Assessment of Entrustable Professional Activities Among Dutch Endocrine Supervisors.

Entrustable Professional Activities (EPAs) are an important tool to support individualisation of medical training in a competency-based setting and are increasingly implemented in the clinical speciality training for endocrinologist. This study aims to assess interrater agreement and factors that potentially impact EPA scores. Five known factors that affect entrustment decisions in health profesions training (capability, integrity, reliability, humility, agency) were used in this study. A case-vignette study using standardised written cases. Case vignettes (n = 6) on the topics thyroid disease, pituitary disease, adrenal disease, calcium and bone disorders, diabetes mellitus, and gonadal disorders were written by two endocrinologists and a medical education expert and assessed by endocrinologists experienced in the supervision of residents in training. Primary outcome is the inter-rater agreement of entrustment decisions for endocrine EPAs among raters. Secondary outcomes included the dichotomous interrater agreement (entrusted vs. non-entrusted), and an exploration of factors that impact decision-making. The study protocol was registered and approved by the Ethical Review Board of the Netherlands Association for Medical Education (NVMO-ERB # 2020.2.5). Nine endocrinologists from six different academic regions participated. Overall, the Fleiss Kappa measure of agreement for the EPA level was 0.11 (95% CI: 0.03-0.22) and for the entrustment decision 0.24 (95% CI 0.11-0.37). Of the five features that impacted the entrustment decision, capability was ranked as the most important by a majority of raters (56%-67%) in every case. There is a considerable discrepancy between the EPA levels assigned by different raters. These findings emphasise the need to base entrustment decisions on multiple observations, made by a team of supervisors and enriched with factors other than direct medical competence.

Factors necessary for entrustment decision-making in surgical operating rooms: A modified Delphi study.

Objective: Resident autonomy in an operation theatre has been directly linked with patient safety in healthcare. The objective of this study was to identify the factors necessary for making resident-entrustment decisions from the perspective of a supervisor/consultant viewpoint. The second objective was to develop a checklist for assessing resident readiness for independent work. Materials and methods: This study employed a mixed-method Delphi approach. In the first stage, a comprehensive literature review and a qualitative exploratory study produced a list of factors related to residents. The second phase involved content validation by a panel of experts, followed by a two-round Delphi study with 20 expert panelists. Results: A total of 49 resident-related factors for entrustment were identified, which were reduced to 46 after content validation. During Delphi Round I, 17 factors were fully accepted, 7 were rejected and 22 items were partially accepted. Out of the 39 items sent to Delphi Round II, 23 items were accepted and 16 were rejected. A final 23-item checklist was formed based on the following factors; 6 Cognitive (knowledgeable, risk manager, safe doctor, general manager, field of interest, communicator), 5 Psychomotor (past performer, competent, ability to pick critical findings, ability to act situationally, decision maker) and 12 affective (responsible, leader, honest, empathetic, ethical, receptive, humble, emotionally intelligent, motivated, accountable, team player, disciplined) factors. Conclusion: The study resulted in the formation of a checklist based on the factors necessary for entrustment decision-making in surgical operating rooms. Some of the novel contextual factors were 'general manager', 'field of interest', 'ability to pick critical findings', 'accountable', 'risk manager', and 'past performer'. This framework offers a guideline for supervisors and residents to evaluate progress throughout the residency program. The developed tool demonstrates good content validity and is suitable for entrustment assessment following construct validation.

Entrustment Decision Making in the Intensive Care Unit: It's About More Than the Learner.

