Peer education is defined as the educational activities carried out by the peer students who are not professional educators but who are educated in the related subjects. It is a way for students to help each other and learn by teaching (Şenyuva & Akince, 2020). The success of peer education is closely related to good planning and organization (Ünver & Akbayrak, 2013). When peer education programs are properly planned and applied, it ensures the development of students (Andrews & Manning, 2016). Peer education application stages; determining the subject of peer education; identification of peer educators and peer learners; determining the environment where peer education will be provided (skill lab/clinic); training of peer educators; application; evaluation and feedback.

Peer education also has the potential to teach students new ways to deal with their problems (Şenyuva & Akince, 2020). It also increases academic success (Öztürk & Göçmen Baykara, 2019; Manyama et al., 2016) and general satisfaction of students (Ravanipour, Bahreini, & Ravanipour, 2015). Because students can ask their peers without hesitation and a stressfree education environment is created during peer education (Şenyuva & Akince, 2020; Ünver & Akbayrak, 2013; McKenna & French, 2011; Christiansen & Bell, 2010; Nikendei, Andreesen, Hoffmann, Obertacke, Schrauth, & Jünger, 2008). Peer education improves self-confidence, leadership characteristics, and communication skills of students. Because students gain cognitive, psychomotor and affective skills in peer education. In addition, this approach develops lifelong learning skills of students (Karimi-Moonaghi, Mirhaghi, Oladi, & Emami-Zeydi, 2015; Ramm, Thomson, & Jackson, 2015; Stone, Cooper, & Cant, 2013; Ünver & Akbayrak, 2013; Christiansen, Bjørk, Havnes, & Hessevaagbakke, 2011). It also supports personal success, provides awareness in interpersonal relations and improves internal control focus (Şenyuva & Akince, 2020).

Aldridge (2017) conducted a literature review by investigating 96 studies conducted between 1980-2016. As a result of the investigation, six themes that were effective on the psychomotor skill learning of nursing students were created. In one of these themes, it was determined that peers have an important role in skills training and students create information and support for each other in psychomotor skill teaching. Ravanipour et al. (2015) used the peer education method in teaching of medication and intravenous therapy. New learners stated that they provided more in-depth learning while learning in this way. Öztürk and Göçmen Baykara (2019) conducted a study to evaluate the effect of peer education on the teaching of nursing skills. The results indicate that the skills of students who learned in the peer group were more developed, better reinforced, and retained longer than the skills of students who learned with the present teaching methods.

The use of peer education method in skill trainings positively affects the development of students’ psychomotor skills. It is stated that the students who practice together with peer educators in skill training have a high rate of performing the skill fully on the first try. Skill trainings must be organized so as to improve problem solving skills of students as well as providing students with knowledge and skills (Tiwari, Lam, Yuen, Chan, Fung, & Chan, 2005). For this reason, active learning methods should be used in skill training to increase students’ motivation and interest in practice (Şenyuva & Akince, 2020; Ünver & Akbayrak, 2013; Çulha, 2019).

Setting
The study was carried out in the nursing department of a university. Nursing education at the university is at the undergraduate level. Each year consists of two semesters and education continues for 8 semesters. In the first three years, the lessons are carried out in theory and practice, and the fourth year is the internship period.

Procedure of the Skill Training
The skill trainings are taught in the first and second periods of the first year and in the first period of the second year. The students learn these skills on models in the laboratory before starting clinical practice. First of all, the theoretical parts of the basic nursing skills are taught to the students. Then the practices are taught by demonsrating in the laboratory environment.

The skill trainings are conducted with the instructor and the intern students who are peer educators. Although peer educators had taken nursing skills training lessons before, peer educators are re-trained about the skills about a week before the skill training. First of all, intern students are reminded about the theoretical part of the skill training and they are given the opportunity to repeatedly demonstrate the nursing skill on models in the skill laboratory. Intern students are asked to practice until they until they obtain sufficient competence in skills.

Then the practice schedule is prepared. This schedule contains the name of the students who will practice, the practice time, the name of the instructors and the peer educators. According to the practice, the instructor and peer educators work with an average of 6-12 students. The prepared schedule is announced to the students 2-3 days before the practice.

In the study, the peer education method was used in skill trainings as injections, intravenous practices, asepsis, hygiene practices, collecting samples for laboratory testing, measurement of vital signs, movement and positioning, urinary, gastrointestinal, respiratory system practices. A total of 85 hours of skill training was carried out in the skill laboratory, which is different for each skill training. Different intern students are assigned for each skill training. Different stations have been created according to the practices. For example, in gastrointestinal system skill trainings, different stations have been created for skills as nasagastric / orogastric catheter application, feeding from nasogastric / orogastric catheter, colostomy care and enema. “Basic Nursing Skills Learning Guide” is used to evaluate skills (Taşcı et al., 2018). This guideline includes the skill checklists. Through the skill checklists in this guide, it is checked whether the skill is done correctly or not; and the skill development of the student is provided in a standard way.

