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Student peer mentoring in a community-based nursing clinical experience.

ABSTRACT An innovative student-to-student peer mentoring teaching strategy was used to deliver health care to at-risk populations in a community-based setting. Students benefited through a collaborative effort to develop and implement a project in a community agency that did not have a nursing presence. Nursing students from three different levels of education participated in this pilot project. Strengths and weaknesses of this strategy were identified through journals, reflective comments, and pre- and posttest evaluation. Students at each level completed projects that benefited the agency and the population, while meeting educational objectives of the course.

Key Words Community-Based--Teaching-Learning Strategy--Student Peer Mentoring--Nursing Education.

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THE UNITED STATES CONTINUES TO SEE A RISE IN THE NEED FOR CARE IN THE COMMUNITY AMONG ALL POPULATIONS, BUT ESPECIALLY AMONG THE UNINSURED, ETHNIC MINORITIES, AND THE ELDERLY. Nursing education has responded to the need for nurses who are skilled in caring for individuals within the communities in which they live through community-based nursing education programs. Working in such programs, students gain knowledge in community and cultural assessment, communication skills, and health promotion, and they learn how to make appropriate referrals for disease management. * Often, clients receiving community care are uninsured and at risk, with complex physical, emotional, social, economic, and legal problems. This requires that students understand and assess their clients from a broad perspective that includes an assessment of the environment. But undergraduate nursing students often find the community setting daunting. They lack experience with the complexity of the problems many clients have and are deterred by the lack of support provided by traditional clinical agencies. Most students have not previously encountered high-risk, vulnerable populations in unstructured environments within the community. * Agencies that serve vulnerable populations may not even have a nursing presence. They may lack personnel with the expertise to assess and educate clients and make referrals as appropriate, and they rarely have personnel with the time to serve as preceptors for nursing students. * THIS ARTICLE DESCRIBES THE USE OF STUDENT PEER MENTORING AS ONE STRATEGY TO PROVIDE A NETWORK OF SUPPORT TO STUDENTS PLACED IN COMMUNITY-BASED AGENCIES TO WORK WITH VULNERABLE POPULATIONS. IN THIS PILOT PROJECT, A MASTER'S OF SCIENCE IN NURSING (MSN) STUDENT WORKED COLLABORATIVELY WITH RN-TO-BSN STUDENTS IN A REAL-WORLD SITUATION.

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Peer Mentoring Peer mentoring provides a network of support from peers and higher level students, who serve as mentors to students at lower academic levels. Peer mentors educate, guide, coach, support, counsel, and serve as role models for fellow students (Milmer & Bossers, 2004). Morse (2006) describes the characteristics of a good peer mentor as someone who is generous, competent, self-confident, and open to a collaborative relationship. Goodlad (1998) provides a classic framework for peer mentoring whereby students have opportunities to learn about people from different social backgrounds, view issues from another person's perspective, gain self-confidence, and reinforce their knowledge.

Benner's framework of novice to expert was used to guide this project. Benner describes a progression of clinical expertise and asserts that clinical knowledge is gained over time, through personal knowledge, experiences, and common meanings and approaches within the field. The novice lacks practical experience in a new setting and seeks guidance and support from a more competent nurse. The competent nurse has concrete experiences and paradigms to reflect upon, as well as a holistic perspective of the environment and the client's situation. The expert nurse, relying on past experiences, is more visionary and creative when making decisions and solving problems (Benner, 1984).

This peer-mentoring strategy was designed by nurse faculty (experts) to facilitate the application of nursing theory in a nonstructured clinical experience. Faculty, who evaluated student learning, were not direct participants in the peer-mentoring dialogue. The graduate student (competent) worked with two levels of undergraduate nursing students (advanced beginner and novice). The Figure above shows the indirect line of communication between nurse faculty and the undergraduate students for the mentoring process.

Implementation of the Pilot Project This peer-mentoring project was implemented in a nonprofit, grant-funded community agency that provides education and support to at-risk families from the prenatal period continuing until the children are five years of age. The agency is staffed with social workers and counselors, but lacks funding for nurses. Families served by this agency are frequently court mandated to attend parenting classes in order to retain or regain custody of their children. In general, the population served by the agency has low literacy and income levels and is at risk for abuse and health problems, including mental illness.

