Genetic counselors with advanced skills: II. A new Career Trajectory Framework

Abstract

Career development frameworks help professionals better understand career decision-making, but the genetic counseling field lacks a comprehensive framework to describe career development. The purpose of this qualitative study was to explore commonalities across participants’ career trajectories and identify factors which influence decision-making throughout genetic counseling careers. Using purposive sampling, 17 genetic counselors with advanced skills were interviewed about their career trajectories, factors which influenced career decisions, and the process and outcomes of those decisions. Content analysis was both inductive and deductive, employing triangulation techniques to enhance analytic rigor. Results highlighted common experiences and critical processes of interviewees’ career trajectories and contributed to the development of the Genetic Counselor Career Trajectory Framework (GCCTF), which depicts an iterative process of considering change in one’s career. Each iteration is prompted by predisposing influences (past experiences, personal attributes, and contextual factors), characterized by self-assessment and flexible planning, and completed when a decision about making a change is reached. Multiple iterations collectively create evolution of a career trajectory. The GCCTF adds to existing theories of career development by emphasizing dynamic processes of considering change and applies established concepts to a specialized healthcare profession. Individual genetic counselors can utilize the GCCTF to expand awareness of factors influencing a specific career decision and gain insight into experiences of change across their careers.

Introduction

Career choice and development were first examined through the work of Parsons (1909) who suggested that satisfactory careers result from three elements: accurate self-awareness, an understanding of differences among professions, and clear thinking on alignment between characteristics of self and profession (Patton and McMahon, 2014, p. 27). Other theorists similarly framed choice of career as a question of best fit between personal characteristics and the requirements of a particular line of work. Subsequent theories, such as Super et al.’s (1996) lifespan life space model, altered conceptions of career choice from an initial matching process to an ongoing strategy of career management (Patton & McMahon, 2014, p. 68). Savickas (2013), building on Super’s theory, expanded understanding of career development as a constant interaction between individual and environment, rather than the internal, cognitive process described in earlier theories (Patton & McMahon, 2014, p. 92).

More recent theories aimed to illustrate the inherent complexity of career choice and development by integrating attention to individual traits or characteristics of particular work roles with processes of career decision-making. Social cognitive career theory describes how career-related interests, goals, and choices develop over time due to a combination of factors that include personal attributes (e.g., gender, health status), environmental influences (e.g., exposure to role models, barriers experienced), and learning experiences. This theory states that people tend to set goals that are consistent with their views of their personal capabilities and of the outcomes they expect to attain from pursuing a particular course of action. Brown and Lent more recently updated the theory to a social cognitive model of career self-management that focuses on how a person directs a career instead of what factors or traits might be involved (Lent & Brown, 2013). Similarly, the developmental-contextual approach of Vondracek et al. (1983) describes interaction between the environment and individual characteristics, acknowledging that the environment, individual, and their interaction may change over time: “As the individual changes and as the contextual influences change, so too will the decision” (Patton & McMahon, 2014, p. 109).

Recognizing the unique contributions of multiple past career theories, current efforts to understand career decision-making seek convergence of past theories using a central, overarching framework. According to Jabareen (2009), a conceptual framework is a “network of interlinked concepts that together provide a comprehensive understanding of a phenomenon or phenomena.” These concepts “support one another, articulate their respective phenomena, and establish a framework-specific philosophy.” Frameworks provide “an interpretative approach to social reality, ... provide understanding, ... and can be developed and constructed through a process of qualitative analysis” (p. 51). Patton and McMahon (2014) presented the Systems Theory Framework (STF) as a “comprehensive conceptualization of the many existing theories and concepts relevant to understanding career development” (p. 242). The STF is composed of four main elements: the individual system, which includes traits and factors unique to each person; the contextual system, representing aspects of the surrounding environment, both local and global, primarily highlighting social norms, trends, and exchanges; interactions within and among systems and that these change over time; and chance (p. 273). Patton and McMahon suggest that the STF can be applied to interpret and guide individuals’ career decision-making. Although the STF framework includes the process of career decision-making, the decision-making process is not described in detail.

Pryor and Bright (2003) took the Patton and McMahon systems theory framework one step further by adding the element of chaos theory. They emphasized the uniqueness and creativity of individual responses to career changes and opportunities, and also discuss the idea that career success may occur with changes of direction that are not necessarily “advancement.”

In the genetic counseling context, Zahm et al. (2016) reported that genetic counseling professional development was influenced by clinical experience, colleagues, key experiences (such as job change), personal life experiences, self-reflection, and new scientific developments in the field. Compared with less experienced practitioners, seasoned practitioners reported more influence from life experiences and clinical encounters; they emphasized the importance of personal experience and reflection on professional development and were more likely to report that the profession of genetic counseling has changed since their early years in the field. Participants defined professional development as skill acquisition/development, broadening their scope and view of practice, and career advancement. Zahm’s (2016) conceptualization bears resemblance to the Patton and McMahon’s (2014) STF by highlighting factors within the individual (self-reflection and experiences similar to aspects of the individual system in STF) and context (colleagues and scientific developments similar to elements of the environmental context in STF) that prompt shifts in a career.

The Association of Genetic Counseling Program Directors (AGCPD) formed the Committee on Advanced Training for Certified Genetic Counselors (CATCGC) to explore and describe all avenues of advanced training that certified GCs use to expand their knowledge and skills, and to make recommendations about how to support the development of advanced skills. The CATCGC presented a pre-conference symposium at the 2014 National Society of Genetic Counselors (NSGC) Annual Education Conference on the topic of career trajectories. The terms “career trajectory” and “career development” are sometimes used interchangeably. We use “career trajectory” to refer to the sum of paths one takes over the course of a career, whether or not the path is associated with an increase in scope, responsibility, remuneration, and/or satisfaction (McKee & Eraut 2011; Oriol et al. 2015). “Career development” is often used to describe career management, especially in the literature on career counseling (for example, Lent & Brown 2013). Analysis of data collected during the NSGC symposium examined how career highs and lows influenced decision making about career goals, actions taken to change circumstances, and outcomes (Hippman & Davis 2016). Themes associated with high points were trailblazing, the necessary risk involved in change, acknowledging and nurturing self-worth, and shifting priorities. Themes associated with low career points were feeling stuck, being held hostage to workplace or personal circumstances, feelings of low self-worth, and experiencing a disconnect between expectations and reality. Career transitions were associated with seeking help from friends and colleagues, using the power of pain to motivate change, following one’s interests and passion to enable change, and gaining clarity by comparing the risks and benefits of potential changes to the current career situation. The important role of serendipity was also acknowledged. The tension between GCs wanting formalized supports such as career ladders or lattices and those believing that such formal supports would stifle creative career trajectories was discussed. Participants noted that positive career change may be subtle and involve deepening skills rather than changing jobs or climbing a career ladder.

