“It’s Too Painful to Explain My Role”: Factors Affecting Professional Identity Formation among Health Professions Educationists

Background: The honorable medical profession is on the verge of being reduced to a business. Evidence suggests that professionalism is fading and today's doctors are faced with value-threatening problems and gradually begin to forget their main commitment as medical professionals. Many of the problems faced by doctors are rooted in non-professionalism. Mere education in the science and practice of medicine produces an inefficient medical workforce and leads to the formation of a distorted professional identity. In the past decade, educational innovations targeting the formation of desirable professional identities have been presented and are considered a vital part of medical education for the development of professionalism. The present study was conducted to examine the relationship between the formation of professional identity and professionalism. Professionalism education is essential in the formation of a desirable professional identity. Methods: This review article was done in 2015 through searching databases, such as PubMed, Elsevier, Google Scholar, Ovid, SID, and IranMedex, using keywords of professionalism and professional identity, and medical education. Among the 55 found articles, 30 were assessed and selected for review. Results: The formation of professional identity is a process with the following domains: professionalism, and development of a personal (psychosocial) and a cultural identity, which is derived from the unification of professional, personal, and ethical development. The main components required for the formation of a desirable identity are, therefore, rooted in the dimensions of professionalism and professional development. The need for teaching professionalism has a reciprocal relationship with the formation of professional identity. Conclusion: There is a reciprocal relationship between formation of a desirable professional identity and development and strengthening of professionalism. Modern medical education should be designed to develop professional identity, and professionalism acts as an essential part of its curricula throughout the entire course of a doctor’s education, with the aim of acquiring a desirable professional identity

The concepts of and are often used interchangeably even though they are different. As this article explains, professionalism refers to appropriate conduct of a lawyer, e.g., honesty, civility, practical judgment. However, a law student or lawyer who has not internalized these professional values is not likely to consistently exhibit them in practice. The breakthtrough of concept of professional identity formation, in both Carnegie Institute's Report and Clinical Legal Association of America (CLEA) Best Practices for Legal Education (both published in 2007) was their recognition that law schools needed to help students develop a One's professional identity would be comprised of values that student will contemplate, reflect on, and ultimately internalize as values held by the kind of lawyer she wants to be. A surprisng number of effective teaching methods have been developed, som in other fields and some in law teaching, to help students reflect on their values, decide whether to internalize values and to develop a method for resolving ethical and value judgments. With such teaching and practice, someone will have a foundation for making sensitive ethical decisions in situations that represent challenges. Such a person is more likely to act according to her values. The notion is as old as Socrates' observation: We are what we repeatedly do. For those who have had value formation part of their law school experience and have developed a professional identity based on those values, they are far more likely to act consistently in ways that reflect professional values. The article surveys earliest law schools in America and how they made it a priority to address ethical values and cultivate a professional identity in their students. The article reviews how law schools, for a variety of reasons, moved away from this priority. The article thus recommends in part that law schools consider practices of earliest law schools, or at least their focus on professional value formation. Moreover, article reviews how ideas in Carnegie and Best Practices are being carried out in a number of modern law schools. These schools combine wisdom of early law schools' priority along with modern teaching methods. The results are courses that can serve as models for schools seeking to begin greater efforts at professional value and identity formation. This article is distinctive in two ways. First, it draws a connection between recent proposals for professional identity formation and character formation that earliest American Law schools made a priority. Second, article explains how professional identity formation ought to begin in first year of law schools. Although developing professional values and identity througout curriculum is important, first year of law school may be most important in process of having students begin to form professional values and an identity. If efforts wait until later, results are likely to be diminished, in part because law school itself in first year will have created barriers to education designed to cultivate professional identity. These barriers are discussed in Carnegie and Best Practices and recounted here. Therefore, article encourages any increased cultivation of professional values and identity and, in particular, efforts in first year to introduce students to professional values that go beyond academic achievent and include professional values that have been shown to be as important to effectiveness in practicing law as analytical skills.

