Beyond Compliance: A Care Ethics-Informed Assessment Framework for Professionalism and Professional Identity Formation in Competency-Based Critical Care Residency Training

Abstract Background Professionalism is a cornerstone of competency-based medical education (CBME), yet its assessment in postgraduate training remains fragmented, largely summative, and poorly linked to professional identity formation. In critical care medicine — defined by vulnerability, moral complexity, and high-stakes relational practice — existing assessment instruments have limited capacity to capture these dimensions meaningfully. This study aimed to develop and evaluate, using educational action research, a participatory, care ethics-informed assessment framework for professionalism and professional identity formation in a critical care medicine residency. Methods A four-year participatory educational action research study (2022–2026) was conducted within a critical care medicine graduate program in Colombia. Four iterative cycles were implemented: (1) diagnostic assessment of professionalism knowledge (n = 105) and psychometric analysis of 146 workplace-based assessment records; (2) multi-stakeholder qualitative inquiry (57 participants; 1,206 coded excerpts) using reflexive thematic content analysis; (3) participatory co-design of the assessment innovation, informed by two scoping reviews on professionalism assessment and critical care training methods; and (4) implementation and refinement of five interconnected lines of action. Reporting follows SRQR and SQUIRE-EDU guidelines. Results The diagnostic cycle revealed a significant gap between declared and enacted professionalism assessment, marked by ceiling effects (88.1% of maximum scores in the professionalism domain), halo bias (first principal component explained 48.9% of the variance), and absent or generic feedback in over 80% of evaluations. Qualitative analysis identified four interrelated themes — the evaluative silence of being; between grading and learning; professionalism as situated practice; and shared vulnerability and relational becoming as the pedagogical conditions for professional identity formation — with an overarching construct: Learning Through Caring, Caring Through Learning. The co-design and implementation cycles produced the Pedagogy of Critical Attentiveness and five lines of action: an integrative formative assessment strategy, a digital logbook for entrustable professional activity documentation (Praktika), bidirectional rotation evaluation, interprofessional simulation, and comprehensive curricular restructuring. Conclusions Professionalism becomes visible, learnable, and assessable when understood as a relational pedagogical practice grounded in care ethics. The Pedagogy of Critical Attentiveness — co-constructed through participatory action research— offers a replicable model for aligning CBME assessment with professional identity formation, applicable across postgraduate residency programs in diverse global contexts.