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Becoming a Clinical Teacher: Identity Formation in Context

Cantillon, Peter MHPE, MSc, MRCGP; Dornan, Tim PhD, MHPE, MRCP; De Grave, Willem PhD

doi: 10.1097/ACM.0000000000002403
Reviews
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Purpose Most clinical teachers have not been trained to teach, and faculty development for clinical teachers is undermined by poor attendance, inadequate knowledge transfer, and unsustainability. A crucial question for faculty developers to consider is how clinicians become teachers “on the job.” Such knowledge is important in the design of future workplace-based faculty development initiatives. The authors conducted a scoping review of research on the relationship between becoming a clinical teacher and the clinical environments in which those teachers work.

Method In June 2017, using the scoping review design described by Levac et al (2010), the authors searched 12 databases. They subjected the articles discovered to four phases of screening, using iteratively developed inclusion/exclusion criteria. They charted data from the final selection of articles and used thematic analysis to synthesize findings.

Results Thirty-four research reports met the inclusion criteria. Most (n = 24) took an individualist stance toward identity, focusing on how teachers individually construct their teacher identity in tension with their clinician identities. Only 10 studies conceptualized clinical teacher identity formation as a social relational phenomenon, negotiated within hierarchical social structures. Twenty-nine of the included studies made little or no use of explicit theoretical frameworks, which limited their rigor and transferability.

Conclusions Clinicians reconciled their identities as teachers with their identities as clinicians by juggling the two, finding mutuality between them, or forging merged identities that minimized tensions between educational and clinical roles. They did so in hierarchical social settings where patient care and research were prioritized above teaching.

P. Cantillon is professor of primary care, Discipline of General Practice, National University of Ireland, Galway, Galway, Ireland; ORCID: https://orcid.org/0000-0003-3776-9537.

T. Dornan is professor of medical education, School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast, Belfast, Northern Ireland, United Kingdom; ORCID: http://orcid.org/0000-0001-7830-0183.

W. De Grave is an educational psychologist, School of Health Professions Education, Maastricht University, Maastricht, The Netherlands.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A585.

Correspondence should be addressed to Peter Cantillon, National University of Ireland Galway, Discipline of General Practice, Clinical Science Institute, Costelloe Road, Galway, Republic of Ireland; telephone: (+353) 91-492262; email: peter.cantillon@nuigalway.ie; Twitter: @CantillonP.

Clinical education, a vital component of both undergraduate and graduate training in the health professions, is often characterized as unplanned, inefficient, and at times intimidating.1 Clinical teachers are critical determinants of the quality of clinical learning environments, yet most clinical teachers have not been trained to teach.2 Faculty development initiatives for clinical teachers have been hampered by poor attendance,3 inadequate learning transfer,4 and resistance to change in clinical communities,5 leading some to suggest that there is a hidden curriculum in the workplace that diminishes the effects of faculty development for clinical teachers.6 In the absence of formal faculty development, many clinical teachers are likely learning their trade on the job, but the medical education community has a poor understanding of the relationship between becoming a clinical teacher and working in clinical settings.7 Given that faculty development is not always effective for training clinical teachers,3–5 and that workplace environments have an overriding effect on teacher development,6,7 we believe that systematic research into the relationship between becoming a teacher and the workplaces that clinical teachers inhabit is essential.

Recent academic reviews of teacher development in mainstream K–12 and higher education have highlighted teacher identity as a critical organizing element in the life of a teacher.8,9 Teacher identity defines how teachers perceive themselves, how they are seen by others, and how they choose to conduct themselves.10 Scholars increasingly regard identity as a key determinant of the scope and nature of professional work.11 In the health professions, identity scholarship has largely focused on the emergence of professional identity in medical students and recent medical graduates.12 By contrast, the research on the development of health professional teacher identity has been minimal. Recent research by Van Lankveld and colleagues13,14 has explored how preclerkship tutors develop their teacher identities in relation to their social contexts, but the health professions education community faces major gaps in its understanding of how clinicians develop their clinical teacher identities. We set out, therefore, to undertake a scoping review of the health professions literature to elucidate what is known about the development of clinical teacher identity in relation to features of social context.

