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2010; 90:1758-1773.PHYS THER. BlackmerPerkins, Pamela D. Ritzline, Lorna Hayward and Betsy Lisa L. Black, Gail M. Jensen, Elizabeth Mostrom, JanPromising Novice Physical TherapistsProfessional Learning and Development of The First Year of Practice: An Investigation of the

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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 betterfacilitate 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 clinicaljudgments 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 11promising new graduates from 4 physical therapist education programs participated.Investigators followed the graduates throughout their first year of practice. Datasources 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 andsocial interaction and learning was primarily directed toward self, (3) growingconfidence 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 beenconducted on expertise in physical therapy, few longitudinal investigations haveexplored the development of therapists across transitions from graduate to novice toexpert practitioner. This study explored and described the learning and developmentof 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 Developmentin 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 retiredAssociate Professor, Departmentof Cooperative Education, North-eastern University.

[Black LL, Jensen GM, Mostrom E,et al. The first year of practice: aninvestigation of the professionallearning and development of prom-ising novice physical therapists.Phys Ther. 2010;90:1758–1773.]

© 2010 American Physical TherapyAssociation

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Strong traditions exist in profes-sional education that suggestthe 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 withoccasional consultation from col-leagues.1,2 Although physical thera-pist education has evolved rapidlyto the clinical doctoral degree asthe entry-level professional degreefor physical therapists in the UnitedStates, there remains a great deal ofdiversity across educational programsand a wide variety of strategies forclinical preparation. Active dialoguecontinues about the state of clinicaleducation, where variation is thenorm, and whether time in clinicalexperiences, 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 considerpostprofessional, entry-level, residen-cies as a clinical education model. Iwould propose that we graduate ourstudents prior to the terminal intern-ship, let them sit for licensure, andthen place them in long-term entry-level residencies.3(p1226)

An assumption in this recommenda-tion is that there is a need for thecontinuation of structured learningexperiences as new graduates tran-sition from the role of student tophysical therapist. Yet, what do weknow, or not know, about the natureof workplace learning in the earlyyears of a physical therapist’s career?

The initial years of practice are atime of both challenge and change asthe novice practitioner emerges as aprofessional physical therapist. Cur-rently in physical therapist education,there continues to be a move towardincreasing the length of time for termi-nal clinical experiences in educationalprograms and a lack of consensus as to

what constitutes the core elements ofbest practice in clinical education.4,5

The physical therapy profession alsocontinues to develop an increasingnumber of clinical residency and fel-lowship programs for specialty prac-tice. Given the discussions on theseissues, it is important to know moreabout the nature of learning and pro-fessional development that occur inclinical practice after graduation, bothpre-licensure and post-licensure. Thefirst year of practice is a key period inthe transition from student to physicaltherapist and to date has been under-investigated. The structure and devel-opment of clinical education or resi-dency programs could be enhancedby better understanding of the earlylearning and development that occurduring that first year of practice fornovice therapists.

There is ongoing discussion across thehealth care professions that profes-sional competence, as a component ofexpertise, is a multidimensional andcomplex concept.6 Competence ex-tends well beyond knowledge andtechnical skills or achievement of min-imal standards. Epstein and Hundert6

argued that professional competenceis developmental, contextual and im-permanent. The acquisition of compe-tence depends on the development ofhabits of mind such as self-awareness,flexibility, and critical self-reflectionthat allow the practitioner to handleuncertainty. We use “competence” notas a minimal standard but as a compo-nent of expertise. The process of thedevelopment of expertise is poorly un-derstood, but an important element isthought to be the continued learningand self-reflection that are essential inmediating movement from mere accu-mulation of years of experience to theacquisition of expertise.7,8

The professional learning that occursduring the early years of clinical prac-tice often is viewed as an essential partof the growth and development ofpractitioners, both as a process of

change within an individual and as theenculturation of the practitioner into agroup. Even so, limited attention hasbeen given to systematically exploringthe early learning and practice ex-periences of physical therapists orto interactions and relationships inthe workplace. These early experi-ences create the contextual surroundfor practice and provide the novicepractitioner with opportunities to gainexperience and develop professionalcompetence.

The work of Jensen and colleagues9,10

and Solomon and Miller,11 among oth-ers,12–18 has significantly contributedto our understanding of expertise inphysical therapist clinical practice andof differences between novice andexpert practitioners.9,10,19,20 Theseauthors have urged a view of expertiseas a “continuous process, not a state ofbeing”10(p20) and posited that profes-sional formation is a developmentalphenomenon that incorporates changewithin an individual in several do-mains, as well as social and profes-sional enculturation. They also em-phasized that the accumulation ofexperience does not equal the devel-opment of expertise.

Exploration of physical therapist stu-dents’ professional socialization hasbeen a focus of several qualitative in-vestigations.21–24 Most agreed there isa need for educators to facilitate theprofessional identity development ofstudents. The studies also showed thatstudents struggle with building self-confidence and frequently experiencecognitive dissonance between “ideal”

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practice and actual clinical prac-tice.22–24 The research suggests thateducators take a more explicit role inguiding 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 theirfirst year of practice. They foundthrough semistructured telephone in-terviews with 10 novice therapiststhat they struggled in communicatingwith challenging patients, experi-enced difficulty with reimbursementissues, and reported feelings of stressand insecurity. Clinical environmentswhere there were role models andmentors facilitated an easier transitionto the therapist’s 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 physicaltherapists 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 reflectivejournals 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,26–28 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 earlyyears of nursing practice.30,31 Stand-ing31 followed a group of 20 nursingstudents as they transitioned to nurs-ing practice. Her specific focus was onthe development of nurses’ clinicaldecision-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.34–41 Early work by Bulloughand colleagues34,35 uncovered thecritical role of mentoring, ongoingfeedback, and evaluation, as well assupport and encouragement, forteachers in the first and early yearsof practice. In a longitudinal study,Levin38 followed 4 teachers over 15years. 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 understandingof 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. Itwas in the internal struggle with whatthey know and what they need toknow to solve a teaching problem thatthere was evidence of reflection andmeta-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.39–45 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 profession’s vision for in-creased autonomy brings with itincreased responsibility and, there-fore, greater accountability.46 In bothacademic and clinical settings, therewill 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 professionalsmust 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




and demonstration and maintenanceof professional competence.27,28,47

The health care system in the UnitedStates is placing increasing emphasison accountability for competent per-formance, and, in turn, our discus-sions in professional education andpractice also must consider the inter-relationships of competence, novicedevelopment, and expertise.6,48

Novice development is a process ofchange within the individual (knowl-edge, skills, and thinking), as well asa contextually grounded encultura-tion and professional socializationprocess. The community of practicein which novice therapists work un-doubtedly plays a critical role as theylearn from and through experience.Sources of learning are diverse andnumerous and include, but are notlimited to, research-based evidenceand theory; practical and personalexperience; dialogue with patients,caregivers, and other health careprofessionals; and reflection on theirown work.45,49 Although a moderateamount of research has been con-ducted on expertise in physical ther-apy and on differences between nov-ice and expert practitioners,9–18 fewstudies have investigated the learn-ing and development of novice phys-ical therapists over time throughoutthe first year of practice.

