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INTRODUCTION
Learning in physical therapy requires a total
immersion within the physical therapy com-
munity of practice.1 Students learn by expe-
rience, by doing, and by being involved in
all aspects of clinical practice and as a result
develop a sense of belonging.2,3 While class-
room learning is critical to student success,
for many the abstract concepts learned in the
classroom do not begin to make sense until
they are applied in the practice environment.
By gaining access to the clinical setting and
engaging in practice, students can develop
shared understanding of physical therapist
practice, begin to identify with the profes-
sion, and ultimately develop an identity as a
physical therapist.1
As Plack1 and Spouse4 suggest, access to
the clinical environment is critical for learn-
ing. However, learning is a complex process,
and simply gaining access is insufficient. It is
through active engagement and participation
that students learn how experienced practi-
tioners act and interact within the commu-
nity of practice. It is through this process that
students ultimately learn what it truly takes
to belong and become a fully participating
member of a profession.5 While engagement
in practice is essential to learning in a clinical
setting—it cannot begin to occur without the
sponsorship of a mentor. In physical therapy
that formal mentor is the clinical instructor.
REVIEW OF THE LITERATURE
Mentorship Within a Community of
Practice: The Master and the Apprentice
Physical therapy clinical education experi-
ences are similar to, yet different from, ap-
prenticeships in other professions. Wenger3
and Lave5 provide the seminal works on ap-
prenticeship learning. However, while they
studied a variety of apprenticeship models,
they made little mention of the relation-
ship between the master and the apprentice.
They comment that the role of the master
in the master: apprentice relationship ranges
from an almost nonexistent relationship to a
well-defined and explicit relationship, with-
out which the apprentice would not have
had access to the community. Wenger3 and
Lave5 do not explore this sponsorship or
mentorship relationship beyond this.
Spouse6studied nursing students and
noted that mentorship, or support from cli-
nicians, significantly increased student ad-
justment to the clinical environment and
ultimately enhanced learning. In physical
therapy, it is well accepted that the CI plays
an important role in the professional devel-
opment of students.7 While mentorship is
a significant factor in professional develop-
ment, there is no clear definition of the term
mentor in professional practice.4
Mentorship Defined
In defining the term mentor most studies
reach back centuries to the role of Mentor
in the life of Odysseus’ son, Telemachus,
in Homer’s Odyssey. Mentor was a trusted
friend to whom Odysseus entrusted Telema-
chus. Mentor acted as teacher, guide, friend,
adviser, protector, and even surrogate fa-
ther.8-11 This mythological story depicts the
essence of traditional mentorship as an older,
wiser, more experienced person influencing
and guiding a younger, less experienced pro-
Vol 22, No 3, Winter 2008 Journal of Physical Therapy Education 7
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research report
The Learning Triad: Potential Barriers and Supports to
Learning in the Physical Therapy Clinical Environment
Margaret M. Plack, PT, EdD
Vol 22, No 3, Winter 2008 Journal of Physical Therapy Education 7
Background and Purpose. Learning in
physical therapy (PT) requires total im-
mersion and engagement in practice.
Engagement cannot begin without the
sponsorship of a mentor or clinical instruc-
tor. This study sought to explore the poten-
tial supports and barriers to engagement
and the role of the mentor in optimizing
learning within the community of physical
therapy practice from the perspectives of
the student and novice clinician.
Participants. Thirteen PT students and
6 new graduates, as well as their most
recent clinical instructors (CIs) and su-
pervisors (CSs), were interviewed. Three-
hundred and forty-four of their classmates
submitted critical incidents for analysis.
Finally, 5 additional PT students, 2 ad-
ditional new graduates, and 5 additional
clinicians participated in 2 separate sum-
mative focus groups.
Methods. One-on-one semistructured
interviews were used to explore the ex-
periences of the students and new gradu-
ates, as well as their CIs and CSs. Critical
incidents were used to obtain the per-
spectives of the participants’ classmates.
Once data were analyzed, 2 summative
focus group interviews were completed to
confirm, refute, and/or extend the find-
ings. Qualitative methods were used to
analyze the data. Triangulation of meth-
ods and subjects, use of devil’s advocates,
member checks, and search for negative
cases ensured trustworthiness.
Results. In the clinical environment, a
learning triad emerged which was instru-
mental to the learning process. The triad
Margaret Plack is chair of the Department of
Health Care Sciences and director and associ-
ate professor, Program in Physical Therapy, The
George Washington University, School of Medi-
cine and Health Sciences, 900 23rd Street NW,
Suite 6145, Washington, DC 20037 (mppt@
aol.com).
This study was approved by the Institutional
Review Board and informed consents were ob-
tained prior to data collection.
Received July 29, 2008, and accepted August
14, 2008.
consists of newcomer, mentor, and com-
munity. Supports and barriers emerged
from all aspects of this learning triad, in-
cluding the past experiences, attributes,
knowledge, and skill of each.
Discussion and Conclusion. The degree
to which a learning situation is supported
or hindered is uniquely defined and must
be individually assessed and modified to
meet the needs of students, clinicians,
and the community. Past experiences,
attributes, knowledge, and skills of each
component of this learning triad can act
to exacerbate or mitigate both barriers and
supports to learning. What emerged from
this study is a model of how challenges,
supports, and barriers all influence the
learning situation. To establish an effec-
tive triadic learning relationship, supports
and barriers cannot be deconstructed and
viewed in isolation; rather, each must be
viewed as a component of the whole.
Key Words: Clinical education, Com-
munities of practice, Barriers to learning,
Supports to learning.
8 Journal of Physical Therapy Education Vol 22, No 3, Winter 2008
tégé through life’s transitions. Terms such
as sponsor, role model, coach, supervisor,
preceptor, advisor, gatekeeper, guide, coun-
selor, and friend have been used synony-
mously with mentor.4,8-10,12 To date there is
little consensus as to the definition of the
term mentor.
Mentoring Functions
In addition to the lack of consensus on the
definition of the term mentor, the functions
mentors provide in the life of the protégé are
also quite diverse.4,8,10-12 Daloz8 describes the
mentor as providing 3 distinct functions for
the protégé: support, challenge, and vision.
Support refers to affirmation and valida-
tion of the protégé’s experiences.8 Support
can take many forms, including what Kram12
describes as career functions (eg, sponsoring,
providing exposure, coaching, and protect-
ing) and psychosocial functions (eg, being a
role model, and providing acceptance, con-
firmation, counseling, and friendship). In
the clinical setting, in addition to providing
support through supervision and teaching,
the clinician (mentor) assesses the student,
provides feedback, and offers emotional
support.13-15 In a community of practice,
Spouse4 also discusses the importance of
social engagement in facilitating learning.
