Enhancing Clinical Reasoning Skills through Structured Reflection Models


 Background:Clinical reasoning is an essential skill to all health care practitioners. McGlynn et al, 2015 mention that lower level of clinical reasoning skills are associated with higher rates of medical and diagnostic errors.. To enhance the clinical reasoning through reflection Hamad Medical Corporation (HMC) – Qatar established a new educational initiative under the title of reflective learning conversation and debriefing.Method:A prospective cross sectional exploratory of mixed methodology research conducted at Qatar- Hamad Medical Corporation (HMC) – In the critical care and trauma units. Anonymous self-reported questionnaires were collected from 236 critical care and trauma nurses who attended the reflective learning conversation and debriefing activities. Semi structured Interviews conducted for 10 nurses who facilitated the reflective learning conversation and debriefing activities. Content analysis and thematic analysis were applied.Results:Attending the reflective learning conversations and debriefing educational activities have a significant positive impact on the clinical reasoning skills of the critical care and trauma nurses. Moreover, attending the group level reflection, feeling threatened, are limitations and barriers for the reflective learning conversation and debriefing. Additionally, reflective practice can be encouraged and enhanced through; having reflective conversation and debriefing models and guidelines, and reflecting on both good and bad experiences.Conclusion:There is a positive correlation between the clinical reasoning and the structured reflections in the format of reflective learning conversation and debriefing. Reflective practice can be enhanced through attending the reflective learning conversation and debriefing activities. There are some limitations and challenges to the reflective learning conversation and debriefing method.


Background
Hamad medical corporation (HMC)-Qatar introduced a new educational method under the title of re ective learning conversation and debrie ng. That method was established to enhance the clinical reasoning and re ective practices of the critical care and trauma nurses. To explore this new educational method, explorative cross sectional mixed methodology research was conducted. A thorough literature review was established to formulate the research questions which are; What is the effect of the structured re ection models on the clinical reasoning skills of the critical care practitioners in critical care and trauma clinical settings?
What are the barriers and limitations of using structured re ection models to enhance clinical reasoning skills of the critical care practitioners in critical care and trauma clinical settings?
How the re ective practice can be encouraged and facilitated at the critical care and trauma clinical settings?
Re ection and health care education Merriam& Caffarella, 1991 discuss that re ection is a method to promote active learning, as learners become actively involved in higher order of thinking, and they need to use their skills to understand, analyse, articulate, and evaluate. This is achievable through having healthy purposeful 'learning conversations' which gives opportunities for learners to explore their values and to gain new evidence based learning. Forneris and Peden-McAlpine, 2006 support Merriam and propose that re ection enhances workers' critical thinking, creates healthy learning environments, and promotes collaborative learning. Koole et al, 2011 echoes previous studies that re ection on experience is essential to promote lifelong learning, and this also is supported by Lobol et al, 2013 who comments that re ective practice helps health practitioners to turn each experience to another learning experience as lifelong learning. Moon, 2007 nds that re ective practice enhances learning metacognition while Davies, 2012 comments that 're ective conversations enhance deep approach of learning, learner-centeredness, self-directed learning'. Herrington & Reeves 2012 suggest that re ective activities that integrate re ective conversations are essential to create authentic learning environments. Wells & Brook, 2014 and Herrington et al., 2014 discuss re ective approaches as an element to enhance authentic learning which enables learners to re ect through intentional learning Bonwell and Eison, 1991 mention that 'active learning and teaching strategies can be achieved through questions, re ective activities, and re ection on small group discussions '. Kolb (1994) support Bonwells' ndings and discusses the strategies for effective teaching and learning where one of those methods is re ective group discussions and dialogues. Schön, 1984 indicates that re ective learning discussions and debrie ng are tools to bridge the gap between theory and practice. Anseel et al., 2009 describe debrie ng as 'an effective learning method for learning-oriented tasks and active learning '. Dreifuerst, 2010, Burns, 2015, and Kuiper et al., 2008 concur with previous studies and suggest that structured debrie ngs as effective for method of learning and teaching. Prilla & Renner, 2014 indicate that debrie ng on face-to face approach is effective to enhance collaborative active learning.
