In the next decade, the nursing profession is projected to face an unprecedented workforce crisis, with estimates suggesting shortages exceeding 200,000 registered nurses by 2030 in the United States. This paper proposes a Collaborative Peer-Teaching Nursing Curriculum Framework (CPTNCF) that draws upon syntheses reporting moderate improvements in learning outcomes with peer-supported methods—for example, knowledge (~0.58), skills (~0.62), and attitudes (~0.71) in one nursing-focused review—while emphasizing that effects vary by context and outcome. Internal analyses indicate that some nursing programs can create workload demands approaching 94.8 hours weekly (preliminary), potentially leaving students with limited time for other essential activities. The framework outlines strategies to reduce instructor workload and enhance student engagement via structured collaborative learning, specifies a two-phase assessment architecture that distinguishes answering from understanding, and includes a pragmatic validation plan to evaluate impact in our local context.
Keywords: nursing education, peer teaching, collaborative learning, workload sustainability, student outcomes
In the coming years, the nursing profession is estimated to face an unprecedented workforce crisis, with projections suggesting potential shortages exceeding 200,000 registered nurses by 2030 in the United States (American Association of Colleges of Nursing, 2019; figures may differ in newer reports). Educational institutions have responded with various program structures aimed at addressing these shortages. However, recent analyses suggest that some programs may create intensive workload conditions, with certain students potentially facing substantial weekly academic demands that could limit time available for other essential activities (Moslow, 2025; internal preliminary analysis). Current approaches may not be optimally serving either student wellbeing or educational outcomes, suggesting a need for innovative pedagogical strategies.
Research indicates that collaborative peer-teaching approaches may offer benefits compared to traditional instructional methods in certain educational contexts. Meta-analytic evidence on peer assessment/peer-supported learning reports positive effects on learning outcomes and satisfaction, particularly where feedback is formative, though magnitude varies by design and outcome (Li et al., 2022). The protégé effect, wherein students who expect to teach others show enhanced learning and metacognitive organization, has been demonstrated in experimental work (Ten Cate & Durning, 2007; Nestojko et al., 2014).
This paper proposes a Collaborative Peer-Teaching Nursing Curriculum Framework (CPTNCF) to address workload sustainability while exploring evidence-informed pedagogical approaches that may enhance learning outcomes. The framework incorporates teach-back methodology—already a core clinical competency for patient education—creating alignment between educational processes and professional practice requirements.
The evidence supporting peer teaching in nursing education appears multifaceted, with various studies suggesting potential benefits across different learning domains. Studies indicate that peer teaching may support development of professional attitudes, confidence, and interpersonal skills. Implementation studies report possible improvements in examination performance and completion rates within structured peer learning programs. The theoretical foundation rests on documented learning principles including the protégé effect and teach-back methodology.
(For detailed literature review findings, please refer to Appendix A: Summary of Peer Teaching Literature in Nursing Education.)
The CPTNCF explores systematic restructuring of learning activities to address both pedagogical effectiveness and workload sustainability. The framework transforms portions of instructor-led delivery into structured peer teaching, while maintaining faculty oversight, formative feedback, and targeted expert interventions.
By redistributing routine content delivery to structured peer teaching, faculty can shift effort from repetitive lecturing and routine grading to high-impact activities (diagnostics, feedback, case design). In one single-site, mixed-methods study, faculty reported reduced grading time (~45%) and less redundant lecture preparation (~60%) after moving to facilitated peer learning; findings may reflect local conditions and require replication (Herrmann & Waterhouse, 2021).
| Activity | Traditional Model (hrs/week) | CPTNCF Model (hrs/week) | Time Change (– = less, + = more) | Reallocation Focus |
|---|---|---|---|---|
| Direct Lecture Delivery | 12–15 | 4–5 | –8 to –10 | Individual support |
| Routine Grading | 10–12 | 2–3 | –8 to –9 | Complex assessments |
| Preparation/Review | 8–10 | 3–4 | –5 to –6 | Innovation/research |
| Student Support | 3–4 | 8–10 | +5 to +6 | Enhanced mentoring |
| Total Weekly Hours | 33–41 | 17–22 | –16 to –19 | Quality improvement |
Note: Negative values indicate time reductions; positive values indicate time increases.
