Table 1. Public hospitals in Singapore 

At the beginning of 2022, Singapore had 165 physiotherapists under conditional registration, with 97 (59.51%) employed by public hospitals (Allied Health Professions Council, 2022). Novice Physiotherapists (NPTs) require close supervision and guidance from their clinical mentors/supervisors. During their initial phase, all NPTs undergo a 13-month conditional registration before qualifying for a full registration status. With an average 200 PT students graduate from the Singapore Institute of Technology each year, coupled with the NPTs under conditional registration, the supervisory tasks shared by the limited pool of PT Supervisors are tremendous. Besides their supervisory roles, PT supervisors are also clinically responsible to managing patients and workplace administrations. 

A recent study conducted in Singapore explored the perspectives of allied health practitioners, including physiotherapists, occupational therapists, and radiographers, regarding clinical supervision in tertiary hospitals (Lim et al., 2022). The findings revealed that newly qualified allied health practitioners often faced challenges related to insufficient clinical supervision, emotional support, and professional guidance from their supervisors. Contributing factors included time constraints and staffing limitations (Lim et al., 2022). These findings underscore the need for a deeper understanding of the experiences encountered by NPTs during their early clinical practice. 

Despite the significance of this issue, no further research has specifically explored the clinical experiences of NPTs in Singapore. Among NPTs, those working in acute public hospitals constitute a compelling subgroup, representing 59.51% of the NPT workforce. Additionally, acute public hospitals provide multidisciplinary services, making them ideal settings for studying the challenges faced by NPTs. Therefore, this study aims to delve into the experiences of NPTs within Singapore’s acute public hospitals. 

II. METHODS

A. Study Design

The study employed a descriptive phenomenological approach to understand participants’ lived experiences (Neubauer et al., 2019). In this approach, researchers intentionally set aside their preconceptions and assumptions in this method, allowing the data to speak for itself (Shorey & Ng, 2022). Giorgi (1997) highlights that descriptive phenomenology is particularly well-suited for phenomena that lack extensive literature evidence. Given the limited research on NPTs’ transitional experiences in Singapore, adopting descriptive phenomenology is appropriate for this study. 

B. Ethical Considerations

Ethical approval was obtained from the University Institutional Review Board (Approval number: 2022033). The participant information sheet was emailed to prospective participants for recruitment. Written informed consent was obtained. All researchers had no authoritative relations with the participants. Participants were assured that their participation was anonymous and voluntary. 

C. Participant Recruitment 

Adopting a convenient and snowballing sampling approach, the researchers approached NPTs and sought referrals for further recruitment. The inclusion criteria were: (1) NPTs who had less than two years of clinical practice after graduation; (2) NPTs who were working in acute public hospitals. The exclusion criteria were: (1) NPTs who had prior working experience in healthcare; (2) NPTs who were not working in acute public hospitals.  

The recruitment email sought voluntary return of information such as place of practice, date of employment, alma mater, and previous work experience in healthcare. A follow-up email was sent to arrange for the online semi-structured interview. Eight participants from six acute public hospitals were included in the study.

D. Data Collection

Data were collected by researchers NK, JL and TL, who were final-year physiotherapy students. The interview guide was developed based on the literature review and validated by MC and MY, both are experienced in clinical supervision. The researchers conducted pilot interviews to test the interview guide and their approaches. The interview guide is presented in Appendix 1. 

With the semi-structured approach, the researchers had the flexibility to follow up on questions. Open-ended questions were used to mitigate the potential issues of over-leading the discussion (Green & Thorogood, 2018). MC provided feedback to NK, JL and TL after each interview. The researchers kept a reflexive journal to record their thoughts, feelings, knowledge and perceptions of the research process (Chan et al., 2013).  

Interviews were conducted between July and November 2022 over Zoom. The interview recordings were transcribed. The research team reviewed the video recordings and the aspects needed to follow up with the next interview (Ryan et al., 2009). Data saturation was reached by the fifth interview. Three more interviews were done to ensure no new findings. Each interview lasted between 33 to 110 minutes, with a mean duration of 77 minutes.

E. Data Analysis

The data were analysed using an inductive approach with no predetermined structure, framework, or theory simultaneously with data collection (Burnard et al., 2008). The four stages include decontextualisation, recontextualisation, categorisation, and compilation (Bengtsson, 2016) as shown in Figure 1.

Figure 1. Data analysis process (Adapted from Bengtsson, 2016)

Figure 2. An example of the analysis process

These themes are supported by subthemes depicting the multiple dimensions of challenges and NPTs’ coping strategies.  

