CONCEPT ANALYSIS 1
Running Head: CONCEPT ANALYSIS
Concept Analysis
Lisa Armstrong
NURS 900.01: Discipline of Nursing (Fall 2012)
October 12, 2012
Dr. J. Samuels
CONCEPT ANALYSIS 2
Concept Analysis: Nurse-to-Nurse Peer Support
1. Introduction
Peer support is a widely adopted and advocated method of support used in diverse health
care settings. The World Health Organization cites the words “peer support” in a variety of
articles, forums, and programs, from mental health and diabetes, to breastfeeding and violence
prevention. Peer supports’ various applications extend across the continuum of disease
management, illness prevention, and health promotion models. Dennis (2003) observes that
“peer support has become a significant element in the delivery of quality health care, recognized
as a complex phenomenon whose application is vague and highly variable, although its benefits
continue to be sought after as a means for improving health outcomes” (p. 322).
Using the Rodgers (1989) conceptual framework, the aim of this concept analysis is to
consider the role of peer support in the specific context of nurse-to-nurse relationships within the
nursing profession, as well as to highlight key areas of nursing within which nurse-to-nurse peer
support may be beneficially employed.
2. Methods
2.1. Literature Review
An extensive literature review consulted various database resources, including CINAHL
Plus with Full Text, Cochrane Central Register of Controlled Trials, Cochrane Database of
Systematic Reviews, Health Source: Nursing/Academic Edition, MEDLINE, PsycARTICLES,
PsycCRITIQUES, PsycINFO, and Social Work Abstracts. Search criteria limitations included a
cut-off date of the year 2000, and to facilitate timely research, only full-text or PDF linked
CONCEPT ANALYSIS 3
articles were considered. Initially, the words peer support were combined with nurse and
nursing. Upon further review of the articles selected, clinical supervision and mentor were later
added. Although several hundred articles resulted from the search, many related to nursing led
peer support services rather than peer support for nurses, and isolating articles which related
purely to nurse-to-nurse peer support proved particularly onerous.
2.2. Other Media
The notion of peer support is ubiquitous, transcending beyond the boundaries of health
care literature into social networking sites such as You Tube, Facebook, LinkedIn, and Twitter,
indicating that mainstream society has a broad conceptual understanding of the two conjoined
words ‘peer’ and ‘support’ in the sense of peer support, rather than the simple combination of
standard dictionary definitions.
3. Definition
Peer; meaning “a person of the same age, status, or ability as another specified person”
and support; meaning “be actively interested in and concerned for the success of”, or “give
approval, comfort, or encouragement to” (Oxforddictioneries.com, 2012). Combined, these two
nouns unite to form a much broader concept than one of simply being actively interested in and
concerned for the success of a person of the same age, status, or ability as another person.
There are many definitions of peer support in the literature, depending on the context in
which peer support is being discussed. In relation to mental health programs, Mead, Hilton, and
Curtis (2001) describe peer support as a system of giving and receiving help founded on key
principles of respect, shared responsibility, and mutual agreement of what is helpful. It is about
CONCEPT ANALYSIS 4
understanding another’s situation empathically through the shared experience of emotional and
psychological pain (p. 135).
In the professional organization Peers for Progress, peer support is defined as linking
people with a chronic condition. With four major functions; assistance in daily management,
social and emotional support, linkages to clinical care and community resources, and ongoing
support extended over time, peer support functions to complement, supplement, and extend
formal primary care services (American Academy of Family Physicians Foundation, 2012).
David and Cockayne (2005) propose that peer support may also include counseling
and/or educational and information giving strategies. Guillaume and McMillan (2002) define
peer support as the mutual support provided between colleagues that enable one to deal with
work related or non-work related stress. Waddell & Dunn (2005) describe it as a “voluntary,
non-evaluative and mutually beneficial partnership between two practitioners of similar
experience who have participated in training and who wish to incorporate new knowledge and
skills into practice” (p. 84). Dennis (2003) offers a wider and more rudimentary interpretation of
the definition: “Peer support could be defined as the giving of assistance and encouragement by
an individual considered equal” (p. 323).
Finding a clear definition for peer support in nursing is challenging, and as peer support
is a widely advocated practice within the healthcare arena, it is somewhat surprising that there
are relatively few descriptions of peer support that can be directly applied to nurse-to-nurse peer
support. Dennis’ (2003) literature review culminated in the best definition of peer support in its
application to the nursing profession: “All peer interventions include some degree of
informational, appraisal, and emotional support. Peer support can be provided through multiple
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modes of interaction, in diverse settings, through various providers, and incorporate a variety of
roles with varying degrees of involvement and structure, extending across numerous
demographic variables and encompass disease-related, illness-preventative, and healthpromoting topics (p. 325).
