Development and initial validation of a practical instrument supporting clinical reasoning and self-directed learning

Clinical reasoning is a core competency in health professions education, which is supported by self-regulated learning (SRL) and adaptive expertise. The Master Adaptive Learner (MAL) framework describes four internal characteristics (curiosity, motivation, growth mindset, and resilience) that support clinical reasoning and SRL development. However, existing instruments typically measure these characteristics in isolation and lack validation within clinical reasoning contexts, limiting their utility for educators. The aims of this study were to generate a list of items that would reflect the four MAL characteristics and pilot, refine, and validate an instrument from the generated items.

Following established best practices in scale development, a multi-phase, mixed-methods approach was used to develop and generate initial validity evidence for a unified Learner Mindset Instrument (LMI). Items were identified through systematic literature searches and refined using a two-round modified Delphi process with clinical faculty and preceptors. Focus groups with student pharmacists were conducted to evaluate item clarity and alignment with intended constructs. The resulting instrument was administered to student pharmacists across five institutions in the United States and Australia. Exploratory factor analysis with varimax rotation, item reduction procedures, and reliability testing were performed.

Nine existing instruments comprising over 150 items were identified through which self-directedness emerged as a distinct construct in addition to the four MAL characteristics. Through Delphi consensus and focus group refinement, the item pool was reduced to 43 items. Exploratory factor analysis supported this five-factor structure. Item reduction resulted in a final 27-item instrument. The reduced instrument demonstrated strong internal reliability (Cronbach's α = 0.893) and acceptable factorability (Kaiser-Meyer-Olkin = 0.77; Bartlett's test p < 0.0001).

The 27-item LMI demonstrates initial evidence of construct validity for measuring internal characteristics relevant to SRL and clinical reasoning. This unified tool may support formative assessment, targeted learner coaching, and evaluation of MAL-aligned educational interventions across health professions education.