Writing for the role: A qualitative exploration of new graduate physiotherapists’ transition to practice of clinical documentation

ABSTRACT

Introduction

Clinical documentation is an integral component of effective physiotherapy practice. Minimal research has explored how new graduate physiotherapists transition to practice of documentation.

Objective

To understand new graduate physiotherapists’ experiences and support needs for transitioning into this professional role, from the perspectives of new graduates and clinical supervisors.

Methods

This study utilized the qualitative methodology of reflexive thematic analysis, situated within a critical realist framework and informed by Duchscher’s stages of transition theory. Semi-structured interviews of 16 new graduate physiotherapists (less than two years post-graduation) and seven clinical supervisors (of new graduate physiotherapists) were subjected to inductive analysis, where codes were organized into themes and subthemes.

Results

Three overarching themes were generated with associated subthemes. Variable preparedness for documentation identified that new graduates were equipped with the basics of documentation, yet challenged by unfamiliarity and complexity. Documentation practices evolve over time outlined experiences of new graduates developing a “written voice” and improving documentation efficiency. Workplace support is necessary irrespective of preparedness, discusses: i) opportunities to practice, reflect and refine skills, ii) protected time for documentation, and iii) access to templates and examples.

Conclusion

New graduate physiotherapists enter the workforce with variable levels of preparedness for clinical documentation, and may experience challenges when facing unfamiliar contexts and clinical complexity. Understanding expectations and engaging in opportunities to improve documentation skills were perceived as beneficial for enhancing new graduate practice of clinical documentation across workplace settings. Implications for workplace support to promote safe and effective practice of documentation are discussed.

KEYWORDS:

• Physiotherapy
• new graduate
• clinical documentation
• transition
• professional education

Introduction

Entering the workforce as a newly graduated health professional involves a period of considerable adjustment, characterized by the transition from supervised learner to autonomous clinician (Brennan et al., 2010; Flott and Linden, 2016; Gambescia and Early, 2017; Jones, McAllister, and Lyle, 2015; Naidoo, Van Wyk, and Nat, 2014; Opoku et al., 2020). Duchscher (2009) described an initial state of “transition shock” where new graduate nurses are confronted by differences between academic and professional environments upon commencing work, and may encounter gaps in their preparedness, knowledge or skills. Duchscher (2008) characterized a subsequent process of “becoming” in three stages of transition: i) doing the work and persevering in the face of a steep learning curve, ii) reconciling preconceived notions with the realities of being in the professional role, and iii) attaining confidence and stability in professional abilities, and a sense of knowing. Duchscher’s transition theories (Duchscher, 2008, 2009) have been used to frame experiences of graduates from other healthcare professions (including physiotherapy) who have reported challenges coping with aspects of transition to work, such as: assuming their professional identity, increased independence, high self-expectations, gaps in preparedness, and increases in clinical caseload volume and/or complexity (Brennan et al., 2010; Kenny et al., 2021; Miles, Kellett, and Leinster, 2017; Monrouxe et al., 2018; Smith and Pilling, 2007; Stoikov et al., 2022). In particular, physiotherapy new graduates often experience anxiety, stress, decreased confidence, and feelings of being overwhelmed upon commencing clinical practice (Atkinson and McElroy, 2016; Foster-Seargeant, 2001; Stoikov et al., 2022).

Composing and reading documentation relevant to the provision of clinical care are core components of effective and safe physiotherapy practice. Clinical documents facilitate recordkeeping, communication between healthcare stakeholders (Hammoud et al., 2012; Kuhn et al., 2015), clinical reasoning (Mamykina et al., 2012), justification of funding reimbursement, and initiatives for service planning, improvement or re-design. Documentation represents a significant proportion of health professionals’ workloads (Rowlands, Coverdale, and Callen, 2016), and reports suggest that clinicians may spend as much time on documentation as they do in providing direct clinical care (Ammenwerth and Spötl, 2009; Christino et al., 2013). In Australia, physiotherapy new graduates are required to enter the workforce sufficiently skilled to practice clinical documentation according to strict professional requirements (PBA and PBNZ, 2015; Malterud, Siersma, and Guassora, 2016), which align closely with international guidelines on clinical documentation practices published by the World Confederation for Physical Therapy (2011).