A. Challenges from Multiple Aspects

This theme is supported by four sub-themes, indicating NPTs encountered challenges from many aspects of their practice context.  

1) Challenges in getting guidance from the supervisors: NPTs reported that they were scheduled to manage patients independently soon after their orientation, often at a different location from their supervisors. Working in different locations to manage different groups of patients posed difficulties for NPTs to learn from their supervisors. Even if the clinics were nearby, their supervisors had to stop their clinics temporarily to guide the NPTs, which caused the accumulation of patients on the waiting list and prolonged clinical hours. Knowing this would happen, NPTs were reluctant to consult their supervisors.

Furthermore, NPTs might not be familiar with the patient’s medical conditions, posing challenges for them to ask questions. Some of them had been ridiculed for asking questions deemed “inappropriate”. For example, the supervisor might pass a remark such as “This kind of question you also ask!” or the supervisor ignores their questions. As a result, NPTs felt they were left alone to struggle with the feeling of inadequacy and anxiety.

2) Challenges from the pace and nature of the work: NPTs operated within a tight timeframe, similar to the experienced colleagues’ schedule, with only 20 minutes allocated for each patient. This brevity limited their ability to build rapport with patients and to discuss treatment options. The rapid succession of patients, where one consultation immediately followed another, left NPTs mentally exhausted and hindered effective patient management.

Meanwhile, NPTs were required to record their consultations with patients promptly. However, unfamiliarity with the items on the documentation often led to incomplete records. The accumulation of unfinished document recordings throughout the day left NPTs with a backlog to address during their shifts. By the end of the day, recalling specific patient details became challenging.

Additionally, NPTs as the “gatekeepers”, must assess patients’ fitness for discharge. Balancing medical guidelines, patient readiness and family expectations are delicate. NPTs occasionally found themselves at odds with doctors’ decisions when they believed a patient’s condition was not ready for discharge. This stance can lead to stress and feelings of being disregarded. NPT Hotel shared:

“We do have our reasoning and know why we do certain things. So sometimes it is frustrating when you bring it across for the doctor, and they don’t take you seriously.”

3) Challenges from patients: Many patients, particularly the elderly, communicate primarily in dialects in Singapore. For NPTs who are educated in English, understanding these dialects could be akin to deciphering a foreign language, hindering accurate assessment and treatment planning. This challenge creates another layer of stress for NPTs to understand the patients and tailor the interventions. Understandably patients’ outcomes were not always predictable. However, NPTs could be blamed when patients experience setbacks after discharge. The weight of unjust accusations took a toll on NPTs’ mental well-being. NPT Charlie shared such an encounter:

“I assessed the patient, and he met all the outcome measures for discharge. The day he went home, he fell! The patient’s family was angry and made a complaint. It wasn’t my fault. He didn’t take his medication, and he is suffering from Parkinson’s Disease…it is a very mentally taxing job…You know, when I called the family, they yelled at me… it is emotionally draining…”

4) Fear and self-doubt: NPTs realised that their knowledge was but a drop in the vast ocean of medical expertise and they started to question their abilities. Each patient encounter became a tightrope walk – a delicate balance between thoroughness and efficiency. Fearing they might miss crucial details, NPTs reported to work early and pored over each patient’s medical record to prepare themselves. Yet, despite their diligence, inadequacy gnawed at their confidence.

Practicing under a conditional license, the aim to achieve competence is like a ticking clock, NPTs must prove their worth within a limited timeframe. The fear of failure loomed large and each misstep felt like a step toward the abyss. NPT Golf shared his feeling of inadequacy:

“You take a long time to read the patient’s medical record to screen them, much slower than your seniors, but you will still miss out important things… you see each patient a bit longer…you spend longer time on documentation (recording), then you have many days with extended working hours…”

B. Finding ways to cope

NPTs adopted various approaches to cope with their work demand, some of the methods helped while some were not so.

1) Be intentional and responsible in learning: Recognising the limitations of case scenario-based classroom learning, some NPTs proactively learn through their daily work. NPT Golf shared the importance of such learning:

“Discharge planning and prognostication required a lot of clinical reasoning, which is very difficult to teach in a lecture. You have to see the real patient to know their background and the cause of the condition and to discuss with the patient their rehab potential.”

