PEER SUPPORT GUIDELINES FOR NURSE EDUCATORS DURING CURRICULUM INNOVATION IN LESOTHO by Mirriam Shawa 2007075571 Interrelated publishable manuscripts submitted in fulfilment of requirements for the degree PHILOSOPHIAE DOCTOR IN NURSING PhD (Nursing) in the School of Nursing Faculty of Health Sciences UNIVERSITY OF THE FREE STATE PROMOTER: PROF. Y BOTMA JUNE 2020 1 DECLARATION I hereby declare that the work submitted in this thesis, titled, “Peer support guidelines for nurse educators during curriculum innovation in Lesotho”, is a result of my own independent investigation. Where assistance and support were sought, these were acknowledged appropriately. I further declare that this work has not been submitted by me for a degree or qualification to any other university or faculty. I hereby cede copyright of this product in favour of the University of the Free State. June 2020 M Shawa a DEDICATION This study is dedicated to my two sons, Edward and Japhet, who were my source of strength and encouragement when the going got very tough for me. b ACKNOWLEDGEMENTS I express my deepest and sincere gratitude to all who assisted and supported me during the journey to make this study a success. Special mention goes to the following people and organisations who made significant contributions to the design and development of this work:  My promoter and friend, Professor Yvonne Botma – your unrelenting support, encouragement, guidance and advice throughout my doctoral study kept me moving. Your incomparable patience, motivation and immense knowledge contributed to my personal growth. Your guidance kept me afloat throughout the research and writing of this thesis. I could not have imagined having a better advisor and mentor for my PhD study. Thank you very much, Professor.  My special son and friend, Dr Champion Nyoni – besides my promoter, your unrelenting support and encouragement throughout this study were immeasurable. Your constant nudging, insightful questioning and critiquing my work at every stage were invaluable. You literally walked this PhD journey with me, always keen to know the progress made and helping me untangle knots that delayed progress. I cannot thank you enough.  My sons, Edward and Japhet – you remained supportive and encouraged me throughout this journey. You understood my preoccupation with the computer while you needed my attention. Thank you for being there and always interested in the progress I was making. You have been my cheerleaders and believed that I could do it. Thank you boys! c  My mother, Violet, and sisters, Elizabeth, Nyuma and Grace – thank you for understanding my prolonged absence from home when you needed a daughter and a sister during family times. Zikomo kwambiri.  Mr B Kaonga – your ongoing emotional support and encouragement despite the physical distance between us played a very vital role. I will always appreciate the friendship.  My employer, the Paray School of Nursing – thank you for availing me the resources and time to study.  Special mention to all my colleagues at the Paray School of Nursing who supported me in different ways. I appreciate it.  The nursing colleges in Lesotho for granting me permission to conduct my study and the nurse educators whose participation contributed insurmountably to this study – thank you for your support and being part of this research.  Mrs A du Preez, the university librarian – you made my work easy during the integrative review by searching for and availing me of literature.  Dr C. Nyoni, Mrs C Nel and Mrs P Shanduka – your critical role in the integrative review is greatly appreciated.  Profs Sarfraz, Petra and Sabone and Drs Tshiamo, Scrobby, Baglangana, Nyaga and Nyoni – for participating in the Delphi survey to validate the guidelines. Without your participation, this study would not have been accomplished. I appreciate your sparing time from your busy schedules to engage in my study. I will remain indebted to you, thank you. d  Dr R Albertyn – for critically reading the manuscripts in this thesis. Thank you for your time and skills.  Ms J Viljoen, the language editor, and Ms E Heyns, the technical editor – thank you for giving my work a professional and academic touch.  My expression of gratitude will not be complete without mentioning the University of the Free State for granting me the tuition bursary that enabled me to undertake this study. Thank you very much for this invaluable bursary. To all others not mentioned above, you are appreciated and have a special place in my heart. e ABSTRACT Background: The curriculum for the education of nurses and midwives in Lesotho was transformed through the adoption of competency-based education. Competency-based education promotes the capabilities of the students. Transforming the curriculum challenged educators’ skills, necessitating new sets of facilitation and assessment skills to enable appropriate enactment of the student-centred curriculum. Such major changes imposed by the curriculum innovation required commensurate professional development and ongoing support for the educators. The absence of ongoing supportive strategies during a curriculum innovation naturally led to unstructured support among educators. However, unstructured peer support is threatened by chaotic implementation and a possible curriculum drift. Therefore, there is a need for structured peer support through the provision of practice guidelines. Purpose: This study sought to develop guidelines to enhance peer support among nurse educators during a curriculum innovation in Lesotho. Methods: A qualitative approach with multiple data collection methods was used to develop peer support guidelines according to the World Health Organization’s Handbook for Guideline Development. The research was undertaken in three phases. Phase I described the existing peer support strategies through an integrative review. Phase II described the experiences of nurse educators related to unstructured peer support during the implementation of midwifery curriculum innovation through an exploratory descriptive qualitative study. Phase III integrated the findings from phases I and II to develop guidelines for peer support during a curriculum innovation in Lesotho. An international expert panel validated the guidelines through two iterative Delphi rounds. f Results: Phase I of the study described the existing peer support strategies through an integrative review. Six themes emerged, namely types of peer support strategies, characteristics of peer supporters, characteristics of an effective peer support strategy, outcomes of effective peer support strategies, challenges of implementing peer support strategies and lessons learnt from the peer support strategies. Phase II of the study described experiences of educators regarding peer support during midwifery curriculum innovation and revealed five themes, namely motivation for educators to participate in peer support, attributes of educators that influence the extent of interaction and uptake of support, unstructured peer support strategies, consequences of peer support among educators and model performance inspires engagement with the new curriculum. The results from the two phases were triangulated and informed the development of the practice guidelines to enhance peer support among nurse educators during curriculum innovation. Five priority areas and seven recommendations were developed. The priority areas were peer supporters, peer support strategies, content/support needs, outcomes of peer support, and monitoring and evaluation of the peer support strategy. External reviewers validated the developed practice guidelines using AGREE II tool and attained an agreement of between 80 and 100% across the items on the tool. Conclusion: Transforming curricula for nursing and midwifery education is inevitable globally. Curriculum changes challenge the capabilities of the implementers and necessitate planned ongoing professional development and support of the implementers of the new curriculum. Such ongoing support strategies may be costly for low- and middle-income countries, such as Lesotho, and could benefit from structured peer support. The absence of such supportive strategies may compromise the fidelity of the implementation of the curriculum change. This study proposes peer support as an affordable intervention to enhance the implementation of a new curriculum, especially in low- and middle-income countries. The effectiveness of such intervention requires the commitment of institutional leaders, experienced and committed peer support providers, a clear modus operandi, tailor-made activities, appropriate resources, and monitoring and evaluation mechanisms. The proposed guidelines may enhance peer support during curriculum innovation. g Keywords: curriculum innovation, peer support, peer support strategy, nurse educator, nursing education, guidelines, implementation, professional development, enhance, competency-based education h TABLE OF CONTENTS Page CHAPTER 1: Overview of the study 1.1 INTRODUCTION .......................................................................................... 1 1.2 BACKGROUND ............................................................................................ 1 1.3 CONTEXT OF THE STUDY ......................................................................... 3 1.4 PROBLEM STATEMENT ............................................................................. 9 1.5 AIM OF THE STUDY .................................................................................... 10 1.6 RESEARCH OBJECTIVES .......................................................................... 11 1.7 THE RESEARCH PARADIGM ..................................................................... 11 1.8 THE THEORETICAL FRAMEWORK ............................................................ 13 1.9 RESEARCH DESIGN ................................................................................... 14 1.10 PHASE I: AN INTEGRATIVE REVIEW OF EXISTING PEER SUPPORT STRATEGIES ............................................................................................... 17 1.10.1 Purpose of Phase I: Describing existing peer support strategies . 17 1.10.2 Research design for describing existing peer support strategies . 17 1.10.2.1 Problem identification .............................................. 18 1.10.2.2 Literature search and retrieval ................................ 21 1.10.2.3 Critical appraisal of selected studies ....................... 22 1.10.2.4 Data extraction ........................................................ 22 1.10.2.5 Data analysis and synthesis .................................... 23 1.10.2.6 Presentation ............................................................ 23 1.11 METHODOLOGICAL RIGOUR .................................................................... 23 1.12 PHASE II: AN EXPLORATORY QUALITATIVE STUDY OF THE EXPERIENCES OF NURSE EDUCATORS RELATED TO PEER SUPPORT .................................................................................................... 24 1.12.1 Purpose of Phase II: Exploring the experiences of nurse educators related to peer support during CBC implementation ..................... 24 i Page 1.12.2 Research design for describing the experiences of nurse educators related to peer support ................................................................. 24 1.12.2.1 Study population ..................................................... 25 1.12.2.2 Unit of analysis and inclusion criteria ...................... 25 1.12.2.3 Sampling and sample.............................................. 25 1.12.2.4 The explorative (pilot) study .................................... 26 1.12.2.5 Data collection technique and process.................... 26 1.12.2.6 Data analysis .......................................................... 27 1.12.2.7 Rigour of the qualitative study ................................. 28 1.13 PHASE III: DEVELOPMENT OF PRACTICE GUIDELINES FOR PEER SUPPORT AMONG NURSE EDUCATORS ................................................. 29 1.13.1 Purpose of Phase III: Development of practice guidelines ........... 29 1.13.2 Developing the guidelines ............................................................ 30 1.13.2.1 Need for the guidelines ........................................... 30 1.13.2.2 Purpose and target population ................................ 30 1.13.2.3 Scope of the guidelines ........................................... 31 1.13.2.4 Evidence of existing peer support strategies ........... 31 1.13.2.5 Evidence of experiences of stakeholders/ stakeholder involvement ........................................ 31 1.13.2.6 Quality of evidence used ......................................... 31 1.13.2.7 Formulating draft recommendations........................ 32 1.13.3 Validation of the guidelines ........................................................... 32 1.13.3.1 Participants in the Delphi survey ............................. 32 1.13.3.2 Validation process ................................................... 33 1.14 ETHICAL CONSIDERATIONS OF THE ENTIRE STUDY ............................ 33 1.14.1 Educational value ......................................................................... 34 1.14.2 Scientific validity ........................................................................... 34 1.14.3 Ethical oversight ........................................................................... 35 1.14.4 Provision of appropriate educational interventions or any other benefits of social value after research .......................................... 36 ii Page 1.14.5 Collaborative partnerships ............................................................ 36 1.15 LAYOUT OF THE THESIS .......................................................................... 37 1.16 CONCLUSION ............................................................................................. 37 CHAPTER 2 Peer support strategies that enhance the implementation of innovation among professionals: An integrative review 2.1 INTRODUCTION .......................................................................................... 38 2.2 MANUSCRIPT DETAILS .............................................................................. 38 2.2.1 Journal information ....................................................................... 39 2.2.2 Contribution record ....................................................................... 39 2.2.3 Associated addenda ..................................................................... 39 2.3 MANUSCRIPT 1 ........................................................................................... 40 CHAPTER 3 Peer support during the implementation of a new curriculum: The experiences of nurse educators in Lesotho 3.1 INTRODUCTION .......................................................................................... 70 3.2 Manuscript details ......................................................................................... 70 3.2.1 Journal information ....................................................................... 71 3.2.2 Contribution record ....................................................................... 71 3.2.3 Associated addenda ..................................................................... 71 3.3 MANUSCRIPT 2 ........................................................................................... 72 iii Page CHAPTER 4 Practice guidelines to enhance peer support among educators during a curriculum innovation 4.1 INTRODUCTION .......................................................................................... 96 4.2 MANUSCRIPT DETAILS .............................................................................. 96 4.2.1 Journal information ....................................................................... 97 4.2.2 Contribution record ....................................................................... 97 4.2.3 Associated addenda ..................................................................... 97 4.3 MANUSCRIPT 3 ........................................................................................... 98 CHAPTER 5 Practice guidelines for peer support 5.1 INTRODUCTION .......................................................................................... 112 5.2 PURPOSE OF THE GUIDELINES ............................................................... 112 5.3 TARGET AUDIENCE AND STAKEHOLDER INVOLVEMENT ..................... 113 5.4 SCOPE OF THE GUIDELINES .................................................................... 114 5.5 FORMULATED RECOMMENDATIONS FOR PEER SUPPORT ................. 114 5.5.1 Recommendations and evidence ................................................. 117 5.6 QUALITY OF EVIDENCE USED IN THE RECOMMENDATIONS ............... 140 5.7 MONITORING &EVALUATION OF THE GUIDELINES ............................... 141 5.8 UPDATING THE GUIDELINES .................................................................... 141 5.9 IMPLICATIONS FOR IMPLEMENTING THE GUIDELINES ......................... 142 5.10 CONCLUSION .............................................................................................. 143 5.11 DECLARATION OF CONFLICTS OF INTEREST ........................................ 144 CHAPTER 6 Conclusion, recommendations and limitations of the study 6.1 INTRODUCTION .......................................................................................... 145 6.2 OVERVIEW OF THE STUDY ....................................................................... 145 6.3 FACTUAL FINDINGS ................................................................................... 147 iv Page 6.4 CONCEPTUAL CONCLUSION .................................................................... 152 6.5 CONCLUSION FROM THE STUDY ............................................................. 153 6.6 RECOMMENDATIONS ................................................................................ 155 6.7 CONTRIBUTIONS FROM THIS STUDY ...................................................... 157 6.8 LIMITATIONS OF THIS STUDY ................................................................... 159 6.9 PERSONAL REFLECTIONS ........................................................................ 161 6.10 CONCLUSION ............................................................................................. 162 6.11 COMPREHENSIVE REFERENCE LIST ...................................................... 163 v LIST OF TABLES Page TABLE 1.1: Difference between the content-based and competency- based curriculum ..................................................................... 6 TABLE 1.2: Phases and framework components in the peer support guideline development ............................................................ 15 TABLE 1.3: Literature inclusion and exclusion criteria .............................. 20 TABLE 1: Summary of articles included in the integrative review ............ 51 TABLE 1: Summary of guideline recommendations on peer support ...... 105 TABLE 5.1: Summary of guideline recommendations on peer support ..... 116 TABLE 6.1: Factual conclusion from the study .......................................... 148 TABLE 6.2: Contributions of the study ....................................................... 160 vi LIST OF FIGURES Page FIGURE 1.1: Phases of implementation of the new CBC in Lesotho ........... 8 FIGURE 1.2: Methodological process for the guideline development ........... 16 FIGURE 1.3: The integrative review process................................................ 18 FIGURE 1: PRISMA flow chart: Process of searching and selecting literature .................................................................................. 49 FIGURE 1: Methodological process for guideline development................. 102 FIGURE 2: Summary of the guideline validation process .......................... 103 FIGURE 6.1: The conceptual conclusion ...................................................... 154 vii LIST OF ADDENDUM Page ADDENDUM A: Johns Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal Tool ......................................................... 173 ADDENDUM B: Critical Appraisal Skills Programme ........................................ 180 ADDENDUM C: Critical appraisal – Case study ................................................ 186 ADDENDUM D: JHNEBP evidence rating scale ............................................... 188 ADDENDUM E: Data extraction tool ................................................................. 190 ADDENDUM F: Semi-structured interview ........................................................ 193 ADDENDUM G: Information brochure – Qualitative study ................................. 197 ADDENDUM H: Consent form........................................................................... 200 ADDENDUM I: Interview transcript samples .................................................... 202 ADDENDUM J: Data coding sheet ................................................................... 236 ADDENDUM K: Agree II tool ............................................................................. 256 ADDENDUM L: Delphi survey .......................................................................... 263 ADDENDUM M: Ethical approval – UFS ........................................................... 267 ADDENDUM N: Ethical approval – Ministry of Health, Lesotho ........................ 269 ADDENDUM O: Institutional permission sample ............................................... 271 ADDENDUM P: Author guidelines .................................................................... 273 ADDENDUM Q: Author guidelines .................................................................... 290 ADDENDUM R: Author guidelines .................................................................... 302 ADDENDUM S: Summary Turnitin Report ........................................................ 315 viii LIST OF ABBREVIATIONS AND ACRONYMS AGREE II Appraisal of Guidelines for Research and Evaluation II AHRQ Agency for Healthcare Research and Quality AJHPE African Journal of Health Professions Education BoS Bureau of Statistics CASP Critical Appraisal Skills Programme CBC Competency-based curriculum CBE Competency-based education CHAL NTI Christian Health Association of Lesotho Nurses Training Institutions CINAHL Cumulative Index of Nursing and Allied Health Literature EMBASE Excerpt Medica dataBASE ERIC Education Resources Information Centre HRSEC Health Sciences Research and Ethics Committee IJANS International Journal of Africa Nursing Sciences IJEMST International Journal of Education in Mathematics, Science and Technology IJNS International Journal of Nursing Studies IPE Interprofessional education JHNEBP Johns Hopkins Nursing Evidence-Based Practice LIC Low-income countries LMIC Low- and middle-income countries M&E Monitoring and evaluation MoH Ministry of Health NEPI Nursing Education Partnership Initiative OSCE Objective structured clinical examination PHC Primary health care PICOT Population intervention control outcome timeframe PRISMA Preferred Reporting Items for Systematic Reviews and Meta- Analysis PSS Peer support strategy UFS University of the Free State USA United States of America WHO World Health Organization ix CONCEPTUAL AND OPERATIONAL DEFINITIONS OF TERMS Curriculum innovation: This refers to ideas or practices that are considered new and different from those that exist in the formal prescribed curriculum, although not actually cutting edge (Halpin et al., 2004). In this thesis, ‘curriculum innovation’ is viewed as the complete transformation of the curriculum with the introduction of new pedagogical approaches different from those in the former curriculum. Guidelines: According to the World Health Organization (WHO, 2014) guidelines refer to any document that contains a set of evidence-based recommendations for clinical practice or public health policy. In this thesis, guidelines refer to a document containing evidence-based recommendations intended to give direction on peer support among educators during a curriculum innovation and will also be referred to as practice guidelines. Nurse educator: Raymond et al. (2017) define ‘nurse educator’ as an individual who is involved in teaching nursing students in the classroom, laboratory or clinical setting. In this thesis, ‘nurse educator’ refers to individuals who are involved in the education of student nurses in nursing and midwifery programmes in Lesotho. Peer support: Peer support is the provision of emotional, appraisal and informational assistance and encouragement by someone who is experienced in and knowledgeable about the specific behaviour or situation to enhance behaviour change in peers (Dennis, 2003). In this thesis, ‘peer support’ refers to the supportive assistance that colleagues who are knowledgeable about or experienced in curriculum innovation provide to their peers who are less knowledgeable during implementation. A Practice Guidelines: According to the Institute of Medicine cited in Sox (2017) practice guidelines are defined as ‘statements that include recommendations intended to optimize patient care, that are informed by systematic review of evidence and assessment of the benefits and harms of alternative care options’. In this thesis, practice guidelines refers to a set of formulated evidence-based recommendations that describe peer support interventions and processes to assist nurse educators during a curriculum innovation. Professional development: Refers to professional development as the ‘learning that results in change to teacher knowledge and practices, and improvements in student learning outcomes’ (Darling-Hammond, Hyler, & Gardner, 2017, p.2). In the thesis professional development refers to all the planned learning opportunities and activities that educators undertake to improve their competencies to support student learning. Recommendations: These are evidence-based statements that inform the intended end-user of the guidelines about the appropriate interventions or decisions to take in specific situations to achieve the best health outcomes possible (WHO, 2014). Recommendations are a component of the guidelines. In this thesis, recommendations refer to evidence-based statements formulated to assist educators during peer support interactions during implementation of a curriculum innovation. The recommendations in this thesis will also be referred to as guidelines recommendations. B PREAMBLE The format of this thesis is in accordance with the recommendations for the PhD through interrelated publishable articles, as presented within the Faculty of Health Sciences of the University of the Free State, South Africa. As opposed to the monograph format, this thesis consists of a collection of publishable articles in conjunction with the introductory and summary chapters. The thesis consists of six chapters. Chapter 1 is an introductory chapter, describing the overall purpose and methods of the study. Chapters 2 to 4 present the interrelated publishable manuscripts, which have been aligned to the guidelines of the targeted journals. Chapter 5 presents the complete guidelines, while the final chapter draws the focus on the conclusion, recommendations and limitations of the study. The researcher adhered to all the research processes as applied in a traditional thesis, which included planning, preparing and conducting the research by applying the same rigorous processes. The researcher thoroughly described all the methodological processes of developing the guidelines for peer support in Chapter 1. A summarised version of the entire methodology aligned with the specific journal requirements is presented in the manuscripts. Given that the thesis format included interrelated publishable articles, a considerable amount of repetition of key issues and concepts will be observed throughout the document. The manuscripts are articulated according to the format of the targeted journals; therefore, a variation in the styles will be observed. However, the referencing style of the American Psychology Association, sixth edition, was adopted for chapters 1, 5 and 6. From chapters 2 to 4, each chapter presents a unique reference list and style based on the targeted journal guidelines. Each manuscript includes an addendum of the author guidelines for the potential journal. A comprehensive reference list for the literature used is presented at the end of the thesis. C PUBLISHABLE MANUSCRIPTS FROM THE STUDY Shawa, M. & Botma, Y. (2020a). Peer support strategies that enhance the implementation of an innovation among professionals: An integrative review. Target journal: International Journal of Nursing Studies. (Not yet submitted) Shawa, M. & Botma, Y. (2020b). Peer support during the implementation of a new curriculum: The experiences of nurse educators in Lesotho. Target journal: International Journal of Africa Nursing Sciences. (Not yet submitted) Shawa, M. & Botma, Y. (2020). Practice guidelines for peer support among educators during a curriculum innovation. Target journal: African Journal of Health Professions Education. (Accepted for publication in August, 2020) CONFERENCE PRESENTATION Shawa, M. & Botma, Y. (2019, June). Experiences of nurse educators related to peer support during midwifery curricular innovation in Lesotho. Paper presented at the SAAHE Conference, University of the Free State, Bloemfontein. D CHAPTER 1 Overview of the study 1.1 INTRODUCTION The introductory chapter presents an overview of the entire thesis. The chapter begins with the description of the background, the context of the study and the problem statement, and then proceeds to explain the aim and objectives of the study. The research paradigm, theoretical framework and research design used in the research project are further outlined in this chapter. 1.2 BACKGROUND Reforms in the education of health professionals is inevitable in the face of the Third and Fourth Industrial Revolutions, globalisation, technological advancements and changing healthcare needs of populations (Xu, David, & Kim, 2018). Since the turn of the 20th Century, there has been three generations of reforms in the education of professionals. The first generation was the science-based curriculum, the second generation was focused on problem-based learning, while the third generation is a systems-based curriculum (Frenk et al., 2010). The systems-based generation of reforms is competency-driven, guiding students from memorisation to transformative learning that empowers them to be critical thinkers (Clark, Raffray, Hendricks, & Gagnon, 2016). The global independent Commission on Education for Health Professionals for the 21st Century proposes transformation directed towards the adoption of competency-based instructional designs to equip graduates with relevant competencies to address the health needs of populations (Frenk et al., 2010). Similarly, the World Health Organization (WHO) (2013), in its guidelines for transforming and scaling up health professionals’ education and training, recommends alignment of the 1 competencies of health professionals with the disease/healthcare needs profiles of specific communities through curriculum reforms. As the low-and-middle-income countries (LMICs) respond to the transformational calls, they ought to take stock of the healthcare needs of communities to be able to contextualise curriculum. Most LMICs, although faced with a heavy burden of disease, experience a shortage of health professions workforce and operational resources for healthcare services (Portela, Fehn, Ungerer, & Poz, 2017). Nurses are the bulk of care providers in LMICs. Such a state of affairs necessitates transformation in nursing education curriculum to equip graduate nurses with relevant competencies that will enable them to practise safely and address the healthcare needs of populations (WHO, 2013). Graduate nurses working in LMICs such as Lesotho may be the only healthcare providers that some populations encounter when seeking healthcare services. In such situations, graduate nurses need to apply critical thinking, clinical reasoning and problem-solving skills in the provision of care to their clients, necessitating curriculum change to incorporate these essential skills (Tanner, 2006). However, curriculum change may pose different challenges to the implementers and necessitates strategies to provide ongoing support. Curriculum change poses challenges ranging from adapting teaching and assessment approaches to acquiring different resources and sustaining change. Curriculum drift is the major threat to curriculum transformation (Wilson, Rudy, Elam, Pfeifle, & Straus, 2012). Curriculum drift is an insidious process in which the implementation of a curriculum transformation reverts to its pre-innovative ancestor driven by poorly supported implementation processes (Wilson et al., 2012). Various factors can lead to curriculum drift, which may include operational practicality not tested, external influences, loss of key supporters or champions of innovation, and replacement by more traditionally oriented educators (Wilson et al., 2012). Other reasons supporting a curriculum drift include lack of ownership of the curriculum by the educators, poor communication and inadequate faculty development (Wilson et al., 2012). Challenges with curriculum change may also emanate from memorisation and the repetitive nature of learning, which might be deeply ingrained among older educators (Botma & Nyoni, 2 2015). The rote learning and repetition approach to facilitation is not aligned to student- centred learning, which is key in a competency-driven curriculum. Ensuring sustainability in the implementation of a transformed curriculum requires innovative and supporting interventions, such as peer support. Peer support is an interpersonal relationship in which two or more people assist each other to deal with a similar challenging situation (Sunderland & Mishkin, 2013). This supportive relationship involves providing assistance and encouragement to enhance behaviour change based on the principles of shared respect, shared responsibility and mutual agreement (Dennis, 2003). Peer support is widely used to aid individuals dealing with chronic conditions such as cancer or mental health conditions. However, peer support can also be used among professionals facing difficulties during a change process. There are various forms of peer support relationships among professionals, which may include, but are not limited to, peer mentoring, peer coaching, peer counselling and support groups (Kram & Isabel, 1985). Peer support promotes interaction and sharing of experiences and becomes a learning opportunity for both parties as it provides an opportunity for structured conversation (Monk & Purnell, 2014). 1.3 CONTEXT OF THE STUDY Lesotho is a mountainous kingdom in sub-Saharan Africa classified under low-income countries with a population of approximately two million (Bureau of Statistics [BoS], 2016). This small kingdom has a geographical terrain that often makes accessibility to healthcare services a challenge. The Kingdom experiences a heavy burden of communicable and non-communicable diseases (Ministry of Health [MoH], 2013). The delivery of healthcare in Lesotho follows the primary healthcare (PHC) system, with nurses forming the bulk of the workforce (MoH, 2013). There are six nursing education institutions that train nurses and midwives, four of which belong to the Christian Health Association of Lesotho Nurses Training Institutions (CHAL NTI) consortium and two national institutions (MoH, 2013). The graduate nurses from these institutions are deployed in all healthcare settings where they are often the only professional care 3 providers. Such a situation requires the newly qualified nurses to apply critical thinking, clinical reasoning and problem-solving skills in the provision of care to populations as outlined in Tanner’s Clinical Judgement Model (Tanner, 2006), for which they might not be adequately prepared and may struggle to transition into practice (Makhakhe & Khalanyane, 2013), necessitating curriculum change. Curriculum transformation was a political decision that was articulated through the strategic plan of the Ministry of Health to strengthen the training of nurses in Lesotho and enhance their competence (MoH, 2013). Until the 2014–2015 academic year, the training of nurses and midwives in Lesotho was content-based, guided by behaviourism as a learning theory, with the majority of placements being hospital-based. The teacher-centred strategies were used and targeted at transmitting knowledge to students and completing the prescribed theory. Students were mainly passive participants who listened to the lectures and took notes from PowerPoint presentations. Clinical learning was routine-oriented, with clinical nurses occasionally guiding the students. Summative assessment of students in the content-based curriculum consisted of various written papers and two clinical procedures, which varied from student to student. For example, one student would be assessed on taking a patient’s weight and administering an injection, while the next may perform a bed bath and suturing of a wound. These assessments determined whether or not the student had attained the ‘competence’ to graduate as a nurse ready to provide care to populations. The graduates from the content-driven curriculum often struggled to adapt to clinical settings, where they have to provide care with minimal or non-existent planned transitioning programmes for newly qualified nurses (Makhakhe & Khalanyane, 2013). Nurses require critical competencies to enable them to function independently and safely in addressing changing healthcare needs of populations, hence the need for competency-based education (Botma, 2014a). 