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Identity Development in Professional Education* ???

2005; Lippincott Williams & Wilkins; Volume: 80; Issue: Supplement Linguagem: Inglês

10.1097/00001888-200510001-00029

1938-808X

George B. Forsythe,

Adult and Continuing Education Topics

What do educators in the professions and the publics they serve expect of their students and graduates? When this question is posed in a variety of professional settings, a common set of answers generally emerges: We want our students to acquire knowledge. We want them to have basic conceptual and applied knowledge, and we want them to have the clinical skills so that they will be competent practitioners. Our field is dynamic. We expect our graduates will continue to develop through years of practice. Therefore, we want them to be willing and capable of learning on their own from experience and continuous study once they leave school. We want them to have the values of the profession; we want them to be ethical, to reason about the ethical implications of practice. And we want them to be doctors, or lawyers, or engineers, or teachers, or ministers, or nurses, or officers; we want them to have a sense of themselves as professionals. What professionals know and can do is certainly critical—professional competence matters. However, these answers also suggest that who they are as professionals also counts. The public and those who prepare professionals for service have this intuitive sense that "who they are" influences how they practice. Hence, we want professionals who have developed a set of internal standards–an internal compass–that regulates their work, and we want them to be able to make the tough calls when their knowledge and skills are tested. We want professionals who have the emotional maturity and the where-with-all to act in the best interest of the client, regardless of external pressures. This is the area of professional education that my colleagues and I have been exploring for the past decade. Like educators in other professions, those of us involved in officer education in the military are concerned about more than the acquisition of knowledge and skills. For sure, we want officers who are technically and tactically competent, and we invest heavily in the development of professional expertise in officer education. But we also want officers who are persons of character, who can make principled, well-reasoned decisions about life-and-death issues in complex and often ambiguous situations. Witness the challenges confronting today's military professionals. The degree of complexity and ambiguity they face in the streets of Baghdad or the mountains of eastern Afghanistan are far more than soldiers faced during the Cold War—at the Berlin Wall or on the DMZ in Korea. And when we encounter professional error and mistake, it often has less to do with knowledge and skills than it has to do with the maturity, judgment, values, and professionalism. These outcomes matter. Theoretical Perspective on Development To understand these kinds of educational outcomes, we have turned to the literature on adult development for some insights. Harvard psychologist Robert Kegan has presented a broad and comprehensive theory of development we have used to inform our work.1,2 Kegan's constructive developmental theory posits major qualitative shifts in how people construct their understanding of themselves and their world. This understanding, Kegan argues, is central to one's personal identity and influences one's relationships with others. My colleagues and I think this framework may hold some clue to understanding professional identity, the sense of who we are as professionals. Kegan is interested in how people construct or organize their understanding of themselves and their interpersonal world. Psychological development, then, involves progressively more complex and encompassing ways of constructing this understanding, helping us to deal with the psychological and interpersonal demands of life. We speculate that this broader notion of psychological development may be relevant for professional development. Our understanding of self and the world has two features—content and structure.3 Content is the surface material—our behaviors, ideas, preferences, aspirations, style. It is the "what" that is "being organized." Professional values and expectations are important content that we imagine will be incorporated into a developing professional's sense of self. Structure refers to the way in which content is organized—its form, complexity, and levels of abstraction. Kegan and colleagues argues that individuals at different developmental levels may share similar content (values, for example) but differ in terms of how those values are structured and understood. So we may get fooled if we don't look beyond the content to understand the structure. Kegan posits a total of six stages of development (0–5) of which three are relevant to our discussion of emerging professional identity (stages 2, 3, and 4). Stage 2 Individuals at Stage 2 organize events into concrete categories and are able to take the perspective of others. This structure enables them to play social roles, delay gratification, follow rules, develop and pursue enduring interests, construct a stable