All phases of the clinical reasoning cycle were found to be reflected upon by the participants during the interviews, showing a variation between analytic and non-analytic reasoning. The clinical reasoning among the participants almost never appeared as an ideal cyclical process about one patient or situation; instead, several processes were ongoing at the same time, and the clinical reasoning cycle was often cut short and repeated during the interviews (Fig. 2). The result below is presented in the order of the clinical reasoning cycle, not according to the VR simulation timeline.

Fig. 2

The clinical reasoning cycle of a participant with several processes ongoing at the same time. Nr 1–10 is showing the actual order of clinical reasoning quotes, according to the timeline in the interview (participant #10)

Consider the situation

To consider the situation, the participants expressed the need to form a general impression of the scene. They described the lack of overview they wanted of the scenario initially and how they repeatedly re-evaluated their impression of the chaotic situation as the scenario went on. To think aloud about the situation was said to be a strategy for keeping control. They reminded themselves of what equipment to use, the rules of leadership, and the guidelines to follow. They considered the explosion in the subway station to be a possible act of terrorism which raised their awareness of other threats in the area.

When interpreting the scenario as an MCI, they started to prepare themselves for the types of typical injuries to expect patients to suffer when there has been an explosion. They expressed a need to estimate whether the available resources were enough to handle the situation.

I thought that, in the alarm call, this was a suspected special event and that there would be many injured at the scene. That we would probably need many resources. I also thought, what has exploded, are there possibly any dangerous substances here? (participant #9)

Collect information

Collecting information and assessing the scenario was described to be challenging as it was difficult to separate relevant information in the large flow of impressions and feelings. The participants expressed intentions to be active in collecting information when visualising the scene to identify safety and security issues. They described how they identified potential threats of additional explosions, collapsing walls/roofs, and poisonous smoke. They expressed a desire to collect further information to be able to proceed and, searched for collaboration partners. To re-evaluate the situation constantly was said to be of importance and they described how they recalled previous knowledge to make sure their assessments of the scenario were plausible.

I looked around. I see victims, one, two, three, one lying outside the subway barriers, I look up at the ceiling to see if there is anything dangerous hanging there. (participant #5)

The participants expressed the intention only to collect information about the patients to enable primary triage because conducting excessively rigorous assessments made them focus too much on one patient. However, expressions of uncertainty about their own assessments were found, as when they described difficulties in evaluating vital signs, especially in children.

Process information

The participants tried to process and discriminate what contextual information was important in the large flow of impressions. They described how they used their previous knowledge, tried to group information to anticipate potential outcomes, and questioned whether the information they had collected was reliable. Both subjective and objective cues were taken into consideration when they described recalling their intuition and past experiences.

When processing information about the patients, they mainly interpreted vital signs and typical injuries after explosions. These interpretations were often brief and were performed in a non-analytical way. The decision on primary triage levels was based on a more analytical reasoning process, as they discussed whether they should deviate from the primary triage guidelines and base their clinical decision on intuition or types of injuries instead. They reasoned about the essence of intuition and referred to previous experiences and theoretical knowledge. Generally, they preferred to give higher priority levels than lower ones, after they had processed the collected information about the injured.

The child couldn’t walk but screamed, so I thought that it wasn’t that bad. It was very difficult to hear the respiratory rate because she was screaming, so I decided to skip the breathing and check the pulse, which I found to be normal. (participant #3)

Identify problems

When the participants described identifying problems in the context, they drew conclusions about collaboration, safety and security issues, communication, and organisation. The participants tended to be quick in identifying what the patient may be suffering from. However, when they described conclusions made about primary triage the reasoning became more expanded.

It is actually wrong, but I based my assessment on the type of injury even though it wasn’t a primary triage parameter, and I classified her as red [highest priority] because she could soon get worse. (participant #3)

Establish goals

When establishing goals for strategies of how to work, the goals were often task-oriented. The goals established were about mental strategies and own actions. The participants described goals for patient care and time consumption but not for individual patient outcomes. However, when describing setting goals for more than one patient, goals for the outcome existed, for example, to save as many as possible. They also reasoned about goals connected to primary triage guidelines and clarified how they personally planned to act upon them.

I have a strategy. First, check that it is safe, and then I will proceed in a certain order; otherwise, I will lose track of whom I have attended to. (participant #2)

Take action

At the beginning of the scenario, actions were frequently described as actionable grabbing bags with different kinds of equipment, but there were also decisions taken to bring only what was needed for their pre-decided tasks, as it is easier to move more quickly if there is not too much to carry.

The participants acted to get a better view and understanding of the scenario. Actions were also described as connected to time as they intended to act quickly and efficiently to save as many as possible. Actions regarding safety and security were constantly ongoing. They described, for instance how they were checking bags lying around, searching through subway carriages, and deciding to evacuate when detecting a severe security threat.