Swap et al16 see the role of the mentor as
helping to instill the core values and norms
of the organization. It is through mentorship
that values are shared, often tacitly through
socialization, in the midst of active engage-
ment in everyday activities. Newcomers also
must learn about the contextual subtleties of
practice, including intricacies such as who
does what and how, and with whom to en-
gage when. Benabou and Benabou17 and
Ragins18 suggest that it is through the “politi-
cal function” and “power perspective” of the
mentor that newcomers learn to negotiate
through the community’s political and social
structures in becoming a member of that
community.17-20
Mentors also challenge protégés. They
provide tension, a gap or cognitive disso-
nance, between the protégé’s perceptions
and his or her experiences, which, to re-
solve, requires learning.8 Challenges can
take many forms including providing tasks,
facilitating reflection, discussing problems,
questioning hypotheses and solutions, ex-
ploring new ideas and alternative perspec-
tives, experimenting with new approaches,
and setting high standards.8 Plack1 describes
3 types of challenges in the clinical environ-
ment: activities explicitly designed by the CI
to challenge the student; attributes of the
student, CI, and community (including the
patient/client and environment); and novel
situations. These challenges are critical to
learning and can be mastered through en-
gagement in practice,1,4,5,21 scaffolding,22
coaching,23 and role modeling.19,24
Finally, Daloz8 and Zachary11 note that
mentors provide vision. Since mentors have
moved beyond the novitiate period, they can
provide protégés not only with a vision of the
future but also a path toward reaching that
vision. The mentor must embody the role of
the professional to provide the protégé with
a full understanding of what it looks like
to be a professional.25(p314) Bandura24 de-
scribes the importance of role models, while
Wenger argues that it is more important
for the newcomer be exposed to the entire
“field of paradigmatic trajectories” available
so that the newcomer can begin to negoti-
ate his or her own trajectory and identity
development.3(p56) Plack1 describes this as
providing the learner with access to history:
history of environment and of others in the
environment, as well as the path the men-
tor took in developing his or her own level of
professional mastery.
Mentorship in Physical Therapy
Education
In physical therapy, students are typically
assigned to a clinical instructor (CI) for the
purpose of orientation and socialization
as well as for help in bridging the gap be-
tween theoretical and practical knowledge.
The mentor may be a volunteer or may be
assigned. This relationship between the stu-
dent and CI constitutes a short-term formal
mentorship as described by Murray.10
The role of the CI includes preplanning,
assessing students, and identifying problems,
as well as providing objectives, learning ex-
periences, formative evaluations, feedback,
and summative evaluations.26 Emery27 noted
4 essential characteristics of effective clini-
cal instructors: communication (ie, sharing
information, providing feedback, actively
listening, and encouraging dialogue); inter-
personal skills (ie, establishing a comfortable
environment, demonstrating empathy, and
being supportive of students); professional
skills (ie, practicing competently, being
systematic in problem solving); and teach-
ing skills (ie, allowing student progressive
independence and providing constructive
criticism). In a case study of an exemplary
clinical instructor, Kelly28 described criti-
cal skills consistent with those reported by
Emery, but also added the importance of be-
ing in an environment that supports clinical
education. While these functions are essen-
tial, they do not address the social or political
dimensions of practice which the newcomer
must negotiate in order to succeed.
Benabou and Benabou17 do address the
mentorship role from a political or power
perspective. During their clinical internships,
students are expected to engage in practice,
which includes not only access obtained
through the mentor but also development of
the ability to “navigate the subtleties of the
organization’s political system,”20(p89) that is,
recognizing and negotiating power relation-
ships within the community of practice.17,20
Spouse4 suggests that it is the early mentor-
ing relationship that allows students to feel
comfortable in the unfamiliar environment
and enables them to move beyond the one-
to-one mentorship relationship to engage
with others in the community of practice.
Spouse4 also adds a critical element often
missing in descriptions of mentor functions:
assessment. In physical therapy, the clinical
internship is a component of the professional
curriculum. The role of the CI as assessor,
grader, and evaluator is not traditionally
viewed as a function of a mentor. While as-
sessment is a critical function of the mentor
in scaffolding learning activities and provid-
ing appropriate challenges and supports,
assessment for the purpose of grading raises
an issue of power that may impact the rela-
tionship itself. Although CIs do not award
grades, they do provide input on student
performance, which ultimately impacts the
grade awarded.
PROBLEM AND PURPOSE
Learning to become a physical therapist re-
quires full immersion and engagement in
practice. However, this engagement cannot
begin without the sponsorship of a mentor or
CI. Daloz8 describes the role of the mentor
as providing support, challenge, and vision.
Plack1 more specifically explored how stu-
dents and novice clinicians learn in the physi-
cal therapy clinical setting. She described the
role of the CI in challenging students as well
as in providing access to the history of those
within the community of practice. This histo-
ry is consistent with what Daloz8 calls vision.
While Daloz’s8 concepts of vision and chal-
lenge have been applied to learning in physi-
cal therapy practice; his concept of supports to
learning has not. In addition, neither Daloz8
nor Plack1 discussed the potential barriers
to learning that may exist in the clinical set-
ting. While vision, challenges, and supports
are critical to learning, without addressing
potential barriers, the teaching-learning situ-
ation cannot be optimized. This study sought
to explore the potential barriers and supports
to engagement, and the role of the mentor,
in optimizing learning within the community
of physical therapy practice, from the perspec-
tive of the student and novice clinician.
METHODS
This study was part of a larger exploration
of how physical therapist students and nov-
ice clinicians learn communication and
interpersonal skills in the clinical setting.1
A qualitative multicase study was designed.
This study was approved by the Institutional
Review Board and informed consents were
obtained prior to data collection. Data col-
lection instruments were pilot tested and re-
fined prior to implementation. Participation
was voluntary, data collection was distanced
from submission of grades, and confidential-
ity was maintained.
Participants
To obtain diverse perspectives the researcher
used a purposive sample along a continuum
of educational experience including: PT
students who had completed 1 clinical in-
ternship (category 1); PT students who had
completed 2 or more clinical internships
(category 2); and PT graduates with 2 years
of clinical practice or less (category 3). Pri-
vate and public institutions in the New York
City metropolitan area offering first profes-
sional degree programs in physical therapy
were considered. Of the 10 schools, 7 had
potential candidates for participation in all
3 categories. Program directors from all 7
institutions nominated individuals who they
believed demonstrated a positive change
in their communication and interpersonal
skills during the time they were enrolled in
the PT education program. To corroborate,
extend, and obtain alternative perspectives,
the students’ or graduates’ most recent clini-
cal instructors or clinical supervisors were in-
terviewed as well. In addition, classmates of
the students and new graduates were asked to
complete a critical incident. Finally, 2 sum-
mative focus groups, with similar representa-
tion, were formed
Data Collection Methods
A 1-1/2 to 2 hour semistructured interview
protocol consisting of 15 questions was de-
veloped to interview the students and recent
graduates. A similar 45-60 minute semistruc-
tured interview protocol consisting of 11
questions was developed to interview each
participant’s most recent CI or CS. In both
cases interview questions included probes
for supports and potential barriers to learn-
ing. Interview questions focused on the chal-
lenges students and novice clinicians faced
in the clinical environment and how they
overcame those challenges. Participants de-
scribed positive and negative learning expe-
riences and were asked to expound on what
made some experience more helpful than
others. They were asked about relationships
that facilitated and those that hindered their
learning. Finally, they were asked to describe
what most prepared them for the clinical set-
ting and what types of experiences may have
hindered their learning.
Critical incidents were used to gather data
from classmates of the participants. Each was
asked to “Think back and provide a detailed
description of an experience that helped you
to better understand and ultimately develop
the communication and interpersonal skills
essential to being a physical therapist. This
incident can be either positive or negative
and should be particularly meaningful to
you as an individual.”29
Finally, structured interview questions
were developed to explore the preliminary
study findings with 2 summative focus
groups. During the focus group sessions, the
researcher probed for confirming, discon-
firming, and missing information.30
Definition of Terms
Challenges are those activities, experiences,
or ordeals the student or novice clinician
needed to overcome or master. In contrast,
for the purpose of this study, barriers were de-
fined as factors that made it more difficult for
the student or novice clinician to overcome
or master these ordeals or that constrained
their participation within the community.
