Education Theory Made Practical – Volume 2, Part 9: Constructive Developmental Framework

Constructive Developmental Framework

Jean Piaget, Lawrence Kohlberg, Robert Kegan

The medical student delivers his presentation after assessing a patient. The patient is described as a middle-aged man, without chronic medical conditions, presenting with unilateral calf tenderness and swelling that developed after playing soccer with his sons three days prior to evaluation.

After the full history and physical is presented, the MS4 confidently states that his plan is to order a venous duplex ultrasound, soft tissue ultrasound of the Achilles tendon, plain radiographs of the tibia and fibula, and blood work including a brain naturietic peptide level. He states that given the patient’s presentation he thinks a calf strain is probable but other conditions need to be ruled out: deep venous thrombosis, Achilles tendon rupture, tibia or fibula fracture, and new onset CHF.

The attending physician evaluates the patient and returns stating that the patient has a calf strain and will be discharged home without any further investigative studies, and with symptomatic care including NSAIDs.

The PGY3, having listened to both the medical student and the attending physician, is now wondering how she will coach the student to become more “self authored” in his approach to assessment and diagnosis.

“Constructive” refers to learning as an active process of meaning-making (or how we make sense of different experiences) ;“developmental” implies that these processes occur over time.¹ CDF postulates that the “ways of living in the world are not inborn, but rather are developed over time as we increase our capacity to take perspectives, view authority in new ways, and see shades of grey where we once saw only black and white.”² Robert Kegan described the stages of development through a progression from the first and second order minds of babies and children (ie, guided by impulse, needs, and wants) to the fourth and fifth order minds of some adults (ie, driven by their own internal morality and understanding of the complexity of the human experience).^2,3,4 Critical in readings about this theory is understanding of “Subject-Object relationship.”³ As an individual progresses through the stages of development, he/she moves from entirely “Subject” perspective, seeing the world as it  affects “me,” to entirely “ Object” perspective, being able to view their experiences from the “world’s perspective.”² ​

With progression through the orders, elements of meaning-making systems in each order move with us to the successive order, moving things from Subject (things that have control over us or “have us”) to Object (things we have control over).​ Although five orders of consciousness/development have been described, for adult educational theory we will limit our discussions to stages three to five (table 1).)

Table 1. Adapted from multiple references. ^1,5,6,7,8,9

Kegan’s theory developed out of Jean Piaget’s theory of cognitive development and Lawrence Kohlberg’s Stages of Moral Development. Piaget divided childhood development into four stages, from an “egocentric” sensory outlook to the formation of “abstract thought.”^10,11Similarly, Kohlberg’s six stages described the development of moral reasoning in a hierarchical fashion through three levels: pre-conventional, conventional, and post-conventional.¹² As an individual aged, his/her individual morality transitioned from one focused on “avoiding punishment” to one governed by “internal moral principles.”¹² These theories sought to describe human development as additive, progressing from one stage to another through experience and learning.

The CDF has been used in business and educational fields to improve leadership and management training. This theory is particularly useful in the context of professional development. One constant of career advancement, regardless of field, is that the work and responsibilities tend to become more complex as one advances. Valcea et al. argued based on Kegan’s work for the “co-development” of “leaders and followers.”¹³ By using “delegation, participation, and feedback”, individuals are exposed and guided through complex situations to prepare them for advancement.¹⁴

Other groups, including Kegan’s own later work, have advocated for experiences intended to lead to “transformation” in order to “increase participants’ effectiveness in understanding and enacting their roles in order to meet the shifting and increasingly complex expectations.”¹⁵ Kegan’s original framework described an individual’s perspective transitioning from simple to diverse and allowed for the creation of training programs to support this progression.

Progression through an emergency medicine residency requires personal development. The goal is transformation of learners into independent practitioners able to balance the complexities of patient presentations and the requirements of the complicated practice environment. It is the responsibility of educators to help resident learners to progress through Kegan’s stages, from “loyal followers” (third order) to “independent thinkers (fourth and fifth order).”³

One way to think about CDF in medical training is to compare competency based educational goals and matching these to the processes outlined in different orders of thinking (noting that different learners advance at different rates). Kegan’s theory provides an appropriate lens through which to analyze the work done by residents on shift in the department  (their cognitive and social growth through residency.)  In a cognitive task – this may model the competency of literature assessment. Stage 3 learners may take an article at face value – or under sole opinion of their mentor or teacher discussing the article. When learners get to 4th order they should be able to appraise and analyze the article independently without influence from others. Lastly 5th order learners may be able to take the article in context and appreciate its limitations and praise – and furthermore see how the article applies to a larger context of literature on the subject.

