Clinical reasoning (CR) is the cognitive process by which physiotherapists collect, analyse and synthesise patient information to make informed decisions (Hage et al. 2022). While clinical reasoning refers to how clinicians think (cognitive and metacognitive processes), clinical decision-making is what clinicians decide to do following the underlying interpretive process of reasoning (Hage et al. 2022). In physiotherapy, effective CR is essential for safe, high-quality care, particularly in intensive care units (ICU), where rapid decisions may influence survival and recovery (Gosselink et al. 2008). However, there is limited evidence on how CR is developed and enacted by undergraduate physiotherapy novices in ICU settings globally and in South Africa.

The ICU is a complex, high-acuity and stressful environment in which physiotherapists manage critically ill patients with multiple comorbidities, advanced monitoring and life-support technologies (Van Aswegen, Patman & Plani 2017). The physiotherapists’ role has long been reported as critical in the ICU multidisciplinary team and includes respiratory management, early mobilisation and prevention of ICU-acquired weakness, all of which require ongoing risk–benefit evaluation (Hanekom et al. 2011; Norrenberg & Vincent 2000). Recent work continues to highlight the central role of physiotherapists in early mobilisation, respiratory care, effective patient communication, and goal setting and functional recovery, reinforcing the need for robust CR skills in this setting (Amundadottir et al. 2017; Karachi et al. 2023). Clinical decisions must integrate pathophysiology, functional status, haemodynamic stability and ventilatory support within a multidisciplinary team. Therefore, these differences in the physiotherapeutic management of critically ill patients may require a different set of skills to develop clinical reasoning in physiotherapy novices and clinicians working in the ICU.

Within physiotherapy, CR typically involves problem identification, hypothesis generation and testing, and treatment planning across assessment and intervention (Jones, Jensen & Edwards 2008). Both novice and expert physiotherapists use hypothetico-deductive reasoning, but experts rely on rapid pattern recognition supported by experiential knowledge (Doody & McAteer 2002; Jensen et al. 2000).

Over time, changes in knowledge organisation allow experts to recognise familiar clinical patterns and act efficiently, whereas novices depend more on explicit, rule-based reasoning (Christensen et al. 2017; Rivett & Higgs 1997). For undergraduate physiotherapy novices, this involves transferring classroom learning into a setting characterised by uncertainty, high stakes and unfamiliar equipment. Clinical reasoning development in such environments depends not only on knowledge, but also on opportunities for guided practice, supervision, feedback and reflection (Schön 1983; Wijbenga et al. 2020).

Most work on CR in physiotherapy has focused on musculoskeletal and neurological practice, with less attention to cardiorespiratory and critical care settings (Smith, Higgs & Ellis 2007b; Smith, Higgs & Ellis 2008). The distinctive features of ICU practice, including technological complexity and the emotional burden of caring for critically ill patients, suggest that CR processes may differ from those in other areas of physiotherapy. Understanding how physiotherapy novices and experienced physiotherapy clinicians describe and perform CR in the intensive care clinical environment can inform curriculum design and clinical education strategies that better prepare novices for critical care practice.

Gaining insight into clinical reasoning processes from both novice and expert perspectives, and identifying potential gaps between these viewpoints, could inform improvements in physiotherapy clinical education for intensive care practice. Therefore, this paper describes the exploration of undergraduate physiotherapy students (novices) and clinicians (experts) perceptions of their clinical reasoning processes and practices in intensive care settings in the Western Cape, South Africa.