Concerns regarding clinical documentation in healthcare professions are numerous. These difficulties include issues relating to content accuracy, redundancy of information and detrimental effects on a clinician’s available time for direct clinical care – which are likewise echoed in reports on physiotherapist documentation (Harman, Bassett, Fenety, and Hoens, 2009; Häyrinen, 2014; Olawale, Akodu, and Tabeson, 2015; Phillips, Stiller, and Williams, 2006; Richoz, Ayer, Berchtold, and Richoz, 2011). Furthermore, the workload resulting from composing and interacting with documentation has been previously linked to health professional burnout (Downing, Bates, and Longhurst, 2018; Shanafelt et al., 2016), and high workload levels are similarly recognized as a potential source of stress and burnout for health professional graduates in nursing and medicine (Duffield et al., 2011; Walker and Costa, 2017). Burnout can have deleterious effects on healthcare professionals, such as difficulties with memory, attention and cognition, which is known to compromise overall clinical care and patient safety (Fred and Scheid, 2018) and may cause early attrition from the workforce, compromising workforce stability and healthcare outcomes (Moores and Fitzgerald, 2017; Stoikov et al., 2022). In light of these factors, challenges identified among physiotherapy graduates and their employers (Atkinson and McElroy, 2016; Stoikov et al., 2022; Wells et al., 2021) emphasize the importance of ensuring successful transition for new graduate physiotherapists into clinical documentation.

Despite the central role of documentation in physiotherapy practice (PBA and PBNZ, 2015), no research has specifically explored the experiences of new graduate physiotherapists in transitioning to clinical documentation practice. Duchscher’s (2008, 2009) description of new graduate transition was developed to address workforce attrition (Murray, Sundin, and Cope, 2019), however it also highlights opportunities to support new graduate transition to professional practice (Duchscher and Windey, 2018). The first two years in the workforce are considered a critical period for skill acquisition (Chipchase, Williams, and Robertson, 2008; Hayward et al., 2013), and understanding specific experiences and challenges in transitioning from student to new graduate physiotherapist may guide provision of workplace support to ensure safe, ethical and legal practice of clinical documentation. The aim of this study was to explore new graduate physiotherapists’ experiences and support needs for transitioning into the professional role of clinical documentation, as perceived by new graduates and clinical supervisors.

Methods

Design

This study utilized a qualitative research design, featuring reflexive thematic analysis of semi-structured interviews (Braun and Clarke, 2019). The use of thematic analysis in this research was inductive, descriptive and sought to gain a rich, in-depth understanding of participant experiences and perspectives (Neergaard, Olesen, Andersen, and Sondergaard, 2009). Reflexive thematic analysis as described by Braun and Clarke (2019, 2021a) involves a six-stage analytic process, where meaning-making occurs at the interface between qualitative data, relevant theoretical knowledge and researcher subjectivity. This approach was selected for its ability to capitalize on the extensive experience of the research team as an explicit tool for understanding participant experiences, in addition to recognizing existing, well-developed theoretical constructs rather than operating in a theoretical vacuum. The two predominating theories which guided analysis and meaning making in this study were critical realism, and Duchscher’s transition theories (2008, 2009).

Critical realist ontology combines realism (something “real” exists independent of perception) with relativism (understanding is always constructed from a certain perspective). Critical realism thus acknowledges the subjectivity of experience and considers the contexts in which they are produced to create understanding (Madill, Jordan, and Shirley, 2000; Willig, 2008). Through the lens of critical realism, reality can be likened to a floating iceberg (Stutchbury, 2022); observable or describable phenomena are the tip of the iceberg above the water surface, however the causal mechanisms which underpin those observable phenomena remain hidden below the water, and must be inferred through a process of analysis (in this instance, Braun and Clarke’s (2019) reflexive thematic analysis). The aim of positioning this research within a critical realist paradigm was to provide a meaningful framework for interrogating the underlying explanations for experiences of new graduate practice of documentation.

Critical realism encourages the critical selection of relevant theory to seek explanations for surface phenomena, and reflexive thematic analysis similarly describes that theoretical knowingness should guide the generation of codes and themes from data. Therefore, to situate data collection and analysis for this research in context of relevant and meaningful knowledge, the research at hand draws on Duchscher’s transition theory (2008, 2009) to inform participant experiences and interpret possible underlying causal mechanisms relevant to the research aims.

The University of Queensland Institutional Human Research Ethics approved all aspects of this study (2022/HE000348).

Participants, recruitment and sampling

Inclusion was limited to two groups: i) new graduate physiotherapists – individuals employed as physiotherapists within the Australian workforce, having graduated from an entry-level physiotherapy program in Australia no more than two years preceding (Chipchase, Williams, and Robertson, 2008), and ii) clinical supervisors - individuals employed as physiotherapists involved in supervision or mentoring of new graduate physiotherapists. New graduate physiotherapists and supervisors were not required to be known to each other. The inclusion of data from different perspectives of both new graduates and supervisors aimed to facilitate rich and meaningful descriptions of new graduate transition to practice of documentation.