The researcher also defined supports as fac-
tors that made it easier for the student or
novice clinician to learn and participate in
activities within the clinical community.
Data Analysis and Synthesis
Analysis was an iterative process, which be-
gan with the development of codes and led
to the development of themes. Analysis was
ongoing and consisted of continuous com-
parison of new and previously collected data.
A conceptual framework was drawn, verified,
and continually revised throughout the pro-
cess. The researcher sought disconfirming
and negative cases in order to facilitate fur-
ther exploration of the data.31 The process
continued until no new codes and themes
emerged and saturation was reached. The
researcher utilized ATLAS/ti32 to assist in
data management.
Credibility and Trustworthiness
The following served to maximize the cred-
ibility and trustworthiness of this study: (1)
triangulation of methods; (2) triangulation of
data sources; (3) purposive sampling for di-
verse perspectives; (4) use of rich descriptions
to support the themes that emerged; (5) search
for negative cases; (6) use of peer reviewers
and “devil’s advocates”; (7) sufficient data col-
lection to allow for saturation; (8) member
checks for accuracy; and (9) summative focus
groups to confirm, disconfirm, or extend the
findings. Further, every attempt was made to
ensure that methods were made transparent
by including a full description of procedures,
instrumentation, and analysis to enhance the
reader’s ability to make judgments regarding
the credibility and transferability of the find-
ings and conclusions.30,33,34
RESULTS
Participants
In total, 19 matched pairs participated (13
student–clinical instructor pairs and 6 novice
clinician–clinical supervisor pairs). Student
and novice clinician interviewees included
5 men and 14 women who ranged in age
from their 20s to 50s, represented Cauca-
sian, African American, Hispanic, and Asian
ethnicities, and completed between 1 and 5
full time internships for a total ranging from
6 and 30 clinical weeks. The clinical instruc-
tors and supervisors interviewed included 9
men and 10 women, each with between 11
months and 25+ years of experience. The
pairs worked in a variety of clinical settings
including acute care hospitals, outpatient
departments, private clinics, rehabilitation
facilities, pediatric centers, a skilled nursing
facility, and an adult day treatment center.
These facilities were located in Staten Island,
Westchester, Brooklyn, Manhattan, Nassau
County, and Suffolk County in New York
and Jersey City in New Jersey (Table 1).
In addition, 344 of 601 classmates of the
interviewees (57.2%) returned critical inci-
dent questionnaires. Returns included: 125
category 1 students (36.3%) from 6 of the
7 schools; 175 category 2 students (50.9%)
from all 7 schools; and 44 category 3 new
graduates (12.8%) from all 7 schools.
Finally, 12 additional students, recent
graduates, and experienced clinicians par-
ticipated in 2 summative focus groups. The
first group consisted of 1 man and 5 women
with 2.5 and 18 years of clinical experience
respectively, who ranged in age from 24 to
48 years. They had worked with between 2
and 10 students and/or new graduates each
(Table 2). The second group consisted of 5
students and 2 new graduates representing
all 3 categories (N=2; N=3, N=2 respective-
ly), who ranged in age from 22 to 28 years.
There were 3 men and 4 women, and the
following ethnicities were represented: Cau-
casian, Asian, and Hispanic (Table 3).
The researcher analyzed data from the
38 interviews, 344 written critical incidents,
and 2 summative focus groups. The results
presented represent the major findings or
themes and subthemes that emerged related
Vol 22, No 3, Winter 2008 Journal of Physical Therapy Education 9
10 Journal of Physical Therapy Education Vol 22, No 3, Winter 2008
to the supports and potential barriers to learn-
ing. In describing how they learned profes-
sional communication and interpersonal
skills, students and new graduates described
how supports and barriers resulted from their
own past experiences, knowledge, skills, and
attributes, as well as from the past experi-
ences, knowledge, skills and attributes of the
clinical instructor/clinical supervisor and
the community itself (eg, patients/clients,
families, and other health care practitioners).
Each had an impact on the learning process.
Given the purpose of the study, which
was to obtain the perceptions of students
and new graduates, the 19 students and new
graduates are referred as interviewees. Quo-
tations taken from the interviews of their
clinical instructors or supervisors, the writ-
ten critical incidents of their classmates, and
the summative focus groups are identified
as such, and the collective is referred to as
participants.
Barriers
As noted, barriers emanated from the past ex-
periences, attributes, knowledge, and skill of
all those involved in the learning situation,
that is, the students and new graduates, CIs/
CSs, and the community/environment.
Past experiences. Five of the 19 intervie-
wees described past experiences that hin-
dered their learning in the clinical setting.
One interviewee, Eva, shared how negative
experiences with a previous CI made it more
difficult for her to communicate on her
subsequent internship: “I was probably still
hesitant to ask for help during the treatment
session, because I still felt kind of pressured
to perform from my previous experience.”
Table 2. Demographics of the Clinical Instructor/Clinical Supervisor Focus Group Participants
Pseudonym Age Ethnicity Gender CI/CS/
CCCE
Type of Facility # Years
Experience
# Supervised
Tim 48 Caucasian M CS/CI Acute care hospital 6.5 2 students
2 graduates
Tanya 41 Caucasian F CS Outpatient private
practice
18 3 students
5 graduates
Ariana 42 Caucasian F CI Pediatric
home care
16 10 students
Nora 24 Caucasian F CCCE/CI Pediatric & adult
rehabilitation center
2.5 5 students
Lena 32 Caucasian F CI Rehabilitation center 10.5 6 students
7 graduates
Abbreviations: CI, clinical instructor; CS, clinical supervisor; CCCE, center coordinator of clinical education.
Table 1. Demographic Profiles of the Interviewees
Pseudonym
Gender
Age
Race/Ethnicity
Noted to have
English as a
Second Language
# Full-time
affiliations
# Full-time weeks
completed
Type of academic
institution
attended
# Months until
graduation
# Months since
graduation
Most recent
Clinical Instructor
or Supervisor
Most
recent
clinical setting
Gender of CI/CS
Vera F 50s Caucasian 1 8 Public 15 Jean/Dee Hosp F
Eva F 30s Caucasian X 4 24 Public 4 Mary Peds OP F
Bill M 20s Caucasian 4 24 Public 12 Larry Pvt Practice M
Dave M 20s Caucasian 1 8 Private 16 Rich Hospital M
Jackie F 30s African
American
X 5 30 Private 4 Mark Rehab Hosp M
Kevin M NA Caucasian 5 30 Private 10 Ray Hospital M
Maryann F 20s Caucasian 1 8 Private 7 Carol Peds school F
Rick M 30s Hispanic X 3 24 Private 1 Bonnie Peds OP F
Brian M 30s Caucasian 3 24 Private 17 Keenan Pvt practice M
Sara F 20s Caucasian 1 8 Private 12 Regina Pvt practice F
Jill F 40s Caucasian 3 24 Private 1 Ann/
Brendan
Pvt practice F
Kelli F 20s Caucasian 3 24 Private 18 Kathy Peds school F
Marie F 20s Asian X 1 8 Public 19 Kris Hospital F
Jan F 20s Asian X 3 24 Public 7 Bob Pvt practice M
Karen F 40s Caucasian 3 24 Public 11 Tom SNF
ADT
M
Kayla F 20s Caucasian 2 26 Public 1 Leigh-Ann Hospital F
Charl F 20s Caucasian 1 6 Private 21 Stan Rehab hosp M
Becky F 20s Caucasian 2 14 Private 10 John Pvt practice M
Patti F 20s Caucasian 4 30 Private 13 Anita Rehab hosp F
Abbreviations: NA, no answer; Hosp, hospital; OP, outpatient; Peds, pediatric; Pvt, private; SNF, skilled nursing facility; ADT, adult day
treatment.
