Clinical experiences are essential for physical therapist (PT) students to develop practical knowledge and critical thinking in the context of the uncertainty and unpredictability of clinical practice.1,2 The Commission on Accreditation in Physical Therapy Education (CAPTE) reports over 20% of a professional PT curriculum is comprised of clinical education, which reflects a trend in growth over the past few years.3 A systematic review by Littlewood et al revealed that “early [clinical] experience has a strong formative influence” and puts biomedical science into “a broader, social context.”4(p389) Mostrom asserts clinical education experiences are essential for PT students because they are “important ‘bridges’ in the developmental trajectories of future therapists,”5(p266) aiding in the transition from classroom to clinical learning and from students to novice practitioners. This is true for several different aspects of clinical practice, including the development of professional identity, critical thinking, and fostering multiple forms of reasoning, such as ethical reasoning, encouraging reflection in action, and promoting socialization within a community of practice.
Reflection is considered by many to be an important part of clinical education and is integrated into numerous health care professional training and educational programs.6–15 Although reflection has been described in several different ways,16–29 most commentators and scholars recognize it as a cognitive skill in which the context examined includes the background, values, and beliefs of all involved parties to gain a better understanding of a lived experience.1,30,31 Almost a century ago, the noted educational philosopher John Dewey argued that learning from experience was best obtained through ongoing reflection in order to understand its meaning.30 In the 1980s, Schön criticized traditional methods of technical and rational knowledge and learning, arguing instead that ongoing reflection in, on, and for action was necessary for health care professionals to understand and manage the uncertainties and unpredictability of clinical practice.1 Similarly, Mezirow defined 3 types of reflection that occurs in practice: (1) content reflection goes beyond simple reporting of an event and attempts to understand its meaning, (2) process reflection includes descriptions of strategies and processes involved in an experience, and (3) premise reflection is a self-critique of one's assumptions, values, beliefs, and biases.31 The goal is to alter future behavior and decisionmaking by learning from experiences.
The written narrative is a method used to promote reflection in health sciences for both students and practitioners.32–49 Through the telling of a story, a writer is able to access thoughts and knowledge, enabling a deeper level of reflection.37 The author is asked to move back and forth between recounting a series of events and the thoughts and perceptions of those events.40,41 This introspection allows for reflection, analysis, and evaluation in preparation for improved patient-centered care in the future. Health care professionals can utilize narratives as a method for ongoing self-assessment of their clinical skills, contextual knowledge, and critical thinking.39,47 The ability to integrate narrative and analytical thinking to assess current performance promotes future learning and development of competence as a clinician.50–54
Since the effectiveness of clinical education depends on understanding the student experience, including issues and challenges faced, reflective narratives have received considerable attention in a range of health professions, including nursing,8,13,15,49,51 medicine,12,29,32,33,36,37,42–46 psychology,17,40,41 occupational therapy,55,56 and physical therapy.5–7,11,16,39,47,48,57–62 While data about the issues encountered by PT students is beginning to emerge, there remains much to be learned about their initial clinical experiences and reflective abilities. Therefore, the purpose of this study was to retrospectively analyze PT student reflective narratives written during initial clinical experiences. The aims were (1) to apply a framework of reflection and evaluate the highest level of reflection attained, and (2) to use a process of phenomenological analysis to explore the themes with respect to issues and challenges faced in the clinic. Results will aid physical therapy educators in curricular development and refinement.
