exact the firest year of pracitice

8/3/2019 Exact the Firest Year of Pracitice

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The First Year of Practice:

An Investigation of the ProfessionalLearning and Development ofPromising Novice Physical TherapistsLisa L. Black, Gail M. Jensen, Elizabeth Mostrom, Jan Perkins, Pamela D. Ritzline,Lorna Hayward, Betsy Blackmer

Background. The goal in studying expertise is not merely to describe ways inwhich experts excel but also to understand how experts develop in order to better

facilitate the development of novices. The study of novice progression helps us tounderstand what successful versus unsuccessful learning looks like. This understand-

ing is critical, as autonomous practice places increased demands for advanced clinical

judgments and the ability to assume professional responsibilities.

Objectives. The purpose of this study was to explore the experiences, learning,and development of promising novice therapists throughout their first year of prac-

tice in the United States.

Design and Methods. A longitudinal, multiple-site qualitative case studymethod was used for within-case and across-case analysis. A purposive sample of 11

promising new graduates from 4 physical therapist education programs participated.

Investigators followed the graduates throughout their first year of practice. Data

sources included: (1) semistructured interviews conducted at baseline and every 3months thereafter for 1 year, (2) reflective journals completed at regular intervals, and

(3) review of academic and clinical education records and resumes.

Results. Four themes emerged: (1) the clinical environment influenced the novicephysical therapists performance, (2) participants learned through experience and

social interaction and learning was primarily directed toward self, (3) growing

confidence was directly related to developing communication skills, and (4) thera-

pists were engaged in professional identity formation and role transitions.

Conclusions. The findings suggest there are common experiences and themesthat emerge as novice physical therapists develop. Although research has been

conducted on expertise in physical therapy, few longitudinal investigations haveexplored the development of therapists across transitions from graduate to novice to

expert practitioner. This study explored and described the learning and development

of graduates during their first year of practice.

L.L. Black, PT, DPT, is Assistant Pro- fessor and Director of Clinical Edu-cation, Department of Physical Ther-apy, Creighton University, 2500California Plaza, Omaha, NE 68178(USA). Address all correspondence toDr Black at: [email protected].

G.M. Jensen, PT, PhD, FAPTA, isGraduate Dean and Associate VicePresident for Faculty Development

in Academic Affairs; Professor, De-partment of Physical Therapy; andFaculty Associate for the Center ofHealth Policy and Ethics, Creigh-ton University.

E. Mostrom, PT, PhD, is Professorand Director of Clinical Education,Doctoral Program in Physical Ther-apy, Central Michigan University,Mount Pleasant, Michigan.

J. Perkins, PT, PhD, is Associate Pro-fessor, Doctoral Program in Physi-cal Therapy, Central MichiganUniversity.

P.D. Ritzline, PT, EdD, is AssociateProfessor and Interim Assistant Dean,Department of Physical Therapy,College of Allied Health Sciences,University of Tennessee Health Sci-ence Center, Memphis, Tennessee.

L. Hayward, PT, EdD, MPH, is Asso-ciate Professor, Program in PhysicalTherapy, Northeastern University,Boston, Massachusetts.

B. Blackmer, PT, EdD, is retired Associate Professor, Departmentof Cooperative Education, North-eastern University.

[Black LL, Jensen GM, Mostrom E,et al. The first year of practice: aninvestigation of the professionallearningand development of prom-ising novice physical therapists.Phys Ther. 2010;90:17581773.]

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Strong traditions exist in profes-

sional education that suggest

the outcomes of entry-level pro-

fessional education result in, at least,

minimal standards of competence.

This new practitioner should be ca-pable of working independently with

occasional consultation from col-

leagues.1,2 Although physical thera-

pist education has evolved rapidly

to the clinical doctoral degree as

the entry-level professional degree

for physical therapists in the United

States, there remains a great deal of

diversity across educational programs

and a wide variety of strategies for

clinical preparation. Active dialogue

continues about the state of clinical

education, where variation is thenorm, and whether time in clinical

experiences, control of the environ-

ment or practice setting, or the qual-

ity and experience of clinical instruc-

tors influence early practice. Delitto,

in his 2008 Mary McMillan Lecture,

argued for the following:

I urge us to at least consider

postprofessional, entry-level, residen-

cies as a clinical education model. I

would propose that we graduate our

students prior to the terminal intern-

ship, let them sit for licensure, and

then place them in long-term entry-

level residencies.3(p1226)

An assumption in this recommenda-

tion is that there is a need for the

continuation of structured learning

experiences as new graduates tran-

sition from the role of student to

physical therapist. Yet, what do we

know, or not know, about the nature

of workplace learning in the early

years of a physical therapists career?

The initial years of practice are a

time of both challenge and change as

the novice practitioner emerges as a

professional physical therapist. Cur-

rently in physical therapist education,

there continues to be a move toward

increasing the length of time for termi-

nal clinical experiences in educational

programs and a lack of consensus as to

what constitutes the core elements of

best practice in clinical education.4,5

The physical therapy profession also

continues to develop an increasing

number of clinical residency and fel-

lowship programs for specialty prac-tice. Given the discussions on these

issues, it is important to know more

about the nature of learning and pro-

fessional development that occur in

clinical practice after graduation, both

pre-licensure and post-licensure. The

first year of practice is a key period in

the transition from student to physical

therapist and to date has been under-

investigated. The structure and devel-

opment of clinical education or resi-

dency programs could be enhanced

by better understanding of the earlylearning and development that occur

during that first year of practice for

novice therapists.

There is ongoing discussion across the

health care professions that profes-

sional competence, as a component of

expertise, is a multidimensional and

complex concept.6 Competence ex-

tends well beyond knowledge and

technical skills or achievement of min-

imal standards. Epstein and Hundert6argued that professional competence

is developmental, contextual and im-

permanent. The acquisition of compe-

tence depends on the development of

habits of mind such as self-awareness,

flexibility, and critical self-reflection

that allow the practitioner to handle

uncertainty. We use competence not

as a minimal standard but as a compo-

nent of expertise. The process of the

development of expertise is poorly un-

derstood, but an important element is

thought to be the continued learning

and self-reflection that are essential in

mediating movement from mere accu-

mulation of years of experience to the

acquisition of expertise.7,8

The professional learning that occurs

during the early years of clinical prac-

tice often is viewed as an essential part

of the growth and development of

practitioners, both as a process of

change within an individual and as the

enculturation of the practitioner into a

group. Even so, limited attention has

been given to systematically exploring

the early learning and practice ex-

periences of physical therapists orto interactions and relationships in

the workplace. These early experi-

ences create the contextual surround

for practice and provide the novice

practitioner with opportunities to gain

experience and develop professional

competence.