Ryan, 2013 suggests that re ective learning and re ective learning conversations could enhance transformative learning. Ryan describe transformative learning as 'lifelong learning and to facilitate changes for improvement in critical review'. Ryan also indicates that, "In treating 'self' as a subject of critical study in relation to others and the contextual conditions of study or work, 'lifelong learning' can be fostered". KING,2005 comments on the transformative learning as "transformative learning is the process of meaning-making that adults navigate as they critically re ect on their values, beliefs, and assumptions and consider fundamentally new". Taylor & Hamdy, 2013 concur with King that there is an interchangeable relationship between critical re ection activities and transformative learning as themes and principles of transformative learning can be 'implemented and achieved through re ective learning activities, as re ective practice, re ective learning conversations, as well as, collaborative re ections'. Lobo1 et al., 2013 mention that re ection can be practiced in different forms both, written or verbal. Tan, Cashell & Bolderston, 2012 indicated that there are many ways to apply and practice re ective learning and this is achievable through re ective leaning dialogues, questions and debates The literature review reveals that the re ective conversations, debrie ng, and collaborative re ection have a positive impact on active learning, learner-centeredness, self-directed learning, transformative learning, lifelong learning, critical thinking, clinical reasoning , deep learning, collaborative learning, professional development, and learning and teaching effectiveness.
Re ection and clinical reasoning Scheffer & Rubenfeld, 2000 suggest that critical thinking and re ective skills are integral aspects of the clinical reasoning process where the critical re ective thinkers are con dent, creative, exible, and intuitive. Furthermore, re ective thinkers have advanced skills of analysing, applying, clinical judging, and transforming knowledge. Atkinson and Nixon-Cave, 2011 discuss that more emphasis is being placed on the process of clinical decision -making and re ection to enhance and improve the clinical reasoning skills. Mamede et al., 2014 agree with Atkinson and comments that structured re ection in the context of clinical reasoning has a focus on the problem-solving, analytical skills, and prioritising process. Guerrasio & Aagaard, 2014, Posel et al., 2014, and Chamberland et al., 2015 discuss that clinical reasoning can be optimised through remembering and facing patient encounters, re ective practice, and re ective learning conversations. These studies are supported by the study of Olle et al., 2018 who brings that, an effective clinical reasoning process should incorporate analytical re ective mental process. Razieh et al 2018., highlight that 're ection-structured re ection improves the clinical decision-making of the critical care nurses, and it should be integrated into all health care practices and nursing clinical teaching plans'. Schmidt and Mamede 2015 comments that 'deliberate re ection' as a tool for learning and teaching clinical reasoning skills for health care practitioners.
The current literature presents that the clinical reasoning skills have a dynamic and interactive relationship with the critical thinking and re ection process of the health care practitioners and it is recommended to incorporate the clinical reasoning into the structured re ective learning conversations Method This research adopted the pragmatic research paradigm for a prospective explorative cross sectional mixed methodology research which aims to answer three research questions: What is the effect of structured re ection models on the clinical reasoning skills of the critical care practitioners in critical care clinical settings?
What are the barriers and limitations of using structured re ection models to enhance clinical reasoning skills of the critical care practitioners in critical care clinical settings?
How re ective practice can be encouraged and facilitated at critical care clinical settings?
The nature of each research question was examined, and some of the questions have a qualitative nature and the others are qualitative in nature. To answer all research questions effectively, the pragmatic paradigm was adopted. Dudovskiy, 2016, &Kivunja andKuyini, 2017 discuss that pragmatic paradigm is an integration of the quantitative and qualitative methods as ''multistrand-conversion-concurrent design''. Shannon-Baker, 2016 mention that ''pragmatism breaks down the hierarchies between qualitative and quantitative ways of knowing in order to look at what is meaningful from both''. Additionally, Morgan, 2007 discusses that pragmatism reduces the dissociation between ''complete objectivity'' and ''complete subjectivity'' which acts as complementarity joint format.

