Abstract
Background Physical therapists work in complex health care systems requiring professional competence in clinical reasoning and confidence in decision-making skills. For novice physical therapists, the initial practice years are a time for developing professional identity and practical knowledge.
Objectives The study purpose was to extend previous research describing the experiences, learning, and professional development of 11 promising novice therapists during their first year of practice. The present study examined the continued development of the same therapists during their second year of clinical practice.
Design Seven researchers from 4 physical therapist educational programs in the eastern and midwestern United States used a longitudinal, qualitative, multiple case study approach.
Methods Eleven physical therapist graduates identified as “promising novices” were recruited using purposive sampling. Participants ranged in age from 24 to 29 years and entered varied practice settings. Data were collected for 2 years using semistructured interviews, reflective journals, and participant observation.
Results A conceptual model describing the participants' ongoing development during the second year of practice emerged. The 3 themes were formal and informal learning, increasing confidence and expansion of skills, and engagement in an environment characterized by collaborative exchange and opportunities for teaching. The second year represented consolidation and elaboration of practice-based learning and skills. The expansion of confidence, skills, and responsibilities and the externalization of learning the participants experienced promoted professional role formation. Learning previously directed inward and self-focused turned outward, fueled by growing self-confidence.
Conclusions Research illuminating the professional role formation experienced during early clinical practice is not widely available. The current study and further research into the learning and development of novice practitioners may assist educators in the design of pedagogical strategies and learning environments that enhance the professional development of physical therapists.
Physical therapy, like other health professions, is experiencing dramatic changes, such as the challenges of disparities in health care, escalating health care costs, and demands for more efficient and cost-effective practice. Physical therapist education has evolved rapidly so that the clinical doctorate is the entry-level professional degree. Simultaneously, the scope of physical therapist practice has changed so that direct access is the norm in 46 states, which requires autonomy in clinical decision making.1,2 Physical therapists are working in a multifaceted health care system that requires professional competence in the clinical domain, independent decision making, and the ability to engage in interprofessional collaboration.3–9
For novices, the initial years of practice are times for the continued development of professional identity, knowledge base, clinical reasoning, and decision-making skills. These areas of growth may be challenged or augmented in a community of practice (CoP) that is constantly responding to uncertainties in the health care environment. For Wenger, learning is a social enterprise and involves “participation in a community” that shares meaning with respect to learning and work.10,11 Individuals belonging to a CoP collaborate within a workplace, form an identity, and have a specific way of “talking about how learning changes them as people and professionals.”10(pp4–5) Meeting these challenges in clinical environments requires the professional development of successful physical therapists through the integration of knowledge, clinical expertise, and professional skills.12–14
One strategy for preparing students to manage the complexities of clinical practice includes increasing the length of time spent in clinical education and investigating models for final clinical internships in physical therapist education programs. However, what constitutes the core elements of best practice in clinical education has not been fully explored.8,15 Among the areas for investigation are the early years of clinical practice, when a novice learns about the profession in a particular CoP.10,11 Exploring the processes and stages of novice physical therapists' maturation into professionals warrants attention. The knowledge gained from such exploration may guide pedagogical approaches both in the classroom and in the clinic.
On the basis of research done by the Carnegie Foundation's Preparation for the Professions initiative—specifically, investigations of school and workplace learning in medicine16 and nursing17—we identified 3 key areas as central to the sustained development of novice professionals with a clinical doctoral degree in physical therapy (DPT degree): the relationships among professional role formation, professional socialization, and learner engagement in the CoP; reflection and the development of clinical reasoning; and the development or advancement of professional competence.16,17
Professional Role Formation and Engagement
The American Physical Therapy Association (APTA) has responded to the needs for elucidating the professional identity of physical therapists as doctors of physical therapy and facilitating their ability to assume the obligations and responsibilities of clinical practice in the 21st century. To meet these needs, as part of the strategic plan for transitioning to a doctoring profession, APTA identified 7 core values—accountability, altruism, compassion and caring, excellence, integrity, professional duty, and social responsibility—that underpin the professional skills essential for physical therapists with a DPT degree.7,18 Unfortunately, novice physical therapists often struggle to build self-confidence in their roles and often experience cognitive dissonance with respect to theoretical knowledge and the actualities of clinical practice in both Europe19–21 and the United States.22
Research has documented the potential influence of professional education programs on the instruction of professionals, such as teachers, lawyers, and psychologists, with a discipline-based identity.23,24 Educators have an opportunity and a responsibility to guide the development of students' professional identities. To do this, they need a clear understanding of the continued process of professional role formation experienced during the early years of practice. Such knowledge can assist faculty in the design of effective pedagogical strategies for enhancing the professional development of students in a DPT degree program.