The work of Jensen and colleagues9,10

and Solomon and Miller,11 among oth-

ers,1218 has significantly contributed

to our understanding of expertise in

physical therapist clinical practice andof differences between novice and

expert practitioners.9,10,19,20 These

authors have urged a view of expertise

as a continuous process, not a state of

being10(p20) and posited that profes-

sional formation is a developmental

phenomenon that incorporates change

within an individual in several do-

mains, as well as social and profes-

sional enculturation. They also em-

phasized that the accumulation of

experience does not equal the devel-opment of expertise.

Exploration of physical therapist stu-

dents professional socialization has

been a focus of several qualitative in-

vestigations.2124 Most agreed there is

a need for educators to facilitate the

professional identity development of

students. The studies also showed that

students struggle with building self-

confidence and frequently experience

cognitive dissonance between ideal

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Professional Learning and Development of Novice Physical Therapists

December 2010 Volume 90 Number 12 Physical Therapy f 1759
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practice and actual clinical prac-tice.2224 The research suggests thateducators take a more explicit role in

guiding the professional formation ofstudents. Although we have some in-

sight into student professional forma-tion, there are fewer studies of profes-sional formation of novice physicaltherapists in the first year of practice.Solomon and Miller11 used a groundedtheory approach to gain insight intonovice physical therapists during their

first year of practice. They foundthrough semistructured telephone in-terviews with 10 novice therapiststhat they struggled in communicating

with challenging patients, experi-enced difficulty with reimbursement

issues, and reported feelings of stressand insecurity. Clinical environments

where there were role models and

mentors facilitated an easier transitionto the therapists role. The study con-cluded that the first year of practicesignificantly influences professionalsocialization of novice therapists.

Few studies have investigated longi-tudinally and qualitatively the learn-ing and development of physical

therapists during their early and for-mative years of practice. Tryssenaarand Perkins25 conducted one of thefew longitudinal studies that exam-ined the development of novicephysical therapists and occupationaltherapists during their first year ofpractice. Using a phenomenologicalapproach to inquiry and reflective

journals as data sources, Tryssenaarand Perkins followed the transitionof 6 occupational therapist and phys-ical therapist students from their lastfieldwork experience through theirfirst year in practice. They found theidealism of the new graduate wasquickly tempered by the reality ofthe workplace, where the complex-

ity of the system often challengedtheir ideals. They described a seriesof stages experienced by new thera-pists that included transition, eupho-ria and angst, recognizing and recon-ciling the realities of practice, and

adaptation. As the new graduatesmoved through their first year of prac-tice, they increased in self-confidence,

also developing a more patient-centered approach with experience.

In nursing, much of the work on nov-ice learning and development hasgrown out of the landmark work ofBenner and colleagues,2628 who pro-posed a 5-stage model of developmentfor nurses, moving from novice to ex-

pert, that drew heavily on a model ofskill acquisition proposed by Dreyfuset al.29 More recent investigations havefocused more directly on the early

years of nursing practice.30,31 Stand-ing31 followed a group of 20 nursing

students as they transitioned to nurs-ing practice. Her specific focus was onthe development of nurses clinical

decision-making skills, and she foundthat prescriptive clinical decision-making modes were valued for opti-mizing performance, yet did not pro-mote the reflective and interactiveskills needed in practice. She advo-cated earlier and focused teachingand learning strategies targeting thereflective and interactional compo-

nents of clinical decision making.Based on their interpretative phenom-enological study of newly graduatednurses (first 18 months of practice),Schoessler and Waldo30 proposed aprocess model of nurse developmentthat incorporated several theoreticalframeworks, including those of Ben-ner,26 Kolb,32 and Bridges.33

A great deal of qualitative researchand theory work has been done onnovice development in teacher edu-cation.3441 Early work by Bulloughand colleagues34,35 uncovered thecritical role of mentoring, ongoingfeedback, and evaluation, as well assupport and encouragement, for

teachers in the first and early yearsof practice. In a longitudinal study,Levin38 followed 4 teachers over 15

years. She discovered that theseteachers did not experience a wash-out effect, that is, lose what they had

learned in their teacher preparationprogram, if they engaged in reflec-tive learning. Their understanding

of teaching and learning moved awayfrom an intense focus on an inner level

(self) as they developed more com-plex ways of thinking when con-fronted with complex problems. It

was in the internal struggle with whatthey know and what they need toknow to solve a teaching problem thatthere was evidence of reflection and

meta-cognitive thinking. These teach-ers did not blame their students whenconfronted with issues but looked tothemselves to make changes.

In the teacher education and profes-

sional development literature, numer-ous reviews of research on teacherlearning also support a situative per-

spective and social constructivist viewsof learning in the early and ongoinglearning of teachers.3945 These viewscall attention to the active construc-tion of meaning and practice knowl-edge by individual teachers throughparticipation and social engagement inthe community of practice in whichthey are working.

In professional education, we areconcerned about the developmentof professional competence and ex-pertise in novices. In physical ther-apy, the professions vision for in-creased autonomy brings with itincreased responsibility and, there-fore, greater accountability.46 In both

academic and clinical settings, there will continue to be increasing em-phasis on demonstrating account-ability for competent performance.For educational programs, we mustdemonstrate that our graduates arecompetent and ready to begin prac-tice. Inherent in these concerns isthe implication that professionals

must remain professionally compe-tent over time. Therefore, when dis-cussing expertise, it is critical toconsider the stages of progressiontoward development of expertisethat include novice development




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and demonstration and maintenance

of professional competence.27,28,47

The health care system in the United

States is placing increasing emphasis

on accountability for competent per-

formance, and, in turn, our discus-sions in professional education and

practice also must consider the inter-

relationships of competence, novice

development, and expertise.6,48

Novice development is a process of

change within the individual (knowl-

edge, skills, and thinking), as well as

a contextually grounded encultura-

tion and professional socialization

process. The community of practice

in which novice therapists work un-

doubtedly plays a critical role as theylearn from and through experience.