Data collection methods:
In this research two data collection strategies were applied. The rst data collection strategy is a survey questionnaire, and the second is a focus group interview. The questionnaire strategy was selected as this research uses a mixed methodology, and the literature re ects that the survey questionnaire is an appropriate data collection strategy for the mixed methodology design with large research sample size. Kivunja and Kuyini, 2017, Shannon-Baker, 2016, and Dudovskiy, 2016 discuss that the questionnaire/survey is a suitable strategy to obtain data for both quantitative and qualitative researches. However, it is chie y quantitative.
Self-reported questionnaire was designed, and then reliability and validity were tested. The questionnaires were completed by 236 critical care nurses at Hamad Medical Corporation HMC /Medical Critical Care and Trauma Critical Care Units. Information sheet, participant's rights, and ethical approval letters have been provided to all research participants. A hard copy of the questionnaire was given to the participants, who achieved the inclusive criteria, and two weeks duration was given to complete the questionnaire. Participants were asked to put the completed questionnaires anonymously inside a monitored and secured sealed research box which is available inside each unit.
The second data collection strategy was the focus group interview. This strategy was selected because it is appropriate strategy for the mixed methodology research designs.. Moreover, this strategy is appropriate to get data from small research sample size. Abdul Rahman et al, 2018 andFlynn andKorcuska, 2018 discuss that focus group method is an appropriate strategy to be used in the mixed methodology researches and pragmatic paradigms. That was supported by Kivunja and Kuyini, 2017, Shannon-Baker, 2016, and Dudovskiy, 2016 comment that focus group is a suitable strategy to obtain data for qualitative research and for mixed methodology, and to get data from small number of participants.
The focus group sample of this study was the re ective learning facilitators who exposed to facilitate the re ective learning conversation and debrie ng sessions, and who are working in Medical ICU and Trauma ICU, and who have facilitated at least 10 re ective sessions to ensure having satisfactory exposure level. Semi structured interview was conducted for a total of 10 facilitators, and the interview process was stopped when we reached the data saturation level.

Questionnaire design
To my knowledge, this is the rst study to report the validity and reliability testing of a questionnaire to assess structured re ective models effect on clinical reasoning skills in critical care clinical settings. The questionnaire was designed based on a thorough literature review. A total of (236) critical care nurse out of (300) nurses completed the questionnaires with response rate of 79%. The questionnaire validity and reliability were tested and assured. The questionnaire validity and reliability were tested through piloting the questionnaire to 20% of the sample size.
The rst questionnaire considered the demographic questions about; (gender, work experience in critical care, times of attending re ective learning conversation and debrie ng activities, attending re ective sessions as facilitator, and times of being re ective session facilitator), and these were added to questionnaire to understand the in uence of them on the study results.
The second questionnaire section was designed as 22 questions which were sub-scaled into four dimensions: (impact of structured re ection models on clinical reasoning, bene ts of attending structured re ection models, barriers of attending structured re ection models, and enhancement methods of re ective learning conversation and clinical reasoning skills). Each item was scored from1-5 based on a ve-point of Likert's scale (Strongly disagree=1, disagree=2, neutral=3, agree=4 and strongly agree=5).However, there were four negatively worded sentences which were scored inversely, and the presence of these negatively worded was made intentionally to strength the questionnaire and to enhance the reliability and validity levels.