Concurrently, the CATCGC developed a model of advanced training (Baty et al, 2016) based on the assumption that there are many types of advanced training utilized by certified GCs and many options open to the profession going forward. The CATCGC conducted an IRB-approved semi-structured interview study of North American GCs acknowledged to have the advanced skills described in the model, both to provide input on the model of advanced training and to share insights into how participants made changes in their personal career trajectories. Baty et al. (in press) reported results related to the goal of evaluating the model of advanced training, which was both validated and refined as GCs considered whether the model comprehensively and accurately reflected their own experiences.

The current paper reports results related to the second goal, exploring career trajectories of study participants by utilizing the rich descriptions of the positions, paths, and skills GCs pursued to further develop their careers, with attention to three main questions:

• What factors influenced interviewees’ trajectories?

• What were the motivations, facilitators, and barriers related to career decision-making?

• How might GCs and trainees use this information to create their own trajectories?

Methods

Participants

Purposive sampling was used to identify potential interviewees known to have experiences of advanced training for skills, along paths, or with positions included in our educational model. Advanced training was defined broadly - including both formal and informal methods of professional learning that genetic counseling professionals use to enhance skills and/or increase their knowledge base relevant to the performance of genetic counseling activities. A list of 77 potential interviewees was comprised of individuals nominated by four North American genetic counseling organizations (ABGC, ACGC (Accreditation Council for Genetic Counseling), CAGC (Canadian Association of Genetic Counsellors), and NSGC) as well as individuals nominated by CATCGC members. A total of 17 GCs was interviewed, with interviewees chosen to maximize the balance of advanced skill areas identified in the educational model. Thirty-five percent of interviewees had a doctoral degree. All NSGC regions were represented, two interviewees were Canadian, and many interviewees resided in more than one NSGC region at various times in their careers. Demographics, reported in Baty et al. (in press), were similar to overall demographics of the genetic counseling profession (94% White, 94% female).

Procedures

Interviewees were contacted by e-mail followed by a recruitment phone call. E-mails were sent to 18 potential interviewees, with one non-response. All 17 who responded participated in the interview. Those agreeing to an interview were sent a second e-mail which included an informed consent document and a link to a demographic questionnaire administered by SurveyMonkey. As specified in the informed consent cover letter, return of the questionnaire implied consent. The questionnaire collected information about each interviewee’s educational and professional experiences to provide contextual information for the interview analysis.

A semi-structured interview guide was developed by CATCGC members and reviewed and revised by a 5-member the analysis team, which included 3 North-American genetic counseling program directors and 3 members with substantial formal qualitative research expertise. The first objective of the study, to assess the model of advanced skills/knowledge development, is reported in a separate article (Baty et al., in press). To describe career trajectories of study participants and evaluate factors influencing career trajectories and decision-making (the second objective), interviewees were asked to describe the course of their careers, including positions held, roles performed, paths taken, skills and training needed for positions, how career decisions were made, and advice for others interested in their path.

Interviews, conducted between December 2015 and May 2017, were conducted by phone using both an interviewer and note taker. Eight CATCGC members conducted the interviews and served as note takers, including four of the authors. The length of phone interviews varied from 38–88 minutes, with a mean of 64 minutes. Interviewers utilized the interview guide to structure data collection and the note taker took notes to use for analysis. Interviews were recorded to allow for clarifying or corroborating notes, but recordings were not transcribed. Our methodology was based on an interpretive paradigm, in which data are co-constructed and extensive field notes are part of the interpretive process (Richards & Morse 2007). The audio recordings were used for back-up, verification and review when field notes needed clarification, and retrieval of exact quotes for publication (Halcomb & Davidson 2006). Notes and interview recordings were stored in an encrypted University of Utah cloud storage program developed for collaborative research. Codes with highlighted relevant text were extracted into an Excel spreadsheet. Data were organized both by code and by interviewee in order to control for overrepresentation or redundancy of coded segments from an individual interviewee.

Data analysis

The analysis team used qualitative content analysis, which was both inductive and deductive (Hsieh & Shannon 2005; Guest et al. 2006; Elo & Kyngas. 2008), to assess career trajectories. A preliminary code book containing 27 codes was developed by all analysis team members after reading through all interview notes. After preliminary coding of 10 interviews, the full analysis team refined, collapsed and re-categorized some codes. The collated codebook, which contained 22 major codes, was then used to code all interviews with periodic review of the codebook as coding proceeded. No new major codes emerged during this phase of the coding. The notes from each interview were coded independently by two analysis team members. Utilizing all five analysis team members, paired coders were mixed to maximize diversity and richness in the analysis, and every interview had at least one coder who did not interview or take notes for that interview. The pair assigned to each interview discussed coding calls, with the goal of seeking disconfirmatory evidence and of deepening and dimensionalizing thematic construction, and produced a final coded interview with consensus codes. All analysis team members reviewed all coded segments and both discussed and wrote memos on emerging themes. One audio recording was truncated, so the quote recorded by the notetaker was approved by the interviewee after the interview.

The literature on professional development, career trajectories, and theories of career choice and development helped to frame the analysis of personal stories of considering, pursuing, and reflecting on changes over the course of one’s career. We adapted the STF described in our introduction to build a framework – the Genetic Counselor Career Trajectory Framework (GCCTF) – which helped identify themes that were a good fit for the data. After relating our data to existing career development theories, we returned to our raw data again to ensure that all the themes in our framework mapped back to our data – as a form of technique triangulation (Humble, 2009). Major codes used in this analysis and their relationship to themes are presented in Table 1. Interviewee quotes are in italics.