sense of self, and participate in close relationships based on social exchange. Individuals at Stage 2 derive their self-esteem from competent performance of valued role behaviors and from achieving external goals. Stage 2 competencies are essential to adequate personal and social functioning. There are, however, limitations to a Stage 2 way of understanding. Although individuals at Stage 2 can take the point of view of others and understand their perspectives, they do so in terms of their OWN needs and interests. That is, their own needs become the lens through which they understand their social world. Now it's possible that these interests will be prosocial or socially acceptable—getting a good education or a job, for example, or helping others—but that is really the content of their understanding. And while Stage 2 individuals are concerned about others, their concern is related to what others will do with respect to them; there is no sense that how others feel about them defines how they feel about themselves. Stage 3 At Stage 3, new capacities emerge that are more encompassing. The Stage 3 individual is able to organize experiences and events into abstract categories and to view multiple perspectives simultaneously. This new ability allows them to become identified with others; hence, interpersonal mutuality emerges at Stage 3. Stage 3 individuals still have needs and interests, but they are able to look at them objectively and to see them in the context of shared understandings. Self esteem is based on an internal sense of being regarded by others. Stage 3 individuals are team players, able to subordinate self interests to societal ideals and expectations, and able to regulate current activities in the light of long range interests and concerns. A Stage 3 understanding is co-constructed: others' feelings become part of how Stage 3 individuals view themselves. While Stage 3 is more encompassing than a Stage 2 perspective, it also has limitations. Stage 3 individuals may expend considerable energy concerned about what others think about them and on avoiding hurting others' feelings, and they take personal responsibility for how others experience them. Others' feeling about them become part of how they experience themselves. Put another way, at Stage 3, we become our relationships; we experience a shared identity at Stage 3 rather than a personal identity. With regard to professional identity, it's as if Stage 3 individuals "are the profession"; they are fully bought in and take on all the expectations of the profession. The limitation, however, is that they are unable to reconcile competing expectations because they have not yet "integrated" the expectations of the profession into their own sense of self. Stage 4 At Stage 4, external expectations and identifications are restructured in terms of individually constructed expectations. At Stage 4 we can take a perspective on relationships and assess them in terms of self-authored principles and standards. The transition from Stage 3 to Stage 4 is the story of moving from "being relationships" to "having relationships." Stage 4 is about psychological autonomy. Self-generated values and principles provide a perspective on one's relationships; the shift is from shared expectations to personal expectations. The Stage 4 person is free to let others be individuals—because this is the first time that self is defined independently from what others think. While individuals have values (content) at both Stage 3 and Stage 4, only Stage 4 people can justify their values in terms of what they believe rather than some external standard alone. From a professional perspective, Stage 4 individuals have internalized and personalized the values and expectations of the profession—they are able articulate the relationship among expectations, and they "own" them as their own. Violations of such expectations bring a sense of violations of one's internal standards, not simply the violation of what others expect. Three examples illustrate what developmental perspective—structure– sounds like at each of these three stages. These excerpts are drawn from research with West Point cadets and Army officers, which is summarized in more detail later in the paper. Stage 2 The following example comes from a 20-year-old sophomore, talking about his understanding of good leadership. During an interview, he had mentioned that he feels more motivated when he has a leader who "puts out a hundred and ten percent." When asked to explain this comment, he makes the following statement: The leaders that I've had in the past, the ones that are really good, I perform well in there. If they are putting out a hundred and ten percent, and they are doing their best, you can visually see it; their uniform looks really cool. You know, if their shoes are really shined, you know, mine should get that good too. And if I see them putting a hundred and ten percent out for us, they're doing it for us—their own troops—and they really care about them, then I'm going to work that much harder for that person. A Stage 2 understanding is suggested in the social exchange nature of the relationship between the cadet and the leader—he puts out for me, so I'll put out for him. In this excerpt, we see the Stage 2 capacity to take two perspectives, one