Past experiences can shape the way CIs in-
teract with students as well. Jackie shared
her experiences and how, at the end of a very
difficult internship, her CI commented, “I
know I’ve been very hard on you but it’s not
my fault, that’s how I was trained too.”
Attributes. All 19 interviewees com-
mented on how specific attributes or traits
of students/novice clinicians, the CIs/CSs,
the community, and the environment hin-
dered learning. All 19 interviewees, as well
as 14 of 19 CIs and CSs discussed problem-
atic student attributes, including a lack of
confidence and fear, cultural or language
differences, and a lack of receptivity or re-
sponsiveness. Sixteen participants reported
that their own lack of confidence and fear
were problematic, while only 6 of the CIs/
CSs raised this as an issue. One CI noted:
Students are always worried that they’re
going to do the wrong thing. Their big-
gest fear when they get there is that they
are not going to know what to do. It’s a
new working environment, much differ-
ent than actual school. So the student
is always worried that they are going to
screw up, especially the first few weeks—
“am I going to give this person the wrong
answer, is he going to think I’m dumb, is
he going to fail me?” They are always wor-
ried, it takes them a few weeks to get ad-
justed to making mistakes and saying,“It’s
okay, I’ll think about it harder.”
Dave also commented that a lot of his class-
mates did not ask questions or make comments
because they afraid of sounding less than intel-
ligent, particularly in front of their CI:
Even if I feel like I was completely wrong,
I said [it] because maybe I would go
back 3 steps, maybe I took a wrong turn
in my thinking. So we would talk about
it. I wouldn’t keep my mouth shut not to
sound stupid. Let him know how stupid
I am. I want to show him all my faults,
let’s fix things at the ground level.
While a lack of confidence was heard in
the majority of interviews, rather uniquely
heard from Eva was that excessive confidence
or pride can be a barrier as well, stating, “If
you are over confident, you cannot ask for
help, and without asking for help, you will
just be stuck where you are, you will never
grow and you will never learn.”
Five of the 19 participants were non-
native speakers of English. They noted that
cultural issues as well as receptive and ex-
pressive language limitations impeded their
ability to communicate and interact in the
clinical environment. For example, Jan com-
mented:
At times, I feel as though I can’t get
the words out. I know the perfect way
to respond in Chinese, but no one here
understands what I want to say, so
you’re trying to find a similar response
in English, but there’s not really a re-
sponse that’s similar enough to relate
the meaning that you want to express.
Finally, 8 CIs/CSs commented on how a
lack of student or novice clinician receptivity
or responsiveness can negatively impact the
learning process. For example, Mary com-
mented:
Not truly being open to criticism. When
there’s difficulty accepting criticism, a
wall starts to build and that wall ex-
pands across the whole department.
They try and talk over me as I’m trying
to help them with the answer. Or they’ll
say “I didn’t learn that.” Even their body
language is defensive and stand-offish.
On the contrary, one student, Becky, stat-
ed that being too accepting can be equally
problematic:
I didn’t think out of the box. I was very
appreciative of what was going on but I
didn’t say, “Oh, but this could be bet-
ter.” I made the best of it. When you
make the best of things you don’t always
realize what’s missing.
Seventeen interviewees as well as 8 CIs/
CSs commented on attributes of the CI and
CS that hindered their learning, including
being inconsistent, overly demanding, con-
descending, unreceptive, and uncaring or
disrespectful. Seven interviewees described
frustration with inconsistent CIs as these 2
students note:
He gave me mixed messages. I was very
confused. I was afraid of telling him
something because he would say, “I’ve
already shown you that” and later on he
would show me like nothing happened.
He was like a little ping pong ball.
One day she [was] agreeable about my
technique when treating the patients;
[the] next day it [was] totally wrong.
I was so intimidated around her that
I become brain dead. I questioned my
knowledge and felt inferior around her.
Eight of the interviewees stated that con-
descending CIs or those who portrayed a
sense of superiority hindered their learning.
Eva described how this type of CI “makes you
Vol 22, No 3, Winter 2008 Journal of Physical Therapy Education 11
Table 3. Demographics of the Student and New Graduate Focus Group Participants
Pseudonym Age Ethnicity Gender Student/
Graduate
Types of
Experiences
# Full-time
Affiliations
# Months of
Clinical Practice
Ralph 22 Caucasian M Student Rehabilitation 1 NA
Paul 27 Asian M Student Hospital 1 NA
Agnes 26 Asian F Student Rehabilitation
Pediatrics
2 NA
Ina 25 Hispanic F Student Skilled nursing
facility,
Outpatient
2 NA
Maggie 24 Asian F Student Hospital,
Nursing home,
Outpatient
2 NA
Judy 28 Caucasian F Graduate Hospital,
Outpatient,
Rehabilitation,
Pediatrics
4 11
Evan 25 Hispanic/
Asian
M Graduate Hospital,
Rehabilitation,
Outpatient
4 5
12 Journal of Physical Therapy Education Vol 22, No 3, Winter 2008
feel that [it] doesn’t matter what you do, you
will never be as smart as I am.” When probed
to see if she had ever encountered someone
like that she responded, “My previous CI was
like that, even though she was just 3 years
out of college, she made a big deal of how
important she is and how superior she is and
[how I] won’t even come close.” Four of the
19 interviewees also described the negative
impact of having an overly demanding or
critical CI/CS. Vera described Jean as being
overly critical: “She would [say] ‘you should
know what that is,’ or ‘go look it up.’ It just
got to the point where I was afraid to ask her
a question so the communication just really
closed down.
Eight interviewees and 16 classmates de-
scribed the negative impact of having a CI/
CS who lacked care or respect. Participants
commonly discussed how demeaning it was
when their CI “put me down in front of the
patient.” Phrases such as these were heard
numerous times: “It made me feel stupid
and inadequate”; “It made the patient lose
all trust in me”; and “I will never do that to
anyone, particularly a student.”
Eleven of the interviewees noted that an
unreceptive or unresponsive CI/CS or com-
munity hindered learning. When asked if
there were any relationships that particularly
hindered her learning, Kelli commented that
it would be difficult learning from “someone
giving orders and not willing to listen to you
as a professional.” Kevin had the following
to say about his first CS: “[She] is really not
open to suggestions at all. That’s how she is.
If we come with any problems [or requests]
the first time is always no. She’s very difficult
to deal with.” When asked whether he ever
discussed this with her, Kevin’s response was,
“No [because] once you get on her bad side
she will make your life miserable. I choose to
stay quiet and do my job for now.”
While more often than not an unfriend-
ly environment was noted to be a barrier,
uniquely heard was the opposite from one
clinical instructor, Leigh-Ann, as she de-
scribed what most hindered her student’s
ability to learn about professionalism:
The fact that everyone is so friendly is
because [they] weren’t always trying
to be so professional. Everyone knows
everybody else’s business. If she was try-
ing to be professional and ask the nurse
about a patient and she had just got-
ten her hair done the night before, the
nurse would be busy talking about her
new hairstyle while she was trying to
talk about the patient.