Background: The provision of graded supervision affording progressive autonomy is fundamental to the progression of a medical learner toward competency for independent practice; the decision of how much supervision versus autonomy to provide a trainee in the execution of clinical care constitutes an entrustment decision. Despite entrustment decision making occurring both daily in practice and summatively at points of matriculation through stages of medical training, the factors influencing entrustment decisions remain poorly understood across clinical contexts. Objective: This study was designed to explore the central research question: How are entrustment decisions made in the medical intensive care unit (ICU)? Methods: This qualitative case study used semistructured interviews with attending pulmonary and critical care physicians in the medical ICU at a major midwestern medical center to explore the entrustment decision-making process as it was enacted in the clinical environment. Results: Five major themes emerged from the data: 1) task, circumstance, and trainee factors contribute to entrustment decision making; 2) ad hoc entrustment decisions are enacted by supervisors with a consideration of the care team as a unit, not only an individual; 3) autonomy does not only arise out of entrustment, but outcomes of prior autonomous actions by the trainee inform the intention to entrust; 4) entrustment decision making includes a social process of back-and-forth akin to negotiation; and 5) entrustment is a learned skill. Conclusion: The process of entrustment decision making in the ICU is more complex than prior frameworks have captured; a model with more complete incorporation of the factors that influence entrustment in the ICU is presented. It is not clear how often ad hoc entrustment decisions in clinical practice are primarily driven by factors pertaining directly to trainee competence, which carries implications in the use of entrustment for assessment.

Scoping review: exploring residents' views of supervisor entrustment and its effect on learning and professional development.

This scoping review aimed to systematically explore the complex and nuanced perceptions of residents entrusted with significant responsibilities by their supervisors in the clinical context. We conducted a comprehensive search strategy targeting six major electronic databases. Data were extracted using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist and a scoping review protocol. Resident perceptions regarding entrustment and its impact on learning and professional development were categorized. This review elucidated the role of supervisor entrustment in shaping residents' clinical performance, notably influencing autonomy, self-confidence, responsibility for patients, learning needs and goals, uncertainty management, and professional identity formation. Residents identified factors that promote and hinder performance and entrustment development resulting from supervisor entrustment and distinguished between appropriate supervision and over- or under-supervision. Our review suggests that residents' perceptions of supervisor entrustment, as bestowed by supervisors, serves as a catalyst for enhancing autonomy, thereby exerting a significant influence on clinical performance, and fostering the development of a professional identity. However, residents' views on appropriate supervision differ in some ways from supervisors' perspectives. Further research is needed to bridge the gap between residents' expectations of autonomy and what they are given, and to explore the intricate relationship between autonomy and entrustment.

Parental entrustment of healthcare responsibilities to youth with chronic conditions: A concept analysis.

PURPOSE: Chronic health conditions impact nearly 40% of children in the United States, necessitating parents/caregivers to entrust healthcare responsibilities to youth aging into adulthood. Understanding the parental entrustment process may lead to tailored transition support; however, the concept lacks conceptual clarity, limiting its research and practical applications. DESIGN AND METHODS: Rodgers' evolutionary concept analysis method was used to clarify the parental entrustment of healthcare responsibilities to youth with chronic health conditions. PubMed, CINAHL, and PsycINFO databases were searched without date restrictions, including full-text, English-language, primary source articles related to parent-child healthcare transition preparation. Following title, abstract, and full-text screenings, data were analyzed using a hybrid thematic approach to identify antecedents, attributes, and consequences. RESULTS: Forty-three studies from August 1996 to September 2023 were identified. Antecedents encompass social cues and readiness factors, while attributes involve a) responsibility transfer, support, and facilitation, b) a dynamic process, c) balancing trust and fear, d) navigating conflict, and e) parental letting go. Consequences entail shifts in parental and adolescent roles. Parental entrustment is an iterative process wherein parents guide their maturing child through responsibility transfer via facilitation, support, conflict navigation, and trust building. CONCLUSION: The clarified concept underscores the role of parents/caregivers in empowering youth to manage their health. Introducing a working definition and conceptual model contributes to understanding the processes families navigate in the larger landscape of healthcare transition. PRACTICE IMPLICATIONS: This clarification holds implications for clinicians and policymakers, offering insights to enhance support and guidance for families navigating healthcare transition.

Measuring Chief Resident Skill and Entrustment Progression in An Operative Coaching Program: Four Years' Experience.