at a time: the cadet's and the leader's. As a follow-up, the interviewer seeks to clarify why it is important that leaders care. In response, the cadet explains: I guess for me it's because of the tangible rewards of what will happen if somebody does really care about you. Maybe, like for instance, if they are putting a hundred and ten percent out, then you're going to put a hundred and ten percent out there. And then you are all going to feel better about everything else. Here, the follow-on question clearly reveals the cadet's perspective that a motivated leader will yield "tangible rewards," and thus satisfy the cadet's personal needs. And presumably he "feels better about everything else" because he, individually, is being more successful. Stage 3 By way of comparison, consider the following description of leadership found in the interview of a cadet scored at Stage 3. I think the best cadet is the one who really understands that his real mission in life—in the Army—is being there for his troops. I mean he's got to have a commitment to the Army's goals overall. HOW DO YOU KNOW THAT'S THE RIGHT THING? I guess its one of those gut feelings that you have. And I'm of the firm belief that if you don't want that, if you're here just for yourself, you know, get the heck out of here. And, you know, the Academy kind of makes you realize that taking care of your troops is the most important thing. SO YOU HAVE THAT RESPONSIBILITY. WHERE DOES THAT RESPONSIBILITY COME FROM? I think the responsibility as a leader to take care of your troops comes from the fact that you're the lieutenant. In addition to the fact that you're a human being. You know, as a human being you have a responsibility, I think, to take care of everybody else. In this excerpt, we see that the Academy's expectations of an Army officer and the position of a lieutenant have become internalized and help define this cadet's perspective on himself. We don't see this cadet construct his understanding of leadership around his individual needs, as we did in the previous example of a Stage 2 point of view. Quite the contrary, he demonstrates the ability to take a perspective on self interest (a stage 3 structure) when he criticizes those who are "here just for yourself" and suggests they "get the heck out." Stage 4 The third example comes from an interview with an officer in his early 40s with about 20 years of commissioned service.4 The officer is talking about a leadership experience where he felt particularly successful. … I also feel to be successful you have to undergo hardships. You know, units and organizations, whether it's a staff organization—coming together not during good times, but overcoming bad times—inspections, field exercises, and stuff—that's where they come together. That's where you become successful. But my personal success is geared not by the jobs I have, by the ranks or medals I obtain, but by the accomplishments of the units and the people below me. WHAT'S THE MOST VALUABLE KIND OF INFORMATION THAT YOU GET FOR YOURSELF IN TERMS OF HOW YOU ARE DOING? It's my opinion, my assessment. I have never really doubted—even though OERs [performance reports] and awards from your superiors are nice pats on the back—probably my greatest satisfaction has always come from me just going out and watching somebody do something they could not do. Units who had problems before are now successful. SO IT'S YOUR OWN JUDGEMENT ABOUT THESE THINGS? If I think that's the best we can do, then I feel good. That's my philosophy. There have been times where I thought we did a good job and my boss has not. But, once again, I felt good and at peace with myself. Here we see an officer with a clear sense for how he understands his own success. This understanding of success is self-assessed; it comes from a set of internal standards that he can articulate, not from a need for tangible rewards (Stage 2) or how others perceive him (Stage 3). Research Findings in a Professional Education Setting What does this all mean for education in the professions? In his two books on the subject, Kegan posits that the transition from Stage 2 to Stage 3 takes place during adolescence and the transition from Stage 3 to Stage 4 is the primary emphasis of adulthood. In fact, according to Kegan, it appears that nearly half of Western adults spend their chronological adulthood making sense of themselves and their world from a Stage 3 perspective and trying to make the transition to Stage 4.2pp. 188–91 If this is so, then it has significant implications for the professions. If Stage 4 is essential to effective performance, then professional schools concerned about professional identity must attend to selection or development or both. This section summarizes research conducted within the military profession5 using Kegan's theoretical framework, focusing on two broad questions: (1) What is the pattern of development across an officer's career?, and (2) Does psychological maturity make a difference in professional performance? By examining the methodology and findings in officer education and the military profession I hope to start a dialogue and stimulate similar research in the health professions. What is the developmental pattern across an officer's career? Two related studies examined this question: (1) a