Students are organized into triads for balanced dynamics. Two rotation strategies are supported: Option A (rotate at midterm and final) preserves cohesion while adding exposure; Option B (rolling 4-week rotation) maximizes partner diversity at the cost of more frequent norm resets. For core clinical modules, Option A is recommended; Option B fits survey/content-heavy blocks.
| Student | Weeks 1–4 | Weeks 5–8 | Weeks 9–12 | Skills Developed |
|---|---|---|---|---|
| Student A | Teacher | Facilitator | Assessor | Complete skill set |
| Student B | Facilitator | Assessor | Teacher | Complete skill set |
| Student C | Assessor | Teacher | Facilitator | Complete skill set |
To ensure complete engagement and accountability in each role, students would complete weekly responsibility checklists that document their activities and contributions. These checklists serve multiple purposes: they provide clear expectations for each role, create a record of individual participation, and help faculty identify students who may be struggling with their responsibilities.
Students assigned to the Teacher role must complete three distinct phases of responsibilities throughout the week. During the preparation phase, which must be completed by Tuesday, the student teacher undertakes seven essential tasks. These include reviewing all instructor-provided materials including PowerPoints, readings, and supplementary resources; identifying and documenting three specific learning objectives that align with course outcomes; creating a teaching plan that synthesizes information into a 50-minute presentation; developing at least three check-for-understanding questions to assess peer learning; preparing one hands-on activity or case study that applies the concepts; submitting the teaching plan to group members for preview at least 24 hours before the session; and documenting preparation time spent, with an expected investment of 3-4 hours.
The delivery phase occurs during the Wednesday session and requires the teacher to arrive prepared with all materials organized and ready, deliver an opening overview stating the three learning objectives, present content using the assigned teaching method for the week, engage peers with interactive elements at least every 15 minutes, ask check-for-understanding questions and document responses, address peer questions and document areas needing clarification, and complete the session within the allocated time frame.
The reflection phase, completed by Thursday, involves five components: documenting what went well during the teaching session, identifying areas that need improvement for future teaching, noting concepts that peers found challenging, submitting the completed checklist to faculty via the learning management system, and responding to peer feedback within 24 hours.
The Facilitator role encompasses pre-session, during-session, and post-session responsibilities designed to ensure smooth group functioning and productive discussions. Pre-session responsibilities, completed by Tuesday, include contacting all group members to confirm session time and location, reviewing the Teacher's plan and providing constructive feedback, preparing backup questions to stimulate discussion if needed, ensuring all necessary resources and materials are available, creating a session agenda with time allocations for each segment, and setting up any required technology or room arrangements.
During the Wednesday session, the Facilitator must monitor time and provide gentle reminders to keep the session on track, ensure equal participation by inviting quieter members to contribute, redirect off-topic discussions back to learning objectives, take notes on key points and areas of confusion, mediate any disagreements using respectful communication techniques, and document the participation level of each group member.
Post-session responsibilities, completed by Thursday, require the Facilitator to compile and distribute session notes to all group members, schedule and facilitate a 15-minute debrief discussion, document any unresolved questions for instructor follow-up, complete a participation tracking form for each member, submit a group dynamics report noting any concerns, and coordinate next week's role transitions.
The Assessor role provides quality control and constructive feedback through three phases of structured activities. The preparation phase, completed by Tuesday, requires the Assessor to review the course-specific evaluation rubric thoroughly, familiarize themselves with the week's content expectations, prepare an observation form with specific criteria to monitor, review previous feedback given to identify improvement areas, and set up an anonymous peer feedback collection method.
During the Wednesday assessment phase, the Assessor must complete a detailed rubric evaluation during the teaching session, document specific examples of effective teaching strategies, note areas where content accuracy needs verification, track peer engagement and participation levels, record questions asked and quality of responses, and monitor time management and pacing.
The feedback phase, completed by Thursday, involves seven essential tasks: providing written feedback using the "sandwich" approach of positive-constructive-positive commentary, including at least three specific strengths observed, offering two to three concrete suggestions for improvement, verifying content accuracy with course materials and flagging any errors, submitting formal evaluation through the designated system, meeting with the Teacher for a 10-minute verbal feedback session, and completing anonymous ratings of group members' preparation and participation levels.
The framework suggests restructuring traditional three-hour class blocks into more dynamic learning sequences. The first hour would begin with forty minutes of focused instructor-led content delivery, where faculty present core concepts, clarify complex topics, and provide the foundation for peer teaching activities. This would be followed by twenty minutes dedicated to introducing group activities and ensuring students understand their assignments.