4. Defining Attributes
In depth analysis of the literature reveals three significant defining attributes which
outline key supportive functions of a nurse-to-nurse peer support relationship.
4.1. Ethical Decision Making
In the application of ethics, Taft (2001) explains that when a situation is presented that
calls for an ethical decision, nurse colleagues are the appropriate players to judge each other by
the standard of what a "reasonable nurse" would similarly do, and a nurse is well-advised to seek
out peer input. Similarly, Lachman, Murray, Iseminger, and Ganske (2012) discuss moral
courage for patient advocacy, stating that “interventions to protect patient safety and improve the
quality of care and health outcomes are enhanced when morally courageous nurses elicit peer
support for advocacy endeavors” (p. 26). In these examples, peer-support is crucial in the shared
decision making of complex ethical or moral cases, especially with regard to the litigious aspect
of the health care environment.
4.2. Stress Management/Nurse Burnout
The concept of stress is widely discussed in nursing literature. A stressful environment
can lead to nurse dissatisfaction, burnout, and resignations, which can prove detrimental to
patient care, and decreases the quality and quantity of care provided (Atherton & Alliston, 2011).
Nurse’s work in a high risk, high stress environment (Ye & Wang, 2006) and stress affects the
CONCEPT ANALYSIS 6
mental and physical health of the nurse as well as having an economic cost to the community
(Chang, Hancolck, Johnson, Daly, & Jackson, 2005). Peer support has been demonstrated to
reduce the effects of stress through restorative function (Brunero & Stein-Parbury), enhancing
social support through engagement in social activities (Chang, et. al), and alleviate work-related
stress and burnout through the provision of emotional comfort, new insights, personal rewards
and recognition, and a “much needed source of humor, optimism, and encouragement when the
going gets tough” (Maslach & Goldberg, 1998, p. 67).
4.3. Professional Development
Positive outcomes from involvement in nurse-to-nurse peer support are numerous.
Brooks (2009) suggests that peer support may provide an opportunity to bridge the gap between
nursing theory and practice through the transfer of new skills from the classroom into the
workplace. Peer support provides an opportunity for a nurse to become a more reflective
practitioner and to further their professional development (Bedward & Daniels, 2005). Peer
support has been cited as a means of promoting professional accountability, skill, and knowledge
development (Brunero & Stein-Parbury, 2008) and is considered a simultaneous movement
towards autonomy and community building (Mead, Hilton, & Curtis, 2001). “Through the
establishment and engagement of peer support programs, nurses have become increasingly
sensitive to their own psychosocial needs, better enabling them to face the daily challenges of
life” (Ye & Wang, 2006, p. 1375). Participation in peer coaching has also been demonstrated to
make a significant difference in professional growth and autonomy, self reflection and self
awareness, self confidence, self actualization, and empowerment (Waddell & Dunn, 2005).
5. Related Concepts
CONCEPT ANALYSIS 7
Concepts within the nursing profession that exhibit similar traits to peer support include
clinical supervision, mentorship, and peer coaching.
5.1. Clinical Supervision
Clinical supervision is considered a more formalized process of nurse-to-nurse peer
support or supervisor-to-nurse support, achieved through the process of “professional support
and learning in which nurses are assisted in developing their practice through regular discussion
time with experienced and knowledgeable colleagues” (Brunero & Stein-Parbury, 2008, p. 87).
Clinical supervision can be one-to-one or group-based, generally focuses on clinical practice, and
has proven beneficial in reducing professional isolation in clinical environments (Bedward &
Daniels, 2005) as well as relieving feelings of stress in nurses (Lyth, 2000).
5.2. Mentorship
Mentors are positioned to introduce new and seasoned nurses to networks of peer
colleagues, and focus on nurturing a partnership that is mutual and equal, creative, inspirational,
and strategic (Dracup & Bryan-Brown, 2004). Mentorship tends to be one-to-one rather than
group based, often involves a hierarchical relationship (Waddell & Dunn, 2005), and is usually
described within the context of a student/teacher or student/preceptor learning environment.