REVIEW OF THE LITERATURE
Recent qualitative studies of reflective narratives written by novice practitioners and students in the fields of medicine,50,63,64 occupational therapy,55,56 nursing,6,13,49,51 and physical therapy52,53,65–67 illustrate the challenges of early clinical practice. A seminal study of nurses transitioning from novice to expert by Benner et al has provided a template for other health care professionals. Pertinent to the study of early clinical experiences were the authors’ findings that novice nurses have difficulty with confidence, practical reasoning skills, multi-tasking, fear of failure and making mistakes, and inability to reflect-in-action.51 Similarly, novice PTs rely more on technical and rational knowledge, struggle with critical thinking, confidence, the proper amount of caring, and are limited in their abilities to ethically engage with patients. Solomon and Miller used a grounded theory approach to gain insight into issues faced by 10 novice PTs, which included communicating with challenging patients, reimbursement issues, and feeling stress and insecurity.65 In a series of studies exploring clinical caring, Greenfield et al recounted that novice PTs have more difficulty in caring for difficult patients than experienced PTs.68,69 Specifically, novices were inclined to be defensive and blame patients who were angry, uncooperative, and lacking motivation, while experienced PTs were more empathetic and creative. Furthermore, it was an effort for novices to find a balance between effective caring versus enabling patients. Black et al52 and Hayward et al53 followed “promising” novice PTs during their first 2 years of clinical practice and noted concerns regarding communication within a community of practice, development of practical and relational skills, and self-confidence.
Like novice clinicians, health care students encountered similar issues during their early clinical experiences. Medical students described their transition to clinical care as characterized by indecision with respect to practical procedures, increased responsibility related to workload, and feelings of uncertainty.63,64 As a result, they overly focused on technical skills required to find the right diagnosis. Occupational therapist (OT) students vacillated between euphoria and angst as they navigated the reality of practice.56
Recent studies explored reflective narratives written by international PT students during their clinical internships. Williams et al identified 6 major themes in the weekly journals of Canadian physiotherapy students during a 6-week clinical placement: (1) the clinical decision-making process; (2) the complexity and richness of interactions with clients; (3) the influence of the practice environment on learning and patient care; (4) acquisition of clinical and administrative skills; (5) the value of clinical experiences in validating previous learning; and (6) the acknowledgement and development of different learning strategies.60 In a follow-up study, Geddes et al specifically explored ethical issues of physiotherapy students during their 6-week clinical placement and reported themes of professional collegiality, professional behavior, respect for others, advocacy, and informed consent.57 Similarly, Larin, Wessel, and Al Shamlan examined reflective journals of 2 separate cohorts of physiotherapy students from the United Arab Emirates during an early 4-week clinical placement and a later 6-week clinical placement and uncovered themes including professional behaviors, the unique aspect of clinical learning, self-development and orientation shifts in the clinic, and ethical issues.59
Wessel and Larin compared themes and the level of reflection achieved in writings by physiotherapy students during their first and third clinical placements. A slightly higher level of reflection was attained (versus pure description of events) in the third clinical experience. Although overall themes were somewhat similar in both clinical experiences, students progressively gained confidence, were more focused on their client, and broadened their perceptions of the roles and responsibilities of the physiotherapist and the ultimate impact of their actions on patients.61 In the US, Mostrom and Shepard reported on the reflections written by thirdyear PT students about delivering patient education. Specific instructions were given to reflect and write on matters such as how one thought about an event in order to reach a better understanding, what and how learning occurred, one's feelings, and personal and professional development. Students had an increased appreciation of the patient's perspective, their own role in patient education, and the need to overcome problems to provide effective care. Writings demonstrated their difficulty with transitioning from therapist-centered care to patient-centered care.70
Additional research exploring physiotherapy students’ clinical experiences described comparable themes, including demonstration of professional roles and identities, the challenges and differences between clinical and classroom learning, and the challenges to providing patient-centered care.58 Also included were death and dying, professional relationships, receiving feedback from clinical instructors, challenges of clinical reasoning, ethical issues, patient-centered care, and anxiety.6
The aims of the current study are to build on the insights gained from previous studies of the issues faced by PT students during their initial, short-term clinical experiences and before their long-term clinical placement. The use of a deductive and inductive approach allows for exploration of levels of reflection as well as a thematic understanding of those issues. Through studying how professional level PT students write about and reflect on their clinical experiences as they transition into the clinic, educators may fully understand those issues and how they want to train the reflective abilities of students in clinical learning.