Table 1.

Interview study of genetic counselors with advanced skills: Major codes and their relationship to themes

Code	Theme
1- Motivation to pursue advanced training – wanted broader picture; increased respect/autonomy; advancement, better job opportunities, higher salary, advancement, stability; following passion; augment existing skills; personal life constraints	1.a, 1.b., 1.c; 2.a.; 3.b; 4
2- Facilitators of advanced training – GC knowledge/skills; prior clinical work; mentor; openness to new experience; confidence; overall trends in medicine; opportunities/needs in workplace; deep self-reflection; lack of challenge; involvement in professional organization	1.a., 1.b., 1.c.; 2.a., 2.b; 3.b; 4
3- Barrier to obtaining advanced training – concern about limited job opportunities; training period involves hardship, investment not worth it; lack of awareness; don’t see need; loss of GC identity	1.a., 1.b., 1.c.; 2.a., 2.b.; 3.a
4- What professional organizations should be doing – provide accessible resources/investment, training, mentorship, advocacy; investigate other professions; manage expectations; promote introspection	1.a., 1.c.
5- Personal career trajectory – identifying need; seeking outside training; being planful; learning on the job; serendipity; alternative degree sequence; career path regrets; adjusting expectations; personal career stories; experimenting; changing career needs	1.a., 1.b., 1.c.; 2.a., 2.b.; 3.a., 3.b., 3.b.i., 3.b.ii., 3.b.iii.; 4
6- Advanced skills – synergy with core skills; advantages discovered after training	1.a., 1.b.; 2.a.; 3.b., 3.b.ii; 4
7- Roles that GCs take on or could take on – transferability of core skills; gaps GCs could fill	3.b
8- Pathways to advancement – reasons for following paths; necessity of path for given role; alternatives to paths; formalized versus non-formalized paths; advanced paths not necessary	1.a., 1.c.; 2.a., 2.b.; 3.b., 3.b.i.; 4
10- Positions – types of positions; disadvantages	1.c.; 2.b.; 3.a., 3.b., 3.b.iii
11- Advice/guidance - decide goals/find own path; learn from others, mentor, network, ask questions; persevere; be open to new things	1.b, 1.c.; 2.a, 2.b.; 3.a, 3.b.; 4
14- Other professional issues – value to field (both negative and positive)y, value to organization; professional identity	1.b.; 2.a., 2.b.; 3.a., 3.b.

Note: Themes: 1.a., Predisposing influences, past experiences; 1.b., Predisposing influences, personal attributes; 1.c., Predisposing influences, contextual factors; 2.a., Considering change, assessing self; 2.b., Considering change, flexible planning; 3.a., Outcomes, no change; 3.b., Outcomes, change; 3.b.i., Secondary Outcomes, paths; 3.b.ii., Secondary Outcomes, advanced skills; 3.b.iii., Secondary outcomes, job change; 4, Recursiveness;

GC, genetic counselor; Codes 4, 12, 13, and 15–22 are reported in Baty et al., in press.

Results

Interviewees included GCs with a large range of years of experience, positions, practice settings, advanced skills, and additional degrees (full demographic information reported in our companion paper (Baty et al., in press)).

Genetic Counselor Career Trajectory Framework

Descriptions of career trajectories revealed three prominent themes: Predisposing Influences, Considering Change, and Outcomes (Figure 1). The theme of Predisposing Influences was defined as factors which increased the chances of actively deliberating on potential changes to one’s career; Predisposing Influences did not dictate whether change would be made intentionally, only that change would be consciously/sincerely entertained. The theme of Considering Change illustrated thought processes of assessing self and engaging in flexible planning about changes in one’s career. The theme of Outcomes highlighted decisions about whether to make changes and results of changes made (most often acquired through advanced training), e.g., paths taken, skills acquired, and/or job changes made. These outcomes in turn may serve as predisposing influences and considerations for future iterations of change that iteratively and collectively constitute evolution of a GC’s career.

Figure 1. Genetic Counseling Career Trajectory Framework.

Theme 1: Predisposing Influences

When describing their careers, interviewees noted enduring influences of past experiences, personal attributes, and contextual factors in shaping and framing decisions to pursue or not pursue particular professional paths. Figure 2 summarizes the themes and sub-themes related to Predisposing Influences.

Figure 2. Influences predisposing to consideration of change to a genetic counseling career: Sub-themes within the theme of Predisposing Influences.

Theme 1.a: Past experiences

Interviewees credited past experiences as predisposing them to consider making changes in their careers. Past experiences of genetic counseling training, clinical work, and professional volunteerism enabled them to develop skills and confidence to imagine taking their careers in new and different directions. Interviewees cited skills (genetics expertise, psychosocial skills, educational skills, research skills, written and verbal communication skills, organizational skills, familiarity with healthcare systems) gained from their genetic counseling training and clinical experiences as important precursors of effective professional learning that promoted development of advanced skills. Prior clinical experience generally referred to clinical practice after graduate school, but a minority of interviewees cited only their clinical experience while students. Clinical experience was valued in non-clinical as well as clinical jobs.

I think really just having a very broad exposure to all the different kinds of diseases ... having an appreciation for genetic testing, and how it’s done. (Participant 10)

Anybody who’s coming out of a worthwhile genetic counseling training program probably already has great active listening skills and the ability to communicate complex or technological issues down to layman’s terms. Those are really, really, really great skills in public health. (Participant 16)

The experiences that I gained sort of built on each other… I felt more qualified than probably anybody else because of the experiences that I’d had and kind of fit what they were looking for. (Participant 1)

Several participants described how volunteering with professional organizations facilitated change consideration through networking and helping them to identify skills they wished to attain or refine through some kind of advanced training.

Theme 1.b: Personal attributes

The second category of influences predisposing to change-focused thought processes consists of personal attributes or characteristics: reflective practice, openness to new experiences, desire for new experiences, and confidence. Deep reflective practice was common, resulting both in decisions to pursue change or decisions to forego change. Openness to new experiences, along with willingness to take risks and seize opportunities, unique personal interests, and curiosity were all traits mentioned in connection with assessments of whether to undertake new training paths, and a desire for change or novelty promoted active consideration of available alternatives.