4 Lesotho adopted competency-based education (CBE) to underpin the design and delivery of nursing education. The CBE approach promotes developmental attainment of competencies and abilities by the students who actively participate and drive their own learning (Frank et al., 2010). The core components of CBE are outcome competencies, sequenced progression, tailored learning experiences, competency- focused instruction and programmatic assessment (Melle et al., 2019). Similarly, the CBE adopted for nursing education in Lesotho applied the six elements of curriculum development as outlined by Harden (2013), namely learning outcomes, content, educational strategies, learning opportunities, educational environment and assessment. Clark et al. (2016) emphasise that CBE focuses on equipping students with specific professional competencies through curriculum transformation. Professional competencies guide the design of a competency-based curriculum (CBC). The CBC designed for nursing education in Lesotho was underpinned by four educational principles, namely constructivism, constructive alignment, scaffolding and authenticity (Biggs, 2003; Biggs, 1996). Such principles promote student-centeredness and the use of evidence-based strategies to enable students to make meaning of the learning material (Botma & Nyoni, 2015). The educators in the CBC required a new set of skills that were aligned to CBE to ensure the fidelity of curriculum implementation (Melle et al., 2019). Botma (2014b) reiterates that a paradigm shift from behaviourism to constructivism requires a new set of skills among nurse educators to implement CBC successfully. In the same vein, Dawes et al. (2005) argue that the CBC approach requires nurse educators to engage with current evidence-based practices in nursing education and practice, hence the need for ongoing professional development. Table 1.1 summarises the differences in the approaches to teaching between the old content- based and the new CBC implemented in Lesotho. 5 TABLE 1.1: Difference between the content-based and competency-based curriculum Element of curriculum Traditional content-based curriculum Competency-based curriculum Learning outcomes  Oriented towards knowledge attainment  Oriented towards competency attainment of specific learning with no specific learning outcome outcomes Content  Content not focused on specific  Integrated content and aligned with specific competencies competency  Content with scientific basis and associated best practice  Some content not contextualised  Scaffolding of content  ‘Correct’ content to be reproduced  Constructively aligned with the learning outcomes and assessment  Dependent on textbooks  Content promotes critical thinking  Dependent on study guides and vast source of up-to-date resources Educational approaches  Teacher-centred strategies  Student-centred strategies  Behaviourist approach to learning  Constructivist approach to learning  Didactic teaching and learning  Innovative learning/facilitation approaches  Knowledge transmission and rote learning  Knowledge construction and meaning making  Students are passive participants  Students are active participants Educational environment  Classroom  Authentic learning environments  Hospital setting  Classroom  Limited exposure to PHC centres  Simulation laboratory  Community  PHC facilities  Hospital setting Learning opportunities  Demonstration of clinical procedures  Experiential learning opportunities  Hospital-based learning experiences  Simulation of authentic learning experiences  Unpredictable teachable moments from  Standardised patients nurses in clinical areas  Community and PHC facilities  Work-integrated learning Assessment  Paper-based examinations  Integrated assessment of competence  Two bedside clinical procedures  Observation of performance in objective structured clinical  No uniformity in assessment of clinical examination skills with every student assessed on  All students assessed on the same stations different procedures. Source: Author-generated 6 The fidelity of CBC implementation requires nursing education institutions to develop and support educators. The educators need to develop an understanding of the paradigm shift, which focuses on competence attainment among the students and the application of new teaching approaches (Dath & Iobst, 2010). The Government of Lesotho, through the Nursing Education Partnership Initiative (NEPI), invested resources on curriculum transformation and professional development to enable nursing education institutions to deliver the CBC appropriately. The resources mobilised included the cost for engaging a consultant for the development of the CBC, purchasing of computers, high-tech mannequins, establishing simulation laboratories, strengthening libraries and capacitating nurse educators from all the nursing education institutions in the CBC (Middleton et al., 2014). Preparations and investments such as these are essential for successful implementation of the CBC and averting curriculum drift. The professional development activities resulted in differences in understanding of the principles and processes for CBC implementation among educators, thereby setting the stage for ongoing support (Botma & Nyoni, 2015). Although Lesotho had transformed the prescribed curriculum for nurse and midwifery education, there was no deliberate plan for ongoing professional development and support of nurse educators throughout the transition period. Extensive ongoing support is critical during curriculum change to educate and encourage educators to adapt to their new roles (Dath & Iobst, 2010). In the case of Lesotho, the early adopters who had acquired a better understanding of CBE principles provided unstructured support to their colleagues during Phase 1 implementation of the curriculum reform in the midwifery programme. Peer support can benefit nurse educators to enact the curriculum reform as planned. However, effective peer support among nurse educators during curriculum innovation requires structure and guidance to enhance interactions, hence the need to develop guidelines for peer support. Figure 1.1 illustrates the phases of implementing the new CBC in Lesotho. 7 • The development of the new curriculum Pre-phase • Professional development activity • Implementation of the CBC in the Diploma in Midwifery programme Phase 1 • Implementation of the CBC in the Diploma in Nursing programme Phase 2 FIGURE 1.1: Phases of implementation of the new CBC in Lesotho (Source: Author-generated) Pre-phase: The pre-phase saw the conducting of a needs assessment in preparation for the designing and development of the CBC. A new curriculum and some teaching materials were designed underpinned by the tenets of constructivism, constructive alignment, scaffolding and authenticity. Professional development for nurse educators from the six nursing education institutions in Lesotho was conducted. Teaching resources were acquired for all nursing education institutions. The key players in this phase were the consultant, who is a curriculum specialist, and the nursing and midwifery education task team consisting of the educator representatives from different nursing education institutions, clinical practice and the regulatory body. NEPI funded the processes. Phase 1: In the 2014–2015 academic year, the CBC for the midwifery programme was rolled out in five institutions. Some teaching materials were still being developed. Educators had different understandings regarding the implementation of the CBC. There was a change in the teaching and assessment approaches. One of the nursing 8 education institutions had multiple early adopters who readily implemented the new curriculum with less challenges, while educators from most of the other institutions were sceptical and resisted the new curriculum. The early adopters became the drivers of the new curriculum and naturally began providing support to their colleagues. Unstructured peer support emerged among the 18 midwifery educators in different nursing education institutions in Lesotho. Phase 2: In the 2017–2018 academic year, the CBC was introduced in the Diploma in Nursing, a three-year programme in one institution in Lesotho, although the other four institutions were still hesitant. A second institution introduced the CBC for the Diploma in Nursing in the 2018–2019 academic year, while the other three institutions continued using the old content-based curriculum. The scepticism that prevailed during the implementation of the Diploma in Midwifery CBC was also observed among the nurse educators in the Diploma in Nursing programme. As opposed to the Diploma in Midwifery programme, the Diploma in Nursing programme had more than 60 educators involved in the education of nurses across the five nursing education institutions in Lesotho. These educators had different understandings of and readiness for the implementation of the CBC, although there was no planned ongoing professional development and support in place. This discrepancy can be a recipe for poor implementation of the new curriculum. 1.4 PROBLEM STATEMENT The transformation from the content-based curriculum to the CBC for nurse training in Lesotho requires a paradigm shift from behaviourism to constructivism with a focus on competence attainment among students. However, there was no deliberate plan or strategy in place for ongoing support of the implementers of the new curriculum. Phase 1 implementation of the CBC in the midwifery programme revealed that nurse educators had different understandings of the principles underpinning the CBC, while others were sceptical about its practicality. The uncertainty was verbalised during meetings among nurse educators from different nursing education institutions in Lesotho. Anecdotal 9 evidence from activities during the Phase 1 implementation in the midwifery programme indicated that the educators who were able to implement the CBC appropriately provided unstructured support to their colleagues whenever there was a need. Ad hoc meetings were conducted whenever there was a challenge related to the implementation of the new curriculum. This approach enabled the educators to support one another and sustain the change process during Phase 1 of the implementation of the CBC. However, unstructured peer support would be a challenge during the Phase 2 implementation for the nursing programme, which has more than 60 facilitators compared to a smaller group of 18 in the midwifery programme. The peer support activities among midwifery educators were unstructured because there were no frameworks or guidelines to enhance the interaction of peers during the implementation of the new curriculum. Unstructured peer support might be unsustainable and pose challenges such as chaotic implementation, lack of accountability and poor motivation to participate in the long term (McLean, Cilliers, & Wyk, 2008). Such challenges may be averted or reduced with the availability of well- designed, structured peer support and professional development (Dath & Iobst, 2010). Furthermore, guidelines consisting of evidence-based recommendations may provide directions and enhance peer support interactions among educators. However, no existing guidelines for peer support among professionals during a curriculum innovation or any change process were found. In the absence of guidelines for peer support or planned professional development and ongoing support, the research question which arose was: What guidelines can be developed to enhance peer support among nurse educators during a curriculum innovation in Lesotho? 1.5 AIM OF THE STUDY The aim of this study was to develop guidelines to enhance peer support among nurse educators during curriculum innovation in Lesotho. 10 1.6 RESEARCH OBJECTIVES The objectives of this study were to:  describe existing peer support strategies that enhance the implementation of an innovation or new programme among professionals through an integrative review;  describe the experiences of educators regarding peer support during midwifery CBC implementation in Lesotho through an exploratory descriptive qualitative study;  develop guidelines to enhance peer support among educators during the implementation of the CBC in Lesotho using the WHO (2014) Handbook for Guideline Development as a framework; and  validate the developed peer support guidelines using a Delphi survey. 1.7 THE RESEARCH PARADIGM The research paradigm describes the researcher’s worldviews, understanding and interpretation of reality based on the set of common beliefs shared by scientists (Rehman & Alharthi, 2016). Every researcher holds different views concerning the nature of reality, which influences their choice of strategies used in an inquiry. Therefore, it is important for researchers to declare their research paradigm so that the research community may appreciate and make appropriate meaning of the research findings. In this study, the researcher adopted interpretivism as an overarching research paradigm for the development of guidelines for peer support. Interpretivist paradigm The interpretivist paradigm postulates that individuals socially construct reality as they interact with the world around them (Kivunja & Kuyini, 2017; Scotland, 2012). The researcher assumed that implementing a curriculum innovation was an individual experience among educators. Some educators may face challenges to enact the new 11 curriculum appropriately and could benefit from peer support. As a social intervention/interaction, peer support may enable curriculum implementers to develop appropriate understanding and enactment of the new curriculum. Interpretivism enabled the researcher to develop an understanding of the phenomenon of peer support as experienced by the educators involved in the curriculum innovation in Lesotho and to guide the development of guidelines that may influence peer support among educators. In the subsequent paragraphs, the epistemological, ontological and methodological assumptions related to interpretivism are discussed and it is demonstrated how they were applied in this study. Ontology describes the belief system related to the nature of reality to which the researcher ascribes (Kivunja & Kuyini, 2017). Scotland (2012) states that every paradigm holds a different ontological view that guides researchers in understanding and making meaning of the data they gathered. Researchers ascribing to the interpretivist paradigm assume that reality is diverse and humans view the same situation differently. The researcher in this study adopted the relativist ontology that believes in multiple realities that can be explored and meaning reconstructed as the researcher interacted with the participants (see Kivunja & Kuyini, 2017). Epistemology refers to how the researcher acquires and explains knowledge about reality to other scientists (Kivunja & Kuyini, 2017). A subjective epistemology was adopted for this study. The subjective epistemology enabled the researcher to construct knowledge socially through interaction with the participants (see Kivunja & Kuyini, 2017). The researcher engaged in independent thinking and cognitive processes to make meaning of the data gathered through personal interactions with the participants and existing literature on the subject. The researcher engaged actively in various interactive processes with the participants in the quest to collect data regarding the phenomenon under study (see Kivunja & Kuyini, 2017). 12 Methodology relates to the systematic processes that the researcher employs to gather the appropriate data that will help answer a research question (Kivunja & Kiyuni, 2017). The researcher applied a naturalistic methodology in this study and it guided data collection from participants within their institutions, which was the natural settings (see Kivunja & Kuyini, 2017). Qualitative approaches were used to collect and analyse the data (see Scotland, 2012). 1.8 THE THEORETICAL FRAMEWORK This study adopted the WHO Handbook for Guideline Development and the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool as the underpinning theoretical frameworks. The two sources guided the systematic development and validation of the guidelines. The WHO handbook provided a roadmap for the development of the guidelines, while the AGREE II tool guided the evaluation of the quality of the guidelines (Brouwers et al., 2010; Grove, Gray, & Sutherland, 2016; WHO, 2014). According to the WHO (2014) handbook, the process of guideline development includes, among others, identification of priority question and outcomes, retrieval of evidence, assessment and synthesis of evidence, formulation of recommendations and the validation of recommendations. In addition to the WHO Handbook for Guideline Development, the AGREE II tool also alludes to stakeholder involvement in the process of guideline development. These activities were grouped and undertaken in three different phases, which are explained in subsequent sections. Table 1.2 illustrates the summary of steps undertaken in the process of developing the peer support guidelines using the WHO Handbook for Guideline Development and the AGREE II tool. 13 1.9 RESEARCH DESIGN A primarily qualitative research design using multiple data collection methods was utilised. Three interrelated studies were conducted in three phases, which culminated in the development of the practice guidelines for peer support. In Phase I of this study, data were gathered through an integrative review, while Phase II data were generated through an exploratory descriptive qualitative study. Evidence from the two phases was triangulated to inform the development of guidelines in Phase III of the study. The developed guidelines were validated through a Delphi survey. Figure 1.2 presents the methodological process for the guideline development and the outcomes of the three studies. 14 TABLE 1.2: Phases and framework components in the peer support guideline development Phase of Framework Design Population used Data collection method Output study component(s) Phase I Formulating key Integrative review Published articles Data extraction and Existing peer support questions and synthesis strategies (Article 1) conducting literature review Phase II Stakeholder Exploratory Nurse educators in Semi-structured interviews Experiences of nurse involvement qualitative design Lesotho educators of peer support (Article 2) Phase III Formulation of WHO Handbook for Guidelines Discussion and consensus Draft peer support guidelines Guideline development task guidelines (Article 3) Development team Validation of Delphi survey Experts in nursing Iterative process using Finalised peer guidelines education AGREE II tool support guidelines (Article 3) Source: Author-generated 15 FIGURE 1.2: Methodological process for the guideline development (Source: Author-generated) 16 The next section describes in detail each phase of this study. 1.10 PHASE I: AN INTEGRATIVE REVIEW OF EXISTING PEER SUPPORT STRATEGIES The first phase of the study focused on describing the existing peer support strategies that enhance the implementation of innovations among professionals through an integrative review. 1.10.1 Purpose of Phase I: Describing existing peer support strategies The purpose was to synthesise and describe the existing peer support strategies that enhance the implementation of innovations or new programmes among professionals through an integrative review. Phase I addressed the first research objective and was aligned with the steps in the WHO Handbook for Guideline Development. 1.10.2 Research design for describing existing peer support strategies An integrative review was undertaken to describe the existing peer support strategies that enhance the implementation of innovations among professionals. The integrative review combines diverse methodologies to generate a comprehensive understanding of a phenomenon (Whittemore & Knafl, 2005). This rigorous scientific process enables the evaluation and synthesis of evidence to inform the development of policies and guidelines (Souza, Silva, & Carvalho, 2010). The researcher intended to generate evidence from a broad range of methodologies to contribute to the development of peer support guidelines. The researcher in the current integrative review adopted the Whittemore and Knafl (2005) framework in the interlinked stages, as shown in Figure 1.3. 17 Critical appraisal Problem Literature search of selected identification and retrieval studies Data analysis Data extraction Presentation and synthesis FIGURE 1.3: The integrative review process (Source: Author-generated) The discussion in the next section expands on each of the stages and how they were applied in this study. The methodological rigour applied during the integrative review will also be discussed. 1.10.2.1 Problem identification Problem identification was conducted through a ‘quick and dirty’ to gain insight into the existing literature on peer support, refine the focused research question, determine the inclusion and exclusion criteria and develop the initial search string search. a. The ‘quick and dirty’ search A ‘quick and dirty’ search was conducted without any language or time restrictions using the Google Scholar search engine to scope literature on peer support. The following search terms were used: peer OR colleague, AND support, OR mentor, OR guide, AND 18 educators, OR healthcare professionals, OR professionals, AND curriculum change, OR change, OR innovation, AND guidelines. The ‘quick and dirty’ search generated 30 300 hits from 1986 to 2016 from various databases and study designs, including systematic reviews and quantitative, qualitative and case study designs. The findings from the ‘quick and dirty’ search were used to refine the focused research question and the initial search string used during the integrative review. b. Refining the research question The focused research question that was used in this integrative review was refined in line with the results from the ‘quick and dirty’ search. The refined research question was: What peer support strategies enhance the implementation of innovations/new programmes among professionals from the first of January 2000 to November 2016? The year 2000 was used as the starting point, because the researcher assumed that it was the time when there was a marked increase in electronic publications. The population, intervention, comparator, outcome, and timeframe (PICOT) elements were identified as follows: P: Professionals I: Peer support strategy C: Not applicable O: Enhance implementation of innovation T: Since January 2000 19 c. The inclusion and exclusion criteria This integrative review included or excluded published theoretical and empirical literature from different methodologies (see Whittemore & Knafl, 2005) that reported on peer support based on the predetermined criteria. Refer to Table 1.3, which outlines the criteria. TABLE 1.3: Literature inclusion and exclusion criteria Inclusion criteria Exclusion criteria  Reflect a peer support strategy  Reflect on any other strategies  Report on an innovation or new  Report no innovation programme  Report no outcome of implementation  Outcomes reflective of enhanced  Involved peer support among non- implementation professionals and students engaged in  Professionals involved in the innovation professional studies  Published full articles in English  Unpublished literature  Published between 2000 and 2016  Published in any other language  Published before 2000 Source: Author-generated d. The search strategy The search for literature was guided by the key terms and their synonyms derived from the research question. A search string was developed with the Boolean operators ‘AND’ and ‘OR’ to combine or supplement keywords and focus the search (Polit & Beck, 2017). The initial search string included the following terms: peer or colleague or cohort or friend or fellow; AND support* mentor* or counsel* or guide* or advisor; AND innovation or ‘new program’ or ‘new curriculum’ or ‘new practice’ or ‘new behaviour’ or ‘intervention’ or ‘change’; AND ‘professionals’ or ‘healthcare professionals’. 20 1.10.2.2 Literature search and retrieval The literature search was conducted with the assistance of the librarian from the University of the Free State (UFS) based on the generated search string described earlier. Various electronic databases were searched and generated 369 abstracts and titles. An additional four articles were identified through ancestral search, bringing the number to 373. Performing an ancestral search earlier in the processes enables a further search of the added sources at a later stage. A record of the generated abstracts, the initial and every refined search string, results and databases was stored in an electronic folder on a computer to keep an audit trail of the integrative review. The researcher evaluated abstracts and titles for possible duplicates and eliminated four abstracts. The remaining 369 abstracts were evaluated against the research question and the inclusion criteria, upon which 264 abstracts were excluded. The remaining 105 abstracts were included in the subsequent step of the literature search. The full citations of the 105 abstracts and titles that met the inclusion criteria were compiled and sent to the university librarian, requesting for the retrieval of the full articles. Five reviewers individually evaluated the retrieved full articles against the inclusion criteria and eliminated 94 articles. Any discrepancies relating to the articles’ inclusion during the evaluation phase were discussed and resolved among reviewers through Skype or Zoom meetings and consensus was reached. Most of the articles excluded were either pilot studies, merely describing peer support without any innovation, or studies related to peer support among students and patients living with chronic conditions such as diabetes mellitus, breast cancer and mental health illnesses. Eleven articles were included in the subsequent stage of appraisal. 21 1.10.2.3 Critical appraisal of selected studies Four of the preceding five reviewers critically appraised articles independently using various validated appraisal tools based on the methodologies of the articles. The methodologies included the quantitative method (n = 2), qualitative method (n = 1), case study (n = 3) and non-empirical research (n = 5). The reviewers evaluated the methodological integrity of each full-length article using the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) Research Evidence Appraisal Tool, the Critical Appraisal Skills Programme (CASP) and the Centre for Evidence-Based Management Tool (Addenda A, B, C). No reports were excluded based on the critical appraisal. a. Quality of evidence The studies that were included in this integrative review were assessed for their quality by comparing their relevance to the research question and the JHNEBP Research Evidence Rating Scale (Addendum D). This scale classifies reports into three quality levels, namely high quality, good quality and low quality. Based on the JHNEBP Research Evidence Rating Scale, two articles were classified as of high quality, while the other nine were of good quality. No report was excluded based on this quality rating system. The reviewers reached consensus on the ratings of the evidence through discussion. 1.10.2.4 Data extraction The researcher, research promoter and two research collaborators extracted data from the included articles using a data extraction tool (Addendum E). The data extraction table was developed based on the research question and piloted by the researcher and the promoter on one article before the exercise. The aim of the data extraction table was to facilitate the summarising, organisation and comparison of findings (see Souza et al., 2010). A package of full articles and the data extraction table was sent to each research collaborators who participated in the data extraction, which took place over a 22 period of 12 weeks. The researcher compiled and recorded all the extracted data received from all the research collaborators. Any inconsistencies that were identified were discussed and resolved through Skype or Zoom meetings. 1.10.2.5 Data analysis and synthesis The extracted data were consolidated into groups according to their similarities in terms of meaning and/or description. Using an iterative process, the extracted data were compared item by item, grouped together and assigned meaningful statements, upon which conclusions were drawn. Themes emerged from the synthesised data. 1.10.2.6 Presentation The results of the integrative review were presented in a descriptive narrative form based on the themes that emerged from the extracted data. The themes described the existing peer support strategies that enhanced implementation of innovations. 1.11 METHODOLOGICAL RIGOUR The rigour of this integrative review was ensured, as described by Whittemore and Knafl (2005), to ensure repeatability of the study and credibility of the findings. The following strategies were applied during the review process:  Using well-defined and systematic literature search strategies  Using reliable and valid data coding procedures  Keeping an audit trail of the search strings, revisions, and inclusion and exclusion throughout the process  Using standardised critical appraisal tools  Piloting the data extraction tool  Collaborating with other researchers during the review and extraction of data. 23 The next section describes Phase II of the study. 1.12 PHASE II: AN EXPLORATORY QUALITATIVE STUDY OF THE EXPERIENCES OF NURSE EDUCATORS RELATED TO PEER SUPPORT The second phase of the study described the experiences of nurse educators relating to peer support during the implementation of the CBC in Lesotho. 1.12.1 Purpose of Phase II: Exploring the experiences of nurse educators related to peer support during CBC implementation The purpose of the second phase was to explore and describe the experiences of nurse educators related to peer support during the implementation of the CBC in Lesotho through an exploratory descriptive qualitative study design. Phase II addressed the second research objective and was aligned with the step of involving stakeholders outlined in the WHO Handbook for Guideline Development and the AGREE II tool. 1.12.2 Research design for describing the experiences of nurse educators related to peer support An exploratory descriptive qualitative design was conducted to describe the experiences of nurse educators related to peer support during CBC implementation in Lesotho. The design enabled the researcher to investigate and develop in-depth understanding of the lived experiences of nurse educators related to peer support during the implementation of a curriculum innovation (see Polit & Beck, 2017). This section details the study population, unit of analysis and inclusion criteria, sampling and sample, pilot study, data collection technique and process, data analysis and the rigour of the qualitative study. 24 1.12.2.1 Study population The population in this phase of the study was the nurse educators who participated in the implementation of the CBC in the midwifery programme in five nursing education institutions in Lesotho. The total population of nurse educators in the midwifery programme was 18. 1.12.2.2 Unit of analysis and inclusion criteria The individual participants were the unit of analysis, who provided thick descriptions of their lived experiences related to peer support during the curriculum innovation in Lesotho (see Botma, Greeff, Mulaudzi & Wright, 2010). The inclusion criteria applied to enhance the unit of analysis were nurse educators who:  worked in nursing education institutions in Lesotho;  were involved in the midwifery programme in any of the nursing education institutions in Lesotho;  participated in the implementation of the CBC;  were engaged in the unstructured peer support activities during CBC implementation; and  were willing to participate in the study. 1.12.2.3 Sampling and sample A convenient sampling technique was utilised to select a sample of 12 participants who had met the pre-determined inclusion criteria. Data saturation was reached after 10 interviews, but all the 12 participants were interviewed. 25 1.12.2.4 The explorative (pilot) study The researcher, also the interviewer, tested the central research question by interviewing two midwifery educators. The central question was “What were your experiences regarding collaborative support activities during the implementation of the new curriculum in the midwifery programme?” The research promoter reviewed the interviewing techniques of the transcribed semi-structured individual interviews to determine the competence of the interviewer. The semi-structured interview enabled the researcher to obtain in-depth information and gave the participants freedom to share their experiences in unstructured order (Polit & Beck, 2017). Open-ended questions and probing questions were mostly used during the interviews. No leading questions were asked. The data from the pre-test were included in the data analysis, as no adjustments had been made to the tool. The participants in the explorative study were informed beforehand about the possibility of including their data in analysis of the main study. 1.12.2.5 Data collection technique and process The researcher conducted semi-structured individual interviews to explore the experiences of participants related to peer support during the implementation of a curriculum innovation in Lesotho. The researcher communicated with the individual heads of each of the five nursing education institutions via email to request for permission and propose dates for data collection. Scheduled appointments with individual participants were made telephonically and agreed dates were set. On the scheduled dates, the researcher visited the individual nursing education institutions to collect data. At each institution, a private and quiet room was arranged in which to conduct the interviews. The prospective participants were identified and provided with information brochures and consent forms (Addenda G and H). Each participant gave written consent to be interviewed and to have the interview audio-recorded. Following the introductory formalities, the researcher commenced the data collection. The central question was 26 “What were your experiences regarding collaborative support activities during the implementation of the new curriculum in the midwifery programme?” See Addendum F. During interview, open-ended and probing questions were used to further interrogate information. All the interviews were conducted in English, with a few interjections of Sesotho comments by the interviewees. The interviews were recorded using a Huawei P8 LiteTM Smartphone, which had the calling functions disabled to eliminate disruptions during the interviews. Data collected from each participant were transferred to a password-protected computer, where they were stored in specially named folders according to the different nursing education institutions. Only the researcher and the promoter had access to the recorded data. 1.12.2.6 Data analysis The researcher transcribed all the audio recordings verbatim soon after the interviews and stored these on the password-protected computer. The few Sesotho comments were translated into English and confirmed by a professional Sesotho translator. Conducting and transcribing the interviews enabled the researcher to familiarise with the data (see Grove et al., 2016). Inductive open coding was done manually by three independent experienced co-coders. The data analysis was conducted using an iterative process. The process involved reading through the printed transcripts to develop a general impression about the data. The next step entailed reading and extracting significant statements or passages, which were recorded on a data sheet (Addendum J). The coders then formulated meanings for each of the significant statements. The meanings were then organised into clusters, which were assigned codes related to peer support experiences. The similar codes were grouped into clusters. Themes were then assigned to the clusters of similar codes. 