Sources of learning are diverse and

numerous and include, but are not

limited to, research-based evidence

and theory; practical and personal

experience; dialogue with patients,

caregivers, and other health care

professionals; and reflection on their

own work.45,49 Although a moderate

amount of research has been con-

ducted on expertise in physical ther-

apy and on differences between nov-ice and expert practitioners,918 few

studies have investigated the learn-

ing and development of novice phys-

ical therapists over time throughout

the first year of practice.

In the United States, we have yet to

systematically explore the learning

and development of physical thera-

pists during the early years of prac-

tice. What are the sources and nature

of learning for new professionals

during their early years of practice?

What forces or factors influence the

nature and trajectory of profession-

al development during this time?

What facilitates or constrains learn-

ing and development? What experi-

ences shape the formation of profes-

sional identity for novice clinicians?

How do novices change over time?

Why do some therapists grow to-

ward expertise and not others? Such

questions urge a longitudinal and

qualitative approach to inquiry.

This study begins to address some of

these questions from a longitudinal

and qualitative perspective to en-hance our understanding of learning

and development during the early

years of practice as a physical thera-

pist. The purpose of the study was to

explore and describe the experi-

ences, thinking, learning, and develop-

ment of promising novice therapists

during their first year in practice.

MethodDesign We used a multiple qualitative case

study approach, using grounded the-ory methods that allowed for within-

case and across-case analysis. Seven

experienced qualitative researchers

representing 4 physical therapist ed-

ucation programs in the East and

Midwest regions of the United States

collaborated as investigators for the

study. The use of multiple investiga-

tors and multiple programs helped

to ensure a larger initial sampling

frame for the study.

ParticipantsFor each university cohort, the inves-

tigators sought a purposive sample

of a minimum of 2 and a maximum

of 4 participants who met selection

criteria. A purposive sample of 12

new graduates from the 4 physical

therapist professional education pro-

grams initially agreed to participate

in the study. One individual discon-

tinued enrollment early in the study

period, leaving a final sample of 11

participants (Table). To bound the

study and sampling frame, we de-

cided to recruit new graduates who

were viewed as promising novices,

with the assumption that those in-

dividuals may be more likely to be-

gin to develop the characteristics

and attributes of expert therapists

earlier in their careers than others.

Participant selection criteria for

the study included the following:

completed a physical therapist de-

gree, graduated with a GPA of 3.0

or higher, excelled in the final year

of clinical education experiences

(as determined through nomination

by the clinical education faculty), en-gaged in extracurricular and profes-

sional activities during their educa-

tional preparation, and demonstrated

characteristic behaviors associated

with professionalism, as described in

the APTA professionalism/core values

document.50

Participant demographic data are pro-

vided in the Table. The novice thera-

pists ranged in age from 24 to 29 years

and entered practice in a variety of

practice settings. The sample con-sisted of 8 female therapists and 3

male therapists whose work settings

ranged from acute care hospitals, to

hospital-based outpatient clinics, to

private practice, to rehabilitation set-

tings, both inpatient and outpatient.

In addition, the patient populations

these new graduates were working

with were diverse and crossed the life

span from pediatrics to geriatrics.

Most graduates held a Doctor of Phys-

ical Therapy (DPT) degree either atgraduation or granted through a tran-

sitional degree program. The study

began at the time many programs

were converting from Master of Sci-

ence in Physical Therapy (MSPT) de-

grees to DPT degrees. Several partici-

pants graduated with MSPT degrees

and then completed transition pro-

grams designed to enable graduates to

advance their professional degree to

the DPT level shortly after the award-

ing of the MSPT degree.

Procedures/Data CollectionFigure 1 provides a summary of the

chronology of data collection and

multiple sources of data gathered

across the course of the first year of

the study. Data sources included an

initial brief demographic question-

naire, reflective journals submitted at

least monthly, and a baseline semi-

structured interview conducted at




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entry into the study, followed by

quarterly interviews thereafter for a

total of 5 interviews. The researchers

collaboratively designed the reflec-

tive journal guidelines and questions

and the interview guide based onexisting literature and key concepts

related to professional learning, de-

velopment, and clinical reasoning in

physical therapy. Reflective journal

guidelines and questions provided to

participants at the initiation of the

study are shown in Appendix 1.

Questions for the baseline interview

and selected questions from subse-quent interviews are provided in

Appendix 2. Consistent with the na-

ture of this type of qualitative case

investigation, the types of interview

questions asked by the investigators

diverged to some degree to allow for

follow-up on data provided by indi-

vidual participants in reflective jour-

nals or prior interviews. Participantswere asked to discuss their first-year

performance review during the last

(12-month) interview session. The

Table.Participant Demographicsa

University

Affiliation

Participant

No. Sex

Age at

Entry (y) Degrees Practice Settings

University 1 1 F 24 MSPT Hospital: acute care pediatrics

University 1 2 F 24 MSPT Hospital: long-term care, acutecare and rehabilitation

University 2 3 M 27 DPT Private practice: outpatient

University 2 4 F 27 DPT Hospital: aquatics

University 2 5 M 26 DPT Hospital: outpatient

University 2 6 F 25 DPT Hospital: acute care and

cardiac rehabilitation

University 3 7 M 29 MSPT

DPT

Private practice: outpatient

University 3 8 F 28 MSPT

DPT

Private practice: pediatrics


DPT

Private practice: outpatient


DPT

Pediatric rehabilitation center

University 4 11 F 24 DPT Veterans hospital: inpatient

and outpatient

a Mmale, Ffemale, MSPTMaster of Science in Physical Therapy, DPTDoctor of Physical Therapy.

Figure 1.Chronology of data collection and multiple sources of data gathered across the first year of the study.




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majority of interviews were con-

ducted face-to-face, but some were

conducted by telephone due to

travel or scheduling constraints. All

interviews were audiotaped and

transcribed verbatim.

