Learning to Reflect Together: A Video Reflexive Ethnography and Linguistic Analysis of Collaborative Clinical Reasoning in Intensive Care

Learning to Reflect Together: A Video Reflexive Ethnography and Linguistic Analysis of Collaborative Clinical Reasoning in Intensive Care | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Learning to Reflect Together: A Video Reflexive Ethnography and Linguistic Analysis of Collaborative Clinical Reasoning in Intensive Care Ching-Yi Lee, Hung-Yi Lai, Ching-Hsin Lee, Mi-Mi Chen, Sze-Yuen Yau This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8488427/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 13 You are reading this latest preprint version Abstract Background Collaborative clinical reasoning (CCR) is essential to safe and effective practice in intensive care units, where decisions are shaped by uncertainty, high cognitive load, and interprofessional dynamics. Although CCR is widely recognised as a collective cognitive process, little is known about how clinicians learn to reason together or how reflective educational interventions influence the language and social organisation through which CCR is enacted. Methods This mixed-methods Groundwork study examined the impact of a Video Reflexive Ethnography (VRE) intervention on CCR within a multidisciplinary neuro-intensive care unit in Taiwan. Twelve clinicians (physicians, nurses, and a respiratory therapist) were video-recorded during routine bedside rounds. Transcripts of team interactions before and after the VRE intervention were analysed using Linguistic Inquiry and Word Count (LIWC-22) to examine markers of analytical thinking, clout, authenticity, cognitive processing, and social interaction. Quantitative linguistic trends were interpreted alongside qualitative data from retrospective reflective think-aloud sessions in which participants reviewed and discussed selected video excerpts of their own practice. Results No statistically significant differences were observed across LIWC categories following the intervention. However, consistent linguistic trends suggested shifts toward more reflective and collaborative reasoning. Post-intervention interactions demonstrated increased use of language associated with analytical thinking, insight, tentativeness, and authenticity, alongside a decrease in clout-related language. During reflective sessions, participants described heightened awareness of their own communicative habits, greater openness to uncertainty, and increased willingness to invite and consider alternative perspectives from other team members. Conclusions By integrating video-reflexive inquiry with computational linguistic analysis, this study provides insight into how reflection may reshape the cognitive and social dimensions of collaborative clinical reasoning. The findings suggest that VRE can support communicative equity and epistemic humility in interprofessional teams, even when changes are subtle and not readily captured by traditional outcome measures. This work highlights the value of combining qualitative and linguistic approaches to examine learning processes in authentic clinical environments and informs the design of reflective faculty development and interprofessional education initiatives. Collaborative clinical reasoning Reflective learning Video reflexive ethnography Linguistic analysis Interprofessional education Introduction Clinical reasoning lies at the heart of competent medical practice, enabling clinicians to interpret complex data, generate diagnostic hypotheses, and select appropriate management strategies under uncertainty [ 1 ]. In intensive care units (ICU), such reasoning rarely occurs in isolation. Instead, diagnostic and therapeutic judgments emerge through collaborative clinical reasoning (CCR)—the shared cognitive process by which physicians, nurses, and allied professionals negotiate patient understanding and collective action [ 2 , 3 ]. Because ICU work is distributed, time-pressured, and often ambiguous, the quality of CCR directly influences patient safety. Communication failures and unchecked assumptions remain recurrent sources of error [ 4 , 5 ]. Thus, strengthening CCR represents not merely a teamwork enhancement but an educational imperative: clinicians must learn to reason together, cultivating mutual awareness and adaptive dialogue amid cognitive load and hierarchical constraint. Collaborative clinical reasoning as team cognition and learning CCR can be conceptualized as an integration of individual cognition—hypothesis generation, evidence appraisal, and decision justification—with team cognition, which involves building shared mental models, maintaining transactive memory, and dynamically monitoring collective understanding [ 6 ]. Drawing on dual-process theory, clinical reasoning alternates between intuitive, rapid System 1 judgments and analytical, effortful System 2 deliberation [ 1 , 7 ]. Within teams, CCR serves as a social mechanism that distributes cognitive load and counterbalances bias by exposing reasoning to collective scrutiny. From a sociocultural perspective, reasoning is enacted through interaction : talk, gesture, documentation, and tool use constitute the medium through which knowledge is constructed [ 8 , 9 ]. Language, therefore, is not ancillary to reasoning but constitutive of it—it organizes attention, conveys epistemic stance, and structures how clinicians jointly navigate uncertainty. Despite the theoretical promise of CCR, its enactment in clinical environments is impeded by entrenched hierarchies and asymmetries of voice. Senior physicians often dominate rounds, while nurses and junior trainees may defer even when possessing critical contextual knowledge [ 10 ]. Such patterns shape epistemic stance —the degree of certainty, authority, or tentativeness expressed in language [ 11 ]. High-clout, declarative speech reinforces top-down decision-making, whereas tentative or insight-oriented expressions invite inquiry and shared reasoning. Edmondson’s [ 12 ] construct of psychological safety underscores that equal participation requires an environment where questioning and dissent are safe; yet psychological safety alone is insufficient without deliberate reflection on how discourse itself reproduces hierarchy. Overconfidence has been implicated in diagnostic error [ 13 ], and recent work on physician humility highlights epistemic openness as a professional virtue[ 14 ]. Consequently, educational interventions must move beyond communication “skills training” toward practices that surface and reorganize the linguistic and cultural structures of talk through which authority and uncertainty are negotiated. Reflection and the promise of Video Reflexive Ethnography Reflection offers a means to transform such entrenched communicative patterns. DA Schön [ 15 ] reflective practitioner model and DA Kolb [ 16 ] experiential learning cycle both posit that learning occurs when practitioners critically examine their own “knowing-in-action,” experiment with new understandings, and re-enter practice with altered frames of reference. In complex systems like the ICU, however, much of professional performance is tacit and inaccessible to self-report. Video Reflexive Ethnography (VRE) addresses this limitation by recording authentic practice and re-presenting it to practitioners for guided collective analysis [ 17 , 18 ]. Through video-elicited reflection , clinicians can observe their habitual communication patterns, question implicit hierarchies, and notice micro-moments of reasoning that would otherwise remain invisible. The camera serves not as surveillance but as a mirror for inquiry, shifting authority from individuals to the visual evidence of practice and enabling “safe reflection on unsafe acts.” Empirical studies demonstrate that VRE can enhance situational awareness, interprofessional respect, and learning culture [ 17 ]. Yet, the mechanisms through which VRE reshapes cognition and communication remain insufficiently specified, particularly regarding linguistic indicators of reflective learning and reasoning. Language as a window into learning: Computational linguistic analysis If reasoning and reflection are enacted through language, then examining linguistic patterns offers a powerful lens for understanding how learning manifests in interaction. Linguistic Inquiry and Word Count (LIWC) is a validated computational tool that categorizes words into psychologically meaningful domains such as analytical thinking, authenticity, insight, and clout [ 19 ]. Function words—articles, pronouns, conjunctions—are especially revealing of cognitive style and social orientation [ 20 ]. In educational contexts, shifts toward tentative and insight-related language can signify metacognitive engagement, while decreased clout may index redistributions of authority and improved communicative equity [ 21 ]. Thus, LIWC provides scalable, theory-aligned indicators to complement qualitative ethnographic interpretation. However, computational metrics cannot capture turn-taking or pragmatic nuance; triangulating them with reflective interviews or think-aloud data allows richer interpretation of learning mechanisms. This mixed-methods integration responds to growing calls for multi-modal evidence of how reflection translates into cognitive and behavioural change [ 22 , 23 ]. Despite increasing adoption of VRE in health professions education, little is known about how reflective video inquiry alters the linguistic and cognitive ecology of CCR. Empirical studies often describe improved teamwork qualitatively but seldom trace the micro-level transformations in discourse that signal deeper epistemic change. Moreover, most VRE research originates from Western academic centers, leaving under-examined how hierarchical and cultural dynamics in East Asian critical-care settings mediate reflective learning. Addressing this gap, the present study investigates the impact of a VRE intervention on the linguistic features of multidisciplinary ICU discussions using LIWC-22 analysis, supplemented by participants’ reflective commentaries. The study aims to elucidate how reflection mediates the cognitive and social mechanisms of CCR. Specifically, it asks: Do linguistic markers associated with analytical thinking, insight, tentativeness, authenticity, and clout shift following VRE-facilitated reflection? How do participants interpret observed linguistic changes in relation to their reasoning, roles, and participation during reflective think-alouds? What do convergences between quantitative and qualitative findings reveal about how VRE fosters communicative