27 The findings from this qualitative study were triangulated with the integrative review results to inform guideline development. Triangulation enabled the researcher to compare and contrast data from the two preceding phases and establish a better understanding of the phenomenon of peer support (See De Vos, 2012). 1.12.2.7 Rigour of the qualitative study The integrity of the qualitative study was ensured through trustworthiness criteria promulgated by Lincoln and Guba (1986), which include credibility, confirmability, dependability, transferability and authenticity. The researcher clearly described the purpose of the research, methodology, decisions made and their justifications. The application of the criteria of trustworthiness is presented here:  Credibility and authenticity: The researcher is well known to the small community of participants and had a prolonged time of interaction, which enhanced the establishment of rapport and the building of trust (see Cope, 2014; Lincoln & Guba, 1986). The individual interviews took between 30 and 90 minutes. Each interview was audio recorded and transcribed verbatim (See Polit & Beck, 2017). A sample of the transcript has been attached as Addenda J. Detailed descriptions of participants’ experiences were also provided. The data gathered were triangulated with findings from the integrative review. The researcher adequately described the interpretation process and provided verbatim quotations from the data.  Confirmability and dependability: The researcher ensured that data were collected and analysed through an impartial process and minimised the adulteration of the participants’ accounts (see Cope, 2014; Lincoln & Guba, 1986). An audit trail of the data collection and analysis processes is available for inspection. Example of transcripts with coding may be viewed in Addenda I and J. 28  Transferability: This was ensured through the provision of a thick description of the data (see Cope, 2014; Lincoln & Guba, 1986). The researcher provided adequate information about the participants and the research context. The next section describes Phase III of the study. 1.13 PHASE III: DEVELOPMENT OF PRACTICE GUIDELINES FOR PEER SUPPORT AMONG NURSE EDUCATORS The section describes the third phase of the study, which was the development of the peer support guidelines. This phase of the study integrated the findings from phases I and II to develop guidelines for peer support among educators during the implementation of curriculum innovation in Lesotho. 1.13.1 Purpose of Phase III: Development of practice guidelines The aim of this phase was to develop guidelines that would enhance peer support among nurse educators during a curriculum innovation in Lesotho using the WHO Handbook for Guideline Development (2014) as a guiding framework. The major processes highlighted in the WHO Handbook for Guideline Development included formulation of priority questions and outcomes, evidence retrieval and synthesis, assessment of evidence, formulation of recommendations, planning for implementation, dissemination, impact evaluation and updating of the guidelines. The formulated priority question was ‘what guidelines can be developed to enhance peer support among nurse educators during curriculum innovation?’ Evidence was retrieved and synthesised through an integrative review. The evidence was assessed for quality using the JHNEBP tools. A qualitative study was undertaken to explore experiences of nurse educators’ experiences as stakeholders in peer support. WHO supports utilization of qualitative evidence to inform guideline development (Lewin & Glenton, 2018). The evidence from the integrative review and qualitative study was triangulated and used to identify priority areas and formulate recommendations. 29 This phase addressed the third and fourth research objectives, which were to:  develop guidelines to enhance peer support among educators during the implementation of the CBC in Lesotho using the WHO (2014) Handbook for Guideline Development; and  validate the developed peer support guidelines using a Delphi survey. 1.13.2 Developing the guidelines The findings from Phases I and II were triangulated and used to inform the formulation of the guideline recommendations, guided by the WHO Handbook for Guideline Development. The Handbook clearly outlines the rigorous processes and steps taken when developing evidence-based guidelines used globally. The researcher opted to use the WHO Handbook for Guideline Development based on the assumption that the developed peer support guidelines could be used among educators in similar contexts in LMICs. The subsequent discussion presents the processes that were applied to develop the peer support guidelines. 1.13.2.1 Need for the guidelines The need for the guidelines development was identified and articulated in the problem statement of the overarching study, which emanated from the absence of ongoing professional development and support for nurse educators during a curriculum transformation in Lesotho, resulting in unstructured peer support. 1.13.2.2 Purpose and target population The guidelines were developed to inform and enhance peer support among educators during curriculum innovation in Lesotho. The target population and end users of the guidelines will be all the key players in peer support during change implementation and institutional leaders. 30 1.13.2.3 Scope of the guidelines The scope of the guidelines was informed by synthesised evidence from the existing peer support strategies in Phase I and the explorative qualitative evidence of the experiences of nurse educators during curriculum innovation from Phase II. The priority areas included in the guidelines were outlined. 1.13.2.4 Evidence of existing peer support strategies The existing peer support strategies that enhanced the implementation of an innovation were described and gleaned from Phase I of the study. The WHO (2014) Handbook for Guideline Development stipulates a systematic literature review as the basis for developing recommendations. 1.13.2.5 Evidence of experiences of stakeholders/stakeholder involvement The lived experiences relating to peer support among nurse educator were described and gleaned from Phase II of the study and triangulated with the existing peer support strategies from phase I to inform the formulation of the guidelines. The process of triangulation entailed comparing and contrasting the results of the integrative review and qualitative study to enable the researcher gain a better understanding and establish a validated conclusion on peer support (see De Vos, 2012). 1.13.2.6 Quality of evidence used The quality of the evidence used to formulate the guidelines was evaluated using a standardised tool, the JHNEBP Research Evidence Rating Scale. 31 1.13.2.7 Formulating draft recommendations A small guidelines development task team was established consisting of a methodology and curriculum specialist, a senior lecturer experienced in mentoring and engaged in professional development activities and the researcher. The task team formulated the draft recommendations based on the integrated evidence and according to the WHO Handbook for Guideline Development. Each recommendation drafted was discussed among the team members and consensus was reached. The quality of each recommendation was evaluated against the standards stipulated in the WHO Handbook for Guideline Development and the evidence from Phases I and II. 1.13.3 Validation of the guidelines Validation of guidelines was conducted to improve the quality of proposed guidelines for peer support through a Delphi survey. External reviewers validated the draft guidelines using the AGREE II tool (Addendum K) through two cycles of an iterative Delphi survey. The recommendations from the external reviewers were incorporated to consolidate the guidelines. 1.13.3.1 Participants in the Delphi survey The participants in the validation of the guidelines were purposively selected experts in nursing/health professions education drawn from Botswana (n = 3), Kenya (n = 1), Pakistan (n = 1) and South Africa (n = 3). The participants included in the Delphi survey were knowledgeable about peer support, had effective communication skills, capacity and willingness to participate. All the participants had expertise in health professions education. Three of the participants were professors while the remaining had doctorate qualifications. 32 1.13.3.2 Validation process The researcher sent electronic invitations to the identified potential external reviewers to participate in the Delphi survey. The invitation included an information brochure about the validation process (Addendum L). The package of the draft guidelines and the AGREE II tool and timelines was sent to all reviewers who accepted the invitation and were willing to participate in the Delphi survey. The reviewers completed and sent the AGREE II tool to the researcher, who analysed the responses and incorporated comments and recommendations. The researcher communicated the findings from the first round of validation to the reviewers and requested them to participate in the second round of the Delphi survey. The reviewers received packages for the second round of the Delphi survey. The comments of the external reviewers were incorporated and the guidelines were finalised. 1.14 ETHICAL CONSIDERATIONS OF THE ENTIRE STUDY The Health Sciences Research Ethics Committee of the UFS (HSREC 28/2017) and the Lesotho Ministry of Health Research and Ethics Committee (ID 91-2017) approved the research proposal (Addenda M and N). Institutional permission was obtained from the nursing education institutions (Addendum O) before data collection, and the individual participants gave informed written consent. Data were stored using password-protected folders on a computer, which were only accessed by the researcher and the promoter. The framework for ethical educational research guided this study (Burgess & Cilliers, 2017). This framework is underpinned by certain principles, which are presented in the subsequent section. 33 1.14.1 Educational value Burgess and Cilliers (2017) recommend that research should have important educational, research or social application. The guidelines developed during this study have the potential to enhance peer support among educators and promote the appropriate implementation of the curriculum innovation. Appropriately enacted curricula will have a positive impact on students as they acquire competencies and abilities to practise safely and independently. Furthermore, the nurses trained in these programmes may be more appropriately skilled and thereby improve the quality of healthcare provided. 1.14.2 Scientific validity The principle of scientific validity alludes to the selection of an appropriate, rigorous study design and methods to enable reliable and efficient execution of the research study and answering the research question (Burgess & Cilliers, 2017). The researcher utilised primarily qualitative methods underpinned by the interpretivist paradigm, which applied the naturalistic methodology (see Kivunja & Kuyini, 2017). The interpretivist paradigm was applied as described in detail in section 1.7. Data were generated through an integrative review and semi-structured interviews with participants in their natural settings and inductive analyses were applied. The researcher was competent to conduct the study and had support from her research promoter, who is an expert with vast experience in research and nursing education. When faced with limitations, the researcher consulted the research promoter and other research experts and critical readers. 34 1.14.3 Ethical oversight The principle of ethical oversight emphasises the importance of ensuring an independent review of scientific and ethical merits of a study (Burgess & Cilliers, 2017). Ethical approval for the study was granted by the Health Sciences Research Ethics Committee of the UFS and the Lesotho Ministry of Health (MoH) Research and Ethics Committee. However, the initial data collection strategy for the nurse educators was changed from focus group discussions to semi-structured interviews in an exploratory descriptive qualitative study. The change in data collection strategy was due to logistic challenges of bringing all participants together at a central place at the same time. Fair selection of participants: This implies that participants in the study are equitably selected based on the inclusion criteria and research objectives (Burgess & Cilliers, 2017). The researcher established inclusion criteria for participants and literature included in this study. All participants who met the inclusion criteria were given an equal chance to participate in the study. The researcher ensured that the research process did not interfere with teaching and learning in pursuit of gaining knowledge. Favourable risk: This stipulates that the researcher needs to assess for any potential risks and benefits of the research for all stakeholders (Burgess & Cilliers, 2017). This research study posed minimum risks associated with psychological discomfort of reliving some uncomfortable experiences among the participants. Debriefing sessions were provided for each of the participants upon conclusion of their interview session. Voluntary informed participation: This requires from the researcher to ensure that the participants are provided with information to enable them to make a voluntary decision to participate in the study (Burgess & Cilliers, 2017). Mechanisms to eliminate power differentials should be in place. The researcher provided all participants with an information brochure about the study and their right to refuse to participate without risking any penalty, as shown in Addenda G and H. Those who were willing to participate gave written consent. 35 Respect of recruited participants: This implies that procedures to protect the privacy of the individuals and the data should be in place (Burgess & Cilliers, 2017). The researcher ensured that the participants’ confidentiality was maintained by removing identifying information from the data. All the data collected were stored on a password- protected computer and backed-up files on a Google drive and only the researcher and the promoter had access to these files. 1.14.4 Provision of appropriate educational interventions or any other benefits of social value after research The framework stipulates that participants should benefit from their involvement in the study as well as the post-study interventions, or provided with justification for the lack of benefits (Burgess & Cilliers, 2017). All participants in this study were informed that there were no direct benefits. However, they were informed that the developed guidelines would enhance peer support and their ability to administer the curriculum innovation appropriately. 1.14.5 Collaborative partnerships This element of the framework emphasises the need for the researcher to develop collaborative partnerships within the educational environment and communities, the involvement of partners in planning and conducting research, and respecting the diversity in values, culture, traditions and social practice (Burgess & Cilliers, 2017). Although there were limited opportunities for collaborative partnership in this study, the researcher engaged the primary stakeholders and the external reviewers during the development of the guidelines. 36 1.15 LAYOUT OF THE THESIS The thesis is presented in six chapters, with an overview preceding each chapter. The first chapter presented the overview of the entire thesis. Chapters 2 to 4 are presented in the form of individual articles for each phase of the study. Each of these chapters is preceded by an introduction, information about the intended journal and a list of associated addenda. Chapter 5 presents the practice guidelines for peer support, while Chapter 6 discusses the conclusions and recommendations. Chapters 2 to 4 contain individual reference lists based on the specific journal requirements, while Chapters 1, 5 and 6 were written according to the APA sixth edition referencing style. 1.16 CONCLUSION Chapter 1 described the overview of the entire study, which was aimed at developing guidelines to enhance peer support among nurse educators during curriculum innovation in Lesotho. The chapter highlighted the strategy used to develop the practice guidelines. The next chapter describes the integrative review on existing peer support strategies that enhance the implementation of an innovation. 37 CHAPTER 2 Peer support strategies that enhance the implementation of innovation among professionals: An integrative review 2.1 INTRODUCTION Peer support has been utilised in different settings to enhance the implementation of new programmes or innovations among professionals. Studies have attempted to describe the characteristics and outcomes of effective peer support strategies. This chapter presents an integrative review aimed at synthesising and describing existing evidence of peer support among professionals during the implementation of an innovation. 2.2 MANUSCRIPT DETAILS Title: Peer support strategies that enhance the implementation of innovation among professionals: An integrative review Authors: Shawa, M. and Botma, Y. Target journal: International Journal of Nursing Studies Journal details: Double-blinded peer-reviewed Listed in accredited list of journals by the Department of Higher Education and Training, South Africa Impact factor 3.570 Status: To be submitted 38 2.2.1 Journal information The International Journal of Nursing Studies (IJNS) provides a forum for original research and scholarship on healthcare delivery, organisation, management, workforce, policy and research methods relevant to nursing, midwifery and other health related professions. The IJNS aims to support evidence-informed policy and practice by publishing research, systematic and other scholarly reviews, critical discussions and commentary of the highest standard (International Journal of Nursing Studies, 2020). 2.2.2 Contribution record The researcher conceptualised the study, collected data and drafted the manuscript. The study promoter provided guidance during the conceptualisation of the study and was engaged in the data analysis and critical reading of the manuscript. 2.2.3 Associated addenda Addendum A: Johns Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal Tool Addendum B: Critical Appraisal Skills Programme Addendum C: Centre for Evidence-Based Management Tool Addendum D: Johns Hopkins Nursing Evidence-Based Practice Research Evidence Rating Scale Addendum E: Data extraction table Addendum P: Author guidelines for the International Journal of Nursing Studies 39 2.3 MANUSCRIPT 1 PEER SUPPORT STRATEGIES THAT ENHANCE THE IMPLEMENTATION OF INNOVATION AMONG PROFESSIONALS: AN INTEGRATIVE REVIEW ABSTRACT Background: Change is inevitable in the face of globalisation and technological advancements. Such changes have also permeated different professional disciplines, affecting the way in which services are provided. One such discipline is health professions education, which has to review or transform the curriculum to meet changing needs and demands. However, educational changes are not always accompanied by matching preparation or support for the curriculum implementers, who may naturally start seeking support from peers. Objectives: The objective of this study was to describe existing peer support strategies that enhance the implementation of innovations among professionals. Methods: This study utilised the integrative review as the methodology. A search of the Cochrane Database of Systematic Reviews, Agency for Healthcare Research and Quality, Cumulative Index of Nursing and Allied Health Literature, PsycINFO, EMBASE, Medline, EBSCOhost, ERIC, Academic Search Complete, Scopus, ScienceDirect and Google Scholar was conducted using the following keywords and their synonyms: peer, support, innovation and professionals, which were derived from the focused research question. The search was limited to English articles published between 2000 and 2016, and 11 reports were included in this review. Results: Six themes emerged from the review, namely types of peer support strategies, characteristics of peer supporters, characteristics of an effective peer support strategy, outcomes of effective peer support strategies, challenges of implementing peer support strategies and lessons learned from the peer support strategies. Conclusion: Peer support strategies that enhance the implementation of innovation among professionals exist and can be contextualised and applied during educational innovations such as curriculum change. Effective peer support can enhance 40 the self-efficacy and improves confidence among educators. However, there are critical elements that are essential for an effective peer support strategy during an innovation among professionals. What is already known about the topic?  Peer support improves the self-efficacy of the supported individuals.  The knowledge and experience of the peer support provider enhance the effectiveness of the support interaction. What this article adds  This review demonstrates that peer support can be contextualised and used to enhance change such as curriculum innovation.  The commitment of institutional leadership to the peer support strategy is important in enhancing the effectiveness of peer support.  When utilized effectively, peer support strategies can translate into improved student support and competency attainment. Key words: peer support, innovation, change, implementation, strategies, professionals, integrative review. Introduction Globalisation and advancements in technology are occurring rapidly, bringing along changes and innovations. These global developments influence the needs of societies and fuel reforms in curricula used in the preparation of graduates for various disciplines. The changing societal needs make it obligatory that professionals acquire new sets of competencies to enable them to provide relevant quality services (Feller, 2018). These expectations imposed by advancements in technology and globalisation make it imperative for the professionals to engage in lifelong learning activities that will enable them to implement the associated changes and innovations appropriately. 41 Change and innovation are interlinked concepts that are often used interchangeably, although they are not necessarily the same thing. On the one hand, change refers to the alterations or adjustments that can be introduced in an organisation’s existing practices or processes to improve services (Bucciarelli, 2015). Change can take different forms, ranging from minimum alterations in the components of a unit to the total overhaul of the entire system, often referred to as incremental innovation (Ringberg, Reihlen & Ryden, 2019; Shahin, Barati, Dabestani & Khalili, 2017). Minor changes in a unit are easier to adopt, as opposed to major changes that might affect the entire system. On the other hand, innovation involves the introduction of an idea or practice that was not known before by the individual, although not new globally, also known as radical innovation (Ringberg et al., 2019; Shahin et al., 2017). Radical innovations are usually transformative and demand a new set of knowledge, behaviours or skills never practised before and are always associated with change, although the same is not true with change (Bucciarelli, 2015). Change and innovation influence the set of competencies required by professionals in different fields and put them at the centre stage of accountability in providing services and addressing various emerging needs (Rose et al., 2015; Rosenberg, 2018). Inevitably, change and innovation are important processes for any progressive organisation and among professionals. Change and innovation contribute to growth, renewal, transformation and improvement in any organisation or profession (Shahin et al., 2017). However, change and innovation are often not embraced uniformly among the individual implementers. At the time of implementing an innovation, individuals are usually at different levels of readiness to adopt the change. Some can adopt change as soon as it is introduced; others are late adopters, while still others may resist. Rogers in 2003 (as cited in Sahin, 2006) highlighted five different categories of adopters with the associated mind-set, namely innovators, who are usually the risk takers; early adopters, who are open to change; the early majority, who are usually cautious and safe; the late majority, who are often sceptical; and laggards, who are traditionalists and very suspicious. These variations in the adoption rate might also exist among professionals and can be attributed to lack of awareness and knowledge of the change, lack of the 42 necessary skills and ability to implement the change, lack of support for sustaining the change among the implementers and fear of taking risks and leaving the familiar ground to venture into the unknown without any assured support (Mathews & Linski, 2016). The introduction of change and innovation might create knowledge or skills gap among implementers, which needs to be addressed. Awareness of the existing or impending knowledge and skills gap among the targeted implementers may invoke fear of possible failure and incapacity to perform the required change, thereby creating a sense of insecurity and contributing to delays in adoption (Ferguson, Caverzagie, Nousiainen, & Snell, 2017). Proper implementation of the change and innovation requires careful consideration and management of the various adoption rates among different implementers. Specific areas of the change process or innovation may require different strategies, such as capacitation on knowledge and skills, and the provision of various forms of support. The knowledge or skills gap becomes a critical aspect among professionals and requires well-planned interventions to capacitate those involved in the change process (Ferguson et al., 2017). Implementing an innovation is not a once-off event, but an ongoing process involving individuals in an organisation, and therefore requires planned support strategies. Two of the resources on which organisations can capitalise are the innovators and early adopters (Rogers, 1983). Depending on the rate of accepting the change process among individuals, the innovators and early adopters can be role models and provide support to the late majority. The change process can create the need for the acquisition of relevant competencies and increasing self-efficacy. Therefore, innovators and early adopters become a support resource for their colleagues. Lack of appropriate competence impacts on individuals’ performance and self-efficacy and might prompt them to seek support from early adopters. Human beings have the predisposition of working around situations perceived to be obstacles by learning from peers they consider as highly knowledgeable and skilled or role models (Bandura, 1989). As the 43 early adopters become more comfortable with the change, they are likely to encourage the late adopters and provide peer support. Peer support has been used for many decades to promote transition during behaviour adjustments among peers experiencing similar health problems. Although there are various definitions of peer support, Dennis (2003), in a concept analysis, describes peer support as an interactive relationship that involves the provision of assistance and encouragement by individuals considered as equal and have themselves experienced a similar life transition and have grown from it. Therefore, one can conclude that peer support is based on the assumption that individuals can share their lived experiences and use these to support a colleague to adapt to a similar situation. Similarly, experienced or knowledgeable professionals faced with innovation or change in practice can share with and support other colleagues during the change process. Peer support may be a useful strategy that can enhance the implementation of an innovation among professionals. The support strategy can be the ‘oil that lubricates the change machinery’ and enable it to move smoothly until all team members are able to sustain the innovation or change. Peers can support one another through role modelling and providing information and emotional support during the change process, which might increase the self-efficacy of their peers (Bandura, 1989). Dennis (2003) highlights three attributes of peer support as informational, appraisal and emotional support, which can be provided to peers. Peer support promotes interaction and sharing of experiences and becomes a learning opportunity for both the provider and the recipient of the support. Successful mentoring relationships promote interactions that are trustworthy and honest and encourage openness in sharing experiences and learning needs (Bang, 2013; Bryant et al., 2015). Although there is a plethora of literature on peer support concerning students and clients undergoing different health or lifestyle changes, there is limited evidence of such support among professionals implementing innovations, particularly in higher education institutions. 44 The research problem for the current study originated from the challenges experienced by nurse educators in nursing education institutions during the implementation of a curriculum innovation in the absence of planned support strategies in a sub-Saharan African country. The country adopted competency-based education aligned with current trends in health professional education advocating for transformation from traditional information transmission to competency-oriented, student-focused approaches (Frenk et al., 2010). The introduction of the new curriculum meant a paradigm shift in pedagogical approaches among nurse educators as key drivers of the curriculum implementation. Nurse educators had to embrace innovative teaching approaches, which were later observed to be difficult for most of them (Botma & Nyoni, 2015). Such challenges threaten the fidelity of implementing the new curriculum and require planned professional development and ongoing support for educators. Despite this obvious need for support of the curriculum enactors, institutions had no plans in place for ongoing support. Faced with the predicament of implementing the new curriculum, midwifery educators naturally started supporting one another to enable them to accomplish their obligations of educating their students. The innovators and early adopters of the transformed curriculum took the lead in guiding their colleagues. These unstructured peer support activities resulted in empowerment of the implementers, but had limited accountability due to lack of administrative endorsement as reported in another study by the same researchers. The questions that came to the mind of the researcher were: Can peer support enhance the implementation of an innovation? Are there peer support strategies that enhance the implementation of an innovation? Hence, the research question was formulated: What peer support strategies enhance the implementation of innovation among professionals? The aim of this integrative review was to identify and synthesise existing evidence related to peer support strategies that enhanced the implementation of new programmes or innovation specifically among professionals, based on the Whittemore and Knafl (2005) framework. 45 Methods An integrative review was conducted guided by the Whittemore and Knafl (2005) framework which allowed the inclusion of diverse methodologies. The phenomenon of peer support can be considered a mature subject, extenuating the use of an integrative review, and the evidence synthesised thereof will contribute to the development of practice guidelines (Schick-Makaroff et al., 2016; Stetler et al., 1998; Torraco, 2016). The review enabled a comprehensive understanding of the phenomenon of peer support. This integrative review proceeded in a stepwise approach involving literature search, evaluation of abstracts, data appraisal, data extraction and data synthesis (Whittemore & Knafl, 2005). The population, intervention, comparator, outcome, and timeframe (PICOT) elements were identified as follows: (P) professionals, (I) peer support strategy, (C) was not applicable, (O) enhance implementation of innovation (T) between 1 January 2000 and 30 November 2016. Inclusion and exclusion criteria The review included studies that reflected a peer support strategy, an innovation or a new programme, outcomes reflective of enhanced implementation, professionals involved in the innovation, and published in English language between 1 January 2000 and 30 November 2016. The exclusion criteria were studies that did not reflect peer support or reported on other strategies. Studies that did not report on any innovation or the outcome of the implementation were eliminated. The studies that reported peer support among non- professionals, students and pilot studies were excluded. Studies published in other languages or before 2000 were also excluded. 46 Search for relevant literature A search for literature related to the research question was conducted on 12 databases accessed through the university library. Databases searched included the Cochrane Database of Systematic Reviews, Agency for Healthcare Research and Quality, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsycINFO, EMBASE, Medline, EBSCOhost, ERIC, Academic Search Complete, Scopus, ScienceDirect and Google Scholar. The search was conducted to identify abstracts of literature that reflected peer support strategies during an innovation using the synonyms of the search terms identified from the research question. The first search string was developed with the Boolean operators ‘AND’ and ‘OR’ to combine or supplement keywords and focus the search (Polit & Beck, 2017). The initial search string included the following terms: ‘peer’ or ‘colleague’ or ‘cohort’ or ‘friend’ or ‘fellow’; AND mentor* or support* or counsel* or guide* or ‘advisor’; AND; ‘new program’ or ‘new curriculum’ or ‘new practice’ or ‘new behaviour’ or ‘new intervention’ or ‘change’ or ‘innovation’; AND ‘professionals’ or ‘healthcare professionals’. Published literature inclusive of empirical and theoretical research, dissertations, theses, expert opinions, workshops and conference proceedings from January 2000 to November 2016 were included. A record of the initial and every refined search string, results and databases was maintained to keep an audit trail of the integrative review. The literature search generated an output of 373 abstracts and titles. Evaluation of the generated abstracts Each of the generated abstracts (n = 373) was evaluated for any duplicates and four abstracts were eliminated. The abstracts were then evaluated for their relevance to the research question and 264 abstracts were excluded, leaving 105 abstracts. The inclusion criteria for this review were abstracts that reflected:  a peer support strategy;  an innovation or a new programme;  outcomes reflective of enhanced implementation; 47  professionals involved in the innovation; and  published between 1 January 2000 and 30 November 2016 Full articles for the 105 abstracts were retrieved through the assistance of the university librarian and evaluated by the reviewers using the pre-determined inclusion criteria. An audit trail was built by keeping a record of all databases searched, abstracts and articles, search string revisions, articles excluded and reasons for exclusion, as shown in the PRISMA flow chart in Figure 1. Evaluation of literature Five independent reviewers who included senior lecturers in higher education institutions, experts in curriculum development and mentorship, and experienced researchers were involved in reviewing the 105 articles during the evaluation phase. The reviewers independently evaluated the full articles against the inclusion criteria and excluded 94 articles because they were either pilot projects or related to peer support among non-professionals or students. Articles that did not have any innovation or new programme implemented or were merely describing peer support were also excluded. Any discrepancies relating to the articles’ inclusion during the evaluation phase were discussed among the reviewers through Skype or Zoom meetings and consensus was reached. Eleven articles were included for the subsequent phase of critical appraisal. 