Recruitment for both groups was via convenience snowball sampling, whereby professional contacts of the research team were enlisted to approach potential participants based on inclusion criteria. After receiving expressions of interest with consent-to-be-contacted, individuals were invited to participate based on workplace setting, duration of work, study program, and geographic location to capture a range of contexts. Invitation to participate was extended via the preferred contact method nominated by each individual (either text message, e-mail or phone call). If no response was received from an industry contact or potential participant within 14 days at any point during recruitment, participant selection continued. Recruitment was terminated when the research team reached consensus that sufficient richness of data had been gathered to satisfy the concept of “information power” (Malterud, Siersma, and Guassora, 2016) with respect to the specific research aims and pragmatic constraints (Braun and Clarke, 2021b; Sim, Saunders, Waterfield, and Kingstone, 2018):

• The sample was deemed to represent sufficient diversity of perspectives based on participant characteristics relevant to the topic (work setting, work duration, geographical location, university qualification type, university institution).

• Initial coding determined a richness of data was present in each aspect of the semi-structured framework.

• The cumulative amount of interview data (measured in words) reached the limit of researcher capacity to perform quality analysis methods with the given skillset and resources available.

Data collection

Interviews were arranged based on participant availability, with interviews for both participant groups conducted concurrently to enable triangulation of perspectives. Written and verbal consent was obtained from all participants prior to formal data collection. Digitally mediated audio communication (either telephone or Voice over Internet Protocol) was selected to access a geographically dispersed sample population and to optimize cost-effectiveness, flexibility and convenience for participants (Horrell, Stephens, and Breheny, 2015). Interviews were allowed to unfold organically in a predominantly participant-led manner, guided by the semi-structured interview framework which was executed at the discretion and judgment of the interviewing researcher (SW). No limits were placed on interview duration, which varied depending on participant factors (e.g. speed of speech, time required for thought, and extent of experiences on the topic and participant’s available time).

The semi-structured interview frameworks (Tables 1 and 2) implemented during interviews featured open-ended questions to encourage authentic narrative responses (Green and Thorogood, 2004, pp. 81–82) and were augmented with probing cues to elicit further detail where required (Braun and Clarke, 2019). These frameworks were developed by the research team in a collaborative iterative design process. Questions were formulated to address the specific research aims, with consideration given to ensuring questions facilitated discussion of new graduate experiences and practices across the continuum of Duchscher’s transition stages of “doing,” “being” and “knowing” (2008). Framework development culminated in piloting of interviews with a single new graduate physiotherapist and clinical supervisor – the outcomes of which informed amendments to the framework prior to commencement of formal interviews. Additional minor modifications to the framework were undertaken over the course of data collection (question phrasing and order), as a result of ongoing researcher reflexivity.

Table 1. Example new graduate physiotherapist interview questions.

Describe your work as a physiotherapist and the role of clinical documentation in your practice. What factors influence your clinical documentation practices? Please comment on changes in your documentation practices over time. Can you identify any barriers to engaging with clinical documentation? How prepared did you feel for clinical documentation upon commencing professional practice? What influenced your preparedness/understanding in this area? How were you supported to develop your skills? How could new graduate physiotherapists be best supported for clinical documentation?

Table 2. Example clinical supervisor interview questions.

Describe your involvement with new graduate physiotherapists and how they engage with clinical documentation in your workplace. What factors influence new graduate documentation practices? How do new graduates cope in this professional role? How prepared were new graduates for clinical documentation upon commencing work? What aspects were new graduates ready for/challenged by? What support or facilitation did new graduates need to engage in clinical documentation? How could new graduates be best supported for clinical documentation?

Interviews were recorded digitally and subsequently transcribed verbatim by the lead researcher (SW) in an orthographic manner. Transcripts were then edited to facilitate readability and clarity, omitting minor speech hesitations and repetitions, with care taken to ensure meaning was not altered. Any identifying details or remarks were also removed from transcripts, and all participants were given pseudonyms to ensure confidentiality and anonymity. Accompanying field notes summarized researcher insights during both the interview and transcription processes, facilitating reflexivity in the processes of data collection and thematic analysis.

Data analysis

Interview data were subjected to reflexive thematic analysis, led by the first author (SW) in collaboration with the research team. Reflexive thematic analysis methods emphasize the importance of acknowledging researcher perspectives (O’Brien et al., 2014); the research team consisted of academic and clinical staff who all possess physiotherapy qualifications and have worked as physiotherapists in Australia across a range of clinical contexts. The team has extensive combined experience in physiotherapy pedagogy, curriculum development, clinical supervision, and qualitative research (on topics of physiotherapy, pedagogy, learning and work readiness).