NPTs learned to present their clinical reasoning when asked questions, to show that they were proactive in learning. Some NPTs maintained a question log throughout the day and negotiated a dedicated time slot to consult their supervisors after work. Another strategy was to review the next day’s patient list, anticipate difficulties they might encounter, and seek opportunities to see the selected patients with supervisors. With this arrangement, NPTs can learn on the job and get immediate feedback.

2) Focusing on knowing the patient and managing time: NPTs acknowledged that patient care extends beyond physical assessment. They delved into patients’ medical records to know the medications the patient is on, their side effects, and the underlying conditions. By meticulously assessing patients, NPTs gained a holistic understanding of their health status. This knowledge informs treatment decisions and ensures patient safety. Delta’s example underscores this approach:

“Knowing a patient’s medication regimen and potential side effects allows us to anticipate complications. For instance, abdominal bloating from a specific medication may impact diaphragm movement, leading to patient agitation.”

Meanwhile, NPTs recognised the pivotal role of families in patient care. They actively sought input from family members to understand cultural nuances and contextual factors. As each patient comes with unique physical limitations and emotional stressors, understanding patients’ goals, fears, and preferences is paramount. Beta emphasises:

“Our sessions aren’t solely about treatments. We invest time in understanding patients’ problems and engaging them and their families in meaningful conversations…most of the time I focus on knowing them and learning how to engage them…(know) what matters to them.”

NPTs recognise that time is a precious resource. They make deliberate choices to maximise their time at work. For example, they shorten their lunch breaks to catch up with workload demands. They took quick notes or used visual reminders (such as photographs) to aid memory in recording. NPTs also learned to quickly jot down relevant details before the next patient consultation to ensure the accuracy of document recording and continuity of care.

3) Emotional resilience and emotional apathy: NPTs need to go through a series of skills competency assessments. When faced with assessment failure, being resilient is helpful. Delta explained:

“I think a good mindset would be to ask myself ‘Why did I fail this competency (assessment)? Was it because I did not maintain sterility? Did I do something wrong?’…the next time I will remember to correct my mistakes…then I realised that ‘oh, it (failure) doesn’t matter. I can learn and do (it) again…”

Some, like NPT Foxtrot, experience sadness and grief when the patients they care for deteriorate and die. To maintain emotional resilience, NPTs used strategies such as “letting go”, “emotional detachment” and “getting enough sleep” to avoid intense emotions. They also get support from peers, friends, and family.

However, some NPTs worried about the loss of enthusiasm and became too detached emotionally by “seeing every patient as a condition or a case” and transformed patient encounters into mechanical routines. They called it “emotional apathy” or “turned off”.  

IV. DISCUSSION

This study is the first to explore the experiences of newly graduated physiotherapists (NPTs) during their initial two years of clinical practice in Singapore. The findings indicate that NPTs encounter several challenges during this transition, such as obtaining adequate guidance from supervisors, managing patients with complex conditions, and coping with demanding workloads. These findings align with existing literature evidence, suggesting that the challenges faced by NPTs in Singapore are comparable to those encountered in other countries. 

Furthermore, this research provides a nuanced understanding of the factors contributing to NPTs’ transitional challenges. Workplace learning can be difficult due to tight schedules, and multiple members in the process with various roles and responsibilities. According to Billett et al. (2018), the workplace is the most authentic learning place and workplace learning has to be intentional. Firstly, there is a need to set up the curriculum. This happens only when learning is viewed as an integral part of work where the use of knowledge, roles, and processes are continuously negotiated. Therefore, NPTs, their supervisors, and coworkers need to discuss learning opportunities along the pathways of work to plan activities that augment learning.  

Secondly, there is a need to enable effective learning facilitated by experts within the workplace. This means the workplace is a learning community where all members share a common purpose and are willing to help one another learn. The responsibility of teaching and guiding the NPTs are shared responsibilities, members can take part in teaching in their expertise.  

Thirdly, there is a need to consider individual factors and construct learning according to what learners know, can do and value. For this to happen, clinical experts, such as supervisors and senior members need to have conversations with the NPTs to help them identify learning needs, as NPTs sometimes do not know what they do not know.  

However, revealing one’s learning needs can leave one feeling vulnerable; thus, trust relationships and psychological safety are crucial in the workplace. Sellberg et al. (2022) suggested that supervisors can initiate meetings to get to know NPTs and share their own learning experiences as novices. NPTs need to feel safe to share what they know, can do, and need to learn. 

