Reflective learning conversations as an approach for clinical learning and teaching in critical care

Background: Reflective practice has become an integral element in healthcare and education.1,2 Hamad Medical Corporation (HMC) is the largest healthcare organization in Qatar and it aims to: develop highly competent healthcare practitioners, promote nurses’ critical thinking, enhance the implementation of evidence-based practice, encourage deep learning approaches, create positive learning environments, maintain patient safety, and bridge the gap between theory and practice in the critical care clinical settings.3 To achieve this, in 2015, reflective learning conversations and debriefing educational methods have been introduced by the HMC Nursing Education and Research Department. Methods: The HMC critical care education team introduced a new one-hour Continuing Professional Development (CPD) educational activity under the title of “Reflective learning conversation and debriefing”. This educational activity has been officially added to the critical care monthly and annual education plans and calendars. The reflective and debriefing discussion aims to give the chance for the critical care practitioners to share their real clinical experiences.1,2,4,5 The critical care nurses of HMC attend each session in a group of 5-7 clinicians and they are asked to reflect critically on a real clinical cases in relation to challenges, limitations, pitfalls, and improvement plan.2,5 A facilitator with a clinical and educational background facilitates the discussion and nurses are encouraged to summarize the learning lessons from that experience in addition to the recommendations and action plans which will be decided accordingly. This is then disseminated and shared with other healthcare facilities if it fits their scope of service. The reflective learning conversation and debriefing guidelines and protocol were established by the corporate nursing education team and are available to clinicians and facilitators (Table 1). Results: Reflective learning conversation with a debriefing improves nurses and health care practitioner's critical thinking and competency level which was evident by learners’ feedback and clinical competency assessment (Table 2). Furthermore, that educational activity is an attractive teaching and learning method to create dynamic learning environments in the critical care clinical settings which was evident by learners and facilitators’ feedback (Table 2). Moreover, nurse empowerment and active engagement were enhanced and encouraged by applying that educational method which was evidenced by the clinical experts’ feedback (Table 2). Finally, applying that method was effective to enhance evidence-based practice and patient safety in critical care settings (Table 3). Conclusion: Reflective learning conversations and debriefing has been perceived to be an effective learning method. Healthcare practitioners can learn from errors and previous experiences to avoid future mistakes in clinical practice. Sharing clinical experiences provides a medium to discuss cases from different angles and in depth which helps to promote deep learning, evidence-based practice, active learning, and patient safety. The recommendations of reflective learning conversations and debriefings can be applied and utilized to change current practice toward best practice and are applicable in all clinical domains and specialties. Although currently attended only by nurses, such sessions would be even more beneficial if attended by multiple professions.

. Reflective learning conversation guidelines.
session in a group of 5-7 clinicians and they are asked to reflect critically on a real clinical cases in relation to challenges, limitations, pitfalls, and improvement plan. 2,5 A facilitator with a clinical and educational background facilitates the discussion and nurses are encouraged to summarize the learning lessons from that experience in addition to the recommendations and action plans which will be decided accordingly. This is then disseminated and shared with other healthcare facilities if it fits their scope of service. The reflective learning conversation and debriefing guidelines and protocol were established by the corporate nursing education team and are available to clinicians and facilitators (Table 1).
Results: Reflective learning conversation with a debriefing improves nurses and health care practitioner's critical thinking and competency level which was evident by learners' feedback and clinical competency assessment (Table 2). Furthermore, that educational activity is an attractive teaching and learning method to create dynamic learning environments in the critical care clinical settings which was evident by learners and facilitators' feedback (Table 2). Moreover, nurse empowerment and active engagement were enhanced and encouraged by applying that educational method which was evidenced by the clinical experts' feedback (Table 2). Finally, applying that method was effective to enhance Table 2. Learners' feedback on reflective learning conversation and debriefing sessions (n ¼ 700) and Critical Care Nursing Network, scientific and planning committee, and critical care experts recommendations and actions.
Reflective learning conversation and debriefing activity feedback results: -85% of the learners were satisfied with the duration of the reflective learning conversation activity (1 hour) -99% agreed that the process of reflective learning conversation should be structured with clear guidelines -95% agreed that the reflective learning conversation is an active form of learning -97% agreed that the reflective learning conversation is effective to empower nurses to share experiences -97% agreed that the reflective learning conversation is an effective method to improve patient safety -93% agreed that the reflective learning conversation had a positive impact on their professional development and competency level -98% would advise others to attend the reflective learning conversation activity as they believe it was very beneficial Recommendations and actions pertaining to the reflective learning conversation and debriefing CPD activity: -The Critical Care Nursing Network (CCNN) of HMC decided that attendance to the reflective learning conversation activities should be mandatory for all critical care nurses at least once per year -Anecdotal evidence from head nurses across HMC has been obtained of improvements in clinical practice with attendance of reflective learning and conversation activities -HMC critical care competency assessors reported a significant improvement in knowledge and skills of critical care nurses who attended the scheduled reflective learning conversation activities evidence-based practice and patient safety in critical care settings (Table 3). Conclusion: Reflective learning conversations and debriefing has been perceived to be an effective learning method. Healthcare practitioners can learn from errors and previous experiences to avoid future mistakes in clinical practice. Sharing clinical experiences provides a medium to discuss cases from different angles and in depth which helps to promote deep learning, evidence-based practice, active learning, and patient safety. The recommendations of reflective learning conversations and debriefings can be applied and utilized to change current practice toward best practice and are applicable in all clinical domains and specialties. Although currently attended only by nurses, such sessions would be even more beneficial if attended by multiple professions.
Keywords: reflective learning conversation, debriefing, adult education reflective practice

Ethical approval
The reporting of this data has been accepted as an educational quality improvement project by the Nursing Continuing Professional Development Committee of Hamad Medical Corporation and therefore is exempt from Institutional Review Board approval. Table 3. Examples of improvements in clinical practice emerging from the reflective learning conversation sessions.
-Updating the critical care competency framework -Revising the fecal management practice in critical care settings -Implementing competency revalidation for all critical care nurses based on the revised -critical care competency framework -Designing critical care specialty and subspecialty training courses