The six stage approach developed by Braun and Clarke (2006, 2019) involved: familiarization with data, generating initial codes, constructing themes and subthemes, revising and defining themes, and producing a coherent report of the findings. The lead researcher (SW) reviewed interview recordings and researcher journals repeatedly during the transcription process, to become thoroughly familiarized and sensitized to the data (Braun and Clarke, 2021a). Analysis commenced proceeding the initial interview and continued alongside subsequent interviews, using the software NVIVO™ (Version 12.7). Initial codes were generated inductively by identifying the semantic meanings of participant experiences and staying close to participant descriptions and self-identified understandings. Following initial coding, transcripts were reviewed again and latent coding was commenced to capture underlying meanings behind participant experiences. A combination of Duchscher’s (2008, 2009) transition theories and researcher knowledge were employed as sources of sense-making when considering possible causal mechanisms and underlying meanings. Data were further interrogated for latent or “deeper” contextual meaning through the process of grouping similar or related codes to form subthemes. These subthemes were subject to continuous comparison and differentiation as new codes were identified with ongoing interviews. This was a highly iterative process, where subthemes were collapsed or expanded in response contradictions or overlap within the data, and overarching themes were constructed and refined as analysis progressed. Relationships between themes and subthemes were also considered in perspective of the broader dataset and the theoretical framework of Duchscher’s transition theories (2008, 2009). Once theme development was finalized, the “story” of each theme was solidified during write-up of results, and a thematic map was generated to illustrate the relationships and interconnectivity of themes and subthemes

Results

A total of 16 new graduate interviews with a mean duration of 30 minutes 38 seconds (range: 23 minutes 18 seconds, to 40 minutes 24 seconds) and seven supervisor interviews with a mean duration of 31 minutes 59 seconds (range: 21 minutes 55 seconds, to 38 minutes 54 seconds) were conducted from April to July 2022. Participants represented a variety of work settings across different geographical regions of Australia, and new graduate participants represented entry-level physiotherapy qualifications attained from five separate tertiary institutions in Australia. Descriptive statistics of demographic information were generated using Microsoft® Excel (Version 16.62), outlined in Tables 3–5.

Table 3. Participant demographic information.

	New graduates (n = 16)	Supervisors (n = 7)
Age, mean years	24.44	-
Gender, n (%)
Female	9, 56.25	2, 28.57
Male	7, 43.75	5, 71.43
Discipline of practice, n (%)
Hospital	4, 25.00	2, 28.57
Private practice	6, 37.50	2, 28.57
Community healthcare	5, 31.25	2, 28.57
Mixed	1, 6.25	1, 14.23
Physiotherapy degree, n (%)		-
Bachelor entry	13, 81.25
Masters entry	3, 18.75
Work duration, mean years	1.13	8.43
Supervision duration, mean years	-	3.10

Table 4. New graduate participant details.

Subject Number	Age (years)	Gender	Discipline of practice	Time employed (months)	Location of work
NG1	25	Male	Private practice	17	Queensland
NG2	23	Female	Community healthcare	18	Queensland
NG3	22	Female	Hospital	6	Queensland
NG4	24	Female	Hospital	18	Queensland
NG5	21	Female	Community healthcare	6	Queensland
NG6	27	Male	Private practice	9	Australian Capital Territory
NG7	22	Female	Hospital	1.5	Queensland
NG8	26	Male	Private practice/hospital	7	Victoria
NG9	23	Female	Private practice	18	Queensland
NG10	23	Female	Community healthcare	18	Queensland
NG11	23	Female	Community healthcare	6	Queensland
NG12	32	Female	Community healthcare	18	Queensland
NG13	26	Male	Hospital	18	Queensland
NG14	27	Male	Private practice	19	Queensland
NG15	23	Male	Private practice	18	Queensland
NG16	24	Male	Private practice	19	Queensland

Table 5. Supervisor participant details.

Subject Number	Gender	Discipline of practice	Work duration (years)	Supervision duration (years)	Location of work
S1	Male	Private practice	3.5	1	Queensland
S2	Female	Community healthcare	10	3	New South Wales
S3	Male	Private practice	8.5	3	Queensland
S4	Female	Hospital	2.5	2	Queensland
S5	Female	Hospital	22	6	Queensland
S6	Female	Community healthcare	3.5	2.5	Queensland
S7	Female	Community healthcare/hospital	9	4	Queensland

Three overarching themes (Figure 1) were identified with respect to new graduate experiences of transition to practice clinical documentation: 1) variable preparedness for documentation, 2) documentation practices evolve with experience, and 3) workplace support is necessary irrespective of preparedness. These themes and additional subthemes are expanded below, with supporting quotations from participants. Quotations have been edited for brevity, with care taken to ensure meaning is not altered. Additional quotes are included in Table 6.

Figure 1. Thematic map illustrating themes and subthemes.

Table 6. Summary of themes and subthemes.