5.3 Peer Coaching
Peer coaching was developed 20 years ago in teacher education staff development, and
has been demonstrated to foster empowerment, improve delivery of feedback, and promote a
business-like attitude (Waddell & Dunn, 2005). Peer coaching can be as effective as one-on-one
coaching and can enable nurses to share progress and help each other to overcome obstacles or
CONCEPT ANALYSIS 8
resolve issues (McDermott, 2012). Also described as peer cognitive coaching, the “long-range
goal of this approach is enhancement of student achievement, by facilitating the educator's
analysis of the teaching/learning experience and by encouraging improved innovative teaching
practices… nurse educators are encouraged to draw from their vast experiences and develop their
own personal, practical knowledge (Mott, 1992). This type of nurse-to-nurse peer support
focuses on nurses as educators, an important component of the peer relationship continuum given
the advocacy for advancement of education in the nursing profession.
Antecedents
In 2008, nursing was ranked as the fifth most stressful job in the United Kingdom
(Atherton & Alliston, 2011). Chang et. al. (2005) cites nursing stress factors are affected by high
job demands, low supportive relationships, dealing with death and dying, a shortage of essential
resources, work overload, time demands, workplace violence, and poor relationships with
coworkers (p. 58) amongst many other concerns, which has ultimately contributed to the nursing
shortage. Stress has also been linked with chronic physical and mental health problems,
compassion fatigue, and early burnout of nurses.
Evidence in the literature not only demonstrates the clear efficacy of peer support within
a general healthcare context (Dennis, 2003, Lyth, 2000, Brunero & Stein-Parbury, 2006), but
also suggests that nurse-to-nurse peer support could significantly contribute towards a reduction
in stress and staff attrition.
Consequences
Ye and Wang (2006) discuss the success of a nursing peer support program in China,
demonstrating the positive consequences (p. 1375):
CONCEPT ANALYSIS 9
“One debriefing involved a young nurse diagnosed with cancer who died shortly after.
The nurses with whom she once worked, especially the ones who participated in
resuscitative efforts to save her, were very emotionally distraught and could not focus
their energies at work. Immediately, a group debriefing was arranged. The stress
generated, the emotions experienced and resulting coping strategies were communicated
at this session. Two weeks later, each participant was adjusting significantly well.”
In her article Peer-Supported Storytelling for Grieving Pediatric Oncology Nurses, Macpherson
(2008) explains that (p. 149):
“Sharing with and seeking support from professional colleagues is the strategy used most
for managing grief by nurses caring for dying children. These nurses learn to seek
support from peers who understand their work to protect their loved ones from the
distress of hearing about patient deaths and to protect themselves from the distress of
their loved ones’ unwillingness or inability to provide effective support. Pediatric
oncology nurses, in particular, seek meaning-making support within a cohesive network
that encourages emotional involvement with dying patients, acknowledges grief, and
promotes sharing and reflecting on death related experiences. Peer support from
colleagues who understand the professional’s work is strongly recommended.”
These case examples clearly amplify the importance and significance of nurse-to-nurse peer
support within a relevant contextual framework.
Conclusion
Nurse-to-nurse peer support is currently being utilized within the nursing profession, both
formally, and informally, with numerous benefits. However, there is no universal vernacular for
nurse-to-nurse peer support within the nursing community, and the blurring of lines between peer
support, clinical supervision, mentoring, and peer coaching presents difficulties in appreciating
both the formal and informal boundaries of a true nurse-to-nurse peer support program.
Further
analysis is required to delineate the specific attributes and benefits of nurse-to-nurse peer support
within the contextual framework of specific nursing roles as well as the overall profession. In
particular, the related concepts of hierarchy, leadership, mentorship, clinical supervision, and
coaching should be addressed, so that a clear definition of what nurse-to-nurse peer support is,
and what it is not, is further clarified.
CONCEPT ANALYSIS 10
Personal Perspective
From a personal perspective, I believe that informal nurse-to-nurse peer support is
widespread, but is not credited with the unseen benefits that it provides, nor adequate time or
resources allocated to it. In the last couple of weeks, I can recall at least one instance where I
have supported another peer, and requested peer support. As a new nurse, I rely heavily on
informal nurse-to-nurse peer support on a day-to-day basis, and considerate is separate, and over
and above, the feedback I may ask for, and receive from, my clinical leader, supervisor, or
manager. I personally find this level of communication less threatening, more empowering, and
ultimately helpful in a “if it were you, what would you do?” sense, especially when making
moral decisions or ethical judgments in situations I have not been exposed to previously.
