The Effect of Halsted and Peyton Teaching Approaches on Nursing Students

Overview

Intramuscular (IM) injection is a fundamental nursing skill that requires accurate anatomical knowledge, correct technique, and safe practice. The ventrogluteal site is currently recommended in clinical guidelines as the safest area for IM injections because it is far from major nerves and blood vessels and allows effective medication absorption. However, identifying the correct anatomical landmarks and performing the procedure accurately can be challenging for nursing students, particularly during early skills training. Different teaching approaches are used in nursing education to support the acquisition of psychomotor skills. The traditional Halsted approach ("see one, do one") is widely used because it is time-efficient, but it may not provide sufficient structure for learning complex, multi-step procedures. In contrast, Peyton's four-step teaching approach offers a structured and interactive method that includes demonstration, explanation, learner-guided repetition, and independent performance. This approach is designed to enhance understanding, skill retention, and active participation in the learning process. The aim of this randomized controlled trial is to compare the effects of the Halsted teaching approach and Peyton's four-step teaching approach on nursing students' knowledge, skill performance, and self-regulated learning related to ventrogluteal injection administration. The study is conducted with first-year nursing students enrolled in the Fundamentals of Nursing course at a university in Türkiye during the 2025-2026 academic year. A total of 120 nursing students are randomly assigned to either the intervention group or the control group. All students receive the same theoretical instruction and access to standardized instructional videos before laboratory practice. The control group is taught ventrogluteal injection using the traditional Halsted approach, while the intervention group receives training based on Peyton's four-step teaching method. Skill performance is assessed using an objective structured clinical examination (OSCE) with a standardized skill checklist. Knowledge levels are measured using a validated multiple-choice test, and self-regulated learning is evaluated using a reliable and validated self-regulated learning scale for clinical nursing practice. The results of this study are expected to provide evidence on whether a structured teaching approach improves learning outcomes in nursing skills education. Findings may contribute to the development of more effective educational strategies for teaching high-risk and technically demanding nursing procedures, ultimately supporting patient safety and clinical competence in future nurses.

The acquisition of psychomotor nursing skills is a core component of undergraduate nursing education and plays a critical role in ensuring patient safety and clinical competence. Intramuscular (IM) injection administration is one of the most frequently performed nursing procedures and requires precise anatomical knowledge, correct technique, and adherence to aseptic principles. Among IM injection sites, the ventrogluteal region is recommended by current clinical guidelines as the safest option due to its distance from major nerves and blood vessels, adequate muscle mass, and lower risk of complications. Despite these advantages, ventrogluteal injection is often perceived by nursing students as difficult to learn because it requires accurate identification of anatomical landmarks and coordinated psychomotor performance. Teaching methods used in nursing skills education may influence how effectively students acquire, retain, and apply complex clinical procedures. The Halsted teaching approach, commonly summarized as "see one, do one," has traditionally been used in skills laboratories because of its simplicity and efficiency. However, this approach may be insufficient for procedures that involve multiple sequential steps and require high levels of cognitive engagement and error awareness. In contrast, Peyton's four-step teaching approach provides a structured framework for skills training that integrates observation, explanation, learner participation, and independent practice. By actively involving students in the learning process, Peyton's approach is thought to enhance deeper understanding, improve psychomotor performance, and support self-regulated learning. Self-regulated learning is an essential competency for nursing students, particularly in clinical practice settings where learners are expected to plan, monitor, and evaluate their own learning and performance. Educational strategies that promote active participation and structured feedback may contribute to the development of self-regulated learning behaviors. Although previous studies have demonstrated the effectiveness of Peyton's four-step approach in various clinical skills, evidence comparing this approach with the traditional Halsted method specifically for ventrogluteal injection training in nursing education remains limited. This randomized controlled trial was designed to compare the effects of the Halsted teaching approach and Peyton's four-step teaching approach on nursing students' learning outcomes related to ventrogluteal injection administration. The study focuses on three key domains: cognitive outcomes (knowledge related to ventrogluteal injection), psychomotor outcomes (skill performance assessed through an objective structured clinical examination), and learning process outcomes (self-regulated learning in clinical nursing practice). The study is conducted in a controlled laboratory setting as part of the Fundamentals of Nursing course. Prior to the laboratory sessions, all participants receive standardized theoretical instruction on intramuscular injections and access to instructional videos prepared by faculty members. This ensures that baseline exposure to theoretical content and visual learning materials is equivalent across groups. Laboratory practice sessions are then conducted using different teaching approaches according to group allocation. Students assigned to the control group receive ventrogluteal injection training using the traditional Halsted approach. In this method, the instructor demonstrates the procedure, responds to students' questions, and then asks students to perform the skill individually. Feedback is provided during and after practice to correct errors and reinforce correct technique. Students in the intervention group receive training based on Peyton's four-step teaching approach. This approach includes: (1) demonstration of the procedure without verbal explanation, allowing students to observe the entire skill as a whole; (2) a second demonstration accompanied by detailed verbal explanation of each step; (3) performance of the procedure by the instructor under the verbal guidance of the students, encouraging active cognitive engagement; and (4) independent performance of the procedure by each student. This structured sequence is intended to promote understanding of procedural logic, enhance error recognition, and support skill mastery. Following the training sessions, learning outcomes are evaluated using standardized and validated measurement tools. Knowledge related to ventrogluteal injection is assessed through pre- and post-tests consisting of multiple-choice questions. Skill performance is evaluated using a structured checklist during an objective structured clinical examination (OSCE). Self-regulated learning is measured using a validated self-regulated learning scale specific to clinical nursing practice. A pilot study was conducted prior to the main study to assess the clarity and feasibility of data collection tools, and pilot data were not included in the final analysis. Data analysis focuses on comparing changes in knowledge, skill performance, and self-regulated learning between groups. Statistical analyses are performed using appropriate non-parametric methods due to the distribution characteristics of the data. The study is conducted in accordance with ethical principles, and participation is voluntary with informed consent obtained from all students. Participation or non-participation does not influence academic evaluation or course grades. By comparing a traditional and a structured teaching approach within a controlled educational environment, this study aims to contribute evidence-based insights into effective instructional strategies for nursing skills education. The findings are expected to inform curriculum design and teaching practices, particularly for high-risk and technically demanding procedures such as ventrogluteal injection, and to support the development of competent and self-directed nursing professionals.