The effect of near-peer-assisted learning on self-efficacy and clinical performance of undergraduate nursing students during clinical internship: A quasi-experimental study

Copy igh © 2025 Zanjan Uni e si y o Medical Sciences. Published by Zanjan Uni e si y o Medical Sciences. This wo k is licensed unde a C ea i e Commons A ibu ion-NonComme cial 4.0 In e na ional license (h ps://c ea i ecommons.o g/licenses/by- nc/4.0/). Noncomme cial uses o he wo k a e pe mi ed, p o ided he o iginal wo k is p ope ly ci ed. The e ec o nea -pee -assis ed lea ning on sel -e icacy and clinical pe o mance o unde g adua e nu sing s uden s du ing clinical in e nship: A quasi-expe imen al s udy Zoh eh Badiyepeymaiejah omi1, Mohsen Faselehjah omi2, Sasan Rahmanian3* Mohsen Hoja 1 1Depa men o Medical-Su gical Nu sing, School o Nu sing, Jah om Uni e si y o Medical Sciences, Jah om, I an 2Depa men o Communi y Heal h Nu sing, School o Nu sing, Jah om Uni e si y o Medical Sciences, Jah om, I an 3Depa men o Psychia ic Nu sing, School o Nu sing, Jah om Uni e si y o Medical Sciences, Jah om, I an A icle in o Abs ac In oduc ion Nu sing educa ion se es as he ounda ion o de eloping a skilled wo k o ce capable o mee ing public heal h needs; he e o e, any sho comings in his educa ion can signi ican ly impac he quali y o pa ien ca e [1]. A subs an ial po ion o nu sing s uden s' aining occu s in clinical se ings. The p ima y goal o his clinical educa ion is o p epa e s uden s o hei essen ial p o essional esponsibili ies, enhance hei accoun abili y, and os e hei abili y o wo k independen ly [2, 3]. Sel -e icacy in clinical pe o mance plays a c ucial ole in a s uden 's abili y o p o ide independen pa ien ca e. Fo nu sing s uden s, sel -e icacy encompasses hei con idence in execu ing ou ine nu sing asks, while clinical pe o mance sel - A icle his o y: Recei ed 4 Aug. 2024 Accep ed 23 Ap . 2025 Published 13 Jul. 2025 Badiyepeymaiejah omi e al. J Med Edu De . 2025; 18(2): 27-35 Jou nal o Medical Educa ion De elopmen Backg ound & Objec i e: T adi ional clinical educa ion me hods ha e no been e ec i e in imp o ing s uden s' clinical pe o mance. Implemen ing nea -pee assis ed lea ning could help add ess many o he challenges nu sing s uden s encoun e in hei pu sui o e ec i e lea ning.This s udy aims o de e mine he e ec o nea -pee -assis ed lea ning on sel -e icacy and clinical pe o mance o nu sing s uden s du ing clinical in e nships. Ma e ials & Me hods: This s udy u ilized a quasi-expe imen al design wi h a pos - es con ol g oup. The s a is ical popula ion included all nu sing s uden s pa icipa ing in clinical in e nships a Jah om Uni e si y o Medical Sciences om 2021 o 2023, o aling 93 s uden s selec ed h ough a census me hod. The in e en ion g oup, comp ised o 52 s uden s, pa icipa ed in nea -pee assis ed lea ning, while he con ol g oup o 41 s uden s ecei ed adi ional ins uc ion om uni e si y ins uc o s. S uden s' sel -e icacy was e alua ed using he s anda d sel -e icacy in he clinical pe o mance ques ionnai e; hus, clinical pe o mance was assessed using he Objec i e S uc u ed Clinical Examina ion (OSCE) sco es a he end o each pe iod. Da a analysis was pe o med using SPSS 22, he - es o mean sco e compa isons, and Chi-squa e es o quali a i e da a. Resul s: The mean sel -e icacy sco es we e 139.16 ± 0.57 and 109.65 ± 0.89 o he in e en ion and con ol g oups in pos - es , espec i ely. The mean OSCE sco es we e 5.09 ± 0.29 and 4.85 ± 0.76 o he in e en ion and con ol in pos - es . The independen - es e ealed a s a is ically signi ican di e ence in he mean sel -e icacy sco es be ween he wo g oups (p < 0.001, E ec Size = 0.95). Howe e , no