The second hour would consist of fifty minutes of peer teaching sessions, where students in their assigned roles present content to their triads. Faculty would circulate among groups, observing teaching quality and providing support as needed. The final ten minutes would allow groups to synthesize what they have learned and identify any remaining questions.
The third hour would include forty minutes of application activities, where groups work together on case studies, practice problems, or clinical scenarios that reinforce the material covered. The instructor would then spend twenty minutes conducting a whole-class debrief, addressing common misconceptions and highlighting key takeaways.
This structure maintains significant instructor involvement while increasing the time students spend actively engaged with the material. Faculty continue to create comprehensive learning materials, PowerPoints, and source documents that serve as the foundation for peer teaching. Student teachers must then synthesize these materials and present them in their own way, ensuring content accuracy while developing their teaching skills.
| Domain | Required Checks |
|---|---|
| Target | ☐ 3 learning objectives stated ☐ Aligned to blueprint ☐ Observable verbs |
| Explain | ☐ Plan uploaded ≥24h ☐ ≥3 concept links/diagrams ☐ No >5 min without active prompt |
| Assess | ☐ ≥3 CFU questions ☐ Misconceptions (≥2) documented ☐ One mini-application item |
| Clarify | ☐ Clarification notes posted ≤24h ☐ Sources ≤5y or justified |
| Handoff | ☐ 3 takeaways posted ☐ Next steps assigned |
| Artifacts | ☐ Slides or concept map ☐ CFU items ☐ Lesson plan ☐ Session notes |
| Time on Task | Prep 3–4h ☐ met ☐ short ☐ over Delivery 50m ☐ met Debrief 15m ☐ met |
Phase One locks an answer before Phase Two reveals rationale options. This sequencing reduces cueing from rationales to initial answers. (Accessibility accommodations allow moderated navigation as needed.)
| Pattern Category | Answer Correct | Rationale Correct | Interpretation | Recommended Intervention |
|---|---|---|---|---|
| Full Understanding | Yes | Yes | Deep comprehension | Advanced application |
| Surface Knowledge | Yes | No | Likely recall/guessing (provisional) | Mechanism-focused review |
| Concept Confusion | No | Yes | Application difficulty (provisional) | Guided practice scenarios |
| Needs Support | No | No | Comprehensive gaps | 1:1 triage + foundations |
| Trigger (rolling ≥20 items) | Action | Fidelity Check |
|---|---|---|
| Answer-Only ≥ 30% | Mechanism mini-module (20–30 min) + one coached think-aloud | Completion + 1 reassessment item |
| Rationale-Only ≥ 25% | Application practice set with scaffolds | Completion + 1 reassessment item |
| Both-Wrong ≥ 20% | 10-minute triage + foundation review pack | Coach note + reassessment |
| (Rationale% − Answer%) ≥ 30 pp | Guided item-review (verify understanding); no automatic penalty | Faculty sign-off |
To mitigate group-grade externalities, the group component is low-stakes (≤10%) with an individual floor.
| Component | Weight | Assessment Method | Frequency |
|---|---|---|---|
| Individual Performance (75%) | |||
| Weekly Micro-Quizzes | 20% | Two-phase sequential | Weekly |
| Module Exams | 35% | Two-phase sequential | Bi-weekly |
| Final Exam | 20% | Two-phase sequential | End of course |
| Group Performance (10%) | |||
| Teaching Quality | 7% | Rubric (faculty-calibrated) | Per session |
| Collective Outcomes | 3% | Group average with individual floor | Module |
| Participation & Development (15%) | |||
| Active Engagement | 8% | Observation/tracking | Continuous |
| Peer Feedback Quality | 4% | Checklist + samples | Weekly |
| Reflection Journals | 3% | Written submissions | Bi-weekly |
Safeguards. Individual floor = max(individual composite, group-adjusted). Peer-weighting may scale group contribution using normalized contribution indices; any weighting adjustments to peer assessments are reviewed by faculty before applying.
| Outcome | Bloom | Weeks | Two-phase Items | Rationale Type | Weight |
|---|---|---|---|---|---|
| Clinical reasoning (cardio) | Apply/Analyze | 2–4 | 12 | Mechanism-based | 40% |
| Foundational knowledge | Remember/Understand | 2–4 | 8 | Definition/criteria | 25% |
| Prioritization | Analyze | 3–4 | 6 | Trade-off justification | 20% |
| Patient education | Apply | 4 | 4 | Teach-back alignment | 15% |
Purpose. Validate that two-phase items measure understanding and that pattern interpretations hold locally.