In professional education, in a wide range of disciplines, continued development as a professional is shaped by learning and the knowledge used in the practice setting.16,17 Clandinin and Connelly23 argued that although it is important to understand knowledge and pedagogy, it also is critical to understand the professional knowledge “context” in which “teachers live and work.”23(p24) Similar to the discipline of education, physical therapists work within environments that are highly contextual. Elements that comprise the environment include factors related to patients, the discipline of medicine, and the physical space in which physical therapists work, for example. Contextualization of learning and professional identity formation occur as functions of the culture of the academy and the clinical setting. Students, including those in a DPT degree program, transition from the academy to clinical practice as novice professionals within a professional culture and a CoP.
Phenomenography is a research approach developed by a Swedish researcher, Ference Marton, in the 1970s.25 This approach combines qualitative research and descriptive research focused on revealing how people experience, understand, and bring meaning to a specific situation or environment. Both the broadest categories of understanding and the narrowest categories of understanding are brought forward in the data analysis. Several qualitative studies conducted with phenomenography have focused on student learning during the transition from professional education to practice.26–28 Reid et al26 shared the results of 2 major projects—the professional entity project and the journeymen project—exploring the transition from student to professional. These large European projects spanned 4 countries (Sweden, Germany, Poland, and Norway) and a range of disciplines (political science, psychology, engineering, teaching, and law).
On the basis of this qualitative, cross-disciplinary work examining students' journeys from higher education to professional working life, a conceptual model of professional learning centered on the core concept of professional entity was proposed.26 Professional entity is a powerful idea pertaining to the relationship between students' beliefs about their future professional work and their approaches to learning. Strategies such as use of the literature, conversing with peers, and collaborating with a mentor are accessed to gain knowledge about the practice environment. The concept of professional entity is that if developing professionals take a broader view (ie, see the larger picture)—of their future profession, they will use more learning strategies to advance their development.26 In addition, students who perceive that their future professional work is intertwined with their personal and professional identities “take a personal approach to their discipline and actively integrate their learning with other aspects of their life.”26(p24)
An important element of professional learning is professional engagement. For the purposes of this work, professional engagement includes generating meaning from experiences through purposeful interactions, personal identification with the knowledge generated from the experiences, a voluntary commitment to learning, becoming a professional in a discipline such as physical therapy, and developing professional identity.26 As educators, we are interested in encouraging engaged, self-directed learners with a powerful professional identity and a strong commitment to the discipline. Because professional identity is influenced by social interactions in the context of practice, it is important to explore how novices are shaped by early workplace learning experiences.26
Clinical Reasoning and Learning
Although engagement in professional learning and the development of professional identity are important, the continuous development and refinement of clinical reasoning and decision-making skills are essential. Research focused on expert practice in physical therapy has demonstrated that physical therapist experts have an ongoing commitment to learning and lifelong development of their clinical reasoning skills.29–34 Wainwright et al35 found that clinical decision making by experienced and novice practitioners was dependent on depth and breadth of experience. However, novices used more information-driven factors, such as application of evidence, for clinical decision making, whereas experienced therapists relied on directive factors based on observation and interpretation of patient presentation and experience.
Experience alone is insufficient for the development of clinical reasoning; rather, a reflection on the experience contributes to the development and refinement of this process.36,37 Experts use multiple sources of knowledge, scientific evidence, and problem-solving skills and apply practical reasoning by listening carefully to their patients, critically analyzing and making sense of what they hear, and using this information as a crucial source of evidence in the decision-making process.38 Practical reasoning is informed by evidence and knowledge, but concern and respect for the patient result in thoughtful judgment and action.39 Novices are challenged in practice because their focus often is on their technical skills and on finding the right diagnosis and intervention through a process that they hope is certain and predictable.17,22 Instruction in academic environments often teaches for the “right” answer as opposed to teaching for attention to context, which may influence which answer is “best” given the situation.35,39
A key finding from the Carnegie Foundation's studies of professional preparation in medicine16 and nursing17 was the critical importance of acquiring and using knowledge that is situated in practice through the development of cognitive capacities that are flexible and adaptive in relation to the particular demands of a situation. Many health professions are currently studying the development of the clinical reasoning process in the didactic portion of their curricula.38 Educational programs tend to emphasize the analytical aspects of thinking and deductive reasoning and place less emphasis on understanding a patient's experience through narrative thinking or other forms of reasoning.40 Academic programs spend less time on developing the habits of mind and heart, such as narrative, interactive, and ethical reasoning, that can lead to skillful practice and wise judgment.37,38,41
A critical component of the clinical reasoning process is the development of meta-cognitive skills. The meta-cognitive process—or reflective self-awareness—allows practitioners to monitor and adapt multiple aspects of patient care, such as data collection, clinical reasoning, and action, to diverse situational demands. This process also allows practitioners to recognize knowledge limitations. The workplace environment is the social context for the development of these meta-cognitive skills. The early years of practice provide a vital learning environment for the development of meta-cognitive skills in the context of actual practice. Although there is some information about the self-study of developing expertise through the use of reflection in the professions of physical therapy,9 teaching,23,42 and occupational therapy,43,44 exploration of how this process actually occurs is limited.