A person who’s willing to step out on a limb - that would be me - and try something different. (Participant 7)

Most genetic counselors are very bright and ... curious and those are two characteristics of a good researcher. We tend to be quite organized and we tend to ... complete tasks. We generally get along well with people so we would be good managing a research team. (Participant 4)

Theme 1.c: Contextual factors

The third subtheme within Predisposing Influences highlighted contextual factors which shaped stances toward change in career trajectory. Several participants suggested that attributes of a new position - novel tasks, roles, and colleagues - encouraged self-assessment and revealed the importance, utility, or necessity of advanced training to move them through change. Similarly, characteristics of the environment, such as emerging opportunities or shifting requirements, could inspire or require ongoing learning and advanced training. Workplace opportunities and needs included managerial roles, research, psychosocial care, interdisciplinary training, grant submissions, business start-ups, ethics violations, and availability of workplace training. A negative work environment was sometimes the impetus for change, as participants sought escape from stress or lack of fulfillment. Encountering colleagues or collaborators who provided mentoring was also noted as a prominent feature of work context which often inspired shifting opinions about the direction of one’s career. One prominent sub-theme was the role of serendipity in influencing career decisions. For example, serendipity manifested as unexpected changes in the workplace (winning a grant, restructuring, job offers, mentors), in one’s personal circumstances (geographical relocation, spouse’s work situation), or educational opportunities.

I was contacted by a headhunter for a different position ... and then my current boss said, “Gee, did you know we have this other job? I think your skillset fits this better.” ... all of it is an evolution and that’s what my career has been, it has been a series of fortunate opportunities. (Participant 7)

I had mentors who really pushed me and my fellow colleagues to grow, apply for grants and to do studies and to teach… And then I just evolved and took on larger and larger teaching responsibilities and larger and larger grant opportunities, larger research opportunities .... And then I volunteered ... at NSGC and ... picked up more skills …it just seemed serendipitous ... it just kind of evolved with a lot of mentorship and pushing and encouragement. (Participant 15)

More broadly, interviewees also cited overall trends in healthcare as influencing thinking about their careers. Trends such as genetic/genomics/precision medicine becoming more central to public health and medicine in general, new scientific discoveries, the explosion of genetic technologies, and the need for training of other healthcare providers opened opportunities for consideration of change, particularly through advanced training to maintain expertise and competence in an existing position or to expand a current job into new areas of practice.

I had the opportunity to be involved in some personalized medicine initiatives where I was helping to provide genetic counseling... I really gained an appreciation for how much need and how much opportunity there is to work in the space of physician and education for other practicing healthcare providers (Participant 11).

Interviewees also pointed to professional organizations, particularly the NSGC, for supporting development of advanced skills. Interviewees noted that professional organizations promote career development by offering networking events, mentoring and leadership programs, funding opportunities, and continuing professional training offerings (conferences, online courses, webinars, and specialty-specific groups and resources).

I think professional organizational leadership is very useful… having a leadership role within NSGC, it’s sort of free on-the-job training, right? ... there’s a difference between when I was on the committee or I’m part of the SIG versus I’m really involved and I’m talking to the leaders. (Participant 1)

Theme 2: Considering Change

In response to one or more Predisposing Influences, participants were prompted to enter a process of Considering Change, the second main theme to emerge from our data. Subthemes were Assessing Self and Flexible Planning (Figure 3).

Figure 3. Components of considering change to a genetic counseling career: Sub-themes within the theme of Considering Change.

Theme 2.a: Assessing self

Several interviewees noted the importance of self-reflection to identify and clarify motivations as they evolved throughout their careers. This process gave rise to emerging goals that inspired additional self-assessment, particularly before deciding on high investment training paths. Interviewees described multiple motivations and goals influencing consideration of change within their careers, often citing how these mingled and morphed over time.

The way that I made the decision ... was just a lot of self-reflection and thinking about what is it that I would need... what is going to give me the best chance of success in reaching my goals that I set out for myself? So, to expand the clinic ... I’m going to need these management skills in order to better run the clinic. (Participant 6)

Self-assessment was sometimes tied to changes in the field itself, fostering a corresponding need to consider additional knowledge or skill acquisition.

It comes back to the idea that we’re not fully formed. One lesson of my career is that genetics always changes and demands that we change. When BRCA was discovered, it was a game changer. Our job is to stay ahead of the field and prepare for what’s next. (Participant 7)

Sometimes as skills grew, this caused re-evaluation of a planned career path, either in the direction of new knowledge/skill acquisition or deciding that a previously under-valued path was a good career fit.

Research was not what I intended for myself. It was something that… I saw as the stepping stone to get where I ultimately wanted to be. But by the time that I generated all these data… I no longer wanted to do the direct clinical service delivery myself. I actually found that research and the academic track is a really good fit for me.... I get to do these amazing things where you’re achieving multiple goals at the same time. (Participant 8)

The most common motivations for considering change clustered around three themes – augmenting or developing existing skills, advancing one’s career, or following a passion – and many interviewees matched these motivations with a desire for advanced training. These motivations were tied to a variety of goals: to increase autonomy, improve performance, gain greater respect, attain advancement or increase salary, make a broader impact/work on the bigger picture, increase career flexibility, and seek a challenge. Motivations and goals were not mutually exclusive; for example, a primary motivation to improve skills may have arisen from a passion and could easily lead to career advancement.

The conscious desire to improve existing skills was evident in most of our interviews. GCs viewed improved skills as an end goal in itself, enabling them to be more effective in their current work. They also explained wanting improved skills as the means of achieving other goals such as greater independence, more respect, contributing to more effective interdisciplinary teams, or improving client services.

Initially, it was to increase my skill level and eventually I went into a track where I could have a license and that was so that my services would be available to everyone who needed them. (Participant 13)

Anticipation of career advancement or improvement frequently motivated participants to seek advanced training. These motivations were in service to goals such as increased or improved job opportunities, upward mobility, and career flexibility or stability.