signi ican di e ence was ound in he mean OSCE sco es be ween he g oups (p = 0.061, E ec Size = 0.43). Conclusion: The nea -pee assis ed lea ning me hod has a mo e signi ican impac on he sel - e icacy o nu sing s uden s du ing clinical in e nships compa ed o adi ional eaching me hods. Fu he mo e, his app oach can be as e ec i e as ins uc o -led aining in enhancing s uden s' clinical pe o mance. The e o e, i is ecommended o in eg a e his me hod wi h o he educa ional app oaches o u he imp o e clinical pe o mance among nu sing s uden s. Keywo ds: clinical educa ion, pee -assis ed lea ning, sel -e icacy, cinical pe o mance, nu sing s uden s *Co esponding au ho : Mohsen Hoja , Depa men o Medical-Su gical Nu sing, School o Nu sing, Jah om Uni e si y o Medical Sciences, Jah om, I an Email: mohsenhoja [email protected] O iginal A icle How o ci e his a icle: Badiyepeymaiejah omi Z, Faselehjah omi M, Rahmanian S, Hoja M. The e ec o nea -pee - assis ed lea ning on sel -e icacy and clinical pe o mance o unde g adua e nu sing s uden s du ing clinical in e nship: A quasi-expe imen al s udy. J Med Edu De . 2025; 18(2): 27-35. [ DOI: 10.61882/edcj.18.2.27 ] [ Downloaded om edujou nal.zums.ac.i on 2025-10-03 ] 1 / 9 Badiyepeymaiejah omi e al . : The e ec o nea -pee -assis ed lea ning on sel -e icacy and clinical pe o mance 28 Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025 e icacy speci ically e e s o hei belie in hei capabili y o pe o m a ious clinical skills. The impo ance o sel -e icacy in clinical se ings is linked o i s impac on u u e pe o mance [4]. Despi e he impo ance o he subjec , s udies indica e ha nu sing s uden s ained h ough adi ional clinical educa ion me hods o en lack he necessa y p ac ical skills and e iciency in eal wo k en i onmen s, leading o challenges in pe o ming hei job du ies. In his model, s uden s engage wi h ins uc o s in small g oups du ing an 8-hou clinical shi [5]. E ec i e lea ning equi es he suppo and collabo a ion o ins uc o s, men o s, pee s, and o he esou ces, each p o iding unique oppo uni ies o add ess s uden s' lea ning needs. Gi en ha eaching is an ac i i y ocused on c ea ing and acili a ing lea ning o s uden s, i is e iden ha selec ing e ec i e eaching me hods plays a c i ical ole in enhancing he lea ning p ocess [6, 7]. The e a e a ious ypes o mode n aining o nu sing skills using educa ional models; such as explo a o y educa ion model, bedside eaching and need-based educa ion, p oblem-sol ing-based educa ion, coope a i e educa ion and pee -assis ed lea ning [8]. Nume ous s udies ha e been conduc ed o imp o e he quali y o educa ion, and some ha e iden i ied Pee -Assis ed Lea ning (PAL) as an e ec i e s a egy o add essing challenges and enhancing lea ning ou comes [9]. PAL is oo ed in social lea ning heo ies, which asse ha expe iences, unde s anding, and knowledge a e de eloped h ough in e ac ions among indi iduals [10]. PAL ollows he cons uc i is lea ning app oach and is one o he eaching-lea ning me hods used in a ious academic p og ams and age g oups [9]. This me hod includes wo models: using nea pee s o pa ne pee s in educa ion. Nea pee s a e s uden s who a e always a a highe le el, academically o in clinical expe ience, by a leas one yea compa ed o he s uden s hey a e eaching. The dis inc ion be ween nea -pee -assis ed lea ning and pa ne pee -assis ed lea ning lies in he ac ha pa ne pee s a e a he same academic le el as he s uden [11]. Pee -assis ed eaching has been used in heo e ical ins uc ion, labo a o y se ings, clinical skills cen e s, and in e nships [12-15]. The ad an ages o his me hod include enhancing s uden s' ime managemen , communica ion, and