Themes and subthemes	Example quotes
Theme 1: Variable preparedness for documentation
Equipped with foundational skills	As long as you know the basics – subjective, objective treatment and then your plan – you can kind of improvise your way through it [documentation] until you find where you are going to work, then you can start focusing on what they want. (NG5) I think I was prepared to get by, but I wasn’t necessarily very fast or practiced with all aspects of documentation. (NG4)	In terms of documentation like note writing, I think they were competent with that. But [less so] with reports, and doing the little extra bits like a home program, a proper allied health assistance program, and writing AT applications. (S6)
Challenged by unfamiliarity and complexity	I do letters to the GP, which I probably felt, and I probably still feel a bit awkward writing… I am always a bit unsure about what I’m supposed to be writing. Just the details they want or how to phrase things. (NG3)	When graduates first start … there is a lack of preparedness for the range and variety and settings in which types of documentation need to be conducted from new graduates. (S1)
Theme 2: Documentation practices evolve over time
Finding their “written voice”	I have a look at what the previous physio has been doing … and you copy their style and try writing your own. (NG9) It was a bit daunting … you’re writing to a GP or an orthopeadic specialist, and think, “Oh my God, these guys are going to read what I write. I’ve gotta write it all properly.” (NG8)	Developing the skill of report writing… it’s finding that sweet spot with finessing the importance of each point. (S2)
Improving efficiency	It [documentation] was obviously very slow to begin with, because I didn’t know… yeah, I didn’t know what I was doing. (NG2) I’ll get people coming back in that I saw in my first few months of practice. And I’ll look at the notes I’ve written for them … (laughs) … they were hugely detailed to the point of being over detailed with information you didn’t really need. (NG1) I guess it [documentation] was probably one of the more time consuming things and obviously, it’s something that you get faster and more precise as you go. (NG12)	Too waffly … that would tend to be where a grad would go – just writing too much, going on to two pages and doctors just not wanting to read it. Just trying to get the bare essentials down, in as few words as you can, would be where a lot of the grads go wrong. (S3) A big part of working at the hospital was having to write a handover, and most every afternoon the new-grads struggled with knowing what information to put without regurgitating all the information … just picking out those important parts necessary for tomorrow’s physio. (S7)
Theme 3: Workplace support is necessary irrespective of preparedness
Opportunities to practice, reflect and refine	When you transition from student to clinician, you need to alter your practice slightly. I think supervision will be a part of it. (NG13) I guess it’s hard not knowing what we learned in uni … but identifying that gap in knowledge and contributing to filling it. ()	I think exposure, and then having mentors or supervisors to guide them through each unique [document]. (S2)
Protected time for documentation	That’s a real strength of my workplace, the fact that we do have that permanent thirty minutes in the morning and thirty in the arvo that is blocked out for [documentation]. (NG1) The workplace should pay for your time spent documenting. But if they’re not, then making it part of your consult. (NG16)	When first starting, the time pressures to write quick notes and not spend time on them is often seen … can be quite difficult, particularly when you’re first starting and you’re just trying to get up and running. (S3)
Templates and examples are highly valued	Video examples [of documentation] definitely helped me a lot. And just allowing new grads to be able to see other practitioner’s documents. (NG15)	It’s quite fortunate we use our electronic record, and so new grads are provided with pre-populated templates, which they just have to fill in the gaps. (S5)

Theme 1: variable preparedness for documentation

Equipped with the basics of documentation

New graduates and supervisors expressed a clear expectation that new graduate physiotherapists should enter the workplace with a baseline level of documentation skill, and likewise felt that new graduates were typically equipped to undertake the “basics” of documentation with relative autonomy. This was consistent in reports across all workplace settings represented by the participant population:

Generally, they [new graduates] know how to access the electronic record, get the information they require from that and know how to write a note, clinical note and that template.

(S5)

I think I had a general understanding [of clinical documentation]. And then I would just lean on the fact that I’d be able to review previous notes to check I’m doing the right thing.

(NG7)

Despite the almost universal acknowledgment that new graduates entered the workplace with foundational skills in documentation, there was some conflict and contradiction regarding how well these skills served new graduates when confronted with the realities of work. For some, new graduates were able to translate their pre-existing documentation skills into daily professional practice without great concern or difficulty. This was typical amongst participants who reported that the clinical documentation demands upon new graduates were relatively homogenous and straight-forwards (e.g. in-patient acute settings), or the documentation processes were already familiar to new graduates:

I find that they [new graduates] engage quite well, because it’s very structured. So once they get into the swing of things … they generally get an understanding of the expectation for documentation.

(S4)

Other participants indicated that the demands of documentation exceeded new graduates’ skills and capacity, with increased levels of concern about the implications of this. This was more commonly reported in contexts where participants described an increased variety of documentation required for daily clinical practice (e.g. in community, private practice, or rehabilitation in-patient settings):

I think the progress notes, that’s fine, but everything else was just thrown in the deep end and learn to swim.

(NG16)

When it comes to charting progress notes, for the most part graduates are aware and know their strengths and weaknesses in that domain. But when it comes to the more complex documentation, letters and communication, that’s where they don’t know what to do.

(S1)

These accounts of challenge and their meaning are further explored in the next subtheme.

Challenged by unfamiliarity and complexity

In almost all cases, participants expressed that new graduates were challenged when faced with unfamiliar documentation types, processes and/or purposes.