In the United States, we have yet tosystematically explore the learningand development of physical thera-pists during the early years of prac-tice. What are the sources and natureof learning for new professionalsduring their early years of practice?What forces or factors influence thenature 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 andqualitative approach to inquiry.

This study begins to address some ofthese questions from a longitudinaland qualitative perspective to en-hance our understanding of learningand development during the earlyyears of practice as a physical thera-pist. The purpose of the study was toexplore and describe the experi-ences, thinking, learning, and develop-ment of promising novice therapistsduring their first year in practice.

MethodDesignWe used a multiple qualitative casestudy approach, using grounded the-ory methods that allowed for within-case and across-case analysis. Sevenexperienced qualitative researchersrepresenting 4 physical therapist ed-ucation programs in the East andMidwest regions of the United Statescollaborated as investigators for thestudy. The use of multiple investiga-tors and multiple programs helpedto ensure a larger initial samplingframe for the study.

ParticipantsFor each university cohort, the inves-tigators sought a purposive sampleof a minimum of 2 and a maximumof 4 participants who met selectioncriteria. A purposive sample of 12new graduates from the 4 physicaltherapist professional education pro-grams initially agreed to participatein the study. One individual discon-tinued enrollment early in the studyperiod, leaving a final sample of 11participants (Table). To bound thestudy and sampling frame, we de-cided to recruit new graduates whowere viewed as “promising novices,”with the assumption that those in-dividuals may be more likely to be-gin to develop the characteristicsand attributes of expert therapistsearlier in their careers than others.Participant selection criteria forthe study included the following:

completed a physical therapist de-gree, graduated with a GPA of 3.0or higher, excelled in the final yearof clinical education experiences(as determined through nominationby the clinical education faculty), en-gaged in extracurricular and profes-sional activities during their educa-tional preparation, and demonstratedcharacteristic behaviors associatedwith professionalism, as described inthe APTA professionalism/core valuesdocument.50

Participant demographic data are pro-vided in the Table. The novice thera-pists ranged in age from 24 to 29 yearsand entered practice in a variety ofpractice settings. The sample con-sisted of 8 female therapists and 3male therapists whose work settingsranged from acute care hospitals, tohospital-based outpatient clinics, toprivate practice, to rehabilitation set-tings, both inpatient and outpatient.In addition, the patient populationsthese new graduates were workingwith were diverse and crossed the lifespan 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 studybegan at the time many programswere converting from Master of Sci-ence in Physical Therapy (MSPT) de-grees to DPT degrees. Several partici-pants graduated with MSPT degreesand then completed transition pro-grams designed to enable graduates toadvance their professional degree tothe DPT level shortly after the award-ing of the MSPT degree.

Procedures/Data CollectionFigure 1 provides a summary of thechronology of data collection andmultiple sources of data gatheredacross the course of the first year ofthe study. Data sources included aninitial brief demographic question-naire, reflective journals submitted atleast monthly, and a baseline semi-structured interview conducted at




entry into the study, followed byquarterly interviews thereafter for atotal of 5 interviews. The researcherscollaboratively designed the reflec-tive journal guidelines and questionsand the interview guide based onexisting literature and key conceptsrelated to professional learning, de-velopment, and clinical reasoning in

physical therapy. Reflective journalguidelines and questions provided toparticipants at the initiation of thestudy are shown in Appendix 1.Questions for the baseline interviewand selected questions from subse-quent interviews are provided inAppendix 2. Consistent with the na-ture of this type of qualitative case

investigation, the types of interviewquestions asked by the investigatorsdiverged to some degree to allow forfollow-up on data provided by indi-vidual participants in reflective jour-nals or prior interviews. Participantswere asked to discuss their first-yearperformance review during the last(12-month) interview session. The

Table.Participant Demographicsa

UniversityAffiliation

ParticipantNo. Sex

Age atEntry (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 andcardiac rehabilitation

University 3 7 M 29 MSPTDPT

Private practice: outpatient

University 3 8 F 28 MSPTDPT

Private practice: pediatrics


Private practice: outpatient


Pediatric rehabilitation center

University 4 11 F 24 DPT Veteran’s hospital: inpatientand outpatient

a M�male, F�female, MSPT�Master of Science in Physical Therapy, DPT�Doctor of Physical Therapy.

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




majority of interviews were con-ducted face-to-face, but some wereconducted by telephone due totravel or scheduling constraints. Allinterviews were audiotaped andtranscribed verbatim.

Data Reduction and AnalysisData were analyzed using a generalinductive approach, as described byThomas,51,52 using constant compar-ison for within-case and cross-caseanalysis. This approach incorporatescommon strategies for analysis usedin several qualitative analysis tradi-tions, including grounded theory,phenomenology, narrative analysis,and discourse analysis.53–55 Follow-ing each interview, the investigatorsreviewed transcripts and journalsand used open coding to analyzethe interview and monthly reflectivejournal data for each graduate thera-

pist. These data were used to createa descriptive and emerging casereport.56 Investigators from eachinstitution then collaborated to re-view cases to verify codes, catego-ries, and subcategories and to iden-tify emerging themes. Midwaythrough the first year, investigatorsfrom all 4 universities shared theircoding scheme and emergent cate-gories and themes. Discussion anddeliberation by the investigators atthis time led to a preliminary identi-fication of 5 core themes into whichmost categories, subcategories, andcodes could fit: learning, confidence,communication, professional iden-tity formation, and the clinical envi-ronment. These consensus-based corethemes were used as the frameworkfor further analysis of individualparticipant and institutional casestudies. Although these preliminary

themes and related categories hadbeen identified, as data collectioncontinued, the investigators werealert to the potential for discrepantor divergent data to create new in-terpretations or for collapsing oroverlapping categories and themes.At the conclusion of the first year,additional data from the institutionalcase studies was used to refine andfurther develop a preliminary con-ceptual model representing thelearning and development of thesenovice physical therapists during thefirst year of practice, as illustrated inFigure 2.

