, 7, 12, 14). The Nordic Institute for Studies in Innovation, Research and Education (NIFU) highlights peer learning as best practice in clinical placement (15).

The student perspective in peer learning is well documented (4, 7, 9), but few studies explore both the supervisor and the student perspective. No studies in Norway have examined the perspectives of students and supervisors when peer learning occurs between students in the same year of study in a hospital setting. 

According to Markowski et al. (7), there is no gold standard for how to structure peer learning. One method is the main supervisor model, in which student supervision is undertaken by main supervisors and day-to-day supervisors (sometimes referred to in the literature as main preceptors and daily preceptors) (1, 3). 

Objective of the study

Our study contributes knowledge on peer learning structured according to the main supervisor model, as our aim was to describe undergraduate nursing students’ (herein referred to as students), main supervisors’ and day-to-day supervisors’ experiences with peer learning in clinical placement. 

Method

The study used a qualitative, descriptive design with focus group interviews. Reporting follows the COREQ checklist (20).

Setting of the study

The study was conducted in a somatic hospital ward at a university hospital in Norway. The ward has just over 100 nursing staff and 27 patient beds. Four times a year, the ward hosts 12 nursing students for an eight-week clinical placement.

Students plan and deliver person-centred nursing care based on patients’ problems and needs, in collaboration with patients, each other and their supervisors. They are involved in all aspects of the nursing care of their patients. Main supervisors are responsible for supervising, following up and assessing the students, who work in pairs according to the peer learning model.

Approximately 20 of the nursing staff (herein referred to as day-to-day supervisors) provide day-to-day supervision for the students. Table 1 outlines the prerequisites and role descriptions for conducting the clinical placement using peer learning structured according to the main supervisor model.

Sample

The first author recruited the students, and the ward manager recruited the supervisors. Of 24 students, 16 chose to participate. All main supervisors involved (n = 3) were invited and agreed to participate. Five day-to-day supervisors were invited according to the rota, representing a random sample of the 20 available day-to-day supervisors, and all those invited agreed to participate.

Data collection

Data were collected in 2022 through a total of six focus group interviews conducted via Zoom, designed according to the characteristics outlined by Krueger (21) (Table 2). Four focus group interviews were held with students, one with main supervisors and one with day-to-day supervisors. The second author acted as moderator, assisted by a co-moderator who took notes, asked clarifying questions and provided an oral summary at the end (21).

A semi-structured interview guide with open-ended questions was used, inviting participants to describe their experiences (Table 3). The interview guide was pilot-tested on nine students in an earlier clinical placement at the same ward, with no adjustments required. 

Analysis

The focus group interviews were transcribed verbatim and analysed using conventional content analysis, as described by Hsieh and Shannon (22). The first author had primary responsibility for the analysis. Codes were developed by reading the transcripts repeatedly, word for word, and were derived directly from the transcripts.

After two focus group interviews with students, one with main supervisors, and one with day-to-day supervisors, two additional focus group interviews with students were held. These were coded against the existing codes, with a few new codes added. The codes were then organised into categories with similar meanings.

The analysis was iterative, with codes and categories refined and revised over several rounds in consensus meetings with the second and last authors, until the main category ‘Opportunities and challenges in peer learning’ emerged, along with two subcategories: Shared supervisory responsibility can present challenges and Collaboration as a foundation for safe learning (Table 4). The analysis was conducted using Nvivo R1 software.

Ethical considerations

The Norwegian Centre for Research Data (reference number 472311), now known as Sikt – the Norwegian Agency for Shared Services in Education and Research, and the data protection officer at the educational institution assessed the study. Participants provided written informed consent and were given the opportunity to withdraw at any time. The collected data were pseudonymised.

Results

The results of the study are based on students’, main supervisors’ and day-to-day supervisors’ (N = 24) experiences with peer learning structured according to the main supervisor model in clinical placement. The findings are presented under the main category ‘Opportunities and challenges in peer learning’, which comprises two subcategories: Shared supervisory responsibility can present challenges and Collaboration as a foundation for safe learning (Figure 1).

In the text, the subcategories are structured according to the students’, main supervisors’ and day-to-day supervisors’ experiences.

Opportunities and challenges in peer learning

All three participant groups described their experiences, which can be understood as encompassing both opportunities and challenges associated with peer learning. The opportunities primarily related to a greater sense of security, self-confidence and independence among students, and to learning through interaction with peers. Participants also highlighted how they learned from different nurses by observing and evaluating variations in nursing practice, as well as feeling included in the patient care team.