48 FIGURE 1: PRISMA flow chart: Process of searching and selecting literature (Source: Author-generated based on PRISMA 2009) 49 Critical appraisal of selected articles Four out of the preceding five reviewers critically appraised the 11 included articles independently using various validated appraisal tools based on the study design. One reviewer opted out of appraising articles due to other commitments during the same period. The reviewers used the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) Research Evidence Appraisal Tool to appraise the quantitative research evidence and non-research articles (Addendum A), and the standardised Critical Appraisal Skills Programme (CASP) tool was used for the qualitative designs (Addendum B). The Centre for Evidence-Based Management Tool was used for the case studies (Addendum C). No articles were excluded based on the critical appraisal. Quality of evidence This review sought to describe existing peer support strategies that have enhanced the implementation of innovation among professionals. The evidence included in this integrative review focused more on the relevance to peer support than the rigour of the studies (see Schick-Makaroff et al., 2016). The articles that met the inclusion criteria were assessed for their quality by comparing their relevance individually to the focused research question based on the JHNEBP Research Evidence Rating Scale (Addendum D), which classifies articles into three quality levels, namely high quality, good quality and low quality. Based on this rating scale, two articles were classified as of high quality, while the other nine were classified as of good quality. No article was excluded based on this quality rating system. The reviewers reached consensus on the ratings of the evidence through discussion using Skype or Zoom meeting. Table 1 shows the summary of the articles included in the data extraction. 50 TABLE 1: Summary of articles included in the integrative review Peer Strength Quality Article author Journal and Target Context/ Design Innovation support of of & year database population Setting strategy evidence evidence Bang (2013) International Case study Elementary Inquiry-based Hybrid K-8 elementary Level V A: High Journal of science methods of mentoring, teachers in quality Education in teachers instruction using centrally Mathematics, different situated Science and devices schools in Technology Midwest State, (IJEMST) – ERIC USA Bennett & Nurse Education Case study Academic Online teaching Online peer University Level V B: Good Santy (2009) in Practice – faculty programme observation – Department of quality CINAHL dyad Health Sciences and Department of Education, UK Bennett, Education for Qualitative Master’s and Health-related Dyads Fogarty Level III B: Good Paina, Health – design doctoral trainees research progressing International quality Ssengooba, PsycINFO in health capacity building into triads Centre in two Waswa & research universities, M`Imunya, Kenya and (2013) Uganda Bryant et al. Journal of Nursing Non-research Pre- and post- Developing new Horizontal Hartford Level V A: High (2015) Scholarship – (organisational doctoral gerontological and vertical Centres of quality CINAHL experience) (Nursing) nurse scholars mentoring Geriatric and leaders Nursing Excellence and affiliating universities, USA Fleming et al. Academic Quantitative Junior faculty Early career Group- University Level III B: Good (2015) Medicine – design (Medicine) advancement facilitated Paediatric quality PsycINFO mentoring Department, USA Furimsky, Arts Applied Clinical Survey Healthcare Clinical research Paired peer- Clinical Level III B: Good & Lampson Trials – Academic professionals skills for to-peer research sites, quality (2014) Search Complete inexperienced mentoring Canada staff 51 Peer Strength Quality Article author Journal and Target Context/ Design Innovation support of of & year database population Setting strategy evidence evidence Hall & Zierler Journal of Non-research Healthcare Implementation Combination 2 universities Level V B: Good (2015) Interprofessional (organisational faculty- of of and 8 quality Care – CINAHL experience) Interprofessional Interprofessional approaches academic education education health centres, USA Magers (2014) Worldviews on Non- research Healthcare Practice change Unit-based Long-term Level V B: Good Evidence-Based (Practice workers (nurses using evidence- group acute hospital quality Nursing – change and physicians) based practice mentoring care, USA PsycINFO intervention) guidelines Pololi, Knight Journal for Non-research Faculty Scholarly and Collaborative Medical school Level V B: Good & Dunn (2004) General Internal (organisational (academic academic writing mentoring, in East quality Medicine (JGIM) – experience, medicine) skills using dyads Carolina, USA Academic Search writing project) Complete Provident American Journal Critical case Faculty Occupational Formal group Occupational Level III B: Good (2006) of Occupational study (occupational therapy mentoring Therapy, quality Therapy – therapy) curriculum University, USA PsycINFO reform Sexton et al. Academic Non-research Faculty Hands-on Work-based Department of Level V1 B: Good (2016) Psychiatry – (organisational (psychiatry) renewal of community of Psychiatry at quality PsycINFO experience, psychiatry practice University of module modules (“Mod Washington, revision) Squad”) USA 1 Level I: Experimental study, randomised controlled trials (RCTs), systematic reviews of RCTs Level II: Quasi-experimental study, systematic reviews of combination of RCTs and quasi-experiments Level III: Non-experimental, systematic reviews of combination of RCTs, quasi-experimental and non-experimental studies, qualitative studies, or systematic reviews with or without meta-synthesis Level IV: Opinion of respected authorities, nationally recognised expert committee/consensus panels, clinical practice guidelines Level V: Experiential and non-research evidence- literature review, quality improvement, programme or financial evaluation, case reports, opinion of nationally recognised experts based on experiential evidence 52 Data extraction A data extraction tool was developed and piloted by the first author and reviewed by the second author to eliminate any ambiguous questions. The development of the data extraction tool was guided by the research question to ensure the collection of data relevant to the study (see Souza et al., 2010). Using the data extraction tool (Addendum E), the same four reviewers independently extracted data on major elements regarding peer support from each of the included articles. Data that were extracted encompassed the type of peer support strategy used, the context in which the peer support strategy was used, the innovation that required support, reasons for using the peer support strategy, how the peer support strategy was used, the outcomes of using the peer support strategy, the characteristics of the supporters, the tools used to measure the effectiveness of the peer support strategy, the challenges of implementing the peer support and the limitations of the study. The first author recorded and consolidated the extracted data from the four reviewers in one data extraction table. Any response that was included by only a single reviewer was discussed with the reviewer and resolved through a Zoom or Skype meeting. Data analysis and synthesis The extracted data were inductively analysed and synthesised using a stepwise and iterative process, which included data reduction, data display, data comparison and conclusion and verification (Whittemore & Knafl, 2005). Data reduction involved classifying the primary sources into theoretical and empirical evidence and sequentially analysing them. The data extracted from each primary sources was coded, categorised and individually compiled into a data display matrices to enable comparison. Data comparison followed an iterative process across the primary sources guided by the review question and variables related to peer support during implementation of an innovation among professionals. Critical and meaningful elements of peer support during an innovation were identified, categorised and six themes developed. The authors verified the developed themes on peer support against the primary data 53 sources and the review question, and drew conclusions. The six themes that emerged were:  Types of peer support strategies  Characteristics of peer supporters  Characteristics of an effective peer support strategy  Outcomes of effective peer support strategies  Challenges of implementing peer support strategies  Lessons learned from the peer support strategies. Results The results are presented under the identified themes. Types of peer support strategies Professionals who engaged in the implementation of new programmes used a variety of peer support strategies. The peer support strategies were grouped into three categories, namely team mentoring, paired mentoring and multiple techniques. Team mentoring strategies used group support approaches and included group-facilitated peer mentoring, unit-based mentoring, collaborative mentoring and work-based community of practice (Fleming et al., 2015; Magers, 2014; Pololi et al., 2004; Provident, 2006; Sexton et al., 2016). The second category was paired (buddy) mentoring, which took the form of vertical and horizontal mentoring, dyads that progressed into triads, paired peer-to-peer mentoring and online observation (Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Furimsky et al., 2014). The multiple techniques were the third category and used multiple hybrid approaches to peer support (Bang, 2013; Hall & Zierler, 2015). 54 Characteristics of peer supporters The support providers were mainly individuals with high qualifications, holders of high positions, experienced, committed and interested in peer support. The peer supporters possessed high qualifications such as PhDs and/or held positions such as associate professors, programme directors, professional medical editors, physicians and postgraduate alumni (Bryant et al., 2015; Pololi et al., 2004; Provident, 2006). The supporters were experienced in various fields, which included evidence-based practice, interprofessional education and change processes (Hall & Zierler, 2015; Magers, 2014), teaching, research, medical writing and editing, and co-mentoring (Bang, 2013; Furimsky et al., 2014; Pololi et al., 2004). In line with their experience, the support providers were committed to faculty development and interested in the innovation that was being implemented. Such innovations included curriculum design, inter-profession education and evidence-based practice (Hall & Zierler, 2015; Magers, 2014; Provident, 2006; Sexton et al., 2016). Both senior and junior faculty members were engaged in the provision of the support (Bennett et al., 2013; Fleming et al., 2015; Sexton et al., 2016). Other distinguishing characteristics were that support providers were ardent and motivated to give back to their community, and were willing and committed to serve (Bennett & Santy, 2009; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Provident, 2006; Sexton et al., 2016). All the highlighted characteristics are important for an effective peer support strategy. Characteristics of effective peer support strategies A variety of factors characterised effective peer support strategies, including organisational and operational systems of the peer support strategy, clear goals and boundaries for the interactions, a supportive administrative system, leadership and responsibility, strategies for sustaining innovation, mentor–mentee communication, monitoring and evaluation (Bang, 2013; Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Pololi et al., 2004; Provident, 2006; Sexton et al., 2016). The results 55 showed that an effective peer support strategy requires securing the commitment of institutional leaders. Based on the results, there was a need for capacitation of institutional leaders and establishment of high-level committees to steer the peer support strategy. Contextualising the strategy to institutions and the provision of necessary resources are of paramount importance (Bang, 2013; Bennett et al., 2013; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Provident, 2006). Other factors influenced the effectiveness of peer support strategies, such as utilising interactive supportive strategies, recognising and acknowledging the champions in the support strategy, monitoring compliance, devoting time to activities, reinforcement and redirection, and collaborative decision-making, to highlight but a few (Bang, 2013; Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Pololi et al., 2004; Provident, 2006; Sexton et al., 2016). These factors are crucial in ensuring the sustainability of peer support within an institution. An effective peer support strategy requires the establishment of suitable modes of communication and dialogue and maintaining communication between the supporter and the supported, sharing experiences and best practices while ensuring mutual respect (Bang, 2013; Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Pololi et al., 2004; Provident, 2006; Sexton et al., 2016). The results revealed ongoing feedback among the peers, re-education, the monitoring of progress and reinforcement as essential for an effective peer support strategy (Bang, 2013; Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Pololi et al., 2004; Provident, 2006; Sexton et al., 2016). Awareness of the need for support among peers was found to be the motivation for voluntary participation, seeking help and co-creating the mentoring scope between the mentor and mentee (Bang, 2013; Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Provident, 2006). All the reports included in the analysis and synthesis highlighted characteristics of an effective peer support strategy. 56 Outcomes of effective peer support strategies This theme had four sub-themes, which were sustained innovation, professional and personal growth, a community of practice and scholarship. Peer support led to sustained innovation such as successful utilisation of fundamental curricula, improved patient outcomes and new curriculum design (Hall & Zierler, 2015; Magers, 2014; Provident, 2006; Sexton et al., 2016). Professional and personal growth were other significant outcomes among the peers engaged in the support activity from all the reports. Individuals were able to meet the goals they set for themselves and develop various skills (Bang, 2013; Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Pololi et al., 2004; Provident, 2006; Sexton et al., 2016). Engaging in the peer support activities also led to a community of practice, as evidenced by increased interconnectedness, professional networking and a collaborative community (Bang, 2013; Bennett et al., 2013; Fleming et al., 2015; Hall & Zierler, 2015; Provident, 2006; Sexton et al., 2016). Scholarship also developed among individuals who participated in peer support activities, as evidenced by scholarly publications, academic writing and growth in research (Bennett et al., 2013; Fleming et al., 2015; Pololi et al., 2004). Effective peer support should sustain an innovation and contribute to the growth of the peers. Challenges of implementing peer support strategies The implementation of peer support strategies is not without challenges. Some of the challenges experienced in the course of implementing peer support comprised –  timing and time limitations (Bang, 2013; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Provident, 2006; Sexton et al., 2016);  disconnect in relationships (Fleming et al., 2015; Furimsky et al., 2014; Provident, 2006);  power differences, particularly between junior and senior members of staff or leaders (Bennett et al., 2013; Bryant et al., 2015; Sexton et al., 2016); 57  unclear mentoring roles (Bennett et al., 2013; Bryant et al., 2015; Furimsky et al., 2014; Provident, 2006);  technological limitations, such as system failure and internet connectivity (Bang, 2013); and  accessing mentoring support (Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014). These challenges may affect the effectiveness and influence the sustainability of peer support. Lessons learned from the peer support strategies The aspects that were assumed to have contributed to the success of peer support were highlighted in this theme. These aspects that made the strategies work included institutional commitment to the peer support strategy, guidelines of interaction, feedback and information sharing, values and elements for successful mentoring and a community of practice (Bang, 2013; Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Pololi et al., 2004; Provident, 2006; Sexton et al., 2016). Based on the results, other essential variables that contributed to success were the involvement of senior members of staff, alignment of departmental needs and resources, institutional buy-in and approval, a strong mandate from administrators, investment in capacity development and the development of leadership strategies (Bennett et al., 2013; Fleming et al., 2015; Sexton et al., 2016). Establishing clear guidelines and expectations and setting self-determined goals were also essential for a successful peer support strategy (Magers, 2014; Pololi et al., 2004; Provident, 2006). Systematic and consistent sharing of information and regularly evaluated feedback are key in peer support strategies (Bennett & Santy, 2009; Bryant et al., 2015; Furimsky et al., 2014; Provident, 2006; Sexton et al., 2016). The results further underscored the importance of values and other elements in a successful peer support relationship. Some of the values reported were trust, openness to self-disclosure, maintaining confidentiality, 58 persistence, willingness and skill in giving and receiving feedback, relevant and applicable learning opportunities, content expertise and challenging faculty to think and discuss (Bang, 2013; Bryant et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Provident, 2006). These elements need to be considered when planning a peer support strategy. Discussion Peer support can enhance the implementation of change or an innovation such as curriculum innovation in a nursing education institution. The purpose of this integrative review was to synthesise relevant published empirical and theoretical evidence and describe the existing peer support strategies that enhance the implementation of innovations or new programmes among professionals. The review showed that there are peer support strategies that can enhance the implementation of innovation among professionals. Peer support strategies provide opportunities for innovators and early adopters to encourage and enhance the self-efficacy of the late adopters (Rogers, 1983). Self-efficacy is a critical determinant of behaviour change in an individual and can be enhanced through vicarious experience and verbal persuasion from peers in their environment, who may act as role models or support providers during the change process (Bandura, 1989). However, institutions embarking on peer support need to be cognisant of some prerequisites for an effective peer support strategy. This discussion focuses on implications for the three main stakeholders involved during an innovation, namely the institutional leadership, peer support providers and peer support recipients. Institutional leadership The sustainability of effective peer support strategies requires institutional and administrative endorsement. The institutional administrators are responsible for the mobilisation and allocation of resources, which include human, material and time resources. This review showed that peer support strategies can be resource-intense (Gagliardi, Webster, Perrier, Bell & Straus, 2014; Hall & Zierler, 2015) and 59 administrators need to allocate adequate resources for the activities. The functionality of a structured peer support strategy should be guided by essentials such as guidelines, goals, objectives and administrative structures (Fleming et al., 2015; Magers, 2014; Sexton et al., 2016). The effective implementation of support strategies requires operational guidelines, the provision of resources for the support strategy, monitoring and evaluation of compliance with the support strategy, the provision of feedback and recognition of champions. Monitoring and evaluation is the mainstay for an effective support strategy and the responsibility rests on the institutional leadership. Securing top leadership commitment and the capacitation of institutional leaders were important in sustaining the innovation and peer support strategy (Magers, 2014; Provident, 2006). The administrative endorsement also influences the participation of the peers in the support strategy and its sustainability (McLean, Cilliers, & Wyk, 2008). Although administrative endorsement is important, bureaucratic institutions can also become a hindrance to progress if the administrators are not flexible. Peer support providers The integrative review found that most peer support providers were individuals with higher qualifications, experienced and interested in faculty development (Bryant et al., 2015; Fleming et al., 2015; Sexton et al., 2016). The peer support provider should also possess facilitation skills, the capacity to assist colleagues and interest in professional development. Paramount in peer support is knowledge of the support provider related to the innovation and the change process. The peer support providers should be aware that tailor-made strategies geared towards addressing the perceived gaps, are psychologically appealing to the individuals needing support (Knowles, 1980). Contextualised support activities are likely to be appreciated among individuals experiencing challenges in implementing an innovation. Participating in such activities can improve the self-efficacy and confidence of the peers and enhance the execution of their duties (see Bandura, 1989). 60 Aligned to self-efficacy is the co-creation of the support goals directed towards improving the implementation of the innovation by the peer support provider and the colleague seeking support (Shi, 2017). The support provider should ensure that peer support is guided by relevant goals and appropriate support activities, such as knowledge/information provision and skills capacitation. The support environment should be non-threatening and encourage self-disclosure of abilities or limitations, and promote the sharing of experiences and best practices among peers (see Provident, 2006). Such interactions improve self-efficacy and encourage personal and professional growth (see Bandura, 1989). The peer support provider ought to provide constructive feedback, acknowledge successes, reinforce the areas of weakness and provide alternatives (see Bennett & Santy, 2009; Sexton et al., 2016). The review showed that clarifying roles, responsibilities, boundaries and the modes of interaction minimises misunderstanding and enhances the interactions (Bryant et al., 2015; Provident, 2006; Sexton et al., 2016). The support provider needs to address these critical aspects of interaction at the onset of the peer support relationship. During the initial stages of the support interactions, the supporter and the supported need to discuss and clarify their roles in the peer support relationship (Provident, 2006). Role clarification is an important remedy to reduce relationship strains. Peer support thrives where there is mutual respect, trust, confidentiality, skill in giving feedback and willingness to assist colleagues (Bryant et al., 2015). The provision of support requires time and personal commitment, and in the absence of these elements, the effectiveness of peer support can be compromised. Peer support providers also need to be committed to time engagement, while balancing their work and personal life. Peer support recipients Individuals requiring support must be honest with themselves when carrying out self- assessment to identify their own limitations and support needs. An honest self- assessment of one’s ability can bring to the fore the areas of need and enable the support provider to design appropriate support activities. Knowles (1980) postulates that 61 adults perceive the need to learn when they are unable to function effectively at their current competence level or when they face challenges in their daily lives. Therefore, an honest self-assessment and perception of the competence gap prompt adults to voluntarily seek and participate in support activities. Although voluntary participation in support activities was highlighted as desirable, reports did not address the compliance limitations of such participations among individuals who do not feel compelled to participate. The commitment of the institutional administrators to peer support and the use of guidelines might address such challenges (McLean et al., 2008). Individuals in need of support ought to be interested, willing and committed to participate in the support strategy. The recipients of peer support are encouraged to set self-determined goals, bearing in mind the fact that they need to grow past the peer support. Co-creating support goals with the peer support provider is encouraged (see Bryant et al., 2015). Approaches to peer support Various approaches to peer support are used during the implementation of innovations or new programmes. This review found three categories of support strategies, namely team mentoring, paired mentoring and multiple technique mentoring (Bang, 2013; Bennett et al., 2013; Fleming et al., 2015). Despite the differences in the approaches, the purpose of utilising the support strategy was to enhance the capacitation of the professionals and sustain the innovation. None of the peer support strategies was found to be better than the other, as they were all used in different contexts and could not be compared. The team approaches promote teamwork, interconnectedness and communities of practice and are efficient when dealing with big groups of professionals experiencing similar challenges (Fleming et al., 2015; Hall & Zierler, 2015). The communities of practice that develop promote ongoing collaboration and sustain the change process among professionals. Paired/buddy mentoring involving pairs or triads can be appropriate approaches to use when supporting individuals with unique needs or requiring/providing hands-on support. Buddy mentoring is advantageous because 62 individuals have personalised support and quickly develop the trust of other members, thereby strengthening peer relationships (Bennett & Santy, 2009; Furimsky et al., 2014). The different mentoring strategies helped sustain the implementation of the innovation/change with improved outcomes (Fleming et al., 2015; Magers, 2014), professional and personal growth (Bang, 2013; Bennett & Santy, 2009; Hall & Zierler, 2015) and improvement in academic writing (Pololi et al., 2004). Similar strategies might be contextualised and used among professionals in the implementation of new programmes or innovations. The review also found that a multiple techniques approach using different support media or platforms was used in either team or buddy mentoring. Different techniques can be used to provide peer support, which may be a combination of electronic media such as Zoom, Skype, Webinar, emails on one hand and the face to face approach in the same physical space on the other hand. The electronic approaches are convenient, as the mentors and mentees can be just a button-click away. However, such approaches suffer technological challenges, as reported in the results, which may include system failure and connectivity problems (Bang, 2013). Therefore, individuals engaged in the peer support strategies need to be mindful of these challenges for their prompt identification and remedial. Failure to address these challenges may hinder the peer relationships from thriving and impact negatively on the innovation or the change. Outcomes and challenges of peer support interactions Positive outcomes of peer support strategies on the innovation, supporters and the supported were reported in this integrative review. Effective peer support strategies sustain innovation and lead to communities of practice, professional and personal growth and scholarship (Fleming et al., 2015; Pololi et al., 2004). One of the key outcomes of a peer support strategy is improved self-efficacy and confidence of the peers to enable the implementation and sustaining of an innovation or the change 63 process. However, interactions between peer support providers and the recipients of support are not without challenges. The challenges include timing and time limitations, such as the lack of time committed to mentoring and poor time keeping (Bang, 2013; Bennett et al., 2013; Sexton et al., 2016). Studies have highlighted a need for a deliberate allocation of protected time for support activities (Bryant et al., 2015; Watson, Raffin-Bouchal, Melnick, & Whyte, 2012) as well as the timely monitoring and evaluation of activities. Other reported challenges are associated with a disconnect in relationships such as difficult personalities, paired peers working in different locations, power difference and tension between junior mentors and senior faculty members (Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Provident, 2006; Sexton et al., 2016). Such strained relationships between the supporter and the supported are real challenges that can compromise the uptake and effectiveness of peer support. Some of the challenges may be ameliorated by institutional commitment to the support strategy (McLean et al., 2008). However, peer support providers need to be aware of these challenges and take necessary corrective measures. Although only one report in the review provided a solution for the challenge related to senior-junior relationships (Sexton et al., 2016), the authors of this review suggest that the support providers need to be aware of the potentially disruptive relationships during the peer support strategy. The authors further recommend that the support providers be equipped with conflict resolution and conflict management skills. When dealing with peers situated in different locations, alternative strategy options such as multiple techniques need to be considered. The authors of this article argue that although change and innovation are inevitable in any profession, they can be uncomfortable and may not be readily embraced, with the potential of being poorly implemented or not being sustained. The introduction of change or an innovation without any planned ongoing support strategies for the implementers creates uncertainty and discomfort as it challenges their skills set. When the individuals’ self-efficacy is challenged, they may naturally seek assistance from their peers leading to unstructured support. Therefore, peer support becomes a strategy that 64 can cushion peers and sustain the implementation of innovation. However, the sustainability of such unstructured support during an innovation might be compromised, hence the need for guidelines to enhance peer support interactions. Conclusion, limitations and recommendations The aim of this integrative review was to describe the existing peer support strategies that have enhanced the implementation of innovations or new programmes among professionals. The review identified and described the different types of support strategies, characteristics of effective peer support strategies and support providers, outcomes, challenges and lessons learnt. The authors argue and conclude that peer support strategies enhance the implementation of innovations. The strategies presented in this report can be contextualised and applied during the implementation of educational innovation such as curriculum change. One of the limitations of this review was that it found only one study conducted in low- and middle-income countries, while the rest were in high-income countries. The other limitation was that no randomised trials or systematic reviews on peer support were found. Most of the reports included in the review were classified as non-research, which may affect the quality of the evidence synthesised. The language restriction to English was another limitation, which could have omitted relevant reports in other languages. This review found a gap in evidence on peer support strategies used during the implementation of curriculum innovation. The authors did not find any reports that described guidelines for peer support among professionals. 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However, during such challenging times, educators often seek assistance and support from colleagues to enable them to continue to perform their duties. The effectiveness of such kinds of unstructured support can often be compromised. This study explored and described the experiences of nurse educators related to unstructured peer support during the implementation of a midwifery competency-based curriculum. 3.2 MANUSCRIPT DETAILS Title: Peer support during the implementation of a new curriculum: The experiences of nurse educators in Lesotho Authors: Shawa, M. and Botma, Y. Target journal: International Journal of Africa Nursing Sciences Journal details: Double-blinded peer-reviewed Listed in accredited list of journals by the Department of Higher Education and Training, South Africa Impact factor 0.650 Status: To be submitted 70 3.2.1 Journal information The International Journal of Africa Nursing Sciences (IJANS) is an international scientific journal published by Elsevier. The broad-based journal was founded on two key tenets, namely to publish the most exciting research with respect to the subjects of Nursing and Midwifery in Africa, and to advance the international understanding and development of nursing and midwifery in Africa both as a profession and as an academic discipline (International Journal of Africa Nursing Sciences, 2020). 3.2.2 Contribution record The researcher conceptualised the study, collected data and drafted the manuscript. The research promoter provided guidance during the conceptualisation of the study and was engaged in the data analysis and critical reading of the manuscript. 3.2.3 Associated addenda Addendum F: Unstructured interview central question Addendum G: Participants’ information brochure Addendum H: Consent form Addendum I: Interview transcript Addendum J: Data coding sheet Addendum M: Health Sciences Research Ethics Committee approval Addendum N: Lesotho Ministry of Health Research Ethics Committee approval Addendum O: Institutional permission Addendum Q: Author guidelines for the International Journal of Africa Nursing Sciences 71 3.3 MANUSCRIPT 2 PEER SUPPORT DURING THE IMPLEMENTATION OF A NEW CURRICULUM: THE EXPERIENCES OF NURSE EDUCATORS IN LESOTHO ABSTRACT Educators need to be supported in implementing a new curriculum. The context of this study was the implementation of a competency-based curriculum developed and adopted for various nursing education programmes in Lesotho. However, nurse educators experienced limited professional development opportunities and lack of ongoing support during the implementation of this new curriculum and naturally sought support from their peers. Such unstructured peer support could compromise the quality of curriculum enactment. This study explored the experiences of nurse educators regarding peer support during the implementation of a new curriculum. An exploratory descriptive qualitative research design was applied to 12 conveniently sampled nurse educators from five nursing education institutions in Lesotho. Data were generated through individual semi-structured interviews and analysed using inductive reasoning and thematic analysis. Five themes emerged, namely motivation for educators to participate in peer support, attributes of educators that influence the extent of interaction and uptake of support, unstructured peer support strategies, consequences of peer support among educators and model performance inspires engagement with the new curriculum. Some of the educators benefitted from the unstructured peer support during the implementation of the new curriculum. The successful implementation of curriculum change can be enhanced through institutional commitment to peer support strategies and the development of guidelines for peer support. 72 Highlights  Educators need ongoing support during curriculum change.  The successful implementation of curriculum innovation can be enhanced through peer support.  