OBJECTIVE: Operative coaching (OC) may facilitate improvement of surgery residents' competencies by optimizing learning and teaching. We investigated how residents' operative skills and prospective entrustment (PE) progress throughout the chief year in our OC program, how OC is perceived by participants, and how OC may facilitate learning and teaching. DESIGN, SETTING, AND PARTICIPANTS: This is a mixed-methods study conducted within the Ohio State University Wexner Medical Center General Surgery residency. Validated performance evaluations with procedural-specific skill, general skill (GS), step-specific guidance required (SSG) (an autonomy measure), and PE measures completed by chiefs, faculty coaches, and attending surgeons from 7/2018 to 6/2022 were reviewed. We also interviewed OC participants to understand their experience. Descriptive statistical and qualitative content analysis were applied. RESULTS: 441 evaluations from 147 OC cases completed by 22 chiefs, 5 faculty coaches, and 24 attendings were included. Overall, resident GS (p = 0.036), SSG (p = 0.023), and PE (p = 0.002) significantly improved throughout the year. PE significantly correlated (all p < 0.0001) with SSG (r = 0.73), followed by procedural-specific skill (r = 0.59), then GS (r = 0.57). On average, chiefs underestimated their surgical skills while attendings overestimated autonomy they permitted to residents. Chiefs, coaches, and attendings reached consensus on chiefs' PE upon graduation. Five graduated chiefs and 5 attendings were interviewed. Chiefs described OC as effective in improving their self-regulated learning and particularly valued 3 OC elements: neutral authentic feedback, third-party real-time observation, and actionable feedback. Attendings noted OC promoted their engagement in skills assessment and teaching. CONCLUSIONS: Our findings suggest chief residents' skills, autonomy, and PE progress steadily along their OC journey. Despite differences in residents', coaches', and attendings' perceptions of skill, measures of autonomy reliably correlate with entrustment. OC promotes resident learning, faculty teaching, and assessment of resident skills, autonomy, and PE in the OR.

Toma de decisiones de encomienda y evaluación de las actividades profesionales confiables en la educación médica basada en competencias: una revisión de alcance y análisis temático / Entrustment decision-making and evaluation of entrustable professional activities in the competency- based medical education: a scoping review and thematic analysis

Introducción: La evaluación de las actividades profesionales confiables implica que el tutor tome decisiones de encomienda que posibiliten el desarrollo de competencias adecuadas de los futuros especialistas. Objetivo. El objetivo es conocer los componentes que sustentan la toma de decisiones de encomienda como herramienta de evaluación efectiva, segura y eficaz de las actividades profesionales confiables en la educación médica basada en competencias. Materiales y métodos: Se realizó una revisión sistemática en las bases de datos PubMed, BIREME-BVS y Web of Science. Se procedió al análisis y síntesis de los artículos, de acuerdo con la metodología JBI para las revisiones de alcance; el análisis se profundizó en otros artículos de revistas especializadas y citas bibliográficas relacionadas; y el manuscrito final se efectuó con base en las recomendaciones PRISMA-ScR. Resultados: La toma de decisiones de encomienda se centra en la relación tutor-estudiante, con base principalmente en la proactividad, la integridad, la capacidad y la humildad del estudiante, que confluyen en la confianza del tutor para sobrepasar la ‘zona de desarrollo próximo’ y alcanzar un siguiente nivel. Aunque eso signifique un determinado riesgo inicial sobre la seguridad de la atención médica, permite gradualmente generar la autonomía del estudiante. Conclusiones: No cabe duda de que la toma de decisiones de encomienda se basa en la confianza, la encomienda, la supervisión y la autonomía. Una escala retrospectiva-prospectiva que incluya la confianza-encomienda-supervisión-autonomía permite una adecuada evaluación de las actividades profesionales confiables y, por ende, la evaluación de las competencias.(AU)