Throughout data collection and analy-sis, several strategies were used to en-sure rigor and enhance trustworthi-ness.57,58 First, triangulation was usedto ensure consistency; that is, datawere sought from multiple sources

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




(artifacts, questionnaire, journals, andinterviews), and these data emanatingfrom each participant constitute a verylarge data set (Fig. 1). Second, the re-flective journal and interview datawere low-inference data provided di-rectly from participants. Third, all in-terview transcripts were subjected tomember checks; that is, they wereprovided to participants for review,clarification, and additions before fur-ther analysis by the investigators. In-vestigators at each institution com-pleted independent coding on theirrespective cases and then completedconsistency 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 onoverarching categories and themes.Even so, the investigators remainedalert for new data that could be rele-vant but did not “fit” early the earlyconceptual framework. In fact, as dis-cussed below, some of the earlythemes 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 asthe relationships across concepts, inthe learning and development of oursample of novice physical therapiststhroughout their first year of prac-tice. The arrows in the model allpoint inward toward the emergingprofessional identity of the novicetherapists; this is meant to illustratethat the overall direction of growthfor these individuals appeared to bedirected inward toward the self. Thecore concepts in the model are pre-sented below, with supporting low-inference evidence moving from theouter circle of the model to the innercircle.

Clinical Environment andPractice Community: WorkplaceSupports and ConstraintsThese novice therapists in their firstyear of practice were strongly influ-enced, either positively or negatively,by the clinical environment and thepractice community. An early focuson “learning the ropes” of the clinicalsetting prevailed over an emphasis ondeveloping their clinical decision-making skills. The participants reportedtheir first priorities as “getting in theflow” or experiencing the “real world”of the workplace. Those participantswho entered an environment wherethere was a mentoring program fornew therapists found this very helpfuland described the program as a work-place support for their development.

They had . . . a mentorship programwhere you are teamed up with an-other therapist to essentially showyou the ropes and meet with you on aweekly basis. . . . I found this to be anasset, as I had many questions aboutpaperwork, routines, or clinical ques-tions. Participant 10—Journal

Mentoring took place both formallyand informally for most, but not all,of our participants. That is, some newtherapists had mentors specificallyidentified for them as they beganwork, whereas others sought outmembers of the staff who eventuallyserved as mentors.

It is really nice to have so many dif-ferent PTs [physical therapists] tobounce ideas off or to ask questions.Everyone is willing to offer sugges-tions or ideas when you might need anew one. Participant 10—Journal

Two participants noted a lack ofmentors or mentoring in their work-place and felt this was a constrainton their learning and development.Both of these participants contem-plated leaving the clinical agencyduring their first year of practice and,in fact, did leave the agency shortlyafter the 1-year mark in their career.

It’s been an ever-changing environ-ment in our clinic and not having awhole lot of resources to fall back onor be able to ask certain people ques-tions that may have had experience inthat particular area. It’s been kind oftough figuring out stuff on my ownand kind of going from there. . . . Atthat point in time, you do kind ofwish you had a mentor to fall back on.Participant 7—Interview

The participants often recognized pri-mary concerns about becoming an in-tegrated member of the clinic teamand developing their individual clini-cal skills. However, the need fordeveloping time management skillsand becoming efficient and produc-tive members of the clinical commu-nity often ruled their world early in thefirst year. Toward the end of the year,however, they more easily navigatedworkplace constraints or limitationsand were less “rule governed” by theenvironment. Dissatisfaction withsome practices in the clinical environ-ment created cognitive dissonanceand ethical distress and led to jobchanges for 2 therapists at end of firstyear. These were the same therapistswho reported a lack of mentoring.

We get told how we should practice;administration wants us to average acertain number of visits but obtaincertain outcomes. I find this difficultto follow because not every patient isthe same. I try not to follow theserules when treating my patients. Par-ticipant 2—Journal

There was significant variability inparticipant responses to the clinicalenvironment. As forecasted by anearlier quote, instability in the clini-cal environment negatively affectedthe participants’ performance.

It’s kind of like you don’t want to getyourself used to anything just yet be-cause the overwhelming thought isthat I would kind of be here for theupcoming future and then there weresome other changes in the company.Participant 1—Interview




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 alwayslearning . . . and I feel that I am con-tinuing to strive to learn new things.Participant 10—Journal

This category includes participants’perceptions regarding expandingpractical skills, knowledge, abilities,and clinical reasoning skills. Early on,the participants questioned theirclinical skills and judgment; theywere concerned about their perfor-mance as physical therapists. To ad-vance their skills and clinical judg-ment, they identified multiple sourcesof learning in the clinic and used avariety of learning strategies. Partici-pants reported learning through ev-eryday experience (including trialand error), observation, asking ques-tions and engaging in dialogue withcolleagues, and seeking and readingliterature. Their focus often was ondeveloping confidence in their deci-sion making.

The richest sources of learningseemed to come from work experi-ence itself and communications andinteraction with coworkers, mentors,patients, and caregivers in everydaypractice.

So you kind of learn by way of yourwork experience and exposure tothe world of work. Participant 2—Interview

If work was a lake, I feel there isalways someone next to me in a boatwith an outstretched hand. Partici-pant 1—Journal

As noted in the previous section onthe clinical environment/practice com-munity, those novices who had iden-tified a mentor in their first year feltthat they progressed more rapidlythan 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 advancetheir learning.

I need to read more . . . just to keepgoing over things and making sureI’m on top of it . . . and plus the morepeople you see, the more examplesyou have in your head about certaindiagnoses and stuff. Participant 4—Interview

As they progressed through the year,the participants became more awareof and more focused on their pa-tients’ responses to therapy versustheir 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 onpast experiences with patients toprovide appropriate interventions. Itis in these later quotes that self-reflection on past and present experi-ences becomes more visible andserves as a resource for their profes-sional learning and development.

Even with the difficult patients, youkind of learn how to handle them,you know what’s going to work andnot going to work. You kind of seesome patterns with patients. You startto evolve. Participant 3—Interview

I had another challenging case . . .these last few weeks. I learned a greatdeal about tragedy, struggle, and tri-umph from this young girl; more thanshe will ever know. I will rememberthis 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 withany diagnosis without hesitation.

