Units Of Professional Practice Research Articles

For which entrustable professional activities must medical students be prepared if unsupervised patient care without further training is an expectation? An international Global South study

IntroductionTraining medical students requires objectives that are often translated into frameworks of competencies. Since the introduction of entrustable professional activities (EPAs), these tasks or ‘units of professional practice’, originally conceived...

How to develop entrustable professional activities in a training dermatology program; practical tips for dermatology educators.

Entrustable professional activities (EPAs) are units of professional practice that could be observed, assessed, monitored, documented, and entrusted. EPAs when entrusted, outline the physician's qualifications, and shape the scope of practice. This insight highlights the importance of development of EPAs in all medical specialties including dermatology to ensure the best standards for patient's care. Development of EPAs-based training program is considered a challenge for clinical educators. In this paper, we describe practical tips and reflections on our experience in developing EPAs in dermatology doctoral training program that could be a guide for dermatology educators to implement EPAs in dermatology training programs.

Facilitating flexibility in postgraduate nursing education through entrustable professional activities to address nursing shortages and career prospects.

To communicate how the Dutch postgraduate nursing education landscape was redesigned using entrustable professional activities (EPAs). The goal of this initiative was to reduce training time, enhance transfer across nursing specialities and contribute to a better-aligned continuum of initial education, postgraduate education and continuing professional development. Nursing shortages continue to worsen worldwide. An approach to address this growing shortage is to create a more flexible postgraduate training structure, offering training in the just-in-time and just-as-needed models. EPAs can be used as building blocks for training and assessment. Experience with EPAs (i.e. units of professional practice that can be entrusted once a trainee has demonstrated the required competencies) in health professions education, including nursing, is rising rapidly. While EPAs are largely used to create training flexibility within a programme, they can also be used to create flexibility across programmes. In 2018-2022, training hospitals and education institutions in the Netherlands collaborated in the CZO Flex Level Project to redesign the postgraduate nursing education landscape using EPAs. The implementation of a flexible postgraduate nursing education model nationwide will face several challenges. An overview of these challenges and suggestions for future research on the effects of the new structure on nursing competence, satisfaction and career development are provided. EPAs can imbue flexibility within and across training programmes. Designing an EPA-based educational landscape requires nationally coordinated efforts. Redesigning educational structures to allow for more flexibility is critical to address major societal challenges in healthcare.

Implementation of Entrustable Professional Activities in General Surgery: Results of a National Pilot Study.

The ongoing complexity of general surgery training has led to an increased focus on ensuring the competence of graduating residents. Entrustable professional activities (EPAs) are units of professional practice that provide an assessment framework to drive competency-based education. The American Board of Surgery convened a group from the American College of Surgeons, Accreditation Council for Graduate Medical Education (ACGME) Surgery Review Committee, and Association of Program Directors in Surgery to develop and implement EPAs in a pilot group of residency programs across the country. The objective of this pilot study was to determine the feasibility and utility of EPAs in general surgery resident training. 5 EPAs were chosen based on the most common procedures reported in ACGME case logs and by practicing general surgeons (right lower quadrant pain, biliary disease, inguinal hernia), along with common activities covering additional ACGME milestones (performing a consult, care of a trauma patient). Levels of entrustment assigned (1 to 5) were observation only, direct supervision, indirect supervision, unsupervised, and teaching others. Participating in site recruitment and faculty development occurred from 2017 to 2018. EPA implementation at individual residency programs began on July 1, 2018, and was completed on June 30, 2020. Each site was assigned 2 EPAs to implement and collected EPA microassessments on residents for those EPAs. The site clinical competency committees (CCC) used these microassessments to make summative entrustment decisions. Data submitted to the independent deidentified data repository every 6 months included the number of microassessments collected per resident per EPA and CCC summative entrustment decisions. Twenty-eight sites were selected to participate in the program and represented geographic and size variability, community, and university-based programs. Over the course of the 2-year pilot programs reported on 14 to 180 residents. Overall, 6,272 formative microassessments were collected (range, 0 to 1144 per site). Each resident had between 0 and 184 microassessments. The mean number of microassessments per resident was 5.6 (SD = 13.4) with a median of 1 [interquartile range (IQR) = 6]. There were 1,763 summative entrustment ratings assigned to 497 unique residents. The average number of observations for entrustment was 3.24 (SD 3.61) with a median of 2 (IQR 3). In general, PGY1 residents were entrusted at the level of direct supervision and PGY5 residents were entrusted at unsupervised practice or teaching others. For each EPA other than the consult EPA, the degree of entrustment reported by the CCC increased by resident level. These data provide evidence that widespread implementation of EPAs across general surgery programs is possible, but variable. They provide meaningful data that graduating chief residents are entrusted by their faculty to perform without supervision for several common general surgical procedures and highlight areas to target for the successful widespread implementation of EPAs.