Phenomenon: Professional identity formation is a key component of health professional education. Changing expectations of healthcare requires more than competencies, but also an ingrained responsibility to patients, with our values and behaviors aligned with community expectations of patient-centered health professionals. Research into professional identity formation has focused on nursing and medical training, and, although allied health professionals make up one third of the workforce, research is uneven across these disciplines. Health professions educators from these under-researched disciplines have less guidance for how to support students’ professional identity, meaning students may graduate with less mature professional identities. This systematic literature review synthesizes the research on professional identity formation across nine similar allied health disciplines. The purpose is to guide health professions educators in the formation of professional identity in allied health students. Approach: We carried out a systematic literature review, registered on Prospero, following the PRIMSA framework, to find, appraise, and synthesize research on professional identity for nine allied health professions. We synthesized extracted data using a narrative synthesis with convergent qualitative meta-integration of qualitative and quantitative data. Results: Our database searches combined with ancestry and forward searching resulted in 70 studies that met inclusion criteria. Studies came from 17 countries, from seven of the included disciplines (art therapy, dietetics, occupational therapy, physiotherapy, podiatry, psychology, and speech pathology) and from undergraduate, postgraduate, and new graduate perspectives. We found professional identity was influenced by the places of learning (curriculum and clinical experiences or placements), interactions with people (relationships with academics, peers, supervisors, patients,and role models), and educational practices engaged (dialogue, reflection, processing challenges), each acting on the individual person (student or new graduate) who also brought unique characteristics and experiences. Insights: This model of influences can inform health professions education to enable students to develop and graduate with a stronger professional identity formation.

The article analyses the main models and theories on the study of the concept of "professional identity" and the main factors influencing the formation of students' professional identity during their studies in higher education institutions. The article studies and compares the Erikson model of identity development, the theory of social identity, and the theory of career choice. The main provisions of professional identity in the works of world and national scientists are considered. Novelty of the work includes the study of domestic and international experience of educational work aimed at the formation of a positive professional identity of students. The authors propose forms and methods of work that will contribute to the formation of the professional identity of medical students, in particular, it is proposed to introduce comprehensive educational programmes and include certain topics, courses, etc. in the curriculum that would contribute to the formation of professional competence and identity of students of professional higher education. Relevance of the topic is due to the fact that the problem of professional adaptation and identification of students in higher education institutions after they have chosen a speciality, and the effectiveness of their work requires a detailed study. The authors investigated the content of the concept of "professional identity". The authors reviewed the influencing factors on the formation of professional identity, in particular, the role of educational work and the role of the teacher in the process of forming students' professional identity. The problems of professional identity formation at the university stage in Ukrainian higher education institutions are studied. The emphasis is placed on the modernisation of teaching and educational work in the higher education system of Ukraine. It is emphasised that practical training, which universities should provide through internships, cooperative programmes, research projects and practices, is of great importance in the formation of professional identity in students.

