Strong Professional identity construction as a change lever

Formation of professional identity

According to the Bologna Plan, undergraduate education should prepare students to enter the labor market in their profession. To this end, it is important that during undergraduate studies, the university provides students with the technical knowledge and practical experience that will enable them to acquire the competencies necessary for their professional activity. It is a time when students must also “become professionals”. This process, which begins at the undergraduate level, is called “professionalization” and is an essential component of health sciences education [1].

It is a very complex process that involves a continuous transformation of the student’s “self”, through the transformation from “being a student” to “being a professional” who understands, adopts and internalizes, deeply and integrally, the values, culture, ethics, beliefs and attitudes and behaviors of what, in our case, the pharmaceutical professional should be [2-5]. This process of professionalization, which begins during the undergraduate education and continues in the graduate’s daily work, is called the “formation of the professional identity” (PI). [3, 6-8].

The concept of “professional identity” refers to how professionals define themselves in relation to their professional role, encompassing both their sense of identity and the expected behaviors associated with that role. How professionals perceive their roles influences how they then implement their work activities [5, 8]. The formation of a PI raises two central questions, “who am I?” and—by implication—”how should I act?” as the professional I am (9).

It seems that the way to move towards greater professionalism is to generate a PI that is consistent with the objectives, values, beliefs and ethics of the profession that will make it possible to respond to the demands of society [5,10]. In reality, identity refers to the sense of “being” a professional formed through the continuous interaction between the “self” and the “context” [4,7,9,10]. In our case, it involves understanding the “role of the pharmacist” in society.

During student pharmacist training, curricular experiences should be directed toward the development of a PI, which describes “a certain kind of person,” an individual who must be able to “think, act, and feel” in a way that demonstrates that he or she is truly a patient-centered pharmacist; [8,11] someone who is able to answer the questions of “who am I” and “how can I act” professionally [9].

Objective of the pharmaceutical profession

While it is true that there is a lack of agreement in the pharmacy profession about “what it means to be a pharmacist today” [12], it is also true that most professional organizations advocate support for patient-centered practice operationalized through the provision of clinical services, whether in pharmaceutical care (PC) or public health [11,13-18]; and, according to the general discourse of national and international professional leaders, we can indeed speak of a new paradigm for pharmacy practice [13-15,19-23].

Professional identity of the pharmacist

Although more research should be done on the perceptions of both student and practicing pharmacists about their professional identity, several narratives have been described about the different PIs identified. The pharmacist has been defined as a dispenser, merchandiser, clinician/health care provider, scientist, expert adviser, manager, businessman, social caregiver, etc. [8, 11, 24-26] This variability reflects a degree of ambiguity in the role expected of this professional and a lack of clear direction and characterization of what makes the pharmacist “unique,” although it may also suggest a flexible and broad view of the role of this professional [24].

For the sake of simplicity, I will refer to two of the most frequently described identities in literature: the most common and the most desired [8,25]. Others, such as scientist, merchandiser, businessman or manager, although they have a certain presence, are not reported as majority identities to define the profession and its corresponding professional role.

In research on this subject, the most frequently described PI is that of the “Dispensing Pharmacist”, which includes activities such as medication compounding and and counseling. It is the most deeply rooted PI and the one that best explains the situation of pharmacists internationally, which is also the case in Spain [26-29]. According to the narrative of this PI, the activity of dispensing medicines and medical devices explains the core of what the pharmacist is today as a professional. This identity is associated with technical skills and scientific knowledge of accuracy and precision. Its narrative, which focuses on the drug as the product that it is, and therefore on the logistics of its distribution, fits very well with other related activities, such as medicines compounding, cosmetics manufacturing and dose-administration aids preparation. In addition to these product-oriented activities, the pharmacist advises patients on all types of health problems in general, although these are usually minor problems [30] and do not involve the assumption of additional responsibilities. If a problem arises, the usual response is to refer the patient to the physician or other health care professional, which may reflect a certain lack of autonomy in the professional practice of the profession [29].

There is another professional identity, that of the clinician or health care provider, whose narrative relates very well to the aforementioned recommendations issued by professional organizations. In fact, as mentioned above, it seems that all pharmacy organizations recognize the need for pharmacists to have a more patient-centered activity while taking responsibility for their health outcomes, which implies a change in their daily practice [11,13-16,18,31].

It is true that since the development of the philosophy of pharmaceutical care, [23,32] which advocates the clinical practice of the pharmacist focused on the person and on achieving health outcomes, a whole body of doctrine has been developed, both theoretical and practical, with recommendations for the implementation of professional services in the Pharmacy [13,16,18,33]. In Spain, the Foro de Atención Farmacéutica en Farmacia Comunitaria (Foro AF-FC) has defined and implemented a significant number of clinical services (professional pharmaceutical care services), some of them PC and others community oriented (public health) [14]. However, both in Spain and internationally, with some exceptions, this activity is not the one identified as habitual among pharmacists, and the necessary change in behavior that patient-centered care entails has not yet taken place. Nevertheless, the discourse corresponding to the PI of the clinical pharmacist, based on PC and person-centered care models, although not materialized in practice, represents an “aspiration” to be achieved, even for dispensing pharmacists. This gap between “the desired” (aspiration) and “reality” places the profession in an internal contradiction. It adopts as its own the discourse of an identity that “does not correspond to the aspirations and expectations”, since it longs for another identity, with the degree of dissatisfaction that this can generate [34-36].

In Spain, the discourse of our professional leaders is clear [37]. They say that we, as pharmacists, are clinical, social and digital. Apart from the social and digital aspects, which are not the subject of this reflection, the profession has not yet adopted a “generalized and sustainable clinical practice” in which the pharmacist, through the provision of care services, contributes to improving the health of patients, including their quality of life.