I feel that [early] last year I felt morecomfortable with certain diagnoses,and I’d just go in and do the evals, butit seems like now I can take any evaland not worry when I go in. Partici-pant 4—Interview

Toward the end of the first year, theparticipants’ learning was still pri-marily directed inward, but an out-ward turning began to emerge asthey prepared to enter their secondyear of practice. Shifts occurredfrom a focus on general skill andknowledge building to developmentof more specialized knowledge andan expanded repertoire of abilities.Several participants at this time alsobegan to experience clinical teach-ing as part of their learning.

From the previous journal, I think Italked about how it was weird to bea teacher to the new therapist whocame in, so that’s a learning experi-ence. Even though you’re teaching,you’re learning at the same time. Thatwas 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 astate of increasing awareness of abili-ties and competence (including trustin clinical decisions) as perceived byoneself and others. The most notablearea of growing confidence through-out the first year was in the area ofcommunication skills, including: talk-ing to patients, caregivers, and othercolleagues; listening skills; and inter-preting or understanding what wascommunicated to them. Initially, theparticipants, somewhat to their sur-prise, struggled with communication(both verbal and nonverbal).

Just finding something on a commonlevel or trying to understand their per-sonality in terms of how they like tocommunicate except as a therapist, Ifeel you have to be fairly open in yourcommunication because you need tolearn a lot about the patients in treat-ing them. Participant 5—Interview

Reports of increased confidence mostfrequently occurred after positive in-teractions with peers, other profes-sionals, employers, and patients.




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.

There’s always those experienceswhere you really feel that you fit. Justthe interactions with the physiciansmore and them noticing you and thencoming 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 toverbal and nonverbal communica-tion in interactions with patients andother health care providers. The par-ticipants became better able to rec-ognize and handle communicationissues before they became problems.

Knowing when the patient is ready toprogress to the next step has gotten alittle bit easier just by reading peo-ple’s faces and that nonverbal com-munication. Participant 2—Interview

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 linkedwith emerging professional identi-ties and role transitions.

I remember being nervous aroundpostsurgical patients when I started. . . but now I don’t really have thatnervousness. Participant 9—Interview

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 latterhalf of the first year of practice.

My regional manager called me therising star of the north regions, andfor once I really believed those words.. . . Feedback like this really helps meto increase my confidence in the careI 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 respectfrom patients and colleagues andwho to rely on for information to“know the ropes” and make theirway 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 anawareness 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 theymight become in the future.

Now I am becoming more part of theteam, I find senior therapists comingto me with questions. . . . It’s nice toknow that I can offer ideas and sug-gestions even though I may not al-ways have as much experience. I feelthat my opinion is valued. Participant10—Journal

As the year progressed, the partici-pants recognized the value of theirrole and moved rapidly forward intotaking social responsibility for pa-tients, being patients’ advocates, andseeking out leadership roles. Theywere 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 todetermine when a patient should orshould not be discharged. I don’tthink that someone in business ad-ministration should make decisionsthat they are not trained to make. Par-ticipant 2—Journal

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 allaspects of what I do, both within theclinic and outside of the clinic. Partic-ipant 3—Journal

So much relies on how you communi-cate with patients, with other thera-pists, with support people, and withother people in the health professions. . . general getting to know your pa-tient . . . along with professional com-munication across the whole of healthcare. Participant 3—Interview

By the end of the year, most partici-pants were expanding into newroles and beginning to envision andchart longer-term career paths. Theywere looking forward to new chal-lenges and responsibilities as part oftheir role.

One thing that has been kind of neatis that my supervisor had started giv-ing me a lot more responsibilities.. . . I feel like he comes to me with alot more questions now than he usedto, and for advice. Participant 11—Interview

I see myself playing an important partin whatever I choose to specialize in.Participant 11—Interview

The experiences of participants werenot 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




our sample. Some participants re-ported high levels of stress that de-creased with experience, some re-ported low levels of stress, and othershad intermittent episodes of highstress 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 Campoet al,59, Balogun et al,60 and Wandlingand Smith61). The classic work ofMaslach62 viewed burnout as beinglinked to the interplay of many fac-tors—contextual, interpersonal, andpersonal. It is not surprising that theexperiences of our participants variedin this regard.

DiscussionThe purpose of this study was toexplore and describe the experi-ences, thinking, learning, and devel-opment of promising novice physi-cal therapists during their first yearof practice. The first year of practice,when a new therapist begins to as-sume full responsibility for patientcare and seeks to become integratedinto the clinical community in whichhe or she is working, is an importanttransition period we know relativelylittle about. For our sample of novicetherapists, we identified 4 core con-cepts that appear to be tightly inte-grated in a developmental processthat is largely focused inward on in-dividual learning and growth in thecontextual surround of the clinicalpractice community. These 4 con-cepts—the clinical environment andpractice community, learning throughexperience, growing confidence, andemerging professional identity androle transitions—form the basis of ourconceptual model (Fig. 2).

In their most recent conceptualiza-tions of expert practice in physicaltherapy, Jensen and colleagues10 pos-ited that professional formation is akey developmental process in novice-to-expert transitions. They described

professional formation as a processthat incorporates change within anindividual, as well as social and pro-fessional enculturation; professionalformation provides a scaffold for theachievement of professional compe-tence that is grounded in social andmoral engagement in a community ofpractice. Our findings reveal whatwe believe to be the “seeds” of profes-sional formation for our therapists.The results point to the pervasive,highly contextualized and embeddednature of learning that occurred in thepractice communities as these novicesbegan their careers. A great majorityof the learning described by our par-ticipants was ignited through socialencounters and interactions with pa-tients, caregivers, coworkers, andmentors, among others.

The conceptual model we have pro-posed suggests that much of thelearning and change the participantsexperienced in their first year of prac-tice was directed inward and wasreflected in gradual growth of self-confidence in their communicationand relational skills, practical skillsand knowledge, and clinical problem-solving and decision-making abilities.There was a dynamic interactionamong engagement in the practicecommunity, individual learning andgrowth, and the emergence of a pro-fessional identity associated with roletransitions.

Clinical Environment as aCommunity of PracticeThe clinical environment was thecommunity of practice for our par-ticipants and exerted a powerful in-fluence on the novice in the first yearof practice. The environment has thepotential to influence the novice ineither a positive or negative direc-tion, depending on the novice’s per-ception of acceptance in the com-munity and support for his or herdevelopment by coworkers. Thosein clinical settings with a formalmentorship program found that the

mentors’ support for “learning theropes” was especially critical in theearly 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 thatthe most influential factor in profes-sional development during the firstyear of practice was mentorship as-sistance. In a study of physical ther-apists, mentors and role modelswere identified as key resources, par-ticularly for new graduates.11,64 Like-wise, a study of physical therapistsand occupational therapists duringtheir first year of practice25 showedthat access to mentors and supportenhanced new practitioners’ under-standing of “what it meant to be atherapist.”25(p24) Although formal,one-to-one mentorship relationshipscan exert a positive influence onnew practitioners, we also foundthat many of our participants de-scribed the development of informalrelationships with coworkers in thepractice community that served assupports for their learning duringthe first year.

