The results of this study identify the reliable and valid tools, corresponding to the proper theories, for assessing and measuring the formation and development of professional identity in Health Profession Education. Out of the 17 studies included in the present scoping review, 14 used reliable and valid tools for the assessment of the formation and development of professional identity. There were also 13 tools developed based on specific underlying theories.
The available studies to assess the formation of identity have used three strategies more than others: standard inventories or repertory grids, open-ended interviews and open essays [12]. A variety of Scales or questionnaires can also be found for assessing identity formation in studies [39, 54]. It should be noted that there were several qualitative studies using open ended interviews and reflection writing that emphasized on different influential aspects for the formation and development of professional identity. Such studies were not included in our research [82]. In this study, only tools such as standard inventories or Repertory grids [46], scales or questionnaires [28, 33, 34, 44, 45, 47, 48, 51–53, 55] and open essays [12, 50] were included. Psychometrics of these instruments were either conducted in the study or were performed in future studies for the same target group or another one. Madil study (2005) uses tools such as repertory grids based on George Kelly's Personal Construct Theory and thereby investigates identity changes in medical students during the first year of medical education, especially in relation to their experience with cadaver dissection [46].
Tagawa's studies from 2019 to 2020 are among the studies that have developed scales and questionnaires to assess the formation and development of professional identity. Based on Kagan's theory, these studies created a Developing Scale (DS) and a quantitative questionnaire consisting of 27 items [39, 54]. Some studies have also used open essays tool to assess the professional identity and its formation or development and have used reflection writing. Among these studies, those aiming at developing and using the open essays tool were included in our study [9, 12, 25, 50]. Open essays are in fact open answers to questions and are considered as a qualitative tool. One of these tools is found in the Bebeau’s study in 2012. He proposed the Professional Identity Essay (PIE) tool for the formation and development of professional identity in dental students based on Kagan's constructive-developmental theory [12]. He stated that this tool for admission to colleges is a potential source of information about identity development and formation. However, considering the fact that the use of essay and the answers to open questions in a monitored environment often reflects the training of teachers to students to develop their professional identity with the help of reflection, it may not actually show the level of identity of individuals in real terms [12]. Kalet et al. adapted and used this tool to measure the professional identity formation in medical students in their 2016 and 2018 studies [9].
Despite high emphasis on the procedural nature of the professional identity formation, some of the identified assessment methods are based on observable behavior. But relying on visible behaviors alone will lose the recognition of important aspects of professional identity [16]. However, other studies believe that by measuring the visible behaviors and revealing some specific characteristics of the professional identity, a snapshot of the mentioned path and process is obtained [38]. These overall views can help one identify the path and the process of forming the professional identity. Also, Cruess, in his study in 2016, considers the main purpose of assessing the professional identity formation and his proposed "Is" level to be on top of Miller's pyramid to determine whether these behaviors and characteristics are an integral part of the learner's identity or not [16].
However, according to the emphasis of researches on developmental theory, the professional identity is a long and continuous process in the direction of formation and development. It is stable for relatively long periods, and generally makes its presence felt in dynamic transitions. There is also the possibility that a measurable growth in the professional identity formation will be expected in each student after a year and a half of training [25]. Considering the emphasis of studies on the process and continuous nature of the formation and development of professional identity, none of the tools identified in the studies had investigated the change in the formation of students' professional identity over time in the form of cohort study.
This hypothesis that the professional identity formation in students is a smooth, predictable, and linear way is an entirely untrue hypothesis. Basically, the pathways of development for every student are different from others and they are completely dependent on the context [9]. Cruess stated in 2015 that the professional identity formation in which medical students transform from beginners to people with the identity of a doctor will not only have a procedural nature but also have a variety of dimensions [83]. Some experts of linear models have considered the growth of adult professional identity very simple, but medical specialists consider the development and professional identity formation to be a very complex cultural and social phenomenon. To them, the professional identity formation is a multi-dimensional, evolving, and lifelong process during one's professional life rather than a procedure with a final destination [2, 9, 23, 27, 84–87].
Among the studies that deal with the non-linear nature of development and professional identity formation and try to quantify the complexity and processes based on the professional identity formation, one can refer to the Tagawa study which was carried out between 2019 and 2020. By considering the constructive-developmental theory of Kegan as the basis of research, Tagawa devised a development scale using a quantitative questionnaire with multi-step scales [39, 54]. He stated that the development scale could be a useful indicator for examining the progress of the individual and the developing professional identity of medical students and the process of their admission to professional society [39]. Moreover, using a quantitative questionnaire with multistage scales can facilitate the measuring and assessment of complexity and processes based on the professional identity formation [39, 54].
Kalet et al. drawing on Kagan's constructive-developmental theory also reported different individual patterns in their studies in 2016 and 2018 in general and addressed the non-linear nature of professional identity development [9, 25]. They also proposed that in the process of professionalism understanding and formation and development of professional identity we should move beyond the "shallow" understanding obtained by checklists of values, personality characteristics, or behaviors [9].
Several experts in their studies point out that one of the most important tools for assessing professional identity formation is self-reporting tools [16, 24, 88]. Basically, a large number of tools used are self-reporting. However, due to the complexity of the process of professional identity formation and its multidimensional nature, assessing and measuring it will require more complete self-reporting tools by adopting multidimensional assessment strategies. More comprehensive tools that assess the impact of experiences on the formation of a person's professional identity have a clear conceptual framework and provide the possibility of analyzing the continuous and non-linear process of professional identity formation. Valid and reliable tools, in addition to being applicable on a wide scale, consider the limitation of intercultural studies (considering that the professional development is influenced by the culture and context of any society) and facilitate assessment and identity development methods in Health Profession Education in different paradigms and among various national and ethnic communities [38, 39].
The results of this study will contribute to the future research in making informed decisions for the selection or development of a reliable and valid tool based on a clear conceptual and theoretical framework; tools to assess the formation and development of professional identity not only among students, but also among specialists in various fields of health sciences. Also, the relatively high diversity of identity and growth theories as theories underlying the tools developed in the studies can provide the possibility of comparing these theories to better explain the formation and development of professional identity.
Review Strengths And Limitations
There were several strengths and limitations in this scoping review. In terms of strengths, it can be pointed out that we have selected the process of study selection and search strategy in databases generally and extensively to ensure that nearly all the studies corresponding to the research question have been reviewed. Also, given the recognition of the reliable and valid tools by adopting specific theories as the basis of the study, especially identity development theories, these results can provide a valuable basis for future studies. In terms of limitations, it can be noted that deleting non-English articles may result in language bias. In addition, the quality of the studies entered was not evaluated, although this was accepted in scoping review. Some have suggested that the absence of critical appraisal inherently limits scoping review methodology and its ability to identify "low-quality studies" [89].