equity and epistemic humility in interprofessional teams? Materials and Methods Design and Theoretical Orientation This Groundwork study employed a mixed-methods, video-reflexive ethnographic design [ 17 , 18 ] to explore how reflective viewing and discussion of clinical encounters influence the linguistic and cognitive dimensions of CCR in an ICU. The design aligns with the constructivist view that learning emerges from reflection on authentic practice [ 15 , 16 ] and the distributed cognition perspective that reasoning is co-constructed through interaction, artifacts, and shared context [ 9 ]. Quantitative linguistic data were integrated with qualitative reflections to examine how the VRE process mediates communicative and epistemic change. Setting and Participants The study took place in the neuro-intensive care unit of a tertiary teaching hospital in Taiwan. The ICU operates as a multidisciplinary environment where clinical reasoning unfolds dynamically through rounds, briefings, and informal discussions. Purposive sampling identified twelve participants—five physicians, six nurses, and one respiratory therapist—representing a range of professional roles and hierarchical positions involved in team-based clinical reasoning. Participants were invited through departmental announcements, and all agreed to participate in the study. Inclusion criteria required at least one year of ICU experience and fluency in Mandarin Chinese. Data Collection 1. Ethnographic Videography of Team Interactions The primary method of data collection involved video and audio recordings of NICU team conversations during bedside patient rounds. This ethnographic videography approach enabled researchers to document real-time interactions, providing rich insights into team behaviours, communication dynamics, and clinical decision-making processes. This methodology aligns with existing research that emphasizes the importance of studying clinical reasoning in its naturalistic context. Researchers shadowed the NICU team, recording bedside patient rounds using hand-held video cameras for approximately one hour at a time. Recordings were conducted once per month for six months, resulting in a minimum of six recorded patient round sessions. The sample size of participants varied depending on the day of recording. For example, on a typical day, two chief neurosurgeons, two junior physicians (residents and interns), and three registered nurses were observed interacting within the NICU team. In addition to capturing verbal communication, observations focused on non-verbal behaviours, role negotiations, and the use of clinical cues that initiated collaborative discussions. Researchers also maintained field notes documenting chronological accounts of observed interactions, contextual factors influencing communication, and any emergent themes related to clinical reasoning. 2. Reflective and Retrospective Think-Aloud Sessions Reflective practice is a core component of professional development in healthcare, enabling practitioners to critically examine their reasoning and decision-making processes. In this study, reflective and retrospective think-aloud sessions were integrated as a structured educational strategy to support critical reflection on collaborative clinical reasoning. To examine potential changes in clinical reasoning and team-based decision-making, video-recorded data from bedside observations were analysed before and after participants engaged in reflective think-aloud sessions. The retrospective think-aloud approach was designed to prompt participants to articulate their reasoning while reviewing selected video excerpts of their own patient-round interactions. Researchers reviewed the video recordings and edited short segments (10–20 minutes each) that captured key moments of collaborative clinical reasoning. These edited clips were used as stimuli during the think-aloud sessions, during which participants were invited to reflect on and explain their reasoning processes. Specifically, participants were encouraged to: Describe their thought processes in reaching a diagnosis or treatment plan. Explain the reasoning behind specific statements, questions, or actions observed in the footage. Identify any factors that influenced their decisions during clinical encounters. Reflect on interactions with other team members and their impact on shared reasoning. Participants were able to pause, replay, or revisit video segments as needed to support articulation of their thought processes. Reflective discussions were conducted either concurrently with the think-aloud activity or in a subsequent facilitated discussion. Facilitation was guided by a semi-structured interview guide developed specifically for this study, informed by ethnographic observations and relevant literature on collaborative clinical reasoning and reflective practice. An English version of the interview guide is provided as Supplementary File 1. All reflective think-aloud sessions were audio-recorded and lasted approximately one to two hours. Recordings were transcribed verbatim and analysed to identify patterns in collaborative clinical reasoning, decision-making strategies, and communicative behaviours among neuro-intensive care unit team members. Data Analysis A total of eight recordings were collected. The video recordings were transcribed in Mandarin, the participants’ primary language, and then translated into English. The translation process involved a team of bilingual experts who ensured accuracy and retention of original meanings. This study employed LIWC to perform a systematic, computational analysis of language use [ 19 ]. LIWC enables researchers to analyse both psychological processes and linguistic content by categorizing words into predefined semantic and cognitive domains. LIWC operates by comparing each word in a transcript to an established dictionary of linguistic categories, calculating the frequency of words related to cognitive, emotional, and social processes. For example, the word encourage may fall under multiple categories such as social, emotional, positive emotion, and cognitive processing. Similarly, the word remorseful may be categorized under negative emotion, sadness, and discrepancy words. By quantifying linguistic features, LIWC provides objective insights into team communication, cognitive reasoning patterns, and emotional tone. LIWC Analysis Process The analysis of transcribed team interactions during patient rounds followed a structured five-step process [ 19 ]: Data Collection: Transcripts were obtained from pre- and post-intervention video recordings of NICU ward rounds. Text Preprocessing: Transcripts were formatted and reviewed for consistency before uploading them into the LIWC software. LIWC Analysis: Specific lexical categories related to cognitive processes (e.g., reasoning, insight), social interaction (e.g., collaboration, communication), and certainty markers were analysed. Comparative Analysis: Differences in language use before and after the VRE intervention were assessed to detect changes in collaborative reasoning patterns. Interpretation of Results: Findings were analysed to determine how VRE influenced team-based communication, cognitive engagement, and social dynamics in the NICU setting. A paired samples t-test was conducted to compare mean LIWC category scores pre- and post-intervention, identifying statistically significant differences in cognitive, emotional, and social language features. Ethical Considerations Ethical approval for the study was obtained from the hospital’s institutional review board (Approval No. 202002453B0). Participants’ confidentiality was maintained through anonymized transcripts and secure data storage. Informed consent was obtained before recording, and participants could withdraw at any time without consequences. Results This section presents the findings from the study, focusing on the changes in linguistic patterns observed through LIWC analysis, as well as qualitative insights derived from reflective think-aloud sessions. The results are organized to reflect the primary and secondary research questions, emphasizing the impact of the reflective practice intervention on CCR. Participant Demographics A total of 12 participants were recruited for this study, consisting of 4 attending physicians, 2 resident physicians, 5 registered nurses, and 1 respiratory therapist. These participants engaged in bedside clinical case discussions during ward rounds, with each case discussion lasting approximately 3 to 5 minutes. Each ward round included at least two different professional roles, ensuring interprofessional engagement in CCR. The primary data source comprised clinical video recordings, with four groups of ward rounds involving first-time participants, and four groups including members who had previously participated in post-video interviews and were now engaging in a second recording session. Participants were also involved in one-on-one interviews lasting 20 to 30 minutes, during which they reviewed their own clinical video recordings. These retrospective reflections provided insights into their reasoning processes and discussions related to CCR. The clinical video recordings were transcribed and analysed using LIWC, focusing on ten psychological and linguistic categories relevant to clinical reasoning. Independent t-tests were conducted to compare pre- and post-intervention mean scores across different LIWC categories. Quantitative Analysis: Linguistic Changes Post-Intervention Statistical analysis revealed no significant differences in the participants' linguistic usage post-intervention. However, notable trends in the LIWC categories suggested potential shifts in cognitive and social dynamics following the intervention. Table 1 presents the comparison of pre- and post-intervention score across LIWC categories. Table 1 Comparison of LIWC Psychological and Linguistic Categories Pre- and Post-Intervention LIWC Category Pre-Intervention Mean (SD) Post-Intervention Mean (SD) p Analytical Thinking 9.13 (6.26) 13.15 (7.66) 0.447 Clout 49.34 (10.00) 46.38 (19.07) 0.793 Authentic 41.76 (11.61) 47.88 (12.82) 0.506 Tone 21.69 (11.61) 27.72 (12.48) 0.506 Cognitive Processes 15.08 (1.48) 15.99 (1.78) 0.462 Insight 1.35 (0.70) 2.34 (0.54) 0.066 Causation 2.88 (1.34) 1.98 (1.23) 0.361 Discrepancy 2.87 (0.66) 2.07 (0.81) 0.177 Tentative 2.73 (1.56) 4.34 (1.14) 0.147 Social Processes 10.13 (2.12) 9.83 (2.09) 0.847 Qualitative Interpretations of Linguistic Trends Although the LIWC results did not yield statistically significant differences, certain patterns in language use suggest potential cognitive and communicative shifts among participants post-intervention. 