Recently, I attended an informative Education Grand Rounds at my institution on professional identity formation (PIF). It was delivered by a clinician and sociologist with most of the presentation focusing on the transition of medical students into residency and on how the residency curriculum might provide support for the development of professional identity. The presenters summarized the complexity of the history of professionalism in medical education (Coulehan, 2005; Hafferty and Castellani, 2010) and suggested that the utility of such a construct should not be limited to the assessment of student behavior, but should contribute to a student's formulation of their professional identity. Beyond merely "how to act," professionalism should speak to "who to become." Recent literature seats the professional identity at the core of medical education (Cooke et al., 2010; Cruess et al., 2016) with the emphasis on reshaping and modifying the academic discourse on professionalism to include the professional identity formation (PIF) (Cruess et al., 2014). For example, the Miller's traditional four-layered pyramid (Miller, 1990) which scaffolds knowledge ("Knows"—level), competence ("Knows how"—level), performance ("Show how"—level), and action ("Does"—level) into a four-tiered pedagogic hierarchy has been augmented (Al-Eraky and Marei, 2016; Cruess et al., 2016) to include a fifth "Is" layer (a new tip of pyramid) emphasizing identity. Educators now believe that health care professionals in training should "consistently demonstrate the attitudes, values, and behaviors expected of the one who has come to 'think, act, and feel like a physician'" (Hafferty, 2009; Cruess et al., 2016). Cruess et al. (2016) espouse the development of professional identity as a new principal goal for medical education. Now several reflective tools designed to measure the PIF have been developed (Bebeau and Monson, 2012; Kalet et al., 2017, 2018). Nonetheless, much work apparently needs to be done. One highly cited study examined the PIF in medical students through reflective essays. During orientation incoming, first-year medical students were introduced to the concept of PIF and assessed for the baseline PIF during orientation and then again, 15 months later, prior to clinical clerkships (Kalet et al., 2018). De-identified essays were scored by an adult developmental educational psychologist based on the Kegan's Subject-Object Interview platform for assessing the adults' identity development (Kegan, 1995). This study found that 46% of students in this medical class remained at the same stage in their professional development and 15% of students scored lower than at the time of matriculation to medical school (Kalet et al., 2018). While we can all hope that these results are not the norm, the prospect that half of our trainees might remain stagnant in their PIF through their first two years of training poses a distinct challenge to medical educators. I believe that the basic sciences should play a bigger role in teaching professionalism and in developing the PIF and that this process should commence as early as possible (Bryan et al., 2005; Pawlina, 2006). All our optics should be on the transition from undergraduate education to the medical school environment. Over a decade ago, I organized a plenary session and symposium at the 2007 Association for Medical Education in Europe meeting on the role of the basic sciences in medical education. One of the invited presenters, Dr. Ingeborg Netterstrøm from the University of Copenhagen, spoke on the role of basic sciences in the professional development as a physician (Netterstrøm, 2007). She cited a longitudinal study that followed a cohort of Danish medical students throughout the medical school. From this study, Dr. Netterstrøm learned that medical students have high expectations of themselves in their future role as a doctor. The scope of what they can accomplish in this role is expansive and hopeful. Dr. Netterstrøm was one of the first researchers who brought to the surface the notion that anatomy has a bigger role to play in the PIF than we knew before. Her work was published in one of the first issues of ASE (Netterstrøm and Kayser, 2008) and we are proud indeed to have an early outlet for this important message. In the preclinical phase (especially in anatomy courses), students are exposed to the medical school environment and to the intense study required to fulfill their own high expectations of the ideal doctors they hope to become. Helping students to remain emotionally attuned to this adjustment/adaptation period is necessary to ensure that students successfully navigate the first phase of their continued identity formation as professionals. And this is the work in store for the psychologically-minded anatomy professor. Here, the anatomy teacher is more than a dispensary of knowledge, more than a guide or coach for those with diverse educational backgrounds, cultures, and experiences. Here the anatomy professor has an opportunity to be a counselor and mentor to young doctors who are hungry to learn not just what they need to know, or how they need to act but who they are and who they might become. In the 2006 special issue of Clinical Anatomy on "Professionalism and Anatomy" (Pawlina, 2006), anatomists were in the vanguard of incorporating professionalism in basic sciences. Since then, several studies have indicated how anatomy and basic sciences have taken up the torch to hone curricular focus to develop a culture of