Just being able to say, “Hey, I can see more than one side of the coin here. I have a more broad understanding,” I think is definitely marketable and opens up a lot of additional opportunities for someone.... I think being a genetic counselor and having an MBA, people go, ... Well I know what an MBA is, but that other thing is kind of interesting too.” (Participant 5)

The third common area of motivation to change one’s career trajectory was following passion, to achieve either personal or societal goals. Examples of personal goals were to experience challenge, explore a personal interest in practice or through learning, and the desire for one’s efforts to have a large impact. Societal goals included improving patient welfare, expanding access or increasing quality of services, and contributing to evidence-based practice.

Substantial ... long-term gratification ... I felt like I was successful in achieving my desired outcome [of influencing policy for groups of people]. (Participant 16)

Theme 2.b: Flexible planning

Interviewees expressed a need for planning and purpose when considering changes in their careers, particularly when making decisions about pursuing advanced training. Planning was described as including both structured decision-making as well as responding to chance occurrences and opportunities.

Structured decision-making included careful consideration of all relevant factors, with some serving as facilitators of decision-making and others acting as barriers. Many coupled self-assessments with actively searching for a way to use or develop their talents to improve and/or advance. Anticipated benefits of making a change such as initiating advanced training were assessed in connection with evolving motivations and goals. Motivations of augmenting existing skills were matched to anticipated benefits of advanced training in developing those skills, and goals of fortifying one’s career were tied to the anticipated benefits of earning qualifications for an existing or new position.

[T]here was only the place where I worked ... so if ever something happened and I wanted to leave that job or my job went away I really didn’t have any other options except to move out of the city, and I wanted to expand my ability to get other positions. Because the public health degree is somewhat generalized that allows you to really practice in any area of public health as well. (Participant 6)

When participants were motivated by passion, this was connected with a perceived benefit that advanced training could expand their scope of practice into areas related to that passion.

My interest came out of repeated observations of families in stress and not having the tools to move out of it. I wanted to be better trained. I was personally interested in helping the families and wanting to be a more effective genetic counselor. (Participant 7)

Several interviewees highlighted how deliberate decision-making was facilitated by the appeal of an expanded professional identity. They imagined themselves as professionals with greater capabilities, garnering greater respect, accomplishing more; these aspirational identities intertwined with evolving motivations and goals to which they purposefully matched advanced training that would help them achieve those identities and described how others could do so.

I think [training in curriculum development] will provide added value to them as a job candidate because they have the background and the framework for how to develop effective education and how to evaluate effective education .... I think it adds value ... because so many genetic counselors ... are expected to deliver education as part of their other job responsibilities. (Participant 11)

I’ve actually seen counselors who have done these hallmark studies that have been really important … they wrote the grant, they designed the study, but the person who got the money and is the senior author on all the papers is their PhD boss, because they couldn’t be the PI on the IRB application, they couldn’t be the PI on the funding source ... If you want to play in that world, it’s just really difficult to be accepted based on your merits alone. (Participant 15)

Anticipated benefits and expanded professional identities often facilitated consideration of change and eventual decisions in favor of advanced training by aligning with evolving motivations and goals. In some cases, knowledge and awareness of specific educational options facilitated deliberate decision-making on advanced training by illuminating a direct path forward; the process of decision-making was expedited by readily available means, instead of through clarified commitment to expected outcomes.

I got a [master’s] in epidemiology because the program at the university ... was very strong and it suited my needs, it was an evening program so I could work full time and I could potentially go to school full time and I ... was interested in research and I thought that a degree in epidemiology would be helpful. (Participant 3)

I didn’t know that I would benefit or not benefit [from a PhD]. It seemed like the next step to take and I had a good offer. That’s as much decision-making as went into it. (Participant 14)

In contrast to anticipated benefits, identity expansion, and knowledge of specific educational opportunities as facilitators of deliberate decision-making, interviewees noted corresponding barriers that typically led to decisions not to make a change in one’s career or to forego advanced training. Barriers included analysis of anticipated costs, identity anxiety, lack of awareness of educational opportunities, and seeing no need for change. Most barriers to considering change via advanced training arose in recognition of the anticipated costs of pursuing training, measured in the time, energy, and money required. Advanced training demands a large investment of time and money, or may involve other hardships such as moving to another part of the country. As these resources are finite, participants noted that engaging in advanced training challenged their ability to fulfill other work, family, and personal life commitments, which was experienced as another form of hardship incurred by advanced training. This was particularly true for interviewees who saw no immediate, obvious need for change in their careers.

In North America, a PhD can take 5 years and that’s ... a disadvantage if you’re not entirely sure what you’re doing it for ... There has to be this drive, this motivation to do it for something bigger than yourself. If that’s present, I think that the time isn’t a disadvantage ..., but if that’s not present, then that can be really problematic. (Participant 8)

Well, of course there’s pros and cons to being in private practice.... some of the cons, of course, are needing to do your own marketing and running the billing aspect ... there’s the possibility of isolation. There’s a lot of things you can to do to overcome that, but it is one of the potential downsides. (Participant 13)

Yes, I actually thought I might go to medical school ... why do I even think I’d want to do that? And largely it was because everybody kept saying to me, “why aren’t you a physician?”.... I really didn’t care about being a physician. I really was enjoying ... the work I was doing. So, I took that one off the table. And then I thought, ... maybe I should get my MPH .... I felt like I didn’t belong because I only had this MS and here I am teaching in the School of Public Health.... It doesn’t really change anything that I’m doing ... it doesn’t change my salary .... I can still do the same work .... I still publish the same amount. It was just sort of, letters after my name, so I decided, I don’t really care. (Participant 16)

Some interviewees noted that concerns regarding a loss of identity as a GC acted as a barrier to decision-making about making a change, particularly in cases where additional training could draw someone away from core genetic counseling tasks such as clinical care or alter one’s sense of self to that of another professional. Regret about loss of GC identity varied among GCs, as well as within individual GCs over the course of their careers.

