Metacognition in clinical simulation: metacognitive events during briefing, simulated practice, and debriefing

ABSTRACT Introduction: Clinical simulation involves various cognitive and metacognitive processes. However, metacognition, although present, is often neither valued by educators nor recognized by students. Identifying and mastering metacognition transforms learning, enhances simulation performance, and improves the training of future physicians, making them better prepared for complex care scenarios. Objective: To identify, classify, and describe whether and how the metacognitive process occurs in clinical simulation. Method: This is an observational, longitudinal, descriptive, and qualitative study conducted with medical students in the state of Paraná, Brazil. Data collection involved 16 clinical simulations across two curricular units throughout the semester, resulting in a field diary. The diary was analyzed using theoretical metacognitive categories and the emergence of empirical categories. Results: The types of events identified were categorized into metacognitive knowledge (40.7%), metacognitive skills (30.3%), and metacognitive experiences (29%). Regarding subtypes of events, most occurrences were of task-type metacognitive knowledge (61.8%), especially during the simulated practice stage, highlighting intense retrieval of prior knowledge and the need for decision-making aligned with the objectives. For metacognitive skills, the most prevalent type of event was evaluation (45.7%), indicating a focus on selecting subsequent actions after clinical reasoning. In terms of metacognitive experiences, most events involved a sense of difficulty (71.5%), mainly during the debriefing stage, revealing low familiarity (3.9%) and confidence (14.7%). Conclusion: The study describes and measures the presence of metacognition across the three stages of clinical simulation. Furthermore, it analyzes how metacognitive events are influenced by external factors that promote the explicit manifestation of metacognition, particularly through participant discourse. The results highlight the central role of conflicts and leadership in the metacognitive dynamic, demonstrating how these factors shape interactions, self-regulation, and the development of metacognitive competencies in the simulation context. Thus, the study reinforces the importance of metacognition in enhancing learning through clinical simulation and provides insights for improving this educational strategy.