Professional and lay literature, as well as vast social media content demonstrates great
advocacy for the power of peer support, but I was surprised at how little research and evidence
related specifically to nurse-to-nurse peer support, and how ill-defined the concept is in relation
to other similar concepts outlined in the paper, such as clinical supervision and mentoring.
Finding time in the day to ‘talk’ to fellow nurses is challenging, and yet I find it an
extremely comforting, rewarding, and pressure-relieving way of sharing my issues, concerns,
and triumphs. If I were to suggest a “clinical improvement” in my workplace, I would consider a
nurses “time-out” once weekly to allow staff members to hold an informal nurse-to-nurse peer
discussion group and see if it made a difference to pre-intervention scores on measures such as
stress, morale, perception of collegiality, feeling supported, and clinical judgment.
CONCEPT ANALYSIS 11
References
American Academy of Family Physicians Foundation. (2012). What is Peer Support.
Peers for Progress. Retrieved Oct 8, 2012 from <http://peersforprogress.org/learn-about-peersupport/what-is-peer-support.html>
Atherton, S., & Alliston, S. (2011). Caring for Carers in Critical Care. Kai Tiaki Nursing
New Zealand, 17(10), 12-13.
Bedward, J., & Daniels, H. (2005). Collaborative solutions -- clinical supervision and
teacher support teams: reducing professional isolation through effective peer support. Learning
In Health & Social Care, 4(2), 53-66.
Boyle, D. A. (2011). Countering Compassion Fatigue: A Requisite Nursing Agenda.
Online Journal Of Issues In Nursing, 16(1), 1. doi:10.3912/OJIN.Vol16No01Man02
Brooks, N., & Moriarty, A. (2009). Implementation of a peer-support system in the
clinical setting. Nursing Standard, 23(27), 35-39.
Brunero S, Stein-Parbury J. The effectiveness of clinical supervision in nursing: an
evidenced based literature review. Australian Journal Of Advanced Nursing [serial online].
March 2008;25(3):86-94.
Davis G, Cockayne D. Peer support in child protection practice. Journal Of Community
Nursing [serial online]. October 2005;19(10):18. Available from: CINAHL Plus with Full Text,
Ipswich, MA. Accessed October 12, 2012.
Dennis, C. (2003). Peer support within a health care context: a concept analysis.
International Journal Of Nursing Studies, 40(3), 321-332.
Dracup, K., & Bryan-Brown, C. (2004). From novice to expert to mentor: shaping the
future. American Journal Of Critical Care, 13(6), 448-450.
Lachman, V., Murray, J., Iseminger, K., & Ganske, K. (2012). Doing the right thing:
pathways to moral courage. American Nurse Today, 7(5), 24-29.
Lyth, G. (2000). Clinical supervision: a concept analysis. Journal Of Advanced Nursing,
31(3), 722-729. doi:10.1046/j.1365-2648.2000.01329.x
Maslach, C., & Goldberg, J. (1998). Prevention of burnout: New perspectives. Applied &
Preventive Psychology, 7(1), 63-74. doi:10.1016/S0962-1849(98)80022-X
Mead, S., Hilton, D. & Curtis, L.. (2001). Peer Support: A Theoretical Perspective.
Psychiatric Rehabilitation Journal, 25(2), 134.
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McDermott, L. (2012). Tapping the Wisdom of Peers. T+D, 66(5), 70-72.
Mott, M. (1992). Cognitive coaching for nurse educators. The Journal Of Nursing
Education, 31(4), 188-190.
Peterson, U., Bergström, G., Samuelsson, M., Åsberg, M., & Nygren, A. (2008).
Reflecting peer-support groups in the prevention of stress and burnout: randomized controlled
trial. Journal Of Advanced Nursing, 63(5), 506-516. doi:10.1111/j.1365-2648.2008.04743.x
Taft, S. (2000). An inclusive look at the domain of ethics and its application to
administrative behavior. Online Journal Of Issues In Nursing
Waddell, D., & Dunn, N. (2005). Peer coaching: the next step in staff
development. Journal Of Continuing Education In Nursing, 36(2), 84-91.
World Health Organization. (2012). Retrieved Oct 8, 2012 from <http://www.who.org>
Ye, Z., & Wang, J. (2007). The success of a nursing peer support programme in China.
Journal Of Clinical Nursing, 16(7), 1374-1376. doi:10.1111/j.1365-2702.2007.01937.x