Questionnaire validity
Based on the studies by Wong et al, 2012, Norland-Tilburg, 1990, and Sangoseni et al., 2013, Hosseini et al., 2015 Ayre and Scally, 2014, face validity, theoretical construct, and content validity were assessed by eight educationalists (experts) who are working at Hamad Medical Corporation/ QATAR as educational planners and curriculum designers. The questionnaire face validity was tested by those experts by writing down their comments about items; placement, scaling, ow of information, and grammatical structure. Moreover, the content validity was assessed by those experts by reviewing the questionnaire, and to assess (relevancy, clarity, simplicity, and necessity) of each item, and content validity ratio (CVR) and index (CVI) were calculated for all questions and to exclude any unnecessary questions. Refer to appendix (12.1) and (12.12). Based on Hosseini et al, 2015 the expert review was categorised as (essential, useful but not essential, not essential), and calculated based on the following formula: CVR= Number of experts who choose "essential -Total number of experts/2 Total number of experts /2 To decide on minimum acceptable CVR value a study by Ayre and Scally, 2014 found that for a panel of eight experts CVR should be a minimum of 0.75. Refer to appendix (12.2). Furthermore, Content Validity Index (CVI) was used based on Waltz, Bausell, 1981, andPlichta andKelvin, 2012 recommendations. In content validity index, each statement was scored based on four point ranking scale in the eld of relevancy, simplicity and clarity as;(1= irrelevant, 2= relatively relevant, 3= relevant and 4= highly relevant), and CVI was calculated by the following formula, CVI= Number of experts who give 3 or 4 to / Total number of experts, and according to Plichta and Kelvin, 2012 CVI value of equal or more than 0.79 is acceptable. Refer to appendix (12.2).

Questionnaire reliability
Daly and Bourke.2000 de ned reliability as "the extent to which measurements can be replicated". In this study the questionnaire reliability process was achieved in different statistical measurements which are: internal consistency reliability which was measured by Cronbach' alpha, test-retest reliability which was measured by Pearson's correlation, and interrater reliability analyses which was measured by intra-class correlation coe cient (ICC).
McIntire, Miller 1999 found that reliability of Cronbach alpha is an appropriate test of internal consistency for research questionnaire with multiple dimensions, and that is applied for the questionnaire of this study. McIntire, Miller 1999 reported that Cronbach's alpha must be 0.70-0.80 for adequate and good internal consistency.
The second reliability test was the correlation test-retest (Pearson's test) as McIntire and Miller 1999 commented that testretest reliability involves administering the same measure to the same group of test-takers under the same conditions on two different occasions and correlating the scores , a Pearson's is a test-retest for correlation . Koo and Li, 2016 reported that test retest is valid test for self-report survey instruments. Hogan, 2007 found that the value for a Pearson's coe cient(r) value can fall between 0.00 which re ects (no correlation), and 1.00 which re ects a (perfect correlation).
Rreliability tests were started by piloting 20% of total research questionnaires. The piloting reliability tests were successful by passing the minimum values to con rm adequate level of reliability. Moreover, the nal reliability tests for all collected questionnaires were calculated, and there was a signi cant improvement at reliability values, and that improvement was achieved because of higher number of questionnaire involvement, and details of reliability tests will be discussed later in this article.

Focus group method
Based on literature search, reviewing the ndings from existing literature and highlighting any gaps in the current research, a nine semi-structured interview questions were developed and focus group interviews were applied for two groups of ve re ective learning and debrie ng facilitators. Moreover, the focus group interview questions were reviewed and assessed by eight expert educationalists who are working at Hamad Medical Corporation/ QATAR as educational planners and curriculum designers. Refer to attached appendix (12.11) Focus group research information sheet, participant's rights, and ethical approval letters have been provided to all research interviewees, and expert educator was invited to moderate the interview process. The interviews were stopped when data saturation level achieved and that was with second focus group as no new information obtained and repetition of information observed. Focus group data were audio recorded and saved in principal investigator computer as password protected. Transcripts were reviewed and checked by the participants, and a quotation process for each participant was applied. Transcript of interviews initiated and thematic coding approach achieved by cutting and sorting, and words repetition techniques. Themes and subthemes were derived, and details of this will be discussed in data analysis chapter.

Results
Focus group themes and questionnaire subscales As table (1) shows four themes were derived from the focus group data which were: Relationship between re ective learning conversation and clinical reasoning skills Bene ts of attending re ective learning conversation and debrie ng, Barriers of attending re ective learning conversation and debrie ng, Enhancing re ective learning conversation and debrie ng.
