Collaborative clinical reasoning in the ICU: how teams construct shared understanding in real time

Clinical reasoning research has predominantly conceptualised reasoning as individual cognition, yet contemporary clinical practice distributes reasoning across teams, tools, and time. This study examines collaborative clinical reasoning (CCR) as a social practice constituted through observable interactional mechanisms. Examining ICU teams as an epistemic extreme case-where high stakes and time pressure amplify reasoning practices present but less visible elsewhere-we ask: through what mechanisms do clinicians construct shared clinical understanding? Video-based microinteractional analysis of 27 h of naturally occurring ICU interaction across 18 encounters, of which 12 episodes were analysed in depth, identified three interactional mechanisms through which CCR is accomplished. Progressive clarification is a mechanism of shared problem construction through layered, profession-specific contributions. Conditional alignment is a mechanism of epistemic negotiation enabling hypothesis exploration while preserving team cohesion. Situated coordination is a mechanism of material-interactional coupling whereby spatial positioning and artifacts structure participation. These mechanisms represent candidate practices that may be noticed, supported, and potentially coached; their learnability was not directly tested in this observational study. By shifting the unit of analysis from individual cognition to interactional accomplishment, this study provides an empirically grounded foundation for understanding how collaborative reasoning may be supported and sustained through participation in clinical work.