Preparing Pharmacy Educators as Expedition Guides to Support Professional Identity Formation in Pharmacy Education

Embracing the Expedition

Professional identity formation is critical to supporting practice transformation and is being established as a goal of modern health professions education.¹ Medical education has defined professional identity as “a representation of self, achieved in stages over time during which the characteristics, values, and norms of the medical profession are internalized, resulting in an individual thinking, acting, and feeling like a physician.”² However, another description, less specific to physician training, was provided in a report by Cooke and colleagues as a “moral and ethical core of service and responsibility around which habits of mind and practice could be organized.”¹ In their 2010 description of the need for reform of medical education, Cooke and colleagues explained how the development of professional values and aspirations supports affective educational goals of performance excellence, accountability, humanism, and altruism. In concert with other leaders in health care education reform, they called for professional curricula to integrate the cognitive and moral aspects of practice, as students are challenged with developing both technical competence and deeply ingrained moral responsibility.^1,3 Monrouxe further suggested it is essential for students to develop and embrace a professional identity during their training, as this allows for internal professional regulation, supporting educational goals of self-directed, lifelong learning.⁴

There are additional benefits to a focus on identity. Pharmacists today face a professional imperative to address challenges in the health care system through practice transformation. A programmatic focus on professional identity can help students envision the scope and nature of pharmacists’ work as including the ability to influence necessary change. A strong professional identity helps students to confidently explain, present, and conduct themselves and collaborate interprofessionally⁵ as they continue to advocate for expanded roles for pharmacists. Nonetheless, a decision by members of the American Association of Colleges of Pharmacy (AACP) to intentionally support professional identity formation^6,7 comes with challenges and questions. Why should professional identity formation be a priority in teaching? Are educators prepared to guide and support students in their professional identity formation journey? What do educators need to know about the process of professional identity formation? What actions should educators take with individual learners? How do educators better understand the progress students are making?

The purpose of this paper is to provide an educator-friendly guide to “getting started with professional identity formation” to bolster support for professional identity formation within the Academy. Specifically, this paper introduces professional identity formation examples, theories, and definitions to begin preparing educators to serve as tour guides for Doctor of Pharmacy (PharmD) students on their professional identity formation journeys. As authors, we envision students’ development of professional identity as a journey of self-discovery and employ a “traveling” metaphor to aid readers in relating to the challenges and complexities inherent to this lifelong journey. We encourage educators to explore and adapt these approaches while planning their own students’ professional identity formation excursions. Nonetheless, it is important to remember there is no single, clear path to professional identity formation, and some road bumps and diversions requiring redirection along the way should be expected.

Embarking on a Continuous Journey

Supporting the transformation of a layperson into an individual who can “think, act, and feel” like a pharmacist² is a challenging and complex task requiring repeated, diverse, and intentional pedagogical approaches throughout training and professional practice. This professionalization is a dynamic, lifelong, social, and educational process shaped through formal and informal interactions, experiences, and relationships with others.^8,9 All educators, administrators, preceptors, and student services professionals contribute to professional identity formation, positively or negatively, knowingly, or otherwise, through attitudes, expectations, interactions, and activities throughout the curriculum and cocurriculum.¹⁰

There are many student, educator, and environmental conditions to consider when implementing and refining feasible, sustainable, and high-impact approaches to deliberately support student professional identity formation in ways that fit an institution’s culture and mission. Educators are encouraged, over time, to find traveling companions who bring creativity, curiosity, adaptability, and responsiveness to expand and enhance work in this area. While partners, teamwork, and professional identity formation–focused curricular approaches are goals, individual educators can begin with initial, small-scale efforts to make progress on the path toward larger milestones. Though some may argue that professionalization occurs naturally within modern pharmacy curricula, careful planning, including choice of companions and route, increases the likelihood of meaningful and enjoyable progression toward professional identity formation for travelers.