1. Increase in Analytical Thinking The mean analytical thinking score increased from 9.13 to 13.15, indicating a trend toward more structured, logical reasoning in clinical discussions. Participants appeared to rely more on explicitly structured arguments and logical explanations, suggesting greater use of System 2 thinking in reasoning. Example • “Based on the CT results, the intracranial pressure is not high, and we plan to conduct blood tests and an X-ray on Thursday.” Key LIWC words: “Based on,” “conduct,” “plan” 2. Decrease in Clout: Shift in Power Distribution A decline in clout scores (49.34 to 46.38) was observed, with an increase in variability post-intervention. This may reflect a more balanced distribution of authority within the team, suggesting that collaborative decision-making became more egalitarian, rather than being dominated by senior physicians. Example • “No need for a gram stain, directly proceed with the routine check.” Key LIWC words: “No need,” “directly” (indicative of hierarchical authority pre-intervention) 3. Increase in Authentic Communication Participants exhibited a higher level of authenticity in communication post-intervention (41.76 to 47.88), suggesting they engaged in more open, reflective discussions. This may indicate greater self-awareness and honesty in clinical reasoning. Example • “His breathing doesn’t seem as smooth. I’m concerned and think we need to observe a bit more.” Key LIWC words: “concerned,” “observe” 4. Rise in Tentative Language: Cautious Clinical Reasoning The tentative language score increased from 2.73 to 4.34, suggesting participants adopted a more cautious and deliberative approach to clinical reasoning. This may reflect a greater awareness of uncertainty in decision-making and an increased willingness to consider alternative diagnoses. Example • “It seems that the patient’s symptoms may be caused by an infection, but it’s still uncertain.” Key LIWC words: “seems,” “may,” “uncertain” 5. Increase in Insight: Deeper Reflection on Cases The insight category increased from 1.35 to 2.34, indicating that participants were engaging in more reflective and self-aware discussions post-intervention. Greater insight is associated with critical thinking and deeper cognitive engagement. Example • “This case reminds me of a similar one I handled before.” Key LIWC words: “reminds,” “handled,” “similar case” Discussion This study examined the impact of VRE on CCR in multidisciplinary teams within a NICU. By integrating qualitative ethnographic videography with computational linguistic analysis using LIWC, this research sought to identify linguistic and cognitive shifts following a structured reflective intervention. While no statistically significant differences were observed across LIWC categories, notable trends suggest subtle but meaningful shifts in participants' cognitive and communicative engagement post-intervention. Specifically, increases in analytical thinking, tentative language, insight, and authenticity suggest a move toward more structured, reflective, and participatory decision-making. The observed decline in clout scores indicates a redistribution of authority within the team, pointing to a shift toward a more egalitarian approach to clinical decision-making. These findings contribute to ongoing discussions on the role of VRE in enhancing interdisciplinary collaboration, fostering cognitive flexibility, and promoting reflective practice in high-stakes healthcare environments. The observed linguistic shifts align with dual-process models of reasoning which delineate intuitive versus analytical reasoning [ 4 , 24 , 25 ]. The post-intervention increase in analytical thinking scores suggests a shift toward more deliberate, evidence-based decision-making, characteristic of System 2 processing. As emphasized in Markowitz et al., analytic thinking scores in LIWC do not directly measure intelligence but rather reflect a cognitive style—a preference for systematic, effortful processing of information [ 20 ]. This distinction is crucial, as it suggests that post-VRE, participants were more motivated to engage in deeper reasoning and reflection rather than merely exhibiting superior cognitive ability. The changes in function words—particularly tentative language and insight-related words—indicate increased cognitive flexibility and a greater openness to reconsidering decisions [ 21 , 22 ]. This linguistic shift aligns with research on diagnostic calibration, which suggests that overconfident physicians are less likely to seek additional information, increasing the risk of diagnostic errors [ 26 ]. Encouraging epistemic humility—where clinicians acknowledge uncertainty and actively seek additional perspectives—may counteract this tendency, leading to more thorough reasoning and improved diagnostic accuracy [ 14 ]. The rise in tentative language (e.g., words such as “seems,” “might,” and “possibly”) is particularly significant. In traditional ICU settings, clinicians are often expected to communicate with confidence, minimizing expressions of doubt [ 13 ]. However, the increase in tentative language suggests that VRE facilitated a shift toward a more open, exploratory reasoning process, where team members were willing to consider alternative explanations and discuss diagnostic uncertainty [ 27 ]. This has direct implications for improving diagnostic accuracy and fostering a culture of collaborative inquiry rather than authoritative decision-making. The decline in clout scores in post-intervention suggests a redistribution of authority within the NICU team. Traditional ICU team dynamics often reflect strong hierarchical structures, with senior physicians dominating discussions while junior team members, including nurses, may be less inclined to voice their perspectives [ 5 ]. The decrease in clout indicates that VRE may have contributed to flattening these hierarchical structures, allowing for more balanced participation in decision-making. Additionally, the findings of Moore et al. suggest that lower clout is often associated with deeper engagement in cognitive processing, indicating that junior clinicians may be contributing more meaningfully to discussions, even if their statements appear less authoritative [ 28 ]. This shift in conversational dynamics is crucial for enhancing team-based reasoning and ensuring that all perspectives—particularly those from traditionally less dominant voices—are integrated into clinical decision-making. The findings reinforce VRE as a powerful tool for promoting reflective practice in medical education. Reflection is a key component of experiential learning theory, which posits that deep learning occurs when individuals analyse their experiences, extract insights, and apply them to future decision-making [ 29 , 30 ]. The increase in authenticity scores post-intervention suggests that participants engaged in more self-aware, honest discussions about their clinical reasoning processes, further supporting the role of VRE in fostering meta-cognitive awareness and self-assessment. To maximize the impact of VRE, medical educators should incorporate structured debriefing protocols that encourage clinicians to analyse their linguistic choices, cognitive biases, and reasoning strategies. Reflective discussions should focus on how language shapes team cognition, the role of epistemic humility in clinical decision-making, and strategies for mitigating cognitive errors. Research Limitations While this study provides valuable insights into the impact of VRE on CCR within multidisciplinary ICU teams, several limitations should be considered when interpreting the findings. These limitations highlight areas for future research and methodological refinements. One primary limitation is the small sample size, which may have restricted the statistical power of the analysis and limited the ability to detect significant differences across linguistic and cognitive measures. Given the dynamic nature of ICU settings, where team composition varies daily, findings may not be fully generalizable to other clinical environments or healthcare institutions. Future studies should aim to include larger and more diverse samples, incorporating multiple hospital settings and different medical disciplines to enhance the external validity of the findings. Moreover, the high-stakes, time-sensitive nature of ICU environments may have influenced participant behaviours and linguistic patterns. Clinicians may have adapted their communication styles due to the awareness of being recorded (i.e., the Hawthorne effect), potentially affecting the authenticity of team interactions. Although efforts were made to minimize observer effects, future research could explore longitudinal designs or more discreet recording methods to capture more naturalistic communication patterns. Although LIWC is a powerful tool for quantifying linguistic and cognitive patterns, it has inherent limitations. LIWC categorizes words based on predefined lexical databases but may not fully capture nuanced aspects of clinical discourse, rhetorical strategies, or the deeper meaning of conversations. Future research could employ a mixed-methods approach, integrating LIWC with qualitative discourse analysis or ethnographic fieldwork, to gain a richer understanding of how language shapes collaborative reasoning in ICU teams. Despite these limitations, this study contributes to the growing body of research on VRE as an effective tool for enhancing interprofessional communication and collaborative reasoning in ICU teams. Addressing these limitations through expanded sample sizes, longitudinal tracking and qualitative integration will strengthen the evidence base for VRE and further refine its application in medical education and clinical practice. Conclusion This study contributes to the growing body of research supporting VRE as an effective intervention for enhancing collaborative clinical reasoning in ICU teams. By incorporating structured reflection, epistemic humility training, and psychological safety interventions, institutions can leverage VRE to develop more adaptive, communicative, and cognitively engaged healthcare teams. Future research should explore scalable implementations of VRE across different clinical environments, longitudinal effects on reasoning patterns, and integration with emerging AI-driven linguistic analysis tools. Declarations Ethics approval and consent to participate The study was approved by the Institutional Review Board of Chang Gung Medical Foundation (IRB No. 202002453B0). Written informed consent to participate was obtained from all participants prior to data collection. All procedures involving human participants were conducted in accordance with the ethical standards of the institutional research committee and with the Declaration of Helsinki. Consent for publication Not required as all figures and tables within the manuscript were created by the research team. Competing interests None. Funding This work was supported by Chang Gung Medical Foundation, Taiwan [grant number: CORPG3G1071] and by Ministry of Science and Technology (R.O.C.): [grant number: NSTC 113-2628-H-182-002-MY2] Author Contribution Ching-Yi Lee secured funding and ethical approvals, coordinated research activities, and was responsible for data collection, analysis, and drafting the manuscript. Hung-Yi Lai and Ching-Hsin Lee conducted the statistical analysis, contributed to the interpretation of quantitative findings, and assisted in drafting the results section. Mi-Mi Chen facilitated participant recruitment, managed data collection, and provided critical input on the study's cultural and clinical context. 