The CDF framework may even be applicable to the RIME framework as well (reporter, interpreter, manager, educator/leader roles of residents). As residents progress through the different CDF stages so inherently should their cognitive reasoning/decision making process and ability to manage the cognitive and social complexity of leadership in different contexts (self, interprofessional teams, organizational teams).

Transformative growth can be supported through observation of role-modeling by attending physicians both in clinical and leadership roles, self reflection on observations on different perspectives and leadership styles, and increasing levels of clinical autonomy and supervisory roles (combined with formative feedback) as residents progress through training.

The CDF provides a structure to understand how people grow intellectually and socially

as they age. Limitations have been noted that the model does not explicitly deal with the context/complexity of the human being who is progressing through the stages of development; there is no specific part of the framework that addresses intelligence, morality, wellness, gender, or ethnicity. ²

There is also an inherent negativity when a hierarchical system is used to describe individuals with different skills and outlooks.² The assumption is that being in the Fourth Order is superior to being in the Third Order. While this may be true in some scenarios, for example in leadership positions, it may not always be better to be further along on Kegan’s steps. Teams typically benefit from diversity; a team full of leaders is not always the most effective. Different learners will also progress at different paces through development.

Rodgers C, Scott K. The development of the personal self and professional identity in learning to teach. In: Cochran-Smith M, Feiman-Nemser S, McIntyre DJ, Demers KE, ​Handbook of research on teacher education: a project of the Association of Teacher Educators​. New York, NY: Macmillan; 2008. https://www.routledgehandbooks.com/doi/10.4324/9780203938690.ch40. Accessed June 28, 2017. 

Rodgers and Scott (starting on page 739) discuss the role of Kegan’s framework in each development. They provide descriptions of how teachers from different stages see themselves interacting with the world around them. They also build off Kegan’s work and discuss teacher education programs that have been developed based on his and similar theories.

Berger JG. A summary of the Constructive-Developmental Theory of Robert Kegan. StudyLib; 2007. http://studylib.net/doc/7860146/a-summary-of-the-constructive-developmental-the-story-of-robert. Accessed June 25, 2017. 

Jennifer Berger provides a nice summary of Kegan’s theory through the lens of adult professional development. She provides case studies to better describe the more advanced stages. She also discusses the main critiques of this model – see limitations section of this paper.

Helsing D, Howell A, Kegan R, Lahey L. Putting the “Development” in Professional Development: Understanding and Overturning Educational Leaders Immunities to Change. ​Harvard Educational Review.​ 2008;78(3):437-465.

In this later work of Kegan and colleagues, his original theory is expanded upon to discuss barriers to growth which they call “Immunities to Change.” Through guided exercises, teachers expose assumptions/perceptions that they are “subject” to that are limiting the ability to move towards their goals. The experience of identifying what they are subject to and object to as well as identifying what conscious or unconscious behaviors that they are doing which keep them ‘Subject’ to begins the process see the world in a new way and facilitate progression of thoughts/assumptions/beliefs from “subject” to “object.” This process of transformation can lead to clearer pathways to complete goals/missions based on values and lead to clearer perspective on perhaps some internal conflicts.

While the medical student was right in considering deep venous thrombosis , Achilles tendon injury, fracture and congestive heart failure, the student will need to be able to go through a process of coming up with/trying out his own process/framework to approach diagnosis and assessment. The resident decided to help the student (likely in third order) by taking the time to have a discussion with him about his work up, and the influence that other attendings and books have had on his presentation and evaluation style during this rotation. She used the time to role model her decision process. She helped the student create a comparison table of illness scripts based on the student’s differential list. She engaged in an open discussion with the student regarding the gap between her determined pre-test probabilities for the possible diagnoses and the student’s. Furthermore she modeled using decision-making tools, including Wells’ Criteria for deep venous thrombosis, and discussed how different tests could change her plan for diagnosis/treatment. Finally she asked the student to reflect on what strategies for diagnostic reasoning resonated for him based on other approaches he had seen.