Few studies have investigated longitudinally and qualitatively physical therapists' learning and development during their early and formative years of clinical practice.22,34 The purpose of this longitudinal study was to extend previous research22,35 that explored and described the experiences, thinking, learning, and professional development of 11 promising novice physical therapists during their first year of clinical practice. In the present study, we examined the professional role formation, continued learning, and development experienced by these novices during their second year of clinical practice.
Method
Design
Seven researchers from 4 physical therapist education programs in the eastern and midwestern United States collaborated in the study; all were experienced in qualitative research. A qualitative, multiple case study approach with grounded theory methods that allowed for within-case and cross-case analyses was used. A multisite approach was used to ensure broader and more representative sampling for participant selection.
Participants
Each university cohort recruited a purposive sample (minimum=2, maximum=4) of participants meeting the selection criteria. Twelve new graduates from the 4 programs initially agreed to participate, but the early withdrawal of 1 participant resulted in a final sample of 11 (Tab. 1). The sample consisted of new graduates viewed as “promising novices” on the basis of the assumption that they would demonstrate the early development of characteristics and attributes of physical therapist experts.
Participant Demographicsa
Participant inclusion criteria, which also served as an operational definition for “promising novices,” were as follows: graduation in the most recent cohort of a physical therapist degree program during the recruitment period, a physical therapist degree program cumulative grade point average of 3.0 or higher, evaluation by clinical education faculty as having scored at entry level or higher on the clinical performance instrument in the final clinical education internships, evidence of a high level of engagement in extracurricular and professional activities during physical therapist education, and demonstration of professional behaviors consistent with the APTA document “Professionalism: Physical Therapy Core Values.”7
The selected participants ranged in age from 24 to 29 years (8 women and 3 men) and entered a variety of first-time practice settings (Tab. 1). The majority of degrees were DPT degrees attained either at initial graduation or through the completion of a transitional degree program shortly thereafter. This factor reflects the initiation of the study during the time when many physical therapist educational programs in the United States were transitioning from a master's degree (master of science in physical therapy in our sample) to a DPT degree for entry into the profession. All participants gave written informed consent prior to the start of the study.
Procedure and Data Collection
Figure 1 shows a schematic of data sources and a chronology of data collection during the 2 years of the study. After the participants entered the study, they completed an initial demographic questionnaire and a baseline semistructured interview. Reflective journals and additional semistructured interviews were used to provide data about the participants during the first year of the study.22 Journal and interview guidelines were designed collaboratively by the researchers on the basis of existing concepts and theories of clinical reasoning and professional development. Examples of reflective journal guidelines provided to participants and interview guidelines have been described by Black et al.22
Data sources and chronology of data collection.
A semistructured approach was chosen to allow the investigators to explore themes and issues from data provided by individual participants in their journals or prior interviews. Consequently, as the study progressed, the interviews became more individualized to each participant's experience and unique situation. Interviews were done either in person or by telephone, as dictated by travel or scheduling constraints. A limitation of conducting a few of the interviews by telephone was the loss of observation of nonverbal communication during exchanges. However, the participants were interviewed by investigators who had had lengthy (2-year) professional investigative relationships with the interviewees. These strong relationships, built through frequent interactions (Fig. 1), allowed the investigators to know the participants very well and to attend to other paralinguistic features of interactions (eg, changes in tone, pitch, pace, or volume) that might add meaning beyond the words exchanged during a telephone interview. All interviews were recorded and transcribed verbatim. Participants were provided with the opportunity to review interview transcripts for accuracy.