professionalism (Pearson and Hoagland, 2010; Jones, 2013; Kissler et al., 2016; Kumar Ghosh and Kumar, 2019). However, anatomy is not alone in this effort. Identity development is a common denominator across health professionals and of the human condition. Professional identity formation is a multistage process and should start early in medical education (Barone et al., 2019). The early aspects of development involve directing students to follow social roles and norms (i.e., assignments in classroom, laboratories, learning in teams, and being a team leader) and to follow the instructions as specified by the anatomy course director (i.e., no photography or use of social media in the dissection room; be respectful for body donors). These social orientations are essential and foundational. Subsequently, students should learn to develop their own set of ethics and expectations and to govern codes of conduct among themselves through tools such as team charters (Pilette, 2017; Dougherty et al., 2018). Here students' develop an appreciation for the diversity of views and opinions of classmates and instructors—an awareness that is an important milestone in the early stages of PIF (Dougherty et al., 2018; Barone et al., 2019). Basic science education should not be limited to the expectations that students learn only the knowledge necessary to pass the course examination or to memorize facts that will help them pass their National Board of Medical Examiners' Subject or Step 1 examinations. On a daily basis, medical students must be made aware that they are not only learning for their own sake in terms of a grade or honors status, but that the investment of their time and energy will directly translate into the quality of patient care they will one day provide. They must relate the content they are learning to future patient problems through clinical correlates and begin to imagine how they will be better doctors in the future because of their investment in the here and now. Anatomy education is a setting for the development of an authentic curriculum (Pawlina and Drake, 2016) where students learn through clinical contexts that involve peer-to-peer and interprofessional communications, critical reflection through self- and peer assessments, and where professional imagination takes root. All educational activities should simulate a "community of practice" so that students in their preclinical years can imagine themselves in clinical settings, using the knowledge acquired and their communication skills to be effective for team members and problem-solvers. Students must develop a sense of duty to a larger group, which is usually a stark contrast from the solitary and "every person for themselves" manner of collegiate undergraduate courses (Gonzalo et al., 2017; Cruess et al., 2018). Let anatomy be the place where students learn that academic success is communal, not solitary. Professional identity is collaborative. As anatomists, we are integral to the identity development of our students. Anatomy courses clearly can provide more emphasis on the development of professional values, actions, and aspiration by role modeling and mentoring. The professional socialization of incoming students from diverse, often non-medical backgrounds into the anatomy laboratory allows not only an opportunity to develop an identity as a medical student, but as a member of a professional health care team when they join their dissection groups. Anatomy starts the development of collegiality as we see dissection team members unite over common goals and respect each other's diversity—both essential elements of early professional identity formation. We should not forget that PIF is heavily influenced by the hidden curriculum; thus, interaction with role models, modeling professional behavior, and the development of healthy social networks are essential aspects of the implicit education at work in the anatomy course (Goldie, 2012; Hafferty and O'Donnell, 2015). In this liminal realm, where feelings and schema contribute to the delicate psychology of PIF, frustration, anxiety, self-doubt, and an inadequate sense of belonging to the profession are conflicts that can be worked through sufficient mentoring and counseling along the way (Barone et al., 2019). It is important that we not dismiss these humanistic aspects of the educational experience which commonly emerge to the surface of student's experiences in the classroom (Evans et al., 2018). Millennial learners seem to be particularly sensitive and require authentic guidance through the challenges inherent in the PIF (Barone et al., 2019). Professional identity formation is a central psychological milestone for every person who aspires to become a professional. As such it behooves the anatomist to consider their role as an oracle to the student who, upon entering its gateway asks; "Who shall I become?" The dissection laboratory is a sanctuary of reflection on the human experience, both concrete and ephemeral. Writing exercises and narrative medicine may be useful modalities to explore further with regard to improving narrative competence and one's sense of story as it relates to the PIF (Miller et al., 2014; Wald et al., 2015, 2019). In the anatomy laboratory, we trace the limits of the physical and name all that can be seen with the eye, all the while wondering what remains nameable that cannot be seen. The anatomy laboratory is a place where students necessarily consider the end of their story (Hammer, 2010), at the beginning of their quest.