The rst theme was sub-themed into two elements; re ective learning as effective learning and teaching method, how re ective learning conversations can enhance the critical care nurses clinical reasoning skills. The second theme was subthemed to three elements; professional development, evidence based practice, and clinical skills. The third theme was sub-themed to three elements; environmental, psychological, and technical barriers. The fourth theme was sub-themed to four elements; structured versus non structured re ection, re ection on bad versus good experiences, re ective conversation timing, and enhancing the facilitator role. Questionnaire demographic data analysis The demographic data in the survey includes the (gender, work experience in critical care, times of attending re ective learning conversation and debrie ng activities, attending re ective sessions as facilitator, and times of being re ective session facilitator), and this kind of data help to assess whether there is a difference in understanding between different groups of participants (based on their demographic data) and this may in uence or cause variations in the results of the survey.
Demographic analysis shows that study sample has good distribution between males and females with percentage of 40% and 60% respectively. (Figure, 1) 30% of study sample were juniors critical care nurses while 65% were seniors and this could help to know the point of view for junior and senior nurses about re ective activities. See gure (2) 70 % of critical care practitioners attended 5-10 times re ective learning conversation and debrie ng sessions which re ects a good exposure level to re ective leaning process, and this could enrich the study data and validity of obtained As discussed previously reliability was tested by Cronbach alpha, intra-class correlation ICC, and Persons correlation.
Moreover, validity was tested by face and content validity which achieved by calculating CVR, CVI. The rst study subscale of this study is; impact of structured re ective learning conversation and debrie ng on clinical reasoning skills, and this subscale has two variables as the table below shows: As the above table of (Domain-subscale1) shows for sample size (n) =236 the overall item mean (M) = 4.356 and Std. Deviation = 0.596. Additionally, the mean and standard deviation for the two subscale variables are almost similar with no signi cant differences as for the variable of "attending re ective learning conversation and debrie ng activities impacted positively on my clinical reasoning skills", the ( M=4.3686; Std = 0.617), and for the variable of "Frequent and continuous attendance of re ective learning conversation and debrie ng activities is important to enhance my clinical reasoning skills" where the ( M=4.3559; Std = .65266) and these scores re ect that both variables clustered closely around the overall mean (M=4.3686) and this gives evidence that the mean is representative for both variables of (Domain-subscale1). Refer to table 2& 3 On the other hand there is a high percentage of participant's agreement that re ective learning conversation and debrie ng activities have a positive impact on critical care nurse's clinical reasoning skills and the agreement percentage ranges between (98% -99%) which represents the (agree-strongly agree) questionnaire category, and this agreement re ects a real participant's experience and understanding as they are regularly attending the re ective leaning conversations and debrie ng activities. Refer to table 2& 3 Moving to the focus group ndings which they show a signi cant alignment and correlation with the questionnaire data analysis ndings which revealed that all interviewees agreed on the effectiveness of re ective learning conversations and debrie ng as learning and teaching method, in addition to the positive impact of re ective learning conversations on clinical reasoning skills of critical care nurses.p3-"yes it will enhance clinical reasoning skills as each staff will learn from colleagues, it will also create wide circle of exposure to everyone, as if I have situation it will help my colleagues". p5-"yes its very effective method of learning and teaching, especially to primary staff who are involved in direct patient care". p10-"Yes, It improves clinical practice, nurse's knowledge, critical thinking and reasoning, and ultimately patient's outcome".
In summary, the questionnaire and focus groups data reveal that frequent attendance of structured re ective learning conversations and debrie ng activities have a signi cant positive impact on clinical reasoning skills of critical care nurses.
