A scoping review was conducted according to Arksey and O’Malley’s six-stage framework for scoping reviews [14]. The review protocol has previously been published [15]. Our findings are presented in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [16].

To identify relevant literature for inclusion, eligibility criteria were applied as per the population, concept and context framework as well as the types of evidence and language [17].

Studies were selected based on those relating to peer or near-peer faculty within undergraduate healthcare education simulation. Simulation activity was defined as per the Healthcare Simulation Dictionary as ‘the entire set of actions and events from initiation to termination of an individual simulation event; in the learning setting, this is often considered to begin with the briefing (pre-briefing) and end with the debriefing’ [18]. As a result, we did not include studies of peer or near-peer faculty teaching clinical skills (for example, venous cannulation), as these did not typically involve a debrief and because this type of peer teaching has already been the subject of previous systematic reviews [4,9,10].

There were no limitations on the type of healthcare programme or types of simulation. Undergraduate healthcare education was defined as any pre-licensure healthcare programme including medical, nursing, dental or allied health professions students.

In this review, we defined ‘peer’ as someone of the same academic status in terms of year and discipline (e.g. medicine or physiotherapy) and ‘near-peer’ as those from the same background but one or two academic years apart [3]. Those from different disciplines, in the case of interdisciplinary programmes, but who are from the same or similar academic levels will also be referred to as ‘near-peer’ [19]. As per our protocol, we also included within our definition of ‘near-peer’ those within two years of certification/graduation, such as newly qualified doctors being faculty for senior medical students [15]. We purposefully refer to peer and near-peer ‘faculty’ to acknowledge that they are undertaking a formal, designated role as simulation practitioners. These may include technical personnel, simulated participants and educators as detailed in the ASPiH standards [12].

There was no restriction regarding the quality of the study since the aim of the scoping review was to understand the contexts and mechanisms by which peer and near-peer Faculty were trained, utilized and assessed. Our scoping review included any empirical primary research studies or other published academic work, both quantitative or qualitative research study designs or descriptive articles in peer-reviewed journals. This review included experimental and non-experimental designs describing peer-faculty use within undergraduate healthcare education. Review articles were excluded as primary evidence, although their reference list was checked for any relevant primary studies which would fit the inclusion criteria, and these were charted within the scoping review.

Articles were deemed eligible for inclusion if they explored any aspect of peer and near-peer Faculty involvement in undergraduate healthcare programme simulations.

This review only included articles available in English translations.

The search strategy was developed along with a research librarian and used Medical Subject Headings (MeSH) and keywords relating to simulation and peer or near-peer faculty within the titles, abstracts and index terms (see Supplementary Material for full description). A reference list search of review articles was carried out to identify any further studies not detected during the primary search [20].

Eight databases were searched: PubMed, PsychINFO, Embase, Scopus, Web of Science, CINAHL, ERIC and Google Scholar.

Identified citations were imported into the reference management software Rayyan (https://www.rayyan.ai). Any duplicates were removed. Titles and abstracts were screened by a first reviewer (ARM) against the inclusion and exclusion criteria. Following this stage, these selected publications were screened by full text by two researchers for inclusion, one consistent researcher (ARM) plus one other researcher (CB or RF). The researchers were blinded to each other’s decisions. Any exclusion reason was recorded. Any disagreement on article inclusion or exclusion, as indicated by the ‘conflict’ list from Rayyan, was resolved by discussion in the presence of a third reviewer. Any papers inaccessible were made available once corresponding authors were contacted through institutional access policies.

A standardized data extraction template was created, focusing on variables pertaining to the research questions including article data, variables relating to learners and faculty (both peer/near-peer faculty and other staff), simulation activities, peer faculty training and supervision and benefits and challenges associated with peer and near-peer faculty involvement (see Supplementary Material).

After data extraction and charting, the findings were synthesized to address the four key research questions. The roles of peer and near-peer faculty were analysed and presented both quantitatively and qualitatively through tables and narrative descriptions. A narrative synthesis was conducted to explore aspects of initial and ongoing training.

The methods used to assess the impact of peer and near-peer faculty were examined in relation to learners, Institutions and the peer/near-peer faculty themselves. A thematic approach was applied to summarize these evaluations across different SBE contexts.

Lastly, the available literature on ongoing competency assessment was synthesized and presented descriptively. Any gaps identified in the literature are highlighted as areas for future.

Knowledge users were engaged throughout the review process including a research librarian, a medical student with no prior formal simulation training (who was also a member of the core research team), a designer of a peer-faculty programme and a member of a student faculty programme. The research librarian and medical student were involved in the overall research strategy, protocol development as well as conducting the review. The medical student, programme designer and member of the student faculty programme were invited to comment on the final results, which informed this final manuscript.