The intersectionality of professional and personal identity formation in a virtual pre-health pathway program

Surgical care practitioners are non-medical members of the surgical team, who provide direct surgical care to patients, delegated by consultant surgeons. The surgical care practitioners' professional role is within the new non-medical or nursing workstream, practising under the medical model of care in response to staff shortages and the rising expectations that are affecting the National Health Service. This article seeks to contribute to a better understanding of the phenomenon of the emergent professional identity of surgical care practitioners. Six surgical care practitioners were purposively sampled for in-depth, semi-structured interviews whereupon their concepts of professional transition and professional identity formation from their individual points of view were explored using a phenomenological approach. Transcripts and reflective texts were subject to repeated interpretation in a hermeneutic circle of understanding. Interpretation of the results in context allowed for a discussion informed by self-interpreted constructions and revolved around eight cluster themes that emerged explicating how surgical care practitioners experienced professional transition and professional identity formation. In addition, a notion of 'journey' in the development of professional identity (narratives about professional identity formation: the hero's journey) was embedded in the reflections of the participants and their narratives produced rich accounts of the phenomenon under investigation.

This article is a comprehensive study of the dynamic characteristics of teachers’ professional identity formation in the context of the system of continuing pedagogical education. Professional identity is understood as a key determinant of the successful implementation of educational activities, contributing to the formation of a stable awareness of an individual’s own belonging to a certain professional group and expressed through the adoption of appropriate ethical and regulatory guidelines. The theoretical analysis of the problem is based on a critical comparison of conceptual approaches to the process of professional and pedagogical identity formation. Empirical confirmation of the hypotheses put forward was carried out through a sample survey of students of Chechen State Pedagogical University via a questionnaire method using a scale for diagnosing professional identity statuses. The article describes the practical experience of the Chechen State Pedagogical University in the continuous formation of the professional identity of schoolchildren interested in the teaching profession, students and teachers of schools in the Chechen Republic. The research conducted significantly enriches the theoretical understanding of the specifics of a teacher’s professional development and offers theory-based strategies for productive support of professional identity formation in the modern Russian system of continuing pedagogical education.

Professional identity formation plays a crucial role in the transition from medical student to doctor. At McMaster University, medical students maintain a portfolio of narrative reflections of their experiences, which provides for a rich source of data into their professional development. The purpose of this study was to understand the major influences on medical students' professional identity formation. Sixty-five medical students (46 women; 19 men) from a class of 194 consented to the study of their portfolios. In total, 604 reflections were analysed and coded using thematic narrative analysis. The codes were merged under subthemes and themes. Common or recurrent themes were identified in order to develop a descriptive framework of professional identity formation. Reflections were then analysed longitudinally within and across individual portfolios to examine the professional identity formation over time with respect to these themes. Five major themes were associated with professional identity formation in medical students: prior experiences, role models, patient encounters, curriculum (formal and hidden) and societal expectations. Our longitudinal analysis shows how these themes interact and shape pivotal moments, as well as the iterative nature of professional identity from the multiple ways in which individuals construct meaning from interactions with their environments. Our study provides a window on the dynamic, discursive and constructed nature of professional identity formation. The five key themes associated with professional identity formation provide strategic opportunities to enable positive development. This study also illustrates the power of reflective writing for students and tutors in the professional identity formation process.

The use of entrustable professional activities (EPAs) and entrustment decision-making in health professional education was proposed to operationalize competency-based education. To ground its use, a common conceptualization of ‘competence’ is needed. Based on theoretical notions of epistemology (distinguishing propositional, procedural, and experiential knowledge) and inspired by the theoretical insights of Vygotsky, Maslow, Billett, and others, the authors elaborate a three-layered model that includes canonical competence (what every professional should have mastered, independent of context), contextual competence (the ability to work in relevant contexts and apply canonical competence), and personalized competence (the individual approach to high-level practice). The model aligns well with curricula that stress knowing, doing, and being, combining competency-based standards with professional identity formation. EPAs and entrustment decision-making typically regard the contextual layer of competence. This is because entrustment decisions, to support trainees in their progressive, professional autonomy, happen in clinical contexts where canonical, context-independent knowledge and skill are necessary but insufficient. Passing the threshold of entrustment with clinical responsibilities draws on both canonical competence and the ability to work in clinical contexts, responding to the needs of patients, of collaborators, and working within the rules and habits of the local environment. Once a trainee is entrusted with clinical responsibilities, and feels confident about the first two layers of competence, personalized competence can emerge more prominently, leading to integrated professional and personal identity formation. The three layers of competence together establish the conditions to think, act, and feel like a health professional: the knowing, the acting, and the being.

A fundamental goal of medical education is the active, constructive, transformative process of professional identity formation (PIF). Medical educators are thus charged with designing standardized and personalized curricula for guiding, supporting, and challenging learners on the developmental professional identity pathway, including the process of socialization. The author of this Commentary provides an overview of foundational principles and key drivers of PIF supporting the being, relating, and doing the work of a compassionate and competent physician. Key elements of PIF including guided reflection, use of personal narratives, integral role of relationships and role modeling, and community of practice are viewed through various lenses of PIF theory and pedagogy. Questions informing the PIF discourse are raised, including interprofessional identity considerations. Central emergent themes of reflective practice, relationships, and resilience are described as supporting and reciprocally enhancing PIF. Overarching lessons include attending to learners' and faculty's PIF within a developmental trajectory of the professional life cycle; process and content within PIF curricula as well as learners' individual and collective voices; curricular/extracurricular factors contributing to socialization, self-awareness, development of core values, and moral leadership; integrating PIF domains within pedagogy; faculty development for skilled mentoring and reflective coaching; and implementing resilience-promoting skill sets as "protective" within PIF. Outcomes assessment including the impact of curricula on learners and on patient-centered care can be challenging, and potential next steps toward this goal are discussed.