I think many of us who’ve been in industry for a long time or who have left clinical jobs to go to industry .... you’ve gone to the dark side. There’s this feeling ... you’re not doing what you’re trained to be doing ... And I think that’s a natural feeling, but for NSGC to be inclusive of all genetic counselors regardless of their role ... would go a long way to people like me and others who have forged new paths and still identify as a genetic counselor. (Participant 5)

Some interviewees did pursue advanced degrees and purposely retained genetic counselor identification and certification.

You know, my PhD is not in genetic counseling. But because I identify so hard as a genetic counselor and I put that front and center in everything that I do academically, then you can’t take that out of the equation for me and my work. So, it’s how I present myself.... This is research I’m doing as a genetic counselor. [Participant 8]

Some GCs indicated that a lack of awareness of mechanisms of change, such as specific advanced training paths and how these might align with genetic counseling and types of jobs available to a GC with additional expertise, was a barrier to decision-making. There was also a fear that changes in level or scope of expertise might make one overqualified for certain positions or qualified for disagreeable roles, further limiting the range of jobs that are both available and desirable. Lack of awareness of options and alternatives complicated deliberate decision-making by raising questions regarding the balance of costs and benefits related to potential changes, or the need to change altogether.

People have…fears around closing doors for themselves if they were to take on a PhD after having trained as a genetic counselor…am I cutting off the possibility for myself of working clinically to provide clinical, direct patient service? And the evidence that I’ve observed here is, absolutely not. (Participant 8)

When you don’t know that you don’t know it, why would you ever consider learning about it? (Participant 9)

Considering change was marked by a preponderance of conscious self-assessment and deliberate planning. However, interviewees also intimated these careful analyses were coupled with the perpetual need to respond to chance occurrences. Whether opportunities occurred serendipitously or circumstances surrounding a deliberate decision changed, the process of deciding about a potential change required weighing pros and cons and an awareness that those pros and cons could and would be subject to chance. Some interviewees described initial resistance to serendipitous developments, but all eventually accommodated chance as it arose.

This job just happened to be advertised at the right time.... It just really ended up combining all of the things that I really wanted to find in my next career step. (Participant 9)

I hadn’t really considered that my career path would go in that direction [sales]. It kind of came to me, I didn’t really seek it out. (Participant 5)

Theme 3: Outcomes

The primary outcome of this decision-making process was the decision to either not make a change or make a change.

Theme 3.a: Decision not to make a change

If a decision was made not to make a change, that concluded the cycle of change consideration and no further outcomes followed directly from the decision. Any advanced skills or training options entertained during the phase of consideration of change were not actively pursued. The process of deciding not to make a change could act as past experience for future iterations of decision-making if and when future shifts in predisposing influences might initiate a new cycle of change consideration. One reason for deciding not to pursue specific advanced training was due to experiencing purpose and fulfillment in one’s current job.

Most of the time I’m probably not making a huge amount of money for my company [in laboratory utilization], but you can see the huge amount of money that you’re saving for patients and the healthcare system. Every day, every hour of every day, that is how much we’re changing things. (Participant 17)

Theme 3.b: Decision to make a change

When the primary outcome of consideration was a decision to make a change, secondary outcomes discussed in the interviews included: advanced education paths taken, advanced skills acquired, and job changes enacted – either within existing job roles or by taking a different job. Most GCs were pleased with the outcomes that followed from their decisions. A minority of this set of interviewees expressed regret about their career trajectory. When regret was expressed, it was most often in relation to a lack of change, such as foregoing advanced training or advanced degree, or late attainment of advanced skills. However, some GCs expressed regret about an unfulfilling path, sometimes not completing the path due to regret, or perceived lack of benefit following completion.

Theme 3.b.i: Changes made: Paths

There were many advanced training paths used by GCs to alter their career trajectories, including doctoral and second master’s degrees; certificates; courses of all types (e.g., non-matriculated, short courses, online); workshops and webinars; institutional training; on-the-job training; and self-directed learning (e.g., literature search, reading, experimenting). While career progression and advancement occurred with varying degrees of formal and informal training, onthe-job training was the most frequently mentioned path. Some participants experienced alternative sequencing of degrees (another post-graduate degree before their genetic counseling degree).

I got a lot of onsite training from [company] in terms of how to hire people, how to develop people, how to coach people; a lot of hands on experience with marketing initiatives, and understanding how they work and what’s really effective. (Participant 5)

I was definitely taking additional classes.... project management was 5 courses over the course of 2 years to really get an understanding about classic health project management. I ... completed that certificate, which really got me more interested in managing projects and being on that level as opposed to the doing side of things. (Participant 2)

While we only examined advanced degrees earned after a master’s in genetic counseling, skills obtained from prior degrees were often put to use by GCs and served as a predisposing influence.

Interviewees’ deliberations sometimes resulted in decisions not to pursue specific advanced training paths. In some cases, this was due to logistical barriers (discussed above).

And the reason I didn’t get a PhD ... I did my masters full time while working full time and I kept thinking back to those times and how really, really difficult those two years were. And I just couldn’t see myself doing it again and I couldn’t see myself not working and going to school full time. (Participant 3)

Theme 3.b.ii: Changes made: Advanced skills

Both positive and negative consequences followed attainment of advanced skills, although positive consequences were discussed more often in these interviews. Related to the acquisition of advanced skills were the bolstering of personal attributes, such as feelings of competence and confidence, and achievement of a wider perspective and scope of practice.