eaching skills. I deepens lea ning and p omo es an ac i e, collabo a i e lea ning s yle, imp o es es sco es, and p epa es s uden s o highe - le el exams. Addi ionally, i boos s sel -con idence, educes s ess du ing ques ioning o exams, ein o ces ime managemen skills, p o ides con inuous access o educa ional ac i i ies, and gene ally inc eases cos - e ec i eness and e iciency [16]. In PAL, since s uden s a e mo e amilia wi h each o he 's educa ional needs and can be e unde s and each o he 's lea ning p ocesses compa ed o any ins uc o , hey help each o he mo e e ec i ely du ing he lea ning p ocess [11]. Each clinical educa ion expe ience no only in ol es acqui ing speci ic knowledge o p ac ical skills bu also enhances s uden s' con idence in hei p o essional abili ies, a concep known as sel -e icacy. The p ima y goal is o ele a e s uden s o he highes le el o lea ning, which is p o essional compe ence. Sel -e icacy a ec s many impo an aspec s o mo i a ion, such as ac i i y choice, e o le el, pe sis ence, and emo ional eac ions, and can be a ac o in s uden s' academic success [17]. Gi en ha he goal o medical educa ion is o enhance s uden s' clinical sel -e icacy, and in ligh o cu en challenges in medical acul ies—such as inc eased s uden admissions, a sho age o a ailable ins uc o s, and limi ed ins uc o p esence in educa ional se ings— he e is an u gen need o guidance and suppo o s uden s by le e aging he capabili ies o senio s uden s. Employing his me hod appea s o be a iable solu ion o add ess some o hese challenges. Howe e , despi e he bene i s o PAL, exis ing s udies p esen con lic ing esul s ega ding i s impac on s uden s' lea ning [11, 13, 23, 25] and sel -e icacy [4, 17, 21], indica ing a need o u he esea ch. This s udy aims o de e mine he e ec o nea -Pee -Assis ed Lea ning (nea -PAL) on he sel - e icacy and clinical pe o mance o nu sing s uden s du ing hei in e nships a Jah om Uni e si y o Medical Sciences. Ma e ials & Me hods Design and se ing(s) This s udy was a quasi-expe imen al s udy wi h a pos - es con ol g oup design conduc ed a Jah om Uni e si y o Medical Sciences. Pa icipan s and sampling The s a is ical popula ion consis ed o all nu sing in e nship s uden s a Jah om Uni e si y o Medical Sciences du ing he i s semes e s o he academic yea s 2021-2022 (52 s uden s in he in e en ion g oup) and 2022-2023 (41 s uden s in he con ol g oup), o aling 93 pa icipan s selec ed h ough a census me hod. Gi en he limi ed numbe o s uden s, he census me hod was app op ia e. The s uden s comple ed clinical in e nship cou ses in adul /elde ly nu sing, nu sing ca e in In ensi e Ca e Uni s (ICUs), and Ca diac Ca e Uni s (CCUs). To [ DOI: 10.61882/edcj.18.2.27 ] [ Downloaded om edujou nal.zums.ac.i on 2025-10-03 ] 2 / 9 Badiyepeymaiejah omi e al . : The e ec o nea -pee -assis ed lea ning on sel -e icacy and clinical pe o mance Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025 29 mi iga e he isk o in o ma ion leakage, he s udy ocused on wo g oups o i s -semes e s uden s due o he small size o in e nship s uden s in each yea . The inclusion c i e ia we e unde g adua e nu sing s uden s en olled in clinical in e nships du ing he academic yea s 2021 and 2023, in o med consen o pa icipa e in he s udy, i s - ime en ollmen in he in e nship cou se, and no p e ious educa ion o employmen in o he medical sciences ields. Exclusion c i e ia we e wi hd awal om he s udy, academic lea e, s uden ans e , and excessi e absen eeism om he cou se. All s uden s pa icipa ed in he s udy, and none we e excluded. Tools/Ins umen s The clinical pe o mance sel -e icacy ques ionnai e consis ed o 37 ques ions di ided in o ou domains: "pa ien assessmen " (12 ques ions), "nu sing diagnoses and planning" (9 ques ions), "implemen a ion o he ca e plan" (10 ques ions), and "e alua ion o he ca e plan" (6 ques ions). Responses we e measu ed using a i e-poin Like scale, anging om "s ongly disag ee" o "s ongly ag ee." Each ques ion was sco ed om 1 o 5, wi h he o al sco e anging om 37 o 148, whe e a highe sco e indica ed be e sel -e icacy. The Clinical Pe o mance Sel -E icacy Ques ionnai e was de eloped by Che aghi e al. This ques ionnai e was compiled based on a quali a i e esea ch and con en analysis o indi idual and g oup in e iews, as well as a e iew o a ailable sou ces. Con en alidi y, ace alidi y and ac o analysis o he da a ob ained in he esea ch we e con i med. The concu en alidi y o he "clinical pe o mance sel -e icacy" ool wi h he "gene al sel - e icacy" ool was con i med (p < 0.01, = 0.73) along wi h a C onbach's alpha coe icien o 0.96 [17]. The OSCE was designed by cou se ins uc o s p o icien in he OSCE me hodology, in ol ing se e al sessions o de elop he exam bluep in , checklis s, passing sco es, and implemen a ion and supe ision p ocedu es. To p epa e a bluep in o he es , he a ious dimensions we e ou lined o add ess he lea ning needs and capabili ies o in e nship s uden s. Ins uc o s we e eques ed o submi hei ques ions based on hese dimensions o he g oup manage , aligned wi h he designa ed s a ions. All he scena ios we e discussed and e iewed in he g oup o p o esso s and he inal app o al was gi en. The exam comp ised six s a ions, which included he ollowing p ocedu es: inse ing a nasogas ic ube, u ina y ca he e iza ion, endo acheal ube suc ioning, in amuscula injec ion, adminis e ing in a enous medica ion, and changing d essings. Each s a ion was allo ed i e minu es, wi h scena ios de eloped by clinical in e nship ins uc o s and e iewed by he acul y g oup. Scena ios in ol ed pe o ming a p ocedu e. E alua ion checklis s we e de i ed om nu sing p inciples and echniques ex books, wi h each i em sco ed as 0 (no pe o med), 0.5 (pa ially pe o med), o 1 ( ully pe o med). The o al sco e anging om 0 o 6, whe e a highe sco e indica ed be e clinical pe o mance. The exam was conduc ed in one day, and sco ing was done using he checklis s. One ins uc o ela ed o he subjec was used o e alua e he s uden s a each s a ion. A e comple ing all he s a ions, s uden s es ed in a qua an ine s a ion, whe e hey we e supe ised by a moni o o con ol any in e ac ions. The OSCE exam o bo h g oups was held wi h he same ins uc o s a each s a ion, and o blinding, ins uc o s o he han he clinical ins uc o s o he clinical in e nship we e used. Da a collec ion me hods Nea -PAL was implemen ed o he in e en ion g oup a e he esea ch p oposal was app o ed, he e hical code was ecei ed, and consen om he Nu sing School's educa ional council was ob ained. S uden s in he in e en ion g oup we e in o med ha i hey chose no o pa icipa e in he esea ch, hey could exp ess hei conce ns and comple e he ele an aining cou se a ano he hospi al. s uden s we e also eassu ed abou he lack o e ec o hei decision o pa icipa e/no pa icipa e in he esea ch on he in e nship g ade. All s uden s exp essed hei sa is ac ion and in e es in pa icipa ing in he p ojec . Nea -PAL was used o he in e en ion g oup, wi h senio nu sing s uden s om he Mas e 's p og am in medical-su gical nu sing se ing as nea pee s. Theo e ical and p ac ical educa ional asks we e gi en o he senio nu sing s uden s wi h he ag eemen o he g oup manage and p o esso s o he nu sing depa men . The compe ence o he senio s uden s in he in e en ion g oup was assessed based on hei wo k expe ience in clinical depa men s and h