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Supplementary Files SupplementaryFile1.docx Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 30 Mar, 2026 Reviews received at journal 17 Mar, 2026 Reviewers agreed at journal 11 Mar, 2026 Reviewers agreed at journal 24 Feb, 2026 Reviews received at journal 17 Feb, 2026 Reviews received at journal 12 Feb, 2026 Reviewers agreed at journal 09 Feb, 2026 Reviewers agreed at journal 07 Feb, 2026 Reviewers invited by journal 04 Feb, 2026 Editor invited by journal 29 Jan, 2026 Editor assigned by journal 08 Jan, 2026 Submission checks completed at journal 08 Jan, 2026 First submitted to journal 08 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8488427","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":587316912,"identity":"928a4d3d-c558-4d93-aba9-d76d0d452961","order_by":0,"name":"Ching-Yi Lee","email":"","orcid":"","institution":"Chang Gung Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ching-Yi","middleName":"","lastName":"Lee","suffix":""},{"id":587316916,"identity":"6d077603-3b5d-4c4d-99ae-da23cc3175f8","order_by":1,"name":"Hung-Yi Lai","email":"","orcid":"","institution":"Chang Gung Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hung-Yi","middleName":"","lastName":"Lai","suffix":""},{"id":587316920,"identity":"36bdfb44-1ef4-46cd-8d72-888d5f220ff0","order_by":2,"name":"Ching-Hsin Lee","email":"","orcid":"","institution":"Chang Gung Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ching-Hsin","middleName":"","lastName":"Lee","suffix":""},{"id":587316923,"identity":"ab03ea41-227f-4451-99de-407cfbd8feb9","order_by":3,"name":"Mi-Mi Chen","email":"","orcid":"","institution":"Chang Gung Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mi-Mi","middleName":"","lastName":"Chen","suffix":""},{"id":587316927,"identity":"b4abfb47-c6f2-4c3d-8a68-b7bd7b9d03cd","order_by":4,"name":"Sze-Yuen Yau","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYHAD5gNAQkKGFC1sCSAtPKRo4TEAkwTVGRw/Y/zxR8XhxH7pns+vbtRY8DCwHz66Aa+WMzlmEhJnDifOnHN2m3XOMaDDeNLSbuDVciDHjMGw7XDihhu524xz2IBaJHjM8Gs5/8b4Q+K/w4n7b+Q8M875R4yWGzkGEgcbgLZI5DA/zm0jQovkjWdlkg3H0o1n3EgzY87tk+BhI+QXvvPJmz/+qLGW7Z+R/Phzzrc6OX72w8fwalE4AKaaQQSbBJjEpxwE5BvAVB2IYP5ASPUoGAWjYBSMTAAA5NdNMJ4af2oAAAAASUVORK5CYII=","orcid":"","institution":"CG-MERC) Chang Gung Medical Education Research Centre","correspondingAuthor":true,"prefix":"","firstName":"Sze-Yuen","middleName":"","lastName":"Yau","suffix":""}],"badges":[],"createdAt":"2025-12-31 09:38:53","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8488427/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8488427/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102212715,"identity":"5979cab2-67f6-4281-8adf-b287e7a389cd","added_by":"auto","created_at":"2026-02-09 12:35:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":707482,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8488427/v1/266d3d92-1462-43eb-bc48-96ee3d9117a5.pdf"},{"id":102212704,"identity":"3dcb78dd-da39-403d-9dcd-066485ad86b6","added_by":"auto","created_at":"2026-02-09 12:35:28","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":18720,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8488427/v1/f43fcda2c8bfafe936dbfbc6.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Learning to Reflect Together: A Video Reflexive Ethnography and Linguistic Analysis of Collaborative Clinical Reasoning in Intensive Care","fulltext":[{"header":"Introduction","content":"\u003cp\u003eClinical reasoning lies at the heart of competent medical practice, enabling clinicians to interpret complex data, generate diagnostic hypotheses, and select appropriate management strategies under uncertainty [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In intensive care units (ICU), such reasoning rarely occurs in isolation. Instead, diagnostic and therapeutic judgments emerge through collaborative clinical reasoning (CCR)\u0026mdash;the shared cognitive process by which physicians, nurses, and allied professionals negotiate patient understanding and collective action [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Because ICU work is distributed, time-pressured, and often ambiguous, the quality of CCR directly influences patient safety. Communication failures and unchecked assumptions remain recurrent sources of error [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Thus, strengthening CCR represents not merely a teamwork enhancement but an educational imperative: clinicians must learn to reason together, cultivating mutual awareness and adaptive dialogue amid cognitive load and hierarchical constraint.\u003c/p\u003e\n\u003ch3\u003eCollaborative clinical reasoning as team cognition and learning\u003c/h3\u003e\n\u003cp\u003eCCR can be conceptualized as an integration of individual cognition\u0026mdash;hypothesis generation, evidence appraisal, and decision justification\u0026mdash;with team cognition, which involves building shared mental models, maintaining transactive memory, and dynamically monitoring collective understanding [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Drawing on dual-process theory, clinical reasoning alternates between intuitive, rapid System 1 judgments and analytical, effortful System 2 deliberation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Within teams, CCR serves as a social mechanism that distributes cognitive load and counterbalances bias by exposing reasoning to collective scrutiny. From a sociocultural perspective, reasoning is enacted through \u003cem\u003einteraction\u003c/em\u003e: talk, gesture, documentation, and tool use constitute the medium through which knowledge is constructed [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Language, therefore, is not ancillary to reasoning but constitutive of it\u0026mdash;it organizes attention, conveys epistemic stance, and structures how clinicians jointly navigate uncertainty.\u003c/p\u003e \u003cp\u003eDespite the theoretical promise of CCR, its enactment in clinical environments is impeded by entrenched hierarchies and asymmetries of voice. Senior physicians often dominate rounds, while nurses and junior trainees may defer even when possessing critical contextual knowledge [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Such patterns shape \u003cem\u003eepistemic stance\u003c/em\u003e\u0026mdash;the degree of certainty, authority, or tentativeness expressed in language [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. High-clout, declarative speech reinforces top-down decision-making, whereas tentative or insight-oriented expressions invite inquiry and shared reasoning. Edmondson\u0026rsquo;s [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] construct of \u003cem\u003epsychological safety\u003c/em\u003e underscores that equal participation requires an environment where questioning and dissent are safe; yet psychological safety alone is insufficient without deliberate reflection on how discourse itself reproduces hierarchy. Overconfidence has been implicated in diagnostic error [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], and recent work on \u003cem\u003ephysician humility\u003c/em\u003e highlights epistemic openness as a professional virtue[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Consequently, educational interventions must move beyond communication \u0026ldquo;skills training\u0026rdquo; toward practices that surface and reorganize the linguistic and cultural structures of talk through which authority and uncertainty are negotiated.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eReflection and the promise of Video Reflexive Ethnography\u003c/h2\u003e \u003cp\u003eReflection offers a means to transform such entrenched communicative patterns. DA Sch\u0026ouml;n [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] \u003cem\u003ereflective practitioner\u003c/em\u003e model and DA Kolb [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] experiential learning cycle both posit that learning occurs when practitioners critically examine their own \u0026ldquo;knowing-in-action,\u0026rdquo; experiment with new understandings, and re-enter practice with altered frames of reference. In complex systems like the ICU, however, much of professional performance is tacit and inaccessible to self-report. \u003cem\u003eVideo Reflexive Ethnography\u003c/em\u003e (VRE) addresses this limitation by recording authentic practice and re-presenting it to practitioners for guided collective analysis [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Through \u003cem\u003evideo-elicited reflection\u003c/em\u003e, clinicians can observe their habitual communication patterns, question implicit hierarchies, and notice micro-moments of reasoning that would otherwise remain invisible. The camera serves not as surveillance but as a mirror for inquiry, shifting authority from individuals to the \u003cem\u003evisual evidence\u003c/em\u003e of practice and enabling \u0026ldquo;safe reflection on unsafe acts.\u0026rdquo; Empirical studies demonstrate that VRE can enhance situational awareness, interprofessional respect, and learning culture [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Yet, the mechanisms through which VRE reshapes cognition and communication remain insufficiently specified, particularly regarding linguistic indicators of reflective learning and reasoning.