Traveling With Purpose

Despite a widespread emphasis in pharmacy curricula on teaching professionalism guided by Standards 2016,¹¹ Hammer and colleagues have expressed concern “that acting professionally is not the same as being a professional.”¹² Though educators use a variety of assessment tools to “check-off” professionalism competencies, students may fail to internally adopt the values, commitments, and dispositions of the profession. Intentional and widespread curricular emphasis on professional identity formation as a purposeful extension of professionalism training may serve to help students internalize desired characteristics and traits as they adapt to the role of pharmacist and solidify their professional identity.^1,13

Identity can be described as the way in which one is defined by oneself and others.¹⁴ In order to make sense of their own personal situations, individuals construct and modify identities by drawing on, engaging with, and accepting community norms and practices.¹⁴ Identity formation is a complex, longitudinal interplay between the individual and others in their social network and, in part, with the roles one is expected or allowed to take. Personal identity formation is initiated during childhood and continues throughout adulthood as interactions with family and friends, educational culture and environment, societal expectations, and feedback from others stimulate change.^2,9,15 According to the multiple dimensions of identity theory, several identity components may be developing concurrently within the same individual, as they engage in multiple communities specific to their, for example, profession, hobbies, religion, and sexual orientation.¹⁶ Similarly, developing a professional identity involves social interactions but also involves reflecting and acting on feedback as one’s roles and responsibilities within the professional community evolve (Figure 1). Cruess and colleagues have suggested that the professional identity must be compatible and coexist with personal identities for each to be strong. The strength and compatibility of these many and diverse identities are critical to personal and professional well-being.²

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Figure 1.

Description of Key Elements of Professional Identity Formation During Pharmacy Education^a

^a Schematic inspired by Cruess. Cruess, Boudreau, Snell & Steinert (2015) and Cruess & Cruess (2019).^b The term educator refers to all individuals who influence identity formation of the learner across various disciplines and settings.^c Other models/theories of personal identity development (eg, self-authorship theory, self-determination theory) can also be adopted.^d The professional identity formation process continues past graduation or licensure as a pharmacist.

Jarvis-Selinger and colleagues propose that identity progression is precipitated by a “crisis” that requires change or growth as a response.¹⁵ This crisis can be thought of as a stressful event that precipitates learning and adaptation as a stress response. Physicians have long considered their first cadaver encounter and first patient death as milestone experiences and powerful opportunities for reflective growth shared by all physicians.² However, other types of seemingly insignificant crises, such as being called upon to answer questions in class or administering an intramuscular injection to a patient, can also present potential opportunities for professional identity formation.¹⁷ How well an individual navigates these crises determines, in part, the influence of that experience on the individual’s identity.

The identification or manufacture of suitable “academic crises” will, therefore, be a critically important role for educators, who are specifically responsible for managing the learning environment in ways that optimize the likelihood that learning will occur. Rudland and colleagues suggested that health professions educators can best support students’ learning journey by managing the type and number of stressors experienced by students.¹⁷ For example, educators should strive to avoid intentionally distressing events or environments that can hinder engagement, learning, and growth. To some extent, we do this by managing course loads and examination schedules, providing strong student services and counseling support, and role-modeling positive social norms and behaviors. However, distinct from distress, eustress is thought to support positive outcomes for learners and may have similar implications for identity formation.¹⁷ Eustress is a beneficial form of stress that optimizes attention, motivation, and performance; in essence, it is stress created by a challenge considered achievable. For example, a clinical educator could scaffold a learning experience to provide supervised autonomy, when appropriate, for the student pharmacist to lead clinical encounters with patients or other health care providers. Students may experience some stress given the instructor’s expectations of leadership, but learning often occurs in response to such circumstances, so long as the learner interprets the situation as a challenge and not a threat.¹⁷ Educators can aid students in interpreting and responding to these challenges in beneficial ways such that these provocative learning “crises” can enhance confidence and advance student professional identity formation. Ideally, pharmacy educators will find ways to create authentic situations that force students to think like a pharmacist and act like a pharmacist with the intent of leading students to feel like a pharmacist.

Consulting Guidebooks

As the foundation for evidence-based scholarly teaching, health professions educators are often asked to use theory, which, by definition, provides “a description of the relationships between concepts that help us to understand the world.”¹⁸ Theories can act as a lens, providing clarity and perspective when designing interventions and interpreting outcomes.¹⁹ Because theory can be dense and difficult to decipher, educators sometimes resort to incorporating theory only during the manuscript development stages of a scholarly project. However, explicit use of professional identity formation–related theories in the early stages of instructional design can increase efficiency by providing direction and focus, which, in turn, can increase the coherence, depth, validity, intentionality, and effectiveness of learning activities.^9,18,19

Noble and colleagues reviewed the extrapolation of personal identity formation theories to professional identity formation by researchers in pharmacy, nursing, and medical education.²⁰ Many identity theories exist in harmony with one another with each seeking to understand some particular or unique aspect of identity formation or cohesion. As a result, one particular theory cannot be universally recommended over another. Rather, educators wishing to engage in professional identity formation pedagogy should develop a theoretical framework that logically melds the concepts and premises from one or more theories to structure professional identity formation initiatives.¹⁸ The paragraphs that follow summarize several theories that educators may find helpful in designing excursions for student travelers. Considering the apparent convergence between existing theories previously applied to health professions education and newly emerging explorations,²¹ educators can emphasize application of existing theories of identity formation rather than prioritizing the discovery or development of novel approaches.