Guidelines for peer support can enhance the interactions of educators during curriculum change processes. Keywords: peer support, experiences, curriculum change, nurse educators, implementation Introduction The implementation of a competency-based curriculum (CBC) that demands new pedagogical approaches, without any ongoing support for the educators, threatens the sustainability and fidelity of its enactment (Botma, 2014b; Nyoni & Botma, 2018). The educators as key drivers of curriculum implementation need ongoing support during curriculum change. Ongoing support such as peer support can enhance the implementation of the curriculum change. Peer support, a time-tested collegial collaborative strategy, has been used to socialise, nurture and capacitate individuals in different institutions (Fleming et al., 2015; Sexton et al., 2016). Such a supportive strategy might facilitate transitioning among educators during curriculum reform in academic institutions. Curriculum reform in nursing education is inevitable amid changing disease patterns, calls for task shifting, advancements in science and technology, and globalisation (Frenk et al., 2010; Horton-Deutsch & Sherwood, 2017; Maier & Aiken, 2016). However, inasmuch as the transformation of curricula is inevitable, educator preparation and ongoing support during such changes might be inadequate, especially in low- and middle-income countries (LMICs). Without ongoing support, educators experienced in the didactic teacher-centred approach might suddenly become vulnerable and feel inadequately prepared for the enactment of a new curriculum (Dole, Bloom & Kowalske, 73 2016; Ferguson, Caverzagie, Nousiainen & Snell, 2017) that requires novel student- driven, performance-oriented strategies. The challenge of inadequate educator support in LMICs is unique due to the resource constraints experienced (Frenk et al., 2010), unlike in developed countries, where educator support might be a priority. Institutions embarking on curriculum transformation need to deliberately plan for ongoing support of the educators to ensure the fidelity of its implementation. One can argue that peer support can be an affordable strategy to enhance the implementation of curriculum change in resource-limited countries. The context of the study Lesotho, a resource-limited developing country in southern Africa, adopted competency- based education for the training of its nurses and midwives in 2012. The espousal of competency-based education was done in an effort to address the changing healthcare needs and the heavy disease burden that the country is experiencing (Ministry of Health [MoH], 2013). A grant was received from the Global Nurse Capacity Building Programme through the Nursing Education Partnership Initiative (NEPI) to design and develop competency-based curricula for nursing and midwifery programmes in the country (Nyoni & Botma, 2019). The CBC replaced the traditional content-driven, teacher-centred curriculum with the student-centred performance-oriented approach (see Frenk et al., 2010) in five out of six nursing education institutions in Lesotho. The principles of constructivism, constructive alignment, scaffolding and authenticity underpin this new curriculum (Botma, 2014b). The transformation was extensive and compelled educators to sharpen or acquire new skills corresponding with the curriculum changes (see Botma, 2014a; Gruba, Moffat, Sondergaard, & Zobel, 2004) to enable them to implement the CBC appropriately. The implementation of the CBC in Lesotho took place in two phases, beginning with the midwifery programme in 2014. With the inception of the CBC in the midwifery programme, midwifery educators had to apply the new pedagogical approaches that encompassed the tenets underpinning the new curriculum. Although external support 74 was provided during the curriculum development phase as well as the designing of the learning and teaching material, none was planned for the implementation phase (Nyoni & Botma 2019). Despite recommendations from the rapid assessment conducted prior curriculum development for continuous professional development to support educators during the implementation of the CBC in Lesotho (Botma, 2014a), institutions had planned neither for professional development nor for alternative ongoing support strategies in place. Professional development and ongoing support for the educators on the new pedagogical approaches are critical factors in ensuring the successful implementation of curriculum transformation (Iwasiw & Goldenberg, 2015; Mortel & Bird, 2010). However, ongoing professional development may be costly for resource-limited countries such as Lesotho. The educators in Lesotho received limited capacitation before the implementation of the CBC, which resulted in variations in their capacity levels to enact the curriculum. Botma and Nyoni (2015) reported that midwifery educators in Lesotho struggled to transfer their learning during capacitating workshops to their educational practice. Being at different capacity levels of implementing the new curriculum, the educators from different nursing education institutions naturally started seeking and providing support to and from one another as peers. Among the educators who had been involved in curriculum development and capacitation activities were some who had grasped the concepts and were able to implement the curriculum as intended. Amid the implementation challenges, two early adopters (who became key informants in this study) were able to take the lead to encourage and support their colleagues. Successful implementation of the midwifery CBC required educators to support one another as they worked through the new curriculum. In the absence of formal or planned peer support structures in place, the midwifery educators started to support one another informally during the implementation of the new curriculum, with the innovators and early adopters taking the lead. This study describes the experiences of the midwifery educators related to the peer support they provided/received during the implementation of the midwifery CBC. The question that was raised was: What could be 75 learned from the experiences of the midwifery educators that can be used to support those nurse educators who need to implement the CBC in the Diploma in Nursing programme during the second phase of implementation? The insights gleaned from the reflections on experiences during the implementation of CBC in midwifery and consideration of relevant theory helped to explain and suggest appropriate peer support guidelines. Methodology This study used exploratory descriptive qualitative research design to describe the experiences of midwifery educators regarding peer support during the implementation of the new curriculum. The 18 midwifery educators aged between 27 and 68 years, who were involved in the first phase of implementation of the new CBC in five nursing education institutions in Lesotho, comprised the study population. The researcher used convenience sampling to select 12 midwifery educators who were available and willing to participate in this study. Data saturation was reached after interviewing the 10 participants. Ethical consideration The Health Sciences Research Ethics Committee of the University of the Free State (HSREC 28/2017) (Addendum M) and the Lesotho Ministry of Health Research and Ethics Committee (ID 91-2017) (Addendum N) approved the research proposal. Institutional permission (Addendum O) was obtained from the nursing education institutions before data collection, and individual participants gave informed written consent (Addenda G and H). The framework for ethical educational research guided this study (Burgess & Cilliers, 2017). The principles underpinning the framework include educational value, scientific validity, ethical oversight, provision of appropriate educational interventions or any other benefits of social value after research and collaborative partnership. Data were stored using a password-protected folder on a computer, which was only accessed by the researcher. 76 Explorative study The first author, also the interviewer, tested the central research question by interviewing two midwifery educators. The central interview question was: What were your experiences regarding collaborative support activities during the implementation of the new curriculum in the midwifery programme? See Addendum F. The co-author reviewed the transcribed unstructured individual interviews to evaluate the interviewing techniques and determine the competence of the interviewer. Open-ended questions and probing questions were mostly used during the interviews. No leading questions were asked. The data from the pre-test were included in the data analysis, as no adjustments had been made to the central interview question. The participants in the exploratory study were informed beforehand about the possibility of including their data in the data analysis of the main study. Data collection Semi-structured individual interviews were used to gather data from 12 midwifery educators in five nursing education institutions in Lesotho. Two of the 12 educators, who were the primary peer support providers, became the key informants for this study. Permission was sought from the nursing education institutions before data collection. The researcher scheduled individual appointments at the institutions where the participants were employed and requested the use of a private, quiet room in which to conduct the interviews. The participants received full information about the study and gave written consent to be interviewed and that the interview may be audio-recorded. 77 Data analysis The first author conducted all interviews in English and transcribed the audio recordings verbatim (Addendum I) as soon as possible after the interviews. The few Sesotho comments were translated into English and confirmed by a professional Sesotho translator. Data from the explorative (pilot) study was included in the data analysis. The paper trail of audio recordings and transcriptions enhanced the trustworthiness of the data. Conducting and transcribing the interviews enabled the interviewer to familiarise herself with the data (see Grove et al., 2016). Three experienced independent coders manually analysed the data using inductive open coding, as described by Creswell (2014). The use of more than one coder enhanced the credibility of the data. Findings Various experiences regarding peer support were reflected by the educators. The following five themes emerged from the data analysis:  Motivation for educators to participate in peer support  Attributes of educators that influence the extent of interaction and uptake of peer support  Unstructured peer support strategies  Consequences of peer support among educators  Model performance inspires engagement with the new curriculum. Motivation for educators to participate in peer support A variety of factors motivated the curriculum enactors in Lesotho to participate in peer support. One of the drivers for peer support was ending of the NEPI funding, which supported the capacitation of educators, and the need to implement the new curriculum. One participant reiterated:2 2 Please note: all excerpts from the interviews are reproduced verbatim and unedited. 78 So when that funding of NEPI ended we sort of naturalised into a system of how do we move on … So the question is what do we do? NEPI is gone, the consultant is gone, we need to implement … that’s when we unearthed a lot of issues as if that training initially didn’t happen. (Participant A1) The educators further described the discrepancies in their knowledge levels, challenges experienced and the desire to know more about the new curriculum as some of the factors that led to their engagement in peer support activities. Each institution had specific needs that required to be addressed. Another educator explained: Our understanding and … progression into the CBC are not the same, based on how we understand. So the meeting that I remember, which was now a workshop, was based on the challenges that we were facing. (Participant C1) Another participant reflected that participation in support activities was driven by the need for more knowledge, challenges experienced and the educational landscape associated with implementing the new curriculum, and said: Then after we had done the blueprint and made sure that everyone understood, then we were capacitated on how to develop those OSCE [objective structured clinical examination] stations, developing checklists, developing scenarios, how to run an OSCE setup. We took some sessions capacitating one another as institutions. (Participant A2) Attributes of educators that influence the extent of interaction and uptake of peer support Different attributes of the educators influenced the uptake, extent and consistency of the peer support during the implementation of the CBC. One participant, in expressing their experiences, commented: 79 [T]here was willingness, I think we were all keen to know, we all wanted to know what this CBC was all about, you know when something is portrayed like it’s a monster, it’s something that is not doable. (Participant A3) Participants lamented the limited application of new knowledge among supported educators. The limited sense of accountability and ‘nonchalant’ attitude of educators further influenced the uptake of peer support. Another participant stated: But with the other institutions we found that even if we share our experiences, how we get things like videos … you find that they are expecting us … to download and give them all the materials ready, even if we refer them to the links and we tell them how you get this … they were expecting us to share a completed thing. (Participant A2) Another critical determinant for the uptake of the support was the biological age of the educators and experience with the former curriculum. Educators who were older with many years of teaching experience were not enthusiastic about the new curriculum, and therefore less likely to seek support. A participant from one institution reiterated: I remember in my institution, particularly when we started, we had an educator who was I think two years away from retirement who plainly and simply said ‘Aaah, I will continue with my content, you do your CBC kids’ … unfortunately she was the head of the programme, so you just had to let it go. (Participant E1) The peer support activities extended to the clinical environment in the form of sharing information during pre- and post-placement meetings, supervisory visits and capacitation, as attested to by participants from all institutions. One participant commented: Through the pre- and post-placement meetings, we were able to address … issues and iron out some of the concerns that they (clinical staff) were having. (Participant C3) 80 There was an assumption that the previous donor-funded projects were unsustainable and taken for granted due to lack of accountability. The participants highlighted that this assumption influenced the perception of the need for peer support among educators. Unstructured peer support strategies Initially, peer support among educators comprised various unstructured strategies such as peer review of specific work, including learning and teaching material. This approach resulted in some of the educators experiencing feelings of emancipation, which gave them the ability to continue with the work. One of the participants stated: They [support activities] helped a lot, particularly for me, I was nominated to be part of the facilitators to the process, and I was part of the planning team and the team that was leading the discussion. And it … was helpful because it was not only the discussion, we were also actively engaged in those activities and then critiquing them to align them to what is expected, so actually it was very beneficial. (Participant C1) The unstructured nature of the peer support strategies presented some challenges among the educators engaged in support activities. The participants indicated that there was inadequate support for reluctant educators, limited accountability and no monitoring and evaluation. These factors influenced educators’ consistency in providing or seeking support and amplified the need for endorsement of peer support strategies by institutional administrators to improve their effectiveness. One participant reflected: The challenge with the peer support was that it had no obligation … because if I feel like I don’t want to develop myself a study guide, no one would force me to, because my school administration felt like it’s not a requirement for us. So nobody made a follow-up and nobody made a reinforcement. (Participant E1) 81 Another participant lamented: After the meeting you would see people trying to do something, though after some time you would wonder what is happening now again, I thought we were on the right track, how come I don’t see what we discussed before. (Participant B1) These unstructured peer support interactions drove the educators to engage in a more structured approach, which resulted in the development of platforms for communication such as WhatsApp groups and emails to support one another. One educator stated: [D]uring exchange of emails to say here am stuck here, how do I overcome this challenge is also another strategy that was used. (Participant D1) Gradually, educators engaged in formal discussions through planned meetings and workshops as support platforms as one participant reflected: We also had another workshop… where there was a task team of nurse educators and they took us took us through the CBC delivery and development of activities. (Participant D1) Consequences of peer support among educators The support activities were empowering and enhanced self-directedness and specific competencies among the educators. The participants claimed that the support activities enhanced their learning and improved specific skills, awareness and implementation of the new curriculum. One educator described their experience: I did have some [challenges] on the use of the mannequins … since I did not go through the training of how to use the mannequins … but as time goes, through the support from other colleagues I was able to cope … through in-house training. (Participant C3) 82 Another participant expressed it as follows: I think now all people are aware … initially there was no awareness and stuff, but for now, with the persistence … of the key people [early adopters] has made … competency-based curriculum to be known [among educators]. (Participant A4) The peer support activities resulted in professional development strategies that were transferable within various contexts. Furthermore, the support activities promoted teamwork among educators, which enhanced the implementation of the new curriculum in the midwifery programme. One participant reiterated: We were struggling together and assisting each other. Though we hardly peer- examine[d] each other, because we kept on asking, do you need assistance to facilitate? … when we are preparing these activities, we were together. (Participant C2) Another outcome of the peer support was interaction among educators, which enhanced sharing and empowering one another. One participant commented: I think that opportunity of discussing, sharing what you are developing with others creates… dilemmas for you, which lead you to learn more and try to perfect the way we have been developing teaching and learning materials for CBC. (Participant A4) Although favourable outcomes were expressed by participants, various emotional reactions were also generated among the supported towards the supporters and the new curriculum. The peer supporters experienced some emotional harassment and felt discrimination related to their new roles as supporters. Some educators associated the new curriculum with the peer supporters and blamed them for its dissemination. Others assumed that the supporter providers were using their peers as research subjects. One supporter recounted some of the comments of the supported peers in this statement: 83 [T]hese workshops are not workshops; it’s his research that he is going to be presenting you wherever he goes. (Participant A1) Although there was initial emotional disharmony during the peer support activities, there was also a positive side to it. The negative emotional reactions of the supported peers led to the development of resilience among the supporters. The peer supporters’ resilience was enhanced secondary to emotional and personal abuse experienced. Two supporters expressed the positive side of the emotional reactions as follows: Even personally, emotionally, we were called names, we were insulted, all that I still think it was also a benefit because I was able to endure all that. (Participant A2) And I think the fact that I had gone through that … blustering, and those insults and those things during development of the curriculum, I think I ended up saying, ‘I have to own it, I cannot have gone through that and then few moments later it falls flat in the face.’ (Participant A1) Model performance inspires engagement with new curriculum Observing the exemplary performance demonstrated by peer supporters inspired other colleagues to engage with the new curriculum. The early adopters of the CBC persistently engaged in and shared the new pedagogical practices with their peers, which became crucial in encouraging and guiding the undecided or those with inadequate or no knowledge of the new curriculum. One participant commented as follows: Those individuals who caught fire … related to issues of competency-based curriculum, those key people enabled to motivate and … carry along those who were a bit reluctant to jump in[to] the ship of implementing [the] competency-based curriculum and also the development of competency-based curriculum-related materials. (Participant A4) 84 The colleagues who were knowledgeable readily provided tangible support to peers during the preparation of teaching/learning materials and the implementation of the new curriculum, thereby empowering/capacitating them. Participants alluded to this experience as follows: [W]ith developing the workbooks, we were having someone … a colleague from one institution who was almost now and then in every meeting wanting to know how far we are with … the development of workbooks … I would say he was serving as our mentor. (Participant C3) The main ingredients that galvanised the supporters during curriculum implementation included a transformative leadership style, internal drive towards excellence, personality traits preferring to be associated with success, self-directedness, internal motivation for professional growth, risk-taking inclination and willingness to provide support. These were some of the comments alluded to by the support providers: He uses [a] transformational leadership style … were people feel comfortable, people are free to come up with their innovative way of doing things … he allows you to work around but where he sees that there may be a problem he quickly assists you so that you do not fall, but basically I think that leadership style that he uses [motivates people]. (Participant A3) The exemplary practice of one institution had rippling effects on institutional level. One institution was exceptional in the implementation of the new curriculum, with a potential of supporting other institutions. Some educators in different institutions sought assistance from colleagues in the excelling institution. One participant stated: Actually where we needed help we call[ed] a colleague from [Institution A] to assist us … the other time he even came to assist us in the strategic plan so we can also be able to include what we are doing in the … curriculum. (Participant C2) 85 Discussion Nurse educators need ongoing support during the enactment of a curriculum innovation. The transformation that comes with competency-based education demands new set of skills among implementers, which might leave the previously experienced educators vulnerable and disempowered (Brownie, Docherty, Al-Yateem, Gadallah, & Rossiter, 2018; McLean, Cilliers & Wyk, 2008). Affordable strategies such as peer support can improve the self-efficacy of individuals during curriculum change and enhance the fidelity of its implementation (Bandura, 1989). However, the consistency of unstructured peer support might be compromised when prolonged engagement is required, such as during curriculum change, which literature reports to be a slow process (Brownie et al., 2018). Peer support ought to address the needs and challenges of individuals aligned with the curriculum innovation. Some of the support activities associated with curriculum innovation include the utilisation of innovative facilitation skills, the use of high-tech equipment such as mannequins and other simulation-based approaches. The varied educational landscape among educators in this study led to the development of tailor- made support activities among peers to reduce the knowledge gap and promote collaboration. Similarly, literature emphasises that tailor-made support activities address relevant and applicable needs of individuals and promote participation and collaboration among peers (Carpenter & Linton, 2016; Hall & Zierler, 2015). However, tailor-made activities alone do not guarantee the success of peer support. There is a need for the commitment of the institutional leadership to peer support. The commitment of institutional leadership to peer support is crucial, as it influences the participation of educators and the allocation of resources for support activities during curriculum change (McLean et al., 2008). The current study highlighted administrative endorsement as fundamental in influencing the uptake and effectiveness of peer support. However, institutional administrators did not declare the endorsement of the unstructured peer support, resulting in a lack of monitoring and evaluation and 86 accountability. The lack of administrative endorsement resulted in some individual educators not feeling obliged to engage in the support activities, inasmuch as they were having difficulties with the enactment of the new curriculum. McLean et al. (2008) emphasise that institutional commitment influences participation in professional development activities. Other limitations associated with lack of administrative endorsement identified in this study were inadequate tangible assistance in some institutions, lack of structured communication and inability to apply newly gained knowledge. Nevertheless, these findings are contrary to those of Bell and Thomson (2018), who advocate for informal support strategies because they encourage ownership. To circumvent these encumbrances, literature proposes strategies such as having an administrative system and the commitment of institutional leadership (Hall & Zierler, 2015; Sexton et al., 2016), the alignment of departmental needs and resources (Fleming et al., 2015), and monitoring and evaluation (Bryant et al., 2015), among other strategies. Ensuring that these important elements are in place is a measure towards enhancing peer support during curriculum change. Equally important to the success of this strategy are the attributes of both the supported and the peer support providers. Various individual attributes influenced the uptake of peer support activities among educators. Most notably were that the educators who expressed a positive, willing and self-directed attitude actively sought assistance and support from their colleagues and enjoyed the activities. The attitude of educators towards the new curriculum determined their initiative and consistency in seeking support regarding the curriculum change. These findings support those of Louws, Meirink, Veen, and Driel (2017), who emphasise the importance of autonomy and self-directedness as essential elements that influence individual engagement with professional development activities. Louws et al. (2017) further describe other attributes that were not mentioned in the current study such as interest in and importance of the learning activity, desire for increased job satisfaction, self-esteem and quality of life as important elements. Despite these positive attributes that promote peer support, there are other deterring factors to participation, such as the biological age of individuals and power differences (Sexton et al., 2016). 87 The age of individuals and their position at work featured as impediments in this study, given that the support providers were younger and had fewer years of work experience. Interestingly, however, this finding contradicts earlier studies, which revealed that individuals of different ages had varying support needs, with the older generation seeking adaption to the younger generation to gain mutual respect, with a focus on learning about interacting with students (Louws et al., 2017). Power differences between senior and junior educators have also been noted to be a hindrance, which may compromise the individual’s willingness to seek or provide support (Bryant et al., 2015; Sexton et al., 2016). Considering the context of this study, where there are strong traditional patriarchal and hierarchical value systems, power distance may have played a role in the uptake of support. Therefore, peer support providers need to be aware of such critical elements that may influence engagement in the support activities. Similarly, the attributes of support providers are critical in enhancing peer support during curriculum change. The support providers in the current study were risk-takers, proactive, willing to support others, and striving for excellence in their work. Various studies have highlighted the characteristics of support providers to include willingness, interest, availability, commitment to professional development and service, expertise in the area to provide support, motivation to give back to the community of professionals, being a good communicator and objectivity (Fleming et al., 2015; Furimsky et al., 2014; Garza & Harter, 2016; Louws et al., 2017). Establishing effective peer support among educators requires individuals to have an internal drive, willingness, self-directedness and a positive attitude. Institutions embarking on peer support should be cognisant of the personal attributes as essential in establishing peer support. In this study, the peer supporters were internally driven to support colleagues during the curriculum change and had good communication and conflict management skills, which aided the settling of differences and establishing common ground among educators. The personalities of the supporters, self-directedness, transformative leadership style and drive for excellence featured as the catalysts for involvement in developing other educators in the current study. Furthermore, support providers displayed exemplary behaviour and verbal encouragement. Bandura (1971) describes the element of vicarious observation 88 as a strong tool in influencing others to learn as they observe the desired behaviour. Portraying and providing exemplar practice by the supporters and leading institutions encouraged colleagues to learn and improve their performance in the delivery of the new curriculum in nursing education institutions. Various platforms can be used for peer support. The current study found that peers communicated and shared information related to the implementation of a new curriculum on various platforms, which included emails, telephone calls and WhatsApp groups, to support one another when the need arose. Electronic platforms are increasingly becoming alternative channels for providing support among colleagues. Chung and Chen (2018) found that online platforms were a source of support for teachers, where they shared best practices on effective teaching, challenges and emotions. The same researchers concluded that there was an association between social support exchange and teacher self-efficacy. The electronic platforms can be an alternative for seeking and providing support, especially for people who are separated by distance or when it is not feasible to have face-to-face interaction. These electronic platforms could be a viable option for support activities among educators in LMICs, where funds for professional development are limited; however, being mindful of connectivity challenges. The peer support during curriculum innovation as reported in this study had both positive and negative outcomes. The outcomes of peer support described in this article included improved implementation of the curriculum innovation, enhanced competencies, personal and professional growth, increased networking, teamwork, a community of practice and a scientific publication. These findings concur with previous studies that report on collaboration and scholarly publications as outcomes of support activities (Hall & Zierler, 2015; Fleming et al., 2015; Pololi, Knight & Dunn, 2004). Collaboration and knowledge sharing are key among educators and promote a community of practice during any change process. Patton and Parker (2017) posit that a community of practice among educators in higher education breaks isolation and encourages sharing, which ultimately help build confidence. The variety of interactions 89 in which the peers engaged during support sessions created avenues for sharing information and experiences and enhanced self-efficacy among nurse educators. Engagement in the peer support activities also elicited some undesirable reactions experienced, particularly among the supporters. The providers of peer support experienced emotional harassment, discrimination and blaming. Literature confirms the challenges associated with peer support strategies such as difficult personalities, tension between junior leaders and senior educators, and power differences (Fleming et al., 2015; Sexton et al., 2016). However, in the current study, the vindictiveness towards the supporters also served to strengthen the resilience of the support providers and motivated them to engage in professional development as they strived to improve their capacity as support providers. Conclusion The curriculum transformation occurred in response to the changing healthcare needs of the country (Lesotho). Despite recommendations to capacitate educators and support them in implementing the curriculum innovation, no formal ongoing support was available. The unstructured support provided through workshops and meetings contributed to the development of skills, confidence and self-efficacy of midwifery educators. Participation in the support activities was driven by the need for more information on the curriculum innovation. However, the unstructured peer support presented challenges, such as lack of administrative endorsement, lack of motivation among educators, limited accountability, limited tangible support and lack of monitoring and evaluation. Therefore, institutions embarking on curriculum innovation need to consider the following key pointers:  Experienced educators can suddenly experience incapability in implementing new pedagogical approaches demanded in the new curriculum.  The successful implementation of curriculum change requires the ongoing support of the implementers.  Peer support can enhance the implementation of a curriculum innovation. 90  The success of a peer support strategy during curriculum innovation requires the endorsement of institutional leaders.  Monitoring and evaluation of the implementation of the curriculum innovation and the peer support strategy can ensure their success.  Practice guidelines for peer support can enhance the interactions of implementers during curriculum change. This study was contextual, and the findings cannot be generalised. However, through the dense description, the findings may be transferable to similar contexts. Furthermore, the study explored the experiences of the nurse educators in the midwifery programme and did not include nurses working with students in the clinical area following the introduction of the new curriculum. There is a need for further research to explore the experiences of clinical nurses working with students training under a transformed curriculum and to evaluate the delivered curriculum against the intended curriculum. Guidelines for peer support have been developed and presented in another article (Shawa and Botma, 2020). The guidelines outline how best to provide peer support during curriculum change and may be beneficial for many LMICs undergoing similar curriculum change. The authors argue that institutions embarking on curriculum transformation need to support the educators to ensure the fidelity of curriculum implementation. Peer support can be an affordable strategy to enhance the implementation of curriculum change in resource-limited countries. 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(2004). Facilitating scholarly writing in academic medicine: Lessons learned from collaborative peer mentoring program. Journal of General Internal Medicine, 19(1), 64–68. 94 Sexton, J.M., Lord, J.A., Brenner, C.J., Curry, C.E., Stanley, I.S., & Cowley, D.S. (2016). Peer mentoring process for psychiatry curriculum revision: Lessons learned from the "Mod Squad". Academic Psychiatry, 40(3), 436–440. Shawa, M., & Botma, Y. (2020). Practice guidelines for peer support among educators during a curriculum innovation. African Journal of Health Professions Education. (Accepted for publication, August 2020). 95 CHAPTER 4 Practice guidelines to enhance peer support among educators during a curriculum innovation 4.1 INTRODUCTION This chapter presents the practice guidelines for peer support for educators during a curriculum innovation in nursing education. The guidelines were developed through the triangulation of the evidence from two studies and validated by a panel of external reviewers. 