longitudinal and cross-sectional study of West Point cadets, and (2) a cross-sectional study of Army officers at different career points. When combined, the data from these studies give us an initial glimpse of what is happening in the profession. Certainly, it is difficult to make stronger inferences about individual development based on cross sectional data, so I offer these findings as tentative. Developmental assessments. Developmental assessments involve semistructured interviews using the method detailed by Kegan and his colleagues.3 A respondent is given a series of index cards, upon which stimulus words reflecting emotion-laden themes (e.g., sad, success, torn, anxious and nervous, and important to me) are printed, and is asked to recall and to make notes on the cards regarding experiences reflected by the word. A trained interviewer invites the respondent to begin by describing one of the events that came to mind in response to a stimulus card. The interviewer then asks a series of follow-on questions to elicit the underlying perspective the respondent uses to understand the event. When the interviewer is able to elicit the respondent's underlying and most encompassing perspective, the interviewer invites the respondent to move on to describe an event elicited in response to another card. The interview continues in this fashion until the interviewer has confidence that the underlying meaning-making structure has been revealed. An assessment interview normally lasts about sixty minutes during which four to seven events are explored. All interviews are audiotaped and transcribed for scoring by one or more trained scorers. Extensive training, typically several hundred hours, is necessary before one can conduct an interview that is scoreable for stage level structure. Unfortunately, some interviews cannot be fully scored because some respondents have difficulty expressing their underlying perspective. Interview score. Using the typed transcripts, a trained scorer assigns developmental-level scores to what are termed "scoreable bits." Scoreable bits may be as short as a single sentence or as long as several paragraphs. Only responses which reflect the subject's underlying meaning-making structures are scored. The challenge of scoring is to sort out the structure from the content, which is not scored. Scores may be assigned for responses that clearly reflect achievement of a full stage (i.e., Stage 2, 3, or 4) or as representing the transition between two adjacent full stages. We calculated interrater agreement at several points in time throughout the project, and reached acceptable levels with the various raters. Longitudinal study participants. We gathered data on developmental level at three points in time during the four years at West Point—at the start of the first year, at the end of the second year, and at the end of the fourth year. We began with 38 in the original group, of which 31 were reinterviewed again at the end of the second year. To account for attrition, we selected at random an additional sample of 24 cadets who were also interviewed at the end of second year. From this combined sample, we reinterviewed 35 in middle of their fourth year. Of these, 21 were interviewed in their first year, 34 during their second year, and 20 at all three points in time. Attrition was a function of a variety of factors, including voluntary resignation, involuntary separation from the Military Academy, and refusal to participate in the study. While these samples may appear small, they are actually quite large for this type of research: this is also the only longitudinal data involving traditional college-age students in a professional school context. These are expensive data: each datum involves about 11–15 hours—2 hours to conduct the interview, 5–7 hours to transcribe the interview, and 4–6 hours to score the interview. Officer participants. We also interviewed officers at several different stages of their careers to get an indication for the developmental patterns across the career. Officer participants represent convenience samples from two grade levels: majors and lieutenant colonels. Thirteen majors attending the U.S. Army Command and General Staff College in the Class of 1996, and 28 officers attending the Industrial College of the Armed Forces and the Army War College in the Class of 1991 were interviewed. The majors had roughly 10–15 years of experience, the lieutenant colonels 18–21 years of service. Findings Developmental Patterns Table 1 presents the cross sectional results for the West Point cadets (at three points in time) and the two groups of Army officers. Three second-year interviews and three fourth-year interviews could not be scored and are, therefore, not included in the analysis. There is a clear trend across the various groups, with a general tendency for the lieutenant colonels to have the highest developmental scores. Fully half of this sample of late career officers were demonstrating full Stage 4 perspectives. More than three-quarters of the rest were in the Stage 3 to Stage 4 transition, and none were scored below a full Stage 3 level. The USMA cadets showed the lowest scores. None were shown to be at Kegan's Stage 4 by the fourth year, and fully a third of this group had not yet reached stage 3. As