When taking action for patient care, there were descriptions of assessments or interventions carried out but also of decisions taken not to act. The interventions were mainly concerned with basic life support. Actions described to decide the priority level in the triage were performed according to guidelines but also depended on the types of injury and patient behaviour. Moreover, the participants repeatedly counted the number of patients and described how they acted to keep track of that number and how they lacked the possibility to record it with a pen and paper.

I went first to the one who was closest. (participant #2)

The participants made communication initiatives and described how they talked to patients, even if they did not get any answers. They also said they tried to collaborate with police officers in the scenario and simulated radio communication.

Evaluate action

Evaluations were described regarding how they acted when proceeding in the scenario, and how strategic decisions were taken accordingly. Dissatisfaction with wasted time and not acting efficiently was expressed. There were also expressions of self-criticism regarding how they formed an opinion of the scenario, such as security awareness and their own safety behaviour.

Something I could have done differently is to have a different scanning approach. I have to think in 3D; I can’t think in flat terms. (participant #1)

The participants evaluated the patient care briefly. They were partly self-critical regarding actions of care when it came to interventions, assessments, and how they decided to prioritise among the patients. They described evaluating the outcome when interventions were made but also when the decision was not to act. They emphasised how important communication was and pointed out things they communicated well but also when they wished to improve their own communication with patients and collaboration partners. They also evaluated their simulated communication on the radio as improvable.

Reflect on the process and new learning

Detailed reflections were described during this last phase of the clinical reasoning cycle. The participants critically reasoned about their systematic work strategies and declared that time frames and guidelines are supposed to be followed but they detected flaws in their own ability to follow them. There were descriptions of doubt and remorsefulness at how they decided on priorities based on the patient’s age, injuries, and uncertainty about vital signs. Even though primary triage guidelines were pre-determined to be used, they critically reviewed how well these guidelines led to best practices. At the same time, they stressed the importance of having distinct instructions and guidelines that are easy to follow.

When reasoning about their patient care actions, they argued about the need to move on and be effective but at the same time, they accepted that it was important to recognise patient needs and to avoid making mistakes because of rushing. They described a negative emotional aspect of leaving patients behind when they had to proceed with other patients, especially when the patient they left was a child. They also concluded that MCIs are demanding, and not comparable to taking care of one patient at a time. They reasoned that they preferred triaging with too high priority rather than too low, but ethical concerns were raised that this type of decision may increase morbidity and mortality. Furthermore, they reflected upon the allocation of resources and who was prioritised for transport to the hospital. They reasoned that the workload should decrease as soon as other personnel started to arrive at the scene.

When reflecting on communication they believed talking would have required a greater effort in a real-life scenario, no matter if it was with patients, collaboration partners, or on the radio. Training on how to communicate better was described to be important, and they said that self-reflecting on this scenario taught them more about their personal way of communicating.

I would have liked to talk to everyone really, whether they can hear me or not, just to say that help is coming soon, you will be taken care of. (participant #1)

The participants described lacking intuition when they were in the scenario and were convinced that repetitive training would lead to better intuitive actions. Increased awareness of how important it is to actively get a visual overview was mentioned, as this assisted in maintaining control and being able to make the right decision at the right time. When viewing the video recording, there were descriptions of having tunnel vision during the simulation, with decreased peripheral vision and limited analytical thinking (Fig. 3). This led to reflections about real-life scenarios and how they now had identified some of their own behaviour regarding stress and tunnel vision, which was described as valuable learning. Managing stress by being systematic, disciplined, and calm, was believed to reduce the risk of losing control.

And if you get to practice more, then you can see if you perceive things differently, do things differently. That would be great. Because you get to test yourself; I have already found things I need to work on. (participant #2)

Fig. 3

The clinical reasoning cycle [11]

When reasoning about risk assessments, the participants believed they would have put more emphasis on personal safety and security in a real-life scenario. They critically reviewed the kinds of risks one is willing to take on the duty, and the importance of reflecting on this matter beforehand to become more prepared. To be able to rely on the security assessments made by collaboration partners, like fire brigades and police officers, was found to be crucial. At the same time, they expressed the importance of being somehow sceptical, and aware that collaboration partners could have missed something due to a heavy workload. Furthermore, they also reflected on what roles one has in comparison to different types of collaboration partners and the importance of cooperating and helping each other, as a team.

The participants said that they wanted to find strategies to work more analytically in the future, using reflection to alter self-image, awareness, and behaviour. Even after completing this VR scenario, they said they were not completely confident about how they would react in a real-life scenario and expressed a desire to become more prepared through more training and learning. They declared that they would be troubled if they could not meet their own expectations in a real-life MCI and made high demands on themselves to act rationally, no matter the surroundings. Reflections about themselves also included their personal responsibility to act as a professional and human being and the importance of being mentally prepared.