4.2 MANUSCRIPT DETAILS Title: Practice guidelines for peer support among educators during a curriculum innovation Authors: Shawa, M. and Botma, Y. Target journal: African Journal of Health Professions Education Journal details: Double-blinded peer-reviewed Listed in accredited list of journals by the Department of Higher Education and Training, South Africa Impact factor – Not documented Status: Under review 96 4.2.1 Journal information The African Journal of Health Professions Education (AJHPE) is a journal for health professions educators. It carries research articles, short scientific reports, letters, editorials, education practice, personal opinion and other topics related to education of health care professionals within African continent (African Journal of Health Professions Education, 2020: online). 4.2.2 Contribution record The researcher and the research promoter developed the guidelines for peer support. The researcher further validated the guidelines through two cycles of a Delphi survey using external reviewers and incorporated the inputs to consolidate the final guidelines. The research promoter critically read the finalised guidelines. The researcher drafted the manuscript under the guidance of the research promoter, who also critically reviewed the manuscript. 4.2.3 Associated addenda Addendum K: AGREE II Tool Addendum L: Information brochure for external reviewers Addendum M: Health Sciences Research Ethics Committee (UFS) Addendum N: Lesotho Ministry of Health Research and Ethics Committee Addendum R: Author guidelines for African Journal of Health Professions Education 97 4.3 MANUSCRIPT 3 PRACTICE GUIDELINES FOR PEER SUPPORT AMONG EDUCATORS DURING A CURRICULUM INNOVATION ABSTRACT Background: Curriculum transformation in nursing education addresses changing healthcare needs of communities. However, without ongoing support of educators, the fidelity of curriculum enactment is compromised. Nursing education institutions in Lesotho implemented a competency-based curriculum that required novel pedagogical approaches. New facilitation approaches can challenge implementers, as was observed during the implementation of the new curriculum for the midwifery programme in Lesotho. Without ongoing professional development and support, the educators resorted to supporting one another. However, the sustainability and effectiveness of the unstructured peer support was compromised, hence the need to develop guidelines to enhance peer support among educators during curriculum innovation. Objective: To develop and validate guidelines to enhance peer support among educators during curriculum innovation. Methods: Primarily a qualitative research design with multiple data collection methods was conducted guided by the World Health Organization Handbook for Guideline Development as the framework. Three interrelated phases inclusive of an integrative review, an exploratory qualitative study, and guideline development and validation were conducted. External reviewers validated the developed guidelines through a Delphi survey. Results: Practice guidelines for peer support among nurse educators during a curriculum innovation were developed and validated. Five priority areas and seven recommendations are addressed in the guidelines. 98 Conclusion: Practice guidelines can enhance the peer support interactions during implementation of a curriculum innovation. Peer support is an affordable strategy that can enhance implementation of curriculum innovation in resource-limited settings. Institutional leadership needs to endorse the support strategy and the practice guideline. Keywords: curriculum innovation; guideline; peer support; implementation Background Curriculum transformation in higher education institutions contributes to enhancing the quality of graduates and prepares them to address emerging socioeconomic and health challenges in different communities.[1,2] The successful execution of a transformed curriculum depends on the capability of the faculty as the drivers of the curriculum implementation.[3] However, transforming the curriculum from one learning theory to another that is underpinned by different principles and pedagogical approaches can challenge the educators’ existing set of skills. Ill- equipped educators may struggle to implement the curriculum as intended, thereby necessitating support strategies to enhance their abilities to appropriately enact the transformed curriculum. Therefore, educational institutions embarking on curriculum transformation need to proactively formulate clear strategies for relevant ongoing faculty development to support the change process.[4] However, planning and undertaking formal professional development and capacity- building interventions in low- and middle-income countries (LMICs) may be deterred by limited resources. Therefore, LMICs embarking on curriculum transformation may benefit from affordable support strategies such as peer support. Evidence shows that peer support can sustain and improve the outcomes of an innovation.[5–7] Peers can support one another through encouragement and providing emotional support and information to improve knowledge and skills. Such supportive activities and exemplar behaviour may increase peers’ self-efficacy and enhance the implementation of the change process. Bandura highlights vicarious experience and verbal persuasion as some of the means through which peers can support one another.[8] However, the absence of a structured approach to the initiative, such as guidelines, peer support activities could be compromised. The researcher 99 argues that peer support guidelines can give direction and enhance the interactions of peers during the change process such as curriculum innovation. This article describes the guidelines for peer support developed for educators engaged in curriculum change in nursing education in Lesotho, a low-income country in southern Africa. The context of the study reported in this article is the implementation of a curriculum innovation in the midwifery programme in the kingdom of Lesotho. In 2014, the nursing education institutions in Lesotho implemented the initial competency-based curriculum (CBC) in the one- year midwifery programme. The transformed curriculum required a new set of skills among the nurse educators, who were at different levels of readiness. However, the institutions had no deliberate plan for ongoing support or professional development. Naturally, the early adopters of the new curriculum provided unstructured support to their peers. Although the unstructured peer support were successful, there were some limitations, such as lack of administrative commitment, lack of accountability and lack of monitoring and evaluation.[9] Methods The practice guidelines were developed primarily through a qualitative research design using multiple data collection methods guided by the World Health Organization (WHO) Handbook for Guideline Development as a framework.[10,11] Three separate interrelated studies were undertaken in different phases addressing specific objectives as illustrated in figure 1. The initial study synthesised existing peer support strategies that enhanced the implementation of an innovation or new programme among professionals between 2000 and 2016 through an integrative review. The details and findings of this phase have been reported elsewhere. [11]. The second study described the experiences of midwife educators regarding peer support during the implementation of a new curriculum in Lesotho. Data were collected from 12 midwife educators through semi-structured interviews, which were recorded, transcribed verbatim and analysed inductively. Data saturation was reached with the 12 participants. The details and findings of this phase are reported elsewhere.[12] 100 The third and final phase involved triangulation of evidence from the two preceding phases, followed by development and validation of guidelines for peer support. In line with the WHO Handbook for Guideline Development,[11] the first author established a guidelines development task team of three consisting of a methodology expert and curriculum specialist, a senior lecturer who is an experienced mentor engaged in professional development, and the first author. Based on the triangulated evidence from the phase one and two, the guidelines development task team identified, discussed and agreed on priority areas and recommendations through consensus. Secret voting was used to reach a decision whenever there was a disagreement. Five priority areas and seven recommendations were formulated and evaluated against the quality assessment framework described in the WHO Handbook for Guideline Development.[11] Validation of the guidelines was conducted by a panel of external reviewers through a Delphi survey. Detailed description of the development process and the guidelines are presented in the supplementary material. Rigour of the guideline development process The validation of the draft guidelines by an expert panel contributed to the rigour of the development of the guidelines. The guidelines development task team purposefully identified 16 experts in nursing education and mentorship from Africa and Asia based on their qualifications, expertise and experience. Nine reviewers accepted the invitation to participate in the Delphi survey. The expert panel used the 23-item Appraisal of Guideline for Research and Evaluation (AGREE II) tool to evaluate the guidelines through a two-cycle Delphi survey.[13,14] The AGREE II tool addresses six domains, namely:  Scope and purpose  Stakeholder involvement  Rigour of development  Clarity and presentation  Applicability  Editorial independence. 101 FIGURE 1: Methodological process for guideline development (Source: Author-generated) 102 The response rate during round one of the Delphi survey was 89% and 75% during round two. Hasson and colleagues citing Sumsion, suggest that a response rate of 70% is rigorous for a Delphi survey.[14] The responses from the expert reviewers were analysed using the ratios and percentages of agreement for each of the items on the AGREE II tool. The task team made amendments and consolidated the recommendations based on the analyses of both rounds of the Delphi survey. Figure 2 shows the summary of the guideline validation process. Consolidation • Population: 6 • Population: 9 external reviewers external reviewers • 17 items (> 80% agreement) • Response rate: 75% • Response rate: 89% • 6 items (< 80% agreement) • > 90% agreement Round 1 Round 2 FIGURE 2: Summary of the guideline validation process (Source: Author- generated) Ethical consideration for the development of the guidelines Ethics approval was obtained from the Health Sciences Research Ethics Committee at the University of the Free State (HSREC 28/2017) and the Lesotho Ministry of Health Research and Ethics Committee (ID 91-2017). All participants in the qualitative study and the Delphi survey received detailed information and participated voluntarily. The external reviewers remained anonymous to one another throughout the guidelines validation process.[14] 103 Results Five priority areas and seven recommendations were developed for the peer support guidelines. The priority areas are as follows: Priority area 1: Peer supporters The focus of this area is the qualifications, capabilities and attributes of the peer support providers. The triangulation of the findings from the two preceding phases suggested that peer supporters should be in possession of a higher qualification such as a Master’s or doctoral degree in nursing/health professions education. However, it is unlikely that many educators in LMICs have the necessary higher qualifications. Therefore, a formal qualification in nursing/health professions education is acceptable for a peer supporter. Attributes such as experience, motivation and commitment to peer support are valued and readily accepted among peers. Priority area 2: Peer support strategies This priority area focuses on the strategies for providing support and the characteristics of an effective support strategy. Evidence shows that relevant and tailor-made strategies and platforms have positive outcomes and are acceptable and valued by peers receiving support. Strategies include group support approaches and paired techniques. Acceptability and feasibility are high when there is institutional commitment to the support strategy. Priority area 3: Content/support needs Tailor-made support content is valued and acceptable, and has a positive effect on the peers. Assessment to determine the content or support needs should be done in collaboration with those who need support. The content should be aligned to the new curriculum implementation needs of individuals. 104 Priority area 4: Outcomes of peer support The goals and objectives of peer support strategy should be directed towards sustaining the curriculum innovation, improved curriculum implementation, promotion of professional and personal growth. The commitment of institutional administrators enhances accountability and promotes the success of the peer support and ultimately sustains the curriculum innovation. Priority area 5: Monitoring and Evaluation of the peer support strategy Monitoring and Evaluation is an essential component of successful peer support, and enhances and sustains the peer support strategies. Peer support strategy should have a monitoring and evaluation mechanism that provides opportunity for feedback and enhance effectiveness of the strategy. Table 1 presents a summary of the practice guideline recommendations. TABLE 1: Summary of practice guideline recommendations on peer support Priority area Recommendations A1: Peer supporters A1.1: Peer supporters should be in possession of higher qualifications, such as Master’s or doctoral degree in nursing/health professions education and expertise in a specific discipline. In the absence of such high qualifications, a formal qualification in nursing/health professions education is acceptable for a peer supporter. The peer supporter should be knowledgeable about the principles guiding the curriculum innovation, experienced in guiding/leading colleagues, and willing to facilitate the professional growth of the peers. Attributes such as experience, motivation and commitment to peer support are valued and readily accepted among peers. Level of evidence used: Moderate B1: Peer support B1.1: Supporters should consider the needs of the peers related to the strategies implementation of the curriculum innovation, such as developing appropriate facilitation materials and using relevant pedagogical and assessment methods. The supporters should select the most appropriate strategies and platforms to provide support. Level of evidence used: Moderate B1.2: The institutional leadership should ensure that the support strategy has clear goals and objectives, explicit systems and mechanisms to enhance and sustain the effective implementation of the strategy 105 Priority area Recommendations during curriculum innovation. Level of evidence used: Moderate C1: Content/support C1.1: The support providers should collaborate with the peers/educators to needs assess and identify support needs to enable the development of relevant and applicable content that is aligned with the implementation of the new curriculum. Level of evidence used: Moderate D1: Outcomes of peer D1.1: The goals and objectives of the peer support activities should be support aligned with the identified needs and directed towards sustaining the curriculum innovation, capacity building, professional growth, community of practice and scholarship. Level of evidence used: Moderate D1.2: Institutions should recognise support strategies as a valued service and commit by allocating resources to meet the departmental/support needs to enhance peer support during a curriculum innovation. Level of evidence used: Moderate E1: Monitoring & E1.1: Institutional leadership should ensure that there is a mechanism for evaluation of the monitoring and evaluation of the peer support strategies used during peer support strategy the curriculum innovation. Level of evidence used: Moderate Source: Author-generated Discussion Practice guidelines can enhance peer support interactions among implementers of a transformed curriculum, particularly in resource-limited institutions that cannot afford ongoing professional development. The lack of ongoing professional development and support compromises the fidelity of the implementation of the transformed curriculum and creates a platform for a curriculum drift.[15] Botma reiterates that educators who are not familiar with the principles underpinning the new curriculum would facilitate curriculum drift.[16,17] Therefore, without ongoing support for the educators during the curriculum transformation, curriculum drift is imminent. These practice guidelines are contextualised and recommend strategies and processes essential for effective peer support among educators engaged in the enactment of curriculum innovation. 106 Various factors, including qualifications, experience and commitment of support providers influence the effectiveness of peer support strategies.[5,6,18] However, in LMICs such as Lesotho, it may not be feasible for most nursing education institutions to have educators in possession of qualifications higher than the basic degree. In the absence of highly qualified support providers, institutions can utilise knowledgeable and experienced individuals such as the early adopters.[17] The institutional leaders also need to develop deliberate professional development plans directed towards building capacity of the potential supporters.[17,19] The peer support providers should also possess effective interpersonal and communication skills to facilitate positive and collegial environment and interactions during support activities.[5,20,21] The content for the peer support strategy should be well-planned and relevant to the curriculum implementation needs of peers. Klinge agrees with Pololi and colleagues that learning occurs naturally when adult students perceive it as relevant and contribute to improving their self- efficacy.[22] Ensuring relevant content requires collaborative assessment and identification of the support needs.[5,23] The designed content should be administered using appropriate strategies such as workshops, presentations, meetings, supportive peer reviews and hands-on methods. Role modelling and encouragement further enhances the self-efficacy of colleagues during the change process.[8] The participants may value and prefer engaging and hands-on strategies that are in line with the challenges they are facing. Knowles’ work cited by Klinge alludes to the principles of adult learning and emphasises the importance of designing needs-driven support strategies that promote active learning.[22] However, peer support providers in LMICs need to be cognizant of the limitations associated with some strategies and platforms, such as connectivity, systems failure and the technological abilities of individuals[20] which might influence the effectiveness and success of the support strategy. Outcomes of an effective peer support strategy include sustained curriculum innovation, personal and professional growth and community of practice.[6,7] Peer support approaches that promote self-directedness and critical thinking ought to be encouraged. Besides these positive outcomes, unintended effects such as negative emotional reactions might also be experienced and compromise the effectiveness of the support.[5,18] Therefore, establishment of a committee instead of one person working on peer support interventions, may create a buffer for the potential 107 emotional strains that individuals may experience.[6,18] Some factors that can compromise the effectiveness of a peer support strategy include disconnections in relationships, power differences, unclear mentoring roles and lack of monitoring and evaluation.[5,18,21] However, critical to the attainment of positive outcomes is the commitment of institutional leadership to the peer support strategy. The guidelines allude to the commitment of the institutional leadership, which is essential in creating an environment conducive to successful peer support strategies.[4] Such commitment is key to the success of peer support and influences the allocation of resources, accountability and monitoring and evaluation of the support strategy.[6,18,21] Both the integrative review and the qualitative study highlighted the importance of administrative endorsement.[9,12] Although monitoring and evaluation is essential for any effective intervention, these quality assurance mechanisms are sometimes disregarded leading to delayed identification of challenges and weakness and subsequently no correctional measures undertaken.[7,24] When consistently performed and recommendations thereof applied, monitoring and evaluation can be the mainstay for the support strategy and sustaining the implementation of the curriculum innovation.[7,18] These peer support guidelines can be adapted to different contexts and used among educators in institutions undergoing curriculum transformation in LMICs. Peer support is one of the affordable approaches that can benefit educators in resources-limited institutions. Conclusion The purpose of this article was to present the guidelines developed for peer support among educators during a curriculum transformation in a low-income country. Educators need ongoing support such as peer support to enhance the implementation of curriculum innovation. However, unstructured peer support can compromise the effectiveness of the strategy. The recommendations developed herein highlight some of the critical elements that should be considered during peer support engagements among educators. Poor or inadequate support can lead to inappropriate enactment of the curriculum, with adverse outcomes for the students and the communities served by the graduates. The authors conclude that practice guidelines can 108 enhance the peer support interactions during implementation of a curriculum innovation in resource-scarce countries. This article presents such guidelines for peer support. Institutional leadership needs to endorse the support strategy and the practice guidelines. Further research is recommended to evaluate the effectiveness of these guidelines in the different institutions that may use them. There is also a need to evaluate the efficacy of the implementation of curriculum reforms funded by NEPI in African countries. Declaration of conflicts of Interest None of the members of the guideline development group had any personal, family or financial interest. Although the principal investigator received a tuition bursary from the University of the Free State, the development of these guidelines was self-funded. References 1. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: Ttransforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923–58. 2. Niehaus E, Williams L. 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An EBP mentor and unit-based EBP team: A strategy for successful implementation of a practice change to reduce catheter-associated urinary tract infections. Worldviews Evidence-Based Nurs. 2014;11(5):341–3. 8. Bandura A. Human Agency in Social Cognitive Theory. Am Psychol. 1989;44(9):1175– 84. 9. Shawa M, Botma Y. Peer support strategies that enhance implementation of an innovation among professionals: An integrative review [Doctoral dissertation]. University of Free State, Bloemfontein, South Africa; 2020. 10. Harrell, MC; Bradley M. Data collection methods: Semi structured interviews and focus groups. Santa Monica, CA: RAND Corporation. 11. World Health Organization. WHO Handbook for Guideline Development. 2nd ed. Geneva: WHO Press; 2014. 1–179 p. 12. Shawa M, Botma Y. Peer support during implementation of a new curriculum: Experiences of nurse educators [Doctoral dissertation]. University of Free State, Bloemfontein, South Africa; 2020. 13. AGREE Next Steps Consortium. 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Available from: http://dx.doi.org/10.1016/j.nepr. 2009.01.019 24. Chukwu CL, Mezieobi DI, Uguwanyi BE, Okpoebo CC. Monitoring and evaluation on effective delivery of social studies for improved academic performance. Rev Eur Stud. 2019;11(1):175. 111 CHAPTER 5 Practice guidelines for peer support 5.1 INTRODUCTION The previous chapter discussed the development of the practice guidelines for peer support. These practice guidelines refers to a set of formulated evidence-based recommendations that describe peer support interventions and processes to assist nurse educators during a curriculum innovation. The current chapter presents the practice guidelines outlining the purpose of the guidelines, the target audience and stakeholder involvement, the scope of the guidelines, formulated guideline recommendations for peer support, quality of evidence used in the recommendations, monitoring and evaluation of guidelines and updating guidelines. For each recommendation, a summary of supporting evidence and considerations thereof are also described. The implications for implementing these guidelines have also been outlined. The guidelines development was nested in the WHO (2014) Handbook for Guideline Development. 5.2 PURPOSE OF THE GUIDELINES The practice guidelines were produced in relation to a curriculum change in nursing education institutions in Lesotho, which transformed curriculum from a teacher-centred to a student-centred approach. This transformation implies a paradigm shift from behaviourism to constructivism with associated pedagogical changes. The curriculum transformation had posed a challenge for implementers, necessitating peer support. 112 The overall objective of these guidelines was to provide recommendations that can inform peer support interactions among nurse educators during the implementation of a curriculum innovation. These systematically developed recommendations can provide direction on peer support interventions and decision making that might benefit the educators, peer support providers, and institutional administrators, and contribute to appropriate enactment of the new curriculum and ultimately improve the quality of graduates. The practice guidelines also intend to give structure to the peer support strategy and enhance its sustainability, particularly when they are endorsed by the institutional leadership. 5.3 TARGET AUDIENCE AND STAKEHOLDER INVOLVEMENT The recommendations in these practice guidelines are proposed to inform peer support interactions among educators implementing an educational innovation. These practice guidelines are based on the evidence from the integrative review and the qualitative study conducted among the educators who had implemented the curriculum innovation in the midwifery programme in Lesotho. The results from the qualitative study were triangulated with the evidence from an integrative review and used to formulate the priority areas and recommendations. The developed guidelines are relevant to all educators who are receiving and providing support during the implementation of a curriculum change or an educational intervention in higher education institutions in LMICs. The practice guidelines are also essential for institutional administrators, managers and all curriculum innovators. These guidelines are intended to enhance peer support strategies among educators during the implementation of an innovation and address various aspects of such support. The guidelines should be used in tandem with the curriculum/innovation implementation plan and the institution’s professional development strategies and policies. 113 5.4 SCOPE OF THE GUIDELINES These guidelines outline critical elements related to peer support strategies among educators during the implementation of a curriculum innovation. Implementing a curriculum innovation presents challenges among educators when their existing skills set are redundant. Educators facing such challenges may not enact the new curriculum correctly and could benefit from peer support. The target audience for these includes educators implementing a curriculum innovation in higher education, institutional administrators and managers. The priority areas addressed in these guidelines include:  peer supporters,  peer support strategies,  content/support needs,  outcomes of peer support and  monitoring and evaluation of the peer support strategy. The specific recommendations and the supporting evidence for each priority area are described in the following sections. 5.5 FORMULATED RECOMMENDATIONS FOR PEER SUPPORT The recommendations were formulated by a small group of guideline developers using the WHO (2014) Handbook for Guideline Development as a framework. The researcher established a task team to develop the peer support guidelines, as proposed in the WHO (2014) Handbook for Guideline Development. The task team consisted of a methodology expert and curriculum specialist, a senior lecturer who is an experienced mentor engaged in professional development, and the researcher. The guideline developers identified and discussed priority areas, which were informed by triangulated evidence from the integrative review and the qualitative study on educators. The themes from the integrative review and qualitative study were the basis for formulating the five priority areas. The supporting evidence for the themes was used to craft the recommendations. The formulated recommendations were discussed among the 114 members of the task team and consensus was reached before finalising them. Seven recommendations were formulated based on the triangulated evidence from the integrative review and the qualitative study. Each recommendation formulated was evaluated against the domains described in the WHO Handbook for Guideline Development (2014) and the triangulated evidence. The domains considered included: ▪ Effects – describes the perceived benefits and harms associated with the intervention and their importance to the stakeholders ▪ Values and preference – describes the relative importance assigned to outcomes associated with the intervention of the stakeholders ▪ Resource implications – describes the anticipated relevant resources that may be required to implement the intervention in the guideline ▪ Equity – describes how the intervention might increase fairness and justice during the implementation of an innovation and reduce inequalities among stakeholders ▪ Acceptability – describes the likelihood that the stakeholders will embrace and apply the recommendations/intervention ▪ Feasibility – represents the practicality of using the recommendations among the stakeholders and is influenced by available resources such as financial, technological, infrastructure and human resources. Table 5.1 presents a summary of the formulated practice guideline recommendations and priority areas included in the peer support guidelines. 115 TABLE 5.1: Summary of practice guideline recommendations on peer support Priority area Recommendations A1: Peer supporters A1.1: Peer supporters should be in possession of higher qualifications, such as master’s or doctoral degree in nursing/health professions education and expertise in a specific discipline. In the absence of such high qualifications, a formal qualification in nursing/health professions education is acceptable for a peer supporter. The peer supporter should be knowledgeable about the principles guiding the curriculum innovation, experienced in guiding/leading colleagues, and willing to facilitate the professional growth of the peers. Attributes such as experience, motivation and commitment to peer support are valued and readily accepted among peers. Level of evidence used: Moderate B1: Peer support B1.1: Supporters should consider the needs of the peers related to strategies the implementation of the curriculum innovation, such as developing appropriate facilitation materials and using relevant pedagogical and assessment methods. The supporters should select the most appropriate strategies and platforms to provide support. Level of evidence used: Moderate B1.2: The institutional leadership should ensure that the support strategy has clear goals and objectives, explicit systems and mechanisms to enhance and sustain the effective implementation of the strategy during curriculum innovation. Level of evidence used: Moderate C 1: Content/support C1.1: The support providers should collaborate with the needs peers/educators to assess and identify support needs to enable the development of relevant and applicable content that is aligned with the implementation of the new curriculum. Level of evidence used: Moderate 116 Priority area Recommendations D1: Outcomes of peer D1.1: The goals and objectives of the peer support activities should be support aligned with the identified needs and directed towards sustaining the curriculum innovation, capacity building, professional growth, community of practice and scholarship. Level of evidence used: Moderate D1.2: Institutions should recognise support strategies as a valued service and commit by allocating resources to meet the departmental/support needs to enhance peer support during a curriculum innovation. Level of evidence used: Moderate E1: Monitoring and E1.1: Institutional leadership should ensure that there is a mechanism evaluation of the peer for monitoring and evaluation of the peer support strategies used support strategy during the curriculum innovation. Level of evidence used: Moderate Source: Author-generated 5.5.1 Recommendations and evidence This section describes the recommendations per priority area and the evidence considered. A1: Peer supporters One recommendation was developed for this priority area which focused on the characteristics of the peer supporters. 117 A1.1: Characteristics, qualifications and motivation of peer supporters Recommendation A1.1: Peer supporters should be in possession of a higher qualification in education, be knowledgeable about the principles guiding the curriculum innovation, experienced in mentoring, motivated and committed to provide support and facilitate the professional growth of the peers. Remarks:  The evidence from the integrative review indicated that support providers possessed high qualifications in the relevant disciplines, which included being PhD holders, professional medical editors and postgraduate alumni, and/or occupied leadership positions such as associate professors and programme directors (Bang, 2013; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Pololi et al., 2004; Provident, 2006). Most of the evidence in the integrative review was from high-income countries. The guideline developers noted that in LMICs few educators might have master’s or PhD degrees; therefore, emphasis should be on the supporters’ experience and knowledge of the curriculum innovation. There may be a need for professional development to build the capacity of the supporters.  Evidence from the qualitative data suggested that stakeholders valued the knowledge and willingness of supporters during support activities. The evidence further indicated that supporters were internally driven to support their colleagues. The guideline developers noted that in the absence of a qualified or willing supporter, the institution may consider collaborating with other institutions that have experienced supporters and source peer support. 118  Evidence from the integrative review indicated that supporters should have experience in evidence-based practice and change processes and interest in areas in which mentees need to be mentored (Bang, 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Magers, 2014; Pololi et al., 2004; Provident, 2006).  The integrative review showed that supporter commitment and interest in mentoring are essential for an effective support strategy (Bennett & Santy, 2009; Bryant et al., 2015; Provident, 2006; Sexton et al., 2016). Similarly, qualitative evidence from the stakeholders suggested that knowledge, experience and willingness of the peer supporter are essential in a peer support strategy.  Guideline developers noted that supporter qualification, experience and commitment to professional development were essential elements for a successful peer support strategy.  