This article explores the interweaving of desistance from violent offending and professional identity formation via a psychosocial case study of a youth worker undergoing training in the UK. It follows the trainee for five years as he attempts to leave his past as a football hooligan behind him and construct a new professional identity as a youth worker. I argue that the case exemplifies how some youth professionals with lived experience of violence, if not given the time and space to build reflexive awareness, may struggle to meet the demands of professional roles such as youth work. I identify what I see as some implications for the promotion of ex-violent offenders as role models to young men involved in violence, as has recently found support within popular and political arenas in the UK. The article concludes that training and continuing professional development regimes, when designed for those with a history of violent offending, might benefit from the deep understanding of violence, professional identity formation and desistance that psychosocial analysis offers.

The professional identity formation of prospective physical and occupational therapists in the clinical practices process has been studied. The presence of the formed professional identity provides their orientation in the professional field and professional community that allows to realize more fully personal potential in a multidisciplinary team, to predict possible consequences of professional choice and to define own professional development prospects. There are three main stages in the formation of professional identity of the prospective physical therapy and occupational therapy specialists: an initial choice; a confirmation or refutation of the initial choice; an implementation of the initial choice in the activity. The dynamics of professional identity formation during the whole period of their professional training in a higher education institution has been determined.
 The peculiarities of early students` professionalization in the process of clinical practice have been revealed in a passive form, later - at the stage of active practice. Among the principles of professional identification development of future masters in physical and occupational therapy in the process of clinical practices, the principle of reflectivity and the principle of a value attitude forming to professional activity have been singled out. The clinical practice, taking place in medical and rehabilitation institutions, involving participation in the rehabilitation diagnosis establishment and in the rehabilitation program has been defined. Formation, development, a moral and psychological qualities complex, as an integral part of professional training of physical and occupational therapy specialists for their future professional activity; ensuring the growth of students` professional competence level; promoting self-identification and choosing the future professional activity direction are the main tasks of the research.
 The professional identification and personal identity formation of the prospective physical and occupational therapist is the unity of three processes: student`s self-acceptance as a prospective physical and occupational therapist; comparison with the professional ideal, norm and sample of a physical therapist; recognition by the external environment of the prospective specialist's affiliation to the professional group of practicing physical and occupational therapists. Throughout life professional identity is a product of continuous personal and professional development of the physical and occupational therapist.

Becoming pharmacists: how the pharmacy curriculum influences professional identity formation

Background: There is a lack of synthesis in the existing literature concerning Professional Identity Formation (PIF) in public health professionals. The community of practitioners in public health may lack an understanding of opportunities for supporting PIF in public health education and practice. Hence, the purpose of the present Qualitative Meta-Analysis (QMA) was to gain insight into situations and factors that facilitate and challenge PIF among public health professionals. Material and Methods: A QMA was conducted to address the study objectives. We retrieved articles on PIF using a systematic search strategy across Medline, Scopus, and Google Scholar. Inclusion criteria included original qualitative and mixed methods research on PIF among public health students or professionals from various backgrounds, grey literature such as thesis, and studies in English, or with English translations, published in peerreviewed journals. Narratives, participant quotes, categories, and themes from the results and discussion sections were used for thematic and content analysis. Reporting followed the PRISMAScR checklist. Results and Conclusion: We derived five main meta-categories: 1) nature of public health practice and professional identity; 2) professional identity formation in the context of public health, which had three meta-categories on the role of the university in PIF, requirement of reconciliation with various other identities, and influence of job profile on professional identity; 3) facilitators of PIF included meta-categories of facilitators related to curricular aspects and while at work; 4) barriers related to PIF included metacategory related to curricular aspects and while at work; and finally, 5) perspectives of self and stakeholders included factors related to self, employers, and society. The results will provide a framework for future research and curriculum development in public health courses aimed at supporting PIF among students.