This study contributes to the growing qualitative evidence on how physiotherapy students (novices) and clinicians (experts) develop clinical reasoning within the complex and dynamic environment of intensive care. It underscores the need for a revised approach to both theoretical and clinical physiotherapy education. The study recognises how positive and negative environmental, educational/curricula and personal factors, as well as clinical exposure and experience shape novices’ and clinicians’ reasoning processes, and strengthen their capacity to apply effective critical thinking, reasoning and decision-making strategies in ICU practice. In this study, clinical reasoning is understood as the cognitive and interpretive processes through which physiotherapists gather, integrate and evaluate information, whereas clinical decision-making refers to the observable choices and actions that follow from these reasoning processes. Whilst closely interrelated in practice, this distinction guided the analysis, with themes reflecting influences on reasoning processes, decision outcomes, or both. A common starting point in the clinical reasoning process of both the novice and expert physiotherapist in ICU practice included information gathering, assessment planning and hypothesis formulation. Novices and experts used patient medical records and objective assessments to formulate hypotheses, identify problems and plan effective treatments for ICU patient management. This aligns with models of physiotherapy CR that emphasise systematic data collection as the foundation of decision-making. Both groups focused on diagnosis, medical history, trends in vital signs and precautions and contraindications as the process-oriented activities that captured how clinical understanding was constructed and justified to assist in deciding whether and how to manage the ICU patient (Edwards et al. 2004; Jones et al. 2008). This finding therefore suggests that ICU services should reinforce structured assessment protocols and ensure that physiotherapists, novice and expert, have consistent access to comprehensive patient records and monitoring data, supporting accurate hypothesis formulation and safe, evidence-based decision-making. With regard to physiotherapy, theoretical and clinical training in intensive care curricula, the findings suggest that academic and clinical educators should explicitly teach and scaffold systematic information gathering and hypothesis-driven assessment processes. This can be achieved by using case-based learning, simulation, virtual or augmented reality and real-life cases, as well as guided practice (clinician support) to strengthen novices’ ability to apply these core components of clinical reasoning in ICU settings.

The clinicians (expert) clinical reasoning processes could be deemed as somewhat superior to novice physiotherapists because of their years of clinical experience and exposure in the ICU and lifelong learning. Clinicians’ accounts reflected pattern recognition and experiential judgement, drawing on repeated exposure to similar cases and postgraduate training knowledge and information. They described ‘automatic’ observations at the bedside and intuitive responses to subtle changes in patient status, consistent with literature on expert clinicians’ integrated, non-analytical reasoning informed by tacit knowledge. Clinicians reported drawing sometimes explicitly and sometimes ‘subconsciously’ on the ICF, Disability and Health when identifying problems and planning interventions, framing reasoning around impairments, activity limitations and participation restrictions in ICU patient management.

Novices were not explicitly asked about their use of frameworks, and they did not spontaneously refer to the ICF when discussing clinical reasoning related to ICU patient management. It cannot, therefore, be concluded that they did not use the ICF; rather, the data suggest that they focused on course content and condition-specific knowledge when talking about their clinical reasoning development and process. This represents a limitation and indicates a need for research that explicitly explores how novices understand and apply frameworks such as the ICF, as structured frameworks can provide scaffolding for novice reasoning development (Christensen et al. 2017) in ICU practice. Nonetheless, the apparent gap between clinicians’ informal ICF-informed reasoning and novices’ emphasis on condition-specific theory suggests a potential educational opportunity. More explicit integration of ICF-based reasoning in ICU teaching and supervision may help bridge the transition from classroom frameworks to clinical application.

Novices identified several factors that enhanced their critical thinking, reasoning and decision-making in intensive care. They emphasised the role of prior theoretical knowledge, particularly respiratory and cardiorespiratory content, in helping them recognise problems and understand complex patient presentations.

Novices, by contrast, emphasised structured, theory-based thinking. They described applying classroom content to unfamiliar ICU presentations, revisiting lectures and notes, and using pathophysiological concepts to justify treatment choices. Their descriptions suggest a stepwise hypothetico-deductive process with strong reliance on formal theoretical knowledge and independent reading. The conclusion that novices used theory-based approaches is grounded in their self-reported preparation and decision-making rather than direct observation.

Independent learning strategies, such as revising notes, consulting guidelines and journals, and using online resources, were commonly used to address knowledge gaps before and during ICU blocks and were perceived to improve reasoning and confidence. Repeated exposure to the ICU environment and support from clinicians and clinical educators were also central to guiding their clinical reasoning ability and skills. Working with ICU patients daily helped novices move from generic diagnosis-focused thinking towards more patient-specific reasoning, whilst prompts and feedback from supervisors helped them to ‘see the bigger picture’ and refine their thinking.