expected, the majors were intermediate between the West Point cadets and the more senior officers in their developmental levels. Like the lieutenant colonels, a substantial proportion (almost 40%) of the majors had reached Kegan's Stage 4, but we also see a much broader range of developmental level scores among the midcareer officers than might be expected. Although these findings hint at a potential developmental pattern, it is also possible that the small sample of majors (n = 13) or the selectivity of the lieutenant colonels may be the result of selection and not development, so these findings are only suggestive at this point.Table 1: Cross-sectional Results for the West Point CadetsHowever, the differences between the fourth-year cadet developmental level scores and the other two groups appear to represent developmental differences, not differential selection. None of the USMA fourth-year cadets who were interviewed had yet achieved Kegan's Stage 4; only two were well into the Stage 3 to Stage 4 transition. These results suggest that the development transition between Stage 3 and Stage 4 occurs after initial entry education once officers are engaged in their professional careers. This finding supports the proposition that Kegan interview scores reflect a progressive developmental process. An even more striking finding is the dramatic increase in the percent of subjects scored as functioning at Kegan's Stage 3 and above in the senior year. At the beginning of the first year only 16% were at stage 3. By the middle of the second year this percentage had risen to 25%. By the fourth year, these percentages had more than doubled to 62%. Many cadets appear to experience a significant developmental progression between the first and fourth year. The cadet longitudinal data bear out this proposition. Sixteen of the 28 subjects (57%) showed developmental progression. Only 2 subjects showed regression. Of the 10 subjects who showed no change from their second to their fourth year, half were already at Stage 3 during their second year, a stage beyond which many college students are not expected to move until somewhat later in adulthood, if at all. With the exception of the two instances of regression, which could be a function of the difficulty of obtaining a reliable developmental score, the longitudinal data suggest that Kegan developmental level scores are tapping a variable that shows progressive developmental change for many cadets. To determine the extent to which the developmental level of West Point cadets is comparable to students at civilian colleges, we obtained 20 scoreable interviews from a comparison sample of first-year students at a large state university in the southeast.6 We found no statistically significant difference between the two first-year samples, both groups were in the early phases of the Stage 2-Stage 3 transition. Development and Leadership. To see if developmental level was associated with leadership, a critical professional competence, we again relied on the data from the longitudinal study of West Point cadets, hypothesizing that more encompassing developmental levels would be associated with more effective performance in leadership positions.7 Measures. The cadets' Military Development (MD) grade provides a measure of leadership performance. The MD grade is a weighted average of military performance ratings by 3–4 key supervisors. Average MD scores were computed for the first two years (underclassmen) and for the final two years (upperclassmen). Military training and leadership during the two under class years are oriented toward mastering assigned military tasks in the role of subordinate. During the last two upperclass years, cadets must plan, organize, and perform as leaders in the organization. MD grades for upperclassmen are thus more reflective of leadership performance. As we expected, development scores were related to military performance at the upperclass (third and fourth years) level, where leader roles are paramount. Spearman's rho correlation coefficient of .41 (p < .01, df = 29) offers preliminary evidence that developmental level makes a difference, at least with respect to military leadership in aspiring officers. Thus, it appears that with respect to rated performance of cadet upper class leadership duties, but not performance of more routine lower class cadet responsibilities (e.g., appearance of the cadet uniform, neatness of one's barracks room), perspective-taking level appears to matter, and higher developmental levels are associated with higher rated performance. Implications for Education in the Health Professions What are the implication of this theoretical framework and these preliminary findings for education in the professions more generally? Theoretical implications The requirements of professional practice make development to Stage 4 a desirable goal within the professions. Until one reaches Stage 4, one is not a truly autonomous professional self, capable of authoring his or her own principles and values within the professional practice context. Self-authorship is important for professionals because they must deal effectively with the demands of professional practice where there is ambiguity and value conflict. Our preliminary findings do suggest that developmental maturity may