INTRODUCTION
Nursing students must apply their theoretical knowledge of pediatric nursing in clinical settings to develop into competent nurses capable of independently caring for child patients [1]. Children have underdeveloped physical functions compared to adults, which significantly increases their risk of complications from infections and injuries. Therefore, children receiving care require precise and meticulous nursing [2].
Nursing students acquire clinical decision-making skills and integrate knowledge and skills through instruction from nursing faculties or clinical instructors. They also gain firsthand experience with job capabilities and interpersonal interactions. Consequently, the development of nursing students’ practice competency is significantly shaped by nursing educators [3]. However, clinical instructors often face an overwhelming workload and feel limited in their ability to provide effective practicum instruction [4]. Nursing students may be reluctant to engage with nursing educators due to fears of receiving negative evaluations [5]. To improve students’ capacity to apply theoretical nursing knowledge in practical settings, nurse educators have employed a variety of teaching strategies [6].
Peer tutoring has been effectively implemented for nursing students, where tutors assist tutees in adapting to efficient learning strategies [7,8]. It is characterized by individuals from similar social groups, who are not professional educators, helping each other learn while also enhancing their own understanding through the act of teaching [9]. This approach is distinct from peer mentoring, which involves a one-on-one relationship that provides encouragement and support from someone more experienced. Peer tutoring specifically requires participants to assume designated roles, focuses heavily on curriculum-based content, and follows clearly established procedures for interactions between tutors and tutees [10].
It has been suggested that simply preparing to be a peer tutor can enhance cognitive processing in the tutor by increasing their focus and motivation to complete tasks, as well as requiring them to revisit their previous knowledge and skills [9]. Nursing student tutors found that engaging in peer tutoring not only boosted their learning capacity but also motivated them to pursue further learning [11]. Tutors created a supportive and non-threatening learning environment where tutees were able to effectively absorb knowledge [8]. Therefore, peer tutoring has been shown to help tutees overcome their academic challenges [12].
Despite the reported benefits of peer tutoring, several shortcomings have been identified, including tutor inefficiency and tutee dependency [5,12]. Additionally, peer tutoring has not been effective in reducing anxiety or enhancing self-efficacy among students [13]. Furthermore, the majority of peer tutoring studies have focused on qualitative research [7,8,12,14]. Therefore, the effects of peer tutoring in nursing education need to be comprehensively evaluated.
This study systematically reviewed research on the impact of peer tutoring in pediatric nursing education and explored the topics and content delivered through this method.
METHODS
Ethical statements: This study is a literature review of previously published studies and was therefore exempt from Institutional Review Board approval.
This study was conducted to answer the research question, “What is the impact of using peer tutoring in pediatric nursing education for nursing students?” The research was carried out in accordance with the research protocol registered in PROSPERO (No. CRD42023399026) and reported following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 [15].
1. Eligibility Criteria
To clearly establish the eligibility criteria, five key articles related to the research question were analyzed. The specific eligibility criteria are presented in Table 1 and are as follows: 1) The tutees were undergraduate nursing students, and the tutors were peers or near-peers, including undergraduate or graduate nursing students; 2) the intervention involved peer mentoring with clearly defined roles for both tutor and tutee, and included education on the knowledge and skills required for pediatric nursing; 3) outcome measures included quantitative results regarding the learner’s learning effects in cognitive, psychomotor, and affective domains, or individual responses to the education; 4) the study designs encompassed quantitative methodologies that presented quantitative outcomes of the intervention, regardless of the presence of a control group; 5) additionally, studies must be published in English or Korean.