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eLanguage as a window into learning: Computational linguistic analysis\u003c/h3\u003e\n\u003cp\u003eIf reasoning and reflection are enacted through language, then examining linguistic patterns offers a powerful lens for understanding how learning manifests in interaction. Linguistic Inquiry and Word Count (LIWC) is a validated computational tool that categorizes words into psychologically meaningful domains such as analytical thinking, authenticity, insight, and clout [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Function words\u0026mdash;articles, pronouns, conjunctions\u0026mdash;are especially revealing of cognitive style and social orientation [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In educational contexts, shifts toward tentative and insight-related language can signify metacognitive engagement, while decreased clout may index redistributions of authority and improved communicative equity [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Thus, LIWC provides scalable, theory-aligned indicators to complement qualitative ethnographic interpretation. However, computational metrics cannot capture turn-taking or pragmatic nuance; triangulating them with reflective interviews or think-aloud data allows richer interpretation of learning mechanisms. This mixed-methods integration responds to growing calls for multi-modal evidence of how reflection translates into cognitive and behavioural change [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite increasing adoption of VRE in health professions education, little is known about \u003cem\u003ehow\u003c/em\u003e reflective video inquiry alters the linguistic and cognitive ecology of CCR. Empirical studies often describe improved teamwork qualitatively but seldom trace the micro-level transformations in discourse that signal deeper epistemic change. Moreover, most VRE research originates from Western academic centers, leaving under-examined how hierarchical and cultural dynamics in East Asian critical-care settings mediate reflective learning. Addressing this gap, the present study investigates the impact of a VRE intervention on the linguistic features of multidisciplinary ICU discussions using LIWC-22 analysis, supplemented by participants\u0026rsquo; reflective commentaries.\u003c/p\u003e \u003cp\u003eThe study aims to elucidate how reflection mediates the cognitive and social mechanisms of CCR. Specifically, it asks:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDo linguistic markers associated with analytical thinking, insight, tentativeness, authenticity, and clout shift following VRE-facilitated reflection?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow do participants interpret observed linguistic changes in relation to their reasoning, roles, and participation during reflective think-alouds?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat do convergences between quantitative and qualitative findings reveal about how VRE fosters communicative equity and epistemic humility in interprofessional teams?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eDesign and Theoretical Orientation\u003c/h2\u003e \u003cp\u003eThis Groundwork study employed a mixed-methods, video-reflexive ethnographic design [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] to explore how reflective viewing and discussion of clinical encounters influence the linguistic and cognitive dimensions of CCR in an ICU. The design aligns with the constructivist view that learning emerges from reflection on authentic practice [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and the distributed cognition perspective that reasoning is co-constructed through interaction, artifacts, and shared context [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Quantitative linguistic data were integrated with qualitative reflections to examine \u003cem\u003ehow\u003c/em\u003e the VRE process mediates communicative and epistemic change.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting and Participants\u003c/h3\u003e\n\u003cp\u003eThe study took place in the neuro-intensive care unit of a tertiary teaching hospital in Taiwan. The ICU operates as a multidisciplinary environment where clinical reasoning unfolds dynamically through rounds, briefings, and informal discussions. Purposive sampling identified twelve participants\u0026mdash;five physicians, six nurses, and one respiratory therapist\u0026mdash;representing a range of professional roles and hierarchical positions involved in team-based clinical reasoning. Participants were invited through departmental announcements, and all agreed to participate in the study. Inclusion criteria required at least one year of ICU experience and fluency in Mandarin Chinese.\u003c/p\u003e \u003cp\u003e \u003cb\u003eData Collection\u003c/b\u003e \u003c/p\u003e \u003cp\u003e1. Ethnographic Videography of Team Interactions\u003c/p\u003e \u003cp\u003eThe primary method of data collection involved video and audio recordings of NICU team conversations during bedside patient rounds. This ethnographic videography approach enabled researchers to document real-time interactions, providing rich insights into team behaviours, communication dynamics, and clinical decision-making processes. This methodology aligns with existing research that emphasizes the importance of studying clinical reasoning in its naturalistic context. Researchers shadowed the NICU team, recording bedside patient rounds using hand-held video cameras for approximately one hour at a time. Recordings were conducted once per month for six months, resulting in a minimum of six recorded patient round sessions. The sample size of participants varied depending on the day of recording. For example, on a typical day, two chief neurosurgeons, two junior physicians (residents and interns), and three registered nurses were observed interacting within the NICU team. In addition to capturing verbal communication, observations focused on non-verbal behaviours, role negotiations, and the use of clinical cues that initiated collaborative discussions. Researchers also maintained field notes documenting chronological accounts of observed interactions, contextual factors influencing communication, and any emergent themes related to clinical reasoning.\u003c/p\u003e \u003cp\u003e2. Reflective and Retrospective Think-Aloud Sessions\u003c/p\u003e \u003cp\u003eReflective practice is a core component of professional development in healthcare, enabling practitioners to critically examine their reasoning and decision-making processes. In this study, reflective and retrospective think-aloud sessions were integrated as a structured educational strategy to support critical reflection on collaborative clinical reasoning.\u003c/p\u003e \u003cp\u003eTo examine potential changes in clinical reasoning and team-based decision-making, video-recorded data from bedside observations were analysed before and after participants engaged in reflective think-aloud sessions. The retrospective think-aloud approach was designed to prompt participants to articulate their reasoning while reviewing selected video excerpts of their own patient-round interactions.\u003c/p\u003e \u003cp\u003eResearchers reviewed the video recordings and edited short segments (10\u0026ndash;20 minutes each) that captured key moments of collaborative clinical reasoning. These edited clips were used as stimuli during the think-aloud sessions, during which participants were invited to reflect on and explain their reasoning processes. Specifically, participants were encouraged to:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDescribe their thought processes in reaching a diagnosis or treatment plan.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eExplain the reasoning behind specific statements, questions, or actions observed in the footage.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIdentify any factors that influenced their decisions during clinical encounters.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eReflect on interactions with other team members and their impact on shared reasoning.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eParticipants were able to pause, replay, or revisit video segments as needed to support articulation of their thought processes. Reflective discussions were conducted either concurrently with the think-aloud activity or in a subsequent facilitated discussion. Facilitation was guided by a semi-structured interview guide developed specifically for this study, informed by ethnographic observations and relevant literature on collaborative clinical reasoning and reflective practice. An English version of the interview guide is provided as Supplementary File 1.\u003c/p\u003e \u003cp\u003eAll reflective think-aloud sessions were audio-recorded and lasted approximately one to two hours. Recordings were transcribed verbatim and analysed to identify patterns in collaborative clinical reasoning, decision-making strategies, and communicative behaviours among neuro-intensive care unit team members.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eA total of eight recordings were collected. The video recordings were transcribed in Mandarin, the participants\u0026rsquo; primary language, and then translated into English. The translation process involved a team of bilingual experts who ensured accuracy and retention of original meanings.\u003c/p\u003e \u003cp\u003eThis study employed LIWC to perform a systematic, computational analysis of language use [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. LIWC enables researchers to analyse both psychological processes and linguistic content by categorizing words into predefined semantic and cognitive domains. LIWC operates by comparing each word in a transcript to an established dictionary of linguistic categories, calculating the frequency of words related to cognitive, emotional, and social processes. For example, the word encourage may fall under multiple categories such as social, emotional, positive emotion, and cognitive processing. Similarly, the word remorseful may be categorized under negative emotion, sadness, and discrepancy words. By quantifying linguistic features, LIWC provides objective insights into team communication, cognitive reasoning patterns, and emotional tone.\u003c/p\u003e \u003cp\u003eLIWC Analysis Process\u003c/p\u003e \u003cp\u003eThe analysis of transcribed team interactions during patient rounds followed a structured five-step process [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eData Collection: Transcripts were obtained from pre- and post-intervention video recordings of NICU ward rounds.