Abstract
BACKGROUND: The importance of systems thinking in Health Systems Science is increasingly recognised, yet its integration into undergraduate medical education remains inconsistent. Evidence on the use of simulation games to promote experiential learning and systems thinking development during the preclinical phase is also limited. This study examined the effect of the simulation game Friday Night at the ER (FNER) on the development of systems thinking in preclinical medical students. The research questions focused on (1) What core systems thinking strategies affected team performance scores in the FNER game? (2) How were these strategies related to the Habits of a Systems Thinker framework? (3) What emotions and insights did students gain through the FNER game? METHODS: Following simulation-based experiential learning in a systems-focused curriculum, we analysed open-ended reflections from 22 preclinical medical students (mean age 24.3; 11 females, 11 males) using a hybrid qualitative content analysis. Strategy-related responses were examined through directed content analysis informed by two frameworks: core systems thinking strategies embedded in FNER and the Habits of a Systems Thinker, representing foundational Health Systems Science competencies. Emotional and insight-related reflections were analysed inductively to identify effective emergent themes. RESULTS: Students employed three key strategies—collaboration, data-driven decision-making, and innovation—during gameplay. High-performing teams demonstrated a more frequent and integrated use of these strategies, implicitly applying multiple habits of a systems thinker, such as Habit 1 (seeing the big picture), Habit 6 (changing perspectives), and Habit 11 (considering consequences). Low-performing teams, focused on individual tasks, failed to drive collaboration at the team and organisational levels, and remained stuck in linear thinking. Five effective themes emerged from students’ reflections: collaboration and teamwork, value-driven decision-making, innovation and change, patient-centred care, and indirect experience of hospital systems. CONCLUSIONS: FNER is an educational tool that promotes the use of role-play simulation games to teach systems thinking, a core linking domain in Health Systems Science. By fostering collaboration, innovation, and data-driven decision-making, the game helps preclinical medical students begin forming a professional identity as system-based practice physicians capable of navigating and improving complex healthcare systems. TRIAL REGISTRATION: Not applicable.