Data Reduction and AnalysisData were analyzed using a general

inductive approach, as described by

Thomas,51,52 using constant compar-

ison for within-case and cross-case

analysis. This approach incorporates

common strategies for analysis used

in several qualitative analysis tradi-

tions, including grounded theory,

phenomenology, narrative analysis,

and discourse analysis.5355 Follow-

ing each interview, the investigators

reviewed transcripts and journals

and used open coding to analyze

the interview and monthly reflective

journal data for each graduate thera-

pist. These data were used to create

a descriptive and emerging case

report.56 Investigators from each

institution then collaborated to re-

view cases to verify codes, catego-

ries, and subcategories and to iden-

tify emerging themes. Midway

through the first year, investigators

from all 4 universities shared their

coding scheme and emergent cate-

gories and themes. Discussion and

deliberation by the investigators at

this time led to a preliminary identi-

fication of 5 core themes into which

most categories, subcategories, and

codes could fit: learning, confidence,

communication, professional iden-

tity formation, and the clinical envi-

ronment. These consensus-based core

themes were used as the framework

for further analysis of individual

participant and institutional case

studies. Although these preliminary

themes and related categories had

been identified, as data collection

continued, the investigators were

alert to the potential for discrepant

or divergent data to create new in-

terpretations or for collapsing or

overlapping categories and themes.

At the conclusion of the first year,

additional data from the institutional

case studies was used to refine and

further develop a preliminary con-

ceptual model representing the

learning and development of these

novice physical therapists during the

first year of practice, as illustrated in

Figure 2.

Throughout data collection and analy-

sis, several strategies were used to en-

sure rigor and enhance trustworthi-

ness.57,58 First, triangulation was used

to ensure consistency; that is, data

were sought from multiple sources

Figure 2.Preliminary conceptual model representing the learning and development of the novice physical therapists during the first year ofpractice.




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(artifacts, questionnaire, journals, and

interviews), and these data emanating

from each participant constitute a very

large data set (Fig. 1). Second, the re-

flective journal and interview data

were low-inference data provided di-rectly from participants. Third, all in-

terview transcripts were subjected to

member checks; that is, they were

provided to participants for review,

clarification, and additions before fur-

ther analysis by the investigators. In-

vestigators at each institution com-

pleted independent coding on their

respective cases and then completed

consistency checks, coming to con-

sensus on appropriate codes and cat-

egories across their institutional cases.

This process was repeated again wheninvestigators from all institutions de-

liberated and came to agreement on

overarching categories and themes.

Even so, the investigators remained

alert for new data that could be rele-

vant but did not fit early the early

conceptual framework. In fact, as dis-

cussed below, some of the early

themes were deemed to be overlap-

ping or intertwined rather than dis-

tinct from one another.

ResultsThe conceptual model shown in Fig-

ure 2 provides a visual representa-

tion of the core concepts, as well as

the relationships across concepts, in

the learning and development of our

sample of novice physical therapists

throughout their first year of prac-

tice. The arrows in the model all

point inward toward the emerging

professional identity of the novice

therapists; this is meant to illustrate

that the overall direction of growth

for these individuals appeared to be

directed inward toward the self. The

core concepts in the model are pre-

sented below, with supporting low-

inference evidence moving from the

outer circle of the model to the inner

circle.

Clinical Environment andPractice Community: WorkplaceSupports and ConstraintsThese novice therapists in their first

year of practice were strongly influ-

enced, either positively or negatively,by the clinical environment and the

practice community. An early focus

on learning the ropes of the clinical

setting prevailed over an emphasis on

developing their clinical decision-

making skills. The participants reported

their first priorities as getting in the

flow or experiencing the real world

of the workplace. Those participants

who entered an environment where

there was a mentoring program for

new therapists found this very helpful

and described the program as a work-place support for their development.

They had . . . a mentorship program

where you are teamed up with an-

other therapist to essentially show

you the ropes and meet with you on a

weekly basis. . . . I found this to be an

asset, as I had many questions about

paperwork, routines, or clinical ques-

tions. Participant 10Journal

Mentoring took place both formally

and informally for most, but not all,

of our participants. That is, some new

therapists had mentors specifically

identified for them as they began

work, whereas others sought out

members of the staff who eventually

served as mentors.

It is really nice to have so many dif-

ferent PTs [physical therapists] to

bounce ideas off or to ask questions.

Everyone is willing to offer sugges-

tions or ideas when you might need a

new one. Participant 10 Journal

Two participants noted a lack of

mentors or mentoring in their work-

place and felt this was a constraint

on their learning and development.

Both of these participants contem-

plated leaving the clinical agency

during their first year of practice and,

in fact, did leave the agency shortly

after the 1-year mark in their career.

Its been an ever-changing environ-

ment in our clinic and not having a

whole lot of resources to fall back on

or be able to ask certain people ques-

tions that may have had experience in

that particular area. Its been kind of

tough figuring out stuff on my ownand kind of going from there. . . . At

that point in time, you do kind of

wish you had a mentor to fall back on.

Participant 7Interview

The participants often recognized pri-

mary concerns about becoming an in-

tegrated member of the clinic team

and developing their individual clini-

cal skills. However, the need for

developing time management skills

and becoming efficient and produc-

tive members of the clinical commu-

nity often ruled their world early in the

first year. Toward the end of the year,

however, they more easily navigated

workplace constraints or limitations

and were less rule governed by the

environment. Dissatisfaction with

some practices in the clinical environ-

ment created cognitive dissonance

and ethical distress and led to job

changes for 2 therapists at end of first

year. These were the same therapists

who reported a lack of mentoring.

We get told how we should practice;

administration wants us to average a

certain number of visits but obtain

certain outcomes. I find this difficult

to follow because not every patient is

the same. I try not to follow these

rules when treating my patients. Par-

ticipant 2Journal

There was significant variability in

participant responses to the clinical

environment. As forecasted by anearlier quote, instability in the clini-

cal environment negatively affected

the participants performance.

Its kind of like you dont want to get

yourself used to anything just yet be-

cause the overwhelming thought is

that I would kind of be here for the

upcoming future and then there were

some other changes in the company.





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Learning Through ExperienceAn emphasis on learning through ex-

perience was present for all partici-

pants and was a core category:

As a physical therapist I am always

learning . . . and I feel that I am con-

tinuing to strive to learn new things.

Participant 10 Journal

This category includes participants

perceptions regarding expanding

practical skills, knowledge, abilities,

and clinical reasoning skills. Early on,

the participants questioned their

clinical skills and judgment; they

were concerned about their perfor-

mance as physical therapists. To ad-

vance their skills and clinical judg-ment, they identified multiple sources

of learning in the clinic and used a

variety of learning strategies. Partici-

pants reported learning through ev-

eryday experience (including trial

and error), observation, asking ques-

tions and engaging in dialogue with

colleagues, and seeking and reading

literature. Their focus often was on

developing confidence in their deci-

sion making.