Across many professions, there isincreasing interest in and evidencefor the critical importance of socialcontext and the community of prac-tice for professional learning and de-velopment.42,45,65–71 Perspectives onlearning that focus on the situatedand social nature of learning andthe importance of co-participation inpractice communities have beenwidely discussed in the literature forseveral decades.67–74 These perspec-tives, sometimes referred to as “situ-ated learning” or the “social con-struction of knowledge,” encourageus to think about learning as a pro-cess and product of social interac-tion, engagement, and meaning-making in authentic practice contexts,




not as the mere acquisition of knowl-edge that takes place in the heads ofindividuals. These views also drawheavily on several theoretical per-spectives of learning and develop-ment, including that of Russianpsychologist L.S. Vygotsky.75–77 So-ciocultural theories of learning, alsoreferred to as sociohistorical theories,emphasize the essential contributionof social engagement to learning anddevelopment and posit a directionalpath of learning that moves from theexternal plane (social) to the internal(psychological) and then outwardagain as an individual grows into theintellectual and cultural practices ofhis or her community.75

Lave and Wenger68 first describedlearning in social context as a phe-nomenon that occurs across a con-tinuum of participation in a practicecommunity—from “legitimate pe-ripheral participation” to full partic-ipation. This view is congruent withsociocultural theory and resonateswith the findings in our study, wherenovices, by definition, were workingin a community of practice withtherapists more experienced or ex-pert than they were. At first, theyfelt like peripheral, albeit legitimate,participants but by the end of thefirst year, for the most part they feltlike integral members of the clinic“team.” Across the course of theyear, they also described how theyoften adopted or appropriated cer-tain behaviors, skills, or forms ofknowledge based on observationsand their interactions and dialoguewith others.

Learning Through ExperienceLearning through experience wasthe first core theme to emerge in ourdata, and it remained the strongestfor our sample of participants. Forthis reason, it is the thickest concen-tric circle in our conceptual modelembedded within the practice com-munity, and it surrounds and contrib-utes to the growing self-confidence

and emerging professional identityof our novices (Fig. 2). Learning tookplace in many ways and assumedmany forms, but the most powerfulsource of learning appeared to be“learning through doing” in an au-thentic workplace environment withall the associated challenges and suc-cesses that are part of the everydaywork of physical therapists. Withinthis experience, which could be pos-itive or negative, interpersonal inter-actions with patients, caregivers,family members, coworkers, men-tors, and others often played a largerole in what was learned.

Similar to Solomon and Miller’s find-ings,11 many of our therapists de-scribed some of their struggles earlyin the year with communication andunderstanding what the patient orothers wanted or needed from them.Their focus often was on their per-formance as a therapist, especiallywhen they encountered challengesin communication or capturing themeanings of others. They were sur-prised how difficult it was at times tofigure out exactly what the patientwanted and how to best work withthe patient and family to achieve tar-geted outcomes. The knowing whatto do for and with this particularpatient at this time was puzzling.Gradually over the first year, how-ever, our participants became moreaware of the critical importance ofunderstanding the patient’s perspec-tives and beliefs and integratingthem into their interventions. Theylearned that to do this, the therapistmust listen well, facilitate the pa-tient’s ability to share his or herstory, and seek to understand themeanings that patients hold. It ap-peared that our novices were jug-gling the tasks of learning about selfalong with the tasks of learningabout and through others, includinggaining more insight into the livesand needs of their patients. Interest-ingly, when we asked our noviceswhat they perceived to be their most

important clinical skill during inter-views conducted in the last half ofthe first year, they almost alwaysidentified communication as theirmost important clinical skill. Further-more, reflections on the challengesassociated with the development ofthis skill often appeared in journaldata. One participant expressed itthis way in response to a questionabout essential clinical skills:

Communication . . . developing rap-port and trust with your patient andyour patient’s family, especially withlittle kids, being able to get them totrust you to let you into their space.. . . Once in a while, I have a kid that’svery challenging that has a lot of sen-sory issues, and it’s hard sometimes todevelop that relationship. Participant10—Interview

Although our participants spoke fre-quently about learning through expe-rience, it is worthwhile noting that ourjournal and interview data also illus-trate that these novices were engagingin reflection on past and present ex-periences and that this contributed totheir learning and sense-making abouttheir experiences. Educational theo-rists John Dewey78,79 and later DonaldSchon80,81 have long emphasized thecritical importance of authentic expe-rience, encounters with genuine prob-lems, and reflection on and in experi-ence as essential sources for learningand professional growth. All of ournovices 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 practitionersand advance “authentic professionallearning.”45

Professional Identity Formation:Who Is the Novice Becoming?An initial goal of our novice physicaltherapists was to become an inte-grated and respected member ofthe clinical community in their work




environment. Our findings and con-ceptual model suggest that the emer-gence of a clearer professional iden-tity for our participants is related totheir gradual integration into thepractice community, their activelearning and engagement in thatcommunity, and their growth in self-confidence and trust in their knowl-edge and abilities as therapists. Bythe conclusion of the first year ofpractice, our therapists had devel-oped a clearer view of who theywere as individual practitioners andwhat their unique contributionswere or might be within that com-munity. Associated with this realiza-tion, they also began to assume newroles in the clinical community andanticipate who and what they mightbecome in the future.

The experience of our novice thera-pists is consistent with descriptionsof “identity work” in professionalpractice communities, as describedby many authors in a variety of dis-ciplines.29,42,45,68,69,71,82,83 As Wengerhas pointed out, when we start tofocus on the concept of identity it iseasy to think of it in only individual-istic terms, and he cautioned againstthis:

Building an identity consists of nego-tiating the meanings of our experi-ence of membership in social com-munities. The concept of identityserves as a pivot point between thesocial and the individual, so that eachcan be talked about in terms of theother.69(p145)

Lave and Wenger68 referred to the“crafting of identities” in practiceand discussed how the nexus of theself and the social shapes the con-struction and sometimes deconstruc-tion or reconstruction of identity.Furthermore, there is a reciprocityinherent in the identify formationprocess: who you are becomingshapes what you know or come toknow, and what you know shapeswho and what you are becoming.