2. Search Strategy
For an extensive search, the COre, Standard, Ideal search (COSI) model [16] was followed in selecting the sources. The Core search accessed databases such as PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, KMbase, and the Korean Studies Information Service System (KISS). The Standard search included the Cumulative Index to Nursing Allied Health Literature (CINAHL) and Research Information Sharing Service (RISS) databases. For the Ideal search, unpublished literature was sourced from the ProQuest and RISS databases, and reference lists from the selected studies were thoroughly reviewed. The studies retrieved were managed using EndNote 21 (Clarivate), where duplicate records were identified and removed. This phase of the project spanned from November 26, 2023, to December 30, 2023. The search strategy incorporated MeSH terms, Emtree terms, and relevant natural language expressions. The main keywords were selected according to the population, intervention, comparison, and outcome (PICO) elements and were as follows: “students, nursing,” “peer group,” and a range of terms related to pediatric nursing such as “pediatric nursing,” “pediatrics,” “neonatal nursing,” “newborn nursing,” “maternal-child nursing,” “maternal child health care,” “child health,” “family nursing,” and “family centered care.”
3. Study Selection and Data Extraction
All authors participated in the literature selection process, which involved an initial review of titles and abstracts to identify potential studies. This was followed by a full-text review to determine their final eligibility based on the established criteria. Data extraction was conducted using a predefined data coding form. One author (BRL), performed the extraction, while another (HA), reviewed the extracted data. The data coding form captured general information about the study, characteristics of tutors and tutees, sample size, education topic, learning contents, tutoring method, preparatory tutor training, outcome measures, and key conclusions. Any disagreements that arose during the literature selection and data extraction processes were resolved through discussion until a consensus was reached among the researchers.
4. Quality Evaluation
The quality assessment tools used were the revised Cochrane risk-of-bias tool for randomized trials (RoB-2) [17] and the risk of bias assessment tool for non-randomized studies (RoBANS) [18]. Two researchers (HA, BRL) independently conducted the quality assessment. The inter-rater reliability for the quality assessment, measured by Cohen’s kappa, was 1, indicating “almost perfect” reliability [19].
5. Measures of Intervention Effect and Reporting Biases
Due to the diversity of outcomes reported in the analyzed studies, no single outcome was consistently reported by three or more studies; consequently, the effect size was not pooled [20]. Therefore, the mean difference (MD) and 95% confidence interval (CI) for the experimental and control groups were calculated and presented for each individual study.
Because the number of selected studies (N=5) was small, a funnel plot could not be used to assess reporting bias [21].
RESULTS
1. Study Selection
The process of selecting studies was presented using a PRISMA flow chart (Figure 1). Initially, a systematic literature search was conducted across various databases, resulting in the identification of 1,605 studies after duplicates were removed. Following a review of the titles and abstracts, nine articles were chosen for a full-text review. During this phase, four articles were excluded, leaving five studies for further analysis. Additionally, the gray literature was explored, yielding 1,591 entries. Duplicates from previously searched literature, totaling 77, were also removed. Including references cited in the selected studies (n=149), a total of 1,663 titles and abstracts underwent review. At the title and abstract screening stage, 1,653 were excluded, leaving 10 for full-text review. However, none of these 10 met the selection criteria. Consequently, a final total of five studies were selected for analysis [22-26].
2. Characteristics of the Included Studies
The characteristics of the selected studies are presented in Table 2. The studies were published from 2010 to 2023 and were conducted in the United States, United Kingdom, Iran, India, and Turkey, with one study from each country. Three studies were conducted in school settings [22,25,26], while two studies were carried out in pediatric clinical settings [23,24]. The two studies conducted in clinical settings were randomized controlled trials (RCTs) [23,24], while the remaining studies included a non-randomized controlled trial (NRCT) [22], a cohort study [25], and a one-group before-after study [26].
The number of participants (tutees) ranged from 24 to 143. Two studies targeted third-year students [22,24], one study focused on fourth-year students [23], and another study included second-year students [26]. One study targeted nursing students at risk of failing major courses, regardless of year [25].
Two studies utilized control groups that received lectures or instructions from faculty [22,23], one study compared the effects with a mentoring group led by nurses (healthcare professionals) [24], and one study used a control group that received no treatment [25]. There was also one study with a single group and no control group [26].