The richest sources of learningseemed to come from work experi-

ence itself and communications and

interaction with coworkers, mentors,

patients, and caregivers in everyday

practice.

So you kind of learn by way of your

work experience and exposure to

the world of work. Participant 2

Interview

If work was a lake, I feel there is

always someone next to me in a boat with an outstretched hand. Partici-

pant 1Journal

As noted in the previous section on

the clinical environment/practice com-

munity, those novices who had iden-

tified a mentor in their first year felt

that they progressed more rapidly

than they might have without a men-

tor. Some participants also empha-

sized their desire to use professional

literature and other structured edu-

cational opportunities to advance

their learning.

I need to read more . . . just to keep

going over things and making sure

Im on top of it . . . and plus the more

people you see, the more examples

you have in your head about certain

diagnoses and stuff. Participant 4

Interview

As they progressed through the year,

the participants became more aware

of and more focused on their pa-

tients responses to therapy versus

their personal performance as a ther-

apist. They were better able to antic-

ipate or recognize how patients mayrespond, see more of the whole pic-

ture with the patient, and rely on

past experiences with patients to

provide appropriate interventions. It

is in these later quotes that self-

reflection on past and present experi-

ences becomes more visible and

serves as a resource for their profes-

sional learning and development.

Even with the difficult patients, you

kind of learn how to handle them,

you know whats going to work and

not going to work. You kind of see

some patterns with patients. You start

to evolve. Participant 3Interview

I had another challenging case . . .

these last few weeks. I learned a great

deal about tragedy, struggle, and tri-

umph from this young girl; more than

she will ever know. I will remember

this patient for years to come. Partici-

pant 10 Journal

By the end of the first year, partici-pants expressed much more willing-

ness to take on new evaluations with

any diagnosis without hesitation.

I feel that [early] last year I felt more

comfortable with certain diagnoses,

and Id just go in and do the evals, but

it seems like now I can take any eval

and not worry when I go in. Partici-

pant 4 Interview

Toward the end of the first year, the

participants learning was still pri-

marily directed inward, but an out-

ward turning began to emerge as

they prepared to enter their second

year of practice. Shifts occurredfrom a focus on general skill and

knowledge building to development

of more specialized knowledge and

an expanded repertoire of abilities.

Several participants at this time also

began to experience clinical teach-

ing as part of their learning.

From the previous journal, I think I

talked about how it was weird to be

a teacher to the new therapist who

came in, so thats a learning experi-

ence. Even though youre teaching,youre learning at the same time. That

was a good experience. Participant 1

Journal

Growing ConfidenceOur participants experienced in-

creases in confidence and indepen-

dence over the first year. For our pur-

poses, we defined confidence as a

state of increasing awareness of abili-

ties and competence (including trust

in clinical decisions) as perceived by

oneself and others. The most notablearea of growing confidence through-

out the first year was in the area of

communication skills, including: talk-

ing to patients, caregivers, and other

colleagues; listening skills; and inter-

preting or understanding what was

communicated to them. Initially, the

participants, somewhat to their sur-

prise, struggled with communication

(both verbal and nonverbal).

Just finding something on a common

level or trying to understand their per-sonality in terms of how they like to

communicate except as a therapist, I

feel you have to be fairly open in your

communication because you need to

learn a lot about the patients in treat-

ing them. Participant 5Interview

Reports of increased confidence most

frequently occurred after positive in-

teractions with peers, other profes-

sionals, employers, and patients.



core

words

-category

avior

erience


9/17

These reports included, but werenot limited to, positive performancereviews by supervisors and achiev-

ing desired outcomes with patients.Often the focus was on the partici-

pants communication with patientsor other health care professionalsand reflection on those experiences.

Theres always those experiences

where you really feel that you fit. Just

the interactions with the physicians

more and them noticing you and then

coming up to you and saying, Hey,

are you working with my patients?

How are they? Participant 4

Interview

The most notable advances in com-munication skills occurred from themiddle to the end of the first year(between 6 and 12 months) whenthe participants became more sensi-tive to the dynamic and nuanced as-pects of communication and recog-

nized the centrality of attending to verbal and nonverbal communica-tion in interactions with patients andother health care providers. The par-ticipants became better able to rec-ognize and handle communication

issues before they became problems.

Knowing when the patient is ready to

progress to the next step has gotten a

little bit easier just by reading peo-

ples faces and that nonverbal com-

munication. Participant 2Interview

Growth in confidence also was re-

ported after successful resolution ofdifficult situations or work with chal-lenging patients, even if the therapygoals were not entirely realized.

These situations were closely linked with emerging professional identi-ties and role transitions.

I remember being nervous around

postsurgical patients when I started

. . . but now I dont really have that

nervousness. Participant 9Interview

Finally, many novices reported anupturn in their confidence followingperformance appraisal meetings with

their supervisors. This may be onecontributing factor in the accelera-tion of confidence during the latter

half of the first year of practice.

My regional manager called me therising star of the north regions, and

for once I really believed those words.

. . . Feedback like this really helps me

to increase my confidence in the care

I am providing, as well as in my inter-

actions with patients. Participant 9

Journal

Professional Identity Formationand Role TransitionsEarly on, participants were con-

cerned about how to gain respect

from patients and colleagues and who to rely on for information toknow the ropes and make their

way through each work day, andthey were learning how to work out-side of their current comfort zone.

As the year progressed, however,participants gradually developed an

awareness of their own unique pro-fessional identity in their clinicalcommunity and developed a clearerand expanded view of their roles asphysical therapists. They becamecomfortable with who they were asindividual therapists and team mem-bers, thus opening the door forthinking about who or what they

might become in the future.

Now I am becoming more part of the

team, I find senior therapists coming

to me with questions. . . . Its nice to

know that I can offer ideas and sug-

gestions even though I may not al-

ways have as much experience. I feel

that my opinion is valued. Participant

10Journal

As the year progressed, the partici-pants recognized the value of theirrole and moved rapidly forward into

taking social responsibility for pa-tients, being patients advocates, andseeking out leadership roles. They

were able to delegate tasks and rec-ognized how to keep others involved.They recognized their improving

ability to prioritize activities andresponsibilities.