On the day of the practice, each intern demonstrated the nursing skills to students in its own group and each student made the basic nursing skill. In addition, intern students answered the questions of peer learners. In skill training, the intern students were never left alone. While the intern student was delivering the peer education, each intern student had an instructor. The instructors evaluated both peer learners and peer educators. The instructors ensured that each skill was performed by each student according to the skill checklist. Figure 1 shows the Practice process flow chart.

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Figure 1: Practice process flow chart.

Participants
The population of the study consisted of all nursing students who were first and second-year students (n=443). The final sample of the study consisted of 190 students (98 first-year; 92 second-year) who met the criteria to participate in the study and volunteered to participate in the study. The inclusion criteria were (1) being a first and second year nursing student and (2) voluntary and (3) participating in the nursing skill trainings with peer educators.

Firstly, the purpose of the study was explained to the students and their both written and verbal permits were taken. The students were asked to complete the questionnaire forms when all skill training was completed in April 2019.

Data Collection Tools
The data were collected using the descriptive characteristics form and student opinion form regarding peer education.

The descriptive characteristics form: This form was developed by researchers based on a literature review (Karimi-Moonaghi, Mirhaghi, Oladi, & Emami-Zeydi, 2015; Ramm, Thomson, & Jackson, 2015; Stone, Cooper, & Cant, 2013; Ünver & Akbayrak, 2013; McKenna & French, 2011; Nikendei, Andreesen, Hoffmann, Obertacke, Schrauth, & Jünger, 2008). There are 6 items in the questionnaire form as age, gender, class, family income status, place of residence during university education and need for physical, academic and emotional support of friend in education life.

Student opinion form regarding peer education: The form developed by investigating the related literature consists of 11 items as “I felt comfortable in our skill practices”, “I was able to ask questions easily to our peer educators in our skill trainings” and “my self-confidence increased in skill training with peer educators” (Karimi-Moonaghi, Mirhaghi, Oladi, & Emami- Zeydi, 2015; Ramm, Thomson, & Jackson, 2015; Stone, Cooper, & Cant, 2013; Ünver & Akbayrak, 2013; McKenna & French, 2011; Nikendei, Andreesen, Hoffmann, Obertacke, Schrauth, & Jünger, 2008). The form has been prepared in order to learn the opinions of the students about peer education in skill training. Options such as “disagree”, “undecided” and “agree” were used to answer the items in the form.

Statistical Analysis
The data were evaluated in IBM SPSS Statistics (Statistical Package for the Social Sciences) 22. Descriptive statistics are given as number (n), percentage (%), mean±standard deviation (M±SD). Intergroup categorical variable comparisons were made with chi-square analysis. p<0.05 was considered significant in all comparisons.

Ethical Considerations
Before the data were collected, written permission from the Health Sciences Faculty and ethical approval from the Ethics Committee of Social Sciences at the University (19/2018) were taken. The aim of the research was explained and written permission were obtained from the students.

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Table 1: Socio-Demographic Characteristics of the Students

In skill traning performed with peer educators; it is seen that the vast majority of students are satisfied with the skill training conducted with peer educators, because most of the students stated that they felt more comfortable (81.0%), they participated in the skill trainings willingly (82.6%) and their stress decreased during skill training (82.6%). In addition, the students said that they could form good relationships with peer educators (78.9%). 77.8% of the students said they could ask their peer educators comfortably. The students stated that they wanted peer educators in clinical practice (83.7%) because they were satisfied with this method (Table 2).

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Table 2: Opinions of Student about Nursing Skills Training Conducted with Peer Education

In Table 3 contains distribution of opinions of student on nursing skill training conducted with peer education according to their socio-demographic characteristics. According to this, it is determined that the opinions of students about peer education are similar in terms of gender, class, family income status and place of residence (p>0.05). However decreased stress of edustudents during skill training and their willing participation in skill training differs in terms of their friend’s need for physical, academic and emotional support (p<0.05). The majority of the students who needed friend support stated that they participate in the skill trainings willingly and their stress decreased during skill training.

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Table 3: Distribution of Student’ Opinions on Nursing Skills Training Conducted with Peer Education According to Their Socio-Demographic Characteristics

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Table 3: Cont.