3. Characteristics of Peer Tutoring
The characteristics of the interventions are presented in Table 3. Two studies structured their interventions around theoretical models. One implemented a cooperative group approach, drawing on cooperative learning theory [25], while the other employed peer tutoring within simulation education, guided by situational learning theory [26].
Regarding educational topics, two studies focused on the cognitive domain, addressing subjects such as pediatric nursing theoretical courses [25] and nursing care for major neonatal diseases [22]. Three studies examined the educational effects in the psychomotor and affective domains, concentrating on communication skills with hospitalized children and their parents [23], medication administration skills for pediatric patients [24], and neonatal and pediatric resuscitation [26].
Two studies provided horizontal peer teaching (HPT), where both tutees and tutors were undergraduates [22,25]. Two studies employed near-peer teaching (NPT) with graduate students as tutors [23,24]. The remaining study used reciprocal peer teaching (RPT), allowing participants to alternate between tutor and tutee roles [26]. Except for one study (insufficient reporting) [22], all were group programs, with tutor-to-tutee ratios ranging from 1:3 to 1:36.5. In the study by Valler-Jones [26], the tutor group supported tutees’ learning, resulting in a ratio of 4:8. The duration of tutoring varied from one day to one semester, employing methods such as feedback and comments (n=3), role-modeling (n=2), explanation (n=1), support and assistance (n=1), and debriefing (n=1).
In four studies, tutors were recruited through voluntary applications, while in one study, tutors were assigned by the faculty [22]. Three of these studies established specific criteria for selecting tutors, all of whom were chosen based on their high academic or test performance [22,23,25]. Each study also provided comprehensive training for the tutors. This training included role-play activities [23], education on the concepts, purposes, and roles of mentoring [24,25], and development of simulation scenarios and skill training [26]. The duration of tutor training was approximately 120 minutes [23,24].
Three studies reported that faculty monitored the peer tutoring process. Faculty observed the tutoring in two studies [23,26], and the study by Valler-Jones [26] provided a final debriefing after the observation. Robinson and Niemer [25] maintained continuous communication with tutors throughout the semester, reviewed documents summarizing the tutoring activities, and supplied the most current learning materials through an online learning platform.
4. Outcomes of the Peer Tutoring
We identified learning effects and individual responses as the primary outcomes of peer tutoring. These outcomes, together with the tools and statistical measures employed for assessment, are presented in Table 2.
Learning effects were measured in all studies. Among the three domains of learning effects, the cognitive domain included measurements of knowledge, school exam scores, and grade point average (GPA) [22,25]. In the study by Bhele et al. [22], knowledge was measured on the 12th day after the intervention, and the MD improved to 20.02 (95% CI 17.54 to 22.50). Robinson and Niemer [25] reported significantly higher exam scores in the tutoring group; however, due to insufficient reporting of statistics, the MD could not be calculated. The effects in the affective and psychomotor domains included improvements in communication skills, self-efficacy in pediatric medication administration, and confidence and competence in caring for critically ill children [23,24,26]. Peer tutoring positively affected communication skills with hospitalized children (MD=10.72, 95% CI 8.87 to 12.57) and their parents (MD=8.99, 95% CI 7.51 to 10.47) [23]. Although positive effects on confidence and competence in caring for critically ill children were reported, the MD could not be calculated due to insufficient statistical reporting, and these results were measured in a single group [26]. In the study by Öztürk Şahin et al. [24], no significant difference in MD was found in self-efficacy in pediatric medication administration when compared to the nurse-mentoring group.
Learners’ responses were measured in two studies [24,26]. In the study by Öztürk Şahin et al. [24], clinical comfort and worry showed no significant differences in MD between the groups when compared to the nurse-mentoring group. In the study by Valler-Jones [26], educational satisfaction was measured using a single-group design with only a post-test, making it impossible to determine the effect.