Finally, 18 interviewees commented on
certain environmental factors that impeded
their learning. Ten discussed grading as a
barrier, as did 11 of their classmates, while 7
interviewees commented on the pace of the
environment as being a barrier. Eva had this
to say:
Pass and fail—that’s your major concern
when you come in. If you are stuck in
that phase, “Oh, I might fail” you don’t
really care about learning; [you’re] des-
perate for passing. I never passed that
stage [in my last internship]. So it was
always anxiety and tension and every
time she spoke to me I froze, and that’s
not really conducive to learning.
While a fast paced environment was most
commonly noted to be a barrier to learning,
the reverse was also heard from one student.
Bill described his clinical environment:
It just wasn’t a busy office, so I was
there at one point and we would see 7
patients for the day. There were 3 of us
[students]. I did a lot of sitting around.
So it wasn’t conducive to a good learn-
ing experience.
Knowledge. Ten of the 19 interviewees
commented that having limited knowledge
or being in an unfamiliar situation was a
barrier, “When you have a patient with a
pathology you know less about, you don’t
know what you’re supposed to say [or] how
to explain this to them and that hinders my
communication.”
Skills. Ten of the 19 interviewees also
commented that having a CI/CS who lacked
skill in providing clear expectations, feed-
back, and student supervision hindered their
learning. Their comments suggest that how,
when, and how much feedback and indepen-
dence their CIs provided were potential bar-
riers. Eva described how ineffective her CI
was in providing supervision and feedback.
She described her as using “I’m watching
you supervision.”
I’m watching you supervision is, I’m
sitting and observing your treatment. I
want to see how you perform. I want to
scrutinize your every move. I will point
out your every mistake but I will never
give you a solution to help you achieve
what you’re trying to achieve.
When probed about the impact of this
type of supervision she commented,
You have a million things running
through your head. You don’t really
concentrate on the patient you are with.
You’re back-playing the beginning of the
day, freaking out about your mistakes. It
showers you with anxiety. You can’t think,
you’re so stressed. It’s just horrible. You
don’t care. You just concentrate on avoid-
ing mistakes. I didn’t learn anything.
Interviewees commented similarly about
being reprimanded in front of others or be-
ing put on the spot: “If you asked me my
middle name I wouldn’t know it.” On the
other hand, Kayla had difficulty with a CI
who gave little to no supervision or feedback.
She commented how it was as if she said,
“Okay, let’s just throw them in there and see
how they do.”
Supports
When asked about factors that supported their
learning, interviewees reported on past experi-
ences, personal and professional, that helped
prepare them for the clinical setting. As with
barriers to learning, interviewees described
their own attributes, knowledge, and skills, as
well as those of their CIs/CSs and the com-
munity, as having facilitated their learning.
Past experiences. All 19 interviewees re-
ported that past experiences (ie, personal,
work-related, and/or clinical), helped prepare
them for professional practice. Sixteen of the
19 interviewees cited their upbringing as hav-
ing had a positive impact on their learning,
while 11 of 19 cited past work experiences,
and 3 of 19 cited volunteer experience. Com-
ments such as the following were heard:
This may sound silly, but the fast-paced
stuff, being a waitress, helped me a lot.
I remember [being] at the private prac-
tice, we had 6 rooms, so it was almost
like 6 tables. You ordered that, she
ordered that. Having to keep it in my
head helped me a lot. Also interacting
with people, I’m a shy person, but as a
waitress I wasn’t shy. So being a thera-
pist, I’m not shy.
Many classmates (n=83) as well as indi-
viduals from both focus groups agreed that
their past experiences minimized the stress
they encountered in making the transition to
the clinical setting.
Attributes. Fourteen of the interviewees and
all 19 of the CIs/CSs pointed to attributes
or personality traits that facilitated student
learning. Interviewees commented on their
own adaptability; initiative, motivation, and
persistence; and receptivity. Rick noted that
flexibility and adaptability were his real
strengths, “I accommodate [easily]. That’s
why I think I get along with people. I adapt
[easily] to many situations. I try to mold to
the situation.” Kelli’s CI commented on her
initiative:
She had great initiative. I never had to
tell her. She’d see patients waiting and
she would automatically know they’re
our patients. She was just so prepared
for the day, not every student does that.
It was just very automatic. The initia-
tive was just there.
While only 2 of 19 interviewees com-
mented that their level of confidence facili-
tated their learning, 6 of 19 CIs/CSs noted
that the interviewees displayed a level of con-
fidence that benefited their learning. Leigh-
Ann was very impressed with Kayla’s level of
confidence as a student:
She’s so confident. I am so amazed, be-
cause as a student I wasn’t like that at
all. It took me a few years to gain that
confidence to be able to just walk over
to anybody and introduce myself. I’ve
never seen that in a student before. It
opened a lot of doors for her. She got a
lot of experience and learned a lot. She
walked over to an orthopedic surgeon
asked [about] a new kind of surgery and
the guy just threw off his scrubs and ex-
plained everything to her.
Fifteen of 19 interviewees, 10 of 19 CIs/
CSs, and 10 critical incidents described
how CI/CS and community receptivity and
responsiveness facilitated learning, as is evi-
denced by Kayla’s advice to new CIs:
Make them feel comfortable. Make
them feel like you’re going to help them,
not like you’re out to get them. Some
CIs are very hard, if you don’t get it this
way, it’s wrong. Be open minded, they’re
just learning.
When asked about what makes a good
CI, participants in the CI/CS focus group
raised the very same issue of receptivity and
responsiveness as evidenced by the following
comments: “Being very easy to approach”;
“Let them have room for mistakes”; “You re-
ally do have to be flexible”; and “You can’t
treat every student the same, you have to be
adaptable to their particular needs and make
them feel as though this is a good learning
experience.”
Beyond receptivity and responsiveness, 13
interviewees, 7 CIs/CSs and 64 classmates
identified care, respect, and empathy as traits
that supported their learning. As noted by
this student who compared 2 of her CIs,
My biggest challenge is to ask for help.
So, for me to ask for help, I better be
stuck. This CI would offer me help
[without my having to ask]. Whenever
she saw me stuck, she said, “Oh, you
need [help?]. Do you want me to show
you?” She wasn’t proud to ask me if I
needed help, because she saw that I was
not asking for it. [Unlike my previous
CI] who said, “Oh, you are not asking
for help. You are a terrible person.”
Interviewees also described supportive at-
tributes of the community and the environ-
ment. Six of the interviewees commented on
the type and pace of the environment as fac-
tors that supported their learning. Five stu-
dents found a very fast-paced environment
supportive, while 1 preferred the luxury of
time with his CI:
There was plenty of time to sit down
with my CI and discuss and sit down
with the patient at the same time. I
could learn a lot of his techniques and
he could see how I was doing. Time
really was a plus. Time to actually sit
down and talk to other therapists was
very helpful.
Finally, as members of the community,
receptive and empathetic patients/clients
also facilitated learning in at least 6 of the
interviewees, as Sara described:
[The] patient knew I was a student. I
was learning and she was okay with
that. She was intrigued by what I knew
and was open to suggestion and under-
stood where I was coming from. The in-
teraction was very beneficial and made
me feel good as far as a student.