I think that documentation for outpatients was more challenging. Partly because they’re lengthier, but it was just a less practiced thing for me. (NG4)

Reporting was also a very new zone. … That has taken, I’d say probably up to a year for me to really grasp, “this is how I’m going to write it, this is how I’m going to present it”. (NG2)

Within an equipment report … even if they [new graduates] have done ten reports, if they haven’t done a trike yet, that’s really unique. And I think that’s kind of when they seek more guidance. (S2)

This was particularly evident for participants who noted difficulties managing the complexity and variety of clinical documents required in their new graduate practice. Sources of increased complexity were described as: managing documentation for multiple different funding sources simultaneously, managing documents for a single very specialized funding scheme, high levels and variety of stakeholder involvement, high degrees of clinical complexity or acuity, and/or large caseloads of clients.

I guess it’s hard because there’s just so many endless [documentation] options with all the different people you have to deal with and different groups. (NG12)

The ICU [intensive care unit] documentation was pretty complex … all the bits and pieces that you should be documenting and specifically how to document … so it’s about [new graduates] getting all those bits and pieces correct. (S7)

Obviously, with the [funding scheme] it’s quite a specific area, and the documentation is quite different from any other documentation. So it’s just the language that they [new graduates] used wasn’t always specific. (S6)

Participants discussed the importance of knowing the goal and audience of a clinical document, and noted that new graduates may struggle to engage with clinical documents appropriately if they lack understanding of context. Familiarity with clinical documents was similarly reported to influence whether a new graduate successfully prioritizes and implements a clinical document in the continuum of client care:

A lot of the time you need to document by writing a letter to a doctor, so they’ve got your view. I just think that sometimes grads often would not write a letter when one would be appropriate … a new-grad wouldn’t understand the networking.

(S3)

Theme 2: documentation practices evolve over time

Finding their ‘written voice’

New graduate participants described the journey of developing a documentation style that is reflective of individual preferences for writing and communicating. This was a deeply personal process, that was said to evolve over time. New graduates described an iterative process that began by emulating examples or colleagues, and that gradually their unique style or “voice” would emerge with incremental changes:

I think for new grads, you need to give them as much as you can to support them, and then allow them to, I guess, breach the restrictions and learn their own style.

(NG10)

We’ve got a template … so it was good in terms of knowing what to include, but then sort of putting your own your own spin on it and communicating in a way that you usually would.

(NG8)

Finding a genuine voice and an avenue for authentic written communication was considered central to the success of documentation outcomes, such as developing rapport and connection with stakeholders addressed in written communications. This was perceived as challenging for some new graduates, who expressed feeling confronted

Finding a way to build rapport with people you’re writing to … as a new-grad, that can be quite daunting and go, “Oh, man, this guy’s a big hotshot doctor and I’m a little new-grad physio.”

(NG6)

Improving efficiency

Participants emphatically and unanimously expressed that one of the most significant areas of change during the new graduate stages of transition was efficiency, with a strong emphasis placed on the desire to spend less time documenting to reduce workload:

The second challenge I had with my documentation as a grad was becoming efficient, because I spent so much time trying to do it … it ate into my day, and it made it harder to get through the caseload that I was expected to see.

(NG13)

Over time they [new graduates] learn how to be more succinct with their wording, and therefore get the same information across in a shorter space of time, shorter amount of words. And just knowing what the relevant information is.

(S7)

Despite this strong drive to improve efficiency, it was clear that new graduates continued to prioritize the importance of maintaining the integrity of clinical documentation processes and outcomes:

Definitely a lot faster with it [my documentation], and hopefully it’s more concise. But I still want to have that level of detail.

(NG12)

You’re given more time in the beginning as a new-grad, and you use that time to full extent. You want to get quicker, but you don’t want to lose the clinical reasoning in the process.

(NG2)

Theme 3: workplace support is necessary irrespective of preparedness

Opportunities to practice, reflect and refine skills

The opportunity to practice was considered fundamental to new graduates’ overall skill development in clinical documentation, with specific reference made to the importance of contextual learning through becoming exposed to and immersed in their new professional role:

Once they’ve been exposed to it, they understand the process. And if they have a chance to practice themselves as well, in a supportive environment, they then find their feet relatively quickly.

(S1)

Like with any skill, like the more you practice, the easier it will become. That I think has probably been the biggest help.

(NG11)

You’ve just got to figure out a way to make yourself the most efficient, which is probably through practice.

(NG9)

Equally critical was the ability to access supports in order to effectively reflect upon and thus refine documentation skills. Supports mentioned included learning resources (e.g. workplace specific training, templates, examples), formal clinical supervision, and informal access to colleague support on a frequent basis:

If I had a spare moment, I’d say, “Hey, do you mind having a look at this?” Or I would flick them the email first and say ‘is this okay?