Our findings with this sample of nov-ice therapists resonate with thesetheoretical perspectives and are con-gruent with descriptions by Plack82

of the learning and development ofphysical therapist students and newgraduates in the United States basedon a cross-sectional qualitative in-vestigation, as well as findings fromothers studies of students and novicesoutside of the United States.11,22–25,63

Plack’s study82 resulted in the devel-opment of a model of learning in aphysical therapy community of prac-tice that incorporates many of thefindings from our investigation, andone of her recommendations for fu-ture inquiry was the need for longi-tudinal research.

For 2 of our participants, dissonancearose between their emerging andclearer professional identity and theirassociated beliefs, commitments, andaspirations and the cultural norms andpractice in their work environments.This dissonance and discomfort led totheir departure from their clinicalagencies close to the end of their firstyear of practice.

LimitationsParticipants were selected from only4 universities and were limited bythe inclusion criteria. However, wedid provide justification for this pur-posive sample in the “Method” sec-tion. The study did not include acomparison with participants whodid not meet the inclusion criteria.

The novice participants were lo-cated in a variety of practice settingswith different job requirements, lim-iting their control of the environ-ment. Limited actual observation ofthe participants occurred. The re-sults were obtained primarily frominterviews and reflective journals.Recognizing the importance of theclinical practice environment on ournovices, we plan further study thatwill incorporate field observations

and field notes to better capture andexplore this dimension of our model.

Our sample did not include nontra-ditional students whose professionaldevelopment may have followed adifferent path. All participants werepracticing in their first year of licen-sure as a physical therapist; how-ever, 2 of the participants were in abridge program from a master’s de-gree to a DPT degree during thisstudy period. Not all participantswere at a DPT level in their first yearof practice.

One could argue that the structurewe provided for deliberate reflection(multiple reflective journals and in-terviews) may have accelerated orenhanced the participants’ learningand insight into their own develop-ment. On the other hand, there isevidence that the reflective process isan important aspect of professionaldevelopment and perhaps should be-come a more explicit, deliberate, andprominent feature of early workexperiences.6,10,27,38,84

ConclusionBased on the experiences and re-ports of our participants, the firstyear of practice is an exciting, chal-lenging, and rewarding period ofpersonal and professional growth.Over the first year of practice, par-ticipants grew in confidence, and bythe end of the year showed signs ofbeing ready to move into new roles.In their initial practice, there was afocus on the mechanics of practice(eg, juggling caseloads and paper-work, learning techniques, findingmentors). By the end of the year,some of the participants were takingpride in becoming mentors to othersand expressed satisfaction in theirown growth. There was increasedevidence of planning for profes-sional growth, for the “next step” intheir careers. Their initial year beganas focused on self and on how to




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 forfurther 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 influenceof the environment in communitiesof practice. Structured learning ex-periences and facilitation of mentor-ships are likely to enhance growthand development during the firstyear of practice.

Further longitudinal study of the de-velopmental trajectories of these andother novice therapists is warranted.We plan to continue the present in-vestigation over several of the earlyyears 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 2–6, 2007; Vancouver, BritishColumbia, 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

References1 Sullivan WM. Work and Integrity: The

Crisis and Promise of Professionalismin America. 2nd ed. San Francisco, CA:Jossey-Bass Inc Publishers; 2005.

2 Sullivan WM, Colby A, Wegner JW, et al.Educating Lawyers: Preparation for theProfession of Law. San Francisco, CA:Jossey-Bass Inc Publishers; 2007.

3 Delitto A. 39th McMillan Lecture. Weare what we do. Phys Ther. 2008;88:1219–1227.

4 CAPTE Commission on Accreditation inPhysical Therapy Education (CAPTE). Eval-uative criteria for accreditation of educa-tion programs for the preparation of phys-ical therapists. Available at: http://www.apta.org/AM/Template.cfm?Section�PT_Programs3&TEMPLATE�/CM/ContentDisplay.cfm&CONTENTID�62414. Ac-cessed December 17, 2009.

5 Craik RL. Does clinical education need aseries of tools to assess success [editorial]?Phys Ther. 2008;88:1106–1107.

6 Epstein RM, Hundert EM. Defining and as-sessing professional competence. JAMA.2002;287:226–235.

7 Tsui ABM. Understanding Expertise inTeaching: Case Studies of Second Lan-guage Teachers. New York, NY: Cam-bridge University Press; 2003.

8 Ericsson KA, Charness N, Feltovich PJ,Hoffman RR, eds. The Cambridge Hand-book of Expertise and Expert Perfor-mance. New York, NY: Cambridge Univer-sity Press; 2006.

9 Jensen GM, Gwyer J, Hack LM, ShepardKF, eds. Expertise in Physical TherapyPractice. Boston, MA: Butterworth Heine-mann; 1999.

10 Jensen GM, Gwyer J, Shepard KF, HackLM, eds. Expertise in Physical TherapyPractice. 2nd ed. St Louis, MO: SaundersElsevier; 2007.

11 Solomon P, Miller, P. Qualitative study ofnovice physical therapists’ experiences inprivate practice. Physiother Can. 2005;57:190–198.

12 May BJ, Dennis JK. Expert decision makingin physical therapy: a survey of practitio-ners. Phys Ther. 1991;71:190–202.

13 Martin C, Siosteen A, Shepard KF. The pro-fessional development of expert physicaltherapists in four areas of clinical practice.In: Jensen GM, Gwyer J, Hack LM, ShepardKF, eds. Expertise in Physical TherapyPractice. Boston, MA: Butterworth Heine-mann; 1999:231–244.

14 Embrey DG, Guthrie MR, White OR, DietzJ. Clinical decision making by experiencedand inexperienced pediatric physical ther-apists for children with diplegic cerebralpalsy. Phys Ther. 1996;76:20–33.

15 Mostrom E. Wisdom of practice in a trans-disciplinary rehabilitation clinic: situatedexpertise and client centering. In: JensenGM, Gwyer J, Hack LM, Shepard KF, eds.Expertise in Physical Therapy Practice.Boston, MA: Butterworth Heinemann;1999:207–230.

16 Mostrom E. Situated expertise: the wisdomof practice in a transdisciplinary rehabilita-tion clinic. In: Jensen GM, Gwyer J, HackLM, Shepard KF, eds. Expertise in PhysicalTherapy Practice. 2nd ed. St Louis, MO:Saunders Elsevier; 2007:214–239.

