Transitioning from professional to interprofessional identity

How to promote professional and interprofessional identity in medical students? What factors (internal and external) may help contribute to their development? Have we done enough to understand their nomological network and malleable nature? What benchmark curricular design is implemented to target their development? These are practical and theoretical questions medical educators ask in their quest to better prepare future healthcare professionals. While we know that fostering a strong sense of interprofessional identity is a means whereby healthcare professionals can work more effectively as a team, further investigations are needed to help us clearly understand the ‘black box’ of their formation in the medical curriculum. The purpose of this commentary is to understand what remains unknown in the light of our collective effort to advance important knowledge about interprofessional identity formation in medical education.

Interprofessional identity is ‘the development of a robust cognitive, psychological, and emotional sense of belonging to an interprofessional community(s), necessary to achieve shared context-dependent goals’.¹ The inclusion of interprofessional identity alongside professional identity resonates with the changing landscape of healthcare management as healthcare becomes more team-based. World health leaders advocate the dismantling of traditional silos and promote interprofessional education (IPE) as interprofessional collaborative practice yields better health outcomes: efficiency, safety, patient/carer satisfaction, and strengthened health systems.² Despite these developments, theory and empirical data remain scant, and factors that facilitate or thwart interprofessional identity formation remain undefined in medical education research and practice.

Reinders and Krijnen's³ article established the nomological network of interprofessional identity by answering the neglected question of what outcomes it predicts. Their data indicated that interprofessional identity translates into interprofessional behaviours and identified the activating effect of interprofessional identity via interprofessional socialisation on various interprofessional collaboration outcomes in IPE as a contextual trigger. Their work was noteworthy as it uncovered the relationships of interprofessional identity with a network of interrelated variables.

Framed using the extended professional identity theory (EPIT), Reinders and Krijnen's³ work underscored the external environmental factors (social agencies) in explaining interprofessional identity formation: socialisation, peer and mentor influences, education and training, experiences, organisational culture, societal normative expectation. What appears missing is the potent influence of internal processes that can lead to interprofessional identity formation. Social cognitive theory⁴ (SCT) highlights the integration of personal and social agencies affecting an individual's action potential. This theory emphasises the reciprocal relationship between personal factors (internal structure: beliefs, goals, sense of self) and social factors (external structure: environment) in shaping behaviour. SCT can be applied to understand interprofessional identity formation by considering the importance of personal and social factors in influencing the healthcare professionals' identity as team members.

Given the reciprocal relationship between external and internal processes through SCT, investigating the potential external and internal processes related to interprofessional identity in IPE is important. An example of an external process is the design of the IPE programme to enhance interprofessional identity. While the implementation of general IPE programmes varies in terms of duration, most of them are implemented in terms of hours/days to a year.⁵ On the other hand, the duration of IPE programmes that examine undergraduate students' interprofessional identity mostly ranges from brief learning experiences, courses over a semester, simulated learning experiences, or integrated within the curricula that last for a year or longer.⁶ Most evaluations of interprofessional identity across the interprofessional literature are snapshots in time or one-time points only,¹ with very few studies examining interprofessional identity over 3 years.⁷ In Reinders and Krijnen's³ study, they implemented an IPE course for over 10 weeks to examine interprofessional identity and its influence on group effort and interprofessional directions (outcome). Although these studies are significant advances to the IPE and interprofessional identity literature, ways to study interprofessional identity across time can be explored. Because identity is dynamic and evolving, it can be argued that it is the same for interprofessional identity. Hence, longitudinal IPE programmes within which studies on interprofessional identity can be integrated are needed to unravel the temporal elements of interprofessional identity. One approach is to embed IPE within the whole medical curriculum and examine changes in students' interprofessional identity as they progress into the medical programme. Such a similar design can be piloted within other health and social care programmes to corroborate evidence on longitudinal interprofessional identity.

Internal processes commonly account for personal factors and are usually examined to explain outcomes. Examples of internal processes are self-efficacy and self-regulatory processes. Self-efficacy pertains to one's confidence in their capabilities to execute or produce a behaviour.^{4, 8} Previous studies and reviews have highlighted self-efficacy's crucial role in education^9-12 and there is an increasing interest in its application to medical education research^13-15 and interprofessional education.^{16, 17} In addition to self-efficacy, self-regulatory processes like goal-setting and self-evaluation of progress can keep learners focused and maintain motivated in their learning.¹⁰ Goal-setting has been explored in medical education and has shown synergy with other learning constructs (e.g., feedback and acceptability)¹⁸ and in a problem-based curriculum.¹⁹ Furthermore, the role of goal-setting in interprofessional education has been recognised.^20-22 Self-evaluation, on the other hand, has been examined in medical education,^23-26 but fewer investigations were noted in interprofessional education.^{27, 28} In Reinders and Krijnen's³ study, they examined how interprofessional identity influences outcomes such as group effort and interprofessional direction. Although they established promising results on the interprofessional identity in IPE that can influence the said outcomes, further examination of other related variables can benefit the literature and practice of IPE. Future investigations can explore further internal processes such as self-efficacy and self-regulatory skills, and how they relate to interprofessional identity and outcomes.

Reinders and Krijnen³ established the positive relationship between interprofessional identity and outcomes such as group effort and interprofessional direction. Although their findings were significant and promising, weak relationships were found between interprofessional identity and group effort and between interprofessional identity and interprofessional direction. Nevertheless, such results could signal that other variables can relate more strongly to the outcomes. Exploration of the mechanisms and contextual factors is suggested to enhance our understanding of the link between interprofessional identity and IPE-related outcomes. More specifically, psychological mechanisms and factors that can either mediate or moderate the relationship between interprofessional identity and IPE-related outcomes are worth examining. For example, Roberts et al.²⁹ found that the perceived relevance of IPE mediated the relationship between professional identification and positive and negative attitudes to IPE. While such results relate to professional identity, it is interesting to see if these will be corroborated by future study findings for interprofessional identity. On the other hand, Mitchell et al.³⁰ found that team identity moderated (enhancing moderation) the relationship between diversity and team performance in IPE and that professional identity threat moderated (antagonistic moderation) the relationship between diversity and team effectiveness. These studies may provide examples of how we can utilise psychological constructs as mediators or moderators to unpack the relationship between interprofessional identity and IPE-related outcomes in future studies. Utilisation of more advanced methodological and statistical techniques (beyond correlations) can advance the methodology behind interprofessional identity and IPE research and enable us to examine the theoretical linkages between variables in a more complex but accurate way.

Fraide A. Ganotice Jr: Conceptualization (lead); writing—original draft (lead).