Professional Identity Formation (PIF) in Health Professions Education: Doing is Different from Being

by Lauren C. McConnell, PharmD, PGY1 Pharmacy Practice Resident, Baptist North Mississippi Hospital

Professional identity formation, or PIF, is the process through which a person becomes a professional — typically from student to practicing professional. The progression of PIF is uniquely individualized and superimposed on each student’s personal identity, values, morals, and beliefs.¹ The goal of forming a professional identity is to develop a resilient sense of belonging within a health profession.² PIF goes beyond students acquiring knowledge (‘thinking’) and demonstrating professionalism (‘acting’) to support one’s perception of self (‘feeling’).

Professionalism, as defined by The White Paper on Pharmacy Student Professionalism, is “the active demonstration of the traits of a professional”.³ Health professions students are intrinsically and extrinsically motivated to join a professional community and are willing to uphold certain professional expectations, such as wearing a white coat, communicating respectfully, and being accountable.^4,5 However, acting like a professional and being a professional are two different phenomena.

Interrelationship Between Professional Identity and Professionalism

Professionalism and professional identity are distinct yet related concepts, which makes the fluid relationship between the two challenging to describe (see Figure 1). Professionalism is an outward display of the conduct of a professional, while a professional identity is the internal perception of one’s role as a professional.⁶ Professional traits and behaviors are crucial for PIF, as ‘acting’ like a professional encourages assimilation to that role.⁷ Similarly, self-awareness of a professional identity is essential for developing a professional demeanor. Several stepwise models exist that have attempted to describe this relationship. Acts of professionalism are observable signs which indicate the concurrent development of professional identity.⁶ Therefore, my professors at Auburn University and I recently proposed a model to illustrate the infinite and undirected interplay between PIF and professionalism, the Möbius Strip.⁷

Figure 1: Professionalism-Professional Identity Möbius Strip

According to Moseley et al., “as the internalization process of PIF occurs, outward professional behaviors are displayed, and as one chooses to behave as a professional, their sense of identity blossoms”.⁷ This model aligns with the proposal that the end goal of health professions education should not just focus on ‘doing’ but also on ‘being’.⁸ As with all educational goals, methods for teaching and evaluating progress are essential. The conundrum is how this fluid process can be measured and supported.

PIF-Friendly Pedagogy

Obtaining a professional identity is the desired outcome in health professions education, as it is the backbone of all decisions students will make as professionals.⁸ However, many students (and admittedly, myself included) fail to recognize themselves as professionals early in their health education journey. For this reason, PIF has long been an elusive target amongst health professions educators. Furthermore, PIF is a non-linear process, and each student progresses toward their professional identity at a different pace, which makes it challenging to foster and evaluate progress.⁹ For this reason, health professions educators should incorporate PIF-friendly teaching strategies into curricula.

PIF pedagogy is the practice of teaching, facilitating, and coaching students through their PIF journey — teaching methods that support the development of an identity that aligns with the values of their profession. Educators are a fundamental component of the student’s journey. The formation of a professional identity is influenced by external factors, such as curricula, learning environments, expectations, mentorship, and feedback.⁵ I distinctly remember key preceptors who created positive learning environments and served as role models that positively impacted how I perceived myself as a future pharmacist. Therefore, it is important for educators to foster relationships and create experiences that are meaningful to students, as PIF is facilitated, not taught.

Self-assessment and self-reflection are two PIF-friendly strategies that educators can use in curricula to help students become more aware of their professional strengths and weakness.¹⁰ The ability of the student to be self-aware of their presence and growth within a professional community increases PIF and creates a sense of belongingness.⁹ Other meaningful relationships outside the formal education environment (e.g., with preceptors, other health professionals, and patients) play a similar and equally important role. To me, there is no replacing the feeling you get the first time a patient mistakenly refers to you as a pharmacist or when a physician shows appreciation by stating ‘good catch.’ Through these interactions, students gain recognition for their place on the healthcare team. Situated learning theory suggests that “learning should take place in a setting the same as where the knowledge will be used”.¹¹ Therefore, it is no surprise that students report early introduction to their profession, direct interaction with patients, and frequent collaboration with other health professionals as key drivers of identity construction.¹²