ough obse a ions o hei clinical pe o mance by p o esso s du ing he ele an in e nships. The clinical compe ence o he selec ed nea pee s was con i med by he Nu sing School's G adua e S udies Council. Nea - Pee Assis ed Lea ning (Nea -PAL) was conduc ed unde he supe ision o expe ienced ins uc o s who se ed as esiden educa ional supe iso s a he eaching hospi als. Be o e s a ing he Nea -PAL, he de ails o he implemen a ion, such as asks ela ed o nea -pee s, how o e alua e and supe ise, we e explained in de ail by he [ DOI: 10.61882/edcj.18.2.27 ] [ Downloaded om edujou nal.zums.ac.i on 2025-10-03 ] 3 / 9 Badiyepeymaiejah omi e al . : The e ec o nea -pee -assis ed lea ning on sel -e icacy and clinical pe o mance 30 Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025 esea ch eam o he educa ional supe iso s. Also, he senio nu sing s uden s we e augh how o ea , ain and supe ise in e nship s uden s in a 2-hou session. In e nship s uden s we e andomly di ided in o g oups o 3 people by lo e y. The s uden s pa icipa ed in in e nship cou se in o a ion in he medical, su gical, ICUs and CCUs o Peymaniyeh and Mo aha i hospi als a ilia ed o Jah om Uni e si y o Medical Sciences. These senio s uden s isi ed he clinical wa ds, p o ided ins uc ion and aining, and conduc ed e alua ions. The educa ional supe iso s also moni o ed his p ocess and sol ed i i he e was a p oblem. The con ol g oup ecei ed adi ional educa ion om nu sing school ins uc o s. Fo he con ol g oup, adi ional educa ion was pe o med by ins uc o s; isi ing clinical wa ds whe e s uden s we e du ing mo ning and e ening shi s, p o iding ins uc ion and conduc ing e alua ions. A he end o he educa ional cou se, s uden s' clinical sel - e icacy was assessed using a sel -e alua ion ques ionnai e, and hei clinical pe o mance was e alua ed h ough an OSCE S uden pa icipa ion in he s udy is shown in Figu e 1. Da a analysis Da a analysis was pe o med using SPSS e sion 22. The no mali y o OSCE and sel -e icacy sco es in he pos - es s was checked using skewness and ku osis es s. Independen - es s we e used o compa e quan i a i e da a (OSCE, sel -e icacy sco es, age, and GPA) and Chi-squa e es s we e pe o med o pe o med o quali a i e (ma i al s a us and sex). A signi icance le el o 0.05 was conside ed. Figu e1. Flow cha o he s udy Resul s The mean age o he s uden s was 20.38 ± 0.029 yea s, and he mean g ade poin a e age was 16.64 ± 0.94. Among he pa icipan s, 76.34% we e emale, while 22.3% we e ma ied. The e was no s a is ically signi ican di e ence be ween he wo g oups in e ms o demog aphic cha ac e is ics (Table 1). The skewness es indica ed ha he skewness alues o he OSCE and sel -e icacy sco es we e 0.66 and 0.71, espec i ely, bo h alling wi hin he no mal ange. [ DOI: 10.61882/edcj.18.2.27 ] [ Downloaded om edujou nal.zums.ac.i on 2025-10-03 ] 4 / 9 Badiyepeymaiejah omi e al . : The e ec o nea -pee -assis ed lea ning on sel -e icacy and clinical pe o mance Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025 31 Table 1. Compa ison o demog aphic cha ac e is ics be ween in e en ion and con ol g oups Demog aphic da a In e en ion g oup Con ol g oup Sig. Age )Mean ± SD( 20.67 ± 3.024 20.890 ± 2.035 p = 0.690, = 0.400 GPA )Mean ± SD( 16.83 ± 0.79 16.91 ± 0.55 p = 0.583, = 0.551 Sex n(%) Male Female 12 (23.1) 40 (76.9) 10 (24.4) 31 (75.6) p =0.882, X2 = 0.022 Ma i al s a us n (%) Ma ied Single 2 (3.8) 50 (96.2) 1 (2.4) 40 (97.6) p > 0.999, X2 = 0.145 No e: Independen - es was used o compa e pa icipan s based on quan i a i e demog aphic a iables o wo g oups. Chi- squa e es was used o compa e quali a i e demog aphic a iables be ween g oups. Abb e ia ions: n, numbe