5. Risk of Bias Assessment
In the two RCTs [23,24], concerns about bias arose due to the omission of details regarding the allocation sequence and the concealment of the group assignment order. Additionally, the study by Cheraghi et al. [23] failed to mention evaluator blinding and lacked a detailed description of the specific methods and fidelity of the interventions provided, leading to a high risk of bias (Figure 2).
In the remaining three studies, a high risk of bias was present due to challenges in excluding the natural progression of learning effects without a control group and the omission of adjustments for differences in confounding variables [22,25,26]. Additionally, the risk of bias was compounded by several study-specific issues: imprecise statistical reporting [25,26], the absence of blinding [26], the use of self-reported outcomes [26], and the high dropout rates of participants [25] (Figure 2).
DISCUSSION
This study carried out a systematic review to assess the impact of peer tutoring on pediatric nursing education among nursing students. Despite extensive searches across various databases, only five studies met the inclusion criteria. The five studies analyzed were conducted in the United States, the United Kingdom, Iran, India, and Turkey, underscoring a significant global research gap in the application of peer tutoring in pediatric nursing education. According to previous systematic reviews, peer tutoring for nursing students has predominantly been utilized in the United States, and most studies have reported qualitative outcomes and focused on fundamental nursing skills or resuscitation training for adults [27-29]. In South Korea, nursing students primarily engage in learning focused on adult patients and face difficulties in studying pediatric nursing due to the limited opportunities for pediatric clinical practice resulting from the declining birth rate and the reduced number of hospitalized children [30,31]. This has resulted in challenges ranging from understanding the characteristics of pediatric patients to appropriately applying nursing skills learned for adults to pediatric patients [31]. Therefore, it is necessary to develop instructional strategies that specifically address the educational content in pediatric nursing that nursing students find challenging to learn or practice directly, and intensive peer education can be particularly useful in this context. However, this review revealed a scarcity of quantitative studies measuring the effects of peer tutoring in pediatric nursing education. Consequently, it is vital to actively pursue research on the implementation and effectiveness of peer tutoring within nursing education in pediatric nursing.
The analyzed papers included two studies that aimed to improve theoretical learning abilities in pediatric nursing [22,25]. These studies reported that the participants exhibited significant improvements in exam scores [25] and knowledge [22] compared to the control group. Both studies employed HPT, where the mentors and mentees were undergraduates. HPT can reduce the burden of theoretical learning and improve learning outcomes by sharing information more easily and favorably based on the reliability shared among peers experiencing similar difficulties [22]. Given the challenging and rigorous nature of nursing education, which often causes students to struggle academically [25], employing HPT to improve cognitive learning in pediatric nursing education could be considered.
In the two studies utilizing HPT [22,25], the tutors were selected for their high academic performance and received training in tutoring during the pre-implementation phase of peer tutoring programs. Of particular note, in the study by Robinson and Niemer [25], the tutors were not only trained in advance but also regularly supervised during the mentoring process. This included the faculty providing the tutors with the latest learning materials and offering mentorship to the tutors themselves. Therefore, when employing HPT where both tutees and tutors are students, it is essential that educational benefits accrue to both parties. This approach can help prepare tutors for future roles as clinical nursing instructors [32]. However, the analyzed studies focused solely on the effects from the perspective of the tutees and did not assess the potential benefits for the tutors. A previous study on peer tutoring in high-risk neonatal nursing education demonstrated that peer tutoring enhanced the academic capabilities of both tutees and tutors through qualitative content analysis [5]. Although tutees and tutors are horizontal peers, their roles in the program differ, which suggests that the educational effects they experience might also vary. Future studies should consistently explore the specific educational benefits that each role can achieve.