Initial placement of NPTs in the same clinic with their supervisors can foster relationships, confidence, and learning. Several clinical supervision strategies, including understanding clinical situations, aligning learning objectives with roles, discussing goals with learners, and actively observing and debriefing learners (Hinkle et al., 2017), can be recommended to NPTs’ supervisors and senior members in the community. Additionally, dedicated time for supervisors and NPTs to discuss and reflect on work and learning, or even engage in social activities, can help boost relationships. 

Clinical supervisors should be carefully selected and trained in supervision skills. A research study suggested that they should be knowledgeable, good communicators, approachable, interested in building relationships with learners, and capable of providing feedback and tailored guidance (Alexanders et al., 2020). A meta-analysis by Nienaber et al. (2015) suggests that supervisor attributes, subordinate attributes, interpersonal processes, and organisational characteristics influence relationship building. Therefore, efforts for relationship building should not only be at the individual level but also the organisational level. Organisations can provide targeted training to supervisors to empower them with the knowledge and skills to mentor NPTs. 

This study also highlights the dilemma NPTs face between the fear of making mistakes and the responsibility of learning. Such fear is not unique to NPTs as studies suggest novice nurses also report similar anxieties during the transition (Cowen et al., 2016; Ten Hoeve et al., 2018). Singapore studies on novice nurses (Chen et al., 2021) and nursing students (Leong & Crossman, 2016) highlighted similar fear, as making mistakes in healthcare is taboo. In their effort to avoid mistakes, NPTs adopt a “safe” approach and avoid opportunities that could significantly enhance their competence and abilities.

Fear of failure limits learning, while comprehensive learning requires a degree of autonomy and the safety to make mistakes. There is a need to change attitudes towards “safe” mistakes. Harteis et al. (2008) suggested that allowing workers to learn from mistakes at work can maximise learning and cooperativeness. Eskreis-Winkler and Fishbach (2019) reviewed five studies on learning from failure, emphasising that effective learning happens from the feedback of mistakes and such feedback must separate failure from personal judgment. Creating a psychologically safe learning environment, where learners feel safe to ask questions and learn from mistakes, is essential (Edmondson, 2023). 

NPTs also faced challenges in their interactions with other healthcare professionals and patients. Patton et al. (2018) highlighted that the clinical setting is a multidimensional learning space where environmental factors, the nature of the work, and member interactions shape clinical learning. Hence educators at higher learning institutes can design learning using role play by engaging students, clinical supervisors, other healthcare professionals, and standardised patients to learn different roles and perspectives.  

This study is the first to explore the transitional experiences of newly graduated physiotherapists (NPTs) in Singapore. It is important to note that NPTs from community and private settings were not represented. Future research should investigate the transitional experiences of NPTs in tertiary and community care settings to provide a more comprehensive understanding. 

This study highlighted several critical aspects of NPTs’ transition, including fear, emotional apathy, intention in learning, and relationship building with supervisors and patients. However, these areas warrant further exploration to deepen our understanding. Additionally, incorporating the perspectives of clinical supervisors could complement the current findings in facilitating NPTs’ learning in transition. 

V. CONCLUSION

This study provides a nuanced understanding of the challenges encountered by newly graduated physiotherapists (NPTs) and their coping strategies during their transition. The findings underscore the necessity for a well-structured clinical supervision setting, a safe learning environment, well-trained clinical supervisors, an emotional support framework for NPTs and clinical roleplay training in schools. It is also crucial to cultivate NPTs’ abilities to learn and to develop meaningful relationships with supervisors and patients. 

Notes on Contributors

Author MC provided research conceptualisation and methodology guidance, performed data analysis, validated findings and wrote the manuscript. Author MY provided methodology guidance, validated findings and provided feedback to the writing of the manuscript. Author NK, JL and TL reviewed the literature, developed the methodological framework for the study, and performed data collection and data analysis as their final-year project. All authors have read and agreed to the published version of the manuscript. 

Ethical Approval

The study was approved by the Singapore Institute of Technology Ethics Committee (Project 2022033). 

Data Availability

The data that support the findings of this study are available at https://figshare.com/s/4f1ecf288001750e72 e4 

Acknowledgment

The authors thank the physiotherapists who participated in the study. 

Funding

This study received no funding. 

Declaration of Interest

The authors do not have any conflicts of interest. Participation in the research was voluntary and anonymous. Novice Physiotherapists were assured that their participation or nonparticipation would not affect their work performance appraisal.

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*Mary Xiaorong Chen
10 Dover Drive
Singapore 138680
Email: Mary.chen@singaporetech.edu.sg