In the literature, it is stated that peer education is an effective learning-teaching method in studies conducted by different disciplines (Karimi-Moonaghi, Mirhaghi, Oladi, & Emami-Zeydi, 2015; Ramm, Thomson, & Jackson, 2015; Stone, Cooper, & Cant, 2013; McKenna & French, 2010; Nikendei, Andreesen, Hoffmann, Obertacke, Schrauth, & Jünger, 2008). It is also stated in the studies that peer education has a great effect in increasing the willingness of students to participate in the lesson because it has entertaining and motivating characteristics (Petres, 2008). In a study searching the effect of peer education on success of the students, the students were more actively attended in the lesson, communicated more easily with their peers, expressed their ideas more easily and enjoyed the lessons. In addition, the students stated that the lessons activities were carried out in an entertaining environment. As interest of the students increased in the lesson, their success levels increased (Yeşiloğlu, Karaca, & Şimşek, 2017). In our study, in accordance with the literature, the majority of the students said that they take part in the skill trainings willingly (82.6%) and an enjoyable learning environment was created in the skill laboratory (70.0%). In addition, it was determined that the level of willingly participation in the skill trainings was higher among the students who needed peer support (p>0.05). Considering that skill trainings are carried out by both the instructors and peer educators, students may feel their peers closer to them hierarchically. Furthermore, this may be due to the fact that the laboratory is arranged to attract attention of students. In addition, it is seen that students who need peer support participate willingly in the laboratory class where they can interact with peers.

In the studies that evaluated the effectiveness of peer education; most of the participants feel more confident and knowledgeable, and their learning capacities and test performance increase (Essa, Al-Battawi, Ali Abd El Salam El Demerdash, & Elsoud Ahmed, 2018; Pålsson, Mårtensson, Swenne, Ädel, & Engström, 2017). The active participation of the students in the learning process through peer education enables them to better understand, internalize and remember what they have learned more clearly (Ünver & Akbayrak, 2013). In this study, stress of the majority of the students (82.6%) decreased due to peer educators during skill training. Furthermore, stress of the majority of the students who stated that they needed peer support decreased during skill training (p<0.05). It is thought that the students feel more comfortable because they communicate more easily with their peers during the skill trainings, not to be afraid of making mistakes and this process facilitates learning. In the literature, peer education method is a technique that facilitates learning of students as it provides active participation of students in the learning process and creates a more comfortable discussion environment (Stone, Cooper, & Cant, 2013; Ünver & Akbayrak, 2013).

Classical education method creates a hierarchical power imbalance between educators and students and in general the flow of knowledge is one-way from educator to student. However, peers find a suitable learning environment through peer education because they do not have positions to reward or punish each other (Ünver & Akbayrak, 2013). Students have a good relationship with each other in this active learning process based on collaboration, and take an active role in discussion and feedback processes (Christiansen & Bell, 2010; Secomb, 2008). In the educational activities carried out with peer education, the students stated there was a stress-free educational environment depending on the peers. So that, the students could ask questions to their peers without hesitation, the peers supported each other and therefore academic success and satisfaction of the students increased (Manyama et al., 2016; Jackson & Evans, 2012; McKenna & French, 2010; Nikendei, Andreesen, Hoffmann, Obertacke, Schrauth, & Jünger, 2008). In the current study, it was found out that the students were able to establish good relations with peer educators (78.9%), felt more comfortable in practice (81.0%) and were able to easily ask questions to their peer educators (77.8%). This situation shows that students communicate with their peers comfortably and they ask their questions comfortably and receive positive feedback in skill trainings with the idea that they have equal status.

Peer education, which enables the student to gain many benefits from the activities, improves both the self-confidence and leadership skills of the students (Pålsson, Mårtensson, Swenne, Ädel, & Engström, 2017; Ramm, Thomson, & Jackson, 2015; Stone, Cooper, & Cant, 2013; Christiansen & Bell, 2010). In a study on the use of peer education model in nursing education, it was reported self-confidence of peer educators and students increased and their motivation for teaching and learning increased (Aşcı, Gökdemir, & Çiçekoğlu, 2016). In another study conducted by McKenna and French (2011), nursing senior students stated their knowledge and confidence in teaching abilities increased and this situation is reflected in their own learning. In our study, 82.1% of the students stated their selfconfidence increased while performing the skills.

Peer education increases the communication skills of the students. In addition to increasing the interaction among students, this process positively affects students’ communication with instructors, patients and relatives of patients (Ünver & Akbayrak, 2013). Ravanipour et al. (2015), it was reported students provided much more in-depth learning with less stress in peer education compared to traditional learning methods and students were very satisfied with this situation. In our study, it stated that the majority of the students wanted peer educators during all nursing skills training (85.2%) and clinical practices (83.7%); and they also wanted to be peer educators when they were interns (81.0%).

There are studies in the literature that the level of peer support does not change according to gender (Yelten, Tanrıverdi, Gider, & Yılmaz, 2018; Çırpan & Çınar, 2013; Çalışkan & Çınar, 2010) and place of residence (Çalışkan & Çınar, 2010). In the study conducted by Yelten et al. (2018) in order to compare peer support and social self-efficacy of nursing and social science students, it was found there was no difference between the peer support levels of both male and female students. However, it was stated total scores of physical, emotional and peer support of female students in nursing were significantly higher than female students in social sciences (Yelten, Tanrıverdi, Gider, & Yılmaz, 2018). In this study, when the opinions of students on peer education were evaluated according to gender, class, family income status and place of residence there was no difference (p>0.05).

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