Exploring clinical reasoning in physical and occupational therapists treating frail older adults in skilled nursing facilities: a Delphi study.

Frailty is highly prevalent in skilled nursing facilities (SNFs), yet little is known about how physical and occupational therapists (PTs/OTs) apply clinical reasoning (CR) when designing and progressing EPs for frail older adults. This study used a three-round Delphi method (DM) to generate expert consensus on the reasoning strategies therapists employ in SNF practice. Licensed PTs and OTs from the USA and Canada were recruited through professional directories and completed iterative surveys focused on assessment, goal-setting and intervention adaptation. Round 1 consisted of open-ended questions analysed through thematic coding; Rounds 2 and 3 involved Likert-scale ratings of synthesised statements, with consensus defined as ≥75% agreement. Forty-four therapists participated in Round 1, with 39 completing all rounds (89% retention). Participants represented a wide range of experience levels and both professional disciplines. Five core themes reached consensus: (i) engagement in therapy, emphasising meaningful, patient-centred activities to enhance motivation; (ii) mobility and movement confidence, reflecting the importance of addressing fear of falling and psychological readiness; (iii) functional outcomes and endurance, prioritising activities aligned with real-world activities of daily living (ADLs) and stamina; (iv) pain and cognition, recognising daily fluctuations that require dynamic clinical adjustment and (v) task-specific interventions, integrating ADL-focused and dual-task activities to promote carryover and ecological validity. These findings illustrate the complexity and adaptability of therapist decision-making when treating frail older adults in SNFs. The themes highlight how PTs and OTs integrate patient goals, functional demands and fluctuating physical and cognitive status into individualised exercise planning. This study provides a foundation for developing frailty-focused education, clinical pathways and interdisciplinary guidelines to support high-quality rehabilitation in SNFs.