Summative Entrustment Decision-Making in a National Entrustable Professional Activity-Based Residency Training Programme: Where theory meets practice

Abstract

Introduction: The Entrustable Professional Activity (EPA) framework was introduced to operationalise and translate competency-based medical education into daily practice. Adoption of EPAs is recommended and supported in guidelines by educational research on trust and entrustment decision-making. However, systematic field studies evaluating the experiences of medical professionals (residents and supervisors) working with an EPA framework in daily practice are lacking. Still these evaluations are necessary to support the design and implementation of new EPA-based residency training programmes. This study provides an in-depth insight and a more comprehensive understanding of the experiences of professionals working in an EPA-based residency training programme. Methods: We conducted a qualitative study using a constructivist approach. Focus groups were used for separate interviews with residents and supervisors assessing their experiences with the first national EPA-based residency training programme in the Netherlands. Thematic analysis was used to analyse the results of the focus groups and to define relevant themes. Results: The EPA framework enabled residents to enhance and individualise their training programme. Personal leadership proved to be essential for finding a balance between the requirements of the national training programme and exploration of residents’ individual talents, experience and learning curve. Supervisors’ supportive and guiding role is crucial throughout the process of EPA acquirement. Independent from each other, supervisors and residents indicated that trust (and not exhaustive testing) is essential in the summative assessment by a Clinical Competence Committee (CCC). Supervisors see added value in the mandatory portfolio that residents compile to help them prepare for the CCC meeting. Starting to work without supervision is an important but challenging goal once an EPA has been acquired. The ability to further individualise the training programme after an EPA has been acquired, varies among residents. Discussion: We found that residents and supervisors see added value in working and learning in an EPA-based residency training programme. Awareness and encouragement of self-regulated learning skills could potentially help create a balance between programme requirements and individualisation. When discussing a portfolio, trust and gut-feelings during CCC meetings is fundamental and helpful for supervisors to get a comprehensive view of the resident’s performance. An autonomy-supportive supervision strategy could encourage and improve residents’ autonomy and practice of working without direct supervision after acquiring an EPA.