Professional identity in pharmacy: Opportunity, crisis or just another day at work?

Vignettes

A pharmacist receives a prescription and believes there is a dosing error, so calls the physician to clarify. The office secretary takes a message to pass on to the physician. An hour later, the secretary calls back and says, “I spoke with the doctor and the prescription was written correctly. Dispense as it is written,” providing no other information or details. The pharmacist then documents “spoke with MD office and confirmed dose.”

In this scenario, the pharmacist identified a potential problem and contacted the physician’s office. Instead of speaking directly with the physician, the pharmacist passed information to the secretary and was satisfied when she called back confirming that the physician wanted the prescription dispensed as written. Why are we so easily convinced that just because physicians confirm they want something, it is automatically correct?

Now, let’s look at the scenario below.

A mother approaches the pharmacist—her son has just been prescribed medication for attention-deficit hyperactivity disorder (ADHD). She is alarmed by the research she has done on these drugs and wants the pharmacist’s thoughts on the use of these medications. The pharmacist responds, “I’m sure the physician thought this was the best thing for your son. You should probably go ahead with it.”

In this scenario, the pharmacist has an opportunity to provide education to a concerned mother about her child’s medication but ignores her request and defers the responsibility for the medication choice back to the physician. In both cases, the pharmacist behaves in a manner that is deferential to the physician and discounts their own skills and expertise. Why? We propose that the underlying reason pharmacists practise in this way is because they lack a professional identity. This has a significant impact on the uptake of professional services and how the profession is perceived by other health care providers and society.

Pharmacists have discussed the topic of practice change for decades, yet research suggests there is little substantive change in day-to-day practice.^1-5 Despite significant transitions in both health care and education, including expanded scopes of practice and a change from Bachelor of Pharmacy to entry-level Doctor of Pharmacy degrees,^6-8 many pharmacists are not engaging with new roles (e.g., renewing and adapting prescriptions, prescribing, regulation of pharmacy technicians) and continue to focus largely on dispensing functions, resembling practice of a century ago.⁸ Why is this the case? Some proposed barriers include lack of time, autonomy, confidence, remuneration, information and recognition by both physicians and patients.^1-5,9-11 However, even as many barriers are addressed, resistance to change continues.^1-5 This is not a Canadian phenomenon. Pharmacy around the world is experiencing the same resistance to practice change.^9,10 Other professions have looked to professional identity formation and its role in preparing health care practitioners to function in and adapt to changing health systems. Specifically, we propose that the absence of a clear professional identity in pharmacy^12-15 contributes to the profession’s inability to embrace change and move forward.

Professional identity and pharmacy

Interest in the importance of professional identity and its influence on pharmacy practice is growing.^16,17 Elvey et al.¹² identified 9 unique identities of pharmacists, which they argued lead to role confusion and a lack of clear professional direction. Gregory and Austin¹⁴ examined how pharmacists navigated personal health crises and reliance on professional identity; their findings suggested that pharmacists may have incomplete professional identity formation compared to physicians and nurses. There appears to be some growing consensus that pharmacists lack a clear professional identity.

Key Points.

• A professional identity is who we are in the context of our chosen profession.

• Professional identity can be understood from various theoretical perspectives, including individual, interactional and institutional theories.

• Professional identity is an important component of practice change.

• Research on professional identity in pharmacy is limited, and this needs to change if we are to truly move practice in the 21st century.

• A unified professional identity is crucial in order for society to see pharmacists as health care providers.

Points clés.

• L’identité professionnelle définit qui nous sommes dans le contexte de la profession que nous choisissons.

• On peut comprendre l’identité professionnelle en fonction de différents points de vue théoriques, y compris les théories individuelles, interactionnelles et institutionnelles.

• L’identité professionnelle est un élément important de la transformation de la pratique.

• La recherche sur l’identité professionnelle en pharmacie est limitée, mais cela doit changer si nous voulons vraiment faire entrer la pratique dans le 21e siècle.

• Il est essentiel d’adopter une identité professionnelle unifiée pour que la société perçoive les pharmaciens comme des fournisseurs de soins de santé.

Professional identity theories

To explore these identity challenges further, one must have some understanding of professional identity theory. Numerous theories, from a broad range of paradigms, exist in the literature.^15,18 Identities are complex, so there are different ways to discuss them. Borrowing from theories in medicine, in Teaching Medical Professionalism, Monrouxe¹⁸ explored individual, interactional and institutional theories of professional identity in the context of health professions. We can use this structure to help understand the professional identity of pharmacists.

