Currently, PIF among pharmacy students has been studied worldwide using questionnaires [7–9], interviews [10, 11], focus groups [12, 13], reflective essays [14, 15] and personal narratives [17]. These studies concluded that pharmacy educators need to consider how to address the variation in how pharmacy students understand professional practice [8] and identify variables that could lead to the increased development of PI, such as having pharmacy experience before starting pharmacy school [7]. Interventions like work-integrated learning with coaching [9] and using innovative strategies such as “role-emerging placements” [10] can improve students’ PIF. More innovative methods of studying PIF in pharmacy students are needed to assess their PIF development over time.

In a study conducted by Bernabeo et al., a set of vignettes involving challenging professional situations was developed, and 40 practicing physicians with relatively diverse experiences completed these vignettes [18]. The study found that the vignettes prompted reflection on the intended areas and a reflective approach allowed physicians to engage with the complexities of their work. This suggests that similarly structured, challenging case vignettes could be an effective tool to foster PIF among pharmacy students by encouraging critical reflection on real-world dilemmas.

Currently, multiple student development theories have been used to inform interventions geared toward PIF, such as self-determination theory [6], social identity theory [15], Baxter-Magolda’s self-authorship theory [14], Crenshaw’s theory of intersectionality [19] and more. One theory missing from pharmacy literature is the use of Mezirow’s TLT [16]. The use of TLT has been studied within medical education with positive results. To date, TLT has been utilized as an andragogical approach in practice-based quality improvement curricular design within medical education. A scoping review performed by Vipler et al. analyzed 28 articles that mentioned “transformative learning” or “transformational learning” and involved those in graduate medical education [20]. None of the articles included trainees from the pharmacy profession. One of the largest themes found in this scoping review was the strong relationship between transformative learning and professionalism. Given that reflection is a foundational component of transformative learning, this connection highlights the potential for structured reflective activities to serve as a catalyst for professional identity formation in pharmacy students. See Appendix A for the ten phases of Mezirow’s TLT in the process of simulation-based learning in healthcare education.

The Professional Self Identity Questionnaire (PSIQ-9) and the Macleod Clark Professional Identity Scale (MCPIS-9) are validated tools that have been used to assess self-perceived PI among health professional students. Originally developed and validated in cohorts of health and social care students in the United Kingdom, the PSIQ-9 was designed to explore how different educational experiences shape identity formation, while the MCPIS-9 aimed to measure variability in PI among students from various disciplines [21, 22]. Each instrument consists of nine items scored on a 5-point Likert scale.

While these tools have been applied in early studies of PI, particularly in medicine and nursing, their use has become more limited in recent years. In addition, the use of quantitative tools to measure the complex and deeply personal process of PIF has been critiqued. Matthews et al. emphasized the need for caution in interpreting quantitative results related to PIF, noting that such tools may not fully capture the nuanced, reflective, and contextual nature of identity development [23]. Similarly, Garza et al. argue that while quantitative instruments can offer a snapshot of students’ self-perceptions, they may be insufficient when used in isolation to assess the impact of PIF interventions, particularly those grounded in transformative learning [24].

In selecting the PSIQ-9 and MCPIS-9 for this study, the goal was to employ accessible, previously validated instruments that would allow for comparison to existing literature and provide a standardized metric for gauging self-perceived changes in PI. However, it is acknowledged that these tools may have limitations in detecting change following a brief, curriculum-based intervention grounded in Mezirow’s TLT. The PSIQ-9 and MCPIS-9 focus primarily on general perceptions of PI and do not include items that assess critical reflection, meaning-making, or transformative shifts in perspective. As such, while these instruments offered a practical means of capturing baseline and post-intervention perspectives, they may not have been optimally aligned with the reflective and experiential dimensions of the disorienting dilemma-based learning strategy used.

This single-center, prospective, interventional-cohort study included second-year pharmacy (P2) students enrolled in the Fall 2023 semester of an introductory to pharmacy practice (IPPE) hospital skills-based course at a large-public-urban college of pharmacy. Seventy-nine students were eligible to participate based on course enrollment. The concepts of TLT and PIF were introduced via a didactic lecture and activity on the first day of class. After the lecture, the research team presented the study protocol and requested student participation. Participation was elicited at three points: week 1 (baseline), week 8 (midpoint), and week 15 (endpoint) of the course. Class time was provided for each data collection point, and an email reminder was sent 1 week after each class period. Refer to Table 1 for the questions and answer choices included in both questionnaires.

