Course directors' reflections on educational design choices for incorporating near-peer teaching into clinical skills teaching.

Purpose: Near-peer teaching (NPT) is widely used to substitute faculty in undergraduate clinical skills training. However, little is known about which educational design choices are made when incorporating NPT, prompting the following research questions: What were course directors' design choices when incorporating near-peers into clinical skills courses? And, what were the reasons for these design choices?

Materials and methods: This descriptive qualitative study carried out 25 semi-structured interviews with course directors from 12 countries who had recently published on NPT, complemented by other, recognized NPT experts. Reflexive thematic analysis of the transcribed interviews combined inductive and deductive approaches. Cognitive Apprenticeship informed the deductive analysis.

Results: Course directors appointed near-peers to teach standardisable skills to small groups of beginners in courses without patients - complemented by faculty supervision. Some directors involved near-peers in co-designing education, co-assessments, or co-facilitating transition to clinical practice. Course directors justified their choices based on near-peers' limited content expertise, but also their adherence to teaching scripts, cognitive congruence with students, social proximity, digital/technical literacy and low costs.

Conclusions: Course directors' design choices were mainly inspired by working around near-peers' limitations. Some courses capitalised on near-peers' unique perspectives, extending near-peer roles to co-designing education and co-facilitating transitions to practice.