o pa icipan s; SD, s anda d de ia ion; GPA, g ade poin a e age; X2, Chi-squa e es ; , independen - es ; Sig, s a is ical signi icance; p, p obabili y- alue. The mean OSCE sco es we e 5.09 ± 0.29 and 4.85 ± 0.76 ou o 6 o he in e en ion and con ol g oups, espec i ely. Al hough he in e en ion g oup (PAL) had highe mean sco es, he independen - es e ealed no s a is ically signi ican di e ence be ween he in e en ion and con ol g oups ega ding OSCE sco es (p = 0.061, E ec Size = 0.43). Howe e , he independen - es did show a s a is ically signi ican di e ence be ween he wo g oups in o e all sel - e icacy sco es (p < 0.001, E ec Size = 0.95). Addi ionally, he esul s indica ed signi ican di e ences be ween he wo g oups in all dimensions o sel - e icacy, including pa ien assessmen , nu sing diagnoses and planning, implemen a ion o he ca e plan, and e alua ion o he ca e plan (p < 0.05) (Table 2, Figu e 2 and 3). Table 2. Compa ison o sel -e icacy and OSCE mean sco es be ween in e en ion and con ol g oups a e he in e en ion Va iables In e en ion g oup )Mean ± SD( Con ol g oup )Mean ± SD( Sig. Pa ien assessmen 46.88 ± 7.15 33.48 ± 9.09 p < 0.001, = 7.960 Nu sing diagnoses and planning 30.22 ± 11.03 23.49 ± 6.21 p = 0.001, = 3.492 Implemen a ion o he ca e plan 39.98 ± 8.28 34.21 ± 10.38 p = 0.004, = 2.983 E alua ion o he ca e plan 22.08 ± 5.11 18.47 ± 4.21 p < 0.001, = 3.650 To al sel -e icacy 139.16 ± 31.57 109.65 ± 29.89 p < 0.001, = 4.581 OSCE 5.09 ± 0.29 4.85 ± 0.76 p = 0.061, = 1.915 No e: An independen - es was used o compa e quan i a i e a iables be ween he wo g oups. Abb e ia ions: SD, s anda d de ia ion; , independen - es ; Sig, s a is ical signi icance; p, p obabili y- alue. Figu e 2. Compa ison o he mean sco e o OSCE in he in e en ion and con ol g oups a e he in e en ion. 4.7 4.8 4.9 5 5.1 5.2 OSCE Con ol In e en ion [ DOI: 10.61882/edcj.18.2.27 ] [ Downloaded om edujou nal.zums.ac.i on 2025-10-03 ] 5 / 9 Badiyepeymaiejah omi e al . : The e ec o nea -pee -assis ed lea ning on sel -e icacy and clinical pe o mance 32 Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025 Figu e 3. Compa ison o he mean sco e o sel -e icacy in he in e en ion and con ol g oups a e he in e en ion. Discussion This s udy aimed o de e mine he e ec o nea -PAL on he sel -e icacy and clinical pe o mance o nu sing in e nship s uden s. The esul s indica ed a s a is ically signi ican di e ence in sel -e icacy sco es be ween he PAL g oup and he adi ional ins uc o -led g oup. Due o he ad an ages o PAL, his me hod has been widely used o educa ion and e alua ion in a ious s udies. Howe e , he e ha e been ew s udies on sel -e icacy using his me hod, which we will discuss. The esul s o a s udy by Pa cheba ieh e al. showed ha PAL posi i ely a ec ed he clinical sel -e icacy o nu sing s uden s [4]. Plasson e al. conduc ed a quasi-expe imen al s udy in Sweden o in es iga e he e ec o PAL on nu sing s uden s' clinical skills educa ion. In his s udy, he in e en ion g oup ecei ed aining h ough PAL o wo weeks, while he con ol g oup ecei ed adi ional aining unde he supe ision o an ins uc o . The esul s also indica ed ha PAL was mo e e ec i e in enhancing he sel -e icacy o nu sing s uden s han adi ional me hods [18]. S udies by Aus ia e al. and Hells öm-Hyson e al. also suppo he indings o he p esen s udy, iden i ying PAL as a ac o ha enhances nu sing s uden s' sel - e icacy [19, 20]. Acco ding o Bandu a, social suppo —such as ha p o ided h ough pee lea ning— is a p ima y sou ce o sel -e icacy [21]. I appea s ha when s uden s ecei e educa ional con en om pee s who a e simila o hem bu possess sligh ly mo e knowledge, hey expe ience less anxie