Nothing changed about my position when I got my PhD - same job, same salary. But what did change was ... the quality of the research that I was doing increased a lot. (Participant 14)

Gave me a language and a way of thinking so that I could work more deeply with patients and families .... Allowed me the confidence to go to places I would not have done with a two-year master’s degree behind me …. It gave the people I worked with the confidence to know ... that I wasn’t doing harm ... with the families .... there was an underpinning of scholarship that ... helped me to do it in a different way. It helped me tremendously to mentor recent graduates and help them to acquire skills that they were afraid to try on their own. (Participant 7)

As my skill level rose, my fulfilment also rose. The degree to which I felt that I was meeting patients’ needs - clients’ needs - increased and that certainly increased my own personal fulfilment. (Participant 13)

If you’re in charge of bringing in your salary through funding in this climate, it’s very, very distressing for a lot of researchers right now. I elected to take a teaching position that does not rely on the research and, in part, that helped alleviate some of that pressure and anxiety to get funding. (Participant 4)

Theme 3.b.iii: Changes made: Job change

The third category of outcomes was job change. Job change included a new role in an existing position, a new credential or title, a different job, or more intangible shifts such as increased respect, responsibility, or independence. Job change was contrasted with no change; for example, some interviewees considered a change and decided it was not in their best interest. In some cases, job change was necessary to advance in one’s career, whereas in other cases career advancement naturally followed from job change (either planned or serendipitous) even though that was not the primary intent of the change. Combinations of degrees and other types of advanced training often resulted in GCs with unique and/or multiple skill sets, which sometimes posed challenges in finding a fitting job. Yet when the right match was made between skill set and job, the position was felt to be very fulfilling. Acquiring advanced skills often enhanced the quality of work in new roles or positions, sometimes in unanticipated ways, as exemplified by the following two participants.

I’ve had a private practice for a long time .... Amidst the things that I’m doing now, I’m on a research team for a number of clinical trials. And I’m on the adjunct faculty at four different universities. (Participant 13)

What led me down the path that I took was early opportunities at [company], the ability to explore different applications of my training .... once I got into personnel management and started working with people and hiring them and developing them, it was really exciting and rewarding for me. (Participant 5)

Theme 4: Recursiveness

Training paths, skills acquired, and job changes – and the absence of these – followed from considerations of change. The impact of these outcomes was both immediate in altering daily work and long-lasting in influencing subsequent cycles of considering change. Paths to attaining new skills and job changes became past experiences and newly developed skills became personal attributes, providing predisposing influences for new cycles of considering change; outcomes of making these changes also shifted the spectrum of motivations and goals then incorporated into future iterations of self-assessment and flexible planning. Many interviewees described how their careers were the products of changes successively considered in this way in conjunction with the influence of, and response to, serendipitous occurrences or opportunities.

Advice for Other Genetic Counselors

Interviewees offered advice to reinforce important points they wished to make and to translate their experiences into action for other GCs contemplating career change. They encouraged others to experiment and be curious about new and different ways of working as a GC; to reflect on, identify, and clarify important motivations and goals; to carefully consider and examine alternatives by gathering information and asking questions; to network and seek mentors for guidance and support; and to be persistent through inevitable challenges. Of the interviewees who did not recommend advanced degrees for all GCs, some had advanced degrees and some did not.

I think my biggest advice is to “never say never.” I say look for what you want in the future but also be open to what comes up and what seems to be available where you are or where you want to be. (Participant 4)

And she [mentor] really just said, think about what you want and think about what’s important and what makes sense in your life now and [she] really forced me to think not up the ladder but across, over, under, around. And reminded me, it’s not about titles, it’s not about where you fit in an office. It’s about what makes you happy every day ... As long as you can pay your bills and as long as you are comfortable with what you’re doing, it’s not about going up the ladder all the time. (Participant 2)

Find the right fit in terms of training and experiences, in terms of your goals and personality. There’s not a cookie cutter way of doing it. There are lots of ways to get to the same point. If you’re interested in advanced training, look carefully at options… If it’s a core interest, explore it, but find the right fit. (Participant 7)

Identify some people that they could reach out to and either have a conversation or have a site visit or some kind of networking to see what that really looks like. In terms of reading, there’s almost no end to self-study that people could do in any of these areas, right? .... Networking and developing a group of people to learn from .... (Participant 5)

Have enough tenacity and stubbornness to stick with it and keep pushing it forward. (Participant 12)

You can’t do research unless you’re just really driven by it because there’s so much tedium and so much challenge in being funded ... publishing, et cetera, but if you love it, it’s like a drug.... it’s no fun if you’re not driven. If you’re doing it because you think you need to or it’s going to be a means to an end, don’t do it.... But if you really want something very stimulating and you want to feel you’re contributing something to the greater good, you should absolutely do it. (Participant 14)

Advice from interviewees was congruent with the GCCTF. For example, the advice to “experiment and be curious” links to the theme of Personal Attributes; “identify values and goals” links to Assessing Self; “examine alternatives” links to Flexible Planning; “network and find a mentor” links to Contextual Factors; and “be persistent” links to the overall iterative nature of the framework.

Discussion

The GCCTF provides a framework that describes factors affecting the evolution of GCs’ careers in an iterative process. Interviewees described many routes – both formal and informal – to achieve goals of advanced skills and career advancement. All interviewees went through change processes that were influenced by past experiences, personal attributes, and contextual factors and this resulted in advanced skills achieved through a multitude of training paths.

It is important to note that the framework is inclusive of changes that are considered but not implemented. Although decisions not to make change were described in some interviews, our sample of GCs were purposefully chosen on the basis of having opted to develop advanced skills throughout their career trajectories. It is likely that this led to overrepresentation of decisions to make change and highlighted positive secondary outcomes of those decisions in the form of advanced skills, advanced training, and intentional job changes purposefully pursued and acquired. Because we did not directly ask how decisions were evaluated, evidence of how GCs reflected on their decisions was indirectly derived from descriptions of secondary outcomes of acquisition of advanced skills. Career advancement theories (Magrane et al. 2012; Morahan et al., 2011) are oriented towards decisions to advance professionally and decisions not to seek advancement may be seen as failures or losses. Both the STF and the GCCTF incorporate decisions not to embark on a specific path as part of the framework of career decision-making.

The GCCTF captures the dynamic nature of career evolution as predisposing influences prompt change considerations, resulting in decisions about advanced training and/or career change. The process occurs repeatedly, with outcomes influencing subsequent cycles of predisposing influences and consideration of change, to perpetually introduce change throughout the span of a genetic counseling career. The multiple levels of change in our framework are consistent with the distinction made in career development theories between two types of change processes: microprocesses of independent instances of decision making and macroprocesses of progress or development over the course of an entire career (Magrane et al. 2012; Morahan et al. 2011; Patton & McMahon, 2014).