The evidence from the integrative review was of levels III and V of good quality, as classified in the JHNEBP Research Evidence Rating Scale (Addendum D). No randomised controlled trials or systematic reviews on peer support during an innovation were found during the integrative review. Note: The remark on the quality of the evidence used (levels III and V) applies to all the recommendations and will not be repeated in the subsequent recommendations. Summary of evidence and considerations Effects: The integrative review evidence described the outcomes of support strategies for the innovations or new programmes. Positive outcomes were reported in all innovations/new programmes included in the integrative review (Bang, 2013; Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky 119 et al., 2014; Hall & Zierler, 2015; Magers, 2014; Pololi et al., 2004; Provident, 2006; Sexton et al., 2016). Qualitative evidence from the stakeholders also suggested positive outcomes, which included educator empowerment, enhanced competencies and improved implementation of the curriculum innovation. However, the qualitative evidence also indicated that there were negative emotional reactions towards the support providers among colleagues who were being assisted during the implementation of the new curriculum. Values: The qualitative evidence suggested that stakeholders considered experience, expertise and commitment of the supporter as important for effective peer support. Similarly, the evidence from the integrative review indicated that interest and commitment to peer support and the innovation are essential values. Resources: The most relevant resources in this recommendation include human resources and time. The institutional administrators need to allocate appropriate human resources for the peer support strategy. Equity: Most of the evidence from the integrative review was from high-income countries and supporters were highly qualified, ranging from associate professors and PhD holders to postgraduate alumni (Bang, 2013; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Pololi et al., 2004; Provident, 2006). In LMICs very few supporters may possess such high qualifications in education, therefore deliberately identifying and capacitating educators who are willing and interested in professional development could help ensure that those in need will be able to access peer support. 120 Acceptability: The qualitative evidence from the experiences of stakeholders regarding peer support suggested that knowledgeable, experienced and willing supporters are essential in a peer support interaction. Therefore, the peers are more likely to accept and participate in support activities that are provided by qualified and experienced supporters. Feasibility: The qualitative evidence from the stakeholders suggested that limited knowledge and experience levels of the supporters may affect the practicality and influence the quality of peer support. The lack of knowledge and honest self- assessment among the individuals in need of assistance may also affect their potential for seeking support. However, the lack of knowledge and honest self-assessment related to the implementation of the curriculum innovation may be mitigated through objective peer evaluation, supervision and performance appraisal reports. The qualitative evidence from the stakeholders showed that early adopters were essential in supporting the implementation of the new curriculum. Therefore, the capacitation of early adopters of the innovation may increase the feasibility of peer support in the face of limited resources in LMICs or when there is no funding for robust professional development. B1: Peer support strategies Two recommendations were developed for this priority area which focused on selecting support strategies and characteristics of effective peer support strategies. B1.1: Selecting strategies for providing support Recommendation B1.1: Supporters should consider the needs of the peers related to the implementation of the curriculum innovation, such as developing appropriate facilitation materials and using relevant pedagogical and assessment methods. The supporters should select the most appropriate strategies and platforms to provide support. 121 Remarks:  Both the integrative review and the qualitative evidence suggested that the support providers should consider the various support strategies and select those that will best meet the needs of the peers.  The integrative review evidence identified team mentoring strategies as group- facilitated mentoring, unit-based mentoring, collaborative mentoring, paired mentoring such as dyads leading to triads, peer-to-peer mentoring, online peer observation and multiple techniques, which include hybrid and multiple approaches to mentoring (Bang, 2013; Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Pololi et al., 2004; Provident, 2006; Sexton et al., 2016).  Similarly, the qualitative evidence indicated that support among stakeholders was provided using group approaches such as workshops, presentations on specific topics, meetings and paired techniques such as supportive peer reviews, hands- on support and one-on-one methods. Face-to-face interactions and electronic platforms such as WhatsApp groups and email communication were engaged in.  The qualitative evidence also highlighted the limitations of using electronic platforms, such as availability and functionality of the communication infrastructure and poor connectivity. The evidence from the integrative review also identified technological challenges such as system failure, connectivity and data loss (Bang, 2013). 122  The guideline developers recommend that the support providers in LMICs be aware of these limitations associated with the use of technology when selecting the mode/platform to use for providing support. The supporters also need to be aware of the technological capacity of the mentees before deciding on a technological platform.  The guideline developers recommend that support providers consider and tailor- make support strategies based on the needs of their peers.  The quality of evidence has already been described earlier. Summary of evidence and considerations Effects: The integrative review evidence described the outcomes of various peer support strategies used during the implementation of an innovation or new programmes. The outcomes included improved and sustained patient outcomes, professional growth, professional networks, the acquisition of knowledge and skills, designed curricula and updated modules, and improved research capacity (Bang, 2013; Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Pololi et al., 2004; Provident, 2006; Sexton et al., 2016). The qualitative evidence from the stakeholders also highlighted positive effects of the peer support strategies, which include the empowerment of peers, improved awareness and understanding of the curriculum innovation, enhanced specific competencies to implement the new curriculum, the promotion of teamwork and strengthened resilience of supporters. Values: The qualitative evidence from the stakeholders indicated that different strategies were used during the support activities. The qualitative evidence suggested that both team and individualised approaches during support activities are considered important among stakeholders. The integrative review highlighted trust, honest 123 affirmation, openness to self-disclosure, collegial relationships, relevant and applicable learning opportunities, regular and positive feedback, confidentiality and role of co- mentoring as essential values in peer support engagements (Bang, 2013; Bennett et al., 2013; Bryant et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Provident, 2006). Resources: The most relevant resources in this recommendation are those required for the selected specific strategy, which may include infrastructure, technological equipment and connectivity, time, human resources and the associated financial resources (Bang, 2013; Bennett & Santy, 2009; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Provident, 2006). Evidence from the stakeholders also highlighted time, communication infrastructure and human resources. Equity: The evidence from the integrative review did not explicitly address equity. However, peer support strategies used had the potential of improving the competence of implementers and sustaining the interventions with subsequent long-term impact reducing inequalities among communities. Strategies selected for the peer support should be accessible to all peers. Acceptability: The qualitative evidence from the stakeholders suggested that tailor- made and individualised peer support strategies, based on the educational landscape associated with implementing the new curriculum, are likely to be accepted. In a similar light, evidence from the integrative review indicated that contextualised support programmes, relevant and applicable learning opportunities, experiential learning opportunities, collaborative mentoring, writing self-determined goals, co-creating scope and expectations of the peer support interactions were acceptable among stakeholders (Bennett et al., 2013; Bryant et al., 2015; Hall & Zierler, 2015; Pololi et al., 2004; Sexton et al., 2016). 124 Feasibility: The qualitative evidence from stakeholders suggested that various strategies were feasible, although time was a constraint where support activities were conducted after official working hours. Limitations associated with the use of technological platforms in LMICs may also make the provision of support unfeasible. Evidence from the integrative review suggested that support strategies used were feasible, although some showed technical and time limitations, lack of mentoring experts and difficulty of pairing peers with supporters in different locations (Bang, 2013; Furimsky et al., 2014; Provident, 2006). B1.2: Characteristics of an effective support strategy Recommendation B1.2: The institutional leadership should ensure that the support strategy has clear goals and objectives, explicit systems and mechanisms to enhance and sustain the effective implementation of the strategy during curriculum innovation. Remarks:  Evidence from the integrative review described the elements of effective support strategy as including clear organisational and operational mechanisms, strategies to sustain innovation, effective communication and feedback, monitoring and evaluation, leadership and responsibility, and guidelines for interaction (Bang, 2013; Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Pololi et al., 2004; Provident, 2006; Sexton et al., 2016)  The qualitative evidence from the stakeholders suggested that the effectiveness of unstructured support is compromised due to limited accountability by both the supporter and the supported, lack of monitoring and evaluation, limited tangible support for implementation, inadequate time to engage in support activities and inadequate support provided to resistant colleagues. These limitations might be addressed by implementing structured peer support strategies and identifying a 125 committee or a focal person to be responsible and accountable for the support activities in the institution. There is also a need for monitoring and evaluation of the peer support strategies implemented in the institution.  The evidence from the integrative review suggested that an effective peer support strategy should have a clear vision, goals and guidelines for engagement in the support strategy, involvement of senior educators, institutional approval, administrative systems and established committees for support strategies (Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Magers, 2014; Pololi et al., 2004; Provident, 2006; Sexton et al., 2016).  Evidence from the integrative review emphasised that the commitment and capacitation of the institutional leadership are essential for an effective support strategy. The integrative evidence further specified the provision of resources, recognition and acknowledgement of champions of the innovation, monitoring compliance and ongoing support as some of the essential responsibilities undertaken by the institutional leadership (Bang, 2013; Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Pololi et al., 2004; Provident, 2006; Sexton et al., 2016).  The leadership should also be conscious of the support needs of the educators in their institution. The qualitative evidence from the stakeholders concurred with the integrative review evidence in suggesting the endorsement of peer support by administrators as fundamental for its effectiveness. The qualitative evidence also highlighted limited accountability when the institution did not endorse the support strategy. The endorsement of the support strategy may be enhanced by ensuring institution administrators’ buy-in of the guidelines and communicating them to the educators themselves, thereby committing their support. 126  Both the qualitative evidence and the integrative review highlighted the importance of communication in enhancing peer support using suitable communication media. All the evidence from the integrative review underscored the importance of mentor–mentee communication and the sharing of information (Bang, 2013; Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Pololi et al., 2004; Provident, 2006; Sexton et al., 2016). The qualitative evidence further indicated that unstructured communication in some institutions compromised the sharing of information on the exemplary practice.  The evidence of the integrative review described the importance of monitoring and evaluation, the provision of ongoing feedback and reinforcement as essential elements for an effective support strategy (Bang, 2013; Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Pololi et al., 2004; Provident, 2006; Sexton et al., 2016). In the same manner, the qualitative evidence reiterated that accountability drives monitoring and evaluation and highlighted that a lack thereof compromised the effectiveness of the unstructured support strategies.  The integrative review highlighted disconnections in relationships such as difficult personalities, power differences, relocation and physical proximity, working in isolation and lack of clarity of mentoring roles as some of the threats to an effective peer support strategy (Bang, 2013; Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Pololi et al., 2004; Provident, 2006; Sexton et al., 2016). The evidence from the integrative review also identified timing and time limitations such as time-consuming models, time lapses between implementation and technological challenges that may affect the effectiveness of support strategies. 127  The guideline developers recommend that support providers take cognisance of the essential ingredients of effective peer support strategies, be alert of the threats and take appropriate precautions. Summary of evidence and considerations Effects: The integrative review evidence described the systems and mechanisms that resulted in a successful and sustained support strategy and implementation of an innovation (Hall & Zierler, 2015; Magers, 2014; Provident, 2006; Sexton et al., 2016). The evidence underscored the importance of institutional buy-in and approval of the support strategy to enhance its effectiveness. The stakeholder evidence also revealed that the peer support activities resulted in educator empowerment and improved competencies. The qualitative evidence further indicated that without administrative ratification, there was limited accountability from both the supporters and the supported, as they did not feel obliged to participate in support activities. The guideline developers suggest that institutions establish mechanisms such as assigning a senior/experienced educator to be responsible for the peer support interventions to enhance accountability. Values: The qualitative evidence showed that stakeholders considered peer support intervention as important. The endorsement of peer support by administrators was perceived as fundamental for effective peer support by the stakeholders. The qualitative evidence also indicated that stakeholders valued the tailor-made support that was readily available and accessible. The evidence from the integrative review also amplified the value of peer support and shed light on the value of involvement of senior educators, a strong mandate from institutional leadership, effective communication and recognition of mentors and successes achieved (Bennett et al., 2013; Fleming et al., 2015; Sexton et al., 2016). 128 Resources: The most relevant resources for this recommendation include those required for the selected specific strategy, which may consist of clear operational policies and guidelines, time, human resources, incentives, communication, connectivity, training, capacitated leadership and the associated financial resources (Bang, 2013; Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Pololi et al., 2004; Provident, 2006; Sexton et al., 2016). The resources should also be aligned to the needs of the units or organisation. The qualitative evidence also emphasised the importance of institutional autonomy in enabling the appropriate distribution of resources. The guideline developers suggest that institutions that are non-autonomous need to identify and assign a senior educator who will be mandated to mobilise resources for peer support strategies. Most of the evidence from the integrative review indicated that resources essential for effective strategies were mobilised based on the needs of individual institutions. Equity: The evidence from the integrative review did not explicitly address equity. However, peer support strategies used had the potential of improving the competence of implementers and sustaining the interventions with subsequent long-term impact reducing inequalities among communities. Acceptability: The qualitative evidence suggested that support strategies that were endorsed by administrators and tailor-made were considered important and therefore likely to be accepted among peers. Similarly, evidence from the integrative review indicated that institutional approval and commitment, and contextualised interventions improve the acceptability of the support strategy (Fleming et al., 2015; Hall & Zierler, 2015; Magers, 2014; Sexton et al., 2016). Feasibility: The evidence from the integrative review suggested that ensuring institutional commitment and approval of the support strategy enhances the feasibility of putting in place various mechanisms to increase the effectiveness of the support strategy (Fleming et al., 2015; Hall & Zierler, 2015; Magers, 2014; Provident, 2006; 129 Sexton et al., 2016). The qualitative evidence from the stakeholders suggested that the monitoring and evaluation of support activities is compromised when institutional leaders are not capacitated in the implementation of the new curriculum. Limited connectivity in some institutions made effective use of electronic communication challenging. Furthermore, limited institutional autonomy also made the acquisition of resources essential for the support strategy difficult. C1: Content/support needs One recommendation was developed for this priority area on content and support needs for the peer support strategy. C1.1: Determining/assessing the support needs Recommendation C1.1: The support providers should collaborate with the peers/educators to assess and identify support needs to enable the development of relevant and applicable content that is aligned with the implementation of the new curriculum. Remarks:  The evidence from the integrative review showed that it was important to identify areas needing support, co-create a mentoring scope with the mentees, sequence guiding support activities, provide learning materials with relevant focused activities and provide experiential and contextualised learning to enhance the support provided (Bang, 2013; Bennett & Santy, 2009; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Provident, 2006; Sexton et al., 2016). 130  The qualitative evidence from the stakeholders also highlighted the importance of considering the educational landscape associated with implementing the curriculum innovation and educational/competency needs of the peers to enable the development of appropriate content for support.  Both the integrative and the qualitative evidence suggested that individuals appreciate the support activities that are relevant to their needs. Hence, support providers should be able to conduct a needs assessment and design content that is tailor-made to individual support needs (Bryant et al., 2015; Pololi et al., 2004).  The integrative review evidence emphasised the importance of awareness of the need for support among peers/educators, openness to self-disclosure of weaknesses and identifying areas needing support, seeking support and voluntary participation in the support activities (Bang, 2013; Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Provident, 2006). Self-disclosure of weaknesses can be enhanced through the creation of a supportive and emotionally safe environment among peers to promote the sharing of personal information (London, 2003). Knowledgeable individuals should also be encouraged to share information with peers experiencing challenges during support activities. The evidence from the stakeholders showed that the difficulties that implementers were experiencing directed most of the peer support activities.  The evidence from the stakeholders suggested that awareness of the need for support among peers is compromised by the cultural background of individuals, which does not encourage young people to develop skills such as critical thinking and self-assessment. Therefore, support providers should be aware of the cultural factors that may hinder self-assessment and openness about individual weaknesses. These limitations might be minimised by promoting a culture of openness among peers and encouraging them to develop a culture of questioning and sharing information. 131 Summary of evidence and considerations Effects: The integrative review evidence described the content of the support activities based on the innovation or new programme that was implemented. Structuring the support content in line with the type of innovation or new programme enhanced the support strategy. The support activities and innovations described in the integrative review were successfully implemented (Hall & Zierler, 2015; Magers, 2014; Provident, 2006; Sexton et al., 2016). The qualitative evidence from the stakeholders indicated that peer support resulted in the empowerment of educators, enhanced competencies and improved implementation of the curriculum. Values: The evidence from the integrative review highlighted the importance and value of trust, openness to self-disclosure, maintaining confidentiality and honesty during the interactions (Bang, 2013; Bryant et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Provident, 2006). The qualitative evidence indicated that peers had different levels of understanding and capabilities related to the implementation of the new curriculum, which necessitated tailor-made activities. The evidence suggested that individuals valued respect during support activities that addressed their needs and improved their self-efficacy. Resource implications: The most relevant resources in this recommendation are those required for the execution of specific activities, which include time, human resources, communication and connectivity to enable the assessment of support needs. Equity: The assessment of the needs should be made known to all individuals in the institution to enable the development of comprehensive content that will meet different needs. The evidence from the integrative review indicated that the needs of individuals or the specific innovation determined the support activities (Bang, 2013; Bennett & Santy, 2009; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Provident, 2006; Sexton et al., 2016). Therefore, the focus should be on aspects related to educational innovation and ensuring that identified 132 needs are addressed during peer support activities. The qualitative evidence also highlighted that the support strategies were needs-driven. The guideline developers recommend that support providers carefully tailor-make support activities to meet the needs of different individuals. Acceptability: The qualitative evidence suggested that tailor-made content based on the educational landscape associated with the implementation of the curriculum innovation is likely to be accepted among peers. The inclusion of content/activities related to the curriculum innovation, such as the new pedagogical and assessment approaches, may make the peer support strategies more appealing to the peers. Feasibility: The qualitative evidence from the stakeholders suggested that determining the support needs among peers can be done. However, the indifferent attitudes of peers may make the assessment of learning needs difficult. Institutional leaders should create a safe and supportive environment that encourages the giving and receiving of feedback and the sharing of personal information to enhance self-disclosure. D1: Outcomes of peer support Two recommendations were developed for this priority area which focused on outcomes of peer support and institutional commitment to the peer support strategy. D1.1: Outcomes of effective peer support Recommendation D1.1: The goals and objectives of the peer support activities should be aligned with the identified needs and directed towards sustaining the curriculum innovation, capacity building, professional growth, community of practice and scholarship. 133 Remarks:  The evidence from the integrative review shed light on some outcomes of effective peer support strategies, which include sustainable innovation, professional and personal growth, scholarship and establishing a community of practice (Bang, 2013; Bennett & Santy, 2009; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Provident, 2006; Sexton et al., 2016).  Similarly, the qualitative evidence from the stakeholders indicated that peer support enhanced specific competencies among educators, empowered peers, improved awareness of the curriculum, enhanced learning, improved implementation of the curriculum and resulted in a publication as some of the outcomes of peer support among stakeholders.  The guideline developers recommend that support providers utilise approaches that promote self-directedness, critical thinking and personal growth. Summary of evidence and considerations Effects: The integrative review evidence indicated that effective support strategies promote the sustainability of the innovation, professional and personal growth, scholarship and community of practice. The evidence showed successful implementation of the innovations with positive outcomes, which included improved patient outcomes, successful utilisation of the fundamental curriculum, the acquisition of various skills among professionals, scholarship and enhanced community of practice (Bang, 2013; Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Pololi et al., 2004; Provident, 2006; Sexton et al., 2016). 134 Values: The qualitative evidence indicated that support strategies had positive outcomes that were important to the peers. The stakeholders felt that peer support activities were empowering and stimulated self-directedness, improved awareness of the curriculum and enhanced learning and implementation of the new curriculum. Resources: The resources necessary in this recommendation include human resources, time, infrastructure, finances, communication and connectivity to enable the utilisation of various strategies and attainment of the goals and objectives of the peer support strategy. Equity: The integrative review evidence indicated that participants in different innovations had access to appropriate support strategies and resources, which enhanced implementation and promoted professional growth (Bang, 2013; Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Pololi et al., 2004; Provident, 2006; Sexton et al., 2016). Acceptability: The qualitative evidence suggested that peer support activities were acceptable among peers, with stakeholders reporting the positive outcomes, which included the acquisition of transferable skills, enhanced competence and resilience. However, the qualitative evidence indicated that there were also negative emotional reactions of educators towards the peer support. These emotional reactions might compromise the acceptability of the support. Feasibility: The qualitative evidence from the stakeholders suggested that it is feasible to engage in a variety of support activities during peer support. Limited resources in LMICs may restrict the use of strategies requiring technology and connectivity. 135 D1.2: Institutional commitment to the peer support strategy Recommendation D1.2: Institutions should recognise support strategies as a valued service and commit by allocating resources to meet the departmental/support needs to enhance peer support during a curriculum innovation. Remarks:  The evidence from the integrative review highlighted the importance of an institutional mandate and commitment to and investment in support strategies (Bang, 2013; Bennett et al., 2013; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Provident, 2006). In addition, the qualitative evidence underscored the importance of administrative endorsement as essential for an effective support strategy. The endorsement by institution administrators may be enhanced through their buy-in of the guidelines. The administrators can also communicate the guidelines to the educators, thereby emphasising their importance and committing support.  The integrative review also suggested the importance of recognition of mentoring as a valued service that can promote growth of the institution (Bennett et al., 2013; Fleming et al., 2015; Furimsky et al., 2014; Sexton et al., 2016).  The evidence of the review further underscored the importance of investing in capacity development and developing leadership strategies (Bang, 2013; Bennett et al., 2013; Furimsky et al., 2014; Fleming et al, 2015; Hall & Zierler, 2015; Sexton et al., 2016). Developing the capacity of the leadership can enhance implementation of an innovation and peer support strategies. 136 Summary of evidence and considerations Effects: The evidence from the integrative review indicated that institutional commitment, aligning departmental needs and resources, investing in capacity building and recognising mentoring and its successes contribute to successful peer support and sustainability of the innovation (Hall & Zierler, 2015; Magers, 2014; Provident, 2006; Sexton et al., 2016). Values: The qualitative evidence indicated that administrative endorsement was considered necessary for peer support strategies. The evidence further suggested that there was limited tangible support and limited accountability, which could compromise the peer support. Accountability may be enhanced by institution administrators’ buy-in of the guidelines and promoting the utilisation during peer support strategies. Resources: The resources required for this recommendation include clear policies and guidelines, performance appraisal systems, time, human resources, competent leadership, communication and connectivity. Equity: The institutional leadership should ensure that resources are aligned with the support needs of all departments/units and that these resources are equitably available and accessible. Acceptability: The qualitative evidence suggested that stakeholders view institutional commitment as important and therefore acceptable for a successful peer support strategy. Feasibility: The qualitative evidence from the stakeholders suggested that obtaining institutional commitment is feasible through the rippling effects of exemplar practice from other institutions. 137 E1: Monitoring and evaluation of the peer support strategy One recommendation was developed for this priority area which focused on the monitoring and evaluation of the peer support strategy. Recommendation E1.1: Institutional leadership should ensure that there is a mechanism for monitoring and evaluation of the peer support strategies used during the curriculum innovation. Remarks  The evidence from the integrative review suggested that monitoring and evaluation can sustain peer support strategies and innovations (Bang, 2013; Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Pololi et al., 2004; Provident, 2006; Sexton et al., 2016). Some of the activities that were aligned with monitoring and evaluation in the integrative review include the monitoring of compliance, progress reports, the provision of ongoing support, reinforcement and redirection, and the provision of expert feedback.  The qualitative evidence from the stakeholders also suggested that accountability drives the monitoring and evaluation of a strategy. The evidence indicated that there was no monitoring and evaluation, as no specific individual was responsible for the peer support activities. Therefore, the institutional leadership should establish a committee or mandate a focal person who could be held accountable for peer support activities in the institution. Such an intervention may enhance the peer support interactions during a curriculum innovation. 138  Monitoring and evaluation of the peer support strategies and activities should be conducted regularly, especially during the initial phases of implementing the curriculum innovation. Regular monitoring and evaluation may help determine the effectiveness and relevance of the peer support strategy as well as identify any challenges that may be encountered.  Monitoring and evaluation tools should be used for gathering information on peer support activities and reports written. Such information is also crucial for the monitoring and evaluation of the peer support guidelines as well as evaluation of the implementation of the curriculum innovation.  There is a need for institutional commitment to the peer support strategy and the involvement of senior educators to enhance the monitoring and evaluation of the support activities (Bennett et al., 2013; Fleming et al., 2015; Sexton et al., 2016). Summary of evidence and considerations Effects: The integrative review evidence indicated that monitoring and evaluation may be a strategy to enhance and sustain support strategies (Bang, 2013; Bennett & Santy, 2009; Bennett et al., 2013; Bryant et al., 2015; Fleming et al., 2015; Furimsky et al., 2014; Hall & Zierler, 2015; Magers, 2014; Pololi et al., 2004; Provident, 2006; Sexton et al., 2016). The qualitative evidence from the stakeholders highlighted the challenges associated with lack of monitoring and evaluation, which included lack of accountability among the support providers and the peers, and lack of follow-up on and reinforcement of the support strategy. Values: The qualitative evidence suggested that the peers valued monitoring and evaluation and utilised peer review activities and frequent meetings to share and evaluate one another’s work related to the implementation of the new curriculum. The evidence also indicated that the stakeholders valued the endorsement of the peer support strategy by administrators. The integrative review evidence also underscored 139 the importance of institutional commitment (Bennett et al., 2013; Fleming et al., 2015; Sexton et al., 2016). Resources: The resources necessary for this recommendation include validated tools for monitoring and evaluation, human resources, time and committed leadership. Equity: The institution should ensure timely and objective monitoring and evaluation of all peer support strategies and activities. The use of validated tools for monitoring and evaluation may enhance equity for this recommendation. Acceptability: Both the integrative review and the qualitative evidence underscored the importance of monitoring and evaluation of peer support strategies as essential for a successful support intervention. Such an agreement suggests the acceptability of this recommendation in the guidelines. Feasibility: The evidence from both the integrative review and the stakeholders suggested that this recommendation is feasible with the institutional commitment to the support strategy. Therefore, it is important for the institutional leadership to endorse the support strategy and establish a monitoring and evaluation mechanism. 5.6 QUALITY OF EVIDENCE USED IN THE RECOMMENDATIONS Evidence used to develop the recommendations was derived from triangulating the results of an integrative review on peer support strategies and evidence from a qualitative study that explored the experiences of educators regarding peer support during the implementation of a new curriculum in a low-income country. The integrative review included quantitative designs, qualitative designs, case studies and non- research organisational experiences. The evidence was evaluated using the JHNEBP Research Evidence Appraisal Tool (Addendum A) for the evidence from non-research organisational experiences, the Critical Appraisal Skills Programme (CASP) for the qualitative design (Addendum B) and the Centre for Evidence-Based Management Tool 140 for case studies (Addendum C) for case studies. Evidence from seven out of the eleven reports included in the review were rated at a strength of Level V and good quality (rated B), while the other four were at Level III of good quality based on the JHNEBP Research Evidence Rating Scale (Addendum D). Data from the qualitative study were obtained through semi-structured face-to-face interviews, which were audio-recorded, transcribed verbatim and analysed inductively. Until recently, guideline development relied heavily on evidence from systematic reviews of randomised controlled trials. However, there has been a shift towards the use of qualitative evidence in guideline development (Lewin & Glenton, 2018; WHO, 2014). 