make a difference, at least in one professional domain for one criterion measure. Although these findings are quite preliminary, they do suggest that this area is worth investigating further. The limitations of a Stage 2 perspective for health professionals should be apparent. Being subject to individual agendas—what's in it for them in a reciprocal sort of way—is antithetical to the values of the profession. No one wants a physician or health care professional who is only in it for the money, the fame, or the opportunity to advance some other personal agenda. What about Stage 3 health professionals? Certainly, the fact that they can hold others' perspectives on them is a big plus. They are team players who have internalized the values of the profession. Their values are those of the profession—they do the right thing because that is what they are supposed to do—they would let down their patients and the profession at large if they didn't. The problem with this is that physicians and other health care professionals must be able to make tough calls for the good of the patient, even when the patient or others might think poorly of them. Physicians must be able to resolve competing values and demands—they must be able to sort out expectations from all of the teams to which they belong. Until they have developed a personalized value system, one that certainly incorporates professional values, but also "authors" those values, then they have not come to the developmental point where they are prepared for the enormously complex demands they will face in their profession. Educational implications We were surprised to find that the story of cadet development was the Stage 2–3 transition. Following on Kegan's early work, we expected to find development characterized by transition between Stage 3 and Stage 4. However, other research with similar aged college samples also suggests similar developmental patterns: what is represented by the Stage 3–4 transition probably takes place after college, if it takes place at all.8 If our findings are generalizable, they suggest that for baccalaureate professional education, educators should consider how to facilitate the completion of the 2–3 transition and help initiate the 3–4 shift. It is unlikely that the 3–4 transition will be complete for most students during entry professional education, placing even greater demands on continuing professional education. For those in postbaccalaureate professional education, these findings highlight another challenge. Again, if these data are generalizable, then we would expect educators to focus on the 3–4 transition, with full recognition that these transitions take time. Conclusion Where might this line of inquiry might take professions education in the future? Three majors areas come to mind: theoretical, empirical, and practical. Theoretical Although the structure of professional identity is important, content also seems to matter. We want professionals to be able to sort out value conflicts using an internalized system of values, and the content counts. Future theoretical work might well focus on the intersection between structure and content in the development of professional identity. Empirical Extending this work to different professional groups is important, and we invite medical educators to join the effort. My colleagues and I are beginning to explore developmental growth with MBA students. The assessment challenge is enormous: these are expensive data. Further research will be enhanced with advancements in measurement; if theoretically possible, data collection procedures must be simplified for this framework to advance into other domains and support educational interventions. Practical Finally, what can we do in professional schools to support this dimension of student development? The related literature on adult development seems to point to the importance of challenging and meaningful life experiences, which speaks to the role of internships and practical experiences in professional education. However, much more work remains. This paper is based on an extensive collaboration over the course of a decade with Philip Lewis, Auburn University; Scott Snook, Harvard University; Paul Bartone, Industrial College of the Armed Forces; Craig Bullis, U.S. Army War College; and Patrick Sweeney, United States Military Academy. The results of this work appear elsewhere: Forsythe GB, Snook S, Lewis P, Bartone P. Making sense of officership: developing a professional identity for 21st century army officers. In: Snider D, Watkins G (eds). The Future of the Army Profession. Boston: McGraw-Hill Primis, 2002:357–78; Forsythe GB, Snook S, Lewis P, Bartone P. Professional identity for 21st century army officers. In: Snider D (ed). The Future of the Army Profession. 2nd ed. Boston: McGraw-Hill Primis, 2005: chapter 8; and Lewis P, Forsythe GB, Sweeney P, Bartone P, Bullis RC, Snook S. Identity development during the college years: findings from the West Point longitudinal study. J Coll Student Dev. 2005:357–73. Support for this project was provided by the U.S. Army Research Institute for the Behavioral and Social Sciences. The views expressed are those of the author and do not represent the views of the U.S. Army, the U.S. Military Academy, or the Department of Defense.