y and s ess. This en i onmen p o ides mo e oppo uni ies o p ac ice and ques ions du ing skill acquisi ion, which can posi i ely impac hei sel -e icacy. In he s udy conduc ed by B annagan e al., which aimed o in es iga e he e ec o PAL expe iences on nu sing s uden s in a clinical labo a o y se ing, no di e ences we e obse ed be ween he in e en ion and con ol g oups ega ding imp o emen s in sel -e icacy [22]. While he di e ing esul s compa ed o he p esen s udy may be a ibu ed o he di e ences be ween clinical educa ion and labo a o y educa ion, he au ho also ci ed implemen a ion challenges o he pee me hod and he insu icien p epa a ion o pee ins uc o s as easons o he lack o di e ence be ween he con ol and in e en ion g oups. The e o e, i should be no ed ha he key o success ul pee educa ion lies in ha ing su icien knowledge, accu a e obse a ion, p o iding eedback, emo ional suppo , and collabo a ion among pee s. Addi ionally, he esul s showed no s a is ically signi ican di e ence in OSCE sco es be ween he PAL g oup and he adi ional eaching g oup. This inding was consis en wi h Haji Hosseini's s udy, which demons a ed ha he p ac ical skill sco es o s uden s who used PAL we e simila o hose o he con ol g oup [12]. Simila ly, he e ec o PAL on den al s uden s' p ac ical skills in he clinic was in es iga ed in Kimyai's s udy, and he esul s indica ed ha he p ac ical skills o s uden s who used PAL we e compa able o hose o he con ol g oup [23]. Hackman e al. ound no signi ican di e ence be ween s uden s' sco es on w i en es s and he OSCE when compa ing PAL o ins uc o -led eaching du ing hei neu ology cle kship [24]. These esul s sugges ha his me hod can be as e ec i e as clinical ins uc o -led eaching. Con a y o hese indings, Williams's e iew s udy indica ed ha pee lea ning imp o ed OSCE sco es [25]. Goldsmi h e al. conduc ed a s udy o de e mine he [ DOI: 10.61882/edcj.18.2.27 ] [ Downloaded om edujou nal.zums.ac.i on 2025-10-03 ] 6 / 9 Badiyepeymaiejah omi e al . : The e ec o nea -pee -assis ed lea ning on sel -e icacy and clinical pe o mance Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025 33 e ec o pee eaching on he p ac ical skills o hi d-yea nu sing s uden s a he Uni e si y o Sydney. Thei esul s showed signi ican imp o emen in p ac ical skills in he PAL g oup o hi d-yea nu sing s uden s [26]. O he s udies compa ing he e ec o pee and non- pee lea ning me hods on s uden s' clinical skills ha e also shown ha pee lea ning is e ec i e [13, 16, 27]. Di e ences in s udy design, pee g oups, in e en ion implemen a ion, academic disciplines, academic yea s o he pee s, and he complexi y o he educa ional con en ela i e o he pee s' abili ies may explain he a ied esul s ac oss s udies. PAL can be success ully in eg a ed in o educa ional cu icula, wi h eedback highligh ing signi ican bene i s o his eaching me hod [11]. Howe e , ully eplacing o mal academic ins uc o s wi h nea pee s would be p ema u e. The e o e, i is c ucial o p o ide app op ia e aining o pee educa o s, moni o he quali y o educa ion hey deli e , and u ilize nea pee s as a complemen o academic ins uc o s [28]. Addi ionally, his me hod may help add ess he sho age o ins uc o s a uni e si ies, inc ease s uden sa is ac ion, and educe he ime and cos o educa ion [11]. None heless, i is c ucial o conside ha s uden s gene ally pe cei e o mal ins uc o s as ha ing be e knowledge, explana o y skills, and communica ion abili ies. Fu he mo e, in mos s udies, he esul s ha e been a ibu ed o he in e en ion wi hou much conside a ion o po en ial in luences om pa icipan s' de elopmen o o he en i onmen al and educa ional ac o s. Gi en hese limi a ions, i is essen