In the second year of the study, the frequency of data collection was reduced (Fig. 1). Reflective journals were completed at least quarterly; additional entries were used to document self-determined “critical incidents” or experiences identified as important in each participant's development. Semistructured interviews were done twice: at midyear and at the end of the year. An additional source of data was an on-site field observation halfway through the second year to allow investigators to follow “a day in the life of” each participant by taking field notes throughout the day (Fig. 1). The observation day ended with a semistructured interview that enabled observers to obtain clarification about the participants' activities and decision making during the day. As in the first year, researchers collaboratively agreed on broad interview guidelines while allowing flexibility for individualization of interviews on the basis of previously collected data and observations.
Data Reduction and Analysis
Throughout the study, multiple strategies were used to maintain rigor and trustworthiness.45,46 Denzin47 identified 4 basic types of triangulation: investigator triangulation, in which multiple researchers participate in the study; data triangulation, which involves the use of repeated sampling over time, space, and people; methodological triangulation, involving the use of multiple sources and methods for data collection (Fig. 1); and theoretical triangulation, in which different theoretical perspectives are used in the analysis. We made use of each of these forms of triangulation.
Our purposive sample was selected on the basis of a combination of inclusion criteria as described earlier.22 Participants were employed in a variety of clinical settings and were working with various patient populations (Tab. 1). Data sources included reflective journals, interview transcripts, and field notes. Seven investigators from 4 institutions engaged in this project. Participants reviewed transcripts for accuracy and to clarify meaning. The semistructured nature of the interviews enabled the researchers to explore questions raised in participants' journals or field observations. The structure of the coding and analysis process served as an additional strategy to ensure rigor.
We used a general inductive approach for analysis48–50 with constant within-case and cross-case comparisons. This approach incorporates multiple analytic strategies from several qualitative traditions, including grounded theory, phenomenology, narrative analysis, and discourse analysis.51–53 Data from the second year were analyzed with the methods used during the first year of the investigation as described by Black et al.22
After interview transcription and review of interview transcripts for accuracy, investigators used open coding to independently analyze interviews, reflective journals, and field observation data. These data were used to create a descriptive case report for each participant. Investigator teams at each institution then collaborated in a cross-case analysis of each subsample. Subsequently, investigators from all institutions worked together to progress from open coding of data and the creation of case reports to the identification of coding categories and conceptual themes across the cases by use of axial coding.54
Results
A conceptual model reflecting the ongoing development of the participants during the second year of clinical practice was generated (Fig. 2); the model for the first year of practice is shown in Figure 3. The second year of practice was clearly different from the first year of practice for the participants. Our revised conceptual model (Fig. 2) reflects an extension of our original conceptual model (Fig. 3); the model was reformulated to represent 3 core themes that emerged from the second-year data: formal and informal learning, the development of increasing confidence and expansion of skills, and engagement in an environment that was characterized by collaborative exchange and opportunities for teaching. The themes are embedded within the context of the clinical environment, which significantly influenced professional development for the first- and second-year clinicians.
Conceptual model for year 2 (revised conceptual model). In both year 1 and year 2, development was grounded in the clinical environment and community of practice. The double-headed arrows indicate the dynamic interplay of roles that occurred as participants transitioned to new practice settings or clinical populations or assumed new responsibilities.
Conceptual model for year 1 (original conceptual model). Reprinted from: Black LL, Jensen GM, Mostrom E, et al. The first year of practice: an investigation of the professional learning and development of promising novice physical therapists. Phys Ther. 2010;90:1758–1773, with permission of the American Physical Therapy Association. This material is copyrighted, and any further reproduction or distribution requires written permission from APTA.
