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Peer learning and ethics in nursing education

In order for nursing education to be effective, many teaching methods are used. One of these methods is peer learning. Peer learning is defined as assisting an individual who is from the same social group and is not a professional educator in the learning process of other individuals. The use of peer learning in the field of nursing is increasing day by day. The studies investigating the use of peer learning emphasize the advantages and disadvantages. Although there are many positive aspects of peer learning, it should not be forgotten that using peer learning in nursing education may lead to ethical problems if not well planned. These ethical problems can be confronted in terms of both the individual receiving care, the student and the peer mentor. Peer learning can be used as an effective teaching method in nursing education when well planned and audited.


Introduction
Nursing is a discipline that provides prevention of illness and disability, treatment of diseases, alleviating of suffering through the diagnosis and treatment, protection of health, health promotion and optimization of health and abilities in individuals, families, groups, communities and populations (American Nurses Association, 2017). In order to fulfill these roles and duties, each country sets the standards of basic nursing education and nurses are trained in accordance with these standards (www.icn.ch, 2017). The aim of nursing education in our country is to train professional nurses who are susceptible any changes and developments affecting the health of individuals, families and societies, assess the nursing care needs, practice nursing care and evaluate outcomes of the care. Additionly, trained nurses are responsible for ethic codes while fulfilling nurse roles and duties (Turkish Higher Education Institution Nursing Commission Education Group, 2014).
In order for nursing education to be effective and to achieve the mentioned objectives, many teaching methods are used in theorical and clinic education. Peer learning is one of these teaching methods. The aim of this review article is to explain what peer learning is used as a teaching method in the nursing education and to examine the ethical dimension of this topic.

Peer Learning
Peer is used to mean of "in terms of age, occupation, social situation, etc. equal each other" (Turkish Language Society, 2017). Peer learning is defined as assisting an individual who is from the same social group and is not a professional educator in the learning process of other individuals. In other words, a more knowledgeable and talented students transmit that they learned less wellinformed learners (Topping, 1996).
Peer learning is defined as in the literature "peer counseling" (Salamati, Naji and Rostami 2014), "peer coaching" (Yava & Sütçü Çiçek, 2016), "peer-assissted learning" (Nestel & Kidd, 2005), "peer learning partnership" (Goldsmith, Stewart, & Ferguson, 2006;Loke & Chow, 2007). In this article, the use of the words "student for the junior student" and "peer mentor for the senior student" has been adopted in peer learning. The foundations of peer learning date back to the Ancient Greek era (Topping, 1996). The pedagogical origins of peer learning, which has been used in teacher education for about 20 years (Yava & Sütçü Çiçek, 2016), come from theoreticians such as Piaget and Perry, who emphasize to obtain information the importance of social interaction, cooperation and non-evaluation in the learning process (Secomb, 2008).
There are advantages and disadvantages of adopting peer learning as a teaching method. Peer learning gives responsibility student and peer mentor of learning and teaching process. Thereby this process facilitates collaborative learning process, enables learners to discover the inadequacies and corrects misinformation (Loke & Chow, 2007). Secomb (2008) conducted a review of the effects of using peer learning on clinic education. It has been determined that with peer learning the students have developed their cognitive and psycho-motor skills, their satisfaction with the learning process and has increased their confidence and academic achievement. Moreover, it has been determined that it is effective on students' autonomy, leadership skill and professional behavior. In addition to these positive effects, peer learning has also increased competition among students in areas of critical thinking, cooperation, communication and technological skills in students. Students are exposed to difficulties and differences, and the development of peer mentors is provided (Smith, 2013b).
The disadvantages of peer learning include the need to integrate the system into the curriculum, the need for time, such as peer mentors' education, peer-student matching, and the cost of educating peer mentors' in the short term, making peer mentors never achieve a professional educator' competence (Topping, 1996). It has also been determined that students and peer mentors are disappointed in their peer learning process due to their passivity, inadequate knowledge levels, and conflicts between them (Loke & Chow, 2007). Mete et al. (2011) determined some disadvantages in their study about peer learning for peer and student. These are peer' negative approach to student, peer' anxiety about inability to put border the student, fear of making mistakes and anxiety about not being role model to student. Also qualitative study of Li et al. (2011) showed that peer learning have disadvantages in terms of peer, student and teacher. Peers complained about student many question, so not having enough time for his/her own patient and afraid of lack of knoledge and skills. Teacher complained about difficulty of matching suitable peer-student and making arragement for peer and student.
Peer learning is not done by individuals or peer co-operation at the same level. To implement peer learning, it is necessary to provide three basic components. These; the availability of the peer mentor/ the meeting of the peer mentor and student, the knowledge/skill that the peer mentor has recently learned student is learning now, and the role of the peer to give to an professional educator or institution. Graduated individuals, professional educators, institutional staff or guest professional educators can not be peer mentor of an student at the undergraduate (Smith, 2013a). The application phase of peer learning consists of 10 steps. These steps (Yava & Sütçü Çiçek, 2016): 1. The new knowledge/skills to be learned are determined and drawed its boundaries. 2. New knowledge/skills that should be taught absolutely are determined. 3. New knowledge/skills' steps for practicing are determined. 4. New knowledge/skills are teached in the appropriate theoric course hour. 5. New knowledge/skills are implemented in practical training. 6. Each peer mentor perform the application and professional educators responsible for peer learning control the peer mentors. 7. Peer mentors and students to apply new skills together. 8. Peer mentors give students feedback (not as a note). 9. Peer learning process is evaluated by the professional educators responsible for peer learning (questioning-questionnaire-skill questionnaire). 10. Peer mentors and students evaluate themselves.
It is necessary for the role to be well defined and to set boundaries so that the peer mentor does not enter into the role complexity in peer learning. Some elements have been identified for these boundaries. These elements are; peer mentor can not grade other students, not reach student and examination informations, not give a teoric lecture, not take responsibility for in instituion affairs and not thinked separately from other students by professional educators (Smith, 2013a).

