Peer education versus traditional education on psychomotor skills and self–efficacy in nursing students: a single–blind randomized controlled trial

Abstract

Background

Peer education (PE) refers to the process of individuals being educated by their peers, that is, people with similar experiences or statuses. This study aimed to evaluate the effects of PE on the psychomotor skills and self-efficacy of nursing students.

Methods

This single-blind randomized controlled trial was conducted with 63 undergraduate nursing students. Data were collected using the “Individual Descriptive Information Form”, “Intramuscular Injection Knowledge Level Assessment Form”, “Intramuscular Injection Psychomotor Skills Assessment Form”, and the “General Self-Efficacy Scale”. Descriptive statistics (numbers, percentages, means, standard deviations, and min–max values) were used. The independent samples t-test and Mann–Whitney U test were used to analyze differences between groups.

Results

The mean age of the participants was 21.22 ± 0.85 years (range: 20 – 23), and 52.4% were female. No statistically significant differences were found between the groups in pretest, posttest, or self-efficacy scores (p > 0.05). However, the psychomotor skill levels differed significantly between the groups (p < 0.001), with the intervention group scoring higher than the control group.

Conclusions

Nursing students who received PE demonstrated significantly better psychomotor skills than those taught using traditional methods. It is recommended to integrate interactive learning strategies such as PE, where students can express themselves more freely and actively engage in the learning process, especially in nursing education areas requiring the development of psychomotor skills.

Background

Education programs aim to equip students with cognitive, affective, and psychomotor skills during the teaching period [1]. To this end, educational strategies are broadly categorized as teacher-centered and student-centered learning approaches [2]. Teacher-centered learning tends to overlook students’ individual capabilities and promotes passive knowledge transfer [2, 3], whereas student-centered learning emphasizes not only what students learn but also how they learn, retain, and apply information [4].

Ongoing pedagogical reforms have shifted educational practices from traditional teacher-centered models toward student-centered ones, encouraging active student involvement in the learning process [5]. Accordingly, active learning strategies such as peer-supported learning, one-to-one mentoring, simulation-based training, problem-based learning, and computer-assisted education are increasingly used in nursing education [1].

Among these methods, peer education (PE) stands out as an approach in which students are taught by peers, learners who are not professional educators but possess similar educational backgrounds. PE promotes independent learning, critical thinking, psychomotor skill development, clinical competence, academic achievement, and lifelong learning [6, 7]. PE allows students to help and learn from each other by teaching, offering a range of terminology in the literature (such as PE, peer learning, cooperative learning, mentoring, peer review learning, peer coaching, peer mentoring, problem-based learning, team learning, peer-led teaching, peer-led education, peer teaching, and peer-assisted learning) depending on the context [6, 8,9,10,11]. While it often involves learners at similar academic levels, differences in experience or educational exposure are possible [12].

PE is considered an innovative, cost-effective, and beneficial instructional approach in undergraduate healthcare education [13,14,15]. It may reduce the need for extensive faculty involvement by enabling students to serve simultaneously as learners and educators [16]. Moreover, it offers creative, low-cost methods to enhance students’ learning, understanding, and the overall quality of instruction [6].

Peer educators have been associated with the development of cognitive, affective, and psychomotor skills [17], increased self-confidence [18], and improved academic performance [19, 20]. In addition to classroom and laboratory learning, students benefit from peer learning in clinical settings, where relationships and friendships facilitate engagement [21].

PE provides an environment conducive to learning by reducing stress, promoting personal achievement, increasing satisfaction, enhancing interpersonal awareness, and fostering communication and lifelong learning skills, as students feel more comfortable seeking help from peers [6, 18, 22,23,24,25,26,27,28,29,30]. Given that nursing curricula encourage the use of innovative methods and include interactive modules that support teamwork, PE is considered a suitable and effective strategy for nursing education.

Aim of the study

This study aims to assess the impact of PE on the psychomotor skills and self-efficacy levels of undergraduate nursing students. It was hypothesized that PE would have a significant effect on both psychomotor skills and self-efficacy levels.