Students enrolled in the course were required to complete the TLT-based PIF toolkit. Students were asked to read an assigned disorienting dilemma case vignette and respond using the TLT-based reflective questions (Table 2). These reflections were conducted via an asynchronous video recording platform in groups of four or five. Students recorded their own responses, listened to their peers’ responses, and then reflected again after hearing their peers’ perspectives. The three-week reflective process occurred four times, a total of four vignettes assigned, during the 15 weeks of the semester. Each week, the students independently completed the reflective process—spending approximately 10 min per week on the activity. The research questionnaires were administered at baseline before any interaction with the toolkit, at the midpoint after completing two vignettes, and at the endpoint after completing four vignettes.

The toolkit was crafted through an iterative process by the principal investigator. Initial focus sessions, with practicing pharmacists, led to the creation of eight disorienting dilemma vignettes derived from the AACP Core Entrustable Professional Activities (see Table 2). The TLT-based PIF tool kit was then evaluated by PIF experts, individuals who have written or spoken on the topic of PIF within the pharmacy educators’ academy, for alignment with pharmacist PI values and beliefs.

Inclusion criteria were pharmacy students enrolled in the course who were over the age of 18 years, able to consent to research, and had completed the TLT-based PIF toolkit as well as the PSIQ-9 and MCPIS-9 questionnaires at baseline and midpoint, or at baseline, midpoint, and endpoint. There were no exclusion criteria beyond those who did not meet the inclusion criteria; however, students who had incomplete questionnaire were not included in the results.

The primary outcome was to assess the change in PI as measured by the mean difference in scores of student pharmacists’ questionnaire responses from baseline to endpoint regarding their PI after completing the TLT-based PIF toolkit. The secondary outcome was to assess the growth of PI over time as measured by the mean difference in scores from baseline to midpoint and from midpoint to endpoint.

Basic descriptive statistics were used to analyze students’ baseline characteristics. The Wilcoxon signed-rank test was employed to evaluate the nonparametric-paired, ordinal data collected from the PSIQ-9 and MCPIS-9 for both the primary and secondary outcomes. Additionally, descriptive statistics were used to analyze the responses from the PSIQ-9 and MCPIS-9. To examine individual-level trends not evident in group-level analyses, we descriptively coded item-level score changes as development (any increase in Likert score from baseline to endpoint), stasis (no change in score), or regression (any decrease in score), following an adaptation of King et al. [25]. For example, a change from 3 to 4 was coded as development, while a change from 5 to 2 was coded as regression.

Among the 11 student pharmacists who completed both questionnaires at baseline, midpoint, and endpoint, most of their PSIQ-9 responses did not change significantly from baseline to endpoint after completing the TLT-based PIF toolkit; only one question showed a difference. The mean increase in scores from baseline to endpoint ranged from 0 to 0.64 across all nine components of the PSIQ-9, with a difference showing PI growth found in the question related to teaching others (+0.64 [p <0.05]). No other questions showed significant differences in responses. Most students demonstrated PIF development on questions about communicating with patients, considering ethical or moral issues, and teaching others. Most students exhibited PIF stasis when asked about working with other healthcare professionals, using patient records, and being involved in a patient emergency. Students showed equal amounts of PIF development and stasis regarding questions related to assessing a patient, engaging with others in a culturally diverse healthcare environment, and reflecting on experiences to identify learning needs. See Table 4 for all primary outcome results.

For the MCPIS-9 responses, most of the 11 student pharmacists showed no significant change from baseline to endpoint after completing the TLT-based PIF toolkit, with only one question showing significance. The mean change in scores from baseline to endpoint ranged from 0 to 1.27 across all nine components, with a significant difference found in the question related to students feeling ashamed of studying pharmacy (−1.27 [p = 0.049]). No other questions showed significant differences in survey scores. Using the descriptive coding, none of the questions demonstrated a majority of PIF progression among students. Most questions showed PIF stasis, while PIF regression was most common in relation to feelings of shame about studying pharmacy and making excuses for belonging to the profession. See Table 4 for all primary outcome results.

Among the 39 students who completed both questionnaires only at baseline and midpoint, most of their PSIQ-9 responses showed no change after completing half of the TLT-based toolkit. The mean increase in scores from baseline to midpoint ranged from 0.10 to 0.49 across all nine components, with significant increases found in questions related to communicating with patients (+0.46 [p = 0.011), using patient records (+0.49 [p = 0.036]), and teaching others (+0.44 [p = 0.021]). Descriptively, most students demonstrated PIF stasis across all questions, though more students showed PIF development than PIF regression. Approximately 15–23% of students selected “N/A” as an answer choice at either baseline or midpoint.