Theme 1: Formal and Informal Learning
The 11 novice physical therapists continued to evolve in the second year, with evidence of informal and formal learning occurring at multiple levels. In addition, a concentration on accessing and actively using learning resources external to the self replaced the internal focus of the first year, when the practitioners were focused on their own performance, knowledge, and skills. They transitioned from the previous frequent concern about “doing the right thing” procedurally to a greater focus on doing what was right for the patient. The participants evolved from relying solely on information-driven decisions to honing their clinical decision-making skills on the basis of keen observation of patients, consideration of situational or contextual issues, and prior learning and clinical experience. These points are illustrated by the following quotes (with sources given parenthetically after the quotes):
…now I look at the [patient] situation differently. The residents/patients need me to be their advocate more than ever. (Participant 4—journal)
I felt that I am constantly learning, but the type of information that I am learning has changed in the sense that before, I was trying to get through my day and do the more dot your “i's” and cross your “t's” type things. [B]ut because now I've seen more than one patient with a certain diagnosis and have seen more things and have a year of experience under my belt that you start to observe patterns and see similarities between people and differences. Also, trying to incorporate something that might have worked with a patient that has a completely different problem. (Participant 2—interview)
…my decisions are coming from clinical reasoning.… I'm able to reason through better, I'm able to come up with decisions that are better in terms of treating the patient. (Participant 5—interview)
[The novice is] making a decision based on safety and patient physiological response. (Participant 5—observation)
The participants learned even more through their interactions and connections with patients, and they used that information to make decisions. For example:
…knowing when the patient is ready to progress to the next step has gotten easier just by reading people's faces and that nonverbal communication. (Participant 4—interview)
Now I find that a therapist cannot successfully treat a patient if he or she is not emotionally involved and has not made a human connection with them. (Participant 4—journal)
The participants expanded their avenues for gathering information. There were informal sources, such as other people, but there was self-reliance as well. For example:
My sources right now are mostly other people. There are texts, there are other disciplines, kind of myself, too, my own experience, my own internal data collection. (Participant 10—interview)
The participants also relied on formal sources for learning, such as searching the literature and APTA Web-based resources. They demonstrated self-directed professional development by considering continuing education programs and thinking about future participation in clinical specialty training. These claims are illustrated by the following quotes:
…doing much more literature review[s] and taking some short weekend or two-day courses especially having done the whole DPT thing. I have the time to look at diagnoses, look at particular problems that I had and think about them, and I wanted to explore them more than I had done. (Participant 1—interview)
I go to the APTA website and search Hooked on Evidence.… I called APTA looking for continuing education courses.… I am enrolled in a year-long leadership program at our hospital. (Participant 11—interview)
I also think that many new graduates are more interested in becoming certified in a specialty area and many of those who have been practicing for longer periods are not. I think over the next few years there is going to be change, hopefully, to provide therapists more opportunity to become specialists in a certain area of physical therapy. (Participant 5—journal)
Theme 2: Increasing Confidence and Expansion of Skills
Although the participants experienced increasing confidence throughout their first year, the second year was a turning point for their professional role formation. The participants noted increased confidence and trust in their abilities and decision making as clinicians. This growth is illustrated by the following quotes:
Before, if I attempted a new approach with a patient and it didn't work, I would feel really bad about it. Now, it's easier to learn from mistakes and move forward.… I think it's just the fact I have a little more experience—gives you more confidence to say, “Okay, this is what I think is right.” (Participant 4—interview)
It's just kind of feeling more comfortable, feeling like I know what I am doing. (Participant 5—interview)
I am more comfortable with my decision-making skills, my ability to help my patients, and I have garnered respect as a senior clinician. (Participant 9—journal)
The second year resulted in additional professional formation as the participants realized that they were still learning but began assuming other roles, such as becoming the “go-to” therapist for others, and they started envisioning themselves on a path toward emerging expertise:
I guess as I become an expert and it will keep happening for years, I hope. It is someone who not necessarily knows all the answers, which would be the opposite of the novice. But is—I think of the term “therapist” as being a real resource, whether it is for patients or other therapists, colleagues, other students in the field—really someone who is so deep in experience you have a really good idea even early on where someone [patient] will get to and how to get them there. (Participant 1—interview)
Moreover, many participants also found themselves seeking or being given leadership roles within their departments. For example:
I have more responsibility. I am interviewing new physical therapists. (Participant 11—interview)
I am now going over to [a clinical agency] for a little while, and that's been more of a consultation service, so we go over, recommendations will be made, or someone will say that this person needs PT [physical therapy], and we are the ones that determine if they need it [PT]. (Participant 2—interview)
One participant indicated that while he did not think his responsibilities had changed, he just had a better idea of what they were:
I don't think my responsibilities have changed. I just think I have a better understanding of what they are. (Participant 5—interview)
The participants continued to gain more confidence in their decision making, communication skills, and expanding roles and were less fearful of speaking with referral sources and other support services personnel:
I can talk to anyone.… I didn't realize I had these strengths before. (Participant 9—journal)