5.7 MONITORING AND EVALUATION OF THE GUIDELINES Monitoring and evaluation of these guidelines will be conducted at different nursing education institutions in LMICs, which will be using these recommendations for peer support activities during curriculum change. Monitoring and evaluation mechanisms will be employed to assess the effectiveness of the guidelines during peer support interactions. Tools for monitoring and evaluation will be developed, validated and used to collect and analyse data related to peer support interactions during curriculum innovation. The monitoring and evaluation should be done once every semester to assess the peer support interactions, changes in stakeholder practice and performance related to the implementation of the curriculum change. 5.8 UPDATING THE GUIDELINES The guidelines should be updated every five years based on the new evidence that may emerge during the monitoring and evaluation processes that may affect the relevance of the recommendations. The WHO (2014) recommends that all guidelines be updated regularly to keep them relevant to needs and consistent with emerging evidence. Based on the evidence from the monitoring and evaluation processes and emerging scientific 141 literature, the recommendations that will be considered to be no longer appropriate/ relevant will be supplemented and the guidelines updated. The process of updating the guidelines will be conducted by a multidisciplinary team, which will include the members who participated in the development of these guidelines, experts on peer support and critical appraisers. 5.9 IMPLICATIONS FOR IMPLEMENTING THE GUIDELINES The developed practice guidelines propose strategies and processes that are essential to enhance peer support during curriculum innovation. At this point, it is worth mentioning some of the inherent implications of which implementers of the guidelines need to be mindful: Institutional leadership commitment: The successful implementation of the guidelines is dependent on the commitment of institutional leadership. The administrators and managers need to ensure that the guidelines are disseminated to all educators and assign a responsible officer or committee to drive the peer support strategy and implementation of the guidelines. Clarification of roles and responsibilities: It is important to clarify the roles and responsibilities of key players associated with the implementation of the guidelines for peer support. The institutional leaders need to consider the capabilities and skills of the educators engaged in peer support. Resource allocation: Aligned with leadership commitment stated above is the allocation of resources essential for the peer support activities, as outlined in the recommendations. Resources may include human, material and time. Poor resource commitment for the support activities might set the stage for unsuccessful/ineffective peer support interventions. 142 Recognition of peer support as a valuable service: It is important to acknowledge peer support as an important strategy, particularly during the curriculum change. Educators who are sceptical of their ability to appropriately enact the new curriculum might benefit from peer support, hence the need for the guidelines. Feedback related to the implementation of the guidelines: Timely feedback should be provided to acknowledge successes and offer alternatives related to the guidelines implementation. It is important to promote a collegial environment that enhances dialogue and effective communication between the support providers and their peers. Monitoring and evaluation: There should be deliberate plans and strategies for monitoring the implementation of the peer support and the guidelines. Lack of a clear strategy for monitoring and evaluation might blind the institutional leadership to the success or failure of the guidelines and/or the peer support strategy. 5.10 CONCLUSION Implementing a transformed curriculum can be overwhelming, even for experienced educators, particularly when there are no planned ongoing support strategies. Naturally, when faced with difficulties, individuals may engage in unstructured peer support. However, such support can be short-lived or inconsistent, thereby threatening the enactment of the new curriculum. Such a peer support strategy needs structure in the form of practice guidelines to enhance the interactions. The proposed guidelines present contextualised processes and strategies that might improve self-efficacy among peers, enhance the fidelity of curriculum enactment and ultimately sustain the curriculum innovation. Further research in this field is recommended to evaluate the efficacy of the guidelines and the fidelity of implementing the curriculum innovation among nursing education institutions. 143 5.11 DECLARATION OF CONFLICTS OF INTEREST None of the members of the guidelines development group had any personal, family or financial interest. The development of these guidelines was not funded; however, the first author received a PhD tuition fee bursary from the University of the Free State, which did not influence the content of the guidelines. Ethical clearance to conduct the study was obtained and written consent was sought from the qualitative study participants. The expert reviewers consented to participate in the Delphi survey after receiving a detailed information brochure about the study. 144 CHAPTER 6 Conclusion, recommendations and limitations of the study 6.1 INTRODUCTION A comprehensive study was conducted with the aim of developing practice guidelines to enhance peer support among nurse educators implementing a curriculum change in Lesotho. This chapter presents a synopsis of the entire study, which includes factual findings on specific research objectives, conceptual findings and conclusions drawn, recommendations made from the study, the contribution to the body of knowledge, the limitations of the study, personal reflections and concluding remarks. 6.2 OVERVIEW OF THE STUDY The current study sought to develop practice guidelines for peer support in response to the situation that prevailed in nursing education institutions in Lesotho following transformation of the midwifery curriculum. Despite transforming the curriculum, which demanded a new set of skills for the educators to enact it appropriately, there was no deliberate plan for the ongoing support of educators. The absence of planned support led the educators to seek support from colleagues who had a better understanding of and capabilities to enact the new curriculum. However, this peer support initiative was unstructured, which compromised its consistency and sustainability. This study sought to develop practice guidelines to enhance peer support among educators during curriculum transformation. The research question was therefore: What guidelines can be developed to enhance peer support among nurse educators during a curriculum innovation in Lesotho? 145 The research objectives that guided this study were as follows:  Describe existing peer support strategies that enhance the implementation of an innovation or new programme among professionals through an integrative review (Phase I)  Describe the experiences of educators regarding peer support during midwifery CBC implementation in Lesotho through an exploratory descriptive qualitative study (Phase II)  Develop guidelines to enhance peer support among educators during the implementation of the CBC in Lesotho using the WHO (2014) Handbook for Guideline Development as a framework (Phase III)  Validate the developed peer support guidelines using a Delphi survey (Phase III). The research design used was primarily qualitative with multiple data collection methods appropriate to each objective. Inclusion criteria for each objective were determined to provide boundaries for the study. The inclusion criteria for the integrative review were published articles for the period 2000 to 2016 and were related to the focused research question. The inclusion criteria for the qualitative study were nurse educators who participated in the implementation of the curriculum innovation in the midwifery programme and engaged in unstructured peer support activities. Rigorous processes were applied, which included the use of the framework of Whittemore and Knafl (2005) during the integrative review, trustworthiness criteria (Lincoln & Guba, 1986), applying the interpretive paradigm and adhering to the WHO (2014) Handbook for Guideline Development. Pertinent evidence regarding peer support came to the fore during the different phases of this study. The next section presents the factual findings for each of the research objectives. 146 6.3 FACTUAL FINDINGS The discussion in this section focuses on the factual findings for each of the research objectives in the different phases of the study. The factual findings for phases I and II are presented parallel to each other based on similarities, as illustrated in Table 6.1. The presentation of the factual conclusions in Table 6.1 illustrates the similarities in the triangulated evidence from the integrative review and the qualitative study. There were many similarities in the factual conclusions from the two phases. Although the content was varied in the different elements of peer support reported, the conclusions from both alluded to the characteristics of peer supporters, support strategies used, motivation for the peer support and many positive outcomes. The challenges and lessons were also similar. Marked differences were noted in the characteristics of effective peer support and monitoring and evaluation, which highlighted many aspects in the integrative review but not much in the qualitative study. On the contrary, the qualitative evidence highlighted many factors that affected the uptake of peer support. The characteristics of the peer support providers include qualification and experience, but most critical is commitment and willingness to provide support. Inherent to the effectiveness of a peer support strategy is the dedication and willingness of the support providers, without which the provision of peer support can be compromised. Institutional leaders embarking on peer support as a strategy to enhance the implementation of change need to be cognisant of this important aspect of the willingness of support providers. 147 TABLE 6.1: Factual conclusion from the study Integrative review: Phase I Qualitative study: Phase II Peer supporter characteristics  Possessed higher qualifications  Early adopters of curriculum innovation  Experienced  Experienced and knowledgeable  Administrators  Internally driven and willing to support colleagues  Commitment and interest in mentoring  Exemplary practice and model performance  Head of programme Peer support strategies used  Team mentoring  Orientation and workload allocation  Paired mentoring  Workshops  Multiple techniques  Peer reviews  Hands-on activities  Frequent meetings Drivers for need for support and content  Voluntary participation  End of NEPI donor funding  Individuals seeking support  Educational landscape associated with implementing the new  Needs assessment curriculum  Co-creation of mentoring scope  Tailor-made peer support Characteristics of an effective peer support strategy  Clear organisation and modus operandi  Committee driving educator support  Strategies for sustaining change  Ad hoc meetings  Communication and feedback mechanisms  Monitoring and evaluation mechanisms  System of identifying the need for support  Commitment from top institutional leaders Attributes affecting the uptake of support  None elicited  Limited accountability and ‘nonchalant’ attitude  History of unsustained donor projects  Limited immediate application of new knowledge  Biological age and experience in the content-based curriculum 148 Integrative review: Phase I Qualitative study: Phase II Monitoring and evaluation  Providing ongoing and expert feedback  Peer reviews  Guidance on change  Sharing information on progress  Reinforcement of change  Checking on progress  Remedying and re-education  Peer observations Outcomes of peer support  Sustained innovation  Teamwork enhanced  Professional and personal growth  Improved curriculum implementation  Scholarship  Enhanced peer learning and self-directedness  A community of practice and interconnectedness  Enhanced specific competencies  Research publication  Development of resilience Challenges of implementing peer support strategies  Timing and time limitation  Inadequate time  Disconnect in relationships and power differences  Communication and connectivity limitation  Lack of clarity of roles and change implementation  Lack of administrative endorsement  Technical challenges  Lack of commitment among some peers  Accessing mentoring support  Emotional abuse of supporters Lessons learnt from the peer support strategies  Importance of the commitment of institutional leadership  The administrative endorsement is fundamental  Setting clear goals and expectations  Active engagement is empowering  Ensuring feedback and information sharing  Communication enhances peer support  Development of a community of practice  Adverse reactions from peers lead to the development of  Personal attributes are elements of successful mentoring resilience among supporters Source: Author-generated 149 Peer support strategies ought to be tailor-made to the needs of the individuals implementing the curriculum innovation. Given that change adoption does not always occur at the same rate among individuals, some adopt change early yet others are late adopters (Rogers, 1983). Similarly, the support needs for such adopters will be different, necessitating tailor-made support strategies. The needs of individuals and institutions should inform the content of the peer support strategy, therefore requiring an appropriate needs assessment before embarking on the intervention. In Lesotho, the ending of NEPI funding that supported the nursing education reforms, which resulted in CBE, was a key driver for peer support. The educators were faced with the reality of a new curriculum, which they were not adequately prepared to implement, leading to unstructured peer support. Despite the expectation placed on the educators to implement the new curriculum, some were not ready to engage and resulted in pockets of resistance to peer support. The uptake of the peer support strategy was affected by a number of factors, including a limited sense of accountability and a ‘nonchalant’ attitude, a history of unsustained donor projects, and the biological age of educators and their experience with the content-based curriculum. Associated to the ‘nonchalant’ attitude was the glaring lack of monitoring and evaluation mechanisms, which was one of the factual conclusions from the qualitative study. Such attitudes compromise the implementation of an innovation and peer support providers need to be aware of these attributes that can affect the effectiveness of peer support. Effective peer support strategies were found to have certain variables, such as clear organisational and operational systems, monitoring and evaluation mechanisms, the commitment of institutional leaders, and the commitment and willingness of the peers involved. Putting in place organisational structures becomes a critical point in the success of peer support. Overlooking such prerequisites for setting up a peer support strategy is setting a stage for failure or an ineffective support intervention. There is a need for the institutional administrators to assign the responsibility to specific individuals or a committee that can be held accountable for the peer support strategies in the institution. 150 Accountability is vital to the effectiveness of peer support and the implementation of the innovation. Lack of accountability or the sense of it, as was identified in the qualitative study, can lead to inappropriate implementation of the curriculum innovation. The situation can further lead to a global waste of resources, such as non-use of expensive high-tech mannequins and other equipment purchased to support the curriculum innovation in the nursing education institutions in Lesotho. In the absence of competence to use the high-tech mannequins or peer support among the educators to enhance the skills, such expensive equipment may go to waste. Therefore, monitoring and evaluation of both of the peer support and implementation of the curriculum innovation becomes a paramount accountability measure to ensure that an ongoing check on progress is made and to identify areas requiring remedying or reinforcement. Peer support strategies in both the integrative review and the qualitative study had positive outcomes. The implications here are that the planners of peer support strategies should have outcomes in mind when planning such interventions. These outcomes can be used to guide the formulation of goals and objectives for peer support. Peer support providers need to be aware of the challenges that may arise during peer support strategies. Some of the challenges are related to timing and time factors, communication, connectivity, power differences and abuse of the support providers. The support strategies should have built-in strategies to address such challenges. The lesson learnt from the existing peer support strategies and the qualitative study can be harnessed and incorporated into the peer support strategies and activities. Some of the lessons include critical elements that can enhance peer support, which include the commitment of institutional leadership, communication and feedback, active engagement and setting clear goals and expectations. 151 6.4 CONCEPTUAL CONCLUSION The discussion of the conceptual conclusion is based on the factual findings and related supporting evidence. Through the evidence synthesised during the integrative review, the researcher gained an understanding of the key elements that made the existing peer support effective, which were adopted and included in the guidelines for peer support. Similarly, using the interpretivist paradigm in an exploratory descriptive qualitative study, the researcher gained in-depth insight into and understanding of the experiences of nurse educators related to peer support during a curriculum innovation and socially constructed the new knowledge. Until recently, guideline development was based on systematic reviews of empirical evidence. However, qualitative evidence is now used to inform guideline development (Lewin & Glenton, 2018; WHO, 2014). The evidence from the two phases was triangulated and used to determine the guidelines priority areas, which were discussed and agreed upon by the guideline development task team. The evidence that the researcher immersed in suggested that peer support can enhance the implementation of an innovation. However, there was a paucity of literature relating to peer support guidelines for educators during a curriculum change. There is, however, a plethora of literature relating to peer support among students and non- professionals, such as patients living with chronic conditions. The lack of literature on guidelines for peer support of professionals was considered as a gap that this study set out to address. The researcher assumes that the developed guidelines might enhance peer support among educators during curriculum change and ultimately influence the implementation of the curriculum innovation. The conceptual conclusion was crafted based on the Donabedian quality improvement framework, which alludes to structure, process and outcome (Donabedian cited in Botma & Labuschagne, 2017). The Donabedian framework was applied to categorise the major elements into structure/prerequisite attributes for peer support, systems and processes of implementing peer support and outcomes of peer support when guidelines are utilized. 152 Figure 6.1 illustrates the conceptual conclusion and how it links to the guidelines for peer support. 6.5 CONCLUSION FROM THE STUDY The study was conducted consequent upon the curriculum transformation to support the innovation in nursing education institutions in Lesotho. With the ending of the donor funding by NEPI and due to the lack of a deliberate plan for the ongoing support of educators, there was a threat to the implementation of the curriculum innovation. The successful implementation of the new curriculum demanded a new set of pedagogical skills of the educators as the key drivers of curriculum enactment. Although the implementation of the new curriculum was preceded by the initial professional development activities funded by NEPI, there was little thought about long-term support strategies for educators. Phase one of the implementation of a new curriculum in the midwifery programme exposed a high level of inadequate preparedness among educators (Botma & Nyoni, 2015). However, the early adopters from one institution naturally started providing unstructured support to colleagues without any official mandate or guidelines. Such unstructured peer support would be a challenge during the second phase of implementation in the nursing programme. The study sought to develop guidelines for peer support to bridge the gap and influence the implementation of the curriculum innovation in Lesotho. Multiple studies were conducted, which generated empirical and theoretical evidence to inform the guidelines development nested in the WHO Handbook for Guideline Development (WHO, 2014) as a framework. The studies adopted the interpretive paradigm and a relativist ontology, generating multiple realities relating to peer support (see Kivunja & Kuyini, 2017). 153 Prerequisite/structure for peer Process of implementing Outcome of an effective support strategy the peer support strategy peer support strategy Authentic and tailor-made Administrative commitment content and strategies Professional growth Moti vation for peer support Guiding sequence of activities Sustained innovation Environment conducive to peer Monitoring and evaluation supp ort Scholarship Clea r modus operandi Communication, sharing and Teamwork and community of feedback practice Vari ous attributes of educators Active engagement Improved curriculum implementation Exemplary practice Teamwork Guidelines for peer support FIGURE 6.1: The conceptual conclusion (Source: Author-generated) 154 Conducting this study revealed critical information related to peer support and the difference it makes during the change process, which cannot be ignored. This affordable intervention can promote professional growth and enhance self-efficacy among educators and may contribute to the sustainability of curriculum innovation in resource-limited countries such as Lesotho. One of the major threats to curriculum innovation is the inability to appropriately enact the curriculum (Botma, 2014b). Ongoing support for educators during curriculum change can cushion sceptical implementers, considering that the uptake and diffusion of change vary among different individuals (Rogers, 1983). Sahin (2006, citing Rogers, 2003), describes variations in the uptake of change, with the possibility of some early adopters assuming a leadership role and providing support to their peers during the introduction of an innovation within the community in which they function. Without ongoing support among educators, the fidelity of curriculum implementation may be unattainable (Melle et al., 2019). Educators implementing a curriculum change need ongoing professional development and support. Providing such continuous professional development can be costly, especially in resource-limited settings such as Lesotho. Structured peer support can be an affordable approach and therefore requires a framework or guidelines for effective implementation. Developing and implementing guidelines to inform contextualised strategies such as peer support are part of the solution for appropriate curriculum enactment. These developed guidelines to enhance peer support among nurse educators therefore contribute significant original knowledge and form part of the solution leading to sustained curriculum innovation. 6.6 RECOMMENDATIONS The following recommendations are made based on the findings from this study and are structured in terms of the stakeholders, namely the Lesotho Ministry of Health as the initiator of the curriculum transformation, nursing education institutional management as the custodians of the curriculum, nurse educators as the implementers and the research community. 155 Recommendations to government (Ministry of Health)  The government of Lesotho, through the Ministry of Health as the initiator of the curriculum transformation and source of funding, is obliged to take an oversight role of the funded projects to maintain its own credibility with funders/donors. Government needs to be committed to and accountable for the funded projects and ensure that they benefit the population.  The Ministry of Health ought to have a robust monitoring and evaluation mechanism to ensure the appropriate implementation of the innovation or intervention. This will ensure that challenges are identified early enough and appropriately addressed to avert the global waste of resources, such as expensive high-tech mannequins that lie unused due to lack of ongoing support.  Government needs to consider assigning the training of nurses to the Ministry of Education and Training, whose focus is the development of human resources. Having the education of healthcare professionals under the Ministry of Health may compromise the monitoring and evaluation of educational interventions. Recommendations to nursing education institutional management  The nursing education institutional management needs to buy-in and endorse the peer support strategy and the guidelines to enhance the implementation of the peer support and the curriculum innovation.  The institutional managers should be committed to the peer support strategy and allocate adequate resources for the activities related to peer support.  There is a need for monitoring and evaluation of the peer support strategy and the implementation of the curriculum to check progress, rectify shortcomings and reinforce the appropriate practices. 156  The institutional leaders need to have an ongoing professional development and support plan for the nurse educators during the curriculum innovation. Recommendations to nurse educators  The educators need to commit to the peer support intervention.  There is a need for educators to engage in continuous professional development. Recommendations to the research community  Further research is recommended to evaluate the effectiveness of the guidelines among educators during curriculum innovation in different institutions utilising the guidelines.  There is a need for research to assess the efficacy of the implementation of curriculum reforms funded by NEPI in African countries. The assumption is that funded projects in LMICs have limited sustainability when funding comes to an end. The question that arises is ‘how did other African nursing education institutions manage the curriculum reforms supported by NEPI after the funding came to an end?’ 6.7 CONTRIBUTIONS FROM THIS STUDY The study builds on the existing evidence advocating for ongoing support for educators during a curriculum change (Dath & Iobst, 2010; Harpe & Thomas, 2009). The literature search revealed limited evidence relating to guidelines for peer support during curriculum change. The researcher proposed and developed these practice guidelines, assuming that they will serve as a roadmap for peer support, while promoting appropriate curriculum enactment. 157 The different phases of this study made a significant original contribution to knowledge in nursing education in LMICs. The developed guidelines for peer support among nurse educators during curriculum innovation in Lesotho are a significant contribution to knowledge. The guidelines may be used by higher education institutions embarking on curriculum change and using peer support as an affordable ongoing support strategy. The developed guidelines are among the few guidelines developed using qualitative evidence as an upcoming practice (Lewin & Glenton, 2018; WHO, 2014). This study makes a significant original contribution to knowledge through the following:  Three articles were written, which addressed the gaps that were identified. There is little literature on peer support for professionals during change processes and this study contributes evidence towards the area of peer support.  Guidelines were developed that can be used in broader but similar contexts.  The developed guidelines are specific for the professionals engaged in curriculum innovation, and few guidelines for professionals during a change process exist.  The study highlighted the need for the Ministry of Health to oversee the continuation of funded projects.  The study further highlighted that the management of nursing education institutions have a responsibility to support nurse educators during curriculum innovation, and these guidelines are the tool that can be used for this.  A paper from one of the phases was presented at an international conference and emphasised the need for contextual support during the implementation of an innovation in education. 158 This study answered the research question articulated through the four research objectives. Each of the phases of the study has contributed to the existing body of knowledge, as shown in Table 6.2. 6.8 LIMITATIONS OF THIS STUDY  Most of the evidence used in the integrative review was on organisational experiences and limited empirical studies were found, which may affect the quality of the guidelines. This limitation was addressed through the use of validated critical appraisal tools.  The integrative review included only evidence from English sources and may have missed significant information in other languages.  The primary qualitative research design generated contextual evidence that informed the development of the guidelines and may have rendered the guidelines relevant to the Lesotho context. However, the rigorous processes, providing thick descriptions, make the guidelines transferable to LMIC contexts. The development processes based on the WHO handbook for Guideline Development included evidence from the integrative review and adhered to an extensive audit trail, thereby enhancing the transferability of the guidelines to other similar settings in LMICs. 159 TABLE 6.2: Contributions of the study Major step of the Research Research objective Manuscript Contribution WHO handbook design a. Describe existing peer Systematic Integrative Peer support This study synthesised and described support strategies that literature search review strategies that existing peer support strategies, enhance the enhance the highlighting the features of effective implementation of an implementation of an peer support strategies, possible innovation or new innovation among challenges and lessons learnt. programme among professionals (see professionals Chapter 2) b. Describe the Stakeholder Exploratory Peer support during The study brought to the fore experiences of involvement descriptive the implementation of experiences of nurse educators related educators regarding qualitative a new curriculum: to unstructured peer support. Benefits, peer support during study The experiences of limitations and challenges of the midwifery CBC nurse educators in unstructured support were highlighted. implementation in Lesotho (see Chapter Lesotho 3) c. Develop guidelines to Formulation of Discussion and Practice guidelines to Guidelines were developed for peer enhance peer support recommendations consensus enhance peer support, highlighting the prerequisites among educators during support among nurse and implications for each of the the implementation of educators during a recommendations included. the CBC in Lesotho curriculum innovation d. Validate the developed External review of Delphi survey (see Chapter 4) peer support guidelines the guidelines Source: Author-generated 160  The sample of participants for the qualitative study was only 12 which could be considered small; however, it included all the nurse educators who participated in the implementation of the new curriculum. Data saturation was reached. The next section presents the personal reflections of the researcher during the journey of working on this study. 6.9 PERSONAL REFLECTIONS This thesis and its related studies present an under-researched area of educator support during curriculum change. Conducting this study led me to the realisation that although considerable resources are invested in the development of and preparations for curriculum transformation, little is done to ensure ongoing support of educators for appropriate curriculum enactment, particularly in LMICs. There is limited or no accountability or monitoring and evaluation mechanisms put in place by governments and/or institutions to ensure the appropriate implementation of the curriculum change and support of the educators. Without the commitment to support and monitor curriculum implementation processes, such expensive innovations become a waste of resources. Ongoing support for educators during curriculum change is neglected, yet it is the key to the successful implementation of a new curriculum. Undertaking this study gave me the understanding that the strategies used in other change processes can be contextualised to provide tangible solutions for educators during curriculum change. While engaging in this study, I recognised that constructing new knowledge requires extended hours of iterative processes involving reading, writing, critical thinking, reflection, refining, generating evidence and developing a deeper understanding of the concepts under study. Conceptual and theoretical frameworks and paradigms become critical elements in providing guidance to the entire research study. The knowledge generated should be embedded in and congruent with the relevant frameworks and paradigm without deviating from the research question and the central argument of the 161 study. It is importance not to lose focus of the research question, as it remains the compass guiding all areas of the study. My experience in this journey made me realise that a doctoral study is a personal journey contributing to the scientific body of knowledge and academic growth. All the hard work should culminate in a solution to a problem through the contribution of knowledge, such as models, frameworks or guidelines informing practice. The invaluable support and encouragement from my promoter and experienced researchers and colleagues formed the scaffolds to lean on as I ventured into the uncharted waters of doctoral studies. The challenges and shortcomings along the journey helped me to go back to the drawing board, reflect and re-plan my actions, and contributed to my personal growth. Furthermore, the quality improvement mechanisms along the doctoral journey contributed to quality assurance and the credibility of the knowledge generated. I realised that paramount to the success of the entire journey, although difficult, were commitment, sacrifice, being organised and good time management. 6.10 CONCLUSION The discussion in this final chapter focused on the overview of the study, the research objectives, key findings related to each objective, the conclusions of the study and the recommendations. The contributions of this study, the study limitations and the researcher’s personal reflections on the journey were also highlighted. 162 6.11 COMPREHENSIVE REFERENCE LIST Author Guidelines. (2020). African Journal of Health Professions Education. 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International Journal of Financial Research, 9(2), 90–95. 172 ADDENDUM A Johns Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal Tool 173 174 175 176 177 178 179 ADDENDUM B CASP tool 180 181 182 183 184 185 ADDENDUM C Critical appraisal – Case study 186 187 ADDENDUM D JHNEBP evidence rating scale 188 189 ADDENDUM E Data extraction tool 190 191 192 ADDENDUM F Semi-structured interview 193 194 195 196 ADDENDUM G Information brochure – Qualitative study 197 198 199 ADDENDUM H Consent form 200 201 ADDENDUM I Interview transcript samples 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 ADDENDUM J Data coding sheet 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 ADDENDUM K Agree II tool 256 257 258 259 260 261 262 ADDENDUM L Delphi survey 263 264 265 266 ADDENDUM M Ethical approval - UFS 267 268 ADDENDUM N Ethical approval – Ministry of Health, Lesotho 269 270 ADDENDUM O Institutional permission sample 271 272 ADDENDUM P Author guidelines 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 ADDENDUM Q Author guidelines 290 291 292 293 294 295 296 297 298 299 300 301 ADDENDUM R Author guidelines 302 303 304 305 306 307 308 309 310 311 312 313 314 ADDENDUM S Summary Turnitin Report 315 316 317 318 319 320 321 322 323 324 325 326 327