Relational professional identity: How do pharmacy students see themselves in relation to others?

Abstract

Background:

As the pharmacy profession moves towards patient-centred care, pharmacy schools have updated their curricula to prepare students for a full scope of practice. A critical objective of the new curricula is the professional socialization of pharmacy students into relational aspects of the profession: how pharmacists should interact with patients and other health care professionals. Through an examination of how one cohort of pharmacy students perceives its relationship to patients and physicians, this study aims to determine how these relational aspects of professional identity evolve with time spent in the program.

Methods:

At 3 time points over a 2-year period, pharmacy students were asked to detail in writing how they would communicate with a physician concerning a hypothetical drug allergy scenario. A directed content analysis of their responses was conducted based on 3 main analytic categories: patient-centredness, physician collaboration and physician deference. These categories were further divided into 6 subcategories that were used as the variables for analysis. Statistical analyses examined longitudinal group trends for these variables.

Results:

Over the 2 years of observation, an examination of the proportion of messages demonstrating the subcategories of interest showed that the only measure of the pharmacy students’ relational professional identity that changed significantly over time occurred for the perception of a sense of shared care for the patient. All other aspects of their relational identity were stagnant and did not change as they progressed through training (χ²; 12.772, df = 2, p < 0.002).

Conclusion:

Our results suggest that the relational professional identity of participants was poorly developed with regards to both patients and physicians. Pharmacy educators must reexamine the methods currently being employed to foster students’ professional identity development to ensure that new graduates are prepared to meet the challenges of a changing scope of practice. Can Pharm J (Ott) 2021;154:xx-xx.

Knowledge Into Practice.

• Previous work on the pharmacist’s professional identity has shown its importance for new graduates’ practice.

• The concept of relational professional identity may help pharmacy educators and clinical teachers establish clearer expectations for pharmacy students’ relationships with patients and physicians, especially in the context of an expanded scope.

• Results indicate that despite being immersed in a rigorous PharmD program, pharmacy students are not confident providers of collaborative, patient-centred care and struggle to be assertive when interacting with physicians.

• Students should be socialized, through both their curriculum and practical experiences, to be patient-centred and to have meaningful interactions with physicians that further patient outcomes.

Mise En Pratique Des Connaissances.

• Des recherches antérieures sur l’identité professionnelle des pharmaciens ont démontré l’importance de celle-ci pour les nouveaux diplômés exerçant la profession.

• Le concept d’identité professionnelle relationnelle peut aider les professeurs de pharmacie et les enseignants cliniques à établir des attentes plus claires à l’égard des relations entre les étudiants en pharmacie et les patients et médecins, notamment dans le cadre d’un champ d’exercice élargi.

• Des données révèlent que, même plongés dans un programme rigoureux de doctorat en pharmacie, les étudiants en pharmacie ne sont pas sûrs de fournir des soins concertés, axés sur les patients, et ont du mal à s’affirmer dans leurs interactions avec les médecins.

• Les étudiants doivent apprendre à nouer des contacts dans le cadre de leurs études et de leurs expériences pratiques afin d’être à l’écoute de leurs patients et d’établir avec les médecins des relations constructives qui améliorent les résultats pour les patients.

Introduction

The process whereby one becomes a professional is referred to as professional socialization.¹ A key aspect of this process is the development of a professional identity.² A strong professional identity has been identified as a means to facilitate a successful transition into practice³ and has also been demonstrated to provide a sense of worth and purpose for members of a group.⁴ Many pharmacists currently lack a clear professional identity,^4,5 and pharmacy has been in a state of transformation for decades, as it attempts to evolve into a role more focused on patient care.^1,6,7 Pharmacy students are faced with challenges in adopting the health care provider identity in the context of constant changes to the profession’s roles and confusion stemming from multiple, often incompatible, pharmacy identities.⁷ Despite these challenges, there is limited evidence to suggest pharmacy curricula are being designed with a strong focus on professional identity formation.⁸

Professional identity has been described as a type of social identity in the health professions field.⁹ According to the social identity approach, a social identity describes an individual’s perception of belonging to a social group,¹⁰ such as the pharmacy profession. Identities provided by social groups are relational¹¹ and lead individuals to perceive differences between members of their group and those of outgroups.¹⁰ Aspects of an individual’s behaviour that are influenced by stereotyped ideas of outgroups can indirectly be used to describe social identity⁹ and, by extension, relational professional identity.