These theories are not mutually exclusive, and many describe different aspects or perspectives on similar and interrelated concepts. For example, the communities of practice²² model and social identity theory²³ both describe how individuals slowly integrate into a group by participating in the group’s activities and rely on feedback from the group to influence their identity as a member of that group (Table 1). Intuitive and well-established, the communities of practice model is already widely applied to health professions education. Likely to be understood by many students and educators, communities of practice offers a sound and relatable description of the mechanisms by which curricular, cocurricular, and experiential education activities lead to the adoption of identity. Thus, some experts advocate for exclusive and widespread adoption of the communities of practice model in health professions education.⁹

However, other established theories of identity formation are equally compelling and offer some advantages over communities of practice, which is a system-focused description of socialization of individuals into a group (Table 2). Self-authorship theory,²⁴ for example, is a more holistic and person-centered theory describing an individual’s advancement through four distinct phases of identity maturity, potentially leading to opportunities to assess student progression over time.²⁵ While the possibility of identity formation assessment is attractive to many educators and administrators, self-authorship theory’s strongest value may be its focus on pivotal “provocative moments” (similar to “crises” described above). Additionally, Baxter-Magolda has provided strong pedagogical support for the development of self-authorship through the learning partnerships model,²⁴ which offers explicit guidance to educators seeking to design learning experiences that can potentially generate provocative moments for students (Table 2). These conditions and requirements can be used by educators as guidelines for manufacturing of the kinds of crises and learning experiences that route travelers just far enough out of their comfort zones to require them to adapt, potentially resulting in progress in their professional identity formation journey.²⁶

An educator’s choice of a guiding theory involves considering the theory’s ability to explain the relationships between variables of interest. For instance, when constructing social activities, social identity or communities of practice theories may be helpful in considering issues of belonging or participation. On the other hand, optimizing activities that focus on the individual may benefit from either self-authorship or provisional selves theory,²⁷ which provide guidance on supporting internal transitions or the role of experimentation in identity formation. In fact, educators can consider drawing on multiple relevant theories to scaffold or guide their work in this area.¹⁸ Although many travelers delight in spontaneous, unscripted, and off-road adventures, deliberate and intentional scholarly teaching maximizes learning for the students involved. Regardless of which guidebook(s) an educator chooses, the experiences and insights of previous travelers are invaluable strategic planning assets.

New Excursions in Familiar Locations

Table 3 illustrates three professional identity formation–building examples for educators training health professions students in various environments. Educators may be relieved to know that useful, professional identity formation–friendly pedagogies (eg, reflective writing,²⁸ interactions with others,²⁹ and mentoring and positive role modeling³⁰) are already embedded in many classrooms and familiar learning environments, but activities may need some modification to more intentionally facilitate professional identity formation. The exact modifications that can stretch an activity from teaching professionalism to supporting professional identity formation are open for further exploration, though some specific reports have been published. For example, intentionally designed narratives and guided reflective assignments can provide students with the opportunity to make sense of their experiences and develop their professional identity.^4,26,31

The typical goal of professional identity formation pedagogy is to help students internalize the meaning of an experience in order to develop an identity that aligns with the values of the profession. Educators, including administrators and student services professionals, can all serve as role models and facilitators of the human and emotional dimensions of the learner’s experience and can lead mentoring conversations that explore meaningful themes of integrity, meaning, resilience, and well-being.³² In particular, they can help learners to navigate transitions (eg, prepharmacy to pharmacy, shadowing to care provision) and process crises and provocative moments (eg, patients resisting advice despite dire consequences). Educators can also assist students in integrating their personal and professional identities by guiding conscious, collaborative, reflection with individuals or small peer groups and by creating environments that allow students to freely and safely discuss vulnerabilities, self-doubts, ethical dissonances, and progress.^26,32,33 In addition, educators can help student pharmacists learn the language of the profession and the language of health care as well as learn to maneuver within the hierarchies and power relationships that facilitate, and potentially inhibit, the role of the pharmacist. Finally, educators can support students as they “play the role” on their way to being a pharmacist, specifically by identifying and helping students process the emotions (eg, anxiety, frustration, satisfaction, pride) that may ensue during their travels (Figure 1).³⁴