Questionnaire subscale-Domain 2; (bene ts of attending structured re ective learning conversation and debrie ng activities) ( For all the variables of (Domain-subscale 2) the CVR=0.1, and CVI=0.1which re ects that subscale 2 is valid. Moreover, the ve item Likert scale shows adequate internal reliability with a Cronbach's coe cient alpha of α= 0.891. Furthermore, ICC = 0.892 with 95% con dent interval = 0.867-0.913 also re ects good level of reliability. The r=.0672, n = 236, and p value=.000 shows that there is signi cant positive strong correlation between the four subscale variables and the correlation ratio is 67.2%. Refer to table 4&5 The above table of (Domain-subscale 2) shows for n=236 the overall item mean is (4.383) and Std. Deviation is (0.560) and the mean and standard deviation for all variables are almost similar with no signi cant differences which re ects mean is representative for all variables of (Domain-subscale 2). Refer to table 4&5 There is a high percentage of participant's agreement that attending structured re ective learning conversation and debrie ng is bene cial to; improve critical care nurse's competence level (98) %, encourage professional development (97%), enhance critical care health care practitioner's lifelong learning (98%), and improve evidence based practices in critical care clinical settings of tertiary hospitals (99%). The agreement percentage ranges between (97% -99%) for all (Domain-subscale 2) variables which represents (Agree-strongly agree) category. Refer to table 4&5 Moving to focus group interviews which signi cantly support the quantitative data ndings as the interviewees agreed that attending re ective learning conversation and debrie ng activities enhances competence level (clinical skills), professional development, and evidence based practice) . p 2; "it will encourage nurses to improve clinical practices as we make them more empowered". P 1; "I found it very e cient to improve or change skill, practice or even attitude" .p 3; "it's done in clinical setting which is good to learn because evidence based support that any teaching bedside is highly effective". P6; "Yes, It helps in professional development and improves reasoning skills". Refer to appendix (12.3 and 12.4).
In summary, there is a general agreement between the questionnaire and focus group ndings that attending structured re ective learning conversation and debrie ng is bene cial to; improve critical care nurse's competence level and professional development, in addition that attending structured re ective learning conversation and debrie ng bene ts critical care health care practitioner's lifelong learning, and evidence based practices.
Questionnaire subscale-Domain 3 (Enhancement of structured re ective learning conversation and debrie ng method) For the variables of (Domain-Subscale 3) the CVR=0.1 and CVI=0.1except variables number 1 as the CVR=.75 and CVI =.88.However, these values were at acceptable validity level as it has been discussed in validity section of this chapter, and the overall outcome for all variables reveals adequate validity level. Refer to table 6 Moreover, the ve item scale shows adequate internal reliability with a Cronbach's coe cient alpha of α= 0.783.
Furthermore, ICC = 0.736 with 95% con dent interval = 0.683-0.783 also re ects good level of reliability. The r=0.231, n = 236, and p value in range of 000-0.5 shows that there is weak correlation between the twelve subscale variables and the correlation ratio is 23.1%. However, as explained previously the justi cation for this poor correlation is having opposite meaning questions which are not negatively worded and those variables are; number 3 and 6 which are correlated negatively with opposite variables number 2 and 5and if we consider variable 3 and 6 the correlation jumps signi cantly and this does not re ect any negative effect on the research results, credibility, validity, and reliability. Refer to table 6 &7 Furthermore, for n=236 the overall item mean is (3.966) and Std. Deviation is (0.860).However, the mean and standard deviation for variables 3 and 6 are signi cantly different from other variables and this re ects that mean is representative for all variables except variables 3 and 6. Refer to table 7 Moreover, there is a high percentage of participant's agreement that re ective learning conversation and debrie ng can be enhanced by; having protocols and guidelines as structured re ection process (98%), re ecting on both good and bad experiences (90%), having re ective sessions for less than one hour (84%), having deep re ections (94%), and nally having re ective session moderator with high level of knowledge and skills in addition to leadership skills (94%). The agreement percentage ranges between (81% -98%) for all subscale variables which represents (Agree-strongly agree) category except for variables number 3 and 6 as these questionnaire variables were designed intentionally by having opposite meaning questions but not negatively worded sentences, and this questionnaire design aims tracking participant's bias factors such as; blind ling up the questionnaires. Refer to table 7 Moving to focus group ndings which reveal that most of interviewees agreed that re ective learning conversation and debrie ng can be enhanced by having protocols and guidelines and structured re ection process.p8-"There is need to have standardized ideas, protocol or model". p2-"yes we need structured model". p6-"There should be structured process, for effective learning there should be re ective model". P9-"structured model is important as it will help to organize and coordinate the class and for better understanding of attendees.". Refer to appendix (12.3 and 12.4).