(NG12)

There’s always someone that’s my go-to person to ask things. And then there’s always other people for me to ask too. … Someone might show me some examples, or just how to rephrase it differently, how I’ve written something.

(NG3)

Just having supervisors that are available … and initially having documents checked over. It’s like a little graded approach to slowly get them [new graduates] independent with their documentation.

(S6)

Accessing supports related to resources such as provision of time, examples and templates are further expanded upon in the following subthemes.

Protected time for documentation

Participants expressed strong views that clinical documentation requires dedicated time in a daily work schedule, and deemed this to be especially important during the transition to the workforce, where allocated time may be increased initially to allow for reflection and accommodate participant accounts of increased cognitive load associated with commencing professional practice:

When I first started I always needed that mental recovery after seeing someone, and I couldn’t just jump straight into charting it. But now that’s not really an issue, you just crack on and get going.

(NG1)

I believe that grads should be allocated time every day for documentation. Paid time for them to actually do documentation and letters. Because they’re quite stressed as it is on the workload. If the grad has enough time in their day, they will be more inclined to do it. [documentation]

(S3)

Participants also noted that creating protected, deliberate time for documentation was a key strategy to establish good documentation habits and build accountability in the new graduate workforce:

I think that by allocating time within their diary, it means they [new graduates] have to be accountable. We have provided that time to you, and therefore the responsibility is on you during that time period.

(S1)

With the hour of time that you get at the end of the day, you don’t feel pressured to get out of there … you’re not wasting your time and your money just sitting there - you’re getting paid for it. So you’re more inclined to do a better job.

(NG6)

Access to document templates and examples

Building an awareness of documentation processes was identified as an important strategy in fostering autonomous practice in this domain. Both new graduate and supervisor participants described that a preferred method of achieving this was through the use of templates and examples:

It’s always beneficial to have even just a checklist, especially when you’re rotating through the different areas, and they can be so vastly different.

(S7)

These examples and templates were not considered a strict proforma, but rather a guide to build consistency and increase engagement in unfamiliar areas of clinical documentation:

It’s not that everyone should be the same. But as a new-grad, you need consistency, you need something to follow.

(NG10)

The onus needs to go on them [new graduates]. But having clear examples would be quite important as a standard … particularly for different clinical areas, because they may not have worked in say, an orthopaedic ward.

(S4)

Templates were additionally acknowledged to have an influence on improving efficiency, and consequently reducing time burden associated with learning and executing documentation skills:

I’m deleting most of that template, just using what I need. But that saves me heaps of time.

(NG14)

Without the aid of examples and guidance in the case of unfamiliar or unpractised documentation, new graduate participants expressed they would feel under duress to produce documentation at an appropriate standard:

If the workplace tells you, “Hey, you’ve got to write a GP letter,” and they don’t tell you what you’ve got to write as a new graduate… you’d freak out, and then spend so much time trying to draft it. And then you’re not too sure if you’re bringing out the correct information … I would probably panic a bit if there’s no guidelines or examples.

(NG9)

Discussion

New graduates physiotherapists’ experiences of transitioning to practice of clinical documentation are variable, seemingly shaped by the intersection between individual circumstances, the level of documentation familiarity, the degree of complexity encountered, and the presence of supports to overcome challenges during their stages of transition. This is consistent with previous research by Stoikov et al. (2022), whose findings suggested that new graduate physiotherapists may experience challenges related to their transition from student to graduate, including changes in caseload volume or complexity, increased independence and realizing gaps in knowledge. Participant accounts in this study also highlighted the importance of ongoing skill development in clinical documentation practices, where new graduates and supervisors both valued opportunities to develop a new graduate’s ’written voice’ and build their confidence with developing documentation practices to meet professional demands. Black et al. (2010) identified key concepts for novice physiotherapist development that mirror those voiced by participants in this study, with specific reference to learning through experience, fostering confidence and developing professional identity. The first two years in the workforce have been recognized as a critical period for learning and skill acquisition (Chipchase, Williams, and Robertson, 2008; Hayward et al., 2013), and thus consideration should be given to fostering clinical documentation skill development and resilience in new graduates as they transition into their professional roles (Stoikov et al., 2022).

The results of this study have highlighted the perceived value of implementing strategies to support new graduates in the area of clinical documentation, including: access to resources (e.g. documentation examples or templates), protected time for documentation, and opportunities to reflect and refine documentation (e.g. under the guidance of mentors and supervisors). Reflection and self-directed learning are crucial to skill development (Murad et al., 2010) and may enhance the transition from student to new graduate through supporting development of their professional skills (Donaghy and Morss, 2007). This sentiment is echoed by the participants in this study, who placed high value on practice, reflection and refinement of documentation skills. To create an environment conducive to such new graduate development (Morrow, 2009), clear and comprehensive expectations around clinical documentation should be provided upon orientation to a new role, in addition to ensuring new graduates have sufficient exposure and understanding of documentation processes required. This is especially crucial in light of the challenges new graduates may face with unfamiliarity and complexity in different work settings. Strategies such as these may assist new graduates to transition into practice of clinical documentation and could be considered by health services given the importance of safe and effective clinical documentation (PBA and PBNZ, 2015).