The scholarship of identity can be conceptualized as an epistemic continuum between, at one end, individualist (positivist) perspectives that situate identity development within the person and, at the other, social relational (relativist) standpoints that conceptualize identity as constructed through social interaction in cultural contexts.15 Individualist standpoints position individuals as agents in the construction of their own identities through an internal synthesis of experience and contextual factors into a single coherent self.16,17 Identity, from this theoretical perspective, is a stable construct (a self-schema) that can be explained in terms of developmental stages16,18 and categorized using identity statuses.17 A social relational perspective, in contrast, construes identity formation as a dynamic social process in which individuals construct their identity interactively with others and in relation to social context. Identity is not a property; rather, it is continuing process, situated in social and cultural settings.19–21 Identity, from this social relational perspective, is complex, fluid, and negotiated. As Gee10 describes, relational identity is “being recognized as a certain ‘kind of person’ in a given context.”

Through this scoping review, we hope to reveal what is known about the development of clinical teacher identity in clinical workplaces using individualist and social relational perspectives as organizing concepts. Whilst acknowledging the potential overlap of individualist and social relational standpoints, we intend to use these concepts to characterize the primary focus of the articles we review. The purpose of the review is to inform both the scholarship of clinical teacher identity formation in the health professions and the design of future faculty development initiatives for clinical teachers. Our scoping review question is “What is known about the relationship between the development of clinical teacher identity and the clinical workplace environments in which clinical teachers are situated?”

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Method

We structured our scoping review (June 2017) using five of the six phases outlined by Levac and colleagues: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) charting the data; and (5) collating, summarizing, and reporting the results.22 We did not enact the optional sixth “consultation exercise” phase.23 Our review team comprised two experienced health professions education researchers (T.D. and W.dG.) and a doctoral student (P.C.). The three of us agreed on the design and purpose of the scoping review, and we also conducted the literature search and the subsequent data screening process following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A585).

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Search strategy

We collaborated with a research librarian to develop a set of search terms and synonyms based on the aims of our review and our research question. We revised and refined the search terms based on the outcomes of an initial search of two databases (i.e., Scopus and Web of Science). We then entered the agreed-upon search terms (see List 1) systematically into 12 electronic databases selected to maximize the comprehensiveness of the search. The databases were Scopus, Web of Science, Ovid Medline, Cinahl, Embase, PsychInfo, ERIC, British Education Index, Australian Education Index, and three databases of doctoral research: ETHOS, Proquest, and OpenGrey. We further enhanced the sensitivity of the search by systematically searching the reference lists of highly cited studies.

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Data screening

We agreed upon an initial set of inclusion/exclusion criteria based on the aims and research question. We excluded studies that examined teacher identity solely in relation to settings other than clinical workplaces. We included studies that explored clinical teacher identity in relation to clinical workplaces even if the authors also examined identity formation in relation to other contexts. Given that our research focus was on the relationship between being a teacher in clinical settings and the development of clinical teacher identity, we used a broad definition of “clinical teacher” ranging from full-time clinicians who teach, to clinicians with academic and/or administrative appointments who also teach in clinical settings.

Two of us (P.C. and W.dG.) independently carried out a review of the titles and abstracts of 10% of the full set of journal articles and PhD theses uncovered in our search. The two of us met to address discrepancies and to revise the inclusion/exclusion criteria. Next, one of us (P.C.) applied the revised criteria to a title/abstract screening of the full dataset. Two of us (P.C. and W.dG.) conducted two subsequent rounds of data screening based on title and abstract review, using a similar process of independently reviewing a 10% sample and convening team meetings to adjust the research focus and the inclusion/exclusion criteria. Finally, the two of us (P.C. and W.dG.) conducted a fourth and final phase of screening which entailed a full-text reading of all the remaining studies to ascertain whether they met the inclusion criteria (see List 2). Figure 1 outlines the data identification and screening phases.