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eText Preprocessing: Transcripts were formatted and reviewed for consistency before uploading them into the LIWC software.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLIWC Analysis: Specific lexical categories related to cognitive processes (e.g., reasoning, insight), social interaction (e.g., collaboration, communication), and certainty markers were analysed.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eComparative Analysis: Differences in language use before and after the VRE intervention were assessed to detect changes in collaborative reasoning patterns.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eInterpretation of Results: Findings were analysed to determine how VRE influenced team-based communication, cognitive engagement, and social dynamics in the NICU setting.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eA paired samples t-test was conducted to compare mean LIWC category scores pre- and post-intervention, identifying statistically significant differences in cognitive, emotional, and social language features.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003efor the study was obtained from the hospital\u0026rsquo;s institutional review board (Approval No. 202002453B0). Participants\u0026rsquo; confidentiality was maintained through anonymized transcripts and secure data storage. Informed consent was obtained before recording, and participants could withdraw at any time without consequences.\u003c/p\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThis section presents the findings from the study, focusing on the changes in linguistic patterns observed through LIWC analysis, as well as qualitative insights derived from reflective think-aloud sessions. The results are organized to reflect the primary and secondary research questions, emphasizing the impact of the reflective practice intervention on CCR.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Demographics\u003c/h2\u003e \u003cp\u003eA total of 12 participants were recruited for this study, consisting of 4 attending physicians, 2 resident physicians, 5 registered nurses, and 1 respiratory therapist. These participants engaged in bedside clinical case discussions during ward rounds, with each case discussion lasting approximately 3 to 5 minutes. Each ward round included at least two different professional roles, ensuring interprofessional engagement in CCR. The primary data source comprised clinical video recordings, with four groups of ward rounds involving first-time participants, and four groups including members who had previously participated in post-video interviews and were now engaging in a second recording session. Participants were also involved in one-on-one interviews lasting 20 to 30 minutes, during which they reviewed their own clinical video recordings. These retrospective reflections provided insights into their reasoning processes and discussions related to CCR. The clinical video recordings were transcribed and analysed using LIWC, focusing on ten psychological and linguistic categories relevant to clinical reasoning. Independent t-tests were conducted to compare pre- and post-intervention mean scores across different LIWC categories.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative Analysis: Linguistic Changes Post-Intervention\u003c/h2\u003e \u003cp\u003eStatistical analysis revealed no significant differences in the participants' linguistic usage post-intervention. However, notable trends in the LIWC categories suggested potential shifts in cognitive and social dynamics following the intervention. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the comparison of pre- and post-intervention score across LIWC categories.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of LIWC Psychological and Linguistic Categories Pre- and Post-Intervention\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLIWC Category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-Intervention Mean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-Intervention Mean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnalytical Thinking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.13 (6.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.15 (7.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.447\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClout\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49.34 (10.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46.38 (19.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.793\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthentic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41.76 (11.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47.88 (12.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.506\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21.69 (11.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.72 (12.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.506\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive Processes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15.08 (1.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.99 (1.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.462\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInsight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.35 (0.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.34 (0.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.066\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCausation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.88 (1.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.98 (1.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.361\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscrepancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.87 (0.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.07 (0.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.177\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTentative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.73 (1.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.34 (1.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.147\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Processes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.13 (2.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.83 (2.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.847\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eQualitative Interpretations of Linguistic Trends\u003c/h2\u003e \u003cp\u003eAlthough the LIWC results did not yield statistically significant differences, certain patterns in language use suggest potential cognitive and communicative shifts among participants post-intervention.\u003c/p\u003e \u003cp\u003e1. Increase in Analytical Thinking\u003c/p\u003e \u003cp\u003eThe mean analytical thinking score increased from 9.13 to 13.15, indicating a trend toward more structured, logical reasoning in clinical discussions. Participants appeared to rely more on explicitly structured arguments and logical explanations, suggesting greater use of System 2 thinking in reasoning.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eExample\u003c/strong\u003e \u003cp\u003e\u0026bull; \u0026ldquo;Based on the CT results, the intracranial pressure is not high, and we plan to conduct blood tests and an X-ray on Thursday.\u0026rdquo;\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eKey LIWC words: \u0026ldquo;Based on,\u0026rdquo; \u0026ldquo;conduct,\u0026rdquo; \u0026ldquo;plan\u0026rdquo;\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e2. Decrease in Clout: Shift in Power Distribution\u003c/p\u003e \u003cp\u003eA decline in clout scores (49.34 to 46.38) was observed, with an increase in variability post-intervention. This may reflect a more balanced distribution of authority within the team, suggesting that collaborative decision-making became more egalitarian, rather than being dominated by senior physicians.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eExample\u003c/strong\u003e \u003cp\u003e\u0026bull; \u0026ldquo;No need for a gram stain, directly proceed with the routine check.\u0026rdquo;\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eKey LIWC words: \u0026ldquo;No need,\u0026rdquo; \u0026ldquo;directly\u0026rdquo; (indicative of hierarchical authority pre-intervention)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e3. Increase in Authentic Communication\u003c/p\u003e \u003cp\u003eParticipants exhibited a higher level of authenticity in communication post-intervention (41.76 to 47.88), suggesting they engaged in more open, reflective discussions. This may indicate greater self-awareness and honesty in clinical reasoning.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eExample\u003c/strong\u003e \u003cp\u003e\u0026bull; \u0026ldquo;His breathing doesn\u0026rsquo;t seem as smooth. I\u0026rsquo;m concerned and think we need to observe a bit more.\u0026rdquo;\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eKey LIWC words: \u0026ldquo;concerned,\u0026rdquo; \u0026ldquo;observe\u0026rdquo;\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e4. Rise in Tentative Language: Cautious Clinical Reasoning\u003c/p\u003e \u003cp\u003eThe tentative language score increased from 2.73 to 4.34, suggesting participants adopted a more cautious and deliberative approach to clinical reasoning. This may reflect a greater awareness of uncertainty in decision-making and an increased willingness to consider alternative diagnoses.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eExample\u003c/strong\u003e \u003cp\u003e\u0026bull; \u0026ldquo;It seems that the patient\u0026rsquo;s symptoms may be caused by an infection, but it\u0026rsquo;s still uncertain.\u0026rdquo;\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eKey LIWC words: \u0026ldquo;seems,\u0026rdquo; \u0026ldquo;may,\u0026rdquo; \u0026ldquo;uncertain\u0026rdquo;\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e5. Increase in Insight: Deeper Reflection on Cases\u003c/p\u003e \u003cp\u003eThe insight category increased from 1.35 to 2.34, indicating that participants were engaging in more reflective and self-aware discussions post-intervention. Greater insight is associated with critical thinking and deeper cognitive engagement.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eExample\u003c/strong\u003e \u003cp\u003e\u0026bull; \u0026ldquo;This case reminds me of a similar one I handled before.