The challenges described were related both to the relationship between students and supervisors and to the relationship between students who were peer supervised. A lack of continuity in supervisors led to uncertainty among students and supervisors regarding students’ development. Unclear role delineation, differing levels of professional competence and variations in students’ personalities were also factors that some participants identified as challenging.

Shared supervisory responsibility can present challenges

The subcategory Shared supervisory responsibility can present challenges addresses the experiences of students, main supervisors and day-to-day supervisors in relation to the shared supervisory responsibility for students in peer learning between several nurses. The students considered the main supervisors important for continuity during clinical placement. However, they wished they could have done more shifts with them, but limited resources made this impossible. The main supervisors provided feedback and guidance on areas the students needed to continue working on during the clinical placement:

‘Even though we did not work with her [the main supervisor] some days, she came to us and talked to us and gave us feedback […] asked how things were going, and just gave us some tips on what to focus on going forward. Even though we did not spend much time “working” with her, I felt that she was present.’ (Student 5)

The shared supervisory responsibility meant that, for better or worse, the students found they started their shifts without prior expectations. They understood that they themselves were responsible for updating supervisors about their own knowledge and skills, and they missed having someone who could see their development from shift to shift. However, the students also described it as beneficial to be able to start afresh with a new supervisor. When students had different supervisors, they had to deal with the fact that nursing procedures were performed differently. 

For some students, it was confusing to learn a certain approach during a shift, only to be told during the next shift that the task should have been performed differently. As students achieved greater learning outcomes and gained more confidence, it became easier for them to deal with and learn from the different ways of, for example, performing a procedure:

‘It was a bit confusing to start with that nursing procedures could be done in so many different ways, because we might have felt more confident with one way of doing things, and then: “No, no. You mustn’t do it like that.” Now I feel that I’ve learned a lot from it. Now that I am more confident in myself, I’m able to see different ways of doing things.’ (Student 6)

The main supervisors found that when students observed a nursing procedure being performed in different ways it enabled them to reflect critically on the advantages and disadvantages of the different approaches. They also emphasised that doing shifts together was important for gaining an overview of each student and to ensure a robust basis for individual student assessment.

The more they collaborated the easier it was to assess the students’ development and provide them with specific feedback during assessment meetings. Conversely, it became challenging when they had not worked together very much and the day-to-day supervisors did not give feedback to the main supervisors:

‘And I don’t think all [the day-to-day supervisors] take it as seriously, giving feedback to us. Because they are only working together once, so they don’t know if they will see the students again.’ (Main supervisor 1)

According to the day-to-day supervisors, it was often challenging to gain an overview of the students’ development throughout the clinical placement and to understand their responsibilities as a supervisor in the context of unstructured student interactions. One day-to-day supervisor described it as having ‘two students dumped in your lap’ without any specific knowledge of their development.

However, the day-to-day supervisors found that peer learning made it possible to identify students requiring additional support, as differences in students' competence were more apparent: ‘The contrast becomes very noticeable; it’s very clear if someone isn’t very competent […] you can see such a big gap. So it doesn’t seem difficult to figure out what they can and can’t do.’ (Day-to-day supervisor 3) 

Collaboration as a basis for safe learning

The subcategory Collaboration as a foundation for safe learning explores students’, main supervisors’ and day-to-day supervisors’ experiences of how the student collaboration contributed to a greater sense of security and learning.

The students viewed one another as a stable and secure presence, providing continuity when supervisory responsibility was shared among several nurses. They were familiar with each other’s development, could ask each other questions without fear of being judged, and could process experiences together.

When the students collaborated on patient care, they felt a greater sense of security and self-assurance. This was especially evident during challenging situations and when performing procedures. They were able to draw on each other’s knowledge, guide one another and make decisions together.

When the students were supervised together, they found that collaboration allowed room both to develop an independent nursing role and to practise comprehensive nursing care. They felt like active participants in the interdisciplinary team, and it was easier to share responsibility. The student peers found that discussions, reflections, supervision and feedback were essential to their learning process. 

In unstructured conversations, they reflected on how they could understand patient situations they had been involved in. They discussed what had been done well, what could have been done differently, and what they had learned. The students gained practice by guiding one another, thereby enhancing their supervisory skills:

‘We’ve really been given the space to try out the nursing role. It hasn’t always felt like we were just students. We’re involved in the decisions being made. We have the opportunity to be the ones who actually have the most contact with the patients we are responsible for.’ (Student 8)

The students described some challenges related to peer collaboration. They sometimes felt uncertain about the division of roles and responsibilities during patient care, and it took time before they became comfortable with the role delineation in everyday practice.