Peer Learning in Nursing Education
In nursing education, it is necessary to use different teaching methods with traditional methods in order to ensure the development of students in theoretical and applied courses. Peer learning is one of the teaching methods used in nursing clinical education (Ünver & Albayrak, 2013). It is stated that peer learning can be used as an effective method in clinical education of nursing students if well-structured and measured standards are developed. Because peer learning, which is used in nursing education, is a method that enables the peer mentor and the student learned knowledge in the theoretical courses to clinical practice through mutual learning-teaching principles (Yava & Sütçü Çiçek, 2016).
The use of peer learning in nursing education has the responsibilities of student, peer mentor and professional educator (Mete, İsbir, Tokat, & Vural, 2011). These responsibilities are shown in Figure 1. It has been reported in many studies that peer learning is an effective method of education and can be used in nursing clinical education (Hurley et al., 2003;Goldsmith et al., 2006;Loke & Chow, 2007;Çalışkan & Çınar, 2010;Stenberg & Carlson, 2015;Bagnasco et al., 2012;Yava & Sütçü Çiçek, 2016). In the study conducted by Goldsmith et al. (2006), most of the students stated that they expressed to feel more comfortable about receiving and giving feedback. In the study, peer consultants expressed to check their knowledge and skills. The study conducted by Hurley et al. (2003) indicates that the students' achievement level of the exam increases. In another study, the students emphasized that peer learning enhanced trust in themselves, motivation to achive their aims, sense of responsibility, and personal growth (Bagnasco et al., 2012).
In the peer learning process, it is stated that both the students and the peer mentors have attainments. Peer learning gives peer mentors more in-depth knowledge as they teach, demonstrate and discuss what they have learned before (Ünver & Albayrak, 2013). In a study by Loke and Chow (2007), both students and peer mentors noted that learning and thinking skills improved, problemsolving and critical thinking skills improved, and they were more systematic in their learning. Working together and supporting each other in peer learning has been shown to be effective in reducing the anxiety that students have when they go to a new clinical setting (Stenberg & Carlson 2015). In addition, peer mentors facing a number of questions during the implementation process is being a driving force in terms of re-organizing their knowledge and improving themselves (Ünver & Albayrak, 2013).
Li and colleagues (2011) reported in their study, students benefited academically from their peer mentors, while peer mentors expressed that they were constantly asking questions rather than searching, so peer mentors could not find time to care for their patients. Professional educators who directed peer learning emphasized that it is difficult to find a suitable peer mentor and student when there is a large gap in the sense of information among student and peer mentor. Mete  Şimşek Arslan, B., Göktaş, A. & Buldukoğlu, K. (2017). Peer learning and ethics in nursing education. Journal of Human Sciences, 14(3), 2999-3005. doi:10.14687/jhs.v14i3.4767 colleagues (2011) found that, in addition to the personal and professional gains of peer mentors, they also experienced an inability to limit students, fear of making mistakes, and worry about not being a good role model.