A retrospective analysis of narratives written by students in the Doctor of Physical Therapy (DPT) program at Emory University was undertaken. To address both aims of the study, a 2-step process of deductive and inductive analysis was used. Each student was de-identified by a sequentially assigned number.
Participants and Sample Selection
Beginning in 2007, first- and second-year Emory PT students participated in a 1 credithour course in which they were required to write a reflective narrative in each of their initial 2-week clinical experiences during “General Medicine” (spring, year 1), “Musculoskeletal” (summer, year 2), and “Neurological Rehabilitation” (fall, year 2) courses. The purpose was to provide opportunities for self-reflection, to encourage students to welcome uncertainty, and to accept difficult situations as an occasion for creative problem solving. Students were given the following questions to assist with writing their narrative:
- What was the central issue you encountered?
- What confuses you about the issue/case?
- What feelings did you experience during this issue?
- How did you and/or others address the issue?
- What did you learn about yourself from this issue/case/encounter?
- What would you do differently if you encountered this issue again?
Narratives utilized for this study were from the student cohort taking the courses in 2012; therefore, participants were a sample of convenience. An electronic databank of 47 narratives formed the initial pool for analysis. Using Hatton and Smith's framework for reflective narratives,71 writings that included descriptive reflection, dialogic reflection, or critical reflection met the inclusionary criteria. Table 1 outlines the operational definitions for these classifications. Those categorized as purely descriptive writing were excluded. A final sample of 30 was generated, determined to be a number appropriate for phenomenological studies (Table 2).72,73 Narratives were written by 26 individual students (22 females and 4 males), with 4 writing 2 apiece. Nineteen were authored during the “Musculoskeletal” course, 9 in the “General Medicine” course, and 2 in “Neurological Rehabilitation.”
Figure 1 illustrates the steps of data analysis. The iterative process involved the narratives being coded by each individual member of the research team and then peer-checked collectively by the entire team. A 2-step analysis occurred that was both deductive and inductive. First, each researcher used a deductive process to classify the narratives as descriptive reflection, dialogic reflection, or critical reflection based on the framework developed by Hatton and Smith.71 The group met to discuss their individual findings and come to a consensus for each narrative's level of reflection. It was during this process that 2 additional levels of reflection were developed, modeled after Hatton and Smith: critical/dialogic and dialogic/descriptive (see Table 1). Subsequently, an inductive approach based on work by Creswell72 and Van Manen73 was utilized to code themes in those narratives that met the inclusionary criteria (writing above the descriptive level). Both Van Manen and Creswell described methods of thematic analysis based on phenomenology. These interactive methodologies facilitated exploration of the themes uncovered during these clinical experiences using the following 2 approaches to analysis: (1) The holistic approach, which attends to the text as a whole and asks, “What is this a story about?” And (2) the selective reading approach, a code for significant statements that capture an idea or theme/structure/dimension of clinical experience.
Individually, researchers coded potential themes that emerged from each student's experiences. Next, the group collectively discussed each narrative and achieved consensus on the emerging themes. Themes were recorded along with line numbers representing their supportive significant statements. Consistent with the approaches of Van Manen and Creswell, the research group identified a primary theme (what the story was essentially about) and secondary themes (based on the selective reading approach) for each narrative. Once all writings were coded both individually and collaboratively, the research group reached consensus on the primary and secondary themes across all narratives.
Several steps were undertaken during data analysis and reduction to enhance the trustworthiness of the results.72–74 First, researchers participated in bracketing their biases by acknowledging past clinical experiences and values that could potentially influence interpretation of student narratives. Second, before data collection began, a pilot study was conducted to practice the method of data analysis and interpretation. Third, each researcher wrote memos to explain their initial coding of the data, which were available for reference during group analysis. Finally, a careful audit trail was maintained linking significant statements to the levels of reflection, the themes, and subthemes.