Since the process of identity formation is highly dependent on social and relational factors,¹² the interactions that pharmacists and students have with other individuals, particularly those outside the profession, have the potential to influence their professional identity formation. Student pharmacists are socialized into an idealized version of the profession, one that includes—often subconsciously—a stereotyped version of the profession’s relationship to medicine, the dominant profession in North American health care.^13,14 Despite pharmacists’ important contributions to patient care, enacting a more advanced pharmaceutical role has proven to be challenging for pharmacists in the context of a still prevalent interprofessional hierarchy.^15-17 In addition to this obstacle, advanced clinical roles require patient-centredness, an aspect of the pharmacist’s identity that is still not as well defined as the technical dispenser role.⁵

To date, the literature on professional identity development in the health professions has largely ignored the relational aspects of identity. Given pharmacists’ need to have a strong professional identity⁵ and the fact that identity is influenced by associations to others⁴—be they individuals or ideas about these individuals—it is critical to determine how the PharmD curriculum is influencing future practitioners’ perceived relationships to physicians and patients. Therefore, this article seeks to determine how students’ relational professional identities changed over the course of 2 years of pharmacy curriculum, based on 3 core dimensions of relational professional identity: patient-centredness, collaboration with physicians and physician deference.

Methods

Participants

Study participants belong to a single cohort of a Canadian university’s PharmD program. Voluntary responses to the study survey were collected at 3 time points: at the beginning of students’ first, second and third years in the program. Students participated in a 5-week practical experience between first and second and second and third years.

Data Collection

Students responded to the drug allergy scenario prompt developed by Lambert¹⁸ using an online survey. This hypothetical scenario instructed students to put themselves in the place of a pharmacist who discovers that a patient has an allergy to a prescribed drug “X”, for which they know a good replacement, drug “Y”. Based on this information, the participants were asked to describe, in writing, what they would say to the prescribing physician over the phone.

Message Coding and Data Analysis

For this exploratory study, the coauthors jointly developed the coding structure to examine identity development using a directed content analysis approach.¹⁹ Following a preliminary review of all 3 years of student response data, 3 broad categories of interest relevant to pharmacist relational professional identity were identified (patient-centredness, physician collaboration and physician deference). Our coding structure contains a similar focus on physician deference as Lambert’s study¹⁸ on politeness strategies. However, whereas Lambert’s analysis focused primarily on physician deference, ours has included this concept as just 1 of 3 main foci we identified to examine relational professional identity. We divided these 3 categories into subcategories that could be assigned binary values, either present or absent from a message. On this basis, a set of 6 such dichotomous variables were established, 2 for each of the broad content themes (Table 1).

Table 1.

Coding structure used to examine relational professional identity in written student messages

Category	Subcategory/variable	Description
Patient-centredness	Patient consultation	Reference to conversation with the patient E.g., “A discussion with the patient has revealed that. . . . ”
	Patient impact	Consideration of the potential harms or benefits to the patient E.g., “‘Drug X’ will harm the patient.”
Physician collaboration	Shared patient	Reference to the patient as “our” or a “mutual” patient
	Working together	Language suggesting a shared purpose with the physician E.g., “We should change it.”
Physician deference	Deference to physician’s time	Expression of regret or gratitude E.g., “Sorry to bother you” or “Thank you for your time”
	Drug recommendation	Clear and direct drug recommendation E.g., “I recommend ‘drug Y’” and not “‘Drug Y’ may be better”

The team employed a systematic set of criteria to determine whether content pertaining to these subcategories was present or absent from each student response. Data were analyzed for each category using descriptive statistics. Overall group trends for each variable were compared over time using Pearson χ² analyses using SPSS version 22 (SPSS, Inc., Chicago, IL), with the Bonferroni statistical correction applied for multiple testing resulting in an α value of 0.008. Recognizing this strict criterion, we also report Cramer’s V as a measure of effect size, with 0 indicating no association and 1 indicating perfect association between time and the subcategory frequency of response.

Ethics

Ethics approval was obtained from the University of Toronto Research Ethics Board.

Results

Overall, there were 51, 41 and 147 responses analyzed for years 1, 2 and 3, respectively, with associated response rates of 22.1%, 17.1% and 63.1%. Results are given for longitudinal group trends for the variables of interest. Since the sample size varied considerably across data collection points, responses by individuals at all 3 time points were too infrequent for analysis. Instead, we compared the proportion of respondents mentioning each subcategory between the 3 time points. The corresponding statistical significance based on the results of χ² 3 × 2 contingency table analyses is listed in Table 2. Only the percentage of students who wrote messages suggesting they perceived that the patient was under joint care demonstrated an increasing trend year after year and was statistically significant (Pearson χ²; 12.772, df = 2, p < 0.002). Mentions of a shared patient were found in zero messages in year 1, were in 14.6% of messages in year 2 and peaked at 20% of messages by third year. While the other subcategories showed varying patterns, none reached our threshold for statistical significance.

