Identity matters. Who we are, and who we are seen to be, underlies much of what we do in in medical education. Identity is rooted in language and interaction and, although we conceptualize identities, they are not fixed or static. Identities are realized through the ongoing dynamic process of identification: it is not something that one can have or not; it is something that one does.1(p5)
Athletic training education reform is not unlike previous reform initiatives in medical education. Throughout the reform process, the goals are to transform both the participants and the profession as a whole. Through innovative and engaging educational processes, competent, confident health care professionals emerge.2 There are many well-documented clinical education evolutionary models, including, but not limited to, apprenticeships, professional modeling, clinical problem solver, competent clinician, reflective practitioner, scientist practitioner, and interactional person-centered models. Although many clinical education models have evolved over the decades, most of these models lack emphasis on the integral role of identity formation.3 Newer models contend that a clinical immersion experience fostering the optimal mix of challenge and support facilitates identity formation. Clinical immersion provides emphasis on reciprocal, participatory activities contributing to identity formation in significant and lasting ways. Developing participants as partners in practice, immersive programs focus on problem solving, reflection, discussion, and actions shared between novice and experienced practitioners.4
Throughout educational experiences, students develop professional identities as they engage in communities of practice through clinical experiences. According to Vygotsky's5 theory of cognitive psychology, learning is facilitated through engagement not only in discipline-specific content but in professional discourse with those around the learner. Professional identity emerges as the educator and student share through a common language their assumptions and aspirations. Although strongly rooted in the role of language, the key to Vygotsky's work extends to the “psychological symbiosis” that occurs when the senior member (educator) scaffolds learning and the junior member (learner) appropriates that knowledge as his own. Through this relationship, the educator fills in missing information that the student needs to complete a task, which in turn is mimicked by the student when confronted with a similar task. This interaction, commonly called the zone of proximal development in Vygotsky's work, refers to the difference between where the student currently is in his or her construction of knowledge and self and the level of potential development attainable through collaborative interaction.5 As students learn through engagement in this relationship, experiences are incorporated into their professional knowledge that extends well beyond technical or practical knowledge. Professional identity as a health care provider emerges as an outcome of this ongoing, interactive relationship.
Developing an identity is integral to the health care professional. Five cultural dimensions of personal professional identity have evolved.6(p149) First, identity is a negotiated experience that is defined not only by how students define themselves, but also by how others see them. In clinical education, students work collaboratively with preceptors to discover an identity that is nurtured through interactions with others. Next, identity within a community is established by interpretation of familiar and unfamiliar cues encountered in the learning environment. These cues can be verbal and nonverbal and come from a variety of sources including the preceptor, other health care providers, and patients themselves. How these cues are interpreted often depends on the nature of the interaction and communication between the educator and the student. Reflection on practice anchors these cues and helps formulate the professional identity of the health care student.
Identity is also a factor of our self-defined learning trajectory, integrating where we have been with where we want to be in the future. Clinical education provides an ideal opportunity for students to set forth goals for professional development. Goal setting should be not only linked to technical skill development but, more importantly, tied to professional discovery. Both parties in the educational dyad need to actively engage in the evolutionary process of the student in order for a strong professional identity to emerge. “It is important therefore that professional learning fosters a familiarity and confidence in discursive practice, which will increase the ability of the students to present and pursue their ideas.”7(p65)
Fourth, identity is formed through the reconciliation of the multiple relationships into one emergent identity. Students encounter many different perspectives, particularly in interprofessional clinical settings. Health care settings require professional and interpersonal skills that foster confidence and self-regulation. Immersion in interprofessional settings creates a challenging dynamic, encouraging students to reach beyond their comfort zone to engage in experiences that are unfamiliar. With adequate guidance and support by the preceptor during these experiences and critical reflection by the student, a strong sense of professional identity can develop to make sense of the complex health care culture.
Lastly, personal professional identity is formulated through the convergence of becoming a member of proximal groups as well as broader groups such as the profession as a whole. Although power relationships may initially impact the learner, effective clinical education dismantles these hierarchies. It encourages students to develop their identity within the immediate work setting and expand their identity to embrace their role in the professional discipline. Clinical education must expand beyond programmatic requirements to empower students to see their potential role as advocates for the profession on a larger scale. This happens when the preceptor facilitates active involvement beyond the academic or clinical program to include larger professional service activities and interactions. Creating an identity beyond the academic program facilitates transition into the profession.
Clinical education is a complex element of educational programs in health care. Understanding identity is important because how we structure our learning experiences and foster the development of professionals within our programs impacts students as they emerge into professional practice. This element of education should not be left to chance. Concerted efforts to embrace the various theories and principles related to collaborative and socially constructed engagement in the educational process should be taken so that the transition to the master's program yields confident, self-regulated practitioners who fully understand their role and possess a strong professional identity within the interprofessional health care market.
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Author notes
Dr Peer is currently an Associate Professor of Athletic Training at Kent State University. Please address all correspondence to Kimberly S. Peer, EdD, ATC, FNATA, Kent State University, 266B MACC Annex, Kent, OH 44242. [email protected].