\u0026rdquo;\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eKey LIWC words: \u0026ldquo;reminds,\u0026rdquo; \u0026ldquo;handled,\u0026rdquo; \u0026ldquo;similar case\u0026rdquo;\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined the impact of VRE on CCR in multidisciplinary teams within a NICU. By integrating qualitative ethnographic videography with computational linguistic analysis using LIWC, this research sought to identify linguistic and cognitive shifts following a structured reflective intervention. While no statistically significant differences were observed across LIWC categories, notable trends suggest subtle but meaningful shifts in participants' cognitive and communicative engagement post-intervention. Specifically, increases in analytical thinking, tentative language, insight, and authenticity suggest a move toward more structured, reflective, and participatory decision-making. The observed decline in clout scores indicates a redistribution of authority within the team, pointing to a shift toward a more egalitarian approach to clinical decision-making. These findings contribute to ongoing discussions on the role of VRE in enhancing interdisciplinary collaboration, fostering cognitive flexibility, and promoting reflective practice in high-stakes healthcare environments.\u003c/p\u003e \u003cp\u003eThe observed linguistic shifts align with dual-process models of reasoning which delineate intuitive versus analytical reasoning [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The post-intervention increase in analytical thinking scores suggests a shift toward more deliberate, evidence-based decision-making, characteristic of System 2 processing. As emphasized in Markowitz et al., analytic thinking scores in LIWC do not directly measure intelligence but rather reflect a cognitive style\u0026mdash;a preference for systematic, effortful processing of information [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This distinction is crucial, as it suggests that post-VRE, participants were more motivated to engage in deeper reasoning and reflection rather than merely exhibiting superior cognitive ability. The changes in function words\u0026mdash;particularly tentative language and insight-related words\u0026mdash;indicate increased cognitive flexibility and a greater openness to reconsidering decisions [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This linguistic shift aligns with research on diagnostic calibration, which suggests that overconfident physicians are less likely to seek additional information, increasing the risk of diagnostic errors [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Encouraging epistemic humility\u0026mdash;where clinicians acknowledge uncertainty and actively seek additional perspectives\u0026mdash;may counteract this tendency, leading to more thorough reasoning and improved diagnostic accuracy [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe rise in tentative language (e.g., words such as \u0026ldquo;seems,\u0026rdquo; \u0026ldquo;might,\u0026rdquo; and \u0026ldquo;possibly\u0026rdquo;) is particularly significant. In traditional ICU settings, clinicians are often expected to communicate with confidence, minimizing expressions of doubt [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, the increase in tentative language suggests that VRE facilitated a shift toward a more open, exploratory reasoning process, where team members were willing to consider alternative explanations and discuss diagnostic uncertainty [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. This has direct implications for improving diagnostic accuracy and fostering a culture of collaborative inquiry rather than authoritative decision-making.\u003c/p\u003e \u003cp\u003eThe decline in clout scores in post-intervention suggests a redistribution of authority within the NICU team. Traditional ICU team dynamics often reflect strong hierarchical structures, with senior physicians dominating discussions while junior team members, including nurses, may be less inclined to voice their perspectives [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The decrease in clout indicates that VRE may have contributed to flattening these hierarchical structures, allowing for more balanced participation in decision-making. Additionally, the findings of Moore et al. suggest that lower clout is often associated with deeper engagement in cognitive processing, indicating that junior clinicians may be contributing more meaningfully to discussions, even if their statements appear less authoritative [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. This shift in conversational dynamics is crucial for enhancing team-based reasoning and ensuring that all perspectives\u0026mdash;particularly those from traditionally less dominant voices\u0026mdash;are integrated into clinical decision-making.\u003c/p\u003e \u003cp\u003eThe findings reinforce VRE as a powerful tool for promoting reflective practice in medical education. Reflection is a key component of experiential learning theory, which posits that deep learning occurs when individuals analyse their experiences, extract insights, and apply them to future decision-making [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The increase in authenticity scores post-intervention suggests that participants engaged in more self-aware, honest discussions about their clinical reasoning processes, further supporting the role of VRE in fostering meta-cognitive awareness and self-assessment. To maximize the impact of VRE, medical educators should incorporate structured debriefing protocols that encourage clinicians to analyse their linguistic choices, cognitive biases, and reasoning strategies. Reflective discussions should focus on how language shapes team cognition, the role of epistemic humility in clinical decision-making, and strategies for mitigating cognitive errors.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eResearch Limitations\u003c/h2\u003e \u003cp\u003eWhile this study provides valuable insights into the impact of VRE on CCR within multidisciplinary ICU teams, several limitations should be considered when interpreting the findings. These limitations highlight areas for future research and methodological refinements. One primary limitation is the small sample size, which may have restricted the statistical power of the analysis and limited the ability to detect significant differences across linguistic and cognitive measures. Given the dynamic nature of ICU settings, where team composition varies daily, findings may not be fully generalizable to other clinical environments or healthcare institutions. Future studies should aim to include larger and more diverse samples, incorporating multiple hospital settings and different medical disciplines to enhance the external validity of the findings. Moreover, the high-stakes, time-sensitive nature of ICU environments may have influenced participant behaviours and linguistic patterns. Clinicians may have adapted their communication styles due to the awareness of being recorded (i.e., the Hawthorne effect), potentially affecting the authenticity of team interactions. Although efforts were made to minimize observer effects, future research could explore longitudinal designs or more discreet recording methods to capture more naturalistic communication patterns. Although LIWC is a powerful tool for quantifying linguistic and cognitive patterns, it has inherent limitations. LIWC categorizes words based on predefined lexical databases but may not fully capture nuanced aspects of clinical discourse, rhetorical strategies, or the deeper meaning of conversations. Future research could employ a mixed-methods approach, integrating LIWC with qualitative discourse analysis or ethnographic fieldwork, to gain a richer understanding of how language shapes collaborative reasoning in ICU teams. Despite these limitations, this study contributes to the growing body of research on VRE as an effective tool for enhancing interprofessional communication and collaborative reasoning in ICU teams. Addressing these limitations through expanded sample sizes, longitudinal tracking and qualitative integration will strengthen the evidence base for VRE and further refine its application in medical education and clinical practice.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study contributes to the growing body of research supporting VRE as an effective intervention for enhancing collaborative clinical reasoning in ICU teams. By incorporating structured reflection, epistemic humility training, and psychological safety interventions, institutions can leverage VRE to develop more adaptive, communicative, and cognitively engaged healthcare teams. Future research should explore scalable implementations of VRE across different clinical environments, longitudinal effects on reasoning patterns, and integration with emerging AI-driven linguistic analysis tools.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eThe study was approved by the Institutional Review Board of Chang Gung Medical Foundation (IRB No. 202002453B0). Written informed consent to participate was obtained from all participants prior to data collection. All procedures involving human participants were conducted in accordance with the ethical standards of the institutional research committee and with the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot required as all figures and tables within the manuscript were created by the research team.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eNone.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis work was supported by Chang Gung Medical Foundation, Taiwan [grant number: CORPG3G1071] and by Ministry of Science and Technology (R.O.C.): [grant number: NSTC 113-2628-H-182-002-MY2]\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eChing-Yi Lee secured funding and ethical approvals, coordinated research activities, and was responsible for data collection, analysis, and drafting the manuscript. Hung-Yi Lai and Ching-Hsin Lee conducted the statistical analysis, contributed to the interpretation of quantitative findings, and assisted in drafting the results section. Mi-Mi Chen facilitated participant recruitment, managed data collection, and provided critical input on the study's cultural and clinical context. Sze-Yuen Yau led the study design, provided overall supervision, guided the study's direction, critically reviewed the manuscript, and managed submission and correspondence with the journal.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data supporting the findings of this study are available within the paper and its Supplementary Information.