Would I Trust or Will I Trust? The Gap between Entrustment Determinations and Entrustment Decisions for Trainees in Pharmacy and Other Health Professions.

Entrustable Professional Activities (EPAs) and entrustment decision making are rapidly becoming mainstream in competency-based education in the health professions. EPAs are the units of professional practice to entrust graduates with once they have developed the required competencies. They were conceived to enable a gradual increase in professional autonomy during training, by allowing trainees to practice activities in which they have demonstrated they have mastered well, with decreasing supervision. However, practicing health care unsupervised generally requires licensure. The question for pharmacy education, as well as for undergraduate medical education, is can students be given any autonomy in practice, even when they have fully mastered an EPA yet remain unlicensed? While entrustment decisions for licensed practitioners have autonomy consequences, some educators in undergraduate programs speak of 'entrustment determinations', to avoid decisions about students that affect patient care, in other words saying, we would trust you, rather than we will trust you. However, graduating learners without the experience of responsibility and reasonable autonomy creates a gap with full practice responsibilities, which may jeopardize patient safety after training. What can programs do to retain the power of using EPAs while at the same time guarding patient safety?

Inconsistently reporting post-licensure EPA specifications in different clinical professions hampers fidelity and practice translation: a scoping review

BackgroundEntrustable Professional Activities (EPAs) are defined units of professional practice entrusted to professionals once they have attained the specific competencies required to complete the end-to-end task. They provide a contemporary framework for capturing real-world clinical skillsets and integrating clinical education with practice. Our scoping review question was: how are post-licensure EPAs reported in peer reviewed literature, in different clinical professions?MethodWe followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist, Arksey and O’Malley and Joanna Briggs Institute (JBI) methodology. Searching ten electronic databases returned 1622 articles, with 173 articles included. Data extracted included demographics, EPA discipline, titles and further specifications.ResultsAll articles were published between 2007–2021 across sixteen country contexts. The majority were from North America (n = 162, 73%) describing medical sub-specialty EPAs (n = 126, 94%). There were comparably few EPA frameworks reported in clinical professions other than medicine (n = 11, 6%). Many articles reported only EPA titles without further explanation and limited content validation. The majority did not include information about the EPA design process. Few EPAs and frameworks were reported according to all the recommended EPA attributes. There was unclear distinction between specialty-specific EPAs and those that could be useful across disciplines.DiscussionOur review highlights the large volume of EPAs reported in post-licensure medicine, including the volume disparity compared to other clinical professions. Basing our enquiry upon existing guidelines for EPA attributes and features, our experience in conducting the review and our primary finding demonstrated heterogeneity of EPA reporting according to these specifications. To promote EPA fidelity, and quality appraisal, and to reduce interpretation subjectivity, we advocate: diligently reporting EPA attributes and features; including reference or citation to EPA design and content validity information; and considering distinguishing EPAs as specialty-specific or transdisciplinary.ConclusionA large volume of post-licensure EPAs were identified in medicine relative to other clinical professions. EPA specifications were absent or variously reported in the literature, risking ambiguous interpretation. The authors recommend that future EPAs are reported with reference to established and evolving construct recommendations, which is integral to concept fidelity and translation to practice and education.