17 King G, Currie M, Bartlett D, et al. Thedevelopment of expertise in paediatric re-habilitation therapists: the roles of motiva-tion, openness to experience, and types ofcaseload experience. Aust Occup Ther J.2008;55:108–122.

18 King G, Currie M, Bartlett D, et al. The de-velopment of expertise in pediatric rehab-ilitation therapists: changes in approach,self-knowledge, and use of enabling and cus-tomizing strategies. Dev Neurorehabil.2007;10:223–240.

19 Jensen GM, Shepard KF, Gwyer J, HackLM. Attribute dimensions that distinguishmaster and novice physical therapy clini-cians in orthopedic settings. Phys Ther.1992;72:711–722.

20 Jensen GM, Gwyer J, Shepard KF, HackLM. Expert practice in physical therapy.Phys Ther. 2000;80:28–52.

21 Richardson B. Professional development.Physiotherapy 1999;85:461–473.

22 Lindquist I, Engardt M, Garnham L, et al.Development pathways in learning to be aphysiotherapist. Physiother Res Int. 2006;11:129–139.

23 Lindquist I, Engardt M, Richardson B. Earlylearning experiences valued by physio-therapy students. Learning in Health andSocial Care. 2004;3(1):17–25.

24 Lindquist I, Engardt M, Garnham L, et al.Physiotherapy students’ professional iden-tity on the edge of working life. MedTeach. 2006;28:270–276.

25 Tryssenaar J, Perkins J. From student totherapist: exploring the first year of prac-tice. Am J Occup Ther. 2001;55:19–27.

26 Benner PE. From Novice to Expert: Excel-lence and Power in Clinical Nursing Prac-tice. Menlo Park, CA: Addison-Wesley; 1984.

27 Benner PE, Tanner CA, Chesla CA. Exper-tise in Nursing Practice: Caring, ClinicalJudgment, and Ethics. New York, NY:Springer; 1996.

28 Benner PE, Hooper-Kyriakidis PL, StannardD. Clinical Wisdom and Interventions inCritical Care: A Thinking-in-Action Ap-proach. Philadelphia, PA: Saunders; 1999.

29 Dreyfus HL, Dreyfus SE, Athanasiou T.Mind Over Machine: The Power of Hu-man Intuition and Expertise in the Era ofthe Computer. New York, NY: Free Press;1986.

30 Schoessler M, Waldo M. The first 18months in practice: a developmental tran-sition model for the newly graduatednurse. J Nurses Staff Dev. 2006;22:47–52.

31 Standing M. Clinical decision-making skillson the developmental journey from stu-dent to Registered Nurse: a longitudinalinquiry. J Adv Nurs. 2007;60:257–269.

32 Kolb D. Experiential Learning. Engle-wood Cliffs, NJ: Prentice Hall; 1984.

33 Bridges W. Making Sense of Life’s Changes.Menlo Park, CA: Addison-Wesley; 1980.




34 Bullough RV. First Year Teacher: A CaseStudy. New York, NY: Teachers CollegePress; 1989.

35 Bullough RV, Knowles JG, Crow NA.Emerging as a Teacher. New York, NY:Routledge; 1992.

36 Bullough RV, Baughman K. “First YearTeacher” Eight Years Later. New York,NY: Teachers College Press; 1997.

37 Dollase RH. Voices of Beginning Teachers:Visions and Realities. New York, NY:Teachers College Press; 1992.

38 Levin B. Case Studies of Teacher Develop-ment: An In-Depth Look at How ThinkingAbout Pedagogy Develops Over Time.Mahwah, NJ: Lawrence Erlbaum Associates;2003.

39 Borko H, Putnam R. Learning to teach. In:Berliner D, Calfee R, eds. Handbook ofEducational Psychology. New York, NY:Macmillan; 1996:673–708.

40 Wilson SM, Berne J. Teacher learning andthe acquisition of professional knowledge:an examination of research on contempo-rary professional development. In: Iran-Nejad A, Pearson PD, eds. Rev Res Educ.1999;24:173–209.

41 Borko H. Professional development andteacher learning. Educ Res. 2004;33(8):3–15.

42 Berry A, Clemans A, Kostogriz A, eds. Di-mensions of Professional Learning: Pro-fessionalism, Practice and Identity. Rot-terdam, the Netherlands: Sense Publishers;2007.

43 Putnam R, Borko H. Teacher learning: im-plications of new views of cognition. In:Biddle BJ, Good TL, Goodson IF, eds. TheInternational Handbook of Teachers andTeaching. Dordrecht, the Netherlands:Kluwer; 1997:1223–1296.

44 Putnam R, Borko H. What do new views ofknowledge and thinking have to say aboutresearch on teacher learning? Educ Res.2000;29(1):4–15.

45 Webster-Wright A. Reframing professionaldevelopment through understanding au-thentic professional learning. Rev EducRes. 2009;79:702–739.

46 American Physical Therapy Association.Vision 2020. Available at: http://www.apta.org/AM/Template.cfm?Section�Vision_20201&Template�/TaggedPage/TaggedPageDisplay.cfm&TPLID�285&ContentID�32061. Accessed December 17, 2009.

47 Boshuizen HPA, Bromme R, Gruber H.eds. Professional Learning: Gaps andTransitions on the Way From Novice toExpert. Norwell, MA: Kluwer AcademicPublishers; 2004.

48 Norman G, van der Vleuten C, Newble D,eds. International Handbook of Researchin Medical Education. Vol. 1. Norwell,MA: Kluwer Academic Publishers; 2002;section 2:159–277.

49 Eraut M. Developing Professional Knowl-edge and Competence. Philadelphia, PA:Routledge/Falmer; 1994.

50 American Physical Therapy Association.Professionalism in physical therapy: corevalues. Available at: http://www.apta.org/AM/Template.cfm?Section�Professionalism1&TEMPLATE�/CM/ContentDisplay.cfm&CONTENTID�41460. Accessed Decem-ber 17, 2009.

51 Thomas DR, A general inductive approachfor qualitative data analysis. School ofPopulation Health, University of Auckland[serial on Internet], August 2003. Availableat: http://www.fmhs.auckland.ac.nz/soph/centres/hrmas/_docs/Inductive2003.pdf.Accessed June 15, 2005.

52 Thomas DR. A general inductive approachfor analyzing qualitative evaluation data.Am J Eval. 2006;27:237–246.

53 Creswell JW. Educational Research: Plan-ning, Conducting and Evaluating Quan-titative and Qualitative Research. UpperSaddle River, NJ: Pearson; 2002.