Methods

Study design

This randomized, controlled, single-blind study was conducted with undergraduate nursing students at a university in Southeastern Turkey.

Setting and participants

The population consisted of 2nd-year nursing students (N = 84) who were enrolled in the Medication Practices in Nursing (MPN) course for the first time. Using G*Power (version 3.1.9.7), the minimum required sample size was calculated as 58 (effect size = 0.8, power = 0.90, α = 0.05), with 29 students per group [31]. To minimize the impact of data loss, all eligible students who volunteered, actively participated in the course, and completed the lab training were included in the sample (n = 66).

Stratified randomization was applied based on gender and academic grade point average, and participants were then randomly assigned to either the intervention group (IG) or control group (CG). The study was completed with 63 students, as two from the IG and one from the CG did not attend the intramuscular injection (IMI) training session.

Data collection tools

Individual Descriptive Information Form (IDIF)

This form consisted of questions about the demographic characteristics of the students.

Intramuscular Injection Psychomotor Skills Assessment Form (IMIPSAF)

This 50-item checklist was also developed by the authors for this study, drawing upon the relevant literature [32,33,34], to evaluate students’ psychomotor skills in performing IMI in the ventrogluteal site (VGS). After the training, a blinded researcher assessed students in a laboratory setting. The IMIPSAF was completed by this independent observer during each student’s simulated performance. Each item was scored as follows: 2 = Adequate (performed completely and correctly), 1 = Partially Adequate (performed incompletely or incorrectly), and 0 = Inadequate (performed inaccurately or not at all), with a total possible score ranging from 0 to 100.

Similar to our study, Öztürk and Baykara [19] calculated the overall psychomotor skills score as the sum of all checklist items. The content validity of the IMIPSAF was established through expert review by 10 nursing academicians prior to implementation. An English version of the IMIPSAF is provided as Supplementary File S2.

General Self-Efficacy Scale (GSES)

Originally developed by Sherer et al. (1982) [35] and adapted to Turkish by Yıldırım and İlhan [36], this 17-item, 5-point Likert-type scale includes three subdimensions: Initiative, Persistence, and Effort. Eleven items are reverse-coded. Higher scores indicate stronger self-efficacy (range: 17–85).

Selection and training of peer teachers

Ten 4th-year nursing students with high grade point averages were invited to serve as peer teachers; four volunteered. These students received training in PE methods, professional traits, and IMI application in the VGS. After theoretical and practical training, their skills were assessed three times by the researcher. The student demonstrating full proficiency was selected as the peer teacher.

Data collection

The study was conducted in seven stages (Fig. 1):

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Stage 1 - Peer teacher training: The selected peer teacher received a 2-week preparatory course.

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Stage 2 - Pretest and consent: Students were informed, written and verbal informed consent obtained, and IDIF and IMIKLAF administered.

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Stage 3 - Theoretical training: A lecturer delivered instruction on IMI at the VGS.

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Stage 4 - Randomization: Block randomization based on gender and GPA assigned students to IG or CG.

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Stage 5 - Lab training: Two weeks later, IG received IMI training from the peer teacher, CG from the lecturer. Both groups received training in a laboratory equipped with a part-task trainer model (hip model) and all standard materials required for IMI practice. The instructional methods were identical for both groups; the only difference was the type of instructor (peer educator vs. faculty member). The laboratory sessions were repeated until students demonstrated adequate performance, and the overall time allocation was comparable between groups.

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Stage 6 - Posttests: Two weeks after lab training, IMIKLAF and GSES were re-administered.

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Stage 7 - Psychomotor assessment: A blinded researcher evaluated IMI skills using the IMIPSAF checklist.

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Data analysis

Data were analyzed using SPSS 26.0 (IBM Statistical Package for the Social Sciences, Armonk, NY, ABD) at a 95% confidence level (α = 0.05). Descriptive statistics included frequencies, percentages, means, standard deviations, and range. Normality was assessed with Kolmogorov–Smirnov and Shapiro–Wilk tests.