Twelve tips to develop entrustable professional activities

Entrustable professional activities (EPAs), units of professional practice that require proficient integration of multiple competencies and can be entrusted to a sufficiently competent learner, are increasingly being used to define and inform curricula of health care professionals. The process of developing EPAs can be challenging and requires a deep yet pragmatic understanding of the concepts underlying EPA construction. Based on recent literature and the authors’ lessons learned, this article provides the following practical and more or less sequential recommendations for developing EPAs: [1] Assemble a core team; [2] Build up expertise; [3] Establish a shared understanding of the purpose of EPAs; [4] Draft preliminary EPAs; [5] Elaborate EPAs; [6] Adopt a framework of supervision; [7] Perform a structured quality check; [8] Use a Delphi approach for refinement and/or consensus; [9] Pilot test EPAs; [10] Attune EPAs to their feasibility in assessment; [11] Map EPAs to existing curriculum; [12] Build a revision plan.

Differences in perceptions of capability, autonomy, and expectations between residents and surgical team members in executing EPAs in Ethiopian medical education

BackgroundEntrustable Professional Activities (EPAs) are units of professional practice that are defined as tasks or responsibilities that are entrusted to an unsupervised execution by a trainee. In 2021, a framework of 29 EPAs was developed for surgical residency training programs in Ethiopia, with the goal of residents being able to perform independently by the time they graduate. However, studies show that surgical residents lack confidence and are unable to execute EPAs autonomously upon graduation, and concerns have been raised about graduate competencies in EPA execution. The goal of this research is to assess how surgical team members judge/perceive residents' performance in executing these EPAs autonomously at the time of graduation and how residents rate their own capability and autonomy in executing EPAs in order to systematically introduce and implement EPAs in Ethiopian medical education MethodsA survey was conducted in the Departments of Surgery at four residency training institutions in Ethiopia. All eligible surgical team members and final-year general surgery residents were invited to participate. Surgical team members were asked to rate the observed performance of a group of graduating surgical residents in each of the 29 EPAs, and residents were asked to rate their own capability in executing EPAs. The analysis focused on variations in performance ratings between surgical team members and residents, as well as across surgical team members. ResultsA total of 125 surgical team members and 49 residents participated in this study. Residents rate their competence in performing these EPAs higher than surgical team members, mean 4.2 (SD = 0.63) vs. 3.7 (SD = 0.9). A statistically significant difference in perceptions of capability, autonomy, and expectations in executing EPAs was observed between the two groups of study (p = 0.03, CI: 0.51–0.95), as well as within surgical team members (p < 0.001). ConclusionsDifferences in perceptions of capability, autonomy, and expectations between residents and surgical team members, as well as within faculty members, were seen in executing EPAs. There were concerns about graduate surgical residents' competence to execute EPAs autonomously at the time of graduation. Surgical team members perceived that a set of graduating surgical residents are not yet safe to perform these EPAs independently (without supervision) and still requires distant supervision.

Entrustable professional activities in nursing education: a scoping review protocol

IntroductionEntrustable professional activities were introduced in medical education more than 15 years ago. EPAs define units of professional practice that can be fully entrusted to sufficiently competent professionals. Today, EPAs...

How can Entrustable Professional Activities serve the quality of health care provision through licensing and certification?

This paper about Entrustable Professional Activities (EPAs) was solicited to support the discussion about the future of licensing within the Medical Council of Canada. EPAs, units of professional practice to be entrusted to learners or professionals once they have shown to possess sufficient competence, were proposed in 2005 to operationalize competency-based postgraduate medical education and have become widely popular for various health professions education programs in many countries.EPAs break the breadth of competence for license down to units of practice that can be overseen, assessed, monitored, documented, and entrusted. EPAs together may constitute an individual's portfolio of qualifications, and define a scope of practice. A medical license and a specialty certification can then be defined as the required combination of EPAs for which one is qualified at any specific moment in time. That 'snapshot' could change over time and reflect the professional development of the individual, both in their competence and in their privileges to practice. Micro-credentialing and digital badges might become an adequate option to show-case one's scope of practice at any time and operationalize the idea of a dynamic portfolio of EPAs.

Common Myths About Entrustable Professional Activities

Entrustable professional activities (EPAs) are continuously gaining worldwide popularity in competency-based clinical training programmes. EPAs are discrete units of professional practice that are used to determine the readiness of a trainee in a particular training context. Despite their evergrowing recognition in health professions education, some critical misconceptions exist on the original nuance of EPAs that can potentially compromise their utility and operationalisation. For instance, EPAs are often confused with other educational entities such as competencies, outcomes and abilities. In this study, we attempt to address some common myths associated with EPAs and provide further clarification through examples to help readers differentiate between a true and a pseudo EPAs.