Moreover, there was general focus group agreement that re ecting is preferable on both good and bad experiences, p2-"yes, I do agree it could be for successful and failed experience, if successful it will bring something new to gain change in clinical practices and by failure experience we will know where is a de cit". p3-"It is not matter of experience whether it is successful or failure, we need to focus on failure cases, nd out the reasons behind it and make it successful". p4-"Yes, successful events are motivation and good learning experience for staffs. And bad experiences can help in understanding the mistakes and to do necessary corrections. Refer to appendix (12.3 and 12.4).
Furthermore, deciding on re ective session timing should be based on situation and discussion case with a range of exibility". "p4-I think sometimes from 15-30 minutes and sometimes the situation will take more than one hour especially if we have a lot of participants". P3-" it should be variable". "p2-I would like to be with no limit, to be open discussion and participants will give their review, so it might take more time". P8-"it should be for maximum 45 minutes to seek the attention of participants". p9-"One hour to 90 minutes, rst one hour to discuss about the incidence, and remaining 30 minutes for discussion". P10-"Re ective learning and debrie ng session should be for less than one hour, including debrie ng time of ve to ten minutes". Refer to appendix (12.3 and 12.4).
Finally, there is a general focus group agreement on importance of having re ective session moderator with high level of knowledge and skills and leadership ability. p4-"yes, facilitator should lead discussion and share any information with participants".p5-"Yes, we need facilitator, so if facilitator is highly knowledgeable we will be able to get the most out of staff". p3-"Yes, facilitator has crucial role in controlling according to guidelines to learn staff". p9-"Yes, Facilitator helps in coordinating the session and in debrie ng". p4-"facilitator Feedback is important if we use in the closure and summary". Refer to appendix (12.3 and 12.4).
In summary, there is a general agreement between the questionnaire and focus group ndings that re ective learning conversation and debrie ng can be enhanced by; having protocols and guidelines as structured re ection process, re ecting on both good and bad experiences, having re ective sessions for less than one hour, having deep re ections, and nally having re ective session moderator with high level of knowledge and skills in addition to leadership skills Questionnaire Subscale-Domain 4; (Barriers of structured re ective learning conversation and debrie ng activities) Moreover, the inversed ve item Likert scale shows adequate internal consistency reliability with a Cronbach's coe cient alpha of α= 0.750. Furthermore, ICC = 0.747 with 95% con dent interval = 0.690-0.796 also re ects a good level of reliability. The r=.429, n = 236, and p value=.000 shows that there is a moderate positive correlation between the four variables of (Domain-subscale 4), and the correlation ratio is 42.9%. Refer to table 8& 9.
For n=236 the overall item mean is (3.179) and Std. Deviation is (1.240), and the mean and standard deviation for all variables are almost similar and this brings reasonable evidence that mean is representative for all variables of (Domainsubscale 4). Refer to table 9.
The descriptive analysis shows that 55% of the participants disagree that group re ective activities are preferred over individual re ective activities and that was very surprising and unexpected. However, the agreement percentage was 55%, and the remaining opposite percentage was 45% which is signi cant to think about the reason by conducting other studies. Furthermore, 60 % disagrees -strongly disagrees that re ective learning conversation and debrie ng activities are time consuming, and 70 % disagrees -strongly disagrees that they feel threatened and shamed while attending re ective learning conversation and debrie ng sessions, and this also was surprising and unexpected ndings. Refer to table 9.
80% of Focus group participants argue the questionnaire ndings and reveal that feeling shy, threatened, attending group re ections, and time restriction are barriers for effective re ective learning conversation and debrie ng. P2-"If you would like to re ect on failure, nurse will feel shy or afraid to come up with failure experience, and we need to encourage them to share experience". p4-"feeling shame, culture, judgement is a barrier". p3-"People are shy to express their negative experiences". However, we should consider that 100% of the focus group interviewees had the experience of being re ective conversation moderators in compare to the questionnaire participants, as 20% of them had the chance to be a re ective facilitator, and this raises a concern on how seniority level and being re ective facilitator could affect the view and perception on barriers of re ective learning and debrie ng, and this brings a need for separate study on seniority level and perception of barriers of re ective learning and debrie ng. Refer to appendix (12.3 and 12.4).