Introduction: The evaluation of entrustable professional activities implies that the tutor makes assignment decisions that enable the development of appropriate competencies of future specialists. Aim. The aim of this work is to recognize the components that support entrustment decision making as an effective, safe and efficient evaluation tool of entrustable professional activities, in competency-based medical education. Materials and methods: A systematic review was carried out in the PubMed, BIREME-BVS and Web of Science databases. The analysis and synthesis of the articles was carried out in accordance with the JBI methodology for scoping reviews; and was further conducted including other articles from specialized journals and related bibliographic citations. The final manuscript was prepared based on the PRISMA-ScR recommendations.Results: Entrustment decision-making focuses on the tutor-student relationship, based mainly on the student’s proactivity, integrity, ability and humility, which converge in the tutor’s confidence to surpass the ‘zone of proximal development’ and reach the next level. Although this means a certain initial risk to the safety of medical care, it gradually generates the student’s autonomy. Conclusions: There is no doubt that entrustment decision-making is based on trust, entrustment, supervision and autonomy. A retrospective-prospective scale that includes trust-entrustment-supervision-autonomy allows for an adequate evaluation of entrustable professional activities and, therefore, the evaluation of competencies.(AU)

Assessing supervisor versus trainee viewpoints of entrustment through cognitive and affective lenses: an artificial intelligence investigation of bias in feedback.

The entrustment framework redirects assessment from considering only trainees' competence to decision-making about their readiness to perform clinical tasks independently. Since trainees and supervisors both contribute to entrustment decisions, we examined the cognitive and affective factors that underly their negotiation of trust, and whether trainee demographic characteristics may bias them. Using a document analysis approach, we adapted large language models (LLMs) to examine feedback dialogs (N = 24,187, each with an associated entrustment rating) between medical student trainees and their clinical supervisors. We compared how trainees and supervisors differentially documented feedback dialogs about similar tasks by identifying qualitative themes and quantitatively assessing their correlation with entrustment ratings. Supervisors' themes predominantly reflected skills related to patient presentations, while trainees' themes were broader-including clinical performance and personal qualities. To examine affect, we trained an LLM to measure feedback sentiment. On average, trainees used more negative language (5.3% lower probability of positive sentiment, p < 0.05) compared to supervisors, while documenting higher entrustment ratings (+ 0.08 on a 1-4 scale, p < 0.05). We also found biases tied to demographic characteristics: trainees' documentation reflected more positive sentiment in the case of male trainees (+ 1.3%, p < 0.05) and of trainees underrepresented in medicine (UIM) (+ 1.3%, p < 0.05). Entrustment ratings did not appear to reflect these biases, neither when documented by trainee nor supervisor. As such, bias appeared to influence the emotive language trainees used to document entrustment more than the degree of entrustment they experienced. Mitigating these biases is nonetheless important because they may affect trainees' assimilation into their roles and formation of trusting relationships.

A Qualitative Study of Drivers for Use of the Primary Care Exception Among Internal Medicine Teaching Faculty.

BACKGROUND: The Primary Care Exception (PCE) is a billing rule from the Centers for Medicare and Medicaid Services (CMS) that allows supervising physicians to bill for ambulatory care provided by a resident without their direct supervision. There has been increased focus on entrustment as a method to assess readiness for unsupervised practice. OBJECTIVE: To understand the factors influencing attending physicians' use of the PCE in ambulatory settings and identify common themes defining what motivates faculty preceptors to use the PCE. APPROACH: This was a qualitative exploratory study. Participants were interviewed one-on-one using a semi-structured template informed by the entrustment literature. Analysis was conducted using a thematically framed, grounded theory-based approach to identify major themes and subthemes. PARTICIPANTS: Twenty-seven internal medicine teaching faculty took part in a multi-institutional study representing four residency training programs across two academic medical centers in Connecticut. KEY RESULTS: Four predominant categories of themes influencing PCE use were identified: (1) clinical environment factors, (2) attending attitudes, (3) resident characteristics, and (4) patient attributes. An attending's "internal rules" drawn from prior experiences served as a significant driver of PCE non-use regardless of the trainee, patient, or clinical context. A common conflict existed between using the PCE to promote resident autonomy versus waiving the PCE to promote safety. CONCLUSIONS: The PCE can serve as a tool to support resident autonomy, confidence, and overall clinical efficiency. Choice of PCE use by attendings involved complex internal decision-making schema balancing internal, patient, resident, and environmental-related factors. The lack of standardized processes in competency evaluation may increase susceptibility to biases, which could be mitigated by applying standardized modes of assessment that encompass shared principles.