As mentioned, an iterative process of data analysis improved the trustworthiness of the results. The initial sample was analyzed both individually and by the research group, ultimately resulting in the exclusion of those narratives containing only descriptive writing. Individual and collective examination and coding continued for the remainder to ensure a consensus on the level of reflection, as well as on the identification of primary and secondary themes. This process of peer checking guaranteed the full richness of each narrative was utilized for thematic interpretation of the issues that students faced during their initial clinical experiences.
The first aim was accomplished as each narrative's level of reflection was identified. The iterative analysis resulted in the creation of 2 new levels in addition to those described by Hatton and Smith.71Table 1 illustrates operational definitions for all levels, along with examples from the narratives. Figure 2 indicates the frequency of each level of reflection found within the writings.
The second aim of the study was establishing a thematic understanding of the issues faced by students during early clinical experiences. Many narratives contained several secondary issues centered on an obvious primary theme, allowing development of both primary and secondary themes for most writings. Table 3 displays the breakdown of primary and secondary themes. Table 4 contains operational definitions for each theme, along with examples of significant statements from the student narratives. Following is a summary of each of the themes.
Theme 1: Patient-Centered Care
Patient-centered care emerged as the most common primary theme (27% of the narratives) and was a secondary theme in 33% of the narratives. We defined it operationally as: “The student dealing with the needs of the patients and their families before personal needs; grappling with emotional intelligence” (Table 4). Students recognized the importance of addressing the needs of the patients before their own needs and began to learn creative and contextual ways of treating patients based on their individual capabilities.
Theme 2: Ethical Conflict
Ethical conflict (along with confidence) was the second most frequently discussed primary theme in the narratives and a secondary theme in 7% of the narratives. Students encountered issues pertaining to fiduciary versus organizational obligations, and limits of using evidence-based practice in clinical care (Table 4, row 2). They wrote about their uncertainty surrounding clinical responsibilities, family dilemmas, end of life care, and clinical roles. Despite having classroom training in ethics, students still felt challenged and found real life experiences far messier than those encountered in the classroom.
Theme 3: Confidence
Given that these narratives were written during initial clinical experiences, we were not surprised that PT students experienced and expressed struggling with confidence. Confidence was the second most frequent primary theme (along with ethical conflict), as well as a prevalent secondary theme. The operational definition was: “PT dealing with a lack of confidence; struggling with feelings of anxiety, insecurity and self-doubt; and seeking affirmation” (Table 4, column 2, row 3).
Theme 4: Professional Identity
Students reflected on what it means to be a PT in the clinical setting and how that role will evolve once they become licensed practitioners. Professional identity was operationally defined as: “The student therapist exploring the physical therapy profession; and understanding the roles and responsibilities of the PT in the health care setting” (Table 4, column 2 row 4). While it was the primary theme in only 4 narratives, it was a secondary theme in over one-third of the writings, demonstrating its importance during professional development.
Theme 5: Student-Clinical Instructor Communication
Navigating the professional relationship with one's clinical instructor (CI) is crucial. In some cases, students encountered negative experiences and questioned the actions and behaviors of their CIs. Others viewed their CIs as positive role models (Table 4, column 3, row 5). In either case, these initial internships were only 2 weeks long, leaving little time for students and CIs to foster relationships.
Theme 6: Classroom to Clinic
The integration of classroom knowledge and clinical practice was a challenging skill that students had not previously encountered. It is the least mentioned primary theme, but is a secondary theme in about 30% of the narratives. Many students recognized their struggle in applying theories and principles learned in the classroom to the clinic. Based on the narratives, we defined this theme as: “The student PT incorporating classroom knowledge in a clinical setting; and using clinical judgment to navigate the complexities of patient care” (Table 4, column 3, row 5).