It is my license and I am educated to

determine when a patient should or

should not be discharged. I dont

think that someone in business ad-ministration should make decisions

that they are not trained to make. Par-

ticipant 2Journal

The participants reported an increas-ing awareness of their role in notonly the clinical community but alsoin the profession and in the socialcommunity outside the clinic walls.

I feel I have more confidence in all

aspects of what I do, both within the

clinic and outside of the clinic. Partic-ipant 3Journal

So much relies on how you communi-

cate with patients, with other thera-

pists, with support people, and with

other people in the health professions

. . . general getting to know your pa-

tient . . . along with professional com-

munication across the whole of health

care. Participant 3Interview

By the end of the year, most partici-

pants were expanding into newroles and beginning to envision andchart longer-term career paths. They

were looking forward to new chal-lenges and responsibilities as part oftheir role.

One thing that has been kind of neat

is that my supervisor had started giv-

ing me a lot more responsibilities.

. . . I feel like he comes to me with a

lot more questions now than he used

to, and for advice. Participant 11

Interview

I see myself playing an important part

in whatever I choose to specialize in.


The experiences of participants were

not consistent across all domains. Ourparticipants were individuals workingin a variety of settings. The reportedexperience of job stress or strain isone area where there was consider-able variation in experiences across




10/17

our sample. Some participants re-

ported high levels of stress that de-

creased with experience, some re-

ported low levels of stress, and others

had intermittent episodes of high

stress associated with either their per-sonal life or their professional life.

There is a small body of work in phys-

ical therapy on stress and burnout,

with variable results (for American ex-

amples of this research, see Campo

et al,59, Balogun et al,60 and Wandling

and Smith61 ). The classic work of

Maslach62 viewed burnout as being

linked to the interplay of many fac-

tors contextual, interpersonal, and

personal. It is not surprising that the

experiences of our participants varied

in this regard.

DiscussionThe purpose of this study was to

explore and describe the experi-

ences, thinking, learning, and devel-

opment of promising novice physi-

cal therapists during their first year

of practice. The first year of practice,

when a new therapist begins to as-

sume full responsibility for patient

care and seeks to become integrated

into the clinical community in whichhe or she is working, is an important

transition period we know relatively

little about. For our sample of novice

therapists, we identified 4 core con-

cepts that appear to be tightly inte-

grated in a developmental process

that is largely focused inward on in-

dividual learning and growth in the

contextual surround of the clinical

practice community. These 4 con-

ceptsthe clinical environment and

practice community, learning through

experience, growing confidence, and

emerging professional identity and

role transitionsform the basis of our

conceptual model (Fig. 2).

In their most recent conceptualiza-

tions of expert practice in physical

therapy, Jensen and colleagues10 pos-

ited that professional formation is a

key developmental process in novice-

to-expert transitions. They described

professional formation as a process

that incorporates change within an

individual, as well as social and pro-

fessional enculturation; professional

formation provides a scaffold for the

achievement of professional compe-tence that is grounded in social and

moral engagement in a community of

practice. Our findings reveal what

we believe to be the seeds of profes-

sional formation for our therapists.

The results point to the pervasive,

highly contextualized and embedded

nature of learning that occurred in the

practice communities as these novices

began their careers. A great majority

of the learning described by our par-

ticipants was ignited through social

encounters and interactions with pa-tients, caregivers, coworkers, and

mentors, among others.

The conceptual model we have pro-

posed suggests that much of the

learning and change the participants

experienced in their first year of prac-

tice was directed inward and was

reflected in gradual growth of self-

confidence in their communication

and relational skills, practical skills

and knowledge, and clinical problem-solving and decision-making abilities.

There was a dynamic interaction

among engagement in the practice

community, individual learning and

growth, and the emergence of a pro-

fessional identity associated with role

transitions.

Clinical Environment as aCommunity of PracticeThe clinical environment was the

community of practice for our par-

ticipants and exerted a powerful in-

fluence on the novice in the first year

of practice. The environment has the

potential to influence the novice in

either a positive or negative direc-

tion, depending on the novices per-

ception of acceptance in the com-

munity and support for his or her

development by coworkers. Those

in clinical settings with a formal

mentorship program found that the

mentors support for learning the

ropes was especially critical in the

early months of practice. Our partic-

ipants, who had mentorship, includ-

ing one therapist enrolled in a resi-

dency (participant 5), felt thatinteraction with their mentor en-

hanced their learning.

In a recent study of novice nurses,

Wolak and colleagues63 found that

the most influential factor in profes-

sional development during the first

year of practice was mentorship as-

sistance. In a study of physical ther-

apists, mentors and role models

were identified as key resources, par-

ticularly for new graduates.11,64 Like-

wise, a study of physical therapistsand occupational therapists during

their first year of practice25 showed

that access to mentors and support

enhanced new practitioners under-

standing of what it meant to be a

therapist.25(p24) Although formal,

one-to-one mentorship relationships

can exert a positive influence on

new practitioners, we also found

that many of our participants de-

scribed the development of informal

relationships with coworkers in thepractice community that served as

supports for their learning during

the first year.

Across many professions, there is

increasing interest in and evidence

for the critical importance of social

context and the community of prac-

tice for professional learning and de-

velopment.42,45,6571 Perspectives on

learning that focus on the situated

and social nature of learning and

the importance of co-participation in

practice communities have been

widely discussed in the literature for

several decades.6774 These perspec-

tives, sometimes referred to as situ-

ated learning or the social con-

struction of knowledge, encourage

us to think about learning as a pro-

cess and product of social interac-

tion, engagement, and meaning-

making in authentic practice contexts,




11/17

not as the mere acquisition of knowl-

edge that takes place in the heads of

individuals. These views also draw

heavily on several theoretical per-

spectives of learning and develop-

ment, including that of Russianpsychologist L.S. Vygotsky.7577 So-

ciocultural theories of learning, also

referred to as sociohistorical theories,

emphasize the essential contribution

of social engagement to learning and

development and posit a directional

path of learning that moves from the

external plane (social) to the internal

(psychological) and then outward

again as an individual grows into the

intellectual and cultural practices of

his or her community.75

Lave and Wenger68 first described

learning in social context as a phe-

nomenon that occurs across a con-

tinuum of participation in a practice

communityfrom legitimate pe-

ripheral participation to full partic-

ipation. This view is congruent with

sociocultural theory and resonates

with the findings in our study, where

novices, by definition, were working

in a community of practice with

therapists more experienced or ex-pert than they were. At first, they

felt like peripheral, albeit legitimate,

participants but by the end of the

first year, for the most part they felt

like integral members of the clinic

team. Across the course of the

year, they also described how they

often adopted or appropriated cer-

tain behaviors, skills, or forms of

knowledge based on observations

and their interactions and dialogue

with others.