In summary, the questionnaire ndings reveal that attending group level re ection is a barrier against effective re ective learning and debrie ng with a border line agreement with a percentage of 55%.Moreover, the questionnaire partially supports that feeling shy is a barrier for effective re ective learning conversation and debrie ng in critical care clinical settings with an agreement percentage of 28%. Moreover, feeling threatened as barrier had an agreement percentage of 30%. And nally, time restriction issues as barrier had an agreement percentage of 41%. In contrary, the focus group ndings reveal that feeling shame, threatened, attending group level re ections, and time restrictions are barriers for effective re ective learning conversation and debrie ng in critical care clinical settings, and this disagreement between the focus group and the questionnaire ndings brings a need to recommend further studies on barriers of re ective learning conversation and debrie ng in critical care clinical settings.

Discussion And Conclusion
The results show that the questionnaire and focus groups of enhancing clinical reasoning skills through structured re ection models have signi cant level of validity and reliability. This study was able to answer the rst research question; "What is the effect of structured re ection models on the clinical reasoning skills of the critical care practitioners in critical care clinical settings?" and both focus group and questionnaire ndings revealed that attending the structured re ective learning conversations and debrie ng and frequent attendance have a signi cant positive impact on enhancing clinical reasoning skills of the critical care nurses, and this nding supports what have been highlighted in the literature review chapter about the positive relationship between re ection and clinical reasoning skills.
Moreover, the second research question "What are the barriers and limitations of using structured re ection models to enhance clinical reasoning skills of the critical care practitioners in critical care clinical settings?" was answered as attending group level re ection is a barrier, and there was partial agreement on feeling shy and threatened, and time restriction as limitations and barriers. However, further studies are needed considering the seniority level of critical care nurses. Furthermore, the literature review chapter re ected that there are no studies on barriers and limitations of re ective learning conversation and debrie ng in critical care settings. Hence, this study can be considered as a beginning and a foundation for further needed studies.
The third research question "How re ective practice can be encouraged and facilitated at critical care clinical settings?" was answered as re ective practice can be encouraged and enhanced by; having structured model and guidelines, re ecting on both good and bad experiences instead of only good or bad experiences, having deep re ections instead of super cial, having re ective moderator with high level of knowledge and clinical skills in addition to leadership skills, and nally deciding on ideal timing of re ective learning and debrie ng activity should be situational with exibility, and more studies are required to decide on this. Moreover, going back to the literature review chapter we observe a strong correlation between the literature review and these study ndings, and these ndings can be utilised to enhance the implementation of re ective practice in critical care clinical settings.

Recommendation And Disseminations
There is a recommendation to run regular re ective learning conversation and debrie ng sessions as clinical education activities in critical care settings of tertiary hospitals There is a recommendation to design a structured model which integrates and consolidates both re ective learning Availability of data and materials "The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request".
Competing interests "The authors declare that they have no competing interests".

Funding (N/A).
Authors' contributions "KA facilitated the questionnaire survey, and the focus group interviews to get the research data. EA analyzed and interpreted the survey and focus group data, and had a main role in writing the manuscript. All authors read and approved the nal manuscript". Figure 1 Gender. 30% of study sample were juniors critical care nurses while 65% were seniors and this could help to know the point of view for junior and senior nurses about re ective activities. See gure (2) Figure 2 Years of experience. 70 % of critical care practitioners attended 5-10 times re ective learning conversation and debrie ng sessions which re ects a good exposure level to re ective leaning process, and this could enrich the study data and validity of obtained information. See gure (3) Being a re ective facilitator. Questionnaire subscale-Domain 1; (Impact of structured re ective learning conversation and debrie ng on clinical reasoning)