Clinical reasoning in intensive care: Insights from novice and expert physiotherapists

Background: Clinical reasoning in the intensive care unit (ICU), a complex, high-acuity and stressful environment, may require a different set of critical thinking and decision-making approaches to undergraduate physiotherapy student training in this setting that needs to be explored. Objectives: To explore clinical reasoning processes of undergraduate physiotherapy students (novices) and clinicians (experts) in ICU settings in the Western Cape. Method: A qualitative exploratory study using semi-structured interviews with purposively sampled participants: seven final-year physiotherapy novices and four physiotherapy clinicians with over 5 years of ICU experience. Data were analysed using Braun and Clarke’s six-phase thematic content analysis. Results: Both novice and expert physiotherapists described using information gathering, assessment planning, and hypothesis formulation from medical folder reviews and objective assessments to guide critical thinking and decision-making in ICU care. Experienced clinicians relied on the International Classification of Function framework and extensive ICU exposure to strengthen their reasoning. Novice physiotherapists reported that theory and its application supported their clinical reasoning, but their effectiveness was limited by the complex, high-pressure ICU environment, emotional burden of critically ill and end-of-life care, and feelings of overwhelm, fear, stress, anxiety and limited experience. Conclusion: The study highlights shared foundations but clear differences in the depth of clinical reasoning between novice and expert physiotherapists, with clinicians’ greater experience and situational familiarity enabling more advanced reasoning in ICU care. Clinical implications: Structured ICU exposure, emotional support and guided reasoning frameworks are needed to help novice physiotherapists apply theory effectively in high-pressure ICU settings.