Table 2.

Frequency of occurrence in sample per year and statistical analysis of message content corresponding to the 6 subcategories of interest

	Percent of messages
	Year 1	Year 2	Year 3	Trend significance	Cramer’s V
Patient-centredness
Patient consultation	0	0	7.5	χ2 = 7.37, df = 2, p < 0.025	0.18
Patient impact	26.4	34.1	28.6	χ2 = 0.712, df = 2, p < 0.70	0.05
Physician collaboration
Shared patient	0	14.6	20.4	χ2 = 12.772, df = 2, p < 0.002	0.23
Working together	13.2	0	8.2	χ2 = 2.14, df = 2, p < 0.34	0.34
Physician deference
Deference to physician time	5.7	0	2.7	χ2 = 2.67, df = 2, p < 0.26	0.11
Drug recommendation	30.2	19.5	21.1	χ2 = 5.18, df = 2, p < 0.08	0.15

Note: Statistical analysis reported for χ² using 3 × 2 contingency tables with α = 0.008.

Discussion

The results of this investigation suggest that relational professional identity formation in this pharmacy student cohort has been quite poor and, importantly, stagnant over successive years, which casts doubts on students’ future ability to practise at full scope. Year 1 results can reasonably be explained by the concept of anticipatory professional socialization. Prior to starting the pharmacy program, students would have formed preconceived expectations about the profession based on broad societal beliefs.²⁰ Our results suggest that this PharmD cohort’s curriculum has had minimal impact socializing the students into a professional identity with a strong relational component. While bearing in mind the limitations of our work, we will examine reasons why appropriate socialization may have failed to occur. Beyond the curriculum, which would have played a major role in identity formation,¹ additional factors that shape the pharmacy identity include experiential rotations and other work practice settings, acquired skills and the influence of role models.⁵

Patient-Centredness

The need for the pharmacy profession to become more patient-centred has been recognized for years.²¹ Yet, a review of the literature identifying motivations for entering the profession showed that “the concepts of patient care, compassion, empathy and altruism are rarely mentioned.”⁵ This may explain why instances of patient-centredness were infrequent in the year 1 results. However, a concerted effort has been made to move the profession in the direction of patient-centred care; this is reflected in the Association of Faculties of Pharmacy of Canada’s (AFPC’s) Educational Outcomes from 2010 and 2017, which promote a vision of pharmacists as providers of patient care.^22,23 Guided by these Outcomes, the students in the study cohort have taken many pharmacotherapy courses emphasizing the importance of the pharmaceutical care process and its focus on the patient. However, our data suggest that measurements of patient-centredness did not vary significantly as students progressed through their training. Furthermore, the proportion of messages at all 3 time points that demonstrated evidence of patient-centredness was low, with only 28.6% of students citing a concern for patient impact in year 3.

Previous research conducted at this university²⁴ showed that the 2010 AFPC Educational Outcomes,²² which guided this cohort’s curriculum design, were not being consistently integrated into classroom teaching. The study found that instructors relied predominantly on informal role modeling of pharmacist roles for identity formation versus explicitly embedding roles into the formal curriculum. In addition, the hidden curriculum can negatively affect identity formation that begins in the classroom. For example, even if formal pharmacy curricula are successful in promoting the importance of patient-centredness, when community pharmacist preceptors lack motivation, are dissatisfied with their work or are hesitant to take on new responsibilities,^21,25,26 professional identity formation could be negatively affected.³ Despite remuneration mechanisms to support the adoption of patient-focused medication therapy management services in the province of Ontario, where the students study, Ontario pharmacists continue to perceive barriers that limit practice change.²⁷ Therefore, students may be receiving conflicting information about their identity as care providers both through what they are witnessing in practical settings and what they are being taught at school.⁷

Physician Collaboration

The 2010 AFPC Educational Outcomes²² lists “Collaborator” as a core dimension of pharmacy education. Students in this cohort have all participated in structured interprofessional education (IPE) events with students from 10 other health science programs throughout their degree. The results of our study present a mixed picture of the effectiveness of these activities, which align with literature that suggests the effects of IPE are not always clear-cut.^9,16 The results presented here showed an increase, over the 3 years, in the proportion of student responses that described a shared responsibility with the physician for the patient’s care, increasing to 20.4% in year 3. However, there was no such observed increase in response content, suggesting that the pharmacist and physician work together. This was suggested most frequently in year 1, in 13.2% of messages. Moreover, at all 3 time points, the proportion of messages containing “collaborative” content was low for both our subcategories of interest.