The first aim of the study was to determine student levels of reflective writing. Of the initial pool of narratives, according to Hatton and Smith, 68% met the criteria for reflective writing, meaning that 17 remaining narratives contained only descriptive writing without any reflective qualities. Of those meeting the inclusionary criteria (n = 30), 80% fell below the critical and critical/dialogic reflection levels (Figure 2). Although students possessed some self-awareness and reflective ability, they lacked skills necessary to deepen their analyses to dialogic or critical levels and express those using written narratives.
Levels of reflection attained are similar to those reported by Wessel and Larin.61 They used a 5-level grading system developed by Williams et al, representing a hierarchy of reflective writing.62 Like Hatton and Smith,71 the first level represented only descriptive writing, while the fifth level represented reflection for future action. Wessel and Larin reported that 22% of the writings in students’ clinical journals only reached the descriptive level (level 1).61 Forty-nine percent demonstrated analysis of learning events and issues, revealing the students’ cognitive and emotional reactions (level 2). In contrast, Williams et al reported almost 40% of students in their study attained level 5, and almost all writings exhibited some level of reflection.60 None of these authors indicate if training in reflection and narrative writing occurred prior to clinical placements or if a reflective framework/model was provided as a guide.
The small number of narratives in our study demonstrating the higher levels of reflection, as well as the large number excluded due to lack of reflective writing (Table 1), indicates a need for formal training on reflective practice and narrative writing prior to early clinical experiences. Delaney and Watkins7 and Delaney and Molloy6 outlined an educational strategy to develop student PT knowledge and skill in writing reflective narratives. Their process was both foundational and iterative. Introduction to important philosophical concepts and theories related to reflective and contextual practice occurred at the beginning of the curriculum. Reflective thinking and assignments were integrated throughout the student curriculum. As a result of the implementation of this strategy, students demonstrated an increased awareness of how multiple perspectives and values from various stakeholders intersected with environmental and social contexts (reflexivity). Also demonstrated was an understanding of how meaning was constructed through dialogue, language, and metaphor (post modernism), as well as a sense of how the social world influenced hierarchies of power and knowledge construction (critical theory).
Several authors have designed models of reflective writing75–78 to assist writers in connecting their first person description of an experience to their reflections, analyses, and future action plans (reflection for action). As the results of this study indicate, clear guidelines and models may be necessary to facilitate reaching critical reflection with increased frequency and on deeper levels. This may be particularly true for novice narrative writers. In the spring of 2013, Emory faculty redesigned the narrative seminars to incorporate the use of Gibbs’ Model of Reflection to guide narrative writing. Students are encouraged to follow this circular template that contains 6 phases.75 The first 2 encourage first person accounts of the experience and feelings that arose. Writers are asked to place themselves into the action and avoid using abstraction in their descriptions. Two evaluative phases follow in which the value and meaning of the experience are judged and discussed along with further thoughts and feelings. Finally, the model culminates in an analysis of what may have gone wrong, what else could have been done, and considerations for future actions in similar situations. Future inquiry will examine whether the introduction of this model changes the frequency and nature of reflection in student narratives.
Themes identified in the current study were similar to those reported by other researchers who examined student PT experiences during clinical placements.6,57–62 Patient-centered care was the most frequent primary theme and reflected the call by the Institute of Medicine to provide care that is respectful, inclusive, and responsive to individual patient and family preferences above those of the clinician.79 Delany and Molloy,6 Larin et al,59 and Ramli et al58 reported dimensions of patient-centered care in student narratives, although not as prevalent as in this study. For example, Delany and Molloy stated that patient-centered care was a theme in writings by only 6% of the 54 PT students in their study.6 However, since many of our students were engaging with patients for the first time in their professional careers, their primary focus may have been on developing positive therapeutic relationships.
As in other studies,6,59 our participants described encountering several ethical issues during their clinical experiences (Table 4). Research suggests that students and novices should begin identifying ethical issues and use ethical reasoning early in their clinical experiences.20 Failure to do so creates risk for experiencing moral uncertainty.68 Participants in this study had taken a course in ethics and professionalism and recognized ethical issues including dilemmas and locus of authority problems, yet they felt uncomfortable with making ethical decisions and in some cases approaching their CIs with ethical concerns.