These findings reinforce the importance of structured clinical education, mentorship, clinician support and feedback in scaffolding CR development in ICU practice and furthermore support the importance of fostering self-directed learning skills early in physiotherapy education to prepare novices for lifelong learning in clinical practice (Mann, Gordon & MacLeod 2017). The findings in theme 2 suggest that ICU clinical teams and educators should provide structured supervision, regular feedback, and repeated exposure to varied patient cases to help novices transition from theory-driven, stepwise reasoning to more nuanced, patient-specific clinical reasoning and decision-making, ultimately strengthening their confidence and performance in complex ICU care. Curricula should integrate strong foundational teaching in cardiorespiratory theory with opportunities for independent learning, case-based reasoning, and progressive clinical immersion, ensuring novices can effectively apply theoretical knowledge, address knowledge gaps and refine their clinical reasoning through guided practice and reflective support.

Novices reported environmental, curricula and personal constraints to their clinical reasoning development process. Thus, their ability to critically think and make decisions in the ICU, where rapid responses are required to sudden changes in critically ill patients’ conditions, is affected. The ICU environment was perceived as stressful and highly technological, with constant alarms and complex equipment affecting their ability to think clearly (Major et al. 2020).

Unfamiliarity with ventilators, monitoring devices and certain conditions contributed to a sense of under-preparedness. The legacy of COVID-19 and online learning was evident, with novices noting that reduced in-person teaching and limited early hands-on ICU practice made it harder to transfer classroom learning into ICU clinical practice. These concerns echo reports by Chesterton, Richardson and Tears (2022) of disrupted training affecting the development of practical clinical skills and highlight the particular vulnerability of cohorts whose formative learning occurred largely online. Novices described fear, anxiety and self-doubt, particularly when treating critically ill or end-of-life patients as personal constraints to their clinical reasoning development and process in the ICU.

Some reported leaving the ICU feeling that they had ‘underperformed’, even when they had completed assessments and treatments. These emotional responses appeared to interfere with their ability to reason clearly and confidently during ICU patient management. The prominence of emotional burden in novices’ accounts adds an important dimension to existing models of CR, which are often primarily cognitive. In environments such as the ICU, emotional reactions may be central influences on how information is noticed, interpreted and acted upon.

Addressing these affective dimensions may therefore be as important as teaching reasoning strategies and frameworks. These findings suggest that ICU teams should provide structured orientation, gradual familiarisation with technology, and supportive supervision that actively addresses novices’ emotional responses, helping reduce cognitive overload and enabling clearer reasoning and safer decision-making in high-pressure scenarios in the ICU. Physiotherapy programmes should strengthen hands-on ICU preparation through simulation, early skills training, and emotionally informed teaching approaches, incorporating debriefing, reflective practice, and resilience-building. This may then ensure novices can transfer theoretical knowledge into practice whilst managing the environmental, curricular, and emotional demands of ICU care.

Overall, physiotherapy clinical reasoning in the ICU is shaped by a complex interplay of theoretical knowledge, clinical experience, environmental pressures and emotional factors, underscoring the need for integrated educational and clinical strategies that strengthen foundational reasoning skills, support experiential learning, and address the affective challenges of critical care practice. These inductively derived findings extend existing clinical reasoning models by foregrounding emotional and environmental influences that are often implicit or underexplored, particularly in high-acuity settings such as the ICU.

This study shows that whilst physiotherapy novices and experts share foundational reasoning processes, experts’ experience enables more nuanced, adaptive decision-making in ICU care.

The depth of clinical reasoning between novice and expert physiotherapists differs, with clinicians’ greater experience and situational familiarity enabling more advanced reasoning in ICU care.

Physiotherapy clinical reasoning in the ICU is shaped by a dynamic interaction of knowledge, experience, environment, and emotion. Whilst novices rely heavily on theoretical foundations and stepwise reasoning, their development is challenged by the technological intensity, stress and rapid decision-making demands of the ICU.

Repeated exposure, supportive supervision and opportunities to integrate theory with practice gradually strengthen their confidence and reasoning sophistication. Importantly, emotional factors profoundly influence how novices interpret and act on clinical information. Together, these insights highlight the need for holistic educational and clinical supports that cultivate cognitive and affective dimensions of ICU reasoning. Strengthening structured ICU exposure, emotional support, and guided reasoning frameworks is essential to help novices translate theory into confident, context-sensitive reasoning under the pressures of critical care.