All 38 included studies were published between 2005 and 2024, with the majority undertaken in the USA [21–33], Europe [34–48] and Australia [49–56], with the remainder in Canada [57], Singapore [58,59] and Saudi Arabia [60]. Most were published as full paper within peer-reviewed journals, although four were only available as abstracts or short educational reports [34,48,49,57].

Student learners were predominately medical [28,29,32,34,35,37,39–42,45,46,48,49,53,55,57,60] and nursing [21,22,24–27,30–33,36,43,44,46,47,50,58–60] students, with only eight studies involving other healthcare disciplines (physiotherapy [23,51,52,54,56], pharmacy [60], dentistry [60], radiography [46], biomedical [46] and paramedic [38,46]). The number of learners undertaking SBE in the included studies ranged from 3 to 637, while the number of peer- or near-peers in faculty roles ranged from 4 to 194, although this was not clearly stated in five studies [21,36,45,48,57].

Nineteen studies had peers within Faculty roles [21,24,27–30,33,36,38,40,41,43–45,47,50,55,56,60]. In the other 19 studies with near-peers acting as Faculty [22,23,25,26,31,32,34,35,37,42,46,48,49,51,52,54,57–59], most were undergraduate students from the same discipline, with the exception of two studies which included near-peers who were newly graduated doctors [34,35] and three studies which included interprofessional learners as near-peer Faculty [32,46,60].

Peers and near-peers undertook a range of Faculty roles within simulation, as shown in Table 1. In just over half of the included studies (21/38), students undertook more than one role. Furthermore, in studies where peer-to-peer learning was employed, students in several studies undertook alternating roles as a learner and as Faculty within the same simulation session [43,44,55].

In one study exploring the impact of a 7-week elective placement within a simulation department, students were encouraged to develop skills in scenario writing, delivery and debriefing and then help deliver SBE for both undergraduate and postgraduate students as part of the Faculty – however, there was no further detail of exactly which roles students took on within this team [49].

In studies involving the development, design or planning of simulation, students in all but one went on to deliver part of their self-designed simulation [60]. In some studies, peer and near-peer tutors who were observing or had taken on the role of a simulated patient or technical operations provided verbal feedback to learners following the simulation but in others, peer- or near-peers facilitated a learning conversation following the simulation which encouraged learner self-reflection [28,31–33,35,36,38,40,43,55].

The training provided for students undertaking roles within SBE was variable, as shown in Table 2. Often, the rationale, intended learning outcomes and time required to complete the training were not clearly described, particularly when peers/near-peers undertook multiple roles. Only two studies described designing training for near-peers with reference to ASiPH’s standards for Faculty development, while noting that these are not specific for students undertaking these roles [52,56]. Furthermore, studies described training for a role or roles within a specific simulation – none described training for peer- or near-peers to undertake Faculty roles in multiple different simulation sessions across a curriculum.

To support students to write realistic and achievable simulation scenarios, many had didactic teaching on fundamental principles of simulation design and were often provided with additional written resources, such as a scenario template and/or intended learning outcomes [30,35,41,43,44,52,56,60]. Where scenario development took place face-to-face, experienced Faculty were usually present to help guide and facilitate the session [35,44,60] and when done online, scenarios were submitted to Faculty for approval prior to piloting [30].

When acting as simulated patients, some students had dedicated training on how to realistically portray relevant signs or symptoms, with or without opportunities for rehearsal with Faculty feedback [24,52,54,56]. This included videos [52] and recorded patient interviews to help students understand patients’ lived experiences [56]. In other studies, students were simply provided with an outline of the scenario content and expected role [26,27], while in some, no training or preparation specifically for this role was described [21,23,37,50,55]. This was more common when peers/near-peers were taking on more than one role within the simulation.

To be able to use technologies within a simulation, students were often provided with a written [28], video [29,50] or hands-on introduction to the technology (e.g. manikin) [34,48], with some undertaking additional observation or rehearsal of the role as preparation prior to the simulation [25,36,57].

Training to help prepare students as facilitators ranged from peer-Faculty undertaking a formal instructor training course [37,41] to those who were simply provided with scenario information and intended learning outcomes with the expectation they undertake self-directed preparation in their own time [22,28,29]. Others had one or more face-to-face training sessions which included explicit instruction on communication skills and debriefing techniques [25,34,42,44,51,56]. Many had access to specific preparatory materials (such as e-learning modules or video tutorials) although the content and time needed to complete them (where stated) was highly variable [23,50,51,58,59]. Structured feedback or debriefing using a pre-defined template was common, particularly with peer-to-peer facilitators [28,31–33,35,36,38,40,43,55]. However, it was often unclear if students had any dedicated practice with Faculty feedback prior to undertaking the simulation.

When undertaking faculty roles within simulation, the supervision of peers and near-peers was also variable. In some studies, students were unsupervised [37], while in others, Faculty observed remotely [36], were present only to answer questions from student learners if required [28,43,57] or to troubleshoot technical issues with equipment [50]. In several studies, experienced Faculty were present throughout the simulation as observers [31,33,38,44] or as embedded healthcare professionals [35].