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Variables with normal distribution (pretest, posttest, self-efficacy) were analyzed with the independent samples t-test.

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Non-normally distributed variables (psychomotor skills scores) were analyzed using the Mann–Whitney U test.

Results

This study was conducted with a total of 63 students. The mean age of the participants was 21.22 ± 0.85 years (range: 20–23), and 52.4% of them were female. The groups were comparable in terms of age, gender, GPA, and prior IMI experience (p > 0.05 for all) (Table 1).

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Table 2 presents the distribution of scores obtained from the IMIKLAF, GSES, and IMIPSAF by group, both pre- and post-intervention. There were no statistically significant differences between the IG and the CG in:

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Pretest knowledge scores (p > 0.05),

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Posttest knowledge scores (p > 0.05), although the CG had a relatively higher mean score,

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Self-efficacy scores (p > 0.05), although the IG had a relatively higher mean score.

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However, psychomotor skill levels differed significantly between the groups (U = 122, Z = −5.146, p < 0.001), with the IG showing higher scores (Median = 73.0, IQR = 6) compared to the CG (Median = 52.5, IQR = 20).

Discussion

Psychomotor skill development is a crucial component of nursing education [37]. For many years, educators have explored diverse instructional strategies to enhance these skills and integrate them into nursing curricula [38,39,40,41,42]. However, there is no universally accepted method for teaching psychomotor skills most effectively [43]. Methods that encourage active student participation are considered essential for the success of skill acquisition. In this context, PE, which allows interactive participation, is recognized as an effective approach to enhance both psychomotor skills [19, 44] and self-efficacy [45, 46] in nursing students.

Patient safety, a key concern in healthcare delivery, includes the prevention of errors and mitigation of harm to patients [47]. One core component of patient safety is safe medication administration, which has drawn global attention in recent years [48, 49]. Within this framework, using the VGS for IMI instead of the dorsogluteal site is emphasized [50, 51]. Studies have revealed significant deficiencies among nurses and nursing students in performing safe IMI practices [52, 53], with most still avoiding the VGS [50, 54, 55]. This underscores the importance of providing students with opportunities to acquire skills in realistic and safe learning environments [48]. Accordingly, there is a growing body of research evaluating the effects of non-traditional teaching methods, including PE, on students' VGS performance and self-efficacy [38,39,40,41,42]. Our study contributes to this body of evidence.

Previous research has shown that PE in both theoretical and clinical nursing education enhances students’ skill development [27, 56, 57], while also improving their self-confidence and self-efficacy [58, 59]. Furthermore, students trained by peer teachers report high satisfaction, enjoy the learning process, and perceive peer learning as effective for skill acquisition and comprehension [60,61,62]. In line with these findings, our study revealed that students in the IG demonstrated significantly higher psychomotor skill levels than those in the CG, whereas no significant difference was observed between the groups in self-efficacy scores.

Additionally, both groups improved their IMI knowledge levels following the lab-based hands-on training, with no significant difference between the IG and CG posttest scores. This suggests that the peer teacher provided training of equal quality to that of the lecturer. Self-efficacy is defined as an individual’s belief in their ability to use the necessary knowledge and skills to achieve a specific goal [63]. The development of self-efficacy is influenced by several factors, such as self-perception, family attitudes, academic achievement, the need for self-efficacy, and past experiences. Self-efficacy is shaped by cognitive, emotional, and environmental factors [64]. Therefore, due to the inherent nature of self-efficacy development, differences in these factors among students may have prevented the present study from fully demonstrating the impact of peer education on self-efficacy. Moreover, Zhao et al. (2021) reported that short-term training programs had only limited effects on self-efficacy, whereas significant differences were observed in long-term follow-ups [65]. In this context, the limited effect of peer education on self-efficacy observed in the present study may also be attributed to the short follow-up period.