Roles. Content leads (faculty) author items/rationales and sign-off on mechanism-based rationales for high-weight assessments; Assessment lead oversees item review, reliability, IRT, and DIF checks; Data/portal lead implements logging and dashboards and schedules analytic runs.
Instrumentation. Log answer, rationale, timestamps, and confidence; tag items with outcome, Bloom level, content area, and rationale type; maintain role/rotation metadata; log both initial and final answers if revisions are allowed, with timestamps.
Analyses (monthly, automated). Item p, point-biserial; ω ≥ .80 at module level; 2-PL/graded-response IRT on rationale choices; calibration (Brier, reliability diagram); DIF scans on answers and rationales; correlate patterns with transfer items and OSCE-style tasks. Mark interpretations provisional until supported.
Pilot comparison. Pilot vs. main class on equated blueprints; adjust for prior GPA/credits; collect exit interviews (confidence/perception). Log fidelity via TEACH tick-box.
Design. Concurrent comparison of pilot (CPTNCF) and main class sections. Primary outcome: module exam averages (common items); secondary: pattern metrics, confidence calibration, time-on-task. Qualitative: exit interviews on confidence and perceptions. Reporting: effect estimates with CIs and implementation fidelity.
The framework recognizes that successful implementation requires appropriate technological support. The primary platform for this framework is a custom-developed assessment and analytics dashboard that provides real-time pattern analysis and intervention capabilities. This platform serves as the central hub for all course activities, integrating with existing learning management systems while providing specialized features for the two-part assessment methodology.
The dashboard platform offers sequential assessment modules that enforce the two-part testing structure, real-time pattern detection algorithms identifying learning categories, automated flagging systems for at-risk students, performance correlation analytics comparing peer assessments with objective test results, comprehensive reporting tools for faculty and accreditation purposes, and student progress tracking with personalized learning recommendations.
All automated alerts remain advisory; any grade-impacting adjustments are faculty-reviewed rather than automatically applied.
The author has developed a specialized testing and analytics dashboard specifically designed to support the two-part sequential assessment system and pattern detection components of this framework. This platform provides comprehensive insights into student learning patterns, enabling early intervention and targeted support.
Key features of the dashboard include a Pattern Analysis Module that categorizes student responses into four learning patterns (Full Understanding, Surface Knowledge, Concept Confusion, Needs Support), Real-time Analytics allowing faculty to view class-wide and individual student performance as assessments are completed, Intervention Alerts providing automated flagging when students show concerning patterns such as high memorization indicators, Topic Performance Tracking with detailed analysis by subject area including diabetes, immunity, hematology, and hemodynamics, Metacognitive Insights analyzing student confidence levels, response times, and teaching readiness, and Export Capabilities providing one-click data export for reporting and research purposes.
The platform has been designed for easy integration with existing institutional systems while maintaining data security and FERPA compliance. Initial testing has shown promising results in identifying at-risk students early in the semester, allowing for timely intervention and support.
The framework's implementation begins with minimal but focused preparation during the first week. Faculty preparation requires only three hours total, consisting of a two-hour workshop where instructors review the standardized rubric, practice scoring one sample teaching session together, and discuss common challenges that may arise during implementation. This is followed by a one-hour technology orientation covering the dashboard platform and how to interpret pattern analysis reports. Faculty are provided with comprehensive support materials including a pre-written bank of two-part questions, the standardized rubric, and a quick reference guide for troubleshooting common issues.
Student orientation is similarly streamlined, requiring just two hours of initial training. The first hour focuses on TEACH protocol training, where students watch a demonstration video and practice in pairs using a provided script to ensure consistent understanding of expectations. This is followed by thirty minutes dedicated to understanding the two-part testing format through example questions that illustrate how the sequential assessment reveals true comprehension versus surface learning. The final thirty minutes are allocated for group formation activities, including signing group contracts, exchanging contact information, and scheduling the first meeting to establish accountability from the start.
