The Effect of Halsted and Peyton Teaching Approaches on Nursing Students

The Effect of Halsted and Peyton Teaching Approaches on Nursing Students' Knowledge, Skills, and Self-regulated Learning in Ventrogluteal Injection Administration: A Randomized Controlled Trial.

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.

Study Overview

• Status: Not yet recruiting
• Conditions: Nursing Skills Education
• Intervention / Treatment: Behavioral: Peyton Four-Step Teaching Approach; Behavioral: Halsted Teaching Method

Detailed Description

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.

• Study Type: Interventional
• Enrollment (Estimated): 110
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Gözde ÖZARAS ÖZ, PhD; Phone Number: +905323495280; Email: gozdeozaras@karatekin.edu.tr

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• First-year undergraduate nursing students
• Enrolled in the Fundamentals of Nursing course for the first time
• Have viewed the online instructional videos related to ventrogluteal intramuscular injection before laboratory practice
• Agree to participate voluntarily
• Provide written informed consent
• Attend all scheduled theoretical and laboratory training sessions

Exclusion Criteria:

• Graduated from a health vocational high school
• Previously received formal education or training on intramuscular injection techniques
• Do not attend theoretical or laboratory sessions related to the study
• Do not complete the data collection tools
• Withdraw from the study at any stage

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Other
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Peyton Four-Step Teaching Approach; Participants in this arm receive training in ventrogluteal intramuscular injection using Peyton's four-step teaching approach, including demonstration, explanation, learner-guided demonstration, and independent performance during laboratory practice.	Behavioral: Peyton Four-Step Teaching Approach; A structured educational intervention based on Peyton's four-step teaching approach, including silent demonstration, demonstration with explanation, learner-guided demonstration, and independent performance of ventrogluteal intramuscular injection in a laboratory setting.
Active Comparator: Halsted Teaching Method; Participants in this arm receive training in ventrogluteal intramuscular injection using the traditional Halsted teaching method ("see one, do one") during laboratory practice.	Behavioral: Halsted Teaching Method; A traditional educational intervention based on the Halsted teaching method ("see one, do one"), in which students observe the ventrogluteal intramuscular injection procedure and then perform it individually during laboratory practice.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Ventrogluteal Injection Skill Performance	Skill performance in ventrogluteal intramuscular injection administration is assessed using a structured Ventrogluteal Injection Skill Checklist during an Objective Structured Clinical Examination (OSCE). The checklist consists of 33 items evaluating correct performance of each procedural step. Each item is scored as 0 (incorrect/not performed) or 1 (correct), and total scores are converted to a 0-100 scale. Higher scores indicate better skill performance.	Immediately after completion of the laboratory training session

Collaborators and Investigators

• Sponsor: Gözde ÖZARAS ÖZ
• Collaborators: Çankırı Karatekin University

Study record dates

Study Major Dates

• Study Start (Estimated): February 1, 2026
• Primary Completion (Estimated): March 1, 2026
• Study Completion (Estimated): April 1, 2026

Study Registration Dates

• First Submitted: February 9, 2026
• First Submitted That Met QC Criteria: February 14, 2026
• First Posted (Actual): February 18, 2026

Study Record Updates

• Last Update Posted (Actual): February 18, 2026
• Last Update Submitted That Met QC Criteria: February 14, 2026
• Last Verified: February 1, 2026

More Information

Terms related to this study

• Keywords: Intramuscular injection; Self-regulated learning; nursşng education; Ventrogluteal injection; Psychomotor skill training; Peyton four-step approach
• Other Study ID Numbers: ARCS-ER-MED-2026-A

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: This study is an educational intervention conducted with undergraduate nursing students. Individual participant data will not be shared because the data consist of educational assessments, skill performance scores, and self-reported learning measures collected within an institutional training context. Data sharing was not included in the informed consent process, and sharing individual-level data could compromise participant confidentiality.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No