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNorman GR, Eva KW. Diagnostic error and clinical reasoning. Med Educ. 2010;44(1):94\u0026ndash;100.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErvin JN, Kahn JM, Cohen TR, Weingart LR. Teamwork in the intensive care unit. Volume 73. American Psychological Association; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFigueroa MI, Sepanski R, Goldberg SP, Shah S. Improving teamwork, confidence, and collaboration among members of a pediatric cardiovascular intensive care unit multidisciplinary team using simulation-based team training. Pediatr Cardiol. 2013;34(3):612\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDietz AS, Pronovost PJ, Mendez-Tellez PA, Wyskiel R, Marsteller JA, Thompson DA, Rosen MA. A systematic review of teamwork in the intensive care unit: what do we know about teamwork, team tasks, and improvement strategies? J Crit Care. 2014;29(6):908\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLingard L, Espin S, Evans C, Hawryluck L. The rules of the game: interprofessional collaboration on the intensive care unit team. Crit Care. 2004;8:1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalas EE, Fiore SM. Team cognition: Understanding the factors that drive process and performance. American Psychological Association; 2004.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCroskerry P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv Health Sci Educ. 2009;14(Suppl 1):27\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeritage J, Maynard DW. Communication in medical care: Interaction between primary care physicians and patients. Volume 20. Cambridge University Press; 2006.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHutchins E. Cognition in the Wild. MIT Press; 1995.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLingard L, Espin S, Whyte S, Regehr G, Baker GR, Reznick R, Bohnen J, Orser B, Doran D, Grober E. Communication failures in the operating room: an observational classification of recurrent types and effects. BMJ Qual Saf. 2004;13(5):330\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeritage J. Epistemics in action: Action formation and territories of knowledge. Res Lang social Interact. 2012;45(1):1\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEdmondson A. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121(5):S2\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatchett CL, Usher EL, Ratelle JT, Suarez DA, Leep Hunderfund AN, Aragon Sierra AM, Sawatsky AP. Physician humility: a review and call to revive virtue in medicine. Ann Intern Med. 2024;177(9):1251\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSch\u0026ouml;n DA. The reflective practitioner: How professionals think in action. Routledge; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKolb DA. Experiential learning: Experience as the source of learning and development. FT; 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAjjawi R, Hilder J, Noble C, Teodorczuk A, Billett S. Using video-reflexive ethnography to understand complexity and change practice. Med Educ. 2020;54(10):908\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIedema R. Video-reflexive ethnography as potentiation technology: what about investigative quality? Qualitative Res Psychol. 2021;18(3):387\u0026ndash;405.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePennebaker JW, Boyd RL, Jordan K, Blackburn K. The development and psychometric properties of LIWC2015. 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarkowitz DM. Analytic thinking as revealed by function words: What does language really measure? Appl Cogn Psychol. 2023;37(3):643\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoksimovic S, Gasevic D, Kovanovic V, Adesope O, Hatala M. Psychological characteristics in cognitive presence of communities of inquiry: A linguistic analysis of online discussions. internet High Educ. 2014;22:1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCui Y, Wise AF, Allen KL. Developing reflection analytics for health professions education: A multi-dimensional framework to align critical concepts with data features. Comput Hum Behav. 2019;100:305\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWoodward-Kron R, Stevens M, Flynn E. The medical educator, the discourse analyst, and the phonetician: A collaborative feedback methodology for clinical communication. Acad Med. 2011;86(5):565\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShrader S, Kern D, Zoller J, Blue A. Interprofessional teamwork skills as predictors of clinical outcomes in a simulated healthcare setting. J Allied Health. 2013;42(1):e1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLang JM, Meixensberger J, Unterberg AW, Tecklenburg A, Krauss JK. Neurosurgical intensive care unit\u0026mdash;essential for good outcomes in neurosurgery? Langenbeck's archives Surg. 2011;396:447\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeyer AN, Payne VL, Meeks DW, Rao R, Singh H. Physicians\u0026rsquo; diagnostic accuracy, confidence, and resource requests: a vignette study. JAMA Intern Med. 2013;173(21):1952\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEvans AM, Stavrova O, Rosenbusch H. Expressions of doubt and trust in online user reviews. Comput Hum Behav. 2021;114:106556.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoore RL, Yen CJ, Powers FE. Exploring the relationship between clout and cognitive processing in MOOC discussion forums. Br J Edu Technol. 2021;52(1):482\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarvey M, Coulson D, McMaugh A. Towards a theory of the ecology of reflection: Reflective practice for experiential learning in higher education. J Univ Teach Learn Pract 2016, 13(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKolb A, Kolb D. Eight important things to know about the experiential learning cycle. Australian educational Lead. 2018;40(3):8\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Collaborative clinical reasoning, Reflective learning, Video reflexive ethnography, Linguistic analysis, Interprofessional education","lastPublishedDoi":"10.21203/rs.3.rs-8488427/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8488427/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCollaborative clinical reasoning (CCR) is essential to safe and effective practice in intensive care units, where decisions are shaped by uncertainty, high cognitive load, and interprofessional dynamics. Although CCR is widely recognised as a collective cognitive process, little is known about how clinicians learn to reason together or how reflective educational interventions influence the language and social organisation through which CCR is enacted.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis mixed-methods Groundwork study examined the impact of a Video Reflexive Ethnography (VRE) intervention on CCR within a multidisciplinary neuro-intensive care unit in Taiwan. Twelve clinicians (physicians, nurses, and a respiratory therapist) were video-recorded during routine bedside rounds. Transcripts of team interactions before and after the VRE intervention were analysed using Linguistic Inquiry and Word Count (LIWC-22) to examine markers of analytical thinking, clout, authenticity, cognitive processing, and social interaction. Quantitative linguistic trends were interpreted alongside qualitative data from retrospective reflective think-aloud sessions in which participants reviewed and discussed selected video excerpts of their own practice.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eNo statistically significant differences were observed across LIWC categories following the intervention. However, consistent linguistic trends suggested shifts toward more reflective and collaborative reasoning. Post-intervention interactions demonstrated increased use of language associated with analytical thinking, insight, tentativeness, and authenticity, alongside a decrease in clout-related language. During reflective sessions, participants described heightened awareness of their own communicative habits, greater openness to uncertainty, and increased willingness to invite and consider alternative perspectives from other team members.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eBy integrating video-reflexive inquiry with computational linguistic analysis, this study provides insight into how reflection may reshape the cognitive and social dimensions of collaborative clinical reasoning. The findings suggest that VRE can support communicative equity and epistemic humility in interprofessional teams, even when changes are subtle and not readily captured by traditional outcome measures. This work highlights the value of combining qualitative and linguistic approaches to examine learning processes in authentic clinical environments and informs the design of reflective faculty development and interprofessional education initiatives.\u003c/p\u003e","manuscriptTitle":"Learning to Reflect Together: A Video Reflexive Ethnography and Linguistic Analysis of Collaborative Clinical Reasoning in Intensive Care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-09 12:35:23","doi":"10.21203/rs.3.rs-8488427/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-30T05:27:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-17T18:06:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"127871223169014904385888083898339986952","date":"2026-03-11T17:15:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"49138151604708191429583716630028476587","date":"2026-02-24T07:59:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-17T13:10:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-12T12:16:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"150399590557023404962822330837509707279","date":"2026-02-09T13:08:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"176159709155157153175865018502029482329","date":"2026-02-07T06:04:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-04T15:22:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-29T10:39:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-08T07:18:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-08T07:00:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-01-08T06:47:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d038432a-1831-446c-8df5-69c190be8f7f","owner":[],"postedDate":"February 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T11:10:25+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-09 12:35:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8488427","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8488427","identity":"rs-8488427","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}