It is important for educators and mentors to not only create experiences that promote socialization and a sense of belonging within the profession but also provide the student with feedback regarding areas of improvement and validation of their beliefs and behaviors related to the pharmacist role.^8,35 Educators and mentors should provide feedback that helps learners develop confidence and to eventually become their own source of feedback.³⁶ Formative feedback from mentors is typically immediate and informal, intended to provide insight about the learner’s motives and actions in a given experience and the consequences of those behaviors on a student’s transition from layperson to pharmacist. An educator’s feedback may be more delayed, and when given as a grade may be seen as more formal, but when done well also supports the student’s skill at self-monitoring. This type of iterative, constructive feedback aids learners in reinforcing strengths, identifying and correcting weaknesses, and practicing desired behaviors.³⁷ It is the reinforcement of these desired behaviors, through formative feedback from other professionals, that eventually leads to the adoption and ingraining of the professional identity.

Professional identity formation is an emotion-packed and potentially unnerving adventure. Just as a debriefing conversation with a colleague can help travelers process their experiences, students benefit from dialogue and support in making meaning of formative moments in their professional identity formation journey. Although supporting professional identity formation may seem exotic and foreign to educators, there are ways to adapt familiar strategies toward a more explicit professional identity formation focus.

Navigating Less-Charted Territory

Assessment of professional identity formation in students has been largely formative and is, thus, less well-documented. This is for practical reasons because, as Crossley and Vivekananda-Schmidt argued, the only person who can meaningfully gauge a subject’s self-identity is the subject themselves.³⁸ Within experiential training, learning logs (ie, entries about patient interactions) have been used to deepen learning and develop self-awareness by asking students to record observations they considered important, interesting, impressive, difficult, distressing or significant.³⁹ Documentation of these provocative moments or crises can then be reviewed by educators and discussed with learners, providing formative feedback and aiding in the self-reflection and meaning making required for identity formation. More work is needed to understand the types of formative assessments that provide useful feedback to both the guide and to the traveler. Similarly, the influence of various forms of reflective exercises that support identity formation and help to resolve identity dissonance merits further investigation.

Summative evaluations, including surveys and attempts to classify an individual’s identity status, have also been explored in research studies. For example, the Professional Self-Identity Questionnaire has been developed “as a research tool to understand the curricular features that contribute to the development of professional self-identity.”³⁸ While this tool is not intended to analyze professional identity or be used as an individual assessment, it may be useful in self-reflection and self-monitoring. Pharmacy was not considered in the development of this tool, but it has since been used to examine the influence of prematriculation pharmacy experience on professional identity formation in pharmacy students.⁴⁰

Other researchers have used commitment to the profession (ie, degree of personal investment) and exploration (ie, trying on identities during a period of reflection) as variables in attempting to classify occupational identity status (ie, a characteristic way of dealing with the salient identity issues).^41,42 For example, in medical education, Niemi examined student reflections to describe four identity statuses of preclinical students: diffuse identity status, vague fantasies and tentative ideas, active exploration of specific alternatives, and achieved professional identity.³⁹ Narrative approaches (ie, tapping into the inner world of the individual as a conscious decision-maker in their personal story) and discursive approaches (ie, examining the roles of talk, interaction, and language in identity formation) have also been used to examine identity formation.⁴¹

Though pharmacy educators seek to better understand personal trajectories in professional identity formation and curricular influences, identity research indicates that developmental changes cannot be detected over short periods of time.⁴² Development of professional identity is likely influenced by proactivity, a strong sense of agency, adaptive personality characteristics, and a host of other personality factors.⁴² Future work in identity strength and identity achievement should consider time frame (especially longitudinal studies), personality characteristics, social and cultural contexts, the influence of family and peers, as well as the influence of various identity formation pedagogies and interventions. Work in professional identity formation assessment may be similar to exploration and discovery; there are few maps and no guaranteed safe and timely arrivals. Travelers should anticipate the need for formative assessment approaches and attempt to share their results with other professional identity formation–interested educators.