Because educators are facilitators of PIF, structured evaluations (e.g., exams or performance-based assessments) are not helpful measures of student progression, particularly given that PIF does not occur at a single point in time. Experts recommend that assessments of PIF should occur longitudinally to ensure that the student’s professional identity is progressively developing over time.¹³ Unfortunately, there are no standardized methods for measuring PIF, and assessments rely on student understanding of who they are within a profession. I remember creating short- and long-term career goals as a first-year student pharmacist, thinking I knew exactly who I was and what pharmacy career path I wanted to pursue. But with each semester, I revisited these goals and was honestly embarrassed by what I thought I knew about who I wanted to be. 

In one study, investigators designed a Professional Self Identity Questionnaire (PSIQ) that attempts to measure the degree to which health professions students identify as a member of their profession.¹⁴ Building on this notion, faculty at Auburn University Harrison College of Pharmacy recently created a PIF instrument to encourage students to reflect on their professional identity. This instrument asks students to self-assess fourteen qualities/behaviors, such as confidence, knowledge, personality, professionalism, and communication.¹⁰ These PIF-friendly exercises, using a combination of self-assessment and self-reflection, attempt to measure what educators cannot see: how students see themselves in relation to their profession.

There are several other activities and instructional strategies that can be used to promote PIF, such as feedback, experiential education, co-curricular activities (e.g., health fairs), mentoring/role modeling, student well-being groups, and white coat ceremonies.^7,15 Of course, most professional curricula already incorporate many of these pedagogical methods, but require active effort by educators to intentionally foster PIF. Reflecting on my time as a student, I now know why I have always appreciated professors who were passionate about what they taught, preceptors who encouraged autonomous work, and mentors who led by example – they intentionally helped create my professional identity. Educators should continue to purposefully use and prioritize PIF-friendly pedagogical methods, particularly early in curricula, to support the process of professional identity formation amongst their students.

References

1. Cruess RL, Cruess SR, Steinert Y. Amending Miller's pyramid to include professional identity formation.Acad Med. 2016;91(2):180-5.
2. Kellar J and Austin Z. The only way round is through: Professional identity in pharmacy education and practice. Can Pharm J (Ott). 2022 Aug 13;155(5):238-240.
3. Roth MT and Zlatic TD. American College of Clinical Pharmacy. Development of student professionalism. Pharmacotherapy. 2009 Jun;29(6):749-756.
4. Holden M, Buck E, Clark M, Szauter K, Trumble J. Professional identity formation in medical education: The convergence of multiple domains. HEC Forum. 2012 Dec;24(4):245-255.
5. Findyartini A, Greviana N, Felaza E, et al. Professional identity formation of medical students: A mixed-methods study in a hierarchical and collectivist culture. BMC Med Educ. 2022 Jun 8;22(1):443.
6. Forouzadeh M, Kiani M, Bazmi S. Professionalism and its role in the formation of medical professional identity. Med J Islam Repub Iran. 2018;32(1):765-8.
7. Moseley LE, McConnell L, Garza KB, Ford CR. Exploring the evolution of professional identity formation in health professions education. New Dir Teach Learn. 2021 Dec 6;168:11-27.
8. Snell R, Fyfe S, Fyfe G, Blackwood D, Itsiopoulos C. Development of professional identity and professional socialisation in allied health students: A scoping review. Focus on Health Prof Educ. 2020 Apr 30;21(1):29-56.
9. Cruess SR, Cruess RL, Steinert Y. Supporting the development of a professional identity: General principles. Med Teach. 2019 Jun;41(6):641-9.
10. Ford CR, Astle KN, Kleppinger EL, Sewell J, Hutchison A, Garza KB.Developing a self-assessment instrument to evaluate practice-readiness among student pharmacists. New Dir Teach Learn. 2021 Dec 6;168:133-145.
11. Li LC, Grimshaw JM, Nielsen C, Judd M, Coyte PC, Graham, ID. Use of communities of practice in business and health care sectors: A systematic review. Implement Sci. 2009 May 17;4:27.
12. Wald HS. Professional identity (trans)formation in medical education: Reflection, relationship, resilience.Acad Med. 2015 Jun;90(6):701–6.
13. Garza KB,Moseley LE, Ford CR.Assessment of professional identity formation: Challenges and opportunities.New Dir Teach Learn. 2021 Dec 6;168:147-151.
14. Crossley J and Vivekananda-Schmidt P. The development and evaluation of a Professional Self Identity Questionnaire to measure evolving professional self-identity in health and social care students. Med Teach. 2021 Dec;31(12):e603-7.
15. Chandran L, Iuli RJ, Strano-Paul L, Post SG. Developing "a Way of Being": Deliberate approaches to professional identity formation in medical education.Acad Psychiatry. 2019 Oct;43(5):521–7.