Knowledge. Besides past experiences and
attributes, 10 interviewees and 32 of their
classmates cited knowledge as being support-
ive to their learning. Knowledge included
familiarity with the type of patient/client,
the setting, and the individuals within that
setting, as well as having supervisors and pa-
tients/clients who were knowledgeable about
the impairments being treated. Kevin, a re-
cent graduate noted, “I am just much more
relaxed with the diagnosis I am more familiar
with, so when I approach a patient I am more
relaxed.” A common sentiment was that be-
ing well prepared helped make the transition
from the classroom to clinic less stressful.
Interviewees also found it helpful working
with knowledgeable clinicians and patients/
clients. One student described how helpful it
was to have a patient/client with knowledge
of his or her dysfunction: “It was the back-
ground of the patient. One of the patients
never had the problem, so it was kind of hard
to explain it to them, while this other patient
had a similar problem and it was so much
easier to explain it to them.”
Skills. Finally, interviewees commented on
how much having CIs/CSs who were skill-
ful in providing clear expectations, effective
supervision and feedback helped their learn-
ing. Sixteen interviewees commented that
having clear expectations was helpful, as this
student notes, “clearly determined objectives
at the start of the affiliation made it less stress-
ful since I knew what was expected of me and
what to work for from the beginning.”
Five of 19 interviewees discussed the type
of supportive supervision they received. For
example, Charl preferred close supervision,
“My CI was there all the time just in case
I needed help”, while Brian preferred less
supervision, more independence, and added
responsibility:
Giving me more responsibility definitely
helped me. It made me feel a little more
confident and that opened me up even
more. I was able to bring more questions
to the table because I had different ex-
periences, so that helped.
Ten of the interviewees also discussed the
timing, frequency, location, and type of feed-
back. Maryann received formal weekly feed-
back: “At least once a week we talked about
how things were going. Throughout that
week I would also get feedback. But, this was
definitely a time when we could sit down”.
One experienced CI stated,
If there is a problem we’ll sit down, we’ll
talk about it. Ongoing communication
works best rather than waiting for a
specific time at the end of the week. If
there is a situation on Monday, I’m not
going to wait until Friday to discuss it,
I’m going to correct it immediately and
be ready to move on.
Eva discussed the importance of receiving
positive and negative feedback saying, “Of
course I would want her to say everything is
great, you’re just the best student, but at the
same time because she gave me the way out,
it made me feel okay.” She went on to say,
“When she gives you positive feedback and
tells you you’re doing good for your level of
experience, then you say, ‘I’m comfortable,
now let’s see how much I can learn.’”
Finally, participants noted the impor-
tance of how feedback is provided as 1 class-
mate noted:
During my first clinical I was very ner-
vous of what my CI would say if I was
doing something incorrectly in front of
a patient. It was important to me that
the patient had confidence in my skills.
She recognized this and discussed my
concerns with me before starting treat-
ments. Together we developed a system
in which I was very comfortable receiv-
ing feedback in front of the patient. She
would make eye contact with me and
Vol 22, No 3, Winter 2008 Journal of Physical Therapy Education 13
14 Journal of Physical Therapy Education Vol 22, No 3, Winter 2008
give me a questioning look. I would
then pause and discuss what I was do-
ing and adjust accordingly. It felt very
collegial and decreased my stress level
to almost nothing.
DISCUSSION
The Learning Triad
Physical therapist clinical education today is
most often provided as a one-to-one model
consisting of a student–clinical instructor
dyad. Some would describe this as a formal
mentoring relationship, even though it is rel-
atively short lived and focused primarily on
career functions and on-the-job training.10,12
Daloz8 suggests that the key functions of a
mentor in a mentoring relationship are to
provide vision, challenges, and supports.
What is different in physical therapist clini-
cal education, as noted by the participants, is
that this mentoring relationship takes place
within a community of practice. So while
Daloz8 suggests that it is the mentor that pro-
vides the vision, challenges, and supports,
findings from this study, in conjunction
with the findings from a previous study by
Plack,1 suggest that vision, challenges, sup-
ports, and barriers can emerge not only from
the mentor (ie, clinical instructor or clinical
supervisor), but also from the newcomer (ie,
student/novice clinician), other members of
the community of practice, and the environ-
ment itself.
Further, while this mentorship or dy-
adic relationship is important, participants
in this study went further to describe how
in the clinical setting a learning triad was
established that was essential to their learn-
ing. This triad consists of the student/recent
graduate, clinical instructor/supervisor, and
the community/environment itself (Figure
1). Participants also identified a number of
factors that supported and at times impeded
their learning, including past experiences,
knowledge, skills, and attributes. These fac-
tors emerged from each component of this
learning triad. In addition, each learning
situation was unique and had its own set of
factors that worked to support or impede
learning (Figure 2).
Barriers and Supports
Barriers. Boud and Walker35 suggest that
barriers to learning include presuppositions,
past negative experiences, expectations, in-
adequate preparation, threats, lack of time,
hostile or unreceptive environment, etc.
This study confirmed the existence of these
barriers in the clinical setting. In addition,
participants described how barriers ema-
nated from the past experiences, attributes,
knowledge, and skills of all 3 components of
the learning triad.
Students and experienced clinicians alike
shared how their own past experiences and
attributes sometimes negatively influenced
the learning situation. They described a lack
of confidence, fear, shyness, language bar-
riers, or cultural differences on the part of
the students/novice clinicians. In addition,
they described CIs/CSs who were incon-
sistent, overly demanding, condescending,
uncaring, or disrespectful, communities that
lacked receptivity and responsiveness, and
even the pace and evaluative nature of the
environment as potential barriers to learning
in the clinical setting. They also expressed
how working with CIs/CSs who lacked skill
in providing clear expectations, feedback,
and supervision was problematic. Finally
participants noted that it was more difficult
when they themselves, their CIs, or their pa-
tients/clients lacked knowledge.
Vera shared a prime example of how the
presuppositions and past negative experi-
ences described by Boud and Walker35 can
be barriers to learning. She described how
she tried to avoid conflict with her father
at all costs, because of his explosive nature.
Similarly, stories she shared about her inter-
actions with her clinical instructor demon-
strated that she continued to avoid conflict
at all costs in the clinical setting as well. As
a result, she avoided questioning her CI and
limited the dialogue that occurred. Without
dialogue, assumptions were made by both
the student and her CI, which further limit-
ed learning. As both Wenger3 and Plack1 sug-
gest, dialogue is central to the development
of shared meaning in the learning process.
Several interviewees described how their
own lack of confidence or fear of being wrong
or making a mistake, prevented them from
asking questions or sharing their thoughts.
In fact, 1 student’s preference for letting his
CI see his weaknesses so that he could cor-
rect them immediately was rather uniquely
heard; more often than not, students were
afraid to look bad in front of their CIs. On
the other hand, a few participants described
how excessive confidence was also a poten-
tial barrier. Overly confident individuals did
not ask for validation or clarification, mak-
ing the assumption that they were correct,
again limiting the potential for the develop-
Figure 1. The Learning Triad
Figure 2. Barriers and Supports to the Learning Process
ment of shared meaning. Again, these traits
impacted their ability to fully engage in dia-
logue and the negotiating meaning essential
to learning.