Many studies have been conducted analyzing barriers and facilitators and attempting to implement activities to achieve this change in the profession, with little success to date [11,31]. Rosenthal’s statement is probably true when she asks the following questions “Do pharmacists really want to advance their practice? Can they change their approach to patient care? Or, are the classic barriers to practice change a convenient script, when the actual barrier is pharmacists’ own psyche and culture? [11]

There are colleagues who claim that pharmacy today iis already a clinical profession, i.e. they assume the PI narrative of the clinical pharmacist. I do not think it is necessary to recall that all professional organizations continue to propose the need to change practice, something they would stop doing if the real change had already occurred. Moreover, a brief look at daily practice in Spain shows that, with a few exceptions, there are no patient records in the dispensing service, in minor illnesses management service, the outcomes of the pharmacist’s intervention are not evaluated nor recorded; more and more multi-compartment aid systems (MCA) are being prepared, but hardly any incidents or drug related problems derived from the provision of such systems are recorded, and the rest of the services described by the AF-FC Forum are practically non-existent. †

† It is interesting to note that a study analyzing the implementation of PA in Spain used “registration” as the implementation variable and not the number of services claimed to be provided in pharmacies. (Arroyo Álvarez de Toledo L, Puche Herrero M, Ramos Morales R, March Cerdá JC. Diez años de atención farmacéutica en España: explorando la realidad. Pharm Care Esp. 2011; 13(6): 289-295)

 

Building a Professional Identity

The construction of a Professional Identity that responds to the demands of society and professional organizations, both national and international, remains an open question for pharmacy. On the one hand, professionalization is understood as the formation of a PI. [26] On the other hand, students entering pharmacy school generally have complex and varied backgrounds; some study pharmacy because pharmacy is in the family, others as a second option, and few because of what is called a true vocation [8, 38]. It seems obvious that the construction of a PI should begin during the bachelor’s degree, which, in addition to what has been said so far, should be different from the one that has evolved in recent years. Current curricula have traditionally prepared, and to a certain extent continue to prepare, a professional with an identity that could correspond to the narrative related to the role of “scientist”, not even with that of “dispenser”.

Some authors have identified a different narrative from the one presented, which corresponds to a plural identity that includes different facets (multifaceted professional identity) and relates multiple aspects of identity associated with the role of the pharmacist [8]. This fact may indicate the difficulty that the profession faces in developing its daily practice. In addition, this multifaceted discourse includes aspects that may generate a conflict of responsibilities, probably indicating that this profession has not yet consolidated its own identity in this transitional phase [36]. For their part, Elvey et al. have identified another narrative, which they call “The character with nothing remarkable”, in which some participants state that pharmacy is an invisible profession [24].

Aware of all this and trying to respond to these problems, Nelson et al. have proposed a professional identity that tries to combine aspects of product and patient-oriented services, aspects that, according to them, have always been shared by the profession and have constituted the “true” professional identity of the pharmacist as a drug expert; it is the prevention, identification and management of medication therapy problems and their causes [39]. This is a good attempt, although this narrative has not been identified in previous studies, either in students’ or practitioners’ descriptions. In reality, it is a personal proposal based on pharmacists being the only health professionals who “look” at the patient through the “medication lens” [39], although it is true that it combines aspects that are conceptually difficult to unite. In this sense, Kellar warns of the possible confusion that can be generated by discourses on multiple identities, a situation described as “discursive pile-up”. [26] This type of discourse occurs when elements of previously described PI discourses are maintained in the curriculum, either formally or hidden, and new ones are added, making it difficult for students to absorb and learn the new, updated discourses. The result of this “accumulation” is that the student graduates with a very fragile professional identity, because the underlying idea is that the different discourses are incompatible with each other, especially those of the dispenser, the merchandiser and the clinician [26].

Therefore, if the profession of pharmacy is to survive, and if society is to view pharmacists as clinical service providers, it is crucial that we collectively forge a unified professional identity [40].

Future curricula

The Commission’s Delegated Directive (EU) 2024/782 of 4 March 2024 [41] has just been published, which opens a window of opportunity for the profession and the university to engage in dialogue, decide on objectives and adapt their curricula towards a more clinical professional practice [42]. However, the new directive maintains the subjects that previously existed and supported the curricula that have been in place until now, which is likely to make this task more difficult. It has already been mentioned that professionals need a strong identity so that they are seen as “unique” professionals, in the case of pharmacy, as health professionals with expertise in medicines.

The pharmacy curriculum includes a wide range of knowledge, covering both pharmaceutical sciences, many of which are basic, and subjects related to clinical practice [43]. Therefore, the Directive should be seen as an opportunity, while maintaining the necessary balance, to broaden the latter set of subjects, avoiding a professional identity that is not centered on a scientific discourse, but that favors the more clinical roles expected of pharmacists in the immediate future. These changes are already taking place in other Western countries, such as in the United Kingdom, where from 2026 graduates will leave university with the competency of independent prescribers [29].

Epilogue

According to professional leaders, the goal of pharmacy as a profession is to care for patients’ medication needs and to participate in achieving health outcomes. For this clinical role to become a reality and for the profession to be reprofessionalized, students must develop a solid identity, and this work must begin at the undergraduate level. This is a difficult process given the dynamic nature of the profession, whose practice has changed so much in recent times [8, 21].

A change in the PI and the role of the profession may ensure that both society and other health care professionals view pharmacists differently than they do today [5, 30, 44, 45].

The publication of Delegated Directive (EU) 2024/782 opens a window of opportunity for both the University and this Profession to discuss where the profession should go and, more specifically, what the professional role of the pharmacist should be.

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