Lack of confidence was a prevalent theme in this study (Table 4). Performing an initial evaluation was a common source of anxiety for many of our participants, as illustrated when a participant said, “I'm nervous that when I do my first evaluation, I will ‘blank’ and forget something” (S3–21). Similarly, Tryssenar and Perkins found that OT and PT students who transitioned to novice clinicians during the course of their study experienced moments of self-doubt and struggled with the feeling that if a more experienced therapist was treating the client, he or she would be making better progress.80 According to Black et al, novice PTs found that “growth in confidence [emerged] after successful resolution of difficult situations or work with challenging patients…”52(p1766) Comparably, our study concluded that students struggled with a lack of confidence in evaluation and treatment skills, which only improved when they received positive affirmation.
As outlined in the narratives, effective student communication with the CI greatly impacted the results of the clinical education experience. Our participants looked toward their CI as a source of mentorship, as well as a source of emotional support. The following demonstrates how a participant relied on her CI to help face the sudden death of one of her patients:
I went home that night thinking about what I could do to help him. I had a plan in order that I would not be able to execute. The truth about my feelings during this time was just that I simply did not know how or what to feel. It still bothers me to this day. My CI and I just addressed this issue by discussing it for 10 minutes. I tried not to show how upset I was but she could see it all over my face, so she explained how she is able to cope with her patients’ deaths. She described the difference between showing empathy and really feeling it; and at the same time, how to still provide the best quality care, but keep distance so you are still able to do the job on a daily basis (S12–25–30).
Some of our participants described frustration in communicating with their CIs to gain their trust, as in the following statement: “The central issues I faced here was that I hesitated to ask my CI for clarification when I wasn't sure how to use a piece of equipment” (S14–12–14).
Other participants described their CIs as engaging in what they perceived as unprofessional conduct, as the following participant stated: “In order to keep numbers up and make a good profit as a clinic, she has appointments scheduled for 3 or 4 people at the same time…I felt that it compromised patient care” (S19–4–9). In these situations, the students did not confront their CIs for fear of negative consequences and even retribution.
Black found that effective communication was integral to student learning and is a skill that needs to be developed by both the student and the CI.81 Delany and Watkins discovered that PT students commonly address “power, hierarchies, connecting with others, and relationships” within their narrative writing.7(p411) Power struggles and hierarchy were also apparent in our students’ narratives, ultimately affecting communication and facilitating or impeding learning experiences.
Delany and Molloy6, Larin et al,59 and Ramli et al58 reported that PT students struggled to find their professional identities, particularly developing boundaries of what is considered responsible caring while considering the needs of patients and families. Several of the participants in this study similarly struggled with their boundaries of caring, as illustrated in the following participant statement:
I learned that I am a very empathic person that has always had trouble separating my heart from my head. I learned firsthand at the hospital that I must learn to do this in order to get through my job on a daily basis. Some of the scenarios I saw there had me upset or thinking about it the whole day, and I know I cannot do that if I want to be a great therapist and live a healthy life (S12–32–36).
The ideological meaning of caring has been touched on by others; Branch discussed the struggle of medical students in developing responsible care toward their patients.82 Similarly, Benner and Wrubel described the challenges of novice nurses while caring for patients and the threat of over-involvement. They proposed that the right kind of caring embodies the art of openness and the values of one's best offering, even if that involvement is not curative.83
Delany and Watkins stressed the importance of reflecting on one's professional identity and for PTs to be self-aware, reflexive, and mindful of their own unique contribution and identity in their care of patients.7 As indicated in Table 4, for these participants, their early clinical experiences were instrumental in helping them form their professional identity, particularly in relation to the roles of other health care professionals. One participant said: “As a Doctor of Physical Therapy, sometimes I will have the expertise and power to disagree with a physician's diagnosis and prescription” (S1–43–44).