One point of interest is that several participants noted that with their increased confidence came the expansion of their professional skills and emerging trust in their observational skills and clinical intuition. Their work became more streamlined, and they were able to view a patient holistically. For example:
I am always learning from my work, definitely. I have noticed though more people walk in the door, PT [physical therapy] patients.… I'm better. I'm more confident, right away. I just have a better sense of where they [patients] are or where we are headed and what they will need from me. It doesn't take me as long to figure out, get a handle on their needs or particular quirks or their movement patterns and stuff like that. (Participant 1—interview)
So things like that you pick up along the way now stick in my head, I don't neglect those minor muscles and if the bigger ones are functioning and they are compensating. I think I am starting to maybe refine things a little bit more and look for the small things or smaller details not just the general…the patient is not walking…but what else is going on there what else can we maximize? (Participant 2—interview)
Theme 3: Collaborative Exchange and Opportunities for Teaching
In the second year, the participants sought advice from their mentors less frequently and began contributing to their colleagues in the CoP by sharing some of their own learning and experience. Several participants stated that they collaborated with peers to solve problems and that they expanded their roles within their clinical settings, as the following quote illustrates:
I have also felt a transition from being the most inexperienced person in my practice setting to the “go to” person. My boss will bounce new ideas off of me, and I have been diligently working toward developing programs for contracture management and wound care in our facility. (Participant 4—journal)
The participants found ways to make meaningful contributions as integral members of the CoP. They described beginning to feel like they were part of a team—true members of a professional community—through collaboration with others, especially peers and superiors. For example:
But I feel like I am a player on the team, so that I am an active participant, so that I'm bouncing ideas off people and asking them things and really trying to collaborate within my discipline and with health professionals that work there as part of what's going on.… (Participant 1—interview)
The participants also began teaching others and exploring the role of educator by serving as clinical instructors for physical therapist students or by assisting medical residents:
I never realized how much knowledge and experience I had to share with this [physical therapist] student until I began to mentor her and answer her questions. (Participant 10—interview)
I feel pretty comfortable. Because they were first-year residents, I feel I almost have more experience than they do, in some areas, and so instead of asking my question—“What are the range of motion limitations?”—I feel like, at this point, I get specific and say it is okay to go through active-assisted ROM [range of motion] between 30 and 80 [degrees], and they say, “Why would you do 30 and 80?” I will be like “because this is what is normally the restrictions or protocol.” They are like “Oh, okay. That sounds good.” (Participant 2—interview)
Discussion
The purposes of this longitudinal qualitative investigation were to build on previous work and to continue to explore and describe the experiences of novice physical therapists during their second year of clinical practice. Four concepts from our first-year findings formed the basis of our original conceptual model (Fig. 3); these concepts were clinical environment and CoP, learning through experience, growing confidence, and emerging professional identity and role transitions. These 4 core concepts were tightly intertwined, and the model depicted how our participants' learning and growth as professionals were largely directed inward and self-focused and how the development of their professional identity and role was influenced by the context of the clinical CoP.22
For the portion of the study discussed in this article, we provided a longitudinal perspective on the continued, dynamic professional learning and growth and expansion of confidence experienced by the same novices during their second year of clinical practice. Three major themes from our second-year findings described how our participants grew and dynamically changed within their work environments; these themes were formal and informal learning; development of confidence and elaboration, consolidation, and expansion of skills; and engagement in the clinical environment through collaborative exchange and opportunities for teaching others. These themes are depicted in our revised conceptual model (Fig. 2).
As shown in the revised model (Fig. 2), although learning was ongoing and continued as a core theme, year 2 was a time for consolidation as well as elaboration of prior learning; expansion of confidence, skills, and responsibilities; and subsequent externalization of learning. These factors contributed to the professional transformation of the participants. Learning that was previously directed inward and self-focused turned outward, fueled by growing self-confidence. This change was reflected in professional transitions as therapists increasingly assumed patient advocacy, clinical teaching, and supervisory roles and responsibilities. By the end of the second year, these more experienced therapists had become integral members of their practice communities and were themselves shaping and reshaping the clinical environments that had previously shaped them. Table 2 shows a summary of the similarities and differences in learning and development that we observed between year 1 and year 2 for our participants.
Similarities and Differences in Learning and Professional Development During the First and Second Years of Practice
Formal and Informal Learning
In year 2, learning turned outward, and our participants grew through experience and interactions with their patients and other clinicians. Through these interactions and informal learning opportunities, the participants experienced increasing self-confidence and clinical skill development. As noted in the first 3 quotes illustrating theme 1 (formal and informal learning), our participants evolved from relying on information-driven factors to honing their clinical decision-making skills on the basis of observation of patients and attention to specific situational contexts and demands. Learning became highly contextualized and connected to a particular patient or clinical encounter. Prior learning and experience informed their clinical reasoning and were transferable and adaptable to other patient presentations and situations.