There has been a longstanding collaboration between the community agency and the department of nursing to meet the nursing needs of the agency, such as home visits for health education and family assessment. However, no policies and procedures were in place for nurses functioning in the agency; nurse faculty served as clinical supervisors for students.

A graduate student in the MSN nurse educator track was hired through an internal university grant to serve as facilitator for the peer-mentored group and as liaison between the clinical agency and the nursing faculty. The graduate student had experience as an RN in a community-based setting and as a nurse educator at a community college. Objectives for the graduate student were to increase her knowledge of mentoring and to obtain practical application of the mentoring process.

As their leadership change project, two RN-to-BSN students in the capstone leadership/management course designed and implemented organizational policies and procedures for nursing care of clients served by the community agency. Two other RN-to-BSN students, students in the community health course, performed a community assessment, including an assessment of the at-risk population and their health care needs. They also conducted homes visits and implemented health care interventions that included teaching normal growth and development of children, the signs and symptoms of illness, general health care of infants and children, and child safety. The students made referrals to other health care providers as needed.

The initial project encompassed one 16-week semester. Students were selected based on their interest in serving families in the community. During the first meeting, all students and faculty met to discuss the elements of the mentoring relationship, criteria for effective mentoring, clinical objectives, and expected outcomes for each student.

A second meeting was held at the agency to review the roles and responsibilities of all participants. The students' overall role was to assess the agency's need for a nursing presence and to develop a plan to meet the health care needs of the at-risk population. The faculty role was to clearly identify clinical course objectives, enhance the development of a partnership with the agency, and evaluate student progress throughout the experience. The agency personnel role was to provide expertise about the characteristics of the population served by this agency. There was time during this meeting to share information about the population, their special needs, and available resources.

Prior to the project, the faculty met with the graduate student to discuss the activities of a mentor and the desired outcomes of the project. They then met weekly to discuss the progression of the project and the group mentoring process. The mentor also met weekly with her mentees; faculty attended the first 10 minutes of these sessions to answer questions regarding the project.

As the establishment of a cohesive group was considered necessary before progressing to specific tasks, the first four mentor-mentee weekly meetings focused on the normal stages of group development: identifying the group purpose, assigning tasks, identifying lines of communication, and identifying a method of conflict resolution (Onega & Devers, 2008). After participants bonded as a group, the actual work of meeting the course objectives began. The weekly group meetings allowed members to evaluate progress, vent frustrations, brainstorm possible solutions, and reassign group tasks. During meetings, each member of the group had to personally reflect about values, past experiences, and beliefs about nursing.

Evaluation Progress of the RN-to-BSN students toward meeting course objectives was evaluated by the course instructors through: a) weekly clinical logs describing subjective and objective information about the clinical experiences; b) clinical performance during site visits using a clinical evaluation tool as a guide; and c) didactic course requirements as outlined in the course syllabus. The graduate student maintained a journal throughout the semester, reflecting on the mentoring process and progress toward meeting the goals of the group.

Quantitative and qualitative methods were used to evaluate the mentoring process and the experience. An investigator-developed peer-mentoring evaluation tool was administered before and after the project. The tool consists of 26 statements, in a Likert scale format, about mentoring and mentoring expectations. Course instructors also conducted qualitative interviews of the group at the end of the semester. Field notes of these interviews were recorded by the researchers and analyzed for common themes.

Project Outcomes Students used the Missouri State Nurse Practice Act and the American Nurses Association Standards of Practice (2004) and Code of Ethics (2001) as a foundation to develop policies and procedures for the new nursing role at the agency. They collaboratively chose the name "Healthy Communities" for the nursing project. This name gave value to the students' work, provided a visual presence for a nursing role in the agency, and provided structure for role implementation. Collaboratively, the roles of the nurse in this agency were defined as assessment, education of the client, and referral as needed.

Working within budgetary constraints, the leadership/management students produced two manuals and an orientation video to be used by future nursing students at the agency. One manual included the Healthy Communities mission, philosophy, policies, procedures, rules, and referral resources. The other manual included evidence-based teaching materials. The orientation video, later converted to a DVD format, included interviews with the agency director and staff that emphasized the strength-based approach used with an at-risk population. The leadership/management students completed a formal presentation of the Healthy Communities project to the agency staff and a classroom presentation in the academic setting.

