Abstract

Introduction
There is a growing imperative to integrate clinical reasoning (CR) training more centrally into medical school curricula. As a pedagogical tool that facilitates explicit CR teaching, high-fidelity simulation (HFS) is perhaps uniquely situated to meet this need. While barriers to CR for medical students on clinical placement are well-documented, a comprehensive understanding of barriers specific to HFS was previously lacking.

Methods
Fourth-year medical students at the University of Sunderland were purposively sampled. Data were gathered via semistructured videoconferencing interviews between April and May 2023. A reflexive, data-driven, inductive thematic analysis was undertaken, and a thematic framework was generated. Data collection ceased upon thematic saturation after 14 interviews.

Results
Barriers to CR during HFS were identified across student and simulation domains. Students reported barriers to (1) information synthesis—due to inadequate knowledge and difficulty interpreting clinical findings—and (2) engaging in metacognition—due to procedural rigidity, stress, and cognitive bias. Simulation-related barriers arose from (3) case design—including excessive case complexity and cognitive overload—and (4) the simulation environment—such as inadequate prebriefing, technological limitations, and overreliance on facilitators. Some findings, such as the impact of cognitive bias, align with existing literature on barriers to CR in other contexts. Others, including the limitations of technology, appear unique to the HFS setting.

Conclusions
Barriers to CR identified within this context contribute novel findings to the existing body of educational research. We advocate that educators should carefully consider these barriers when designing HFS sessions, and when optimizing students for learning through simulation, to enhance CR training.