Our participants' evolution from an information-driven and more deductive decision-making process to one that began to incorporate a more holistic, informal, client-centered approach is concordant with previous research describing the process of novice development for occupational therapists,43,44 nurses,41,55–57 and teachers.26,58,59 The model of skill acquisition described by Dreyfus et al60 provides a framework for describing how a novice with limited experience approaches learning and work by using a rule-based or theoretical approach. With growing proficiency and confidence, a practitioner views a situation more holistically and applies prior learning to novel experiences. In addition, knowledge becomes contextualized; the situation, patient, or environment affects what learning is relevant for the clinician.60 This claim is supported by the third and fourth quotes illustrating theme 1, in which our participants increasingly recognized the patient as an important source of information and learning. Experts integrate multiple sources of knowledge, evidence, and problem-solving skills and exhibit skilled practical reasoning by using their keen abilities to listen carefully to their patients and to analyze and understand the meaning of what they hear.38
Experience alone is insufficient for the development of clinical reasoning skills. Reflection on the experience and in the experience and the therapist's ability to self-regulate and engage in a meta-cognitive process contribute most to learning.61–63 A critical component of the clinical reasoning process is the development of meta-cognitive skills. From Schön's perspective, learning often occurs in the real world or in murky situations when the known facts are in conflict.61 Through conscious and deliberate reflection on experience, the learner is better able to make sense of complex situations and grow professionally.61
Our participants were provided with multiple structured opportunities for reflection on their experiences throughout the duration of the 2-year study (Fig. 1). They each kept reflective journals in which they documented the meta-cognitive thought processes related to their learning. Reflection on experience is important for self-directed professional growth.34,42,61 The repeated interviews were a second structured opportunity for reflection and allowed the participants to remember, reflect upon, and process their clinical experiences and then discuss them concurrently or retrospectively with the interviewers. Research has supported the value of informal discussion and dialogue as vehicles for learning by novices.59
The explicit and ongoing development of meta-cognitive skills through reflective practice, self-assessment, and self-regulated learning is an essential component of professional development. Bereiter and Scardamalia64 argued that expertise is a process of progressive problem solving as the learner continues to engage in thoughtful reflection or self-monitoring of the environment during routine practice. This reinvestment in learning is part of the inner drive or motivation to continue to learn and develop.
During the second year, as indicated by another quote illustrating theme 1, our participants also demonstrated a desire for continued learning through the use of formal approaches, such as continuing education, APTA resources, and specialty certification. The participants seemed to be demonstrating “professional entity” and a broader view of their future as professionals by voluntarily seeking out and cultivating a greater range of learning experiences to advance their development.26
The nature and sources of learning and the developmental trajectories for the therapists in our sample were different during the first and second years (Tab. 2). Primarily, learning that was previously directed inward and self-focused during the first year turned outward during the second year, fueled by growing self-confidence. The therapists also moved from a fact-driven environment and rule-governed approach to a more holistic and contextualized learning approach.56,60 The learning that occurs during the early years of clinical practice is viewed as an essential part of the professional development of practitioners, both as a process of change within an individual and as contextually grounded enculturation into a clinical CoP. Our findings suggested that both processes were occurring for our participants during their first and second years of practice.
Increasing Confidence and Expansion of Skills
Our findings indicated that tremendous amounts of learning, development, and professional formation occurred for our participants during their first and second years of practice. Across both years, there was a dynamic interaction among learning, developmental change, and professional identity formation (Tab. 2, Fig. 2). Most of our participants continued to elaborate and expand prior learning, and that learning was increasingly externalized during year 2 as the participants assumed new roles as patient advocates and teachers of others and gradually assumed more responsibilities in their CoPs. As illustrated by all of the quotes provided for theme 2, the participants also noted increased confidence and trust in their decision making as clinicians.
According to Wenger, CoPs are “a unique combination of 3 fundamental elements: a domain of knowledge, which delineates a set of issues; a community of people who care about this domain; and the shared practice that they are developing to be effective in their domain.”10(p27) Our participants found themselves in CoPs, and our findings supported the pervasive, highly contextualized and embedded nature of learning that occurred in the CoPs in which the novices began their careers. Thus, our findings resonated with sociocultural perspectives on learning and growth that emphasize the essential contribution of social engagement to learning and development. Based largely on the work of Vygotsky,65 those views posit that the path of learning moves from the external level (social, interpsychological plane) to the internal level (intrapsychological plane) as people appropriate some of the knowledge, action, and semiotic and cultural tools and norms around them; this pathway is followed by movement outward again as people grow into and further shape the intellectual and cultural practices of their particular communities.
Jensen et al34 posited that professional formation is a key developmental process in novice-to-expert transitions and described professional formation as a process that incorporates change within an individual as well as social and professional enculturation. They urged a view of expertise as a “continuous process, not a state of being.” Our findings, as illustrated by the quotes provided for theme 2, supported both views. That is, our participants experienced internal change and enculturation into their CoP and growth into expertise as a dynamic and continuous process.