Learning Through ExperienceLearning through experience was

the first core theme to emerge in our

data, and it remained the strongest

for our sample of participants. For

this reason, it is the thickest concen-

tric circle in our conceptual model

embedded within the practice com-

munity, and it surrounds and contrib-

utes to the growing self-confidence

and emerging professional identity

of our novices (Fig. 2). Learning took

place in many ways and assumed

many forms, but the most powerful

source of learning appeared to be

learning through doing in an au-thentic workplace environment with

all the associated challenges and suc-

cesses that are part of the everyday

work of physical therapists. Within

this experience, which could be pos-

itive or negative, interpersonal inter-

actions with patients, caregivers,

family members, coworkers, men-

tors, and others often played a large

role in what was learned.

Similar to Solomon and Millers find-

ings,11 many of our therapists de-scribed some of their struggles early

in the year with communication and

understanding what the patient or

others wanted or needed from them.

Their focus often was on their per-

formance as a therapist, especially

when they encountered challenges

in communication or capturing the

meanings of others. They were sur-

prised how difficult it was at times to

figure out exactly what the patient

wanted and how to best work withthe patient and family to achieve tar-

geted outcomes. The knowing what

to do for and with this particular

patient at this time was puzzling.

Gradually over the first year, how-

ever, our participants became more

aware of the critical importance of

understanding the patients perspec-

tives and beliefs and integrating

them into their interventions. They

learned that to do this, the therapist

must listen well, facilitate the pa-

tients ability to share his or her

story, and seek to understand the

meanings that patients hold. It ap-

peared that our novices were jug-

gling the tasks of learning about self

along with the tasks of learning

about and through others, including

gaining more insight into the lives

and needs of their patients. Interest-

ingly, when we asked our novices

what they perceived to be their most

important clinical skill during inter-

views conducted in the last half of

the first year, they almost always

identified communication as their

most important clinical skill. Further-

more, reflections on the challengesassociated with the development of

this skill often appeared in journal

data. One participant expressed it

this way in response to a question

about essential clinical skills:

Communication . . . developing rap-

port and trust with your patient and

your patients family, especially with

little kids, being able to get them to

trust you to let you into their space.

. . . Once in a while, I have a kid thats

very challenging that has a lot of sen-sory issues, and its hard sometimes to

develop that relationship. Participant

10Interview

Although our participants spoke fre-

quently about learning through expe-

rience, it is worthwhile noting that our

journal and interview data also illus-

trate that these novices were engaging

in reflection on past and present ex-

periences and that this contributed to

their learning and sense-making about

their experiences. Educational theo-rists John Dewey78,79 and later Donald

Schon80,81 have long emphasized the

critical importance of authentic expe-

rience, encounters with genuine prob-

lems, and reflection on and in experi-

ence as essential sources for learning

and professional growth. All of our

novices were doing all of these things.

Dewey79 wisely reminded us, how-

ever, that not all experience is educa-

tive, so it behooves us to further ex-

plore what aspects of early experiencefoster learning for novice practitioners

and advance authentic professional

learning.45

Professional Identity Formation:Who Is the Novice Becoming?

An initial goal of our novice physical

therapists was to become an inte-

grated and respected member of

the clinical community in their work




12/17

environment. Our findings and con-

ceptual model suggest that the emer-

gence of a clearer professional iden-

tity for our participants is related to

their gradual integration into the

practice community, their activelearning and engagement in that

community, and their growth in self-

confidence and trust in their knowl-

edge and abilities as therapists. By

the conclusion of the first year of

practice, our therapists had devel-

oped a clearer view of who they

were as individual practitioners and

what their unique contributions

were or might be within that com-

munity. Associated with this realiza-

tion, they also began to assume new

roles in the clinical community andanticipate who and what they might

become in the future.

The experience of our novice thera-

pists is consistent with descriptions

of identity work in professional

practice communities, as described

by many authors in a variety of dis-

ciplines.29,42,45,68,69,71,82,83 As Wenger

has pointed out, when we start to

focus on the concept of identity it is

easy to think of it in only individual-istic terms, and he cautioned against

this:

Building an identity consists of nego-

tiating the meanings of our experi-

ence of membership in social com-

munities. The concept of identity

serves as a pivot point between the

social and the individual, so that each

can be talked about in terms of the

other.69(p145)

Lave and Wenger68 referred to the

crafting of identities in practice

and discussed how the nexus of the

self and the social shapes the con-

struction and sometimes deconstruc-

tion or reconstruction of identity.

Furthermore, there is a reciprocity

inherent in the identify formation

process: who you are becoming

shapes what you know or come to

know, and what you know shapes

who and what you are becoming.

Our findings with this sample of nov-

ice therapists resonate with these

theoretical perspectives and are con-

gruent with descriptions by Plack82

of the learning and development of

physical therapist students and newgraduates in the United States based

on a cross-sectional qualitative in-

vestigation, as well as findings from

others studies of students and novices

outside of the United States.11,2225,63

Placks study82 resulted in the devel-

opment of a model of learning in a

physical therapy community of prac-

tice that incorporates many of the

findings from our investigation, and

one of her recommendations for fu-

ture inquiry was the need for longi-

tudinal research.

For 2 of our participants, dissonance

arose between their emerging and

clearer professional identity and their

associated beliefs, commitments, and

aspirations and the cultural norms and

practice in their work environments.

This dissonance and discomfort led to

their departure from their clinical

agencies close to the end of their first

year of practice.

LimitationsParticipants were selected from only

4 universities and were limited by

the inclusion criteria. However, we

did provide justification for this pur-

posive sample in the Method sec-

tion. The study did not include a

comparison with participants who

did not meet the inclusion criteria.

The novice participants were lo-

cated in a variety of practice settings

with different job requirements, lim-

iting their control of the environ-

ment. Limited actual observation of

the participants occurred. The re-

sults were obtained primarily from

interviews and reflective journals.

Recognizing the importance of the

clinical practice environment on our

novices, we plan further study that

will incorporate field observations

and field notes to better capture and

explore this dimension of our model.