Figure 1

Figure 1

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Data charting

We used Microsoft Excel (Microsoft, Redmond, Washington) to develop a final dataset charting form as per Levac et al.22 The data charting form allowed us to identify demographic patterns in the dataset and facilitated data synthesis. Two of us (P.C. and W.dG.) used the charting form to extract relevant data based on a detailed full-text re-reading of all of the included studies.

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Data synthesis

We used thematic analysis to identify recurring patterns in the final dataset. We categorized studies as primarily representing either the individualist or the social relational perspective. One of us (P.C.) conducted the thematic analysis, and two of us (W.dG. and T.D.) validated the findings. Given the important role that theory plays in determining the interpretation and transferability of educational research, we used the “levels of theory visibility” typology as developed by Bradbury-Jones and colleagues,24 to categorize how the authors of the included studies explicitly applied theory. The typology includes five levels varying from level 1 (theory is “seemingly absent”) through level 3 (theory is “partially applied”) to level 5 (theory is “consistently applied” throughout the research process).

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Results

The search strategy provided 4,863 unique records following the removal of duplicates. The four screening phases yielded a final dataset of 34 research articles and PhD theses that precisely matched the inclusion criteria (see Figure 1).

We have summarized the demographic details of the final dataset—4 doctoral theses25–28 and 30 journal articles29–58—in Table 1. Notably, our findings show a significant increase in the scholarship of clinical teacher identity development since 2010. All the included publications were situated in developed countries and largely confined to the disciplines of medicine and nursing.

Table 1

Table 1

We found that 21 of the 34 included studies (62%) did not employ a theoretical framework to situate their research, and another 8 studies (23%) made very limited use of theory. Only 5 of the 34 studies (15%) integrated theoretical frameworks throughout the research process. Interestingly, the authors of 14 studies (41%) explicitly stated that they were using either a grounded theory or phenomenological methodology, implying a strong theoretical framework. Yet, on close reading, only 4 of these studies generated what Glaser and Strauss59 termed a “substantive theory” of teacher identity formation (i.e., a theory that arose directly from the analysis and interpretation of empirical data).

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Data synthesis

We categorized 24 of the 34 studies (71%) as primarily individualist in orientation (see Table 2) and the other 10 as primarily social relational (see Table 3). We identified the following three themes in the individualist studies:

Table 2

Table 2

Table 3

Table 3

  • (1) Identity juggling (How teachers position their various professional identities);
  • (2) Identity mutuality (How clinician and teacher identities relate to one another); and
  • (3) Identity integration (How teachers strive to develop a coherent teacher identity).

We identified four themes in the social relational studies:

  • (1) Identity as contingent (How teacher identity is contingent on social acknowledgment and support);
  • (2) Identity as negotiated (How teacher identity is co-constructed between individuals and workplace contexts);
  • (3) Identity as organizationally informed (How identity is shaped by organizational culture); and
  • (4) Identity as communicated (How identity is communicated between teachers and clinical peers).

Tables 2 (individualist) and 3 (social relational) present these themes schematically, and we further elaborate on the two themes in the text that follows. Whilst all included studies have quite distinct individualist or social relational orientations, some overlap between them is inevitable. This overlap means that we have been able to identify social relational findings within individualist-oriented studies and vice versa.

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Individualist themes

Identity juggling.

According to at least one of the articles we reviewed,38 being a clinical teacher meant walking a tightrope between teaching and other professional roles. The various ways in which teachers conceptualized their teaching role vis-à-vis their other professional identities (e.g., invisible, merged, compartmentalized, or hierarchical; Table 2) strongly influenced their teaching motivations and practices. For example, teachers with invisible teacher identities positioned clinical teaching as a low-complexity activity and, therefore, not as high a priority for their continuing professional development.25 In contrast, clinical teachers who conceptualized their teacher identity as explicitly merged with their clinician identity were more likely to value their teaching roles,34 espouse effective teaching behaviors,34 and engage with social networks of educators.44

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Identity mutuality.

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

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Identity integration.

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

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Social relational themes

Identity as contingent.

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

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Identity as negotiated.

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.

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Identity as organizationally informed.

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

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Identity as communicated.

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

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Discussion and Conclusions

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.

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Acknowledgments:

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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