Peer Learning and Ethics in Nursing
Despite the many positive aspects of peer learning on peer mentor and student, their use in nursing education can lead to ethical problems. This is because the students continue their education under the supervision of teaching staff or clinical nurses and taking responsibility for patient care. In this section ethical problems that may arise are examined in the framework of Ethical Principles and

In terms of individuals receiving care;
Failure to properly train peer mentors or to effectively implement the model may lead to misinformation of the student and to the provision of non-professional advice (Ünver & Albayrak, 2013). This may be an ethical problem that may adversely affect patient care and harm the patient. Moreover, the use of peer learning in nursing schools where the number of professional educators is inadequate can be an ethical problem. In such cases, the inadequacy should not be tried to be solved by peer learning. The success of peer learning is closely related to a sufficient number of professional educators experienced in this regard (Ünver & Albayrak, 2013). This may be due to the fact that the peer mentor, who is not under the control of the professional and experienced professional educator, can teach the student wrong konowledge and skills. Practices made with the wrong knowledge and skills will harm the individual who is being care. This can be regarded as a sign that the nurse is not taking into account the principle of non-harmfulness (Turkish Nurses Association, 2009).

In terms of students;
The main ethical problem is the risk of receiving education from an inadequate peer mentor in terms of the knowledge and experience. The question that comes to mind here is that peer mentors will not be as successful as professional educators. It should always be kept in mind that peer mentors can not be like professional educators (Ünver & Albayrak, 2013). Loke and Chow (2007) found that students in their study did not have enough knowledge to answer the questions posed by students. Also, some students stated that the information of the peer mentors was inadequate and they could not answer their questions. In another research, a peer learning program that matched the first and third grades in nursing clinical practice was applied. In this program, professional professional educators have had difficulty in making students' clinical application charts. Due to this diffuculty, third-year students have not had enough time to prepare for clinic education (Goldsmith, Stewart, & Ferguson, 2006). Peer learning practices that are not well planned and that do not have proper clinical schedules are not ethical in the sense that they mean interacting with a poorly prepared peer mentor. Because every educator is obliged to observe the development of the student in education and to treat him equally and fairly (Turkish Ministry of Education, 2015).

In terms of peer mentors;
When the subject is examined in terms of peer mentors, the roles given to peer mentors not be limited, they can lead to ethically risky situations. These risky situations are;  The peer mentor may be forced to fulfill roles related to non-missionary administrative and educational processes. In this case, the professional educators load their roles and responsibilities to the peer mentors. This can cause the professional educator' professional identity to use peer mentor for personal interests (National Education Association, 2010).  If the role of the peer mentors are not limited, some information (such as exam questions, grades, student records) that should be kept confidential about the students can be accessed by peer mentors. Access to this information by the peer mentors are against the principle of keeping the information about the student confidential from the professional ethical principles for the educators (Turkish Ministry of Education, 2015).  Trainers may ask peer mentors to give students' achievement grades. This may lead to a miscalculation of the student due to the attitude of the peer mentor and to the failure to comply with the principle of "fair and equal behavior for every student" (National Education Association, 2010; Turkish Ministry of Education, 2015).

Conclusion and recommendations
Peer learning is a method used for long-term student education. The use of nursing education is increasing day by day. In recent years, the number of studies on peer learning in the field of nursing has been increasing. These studies show that peer learning is an effective teaching method that can be used in the field of nursing. Peer learning has advantages and disadvantages as it is an effective method that can be used in nursing education. Ethical problems can arise from the point of view of the individual care recipient, student, and peer mentor when peer learning implementation steps are not taken into account and the student, the peer mentor and the professional educators do not fulfill the responsibilities. For this reason, it is suggested that the institutions that maintain nursing education with peer learning pay attention to the steps of peer learning application, and check whether the student, the peer mentor and the professional educators fulfill their responsibilities.