Our sample did not include nontra-

ditional students whose professional

development may have followed adifferent path. All participants were

practicing in their first year of licen-

sure as a physical therapist; how-

ever, 2 of the participants were in a

bridge program from a masters de-

gree to a DPT degree during this

study period. Not all participants

were at a DPT level in their first year

of practice.

One could argue that the structure

we provided for deliberate reflection

(multiple reflective journals and in-terviews) may have accelerated or

enhanced the participants learning

and insight into their own develop-

ment. On the other hand, there is

evidence that the reflective process is

an important aspect of professional

development and perhaps should be-

come a more explicit, deliberate, and

prominent feature of early work

experiences.6,10,27,38,84

ConclusionBased on the experiences and re-

ports of our participants, the first

year of practice is an exciting, chal-

lenging, and rewarding period of

personal and professional growth.

Over the first year of practice, par-

ticipants grew in confidence, and by

the end of the year showed signs of

being ready to move into new roles.

In their initial practice, there was a

focus on the mechanics of practice

(eg, juggling caseloads and paperwork, learning techniques, finding

mentors). By the end of the year,

some of the participants were taking

pride in becoming mentors to others

and expressed satisfaction in their

own growth. There was increased

evidence of planning for profes-

sional growth, for the next step in

their careers. Their initial year began

as focused on self and on how to




13/17

enhance their personal growth, self-confidence, knowledge, and com-munication skills.

An important theoretical concept,

supported by our findings, is thatlearning is facilitated through socialencounters. There is a dynamic inter-action between learning and devel-opmental change that occurs withinthe individual in the community ofpractice. There is a critical need for

further exploration and analysis toenhance our understanding of learn-ing and developmental trajectoriesof promising young novice thera-pists. There also is a significant needto explore and analyze the influence

of the environment in communitiesof practice. Structured learning ex-periences and facilitation of mentor-

ships are likely to enhance growthand development during the first

year of practice.

Further longitudinal study of the de-velopmental trajectories of these andother novice therapists is warranted.

We plan to continue the present investigation over several of the early

years of practice for our participants.

Dr Black, Dr Jensen, Dr Mostrom, Dr Perkins,Dr Ritzline, and Dr Hayward provided con-cept/idea/research design, writing, and dataanalysis. All authors provided data collection.

Institutional review board approval for thisstudy was received from all 4 participatinginstitutions.

A platform presentation of this work waspresented at the 15th International Congressof the World Confederation for PhysicalTherapy; June 26, 2007; Vancouver, British

Columbia, Canada. A poster presentation ofthis work was given at the Combined Sec-tions Meeting of the American Physical Ther-apy Association; February 16, 2007; Boston,Massachusetts.

This article was submitted March 2, 2010, andwas accepted August 2, 2010.

DOI: 10.2522/ptj.20100078

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Appendix 1.Example of Reflective Journal Guidelines and Questions Provided to Participants at the Initiation of the Study

Journal Guidelines:Please keep a written reflective journal to document your experiences while you work on this project over the next

year. Below are some guidelines to help you with this task.

1. Date each entry.

2. Please make a journal entry at least once per month (preferably every 2 weeks, if possible).

3. Please use pseudonyms when referring to patients or other individuals in your journals.

Journal Questions:Use your journal writing for the following kinds of reflection that may focus on yourself, your patients and their

caregivers, the clinical setting and professional interactions in that setting, professional roles, the health care agency

or health care system in general, and so on:

1. Thought workpuzzling over a situation or experience; re-enacting and reconstructing what happened so you

can gain a deeper understanding of the experience. In retrospect, are there things you would have changed or donedifferently? Why? Are there things you will do the same? Why?

2. Writing about a lesson learned. What did you learn? How did you learn? Why was this a good learning

experience, or was it? These lessons learned can be personal or professional learning.

3. Writing about your feelings about people (self, patient, others) or situations that arise in the clinical setting. What

did you experience? Did you learn anything about yourself through the experience? Was this a good learning

experience? Why?

4. Writing about what aspects of your role as a physical therapist you find most interesting, challenging, or

surprising. What aspects of your position cause the most stress? What aspects of your position produced the greatest

rewards?

5. Writing about how you see yourself changing over time (ie, your personal and professional development). Where

were you personally and professionally when you began your work as a therapist? Where are you now? How have

you changed? What has not changed?

This list is not necessarily all-inclusivejust something to help you get started. Feel free to write about any thoughts

related to your professional practice and development.




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Appendix 2.Baseline Interview Questions and Probes and Selected Examples of Follow-up Interview Questions Over the Course of the First

Year of the Studya

What factors did you consider in choosing your first job? Of these, which 1 or 2 would you consider mostimportant in your choice? Why?

How did you go about the process of investigating and selecting your first job? What factors do you think influenced the employers decision to hire you for this position? Why do you think

you were hired? What are your hopes and expectations for yourself as you begin your first job as a physical therapist?

Do you have any plans for helping you meet your expectations? What are they?

What are some of your fears or concerns as you start your first job as a physical therapist?

What are your plans for addressing some of your concerns?

What are your hopes and expectations for the clinical agency and staff where you have chosen to work first?What are some of your fears or concerns?

What are your plans for trying to meet your expectations?

Is there an individual on staff who you have identified as a possible mentor, teacher, or supporter foryour early work in this site? If so, how? Why?

What are your plans for addressing some of your concerns?

What are your hopes and expectations for the profession of physical therapy as you move into the field andbegin your work in the profession and the health care system? What are some of your fears and concerns forthe profession?

Where do you see yourself personally and professionally in 1 year? Two years? Five years? How do you view your first job in relation to these career and life plans or goals? Is there anything else you would like to tell me or add to what we have discussed today?

Selected Examples of Follow-up Interview Questions

Exemplar type of question: Please describe an experience or event that you feel shaped your learning anddevelopment as a therapist, and the feelings and thoughts associated with it, in detail.

What has been your most positive experience as a physical therapist over the past 3 months? Why? What has been your most challenging or difficult experience over the past 3 months? Why? How did you

respond in that situation? Where do you feel youve experienced the greatest growth and learning during the past 3 months?

a In follow-up interviews, some questions related to ongoing review of reflective journal data by the investigators. Also, several of the questions in thebaseline interview were repeated as a point for comparison over time.




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