Opportunities for Collaborative Exchange and Teaching
In the second year, because of the participants' growing self-confidence in communication skills, practice knowledge, and clinical judgment, learning and action took an outward turn. Most of our participants continued to elaborate and expand prior learning while that learning was being externalized,66 as indicated by their increasing roles and responsibilities as patient advocates and teachers of others and their gradual assumption of more senior or leadership roles in their CoPs. Our findings were supported by the 4 quotes provided for theme 3.
A core component in the model of professional learning described by Reid et al26 is professional engagement. Engagement allows novices to generate meaning from experiences through purposeful interactions in a CoP. Novices personally identify with their practical knowledge, through reflection on their experience, and engage in continued learning as responsible professionals. Our findings supported the concept of professional engagement. Over time, especially in year 2, our participants engaged in more collaborative interactions and took on more responsibilities within their practice environments. Research has suggested that the most engaged practitioners exhibit personal commitment to and professional identification with their professions.26 Students who are most personally engaged with their disciplines and who view their personal and professional identities as being intertwined are self-motivated to continue to learn more about their professions. This notion is consistent with Sternberg's model of developing expertise, in which intrinsic and extrinsic motivation are central to novice development.67
Limitations
The sample of participants was small (n=11) and was drawn from 4 universities representing only the eastern and midwestern regions of the United States. Also, the participants graduated from physical therapist education programs that were not uniform with respect to the degree awarded—master of science in physical therapy and DPT. However, this variation also may be a strength because, despite program structure, the results were similar for novices who were identified during the last year of formal education as demonstrating professional promise, as operationally defined by our inclusion criteria for participants. Our sample included only novices who demonstrated professional promise and, therefore, may not have reflected all clinicians graduating from accredited physical therapist education programs.
The participants were located in a variety of practice settings with different job requirements; therefore, the work environments varied across the participants. Actual observation of the participants was limited. Most of our data were obtained from interviews and reflective journals. Recognizing the importance of the clinical practice environment for our novices, we incorporated field observations and field notes during the second year of data collection to better capture and explore the impact of the environment on novice development. The inclusion of 11 participants and the perspectives of 7 researchers provided another source of triangulation and potentially increased the validity of the results.47
Although the present study was designed to investigate novice learning and development in the early years of practice, the reader might rightfully ask whether the study itself was a form of intervention that promoted learning and development. The design of our study meant that the participants had multiple opportunities to engage in reflection on and dialogue about learning and development during their first and second years of practice. Did participation in the study itself have an effect on the developmental trajectory of the novices? If so, how? Mostrom and Black68 suggested that these questions and other intriguing but unanswered questions represent areas for future research.
Other potential areas for future research include examination of whether paths toward expertise may be attributed to sex differences, differences in clinical setting or environment, or differences in models of mentoring, such as 1-to-1, team, or even distant mentoring. In addition, a comparison of our findings with those for another cohort of novice practitioners enrolled in a residency program would be interesting.
Conclusions
Our findings indicated that engaged learning in a CoP is a critical component in the development and professional role formation of novice physical therapists during their first and second years of practice. Across both years, there was a dynamic interaction among learning, developmental change, and professional identity formation. In several ways, however, the nature and sources of learning and the developmental trajectories for the therapists in our sample were different during the first and second years. A major difference was that although structured learning experiences and mentorships enhanced growth and development during the first year of clinical practice, in the second year the participants evolved from questioning their knowledge and skills and relying on information-driven decisions to trusting their clinical knowledge and judgment and making clinical decisions on the basis of observation of patients and careful consideration of contextual and situational factors.
The second year of clinical practice was a time for the advancement of professional role formation. Increased confidence and trust in their abilities and decision making as clinicians enabled the participants to better understand and fulfill their roles as contributing members in a CoP and assume additional responsibilities.
Research illuminating the continued professional role formation experienced during the early years of clinical practice is critical. This information may assist educators in the design of effective pedagogical strategies and contextual climates for enhancing the professional development of physical therapist students and novice practitioners. Further longitudinal studies of the developmental trajectories of novice therapists are warranted.
Footnotes
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All authors provided concept/idea/research design, writing, data collection and analysis, study participants, facilities/equipment, institutional liaisons, and consultation (including review of manuscript before submission).
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Institutional review board approval was received from all 4 participating institutions.
- Received May 29, 2012.
- Accepted October 9, 2012.
- © 2013 American Physical Therapy Association
References
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