ial o cau iously a ibu e ou comes o he in e en ion. In addi ion among he limi a ions o his esea ch a e i s single-cen e design, small sample size, lack o a p e- es , and he unexamined long- e m e ec s o he in e en ion on s uden s. Addi ionally, his s udy did no accoun o po en ial con ounding a iables, such as s uden mo i a ion o ex e nal suppo sys ems, which could in luence sel -e icacy and clinical pe o mance. The indings o his esea ch can be applied in educa ional se ings by inco po a ing his eaching me hod, in clinical p ac ice o enhance he quali y o ca e p o ided by s uden s and nu ses, and in managemen o planning clinical in e nships and p ac icum cou ses using his educa ional app oach. Conclusion The nea -PAL me hod has a mo e signi ican impac on he sel -e icacy o nu sing s uden s du ing clinical in e nships compa ed o adi ional eaching me hods. Fu he mo e, i can be equally e ec i e as ins uc o -led eaching in enhancing s uden s' clinical pe o mance. The e o e, i is ecommended o use his app oach in conjunc ion wi h o he eaching me hods ha can u he imp o e clinical pe o mance among s uden s. Gi en he limi ed numbe o s udies in his a ea, u u e esea ch is sugges ed o explo e he use o nea -PAL ac oss a ious nu sing special ies, wi h a ocus on inco po a ing andomiza ion. Addi ionally, in es iga ing he long- e m e ec s o nea -PAL on clinical pe o mance and sel - e icacy in nu sing s uden s is essen ial. Fu he esea ch combining bo h quan i a i e and quali a i e me hods is needed o enhance da a eliabili y and o unde s and o he aspec s o implemen ing his s uden -cen e ed educa ional app oach. Adop ing he PAL me hod as a s uden -cen e ed educa ional s a egy could be e p epa e s uden s o ake on educa ional oles in clinical se ings. E hical conside a ions This esea ch was conduc ed wi h he e hical code IR.JUMS.REC.1401.098. E hical p inciples, such as ob aining in o med consen , olun a y pa icipa ion, explaining he esea ch objec i es, and ensu ing he con iden iali y o pa icipan s' in o ma ion, we e obse ed. A i icial in elligence u iliza ion o a icle w i ing The au ho s decla e ha no AI-based ools we e used in conduc ing he esea ch o p epa ing his manusc ip . Acknowledgmen We a e g a e ul o all he s uden s and ins uc o s who assis ed us in conduc ing his s udy, as well as he Resea ch Depu y o Jah om Uni e si y o Medical Sciences o suppo ing his esea ch p ojec . Con lic o in e es s a emen The au ho s decla e no po en ial con lic s o in e es . Au ho con ibu ions Z.B and M.H concep ualized he s udy. Z.B and S.R d a ed he manusc ip , while M.H and M.F p o ided e isions and c i ical eedback. All au ho s app o ed he inal e sion o he manusc ip o publica ion. Funding This s udy was inancially suppo ed by he Resea ch Depu y o Jah om Uni e si y o Medical Sciences. [ DOI: 10.61882/edcj.18.2.27 ] [ Downloaded om edujou nal.zums.ac.i on 2025-10-03 ] 7 / 9 Badiyepeymaiejah omi e al . : The e ec o nea -pee -assis ed lea ning on sel -e icacy and clinical pe o mance 34 Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025 Da a a ailabili y s a emen The da ase s used and analyzed in his s udy a e a ailable om he co esponding au ho upon easonable eques . Re e ences 1. Rahimi Z, Badiyepeymaiejah omi Z, Taghizadeganzadeh M. 360-deg ee e alua ion o nu sing s uden s' pe o mance. Shi az E-Medical Jou nal. 2024;25(11):e148872. [h ps://doi.o g/10.5812/semj-148872] 2. Chang CY, Gau ML, Tang KY, Hwang GJ. 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[h ps://doi.o g/10.1152/ad an.00035.2012] [ DOI: 10.61882/edcj.18.2.27 ] [ Downloaded om edujou nal.zums.ac.i on 2025-10-03 ] Powe ed by TCPDF (www. cpd .o g) 9 / 9