A randomized mixed-methods study published in Advances in Simulation indicates that structured reflective pauses during clinical simulation alter the structure of collaborative clinical reasoning among dental students, even when traditional performance metrics remain unchanged. The research, conducted at the University of Michigan School of Dentistry, examined whether reflection-through-action during an initial emergency simulation enhances the translation of technical skills and collaborative reasoning practices in a subsequent, novel emergency scenario. The findings suggest that while immediate observable performance scores did not differ between groups, the underlying cognitive and communicative processes of the teams were significantly reorganized by the intervention.
The study involved 110 second-year dental students who were randomly assigned to twelve teams of approximately nine members each. Six teams were designated as the experimental group, while six served as the control group. All participants completed two sequential medical emergency simulations: a respiratory scenario followed by a cardiovascular scenario. The primary focus of the analysis was on team performance during the second simulation, which served as a measure of near and proximal learning transfer from the first scenario to the second.
First, a ten-minute structured reflective pause was introduced at a critical juncture, following initial patient stabilization and before a subsequent aspiration event. During this pause, students individually recorded their clinical reasoning and anticipated complications on Post-it notes, then collaborated in pairs to synthesize their responses. Second, the experimental teams participated in a post-simulation debrief using the PARSE framework, which stands for Patient history/vitals, Anticipate risks, Recognize symptoms, Strategize prevention, and Execute response. The control groups completed the simulations without these reflective pauses and underwent a standard faculty-led debrief that did not utilize the PARSE framework.
To evaluate the impact of the intervention, the researchers employed a multi-faceted assessment strategy. Expert-rated technical and non-technical performance scores were assigned by two independent dental faculty members using a three-point scale. Additionally, students completed self-reported confidence questionnaires after the simulations. The most distinctive methodological tool was Epistemic Network Analysis (ENA), a statistical method that represents the temporal co-occurrence of coded behaviors in team conversations. ENA allows for the visualization of association structures between different types of clinical reasoning utterances, providing a granular view of how teams organize their diagnostic and intervention processes.
Baseline assessments revealed that the control and experimental groups had comparable levels of overall pre-clinical knowledge. However, the experimental group demonstrated slightly higher baseline knowledge specific to cardiovascular conditions. Team familiarity, measured using the Inclusion of Other in the Self Scale, showed no significant differences between the groups, with both entering the simulations with relatively low to moderate familiarity. These baseline characteristics were accounted for in the statistical analyses to ensure that observed differences could be attributed to the intervention rather than pre-existing disparities.
The results of the expert-rated performance measures showed no significant differences between the experimental and control groups. Both groups received similar scores for technical skills, such as medical history evaluation and patient management, as well as non-technical skills, including leadership, teamwork, and situational awareness. Similarly, self-reported confidence levels were uniformly high across both groups, with no statistically significant variation. These findings suggest that the reflective pauses did not produce immediate, measurable changes in the observable execution of clinical tasks or in students’ perceived self-efficacy as captured by standard survey instruments.
However, the Epistemic Network Analysis revealed significant structural differences in the collaborative clinical reasoning displayed during the second simulation. Teams in the experimental condition demonstrated stronger connections between suggesting or requesting action, planning interventions, and taking action. This indicates a more integrated process where diagnostic reasoning was directly coupled with treatment management. In contrast, the control teams showed weaker connections between planning and action, with their conversations emphasizing procedural explanations, disconnected suggestions, and unfocused patient history questions. The statistical analysis confirmed that these differences in network structure were significant, with the experimental group showing a distinct pattern of coordinated reasoning.
The discussion highlights that the PARSE framework functioned as intended by prompting teams to anticipate clinical risks and transition from information gathering to clinical planning and action. The ENA findings demonstrate that reflection-through-action does not merely increase the frequency of desirable behaviors but reshapes the overall structure of collaborative clinical reasoning. This structural change suggests that the intervention supports the formation of adaptive diagnostic and intervention processes, allowing teams to more effectively translate gathered information into directed decision-making under pressure.
The study also addresses the limitations of conventional simulation outcome measures. Expert-rated performance scores and self-reported confidence ratings tend to capture task completion and time to critical actions rather than the internal reasoning processes of teams. The authors note that these global measures may lack the granularity to detect subtle changes in collaborative reasoning, particularly when baseline performance is already high. ENA, by contrast, offers a more sensitive analytic approach for identifying differences in team-based collaborative clinical reasoning, revealing nuances that traditional scoring systems might miss.
Several limitations were acknowledged in the study. The small number of teams, totaling twelve, reduced statistical power and may have obscured some individual-level learning effects. Large team sizes also contributed to uneven verbal contributions, with quieter students less likely to articulate their reasoning. Additionally, the experimental group had slightly higher baseline cardiovascular knowledge, which could have influenced the magnitude of the observed network differences. Variability in instructor facilitation, despite the use of standardized guides, may have also introduced some inconsistency in how the simulations were conducted across different teams.
From an educational standpoint, the findings suggest that incorporating brief, structured reflective pauses into simulation-based curricula can enhance students’ ability to organize information and align team understanding. For dental trainees, who face infrequent but high-stakes emergency scenarios, such cognitive preparedness is essential for patient safety. The PARSE framework provides a practical, low-resource approach that can be integrated into existing curricula without extending total instructional time, offering a shared language for teams to make clinical reasoning visible and coachable.
The study contributes to the clinical simulation literature by highlighting the value of instructor-provided structured reflection-through-action as a mechanism for fostering collaborative diagnostic and intervention reasoning. While traditional outcome measures did not reveal significant differences, the ENA results show that reflective pauses are associated with more frequent connections between planning and action. This demonstrates a novel effect of reflective pauses in supporting the translation of diagnostic reasoning into intervention planning and execution, emphasizing the importance of examining not only how students perform, but how they think and reason while engaging in clinical scenarios.
Subject of Research: Effects of reflection-through-action on collaborative clinical reasoning skills in an emergency dental simulation
Article Title: Effects of reflection-through-action on collaborative clinical reasoning skills in an emergency dental simulation
Article References: Glowski, L., Grotewold, N., Tomaka, S., Danciu, T. E., & Popov, V. (2026). Effects of reflection-through-action on collaborative clinical reasoning skills in an emergency dental simulation. Advances in Simulation, 11(1), Article 78. https://doi.org/10.1186/s41077-026-00463-6
Image Credits: AI Generated
DOI: 10.1186/s41077-026-00463-6
Keywords: Effects, reflection-through-action, collaborative, clinical, reasoning, skills, emergency, dental, simulation, scientific research
News Source: Courtney Benton. (November 7, 2026). Reflective Pauses Reshape Dental Team Clinical Reasoning. Scienmag.