54 Miles MB, Huberman AM. QualitativeData Analysis. 2nd ed. London, UnitedKingdom: Sage Publications; 1994.

55 Strauss A, Corbin J. Basics of QualitativeResearch. Newbury Park, CA: Sage Publi-cations; 1990.

56 Patton MQ. Qualitative Research andEvaluation Methods. 3rd ed. ThousandOaks, CA: Sage Publications; 2002.

57 Lincoln YS, Guba EG. Naturalistic Inquiry.Newbury Park, CA: Sage Publications; 1985.

58 Morse JM, Field PA. Qualitative ResearchMethods for Health Professionals. 2nd ed.Thousand Oaks, CA: Sage Publications;1995.

59 Campo MA, Weiser S, Koenig KL. Jobstrain in physical therapists. Phys Ther.2009;89:946–956.

60 Balogun JA, Titiloye V, Balogun A, et al.Prevalence and determinants of burnoutamong physical and occupational thera-pists. J Allied Health. 2002;31:131–139.

61 Wandling BJ, Smith BS. Burnout in ortho-pedic physical therapists. J Orthop SportsPhys Ther. 1997;26:124–130.

62 Maslach C. Burnout: The Cost of Caring.Englewood Cliffs, NJ: Prentice Hall; 1982.

63 Wolak E, McCann M, Queen S, et al. Per-ceptions within a mentorship program.Clin Nurse Spec. 2009;23:61–67.

64 Solomon P, Ohman A, Miller P. Follow-upstudy of career choice and professionalsocialization of physiotherapists. Physio-ther Can. 2004;56:102–110.

65 Etelapelto A, Collin K. From individualcognition to communities of practice. In:Boshuizen HBA, Bromme R, Gruber H, eds.Professional Learning: Gaps and Transi-tions on the Way From Novice to Expert.Norwell, MA: Kluwer Academic Publishers;2004:231–250. Innovation and Change inProfessional Education; vol 2.

66 Austin Z, Hewitt W. Faculty, student, andpractitioner development within a com-munity of practice. Am J Pharm Educ.2005;69:381–389.

67 Sheppard SD, Macatangay K, Colby A, Sul-livan WM. Educating Engineers: Design-ing for the Future of the Field. San Fran-cisco, CA: Jossey-Bass Inc Publishers; 2009.

68 Lave J, Wenger E. Situated Learning: Le-gitimate Peripheral Participation. Cam-bridge, United Kingdom: Cambridge Uni-versity Press; 1991.

69 Wenger E. Communities of Practice:Learning, Meaning, and Identity. Cam-bridge, United Kingdom: Cambridge Uni-versity Press; 1998.

70 Chaiklin S, Lave J, eds. UnderstandingPractice: Perspectives on Activity andContext. Cambridge, United Kingdom:Cambridge University Press; 1996.

71 Cooke M, Irby DM, O’Brien B. EducatingPhysicians: A Call for Reform of MedicalSchool and Residency. San Francisco, CA:Jossey-Bass Inc Publishers; 2010.

72 Brown JS, Collins, Duguid P. Situated cog-nition and the culture of learning. EducRes. 1989;18(1):32–42.

73 Lave J. Cognition in Practice. Cambridge,United Kingdom: Cambridge UniversityPress; 1988.

74 Rogoff B. Apprenticeship in Thinking: Cog-nitive Development in Social Context. NewYork, NY: Oxford University Press; 1990.

75 Vygotsky LS. Mind in Society: The Devel-opment of Higher Psychological Proc-esses. Cambridge, MA: Harvard UniversityPress; 1978.

76 Vygotsky LS. The genesis of higher mentalfunctions. In: Wertsch JV, ed. The Conceptof Activity in Soviet Psychology. NewYork, NY: Sharpe; 1981:144–188.

77 Vygotsky LS. Thinking and speech. In:Reiber RW, Carton AS, eds; Minick N, trans.The Collected Works of L. S. Vygotsky. NewYork, NY: Plenum Press; 1987:39–205.

78 Dewey J. How We Think: A Restatementof the Relation of Reflective Thinking tothe Educative Process. Lexington, MA:DC Heath & Co; 1933.

79 Dewey J. Experience and Education. NewYork, NY: Macmillan; 1938.

80 Schon DA. The Reflective Practitioner:How Professionals Think in Action. NewYork, NY: Basic Books; 1983.

81 Schon DA. Educating the Reflective Prac-titioner. San Francisco, CA: Jossey-BassInc Publishers; 1987.

82 Plack MM. The development of communi-cation skills, interpersonal skills, and aprofessional identity within a communityof practice. J Phys Ther Educ. 2006;20(1):37–46.

83 Bartlett DJ, Lucy SD, Bisbee L, Conti-Becker A. Understanding professional so-cialization of physical therapy students: aqualitative investigation. Physiother Can.2009;61:15–25.

84 Hayward, LM, Becoming a self-reflectiveteacher: a meaningful research process.J Phys Ther Educ. 2000;14(1):21–30.




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 nextyear. 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 theircaregivers, the clinical setting and professional interactions in that setting, professional roles, the health care agencyor health care system in general, and so on:

1. “Thought work”—puzzling over a situation or experience; re-enacting and reconstructing what happened so youcan 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 learningexperience, 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. Whatdid you experience? Did you learn anything about yourself through the experience? Was this a good learningexperience? Why?

4. Writing about what aspects of your role as a physical therapist you find most interesting, challenging, orsurprising. What aspects of your position cause the most stress? What aspects of your position produced the greatestrewards?

5. Writing about how you see yourself changing over time (ie, your personal and professional development). Wherewere you personally and professionally when you began your work as a therapist? Where are you now? How haveyou changed? What has not changed?

This list is not necessarily all-inclusive—just something to help you get started. Feel free to write about any thoughtsrelated to your professional practice and development.




Appendix 2.Baseline Interview Questions and Probes and Selected Examples of Follow-up Interview Questions Over the Course of the FirstYear 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 employer’s 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 you’ve 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.




doi: 10.2522/ptj.20100078Originally published online October 7, 2010

2010; 90:1758-1773.PHYS THER. BlackmerPerkins, Pamela D. Ritzline, Lorna Hayward and Betsy Lisa L. Black, Gail M. Jensen, Elizabeth Mostrom, JanPromising Novice Physical TherapistsProfessional Learning and Development of The First Year of Practice: An Investigation of the

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