To gain an understanding of the nurse's role with this population, the community health students visited a similar agency that had a nursing presence and accompanied a team of registered nurses and social workers as they made home visits. The visit to the agency served as a foundation for the development of assessment forms for newborn and postpartum clients. General assessment forms, visitation logs, medication sheets, goal assessment forms, and education record forms were developed, field tested, evaluated, and refined by the students. An information sheet for agency families was developed to explain the purpose of nurse home visits and what nurses would do during the visits. The community health students presented their project outcomes to the agency staff, as well as in the classroom.

These RN-to-BSN students, accustomed to the structured acute care environment, were frustrated with the lack of organization, policies, and procedures at the agency. At the beginning of the project, their frustration was noted in their weekly logs. Students reflected upon both positive and negative aspects of interactive communication, conflict management, negotiations, collaboration with their peers, and their work with agency personnel. Their frustration subsided as the project evolved. The students stated they gained support from peer mentoring and felt a sense of pride in their unique finished products.

Input from the graduate student was gathered through a reflective journal. A comment from one journal entry supported the mentor role: "As things start coming to a close my reflections on mentoring define it as a mutually supportive, mutually educational, nurturing relationship that consists of respect, role modeling, commitment, collegiality, and encouragement." The outcomes, hours, and estimated in-kind contributions to the project are represented in the Table.

At the conclusion of this peer-mentoring project, faculty, students, and agency personnel evaluated the experience. They also identified specific student abilities and attributes needed to work in the agency environment. One student commented, "It was a challenging clinical experience in many ways, but I know I learned much through the challenge." Students expressed an overwhelming sense of pride that a real nursing presence was established at this agency to serve an at-risk population.

Although students expressed feelings of frustration about how they were to meet course requirements while remaining in the student-to-student peer-mentoring project, they reported that these feelings lessened as the dynamics of the group evolved. All evaluators stated that students would need a positive attitude, motivation, and a flexible schedule to participate in clinical experiences at this agency. Noting the progress achieved in only one semester, they agreed that the project should continue and be expanded to include additional students and agencies.

Lessons Learned This student-to-student, peer-mentoring project was successful. Students became aware that they could accomplish more collectively than as individuals and that they benefited from the varied experiences of others within the group. Faculty learned from this pilot project that student selection criteria should consider: a) personality fit between students, b) the ability to work within a group, c) the ability to adapt in a nonstructured setting, and d) motivation to create and implement innovative projects.

At first, students were uncomfortable with the generally stated project expectations about establishing a nursing presence in a community setting. Accustomed to acute care settings, they felt frustrated by working without structure. Faculty can reduce student anxiety by providing more information about health problems encountered with at-risk populations and intervention strategies for meeting client needs. In addition, an extended orientation to the community and the client population, along with opportunities to acknowledge and discuss feelings about working in unstructured settings, may improve the comfort level of students.

To meet their goals, students in this project needed to create their own structure by working with a detailed, step-by-step plan. Expectations for clinical experiences at a community agency should be clearly communicated to students at the beginning of the project and reinforced throughout the project. Such repetition supported this group's ability to meet their goals.

Agencies that do not have a nursing presence should be considered cautiously. Students, faculty, and agency personnel must have a clear understanding that nursing students will assess and educate clients and make referrals as appropriate. They will not diagnose and treat clients' illnesses.

The students involved in peer mentoring gained support and encouragement from each other as they worked to complete this innovative community-based project. Through the peer-mentoring process, the students learned how to be mentors and how to be mentees. They benefited from valuable attributes of the mentor-mentee relationship, including commitment, initiative, cooperation, enhanced communication skills, responsibility to a community client, and developing a project that would otherwise not be accomplished. The long-term effects this project may have on these students cannot be evaluated, but it is hoped that they will apply this experience throughout their professional nursing careers. The mentor relationship is typically lacking in nursing practice settings, but it is important for developing the novice nurse and those with less experience in the profession.

The peer-mentoring process between students does not take away from the responsibility of faculty to supervise nursing students in a clinical area. In fact, the project was time consuming, requiring a delicate balance between working with all members of the student group and avoiding interference with the mentoring process.