These findings may have further implications for supporting new graduate physiotherapist transition to practice through integration of established theoretical and practical approaches. The Reporter-Investigator-Manager-Educator (RIME) scheme is a framework for understanding how a learner progresses through medical education in a staged manner (Pangaro, 1999). Subsequent research investigated the RIME scheme as a framework for teaching and evaluating documentation skills in graduate medical education (Stephens, Gimbel, and Pangaro, 2011), and found the framework useful for structuring expectations around documentation skills and guiding the stages at which these skills are introduced to graduate learners. This may be a useful theoretical framework to guide development of physiotherapy new graduate support programs in the area of clinical documentation, given that the new graduate is understood to transition through a period of continued learning upon entering the workforce (Chipchase, Williams, and Robertson, 2008; Duchscher, 2009). Structured new graduate support programs have previously demonstrated merit in facilitating transition to clinical practice within the physiotherapy (Chipchase et al., 2022) and nursing professions (Kenny et al, 2021; Rush et al., 2019). Further research would thus provide insight into the effectiveness of integrating these theoretic and practical approaches in context of supporting new graduate physiotherapists in their transition to clinical documentation.

The perception of variable preparedness for documentation upon new graduates’ transition to work was a key theme generated from the data. Results also demonstrated that irrespective of preparedness, new graduates will still engage in a period of critical learning to evolve their documentation practices and find their “written voice”. Similar to research in medicine graduates (Kilminster, Zukas, Quinton, and Roberts, 2011), our results emphasize that individual preparedness is only part of the picture, with the practice of documentation situated at the junction between the new graduate, the work and the setting-specific factors. The interdependence of these factors suggests that new graduates would, in theory, never be entirely prepared for transition to professional practice of documentation. Despite this, the importance of ensuring new graduates enter the workplace sufficiently skilled to practice clinical documentation according to medicolegal and professional requirements (PBA and PBNZ, 2015) should not be downplayed. In light of reports from participants that new graduates may not be appropriately prepared for documentation, it is recommended that further research be conducted to evaluate objective measures of documentation skill in new graduates. It is also recommended that pre-professional training receive attention in future research, with a focus on barriers and facilitators to preparing new graduates for successful transition to dynamic and complex practice of clinical documentation.

A key strength of this project was the diversity of physiotherapy workplace settings represented by participants in both new graduate and supervisor groups. This allowed for a rich data-set that enabled conclusions to be drawn around similarities and differences in experiences amongst clinical settings. Another strength of the research was the wide distribution of new graduate physiotherapists along the continuum of the two year critical learning period (Chipchase, Williams, and Robertson, 2008) thus allowing meaning to be constructed within context of Duchscher’s stages of transition theory (2008, 2009).

Limitations of the study must also be considered. Whilst efforts were taken to ensure participants were geographically distributed across Australia, due to the nature of snowball sampling, majority of participants in both new graduate and supervisor groups were based in the Australian state of Queensland. This may affect generalizability of findings to other regions of Australia where different social or professional contexts may apply. The same limitation holds true for generalizability of results to countries and regions other than Australia; whilst physiotherapy is a globally recognized profession (WCPT, 2019) and the guidelines for clinical documentation in Australia are closely aligned with international recommendations for practice of documentation in physiotherapy (WCPT, 2011), critical realism emphasizes the importance of context and perspective in generating meaning, thus limiting the ability to generalize conclusions from this research to different cultural and social settings without careful consideration or corroboration from other research projects.

Participants who had polarizing experiences with their transition to work may have declined to participate or have left the physiotherapy profession, resulting in a data sample that does not fully capture the target population. Lastly, as the study explored only perceived experiences of new graduate physiotherapist practices, we are unable to report actual clinical behaviors of new graduates, or the quality of their documentation practices.

Conclusion

Clinical documentation is fundamental to physiotherapy professional practice and is a clinical competency required for entry-level practice. This study indicates that new graduate physiotherapists enter the workforce with variable preparedness in practice of clinical documentation; despite possessing baseline skills, they may be challenged by inexperience, unfamiliar settings and clinical complexity. New graduate physiotherapists’ documentation skills continue to develop after commencing professional practice, and the study findings highlight the importance of workplace supports to ensure safe and effective practice in addition to enhancing skill development.

Acknowledgments

The authors would like to acknowledge the new graduate physiotherapists and clinical supervisors who participated within the study.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

Ms Sarah Wilesmith is supported by a PhD stipend from the Australian Government Research Training Program.