Achieving the Promise of Authentic Workplace-Based Assessments

by Sophie Durham, PharmD, PGY1 Community Pharmacy Practice Resident, Mississippi State Department of Health Pharmacy

Workplace-based assessments (WBAs) can be intimidating and burdensome for students and evaluators alike; however, these assessments pose an opportunity to use real-time direct observation to provide feedback that supports a learner’s growth and development.¹ Unfortunately, students often fail to see the usefulness of feedback in clinical settings or feel that their grades might be negatively affected by observations reported through workplace-based assessments.

Throughout my Advanced Pharmacy Practice Experiences (APPEs), I craved feedback so that I could develop as a clinician and ensure that I was providing optimal patient care. I valued the feedback that I received at the midpoint and final evaluations; however, these evaluations were used to determine my final grade. As a student, I benefitted from receiving more frequent, informal feedback to improve my performance in real time. By providing students with more timely formative assessments, preceptors allow students to reflect on their experiences and make necessary corrections to improve their practices without the stress of contributing to their grades.

WBAs are used to evaluate trainees’ performance in practice and can be used by learners as relevant feedback to engage in reflection. WBAs encompass a wide range of assessment strategies that require evaluators to move away from merely assigning numbers toward a more structured format of assessment. WBAs can be used to provide feedback on trainee-patient interactions, procedural skills, case-based discussions, and multi-source feedback.²

Lauren Phinney and colleagues at the University of California San Francisco used cultural historical activity theory (CHAT) to identify feedback system elements and tensions among these elements to explore workplace-based assessment used during medical clerkships. The school introduced a WBA tool in 2019 that includes drop-down items describing the clerkship specialty, skills observed, entrustment ratings adapted from the Ottawa scale, and space for narrative comments to encourage formative feedback. Students are required to gather two WBAs per week. The research interviewed first and second-year medical students participating in core clerkship rotations.¹

CHAT allows investigators to examine how tools mediate activities. An activity system is defined as the interaction between learners and tools to achieve an outcome. Tensions among these elements can promote change, create knowledge, and lead to new activity patterns.¹ After interviewing students in a series of focus groups, researchers identified five tensions:

1. Misinterpretation of WBA Feedback as Summative Assessment. Although WBAs were intended to serve formative purposes, first-year students perceived the object, or purpose, of the WBA to be for summative purposes. Formative assessments are intended to monitor student learning to provide ongoing feedback to improve teaching and learning. More specifically, formative assessments help students identify strengths and weaknesses. This allows students to target areas of improvement and help faculty pinpoint areas where students are struggling to provide assistance.³ On the other hand, the goal of summative assessments is to evaluate student learning at the end of a rotation and are often high stakes, resulting in the assignment of a grade or score. Even when second-year students correctly identified the purpose of WBAs as low-stakes feedback, students were still concerned that this feedback would be used to inform summative assessments and strategically chose to use WBAs when they anticipated positive feedback instead of opportunities for constructive feedback. Two ways to enhance the distinction between summative and formative evaluations in WBAs are to use two different platforms to complete WBAs and summative assessments and allow students to self-complete WBAs.¹
2. Cumbersome Tool Design that Delayed Feedback. WBA requests were sent via computer, so many of these requests were sent hours after feedback encounters. Students found that the distribution and completion of WBAs were delayed, which resulted in generic or untimely feedback. Utilizing QR codes on smart phones and improvements in technology facilitated supervisor engagement and rapid feedback.¹
3. Concern About Burdening Supervisors with WBA Tasks. While clerkship leaders encouraged students to seek feedback, students were concerned about interrupting workflow or interfering with patient care. Students found the assessments to be labor-intensive and redundant. Students employed strategies to streamline the process, such as recording and submitting comments that preceptors provided during the encounter with the WBA request form, which made it easier for preceptors to complete the assessments.¹
4. WBA Requirement as Checking Boxes vs. Learning Opportunity. The weekly quota of completion of two WBAs overshadowed the purpose of WBAs as a formative feedback mechanism. The authenticity and usefulness of the feedback could be jeopardized when students and supervisors focus on the rule instead of the opportunity to provide feedback. On the other hand, some students reframed this requirement to benefit them. One benefit of the requirement included the ability for students to direct their learning to meet self-identified goals and receive timely feedback to ensure that they were making progress toward achieving these goals. Another benefit of the rule was to initiate consistent feedback discussions with preceptors who did not volunteer to provide feedback.¹
5. WBA Within Clerkship-Specific Learning Culture. Supervisors’ promotion and acceptance of WBAs ultimately set the tone for WBA encounters. Students found that preceptors that actively facilitated WBA encounters provided more useful feedback, while preceptors that gave pushback created a barrier. In addition to using more convenient platforms to complete WBAs, students identified more convenient situations, logged feedback retrospectively, and bypassed tool discussion to minimize the burden on team members in settings that were not conducive to WBAs.¹

In competitive cultures like medicine, it can be difficult to facilitate formative assessments. The author concluded that by incorporating learner input to make intentional changes, perceptions and utilization of WBAs can be enhanced.¹

The authors provided potential solutions to the perceived problems with WBAs. There is often a disconnect between the intention and interpretation of workplace-based assessments.  Thus, we need to consider structuring their format and delivery by gathering student feedback. Through this collaboration with students, we can strive to achieve authentic workplace-based assessments that accurately reflect learners’ progress and are used to improve future performance.

While this study focused on the benefits of WBAs in student-preceptor interactions at one medical school, WBAs can be used in several ways. WBAs can be applied across multiple settings and can be separated into three different categories: observation of clinical performance, discussion of clinical cases, and feedback from peers, coworkers, and patients. These assessment tools provide insight to the trainee, assessor, and academics alike.²

In addition to getting student feedback, I believe we need to gather feedback from preceptors to determine their perceptions of WBAs. Thus, WBAs could be further improved to meet the needs of both students and preceptors. To ensure that we are providing useful and timely feedback to learners, its important to reduce the barriers to WBA use. By using QR codes, separate platforms to differentiate summative and formative assessments, and platforms that are compatible with smartphones when computers are not available, schools can establish user-friendly and time-efficient processes and ensure that WBAs that are valuable without adding substantial burden that jeopardize feedback quality.¹

References:

1. Phinney, LB, Fluet A, O’Brien BC, Seligman L, Hauer KE. Beyond checking boxes: Exploring tensions with use of a workplace-based assessment tool for formative assessment in clerkships. Acad Med 2022; 97: 1511-1520.
2. Guraya, SY. Workplace-based assessment; Applications and educational impact. Malays J Med Sci 2015; 22: 5-10.
3. Formative vs. Summative Assessment [Internet]. Pittsburgh: Carnegie Mellon University; [cited 2022 Nov 18].