The theme of developing a professional identity arose in a study done by Black et al where “participants gradually developed an awareness of their own unique professional identity in their clinical community, and a clearer and expanded view of their roles as physical therapists and team members, thus opening the door for thinking about who or what they might become in the future.”52(p1766)
The narratives included in our study were written during the students’ initial 2-week clinical experiences, which may explain why the theme of applying classroom knowledge to the clinic was primary in only 7% of the student narratives, although a secondary theme in 33%. The students were likely more focused on becoming comfortable in the clinical setting with families, patients, and other practitioners than they were in developing clinical reasoning skills. We expect that they will focus more on clinical reasoning and applying theory to practice during their longterm clinical internships.
Regardless, during the 2-week experiences, many students discussed struggling in applying what they learned in the classroom to situations in the clinic. Schön explained the complexities of practical knowledge by using a “swampland” metaphor, contrasting the “high, hard ground” of classroom knowledge with the “messy, indeterminate swamplands” of clinical practice.1(p22) One is required to think fast and in action in the clinical setting, which has proven to be difficult for novice clinicians.12(p76) Tryssenar and Perkins point out that educators and clinicians, in an attempt to “show best practice and highlight [occupational and physical therapy professions], …shielded students from some of the more unpleasant aspects of day-to-day practice.”56(p22) Thus, it is not expected that students will master the transition from classroom to clinic due to their lack of preparation for real-life scenarios. We believe the use of cases and simulated patient experiences are helpful in trying to prepare students for the intense needs of clinical practice, but fall short of developing the type of clinical knowledge and clinical confidence that develops directly through clinical learning and reflection.
This study contained 2 major limitations. First, this was a retrospective analysis of preexisting data so researchers had to trust that collection was conducted properly. As mentioned, the data was part of our students’ educational requirement. As previously indicated, we are currently using the Gibbs Model to guide the students’ narrative writing to develop a more consistent level of reflection. We believe that the use of a model will help educate students of the proper levels of reflection and create a standardized process of collecting data. Second, author identities were unknown to all team members except the lead investigator (BHG), resulting in an inability to member check the results.
In addition, the inductive methodology identified primary themes and secondary themes. However, based on the methodology, we did not explore how themes and secondary themes may be linked to each other. For example, some secondary themes such as communication may be a dimension associated with developing skills in patient-centered care. Lack of confidence may be a result of difficulties in communication, technical skills, or knowledge translation. In the future, using open and axial coding may sufficiently uncover links between themes and their dimension.
IMPLICATIONS AND CONCLUSION
The purpose of this study was to use the results of the narrative analysis to aid physical therapy educators in designing a curriculum that best prepares students for early clinical experiences. Key themes common to initial clinical experiences should be addressed throughout the curriculum and during clinical preparation sessions. At Emory, for example, these findings supported the development of preclinical seminars on effective and professional communication with CIs. Students will practice skills of effective communication with CIs they admire or have conflict with.
Additionally, researchers identified a lack of formal training on writing reflective narratives. The final sample was comprised primarily of descriptive and dialogic reflective narratives, lacking the depth required for critical reflection. Also, a significant number did not meet the inclusionary criteria due to their categorization as descriptive writing. Educators should be aware of the need to improve the reflective abilities of students, which has previously been recognized as a skill crucial to the development of the expert practitioner.5,22
Emory's PT education faculty discussed the findings of this study and made suggestions regarding how to incorporate reflective narrative training into the curriculum. One idea was to hold a narrative workshop prior to the first clinical experience. Students would be instructed in the history and implications of reflective narratives in health care, have the opportunity to practice writing narratives, and receive feedback in small groups led by the research team members of this study. The Gibbs Model would be utilized as a framework to guide the reflective writing process, allowing for a future study to assess the benefits of using such a model with novice narrative writers. We currently are exploring the levels of reflections and themes of narratives written by students using the Gibbs Model during their short-term and long-term clinical experiences.
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