Regarding the MCPIS-9 responses, most of the 39 students showed no significant change between baseline and midpoint after completing half of the TLT-based PIF toolkit. The mean change in scores ranged from −0.28 to +0.05 across all nine components, with no significant results. Descriptively, most students exhibited PIF stasis for all questions. For most questions, more students demonstrated PIF regression than PIF progression. However, regarding feelings of belonging to the pharmacy profession, more students showed PIF progression than PIF regression and equal numbers demonstrated PIF progression and regression in terms of identifying positively with members of the pharmacy profession.

Among the 11 student pharmacists who completed both questionnaires at baseline, midpoint, and endpoint, there were no significant results for either questionnaire from midpoint to endpoint after completing the TLT-based PIF toolkit. For the PSIQ-9 questionnaire, the change in mean scores from midpoint to endpoint ranged from −0.73 to +0.09, with no significant results. For the MCPIS-9 questionnaire, the change in mean scores from midpoint to endpoint ranged from −0.73 to +0.27, again with no significant results. See Table 5 for all secondary outcomes in more detail.

There were several limitations in this study. The first limitation is that only 14% (11 out of 79) of eligible students participated across all time points. This is likely because completing the questionnaires was not a requirement for course completion and students may not have perceived a benefit. As a result, the sample size is small and may not be generalizable to the entire class or other P2 students.

Additionally, our study, similar to others [21, 27], experienced lower response rates as the study progressed, which may be attributed to questionnaire fatigue, especially at the endpoint, since students were simultaneously completing multiple end-of-semester course and instructor evaluations. Despite providing 10 min of class time to complete both questionnaires, it remains unclear how students utilized this time. Some questionnaires were also incomplete and thus not included in the results, further contributing to the small number of students in this study.

Another limitation is that the original validated PSIQ-9 questionnaire included “N/A” as an answer choice. As a result, in our secondary outcomes, 15%–23% of students selected “N/A”; had this option not been available, we might have gained a better understanding of their PI, as they would have been required to choose from the other available options. Additionally, the phrasing of questions in the MCPIS-9 questionnaire may have confused students if they did not read them carefully, as questions 3–5 were negatively worded. For example, if a student quickly selected “5” (strongly agree) for all the questions without reading carefully, they would indicate that they “strongly agree” with being ashamed of studying for the pharmacy profession in question 3. If this happened with multiple students, our primary outcome showing PIF regression in questions 3 and 4 of the MCPIS-9 questionnaire might be inaccurate.

Moreover, this study could not account for potential confounders. Many factors outside of the TLT-based PIF toolkit might influence students’ PI. For example, positive and negative experiences during their once-weekly IPPE rotations, other coursework, and even the news may impact PI. Research by Dee et al. found that more than 51% of pharmacists experience burnout [4], which is also highlighted in the news, such as reports of nationwide walkouts by community pharmacists at large corporations [28]. Therefore, students’ scores on the questionnaires might have remained the same or regressed from baseline to endpoint due to negative experiences outside of the TLT-based PIF toolkit.

The lack of significant change in PIF, as measured by the PSIQ-9 and MCPIS-9, coupled with the controversial and declining use of these quantitative instruments in recent literature [23, 24], suggests that these tools may not be appropriate for evaluating short-term, reflection-based interventions in pharmacy students. While both instruments have demonstrated past utility in broader health professional education [21, 22, 27], their ability to detect the nuanced, individualized, and developmental shifts inherent to PIF is limited. The findings from this study support the growing argument that these quantitative tools may lack the sensitivity needed to capture the depth of change prompted through reflection [23, 24], and future use of the PSIQ-9 and MCPIS-9 in similar pharmacy education contexts is not recommended.

Rather than focusing solely on quantifiable change, future research should prioritize qualitative methods that align more closely with the core tenets of PIF and TLT. Reflective writing, narrative analysis, and discourse-based interviews offer the opportunity to capture thick descriptions of how students process, internalize, and make meaning of disorienting professional situations. Such approaches are better suited to evaluating the inner transformation students may experience, especially in cases where discomfort, value conflicts, or uncertainty arise. The rich data currently being analyzed from students’ reflective responses to the TLT-based toolkit is expected to offer greater insight into these developmental processes.

In addition, future iterations of the toolkit should incorporate structured debriefing led by pharmacist facilitators. While the toolkit prompted internal reflection, the absence of guided discussion may have left students with unresolved dissonance or uncertainty about their professional roles. When instructors share their own experiences and model vulnerability, they demonstrate that identity development is an ongoing process [29]. This type of authentic engagement helps normalize ambiguity, fosters psychological safety, and supports students in meaningfully reconstructing their evolving identity as pharmacists.