Some students assumed a more prominent role in the peer collaboration, either because they had strong personalities or felt more confident in their professional development, while other students remained more in the background and felt less involved in delivering patient care. By discussing these challenges as they arose, the students learned both how to take a more active role and how to make space for their peers in the collaboration.

The challenge of playing a more prominent role while also making space for others was confirmed by the main supervisors. They found that students needing more support could be overshadowed by more experienced students, who took responsibility for the patient care. Open communication allowed the more reserved students to take on more responsibility, while those who played a more prominent role learned to step back. However, the main supervisors felt it was safe for the experienced student to supervise the less experienced student when the supervisor was not present:

‘The less experienced student tends to follow behind the more experienced student, not taking any responsibility, not trying to communicate, not saying how they’ve planned the day, for example, because it’s always the more experienced one who leads.’ (Main supervisor 2)

The day-to-day supervisors found that the students appeared confident and independent. They considered the students confident when they asked each other questions, discussed matters together, and worked together in the patients’ rooms. The day-to-day supervisors also felt the students seemed independent when planning the care for the patients they were jointly responsible for, and that, as the placement progressed, they had a clear role delineation.

Discussion

The objective of this study was to describe undergraduate nursing students’, main supervisors’ and day-to-day supervisors’ experiences with peer learning structed according to the main supervisor model in clinical placement. The key findings reveal both opportunities and challenges for all three participant groups.

The opportunities primarily centred on how peer learning contributed to a greater sense of security, learning and independence, while the challenges related to the consequences of limited supervisor continuity and collaboration difficulties within the student pairs. 

Challenges of shared supervisory responsibility in peer learning

Students, main supervisors and day-to-day supervisors described challenges related to the unclear division of responsibilities between main supervisors and day-to-day supervisors. Previous studies have also reported challenges with shared supervisory responsibility (7, 9, 11, 23–26). Koch et al. (10) suggest that clinical supervisors can experience role uncertainty when supervisory responsibility is shared between several nurses. In our study, where peer learning was structured according to the main supervisor model, the day-to-day supervisors' uncertainty was related to their responsibilities for supervision and follow-up, while the main supervisors were unsure whether they had a sufficient basis for student assessment. Students who have limited time with the main supervisor can also feel uncertain and insecure about the basis for the supervisor’s assessment (23).

However, other research indicates that having several supervisors can make a positive contribution to the evaluation of students' learning outcomes (15). While the students in our study did not directly express uncertainty about the assessment situation, they did find it challenging to be supervised by different nurses who lacked an overview of their knowledge level and development. 

A national report from 2023 (27) highlights how lack of time and resources, alongside the challenge of balancing supervisory responsibilities with other tasks, are key challenges affecting the quality of supervision in clinical placement. These findings are also supported in international literature reviews (29, 30).

To address these challenges and ensure continuity in supervision, clear role delineation and division of responsibilities between day-to-day supervisors and main supervisors are needed, along with a structure involving fewer day-to-day supervisors for student peers. To ensure effective supervision and contribute to structure, oversight and predictability for all roles involved, it is also crucial to allocate resources and time for the main supervisor (10).

When combined with a positive supervisory culture, this strengthens the learning environment for students (3, 14). Without organisational support, supervisory responsibilities are often deprioritised in favour of other responsibilities in the workplace (27). 

Peer learning in a safe learning environment can make students more independent 

Students and day-to-day supervisors agreed that student collaboration in peer learning increased students’ sense of security, which is a key factor for learning during clinical placements (33). Our students felt it was safer to ask each other questions rather than the supervisors, and they supported each other in challenging patient situations. Several studies confirm that students who collaborate in peer learning experience a greater sense of security (1, 2, 4, 7–11, 13, 31, 32).

It is reasonable to assume that this sense of security contributes to a positive learning environment, which in turn is a crucial prerequisite for quality in clinical placement (27). To facilitate a safe learning environment, supervisors and students both need to be adequately prepared, and the clinical placement must be carefully planned (3, 7, 32).

However, our study and previous research show that collaboration in peer learning can also present challenges. Different personalities, differing levels of professional competence and a sense of competition can have a negative effect on the learning process (2, 10, 13). Students who feel less knowledgeable than their peers may find learning situations stressful (2). In our study, such challenges with unclear role delineation, differing levels of professional competence, or different personalities were described by students, main supervisors and day-to-day supervisors.

The students reported that planning and delivering comprehensive nursing care contributed to greater independence, which was also confirmed by the day-to-day supervisors. Several studies show that peer learning promotes independence in nursing students (9, 13, 14).