Psychomotor skill training reinforces theoretical knowledge through repetition, and this is reflected in the overall knowledge improvement in both groups. A notable strength of this study is that the laboratory environment and instructional content were standardized across both groups. The laboratory was equipped with a hip model and all necessary materials for IMI training. Both the peer educator and the faculty member used the same teaching methods, and the sessions were repeated until students achieved adequate performance. Thus, the only difference between the groups was the type of instructor, which ensured a fair comparison of outcomes. The autonomy and active involvement enabled by PE may have contributed to the higher psychomotor performance observed in the IG. Students were able to take responsibility for their own learning, identify areas for improvement, and practice in a supportive environment. Shaaban and Mohamed (2020) reported that peer teaching reduces faculty workload, allowing more time for feedback and observation processes [60]. Arasappa Vishwanath et al. (2025) emphasized that peer learning creates a safe environment among students, fostering communication, critical thinking, and teamwork skills [66]. Vae et al. (2017) stated that, considering the number of students and financial costs, peer education is a cost-effective method that enables individualized attention, feedback, and correction of practice errors [67]. Although no significant difference was found in theoretical knowledge levels in our study, the intervention group demonstrated a significant advantage in psychomotor skills. This finding suggests that peer education can be used as an effective, sustainable, and resource-saving method in nursing curricula, supporting the results of previous research.

Other studies support our results: Ünver and Akbayrak [27], Moore and Teather [57], and Demir et al. [68] found that learning with peers reduces anxiety and facilitates skill acquisition by providing a safe environment for trial and error. Similarly, Öztürk and Baykara [19] reported that students who received PE performed more complex skills more effectively and retained knowledge better. Sabaq et al. [69] demonstrated significant performance improvement among 3rd-year nursing students trained with PE in pediatric cardiopulmonary resuscitation training. These students also reported lower anxiety and better communication skills. Pehlivan Coştu and Bilgiç [70] found that peer-led instruction was as effective as faculty-led teaching in skill development. Likewise, Shaaban and Mohamed [60] concluded that nursing students who received PE had comparable knowledge and performance outcomes to those trained by lecturers, validating PE as an efficient strategy for nursing education.

Strengths and limitations

This study has several limitations. First, it was conducted at a single institution with a relatively small sample size, which may limit the generalizability of the findings to other nursing student populations. Second, although randomization was used, the potential for unmeasured confounding variables (such as students’ prior clinical exposure or learning styles) cannot be completely ruled out.

Third, psychomotor skills were assessed in a simulated laboratory environment, which may not fully reflect students' actual performance in real clinical settings. Additionally, self-efficacy was measured through self-report, which may be subject to social desirability bias.

Finally, the study did not include a long-term follow-up to assess the sustainability of the knowledge and skills gained through PE. Future studies with larger and more diverse samples, multi-center designs, and longitudinal assessment are recommended to validate and expand upon these findings.

Despite these limitations, a strength of the study is that the laboratory environment, instructional content, and duration were standardized across both groups, ensuring that the only difference between them was the type of instructor (peer educator vs. faculty member).

Conclusions

Laboratory practices conducted with peer support help nursing students gain practical skills and feel more competent during the skill acquisition process. PE allows students to take an active role in their learning, develop knowledge and skills in a low-anxiety environment, and feel comfortable asking questions and making mistakes, which are essential components for effective psychomotor learning and self-efficacy.

Students trained by peers improve their skills without the fear of educator judgment, fostering a more autonomous and confident learning experience. PE creates a supportive environment where students recognize their learning needs, take initiative, and collaborate effectively.

In this study, students in the IG demonstrated significantly higher psychomotor skill levels than those in the CG, while no significant difference was observed in self-efficacy levels between the groups.

It is recommended that future studies explore the effects of various interactive teaching models on students’ psychomotor skill development and self-efficacy, possibly by incorporating additional comparison groups exposed to different instructional approaches.

Data availability

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Abbreviations

PE:

Peer education

MPN:

Medication practices in nursing

IG:

Intervention group

CG:

Control group

IMI:

Intramuscular injection

IDIF:

Individual descriptive information form

IMIKLAF:

Intramuscular injection knowledge level assessment form

IMIPSAF:

Intramuscular injection psychomotor skills assessment form

VGS:

Ventrogluteal site

GSES:

General self-efficacy scale

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