During the active implementation phase, faculty commitment remains manageable at approximately two hours per week. This includes reviewing the dashboard analytics for thirty minutes, observing one peer teaching session for thirty minutes, and holding office hours for struggling groups for one hour. The dashboard's automated monitoring handles most quality control functions, flagging students who show concerning patterns and sending alerts when intervention is needed. Faculty intervene only when the system triggers specific alerts, preventing unnecessary micromanagement while ensuring timely support for students who need it.
The weekly student schedule follows a predictable rhythm that helps establish routine and reduces anxiety. Mondays involve receiving teaching assignments, giving students adequate preparation time. Wednesdays feature the fifty-minute peer teaching sessions where students execute their assigned roles. Fridays conclude with a twenty-minute two-part assessment that evaluates the week's learning. This consistent structure allows students to plan their other commitments around these fixed points while ensuring regular engagement with course material.
As the semester progresses into the optimization phase, faculty requirements decrease further to approximately one hour per month. This includes reviewing the monthly analytics report generated by the dashboard, adjusting rubric scoring if needed based on overall class performance patterns, and optionally sharing successful strategies at monthly faculty meetings. This minimal time commitment is sustainable long-term and allows faculty to focus on high-value activities rather than routine grading.
Student progression continues with weekly rotation through roles, maintaining engagement while building diverse skills. Top-performing groups may be invited to guest-teach struggling groups, creating peer mentorship opportunities that benefit both parties. The semester concludes with a brief ten-minute survey collecting student feedback for continuous improvement of the framework.
The framework's technology requirements leverage the custom dashboard platform while utilizing existing institutional resources wherever possible. Students use devices they already own—phones, tablets, or laptops—ensuring equitable access without additional financial burden. The total faculty time investment across the semester amounts to approximately twenty-five hours, compared to sixty or more hours required for traditional grading and instruction methods. This includes three hours of initial setup in week one, two hours per week during weeks two through eight for monitoring and support, and one hour monthly thereafter for optimization activities.
Support materials provided to faculty include a comprehensive question bank containing over two hundred pre-validated two-part questions, eliminating the need for faculty to create assessments from scratch. A video library of exemplary teaching examples helps both faculty and students understand expectations, while a troubleshooting guide addresses common issues before they require intervention. The dashboard automatically generates grade reports, ensuring consistent record-keeping without requiring specialized software knowledge.
The framework includes clear red flags that trigger mandatory intervention, streamlining faculty decision-making about when to engage. These include dashboard auto-flags for concerning assessment patterns, groups failing two consecutive assessments, student absence from their teaching role, or formal complaints being submitted. All other issues are handled through peer resolution processes or regular office hours, preventing faculty burnout from excessive intervention requirements while ensuring critical issues receive prompt attention.
Based on available research and initial testing of the dashboard platform, implementing this framework may lead to several positive academic outcomes. The pattern analysis capability enables early identification of students who are memorizing without understanding, allowing for targeted intervention before major assessments. Students engaged in peer teaching often demonstrate improved knowledge retention, as the act of teaching requires them to organize and articulate information in ways that strengthen their own understanding. Clinical competencies may be enhanced through repeated practice explaining and demonstrating skills to peers. The framework naturally develops communication and leadership abilities that are essential for professional nursing practice. Many studies report increased student engagement and satisfaction when collaborative learning methods are employed effectively.
The framework aims to create a more sustainable educational environment for both faculty and students. The redistribution of instructional responsibilities provides faculty with what Roughton (2013) describes as "pedagogical breathing room" - the cognitive and temporal space necessary for educational innovation and individualized student support. By reducing repetitive tasks, faculty can engage in what Schön (1983) termed "reflection-in-action," continuously improving their practice based on real-time observations of student learning facilitated by the dashboard analytics.
For students, the distribution of learning responsibilities across group members may reduce the individual burden of mastering all content independently. The flexibility to schedule peer teaching preparation around other commitments could help students manage their time more effectively. Perhaps most importantly, the built-in peer support system may reduce the stress and isolation that often accompany intensive nursing programs.
The framework directly supports development of skills essential for nursing practice. Through regular peer teaching, students develop patient education abilities that are fundamental to nursing care. They practice explaining complex medical information in accessible terms, checking for understanding, and adapting their communication style to different audiences. The experience of working in triads mirrors the interprofessional collaboration required in healthcare settings, where nurses must effectively communicate with diverse team members.