Both in our study and in the study by Drange (11), students described having an independent nursing role in which they felt like a fully qualified nurse. One reason for this may be that it is easier to take independent responsibility in a secure environment with a peer than with a supervisor (23).

Our study also revealed that supervisors expressed greater confidence in students when they collaborated and provided mutual support and supervision. Additonally, students perceived themselves as active contributers in the interdisciplinary team. This may be because peer learning has been shown to strengthen students' self-confidence (31) and foster independence through increased shared responsibility (10). 

It is also well established that peer learning contributes to the development of teamwork skills, thereby preparing students for the transition to fully qualified nurses (7). Since independence is an essential component of nursing practice, the experiences students gain through peer learning can play a key role in strengthening their professional identity and role understanding.

The students described how they learned through discussions, reflections, supervision and feedback with their peers, which in turn helped them stay actively engaged in their own learning processes. As Carlson and Stenberg (8) argue, peer learning aligns with a sociocultural perspective on learning, where students engage in student-centred forms of learning characterised by collaboration, reflection and shared knowledge development. When interactions are positive, this contributes to a learning environment that fosters learning and self-confidence (33).

Despite the advantages of peer learning, it is important to emphasise that students still need good supervisors as role models in the development of their professional identity (7, 27). 

Strengths and limitations of the study

We interviewed participants with various perspectives of supervision in peer learning structured according to the main supervisor model in clinical placement. This participant triangulation helps to confirm findings and strengthens the validity of the study (34). Nevertheless, the majority of participants were undergraduate nursing students, which meant we gathered more information on their experiences than those of the main supervisors and day-to-day supervisors. Given the need for research on supervisors' perspectives, our aim was to include several day-to-day supervisors.

Students who worked together during the clinical placement also participated in the same focus group interviews. This can facilitate easy-flowing discussions (21), but it could also lead students to avoid sharing any collaboration challenges they encountered.

We were involved in planning and developing peer learning within the ward. Since the first author was the students’ clinical academic supervisor, the second author conducted the interviews alongside the third or last author, who served as the moderator’s assistant. 

Given our close connection to the research field, it was important to adopt a reflexive approach in order to prevent our preconceptions from influencing the collection and interpretation of data. However, our in-depth knowledge may have contributed to relevant questions being asked during the interviews.

The second and last authors created mind maps and summaries of all transcribed text and held regular meetings with the first author, during which codes and categories were adapted. This close collaboration in the analysis process strengthens the validity of the study.

In the ward in question, the peer learning supervision was structured according to the main supervisor model, involving both main supervisors and day-to-day supervisors. This means that the presented results also reflect issues related to the supervision structure. Although we only examined experiences with peer learning in one hospital ward, the findings may be transferable to other wards with comparable supervision structures.

Conclusion

The experiences with peer learning structured according to the main supervisor model in clinical placement reveal both opportunities and challenges. The study suggests that peer learning can promote a sense of security and independence for students when delivering comprehensive nursing care, and can make a positive contribution to the learning environment.

The students were actively engaged in their learning processes through discussions and reflections with their peers, along with supervision and feedback from them. These findings highlight the importance of recognising the benefits of supervising students in peer learning. Future research would be valuable to explore whether peer learning also fosters skills for lifelong learning and, in the longer term, contributes to nurses remaining in the profession.

However, the study also uncovered challenges with shared supervisory responsibility when peer learning was structured according to the main supervisor model. These challenges were related to a lack of continuity, which made students and supervisors uncertain about the students’ knowledge levels and development. To address these challenges, future implementation of peer learning should include clear role delineation and reinforcement of the main supervisor’s role through, for example, organisational support in the form of allocated time and resources.

This study contributes to the knowledge base about peer learning in a Norwegian hospital context by highlighting the experiences of students, main supervisors and day-to-day supervisors, with a primary focus on the collaboration between students in the same year of study. Further research is needed to examine peer learning in greater depth from the supervisors’ perspective, particularly in relation to continuity, supervision and follow-up in clinical practice. 

Acknowledgements

We would like to thank Grethe Solvang and Mona Charlotte Sletten at Oslo University Hospital for their inspiring collaboration and contributions in the planning, initiation and execution of the project.

We would also like to thank Professor Edith Roth Gjevjon at Lovisenberg Diaconal University College for her feedback and advice during the study. Finally, we would like to extend our sincere thanks to the participants, who shared their valuable experiences.

The authors declare no conflicts of interest.

Open access CC BY 4.0