Clinician identity underpinned the standing of clinical teacher identity. In particular, perceived clinical acumen reinforced the clinical teachers’ credibility.33,39 In some cases the converse was also true; that is, having a formal clinical teacher role could enhance a clinician’s status amongst clinical peers.42,44 Interestingly, clinical teachers with part-time academic appointments expressed a sense of diminished self-efficacy as teachers in comparison with their full-time clinician colleagues because of their reduced patient care commitments.35
Clinical teachers emphasized the part played by role models, teaching experiences, learner feedback, and reflection in constructing their own teacher identities. They portrayed becoming a teacher as a self-authored process in which they integrated the example of model persons, successes, failures, and reflective insights into a coherent teacher identity.26,43,51 These studies also revealed how teachers strove to achieve congruence among their professional, personal, and teacher identities.38
Teacher identity was contingent on how teachers’ status and role was recognized by clinical colleagues.25,29 In studies of nurse educators, Paterson45 and Ramage46 described how nurses with formal clinical teaching roles felt like unwelcome guests in clinical workplaces. In response, nurse clinical teachers used “courting” strategies to ingratiate themselves with communities of clinical colleagues.45,46 Moreover, driven by a desire to be acknowledged and accepted by clinical colleagues, nurse educators chose not to report examples of poor clinical practice that they had witnessed.45,46
Motivated by a need to be recognized as legitimate participants, clinical teachers aligned their teacher identities with the dominant discourses in clinical teams and health care institutions.31,53 In practice, this aligning meant that clinical teachers tended to uncritically reproduce teaching dispositions and practices handed down from more senior role models and/or that they enacted teacher identities congruent with how the practice of teaching was positioned within their institutions. Observing new entrant clinical teachers, Trede and Smith53 found that these teachers tended to follow orthodox assessment practices even if they disagreed with them. Similarly, Cantillon and colleagues31 described junior doctors’ reluctance to question the teaching practices of their superiors for fear of losing face and recognition within clinical teams. Together, these findings suggest that the development of clinical teacher identity is shaped by contexts characterized by inequalities of power among teachers and by the hierarchical clinical teams or institutions in which the teachers are situated.
Clinical teacher identity development was dependent on how the organizations and institutions in which teachers worked supported the role of “teacher.”27,55 The visibility of a recognizable teacher profile was a vital component of organizational culture that informed the strength of teacher identity.41 Institutions that supported an identifiable teacher profile engendered stronger teacher identities and greater motivation to teach.30,57
Several studies highlighted clinical teachers’ difficulty engaging with fellow clinicians because they lacked a common language that allowed them to communicate their teaching experiences and ideas.25,47,50 Lack of a common language increased teachers’ sense of isolation in clinical communities; however, participating in communities of fellow educators supported the emergence of stronger clinical teacher identities, enhanced motivation, and increased the likelihood of participating in faculty development.25,50
Through this review, we found that most researchers investigating the development of clinical teacher identity (71% of the articles we reviewed) adopted an individualist stance. This standpoint positions clinical teachers as having agency in constructing their identities and considers the clinical workplace a static backdrop to the process of identity formation. The predominance of individualist identity research in the health professions resembles the scholarship of teacher identity in mainstream (K–12 and higher) education 30 years ago.60 Monrouxe and Poole61 highlighted the need for more constructionist approaches to identity scholarship in the health professions when they contrasted “the seductive notion of an individual’s identity being something internal to one’s self that can be a measurable and known entity” with research that “clearly demonstrates that identities (in the plural) are enacted interactionally and are highly fluid and contextual.”61
One purpose of this review was to inform the future design of faculty development for clinical teachers. Individualist-oriented research showed that individuals’ reconciliation of their clinician, researcher, and teacher identities influenced their openness to faculty development and new teaching practices. These insights do not explain why clinical teachers choose to prioritize particular role identities over others. Social relational-oriented research showed how “socialising agents” in social and cultural contexts shaped clinical teacher identity.62 For example, some individuals prioritized their clinician and researcher identities above their teacher identities because they felt that their community better supported their clinician and researcher identities. Communities may favor clinician and researcher identities over teacher identities because the former attract more social capital and require more personal investment.63 Unsurprisingly, health professionals prioritize identities that their peers recognize and support.61,62
Additional obstacles to faculty development include both clinical teachers’ propensity to reproduce socially scripted teacher identities and the reality that many of them practice in hierarchical settings.25,29,31,39,45,46 This replication of others’ practices and obeisance to those of higher rank is akin to the socialization of trainee doctors in hierarchical teams who have been found to privilege scientific medicine over humanistic perspectives in the context of delivering handover reports.64 The pressure to conform leads health professionals to reiterate established identities, norms, and practices.65 These findings illustrate how the hidden curriculum of the clinical workplace6 can interfere with the transfer of ideas and techniques from faculty development into practice. On the positive side, our findings suggest that faculty developers should regard the workplace as a context that can be manipulated to support the development of stronger clinical teacher identities and better teaching practices.66 Examples of such manipulations might include creating opportunities for clinical teachers to meet one another to exchange teaching narratives or to include teaching scholarship as a potential topic in grand rounds presentations.