Here again, study participants’ experiences in pharmacy settings outside the faculty may have influenced their professional socialization around collaboration. Students’ experiential placements may have provided positive interprofessional experiences, thereby improving students’ views on collaboration. The opposite effect could have occurred should students have had negative interprofessional interactions. Furthermore, students seeing pharmacists struggling to win the respect of physicians when trying to enact more advanced roles²⁷ may undermine a collaborative approach to practice.

Physician Deference

The hierarchies experienced by health care providers are not often studied in education scholarship.¹⁶ A goal of this study was to see how pharmacy students are socialized to see themselves relative to the medical profession. It was found that participating students’ responses infrequently demonstrated deference to the physician’s time: only 5.7% of first-year responses included such direct deference. The quality of students’ drug recommendations is a more subtle way to investigate physician deference. Since drug recommendations are a core part of the pharmacist’s scope, pharmacy students should have been able to confidently provide a drug recommendation, especially since the scenario indicated that “drug Y” is a good alternative to the physician’s original prescription. Yet our results indicate that, although not statistically significant, there was a downward trend from year 1 to year 3 in the proportion of responses containing a clear and direct recommendation. It is concerning that at the beginning of third year, only 21.1% of messages demonstrated a confident recommendation of “drug Y.”

Previous literature supports our finding that pharmacy students rarely provide clear, direct drug recommendations to physicians. Lambert,¹⁸ who developed the hypothetical scenario used here, showed that pharmacy students made drug recommendations using a high level of politeness or even frequently refrained from making a recommendation. Moreover, research examining pharmacist-physician communication around expanded clinical roles found that pharmacists employed indirect communication tactics and nonthreatening questions when giving recommendations to physicians.¹⁵ These pharmacists used “gentle hints and suggestions”¹⁵ to circumvent physicians’ defensiveness.

The students, who are taught to provide a single, evidenced-based recommendation, should have been very confident in providing a clinical opinion. We therefore argue that this weakness in making a strong recommendation is because they have internalized their own inferiority towards the medical profession and hesitate to challenge the physician’s authority. The socialization process they have undergone has not dramatically transformed their perceptions of themselves when compared to the physician. They still act as though they are a less credible or valuable member of the patient’s health care team.

The perspective of relational professional identity explored here complements work by Noble et al.,³ who found that Australian pharmacy interns demonstrated a lack of strong professional identity. The new practitioners in their study struggled when the realities of practice did not conform to their idealistic expectations and felt disillusioned with their ability to effectively carry out patient-centred care and to interact meaningfully with physicians. The students in our study face a similar risk of dissatisfaction with aspects of their career if their relational identities remain underdeveloped at the point of graduation. Future research is needed to determine what approach faculties should take to formally integrate identity formation into the curricula so that graduates are confident in their professional identity and have the tools to remain resilient when they feel their identity is challenged.

Limitations

Our study is not without limitations. First, the hypothetical nature of the scenario may have precluded some students from relating to the patient and/or physician in a manner that allows us to accurately measure their relational professional identity. Having said that, it is likely that one would be “bolder” in a hypothetical situation—meaning that our results are actually understated. For our statistical analysis, we had inconsistent sample sizes and follow-up across the 3 time periods of response. This limited the extent to which we could form conclusions on changing attitudes and socializations. The small sample size of individuals repeating the study at 3 time points prevented us from a true repeated-measures analysis.

Conclusion

The novel examination of relational professional identity presented here has provided valuable insight into how pharmacy students are internalizing what it means to be a pharmacist in relation to patients and physicians. It demonstrates that the students’ socialization thus far has not facilitated the formation of a well-developed relational professional identity that can both provide patient-centred care and challenge the physician’s authority when necessary. The evolving and uncertain nature of the pharmacist’s identity may contribute to this. Moving forward, it is imperative that educators ensure that a clear vision for the pharmacist professional identity is taught so that students graduate with a strong sense of who they are and the valuable and unique contributions they can make to the health of patients as pharmacists. ■