On the validity of summative entrustment decisions

Health care revolves around trust. Patients are often in a position that gives them no other choice than to trust the people taking care of them. Educational programs thus have the responsibility to develop physicians who can be trusted to deliver safe and effective care, ultimately making a final decision to entrust trainees to graduate to unsupervised practice. Such entrustment decisions deserve to be scrutinized for their validity. This end-of-training entrustment decision is arguably the most important one, although earlier entrustment decisions, for smaller units of professional practice, should also be scrutinized for their validity. Validity of entrustment decisions implies a defensible argument that can be analyzed in components that together support the decision. According to Kane, building a validity argument is a process designed to support inferences of scoring, generalization across observations, extrapolation to new instances, and implications of the decision. A lack of validity can be caused by inadequate evidence in terms of, according to Messick, content, response process, internal structure (coherence) and relationship to other variables, and in misinterpreted consequences. These two leading frameworks (Kane and Messick) in educational and psychological testing can be well applied to summative entrustment decision-making. The authors elaborate the types of questions that need to be answered to arrive at defensible, well-argued summative decisions regarding performance to provide a grounding for high-quality safe patient care.

The development of a framework of entrustable professional activities for the intern year in Ireland

BackgroundEntrustable Professional Activities (EPAs) are units of professional practice that capture essential competencies in which trainees must become proficient before undertaking them independently. EPAs provide supervisors with a solid justification for delegating an activity to trainees. This study aimed to develop and ensure face validity of a set of EPAs for junior doctors in the first year of clinical practice in the Republic of Ireland.MethodsAn iterative eight stage consensus building process was used to develop the set of EPAs. This process was based on international best practice recommendations for EPA development. A series of surveys and workshops with stakeholders was used to develop a framework of EPAs and associated competencies. An external stakeholder consultation survey was then conducted by the Irish Medical Council. The framework of EPAs was then benchmarked against the 13 core EPAs developed by the Association of American Medical Colleges (AAMC).ResultsA framework of seven EPAs, and associated competencies resulted from this study. These EPAs address all core activities that junior doctors should be readily entrusted with at the end of the intern year, which is the first year of clinical practice in the Republic of Ireland. Each EPA contains a series of defined competencies. The final EPAs were found to be comparable to the AAMC core EPAs for entering residency.ConclusionsA framework of EPAs for interns in Ireland that are appropriate for the intern year has been developed by key stakeholders. The implementation of the EPAs in practice is the next step, and is likely to result in an improved intern training process and increased patient safety.

Entrustment decisions: Implications for curriculum development and assessment

With increased interest in the use of entrustable professional activities (EPAs) in undergraduate and postgraduate medical education, comes questions about their implications for curriculum development and assessment. This paper addresses some of those questions, discussed at a symposium of the 2017 conference of AMEE, by presenting the components of an EPA, describing their importance and application, identifying their implications for assessment, and pinpointing some of challenges they pose in undergraduate and postgraduate settings. It defines entrustment, describes the three levels of trust, and presents trainee and supervisor factors that influence it as well as perceived benefits, and risks. Two aspects of EPAs have implications for assessment: units of professional practice and decisions based on entrustment, which impact an assessment’s blueprint, test methods, scores, and standards. In an undergraduate setting EPAs have great appeal, but work is needed to identify and develop a robust assessment system for core EPAs. At the postgraduate level, there is tension between the granularity of the competencies and the integrated nature of the EPAs. Even though work remains, EPAs offer an important step in the evolution of competency-based education.