Reviewing One’s Passport Stamps

Educators will accumulate professional identity formation–related experiences over time that aid their effectiveness in guiding the journey of others. Prior to offering such assistance, it is important for educators to embrace the intentional, and sometimes uncomfortable, first step of self-reflection. Introspective, professional identity formation–focused professional development efforts enable educators to identify and reflect on their own multiple personal and professional identities (practitioner, educator, parent, etc), including those in conflict.⁴³ Specific activities that may benefit educators should be founded in professional identity formation theory and could include the evaluation of published literature, reflective writing, and small group discussions regarding personal insights and self-reflection. Such experiences can be foundational in helping educators to understand professional identity formation within themselves prior to facilitating it within learners.⁴³

Introspective questions for educators to ask ourselves include, how would I describe my personal and professional identities? Which experiences and individuals have been important influences on my values, attitudes, and beliefs as a professional? What dissonance have I experienced in my identity as an educator? A pharmacist? A scholar? Which of my identities did I feel most or least comfortable expressing during my education or training?

Colleges and schools of pharmacy are encouraged to support and prepare educators to be role models and facilitators of professional identity formation within pharmacy learners. Effective faculty development programming, whether one-time or longitudinal events, will likely require identification of a local “professional identity formation champion” within the institution or organization. These faculty development seminars on professional identity formation can assist educators in reflecting on the formation of their own personal and professional identities, provide an overview of the nature of identity formation, and contribute to an understanding of socialization.^43-47 Faculty development programming can also assist basic scientists in learning from pharmacy practitioners what it means to “think, act, and feel” like a pharmacist. Finally, faculty development programming can facilitate dialogue around existing professional identity formation initiatives and enable collaboration for curricular integration of professional identity formation components within an institution. Joining local and national professional development communities can support educators in their own identity formation as well as enable and allow educators to model vulnerability with others, much as they will be requesting of learners in future professional identity formation initiatives.^43,46

Traveling can broaden one’s mind. From the outset, educators can reflectively consider their own formative excursions and the value of those excursions to their role as a guide now charged with supporting others new to the road. Preparing oneself can make the journey more impactful for both the guide and their learners.

Choosing Travel Companions

Developing professional identity formation activities in a course or experiential rotation may seem daunting, especially when setting out alone. As with other aspects of pharmacy education, this is not a task that ought to be done in a silo. The 2019-2020 AACP House of Delegates adopted the following policy statement proposed by the 2019-2020 Student Affairs Committee⁶: AACP encourages colleges and schools of pharmacy to advance education that is aimed at the intentional formation of professional identity (ie, thinking, feeling and acting like a pharmacist) and developed and implemented in cooperation with professional pharmacy organizations within the broader pharmacy profession.

This is an ambitious goal that will require a strong vision and core group of early adopters.⁷ For program-level implementation, institutional support will also be needed. As described by Cruess and colleagues, “deans and chairs must publicly signal their approval and institute measures that lead to faculty buy-in.”⁹ Developing a program-level professional identity formation approach also requires the identification of an end point toward which the program is working: the professional identity that educators are helping to form in their students.⁴⁸ Just as one’s personal and professional identities must be compatible, the professional identity that a program targets will need to be compatible with the school or college’s mission and local practice standards. As successes drive the growth of efforts beyond the initial work, additional faculty development, support, and coordination will be needed to implement activities widely and longitudinally within a curriculum.

Ultimately, a larger-scale, intentionally designed effort will be needed to support students in and through various phases of their development.⁷ Curriculum and student affairs committees will be integral to curricular changes needed to optimize the professional identity formation programming, while assessment professionals may have knowledge of or access to data useful in understanding student progress. Student services professionals, often trained in identity formation, may be particularly helpful and/or interested in this work. As with many new initiatives, benefit can be derived from within-institution (eg, professional identity formation as part of interprofessional education) and across-institution sharing and joint initiatives (eg, multi-institutional implementation and evaluation of a pedagogical approach). Remember, short trips might be managed on one’s own, but a major journey like that of identity formation requires support and cooperation from others with unique and diverse expertise. Educators should identify companions who can aid in instructional design to collaboratively develop and evaluate opportunities for formative moments that are as memorable and meaningful to students as possible.