In comparison to previous literature on professional development and career development theories (Hippman & Davis, 2016; Magrane et al., 2012; Morahan et al., 2011; Patton & McMahon, 2014; Pryor & Bright, 2003; Zahm, 2016), our framework is consistent with a number of existing themes. Our findings regarding influences which predispose to active consideration of change within one’s career emphasize that decisions regarding advanced training do not occur in isolation, but rather through integration of a variety of influences internal and unique to an individual (personal attributes and past experiences) as well as external (contextual factors). Zahm’s observation that clinical work features prominently in GCs’ professional development is consistent with our interviewees’ claims that previous genetic counseling training and work experiences (represented in the Past Experiences subtheme of the Predisposing Influences theme) informed thinking about advanced training. Additionally, Zahm’s attention to reflective practice as a component of GCs’ professional development is mirrored by its presence as a personal attribute in the GCCTF. Our framework’s inclusion of contextual factors in the workplace and in medicine generally (also in the Predisposing Influences theme) is consistent with Patton and McMahon’s stipulation that multiple contexts - local to global, social and societal – shape career decisions and development. The GCCTF can be used by individuals to help plan their career trajectories, a topic also discussed by Pryor & Bright (2003).

Examination of the positioning of serendipity in our model - situated as both a predisposing influence and a force to respond to during consideration of change – aligns with previous attention paid to the role of chance in career development (Patton & McMahon, 2014; Pryor & Bright, 2003) and trajectory (Hippman & Davis, 2016). Collectively, it appears individuals are aware of the role of serendipity in their careers, tend to accept that chance events by their nature cannot be planned or prevented, and strive to accommodate and incorporate chance occurrences and opportunities through processes of flexible and creative planning as they make necessary adjustments to their decision making, though sometimes after initial resistance proportionate to the extent to which chance complicates or confounds previous planning.

Our framework emphasizes iterative cycles of considering change as a mechanism of career evolution, which is similar to mentions of past, present, and future and recursiveness in the STF of career development (Patton and McMahon, 2014) and the cyclical nature of career advancement found in Magrane et al. (2012) and Morahan et al. (2011). Our framework offers greater attention to processes of change consideration than previous work on professional development in genetic counseling or general theories of career development. Our framework explores and describes precursors to consideration of change, how change is actively considered (through processes of assessing the self and flexible planning), and how decisions and associated outcomes of these processes feed back into multiple points of an ongoing cycle.

Significance

This analysis offers an in-depth illustration of how GCs consider and make change in their careers, in contrast to views of a single, prescribed career path and consistent with an understanding of careers as constructed, complex, iterative, and inclusive of multiple influences such as advanced training and chance. Our framework coheres with the evident trend of GCs leveraging a strong, central skill set to take on an expanding array of roles, often aided by advanced training. We see the GCCTF as a complementary extension of our model of advanced training (Baty, et al., 2016) to a more powerful framework that situates advanced training in the context of large-scale career evolution and frames the processes and components contained therein as dynamic and integrated.

Our data support the STF by providing an example of its application to a specialized healthcare profession. We also expand on the STF by increasing the focus on decision making, elevating it to the central process that transforms separate influences to decisions about change. Although our framework represents processes and components of decision making within the genetic counseling professional context, and context is important as a predisposing influence, the expanded role of the decision-making process in our framework is likely to be transferable to other professions.

Study Limitations

Interviewees were recruited to this study because they had advanced genetic counseling skills and together represented all areas of advanced skills the CATCGC had identified. The sample was not constructed to be representative of all GCs with advanced skills, and is not representative of all GCs (including those who made career decisions not to pursue specific advanced skills, or those who have felt unable to pursue advanced training of various kinds). This affects certain findings (e.g., most of our interviewees found more positive than negative consequences of attaining advanced skills; the prominence of advanced training and advanced skills as motivations, goals, and outcomes).

While four of the five members of the analysis team also conducted interviews, the analysis prioritized measures to privilege participants’ perspectives and think critically about alternative interpretations of the data, including dual coding of all interviews – with at least one coder uninvolved in the interview being coded; group discussion of all data and viewpoints; and awareness of CATCGC members’ individual perspectives and how they might affect the analysis.

The interview guide did not address considerations of diversity in culture/gender/race or ethnicity, nor did the participants raise these issues. It is likely that GCs identifying as minorities in terms of culture/gender/race or ethnicity might find unique barriers, motivations, and possibly even facilitators in terms of career change considerations. This represents an important avenue for future research.

Only GCs practicing in the U. S. A. or Canada were interviewed and there are likely to be differences in career paths and trajectories in other countries. The principles and overall thought process of general career development aspects of the framework are likely to be relevant since they incorporate a person’s past experiences, personal attributes, and contextual factors, however they may vary globally, but specific examples, paths, and outcomes are likely context-dependent (Tams & Author, 2007).

Research Recommendations

This framework could lead to further research related to career trajectories. For example, interviews, surveys, or focus groups of additional stakeholders (GCs making decisions about other career changes besides developing advanced skills, GCs who decided against developing advanced skills, GCs who have felt unable to pursue advanced training opportunities, GCs in other countries, GCs who left the field or experienced burnout, GCs who identify as minorities in terms of culture/gender/ethnicity or race) might validate or refine the framework and help define its boundaries and usefulness. The expansion of the decision-making component of the STF model to describe self-assessment and flexible planning could also be tested in other professions.

Conclusions

The GCCTF illustrates the structure and function of decision making regarding advanced training in its varied forms and highlights how these decisions act as an engine of career development, driving the many trajectories of genetic counseling careers. Past experiences, personal attributes, and contextual factors coordinate to open a cycle of considering change. These factors integrated with self-assessment of evolving goals and motivations and flexible planning (a pragmatic combination of structured decision making and responding to chance) to enable a decision about whether to make a change. GCs have found many paths to job satisfaction, respect, and advancement – by way of decisions to make a change and decisions to not make a change, which is reflected in our framework. The GCCTF was designed for use by GCs and genetic counseling trainees as they construct their own trajectories. The GCCTF describes the processes and components within a lifetime of career evolution, which will enable GCs to strategically approach discrete moments of considering change and simultaneously connect that decision-making process to a more global management and awareness of the evolution of their career.

Figure 4. Secondary outcomes of genetic counselor career decisions to make a change.