Problem-Based Learning in a Medical School: Implementations Challenges

Abstract: Introduction: Considering an integrated curriculum that is guided by dialogical competence according to the National Curriculum Guidelines, the Systematized Educational Unit (UES) and the Professional Practice Unit (UPP) constitutes the curriculum of a medical course in a municipality in the countryside of the state of São Paulo, Brazil. Problem-Based Learning (PBL) is used in the UES and the problematization is used in the Professional Practice Unit as teaching methodologies, seeking an organization that leads to a training that is coherent with the public health sector and the national education scenario. The UES is the focus of this study because we observed that there are divergences among teachers regarding their role as tutors. Thus, we observed that the teaching methodology currently employed at Famema led us to some questions: Do the teachers consider themselves qualified to work with the PBL method? How do evaluations contribute to the teaching-learning process? Thus, this study aimed to analyze the teachers’ understanding of their ability to work with the PBL and the relevance of evaluations for the teaching-learning process in the UES. Method: This is an exploratory-descriptive study with a qualitative approach. Data collection was carried out using a semi-structured interview with teachers who work with the 1st to 4th years in the UES of the medical course, and the selection of the participants was carried out from a non-probabilistic sample of intention, totaling 16 teachers, including four teachers of each of the first four years of the course. The analysis of the data was performed by Content Analysis in the thematic modality, which allowed the definition of two thematic axes: Challenges for teacher training and Potentials and limits of the implemented evaluation process. Results: The trajectory of the PBL in the teaching-learning process from the point of view of teachers showed us a variety of understandings. As for teacher training, weaknesses were identified in the development of the tutoring process, and that the strategies used for training need to be reviewed regarding their implementation and the inclusion of the professionals into the process. Regarding the evaluation, it was observed that the teachers demonstrate difficulties in carrying out an evaluation of the students while integrating the affective, cognitive and psychomotor dimensions. Conclusion: Therefore, regardless the time of the curriculum implementation, Permanent Education should constitute a powerful space for teacher training and process management.

Problem-Based Learning in a Medical School: Implementations Challenges

Abstract: Introduction: Considering an integrated curriculum that is guided by dialogical competence according to the National Curriculum Guidelines, the Systematized Educational Unit (UES) and the Professional Practice Unit (UPP) constitutes the curriculum of a medical course in a municipality in the countryside of the state of São Paulo, Brazil. Problem-Based Learning (PBL) is used in the UES and the problematization is used in the Professional Practice Unit as teaching methodologies, seeking an organization that leads to a training that is coherent with the public health sector and the national education scenario. The UES is the focus of this study because we observed that there are divergences among teachers regarding their role as tutors. Thus, we observed that the teaching methodology currently employed at Famema led us to some questions: Do the teachers consider themselves qualified to work with the PBL method? How do evaluations contribute to the teaching-learning process? Thus, this study aimed to analyze the teachers’ understanding of their ability to work with the PBL and the relevance of evaluations for the teaching-learning process in the UES. Method: This is an exploratory-descriptive study with a qualitative approach. Data collection was carried out using a semi-structured interview with teachers who work with the 1st to 4th years in the UES of the medical course, and the selection of the participants was carried out from a non-probabilistic sample of intention, totaling 16 teachers, including four teachers of each of the first four years of the course. The analysis of the data was performed by Content Analysis in the thematic modality, which allowed the definition of two thematic axes: Challenges for teacher training and Potentials and limits of the implemented evaluation process. Results: The trajectory of the PBL in the teaching-learning process from the point of view of teachers showed us a variety of understandings. As for teacher training, weaknesses were identified in the development of the tutoring process, and that the strategies used for training need to be reviewed regarding their implementation and the inclusion of the professionals into the process. Regarding the evaluation, it was observed that the teachers demonstrate difficulties in carrying out an evaluation of the students while integrating the affective, cognitive and psychomotor dimensions. Conclusion: Therefore, regardless the time of the curriculum implementation, Permanent Education should constitute a powerful space for teacher training and process management.

The viability of interprofessional entrustable professional activities.

Interprofessional education (IPE) and entrustable professional activities (EPAs) represent two topics in health professions education that have attracted significant attention in recent years. IPE (when different health professionals learn with, from and about each other with the aim of optimal care) has an inherent focus on the collective. EPAs (units of professional practice that can be fully entrusted to a trainee, once he or she has demonstrated the necessary competence to execute this activity unsupervised) have a focus on the individual. Attempts to relate the two may cause friction and the question is: can they be reconciled? Are interprofessional EPAs or team-EPAs useful concepts and if so what should they look like? The authors argue that most work in modern healthcare involves interprofessional collaboration. Some EPAs have an inherent strong interprofessional nature, such as emergency teamwork, running multidisciplinary team meetings, and surgery. Other EPAs are less inherently dependent on interprofessional collaboration. The authors conclude that neither interprofessional team-EPAs (for which a team can or should be certified), nor IP-EPAs for individuals, as opposed to other EPAs, are viable concepts. However, the authorsdo not question that certifying health care professionals and entrusting trainees with most clinical tasks will require to ascertain their competence in interprofessional collaboration. This must be included when assessing learners for most EPAs and making entrustment decisions. This can help to strengthen interprofessional competence in the clinical workplace.