In addition to its cognitive learning effects, peer tutoring has shown beneficial impacts on practical skills such as neonatal and pediatric resuscitation [26], communication skills with hospitalized children and their parents [23], and clinical pediatric medication administration [24]. As a result, the tutoring group showed improved communication skills compared to the control group [23], and there was no significant difference in self-efficacy in pediatric medication administration compared to the group that was instructed by clinical nurses [24]. Recent systematic reviews have reported that peer tutoring does not show a significant difference in educational effectiveness compared to expert and faculty-led education, with NPT being reported as the most effective type of peer tutoring [27]. Reflecting on these findings, the two studies [23,24] utilized NPT with graduate students as tutors, and it can be inferred that practical skill training in pediatric clinical settings for senior students led to positive outcomes. Therefore, employing NPT in clinical settings can be an effective instructional strategy to supplement the limited availability of faculty, especially when teaching pediatric nursing skills that require careful education.
The affective impacts identified in pediatric nursing education through the application of peer tutoring include satisfaction [26], clinical comfort, and anxiety [24]. Previous systematic reviews have reported that peer tutoring reduces mentees’ stress [29], but the study by Öztürk Şahin et al. [24] found no significant difference compared to the clinical nurse-instructed group. This is presumed to be due to the use of NPT instead of HPT. Students reported feeling less anxious and more comfortable and confident when they learned through peer tutoring, free from the constant evaluation by faculty and concerns about potential biases from faculty members [5]. Therefore, to create a learner-centered, psychologically safe learning environment, HPT should be considered as a method that would be especially useful for junior students who experience high anxiety due to a lack of coping skills [29]. However, NPT can be considered as a way to focus on learning outcomes, and it would be beneficial for senior students who need to improve their practical skills. To clarify this, future research should explore whether the type of peer tutoring is closely related to its impact on cognitive, affective, and psychomotor learning outcomes.
Among the five analyzed studies, two utilized cooperative learning theory and situational learning theory to design peer tutoring programs [25,26]. Robinson and Niemer [25] faithfully applied the cooperative group approach by forming groups of 3–5 students, where the tutor continuously supported both academic and non-academic issues throughout the semester. The faculty checked attendance as a routine task and monitored changes in the exam scores of group members as an assessment task, thereby improving the exam scores of students with lower GPA. Additionally, Valler-Jones [26] combined situational learning theory with peer tutoring to use peer tutoring in simulations for the care of critically ill children, using the RPT method, which alternates the tutor and tutee roles, to enhance nursing confidence and competence. Additionally, various models such as social cognitive theory, the goal-reality-options-will model, Kolb’s cycle of experiential learning, Pintrich’s model of self-regulated learning, an adapted version of the five senses of student success model, and the multidimensional model of nurse self-concept are being used in peer tutoring [29]. Therefore, utilizing these theories can help enhance the educational effectiveness of peer tutoring in pediatric nursing education.
This study is significant in systematically reviewing the effectiveness of peer education in pediatric nursing education for nursing students. However, the review included only five studies, which limits its scope. In the two RCTs [23,24], concerns about bias arose due to insufficient details on allocation sequence, group assignment concealment, and evaluator blinding, as well as inadequate descriptions of the intervention methods. The other three studies encountered high risks of bias because they lacked control groups, did not address confounding variables, and had issues such as imprecise statistical reporting, absence of blinding, reliance on self-reported outcomes, and high participant dropout rates [22,25,26]. Therefore, future research should implement peer tutoring across various educational topics in pediatric nursing, assess the educational effects, and adhere strictly to standardized intervention protocols.
CONCLUSION
This systematic review aimed to evaluate the effects of peer tutoring in pediatric nursing education for nursing students. Although only a few studies were available, they showed significant improvements in cognitive knowledge, communication skills, and clinical competencies. However, these studies demonstrated high risks of bias due to inadequate control groups, unaddressed confounding variables, and inconsistent reporting. Future research should employ more rigorous study designs, standardized intervention protocols, and comprehensive outcome assessments to more effectively validate the effectiveness of peer tutoring. Such improvements will enhance the educational strategies used in pediatric nursing education, ultimately improving the competency of nursing students.
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