Leadership and mentoring competencies developed through the Teacher and Facilitator roles prepare students for future responsibilities as charge nurses, preceptors, and advanced practice nurses. The framework creates authentic opportunities to practice these skills in a supportive environment where mistakes become learning opportunities rather than patient safety risks.
The Collaborative Peer-Teaching Nursing Curriculum Framework represents an attempt to design an approach that may address contemporary challenges in nursing education. While research suggests potential benefits of peer teaching approaches, careful implementation and systematic evaluation will be necessary to determine effectiveness in specific institutional contexts. The framework seeks to maintain educational quality while exploring instructional practices that might better prepare students for the collaborative nature of modern healthcare.
Success would likely depend on comprehensive preparation, adequate support systems, and commitment to continuous improvement based on evidence. The framework intends to offer institutions a structured approach to exploring alternative pedagogical methods that aim to balance academic rigor with sustainable practices. Through careful pilot testing and systematic evaluation, schools could potentially determine whether this approach contributes meaningfully to addressing the complex challenges facing nursing education.
The framework's emphasis on authentic assessment through two-part sequential testing seeks to help ensure graduates possess not only factual knowledge but also the clinical reasoning capabilities that may be essential for safe nursing practice. By attempting to reveal the difference between memorization and understanding, this assessment approach aims to address longstanding concerns about surface learning that may fail to prepare students for the complex decisions required in clinical settings.
The integration of teach-back methodology throughout the curriculum intends to create natural alignment between how students learn and how they might educate patients in practice. This connection between educational process and professional responsibility could potentially help students develop stronger professional identities and better understand their role as educators within the healthcare team.
Perhaps most importantly, the framework seeks to reconceptualize nursing education as a collaborative endeavor rather than an individual struggle. By attempting to create structured opportunities for peer support and shared learning, it aims to acknowledge that nursing is fundamentally a team-based profession where success may depend on effective collaboration. Students who learn through teaching others could potentially develop not only content knowledge but also the communication, leadership, and mentoring skills that may distinguish excellent nurses.
As nursing education continues evolving to meet workforce demands and changing healthcare needs, frameworks like the CPTNCF may offer promising directions for innovation. While no single approach will solve all challenges facing nursing education, thoughtful integration of evidence-informed pedagogical strategies could potentially create learning environments that aim to be both rigorous and humane. The ultimate goal remains unchanged: preparing competent, caring nurses ready to meet the complex healthcare needs of diverse populations. This framework seeks to contribute to that goal while attempting to create a more sustainable and engaging educational experience for all participants.
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| Study | Design & Sample | Key Findings | Effect Size/Outcomes | Notes / Implications |
|---|---|---|---|---|
| Stone et al. (2013) | Systematic review/meta-analysis (n≈1,900 across 18 studies) | Improvements in knowledge, skills, attitudes; increased confidence | ~0.58 (knowledge), ~0.62 (skills), ~0.71 (attitudes) | Moderate effects; heterogeneity noted; supports peer components |
| Li et al. (2022) | Meta-analysis of peer assessment across disciplines | Positive effects on learning outcomes & satisfaction, stronger with formative feedback | Varies by design/outcome | Supports structured feedback within peer-supported learning |
| Freeman et al. (2014) | Meta-analysis of 225 STEM studies | Active learning reduced failure; increased exam performance | ~6% score gain; 33% lower failure | Justifies interactive components |
| Irvine et al. (2015) | Integrative review (nursing), multi-site reports | Near-peer teaching associated with better outcomes in several contexts | Mixed metrics | Supports role rotation and mentorship |
| Nestojko et al. (2014) | Randomized lab study | Expecting to teach improves learning organization & recall | d≈0.5–0.6 | Mechanism for teacher role benefits |
| Ha Dinh et al. (2016) | Systematic review (teach-back) | Improved adherence/self-management | OR≈1.8; RR≈0.71 | Supports teach-back alignment |
| Herrmann & Waterhouse (2021) | Mixed-methods, single site | Lower grading time; less prep redundancy | ~45% / ~60% | Feasibility evidence; site-specific |
Notes. Internal workload figure is preliminary (N, methods in on-file appendix). Effect sizes and outcomes vary across contexts; interpretations in the main text are provisional until validated against local transfer tasks and OSCE-style performance.