Whilst research on clinical teacher identity development has intensified in line with the growing scholarship of professional identity formation in the health professions,67 it is still too limited to answer many important questions about how clinicians become teachers in clinical workplaces. The parts played by culture, hierarchy, and interpersonal politics remain underexplored. We suggest that research with a relativist epistemology may be best for exploring these issues. Research informed by sociocultural theories including communities of practice theory, cultural historical activity theory, and actor network theory could be used to explore clinical teacher identity. Specifically, investigators could apply these theories to better understand how clinical teacher identity is negotiated in relation to participation in clinical teams, how tensions between clinical and teaching activity systems shape teacher identity, and how social networks support or hinder the development of clinical teacher identity. Investigators may employ ethnographic study designs to reveal how teachers produce and reproduce dominant discourses of clinical education whilst marginalizing nondominant ones. Another potentially fruitful area for future research on teacher identity is the area of transitions. Multiple articles in our review26,30–32,37,39–41,45–48,56 showed how teachers are sensitized to their teacher identities when they transition between roles. Ideas such as these are important to explore at a time when interest in situating faculty development for clinical teachers in workplaces is increasing.68
A limitation of most of the research included in our review was that it was not situated within clearly articulated theoretical frameworks. This is a weakness because positioning research methodologies within explicit theoretical frames of reference justifies their use.69 Moreover, theoretical insights facilitate the interpretation of empirical findings.69 When investigators use theory to frame and articulate their research, their findings are more likely to contribute to the construction of a coherent body of work and are transferable beyond the particular contexts in which the studies were conducted.70
Our study is subject to the inherent limitations of scoping review methodologies.23 We did not include a quality appraisal of the articles we reviewed, and, despite the comprehensive nature of our search strategy, we may have missed some relevant studies. On the other hand, the value of a scoping review is to identify the state of current discourses on a research phenomenon71 and highlight gaps for future research72—both of which we have done. We acknowledge that the differences among our four social relational themes were quite subtle. We suggest, however, that the themes are sufficiently distinct to support recommendations for research and practice.
To conclude, the success of future faculty development initiatives for clinical teachers depends on developing more theoretically informed understandings of how clinical teacher identity arises in clinical contexts. Future research should explore not only how different features of clinical contexts influence teacher development but also the mechanisms whereby social and cultural contexts themselves structure and shape teacher identity and practice. Based on the findings of this review, we suggest that faculty development should attempt to increase teachers’ mindfulness of the environmental factors that shape their teacher identity, beliefs, and practices. We emphasize, as others have done before,41,73 the importance of establishing recognizable teacher profiles within health care and educational institutions to underpin the maintenance and development of clinical teacher identity.
The authors would like to acknowledge the expert support provided by Ms. Jane Mulligan, research librarian, National University of Ireland Galway, in the design of the search strategy for this review.
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