Peer mentoring outside the classroom or acute care setting facilitates student involvement in community and social issues, allowing practical application of classroom theory. Another benefit of actively engaging students in the community setting is that it creates a sense of community commitment and citizenship through public service that may influence future work and volunteer activities (Schmidt, Marks, & Derrico, 2004).

Going Forward After review of the initial peer-mentoring teaching strategy used in the development of Healthy Communities, faculty have expanded the project, now entering the third semester. An additional agency serving a high-risk homeless population and lacking a nursing presence has been included in the collaboration. Now, fourth-year baccalaureate students participate in the project, as well as RN-to-BSN and master's students. Interestingly, students involved in the project in the second semester have selected to work in the same community agency and provide mentorship to students just entering the project.

Community agency partnerships can provide opportunities for clinical research and clinical experiences with diverse populations, as well as community service. Evaluations of the student-to-student peer-mentoring process are needed. Areas for possible research may include the difference between self-selection and assigned mentoring groups and the refinement of tools for the effective measurement of mentoring outcomes. Finally, a longitudinal study for evaluating the effects of peer-mentoring relationships on students' professional nursing careers would be desirable.

About the Authors Susan Sims-Giddens, EdD, RN, is an associate professor, Department of Nursing, Missouri State University, Springfield. Caroline Helton, MS, RN, is an assistant professor, and Kathryn L. Hope, PhD, RN, is a professor, Department of Nursing, Missouri State University. Contact Dr. Sims-Giddens at susansimsgiddens @missouristate.edu.

References

American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Silver Spring, M D: Author.

American Nurses Association. (2004). Nursing: Scope and standards of practice. Silver Spring, MD: Author.

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley.

Goodlad, S. (Ed.). (1998). Mentoring and tutoring by students. Stirling,VA: Kogan Page.

Milmer, T., & Bossers, A. (2004). Evaluation of the mentor-mentee relationship in an occupational therapy mentoring programme. Occupational Therapy International, 11, 96-111.

Morse, J. M. (2006). Deconstructing the mantra of mentorship: In conversation with Phyllis Noerager Stern. Health Care for Women International, 27, 548-558.

Onega, L.L., & Devers, E. (2008). Health education and group process. In M. Stanhope & J. Lancaster (Eds.), Public health nursing: Population-centered health care in the community (7th ed., pp. 289-315). St. Louis: Mosby.

Schmidt, M. E., Marks, J. L., & Derrico, L. (2004). What a difference mentoring makes: Service learning and engagement for college students. Mentoring and Tutoring, 12, 205-217.
Table. Outcomes of the Student-to-Student Mentoring Project

Project Members    Outcomes

Course             Developed and implemented the mentoring process
Instructors          to achieve educational outcomes of courses
                   Served as expert consultants
                   Maintained community partnership
                   Created environment for student-to-student
                     mentoring research
                   Provided real-world experience for nursing care
                     to at-risk populations

Graduate           Gained experience in community-based teaching role
Student            Gained knowledge of mentoring process
                   Gained practical experience in using mentoring
                     process

Leadership and     Assessed community organization
Management         Collaborated with agency staff and colleagues
Students
                   Named project "Healthy Communities"
                   Developed philosophy, mission, policy, and
                     procedures for project
                   Developed manuals and DVD

Community          Assessed community and population
Health Students    Provided care to at-risk populations
                   Collaborated with agency staff and colleagues

Project Members    Estimated Project        Estimated In-Kind
                   Hours Contributed        Dollars Contributed

Course             110 hours                $5,550
Instructors        (55 hours per            ($50 per hour
                   instructor)              per instructor)

Graduate           96 hours                 $2400 ($25 per hour)
Student

Leadership and     92 hours (96 hours       $3,456 ($18 per hour)
Management         per student
Students

Community          192 hours                $3,072 ($16 per hour)
Health Students    (96 hours per student)

                   Total Project Hours:     Total Project
                   590                      Contribution to
                                            Community: $14,428
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Article Details
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Title Annotation:NURSING EDUCATION RESEARCH
Author:Sims-Giddens, Susan; Helton, Caroline; Hope, Kathryn L.
Publication:Nursing Education Perspectives
Article Type:Report
Geographic Code:1USA
Date:Jan 1, 2010
Words:3134
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