In two studies, experienced near-peer Faculty were involved in training and mentoring new students joining the faculty [41,57], while in one study, near-peer tutors were provided with daily performance feedback from supervising staff in addition to dedicated 1:1 mentorship with senior simulation Faculty [51]. Furthermore, two papers describing the same simulation event used a previously validated framework to provide feedback on debriefing ability to near-peer tutors [58,59]. However, in the majority of studies, there appeared to be no clear mechanism for providing feedback to peer or near-peer tutors.

Only one study described formal assessment of competence, with trained observers using the Objective Structured Assessment of Debriefing to evaluate peer-Faculty following interprofessional simulation [32]. However, the main aim of this study was to compare the efficacy of two feedback tools rather than as a way to support and develop a peers/near-peers in Faculty roles.

Ten studies described improvements in learners’ knowledge, skill and/or confidence following simulation through some form of pre and post-test [21,25,27,28,34,38,40,43,48,56,58]. Six studies directly compared outcomes from peer- and Faculty-led simulation. One study found students achieved higher clinical performance checklist scores when simulation was led by a senior student compared to staff Faculty [25], while in another, there was higher student-reported motivation and satisfaction with peer-led simulation compared to Faculty-led [23]. In the other four studies, there was no significant difference found across multiple domains (including clinical knowledge, non-technical skills, self-efficacy and reflection levels) when roles were undertaken by peer- or near-peer tutors compared to Faculty [21,28,38,40].

However, multiple studies used qualitative evaluation of surveys and/or focus groups and found that learners often perceived the environment in peer-led simulations as less intimidating, so they felt more comfortable making mistakes and asking questions [29,33,41,55]. Learners also viewed peers as relatable, credible and empathetic educators who understood their learning needs [52]. Perhaps for this reason, learners in several studies rated experiences of peer- and near-peer-led sessions as more engaging and enjoyable [21,22,37,50].

However, in two studies learners admitted they felt more anxious about being judged by their peers [47,52] and some felt their learning may be compromised by near-peers who were inexperienced [45] or provided feedback that was overly lenient compared to experienced Faculty [51,52].

Peer- and near-peer Faculty self-reported improvements in their teaching, mentoring and leadership skills, while noting that teaching in simulation also helped to consolidate their own knowledge [22,23,26,27,33,36,37,41,44,51,52,54,58,59]. In several studies, participation in Faculty roles within SBE was felt to enhance their professional development and in some cases, have a positive impact on their own clinical practice [21,22,42,49]. For example, in one study, nursing students noted direct transfer of leadership and communication skills from simulation to the clinical setting, reporting they felt less anxious about speaking up in team meetings or engaging in difficult communications after facilitating simulations [44]. In addition, peer-faculty reflected that both writing patient scripts and taking on the role of a simulated patient increased empathy through better understanding of the patients’ perspective and provided valuable insights which they felt would improve their future practice [43,54–56].

Peer-faculty were cognizant of providing a high-quality educational experience for their peers and generally found taking on this responsibility rewarding and enjoyable. This type of teaching experience was also viewed as valuable to their future careers and helped foster interest in medical education more broadly [34,49,52]. Two studies mentioned benefits-in-kind, such as course credit [25] or provision of a gift card [22]. In one study, students who undertook the role of simulated patient were able to count this towards their clinical practice hours [27] but in all others, peers/near-peers volunteered their time without specific benefit or renumeration.

However, some did share their anxiety about having the necessary skills and knowledge to undertake their role [47,58] although confidence in their abilities as peer- or near-peer tutors was found to improve with further experience over time [52]. Challenges arose when learners deviated significantly from what was anticipated within the scenario [55], when mentoring high-performing students [51] and navigating social dynamics when trying to provide constructive feedback without appearing judgemental, particularly to peers [30,35,47,51,52].

The perceived advantages of peer/near-peer Faculty at Institution-level were anecdotal, with few providing objective evidence. Several studies did estimate cost savings, which were usually based on either cost of Faculty time or expenditure for paid actors portraying simulated patients [24,31,38,51,52,56]. For example, one study projected that inclusion of near-peer Faculty, which allowed staff Faculty to supervise multiple simulation rooms simultaneously, equated to saving $2772 USD/semester (or $222,220 USD/year) based on Faculty supervising multiple rooms with student Faculty using 2014–2015 salary pay scales [25]. In three studies, experienced peer/near-peer Faculty were involved in training and mentoring new students joining the Faculty, which was felt to help promote programmatic sustainability [57].

One study highlighted that peer involvement allowed better utilization of their simulation facilities [37], although several others noted challenges around peer-tutor availability and ensuring adequate time and resources for training and supervision [31,35,52,55].