However, it was not only the attributes of
the students or novice clinicians that limited
the dialogue. For example, several partici-
pants described experiences with disrespect-
ful clinicians. They described the sense of
embarrassment they felt as a result of being
reprimanded in front of others and how these
reprimands often came without any attempt
to actively listen or understand the newcom-
er’s thought processes. The resultant embar-
rassment again closed down communication
and made it very difficult for the newcomer
to face others as an emergent professional
with any degree of credibility. Once com-
munication was closed down, the novice
never shared his or her embarrassment and
the negotiation process was further limited.
Moreover, as Plack1 suggests, having lost
credibility, access to additional challenges
and activities would be limited, further im-
peding the entire learning process.
The clinical environment itself is stressful
for these newcomers, in part because of its
novelty.1 Participants in this study described
how stress can be exacerbated by a com-
munity that lacks empathy, is too busy, or is
unwelcoming. This is consistent with what
Boud and Walker35 describe as a hostile en-
vironment, which has the potential to limit
learning. For a number of interviewees, be-
ing in such an environment left them feeling
like an outsider. It did not empower them to
develop a sense of belonging, which Wenger3
suggests is critical to professional identity de-
velopment. An unwelcoming environment
limits the newcomer’s ability to gain access
and fully engage in the activities of the com-
munity again impeding the learning process.
As Kelly28 noted in her study of an exem-
plary CI, it is important that the environ-
ment be supportive of clinical education.
Unreceptive students, clinicians, and com-
munity members are potential barriers to any
learning situation; yet, a lack of receptivity
was heard throughout the data. As Wenger3
suggests, there is a give-and-take component
(ie, production: reproduction) to learning
in a community of practice. Experienced
clinicians are invested in passing on tradi-
tions and expectations of the community
(reproduction), while simultaneously new-
comers bring new information to add to the
evolution of the community (production).
Students and graduates need to feel valued,
respected, and listened to, for what they as
individuals bring to the community.
However, being valued and respected may
have different hues for students versus new
graduates. Compliance and reproduction
are accepted by most students in the clinical
setting, as evidenced by comments such as,
“You need to comply,” “You need to make
your CI happy,” and “Your role as a student
is to absorb all you can.” Being valued and
respected for students often meant not being
yelled at in front of others as noted above,
while for new graduates it meant that their
ideas and suggestions were considered. One
new graduate shared how disempowered
he felt when his contributions to the com-
munity were never validated. His supervisor
never listened to any of his suggestions. This
lack of acceptance or respect impeded his
ability to reconcile differences and negotiate
shared meaning within this community. He
ultimately left that clinical setting to accept
a position where he felt that he could be val-
ued for what he brought to the community.
In that situation, a lack of receptivity present-
ed such a barrier that neither the graduate
nor the community could move through the
negotiation process successfully.
Finally, participants described character-
istics of the clinical environment itself as pos-
ing potential impediments to learning. Some
described the environment as being too fast
paced for learning, although the reverse was
also noted to be a hindrance. For students in
particular, the grading process was an addi-
tional threat and potential barrier to learning.
Some compared their internship experiences
to taking a test every day. A number of stu-
dents described a power differential and how,
fearful of being downgraded, they chose not
to risk disagreement or share differences of
opinion. This power differential significantly
limited their freedom to ask questions and
ultimately engage in effective dialogue. As
Mezirow suggests, having an “equal oppor-
tunity to participate (including the chance
to challenge, question, refute and reflect and
to hear others do the same)” is a prerequi-
site to rationale discourse.36 (p78) This power
differential was exacerbated at times by CIs
who were overly judgmental, authoritative,
condescending, or overly demanding. All
of this led to limited communication in the
clinical learning environment. Without this
communication, both access and negotiation
of shared meaning were impeded, which is
essential to learning in the clinical setting.1
Supports. Just as barriers emerged from all
3 components of the learning triad, so did
supports. All participants described past work
and clinical experiences that helped prepare
them for learning in the clinical environ-
ment. They also commented on particular
traits of students/novice clinicians, the CIs/
CSs, the community, and the environment
that supported their learning. Participants
also found it helpful when they had some
familiarity with the patient/client population
and the clinical setting and when they were
paired with clinical instructors who were
knowledgeable and skillful in providing clear
expectations, feedback, and supervision.
In 1984, Emery27 described the charac-
teristics of an effective clinical instructor,
which included effective communication,
interpersonal relations, professional skills,
and teaching skills. Kelly28 added the impor-
tance of making time for students as well as
having a work environment that is supportive
of clinical education. Daloz8 suggested that a
key function of the mentor is to provide sup-
port to the protégé, and Kram12 suggested
that support from the mentor went beyond
coaching and sponsoring (ie, career func-
tions) to include the psychosocial functions
of acceptance, confirmation, and friendship.
While consistent with each of these findings,
this study also demonstrates that in a com-
munity of practice, providing support is not
limited to the mentor. As with potential bar-
riers, supports to learning can arise from the
past experiences, attributes, knowledge, and
skills of each the newcomer, the mentor, and
the community.
Students and experienced clinicians alike
described how helpful it is for novice clini-
cians to be adaptable, motivated, persistent,
self-directed, and receptive. Equally helpful
to the learning situation was having a CI/
CS who was receptive and responsive, car-
ing, respectful, and empathetic. These at-
tributes all served to facilitate the learning
process and supported Emery’s27 assertions
of how communication and interpersonal
skills are essential to being an effective clini-
cal instructor. Data suggests that when the
mentor and community were receptive to
newcomers they shared information, made
newcomers feel comfortable and welcomed,
and ultimately provided them with access to
people, activities, and history.1
Responsiveness, care, respect, and em-
pathy also led to a comfortable, supportive,
learning environment, which reduced stress
and, further, opened the lines of commu-
nication necessary for the negotiation of
meaning. These very attributes are in keep-
ing with what Kram12 describes as the psy-
chosocial functions of a mentor. However,
what became apparent in a community of
practice is that these are not the sole func-
tion of the clinical instructor, but rather
the responsibility of the entire community.
Kram12 described the role of the mentor.
Emery27 and Kelly28 provided information
about the characteristics of a good clinical
instructor. Kelly28 also described the impor-
tance of being in an environment that is sup-
Vol 22, No 3, Winter 2008 Journal of Physical Therapy Education 15
16 Journal of Physical Therapy Education Vol 22, No 3, Winter 2008
portive of clinical education. Findings from
this study show that it is not only the charac-
teristics of the CI, but of equal importance
in providing a supportive learning environ-
ment are the characteristics of the student
and the community.
Moreover, in keeping with the assertions
of Emery27 and Kelley,28 it was apparent
that when the mentor possessed effective
skills in providing supervision and feedback,
and was consistent and clear in establish-
ing expectations, newcomers felt supported
in their learning. Having clear expectations
established the norms of the community
and facilitated the newcomer’s understand-
ing of those norms. At the same time, pro-
viding consistent and effective supervision
and feedback helped ensure the accuracy
of the learning. Finally, it was apparent that
effective supervision included providing
newcomers with access to engage with other
clinicians and role models, in effect making
them mentors to the process as well.
Barriers and Supports as Uniquely
Defined
While commonalities existed, barriers and
supports were uniquely defined by the in-
dividual. For example, 2 students, Eva and
Jackie, described similarly demanding and
critical clinical instructors. Eva described
how this impeded her learning and stated
that she ultimately learned very little from
that setting, while Jackie viewed it as a chal-
lenge to be mastered. Jackie commented that
although she felt her CI was trying to punish
her by giving her an excessive workload, she
took it as a challenge and learned a great deal
from her experience. In fact, by the end of
her affiliation, she commented that she was
glad her CI had been so demanding because
she felt that she developed a true sense of
what it will be like to be a physical therapist
functioning independently and responsibly.
