Effects of reflection-through-action on collaborative clinical reasoning skills in an emergency dental simulation.

backgroundSimulation-based training is a central component of healthcare education. However, most current instructional designs emphasize post-simulation debriefing, while reflection during the simulation itself, termed reflection-through-action, remains understudied. Prior empirical evidence suggests that structured reflective pauses may enhance learners' metacognitive regulation and diagnostic and intervention clinical reasoning, though whether these learning gains transfer to subsequent, novel clinical scenarios is unknown. This study examined whether reflection-through-action during an initial emergency simulation enhances the translation of technical skills and collaborative clinical reasoning practices in a subsequent emergency simulation among dental students.

methodsIn this mixed-methods study, 110 dental students were randomized into teams and completed two sequential medical emergency simulations. Six experimental teams received structured reflection-through-action during the first simulation, consisting of a guided pause with written prompts and a structured PARSE (Pause-Analyze-Reflect-Strategize-Execute) debrief, while six control teams completed the simulation without reflective pauses. Outcomes accounted for prior knowledge and team familiarity and included expert-rated technical and non-technical performance, self-reported learning confidence, and behavioral process-level analyses using Epistemic Network Analysis (ENA) of team conversations during the second simulation.

resultsControlling for prior knowledge and team familiarity, no differences were seen in expert-rated technical or non-technical performance or in self-reported learning confidence between groups. However, ENA revealed important structural differences in the collaborative clinical reasoning displayed during the second simulation. Learners who engaged in reflective pauses demonstrated stronger connections between suggesting/requesting action, planning interventions, and intervening actions, indicating a greater connection between diagnostic reasoning and treatment management. In contrast, control teams showed weaker connections between planning and action, with conversations emphasizing procedural explanations, disconnected suggestions, and unfocused patient history questions.

conclusionA structured reflective pause did not produce immediate differences on traditional performance metrics but revealed meaningful changes in collaborative clinical reasoning including how teams organized diagnostic, planning, and action during a subsequent emergency simulation. These findings suggest that reflective pauses reshape the structure of a team's clinical reasoning and support near (contextually similar) and proximal (temporal) learning transfer. ENA offers a more sensitive and analytic approach than traditional performance-based outcomes for detecting differences in team-based collaborative clinical reasoning.