Individual identity theory is focused around the notion that identity is situated within an individual, constructed in one’s mind.¹⁸ This is in essence “the self,” which is the starting point to understanding identity for many. Erik Erikson¹⁹ is a key theorist in this paradigm. Using a psychoanalytic approach, he proposed 8 stages (psychosocial crisis) in which we pass from infancy to adulthood. During each transition, a “crisis” point will occur that facilitates examination of roles and drives subsequent changes. Each stage is associated with the discarding of one identity and the acquisition of a new identity. It is these crises that encourage individuals to reexamine their attitudes about themselves and the world, allowing some beliefs to be discarded and others integrated into new identity constructs.¹⁹ From a professional identity perspective, individuals move through stages of professional development. In pharmacy, individuals move from learners in classrooms, to learners in experiential rotations, to novice pharmacists, to experienced pharmacists and so on. Change from one stage to another is not gradual but rather characterized by abrupt discontinuities that are triggered by the emerging crisis. This phenomenon is important, as the transition from a dispensing pharmacist identity to a clinician pharmacist identity will require a “crisis” of sorts to drive the change, not gradual improvements over time or occasional education sessions on how to make decisions or provide clinical services.¹⁹ An example of a crisis that may drive change is a shift to outcomes-based payment. If pharmacists are paid based on improved patient outcomes, providing dispensing services alone will not be economically sustainable.

In contrast to individual theories, interactional identity theories are rooted in social constructionism. From this perspective, professional identities are co-constructed through language, artifacts and action and are continuously renegotiated.^15,18 Identity as a social construct is best epitomized by the work of Erving Goffman²⁰ and his seminal work, The Presentation of Self in Everyday Life. Goffman uses the analogy of a play to discuss the intricacies of identity, which is a collection of how people present themselves (e.g., actor) and how others (e.g., audience) interpret this. Since all people have multiple identities (e.g., profession, gender, ethnicity), the presiding identity is specific to the person’s setting and is selected based on which is likely to lead to the best outcome. Goffman’s theory is exemplified by the recent transition of pharmacists to immunizers. A significant number of pharmacists likely never considered administering injections, as this was not a personally defined professional goal. Despite this, it is probable that these pharmacists will need to provide immunization services, as their colleagues will expect it and the public will demand it. This is problematic for identity formation, specifically adoption of the immunizer identity, as it creates a conflict for the individual pharmacist to resolve. It may not be personally desirable to adopt the immunizer identity, but pharmacists may be ostracized by colleagues and the public if they do not internalize it. In these circumstances, which goals affect the adoption of the identity depend on which will lead to the most favourable outcome for the individual. This example highlights the importance and complexity of interactional identity theories for the profession.

Lastly, institutional identity theories encompass how identities are located or formed through institutions, often organizations in which we learn and work.¹⁸ These theories explore how organizational culture affects identity. In pharmacy, some have speculated that corporate culture affects identity formation. Although messaging from corporate pharmacy supports clinical pharmacy services and the expansion of the professional roles, the corporate culture itself may negatively affect the ability for the clinician identity construct to thrive. In addition, pharmacy education has a significant impact on identity formation, specifically legitimizing the formation of the clinician identity. This likely contributes to the disconnect that new graduates experience when they move into practice, where the clinician identity may not be dominant. The impact of pharmacy culture on professional identity is an underexplored area currently but has potential to uncover challenges, which are affecting or limiting practice change.

Implications of identity research on future practice

Identities can be understood from various perspectives, and formation of strong professional identities is crucial for the survival of the profession. Pharmacy is a profession that has been affected significantly by societal transformations such as mass manufacturing of pharmaceuticals, widespread availability of drug information and inclusion of pharmacists on health care teams.^7,21-26 As such, its traditional roles, such as compounding, dispensing and advising, have been challenged.^7,21-26 It is reasonable to hypothesize that if pharmacists do not identify as clinicians, they cannot see themselves in this role and therefore cannot “be” clinicians. This point is crucial because if practising pharmacists do not have a mental model for the clinical path or if they or others cannot see themselves in this identity, no amount of legislative changes, remuneration models or upgraded education will result in the practice changes the profession is so desperate for.

We propose that pharmacy researchers seek to understand professional identity in pharmacy and its impact on practice change. The fragmented identities among pharmacy professionals today represent a significant challenge for the profession. Moreover, without concerted research efforts, we may lose ground to other health professions in understanding our current identity challenges. Future research that informs an understanding of pharmacist identity and what is required to form 21st-century pharmacist identities is crucial. The findings of professional identity research will act as a foundation for curriculum reform, recruitment and retention activities, professional development and increased social recognition. ■