An Updated Primer on Entrustable Professional Activities (EPAs)

ABSTRACT Since the turn of the millennium, competency-based medical education (CBME) has become a new standard for medical training in many countries. CBME has been operationalized in detailed frameworks of competencies that every physician should demonstrate at graduation, and similar frameworks have been created for specialties. However, the competencies, describing qualities that physicians should possess, do not directly translate into everyday activities of physicians. For that reason, the Entrustable Professional Activities (EPAs) were introduced. EPAs are units of professional practice that may be entrusted to undergraduate students, once they show the competencies needed to perform them without supervision. EPAs have become a popular topic within CBME programs in many countries and hundreds of publications within only a few years. This paper was written to introduce the strengths and weaknesses of EPAs. After a brief historical overview, the reason why EPAs are a bridge between a competency framework and daily clinical practice is explained. While competencies are qualities of individuals, EPAs are units of work. The two can be seen as two dimensions of a matrix, showing that almost all activities in health care are based on multiple competencies, such as communication skill, collaboration, professional behavior, content knowledge. Next, entrustment decision-making as a form of assessment is created and a framework of levels of supervision is presented. Entrustment decisions focus on the level of supervision a student requires for a specific activity, divided into five levels (1: allowed to observe; 2; allowed to perform under direct supervision; 3: allowed to perform under indirect supervision; 4: allowed to perform the activity unsupervised; 5: allowed to supervise the activity performed by more junior learners). For readers interested in applying the concept to practice, a stepwise approach to the curriculum development is proposed. The paper concludes with an overview of the state-of-the-art of working with EPAs across disciplines, professions and countries.

An Updated Primer on Entrustable Professional Activities (EPAs)

ABSTRACT Since the turn of the millennium, competency-based medical education (CBME) has become a new standard for medical training in many countries. CBME has been operationalized in detailed frameworks of competencies that every physician should demonstrate at graduation, and similar frameworks have been created for specialties. However, the competencies, describing qualities that physicians should possess, do not directly translate into everyday activities of physicians. For that reason, the Entrustable Professional Activities (EPAs) were introduced. EPAs are units of professional practice that may be entrusted to undergraduate students, once they show the competencies needed to perform them without supervision. EPAs have become a popular topic within CBME programs in many countries and hundreds of publications within only a few years. This paper was written to introduce the strengths and weaknesses of EPAs. After a brief historical overview, the reason why EPAs are a bridge between a competency framework and daily clinical practice is explained. While competencies are qualities of individuals, EPAs are units of work. The two can be seen as two dimensions of a matrix, showing that almost all activities in health care are based on multiple competencies, such as communication skill, collaboration, professional behavior, content knowledge. Next, entrustment decision-making as a form of assessment is created and a framework of levels of supervision is presented. Entrustment decisions focus on the level of supervision a student requires for a specific activity, divided into five levels (1: allowed to observe; 2; allowed to perform under direct supervision; 3: allowed to perform under indirect supervision; 4: allowed to perform the activity unsupervised; 5: allowed to supervise the activity performed by more junior learners). For readers interested in applying the concept to practice, a stepwise approach to the curriculum development is proposed. The paper concludes with an overview of the state-of-the-art of working with EPAs across disciplines, professions and countries.

Entrustable Professional Activities For Residency Training in Physical Medicine and Rehabilitation.

Entrustable professional activities are observable units of professional practice that can potentially provide a link between competency-based medical education and clinical practice. The authors, part of a subcommittee of the Association of Academic Physiatrists Education Committee, identified a set of entrustable professional activities that would serve residency training programs in the specialty of physical medicine and rehabilitation. Using a modified Delphi process, residency program directors in the field reviewed and validated a set of entrustable professional activities. The final set of 19 entrustable professional activities is presented in this article.