Similarly, 2 students described their ex-
periences with clinical instructors who gave
them a great deal of independence very early
in their clinical affiliation experiences. Jan
noted how the independence really made
her take charge and helped her learn how
to communicate with patients, staff, doctors,
and other physical therapists within the com-
munity. On the other hand, Kayla viewed
this independence as “throwing me into the
lions” without any preparation and as a bar-
rier to her overall learning.
Daloz8 and Knefelkamp et al37 suggest
that attempting to sort challenges and sup-
ports, although useful, is somewhat arbitrary
because what one considers a support, an-
other might consider a challenge. Findings
from this research study support this as-
sertion. Plack1 described some of the chal-
lenges students faced in the clinical setting
and noted that the challenges also emanated
from the attributes, knowledge, and skill
of each component of the learning triad as
well. Interestingly, what one student may
consider a challenge to be mastered, another
may consider a barrier to learning; yet an-
other may consider it a support to learning.
Findings illustrate how there is an interplay
among the challenges, supports, and poten-
tial barriers that novice clinicians face in the
clinical setting.
Knefelkamp et al37 and Daloz8 discuss
the impact of challenge and support on
the developmental process. They suggest
several relationships. If students are highly
challenged and highly supported, they will
learn and grow. If they are highly challenged
and minimally supported, they will retreat.
If students are minimally challenged and
highly supported, learning will simply be
confirmed. Last, if they are minimally chal-
lenged and unsupported—they will stagnate
and little learning will occur. Findings from
the present study suggest that in addition to
challenges and supports, potential barriers
to learning must be considered in this ma-
trix. Learning results from the mastery of
challenges; optimal learning occurs when a
novice is highly challenged and highly sup-
ported.8
However, as the current study demon-
strates, barriers may exist that impede learn-
ing. These barriers may exist anywhere along
the learning continuum (Figure 3). For ex-
ample, a student may be faced with exam-
ining a patient/client for the first time (high
challenge) by a CI who is willing to coach
her through the examination process (high
support). On the surface this appears to be an
optimal learning situation. However, the stu-
dent may lack confidence and be so fearful
of making a mistake that her own personal
attributes present a barrier to her learning.
In this case, the student may need more sup-
port than anticipated by the CI. Engaging
the student in dialogue to develop a shared
understanding of her concerns and formu-
late strategies to facilitate her learning may
optimize this learning situation. Barriers can
emerge at any point in the clinical internship
and, given the evaluative nature of the in-
ternship, ongoing dialogue is essential to en-
sure that learning is optimized. Optimization
of supports and minimization of barriers will
enable learners to master the challenges they
face. Potential barriers to learning must be
recognized and sufficient supports provided
to ensure optimal learning and growth.
Many of the scenarios shared by the in-
terviewees fell neatly into the categories de-
scribed by Knefelkamp et al37 and Daloz,8
in which the students were simultaneously
supported and challenged to grow and learn,
while others illustrated how some newcomers
seemed to grow and learn despite the limited
support they received from their mentors in
the clinical setting. This is because in a com-
munity of practice supports come from the in-
dividual and the community as well as the CI.
For example, while Jackie, who had an overly
demanding CI, did not feel supported by her
CI, the community provided the support she
needed by offering to speak with the CI or to
help the student with her patient/client load.
In addition, Jackie was a self-confident indi-
vidual, which provided an additional support
and helped optimize her learning situation.
Finally, Jackie viewed her situation as a chal-
lenge to be mastered; rather than an actual
barrier to her learning. Similarly, other stu-
Figure 3. Challenges, Supports, and Barriers to Learning
dents found themselves in environments they
did not find very challenging; yet, because
they were self-directed in their own learning,
they found activities to challenge themselves,
which optimized their own learning. These
individuals learned and grew despite the chal-
lenges or barriers they faced. Not receiving
support from their CIs or CSs, these individu-
als also relied more heavily on the other 2
components of the learning triad.
Limitations of This Study
This study used a qualitative approach of a
small purposive sample of convenience of
students and clinicians from the metropoli-
tan New York City area. Qualitative methods
are not designed to be generalizable; howev-
er, sufficient detail and rich description were
provided to enable readers to determine the
transferability of the results to their own set-
tings. The study sample only included indi-
viduals who demonstrated a positive change
in professional behaviors with the assump-
tion that the participants would be able to
articulate how that change occurred. As a
result, students and new graduates whose
professional behaviors were more marginal
were not included.
Finally, with respect to the field of physi-
cal therapy, data collection occurred at a
point in time when there was a change in the
marketplace for physical therapists. During
the period of data collection and for the first
time in the history of the physical therapy
profession there was an overabundance of
PTs in the marketplace. The applicant pool
in academic institutions decreased signifi-
cantly and may have had an impact on the
types of students and new graduates in the
clinical settings. It is possible that had data
been collected at another point in time, the
findings might have been different.
CONCLUSION
The mentorship literature helps define the
one-to-one relationship that exists between
novice and expert clinician. It also helps
delineate the functions of the mentor (ie, vi-
sion, challenge, supports, psychosocial, and
career) and the characteristics of an effec-
tive mentor. However, with respect to physi-
cal therapy, this literature does not explore
the impact of the community and the role
of the community on the protégé’s learning.
Alternatively, while the theoretical frame-
work of Communities of Practice3 provided a
solid foundation for this exploration, findings
from this study demonstrate that the appren-
ticeship model does not sufficiently explore
the role of the mentor within the community
of practice. Findings from this study dem-
onstrate that it is a confluence of theoretical
frames that provides the basis for learning in
the clinical setting.
Within the clinical environment, a learn-
ing triad emerges which is instrumental to
the learning process. This triad consists of
newcomer, mentor, and community. The
community extends from the physical ther-
apy department and all of its staff and sup-
port personnel, to the patient/client, other
health care workers, and support personnel
throughout the facility. When a newcomer
enters a clinical environment, all members
of that environment have the potential to
impact the learning situation. Further, chal-
lenges, supports, and barriers can emerge
from all aspects of the learning triad, includ-
ing the past experiences, attributes, knowl-
edge, and skill of each component of this
triad. Finally, the degree to which a learning
situation is supported or hindered must be
individually assessed and modified to meet
the needs of students, clinicians, and the
community. Past experiences, attributes,
knowledge, and skills of each component
of this learning triad can act to exacerbate
or mitigate both barriers and supports to
learning. What emerged from this study is
a model of how challenges, supports, and
barriers all influence the learning situation.
To establish an effective triadic learning re-
lationship, supports and barriers cannot be
deconstructed and viewed in isolation; rath-
er, each must be viewed as a component of
the whole.
Recommendations for Future Studies
Recognizing the challenges, supports, and
potential barriers to learning within the com-
munity of practice from the perspective of
students and novice clinicians can help us
design academic and clinical experiences
that optimize learning and professional de-
velopment. Future research is needed to
determine whether the supports and poten-
tial barriers identified can be generalized
beyond this study. The model of challenges,
supports, and barriers that emerged should
be assessed in a variety of settings to deter-
mine its transferability and its use in design-
ing effective learning experiences.
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