Understanding and addressing varying perceptions of autonomy.

Recently, there has been a major shift in the concept of resident autonomy in the operating room. As a result, surgical residents' independence has decreased during their training years. This change has been secondary to multiple factors, including fragmented attending resident interactions, hospital demands for productivity, operating room efficiency, and the public's perception of resident participation in surgery. Multiple gender, personality, and racial biases have also influenced the autonomy of surgical residents. In this paper, we have analyzed the impact of all these factors on the current state of resident autonomy after reviewing relevant literature. We have proposed a strategy to increase resident autonomy via increased resident and faculty interactions, case planning, and encouraged recruitment of diverse vascular surgery trainees and faculty.

Minimum Supervision Levels Required for Pediatric Cardiology Fellowship Graduation by Pediatric Cardiology Fellowship Program Directors.

Entrustable professional activities (EPAs) are "observable essential tasks expected to be performed by a physician for safe patient care in practice." Six Pediatric Cardiology (PC) EPAs and their level of supervision (LOS) scales were developed by medical educators in PC using a modified Delphi process and reviewed by the Subspecialty Pediatrics Investigator Network (SPIN). However, their general use in assessment for PC fellows for graduation requirements has yet to be studied. The objective of this study was to determine the minimum LOS required for PC fellows to graduate and compare it with the minimum LOS expected for safe and effective practice for the six PC EPAs, from the perspective of the PC Fellowship Program Directors(FPD). All Fellowship Program Directors(FPD) of ACGME-accredited PC fellowships were surveyed through SPIN between April 2017 and August 2017. For each of the PC EPAs, the FPDs were asked to indicate the minimum LOS expected for graduation and whether they would allow a fellow to graduate if this level was not achieved and the minimum LOS expected for a practicing pediatric cardiologist to provide safe and effective patient care. The minimum LOS was defined as the LOS for which no more than 20% of FPDs would want a lower level. The survey response rate was 80% (47/59). The majority of the FPDs did not require a minimum LOS of five corresponding to unsupervised practice in any of the six PC EPAs at graduation. For EPAs related to imaging, arrhythmia management, and management of cardiac problems, the minimum LOS for graduation was 3, corresponding to being "trusted to perform a task with indirect supervision for most simple and a few complex cases." For the EPAs related to interventional cardiology, heart failure pulmonary hypertension, and cardiac intensive care, the minimum LOS for graduation was 2, corresponding to being "trusted to perform a task only with direct supervision and coaching." The minimum LOS considered necessary for safe and effective practice for all but one EPA was 3. For the EPA related to the management of cardiac problems, the minimum LOS for safe practice was 4, corresponding to being "trusted to execute tasks independently except for few complex and critical cases." Most PC FPDs reported they would not require fellows to achieve the highest entrustment level for any of the six PC EPAs for graduation. It is crucial that educational programs evolve to address these essential activities during training better and that stakeholders ensure that graduating PC fellows have adequate resources and infrastructure to continue professional development as early career pediatric cardiologists.

Developing entrustable professional activities to enhance application of an aggression prevention protocol.

AIM: The research aim of this study was to seek feedback from prevention of aggression training experts about the suitability of Entrustable Professional Activities (EPAs) as an assessment tool for an Aggression Prevention Protocol. The protocol was designed to structure intervention to prevent aggression and reduce the use of restrictive practices following risk assessment using a validated instrument (the Dynamic Appraisal of Situational Aggression). BACKGROUND: Preventing aggression and limiting the use of restrictive practices are key priorities for inpatient mental health services. Assessing clinical activities using a competence framework has limitations, particularly when determining complex interventions. EPAs could provide a suitable method for assessing complex clinical activities like de-escalation and limit setting, which comprise some of the interventions in the Aggression Prevention Protocol. EPAs are new to forensic mental health nursing; therefore, feedback was sought regarding the utility of EPAs to assess aggression prevention interventions. METHODS: Data were collected via focus groups including 11 aggression prevention experts from Australia and New Zealand. A thematic analysis, comparative analysis and a Strength, Weakness, Opportunity and Threats analysis was conducted. RESULTS: Three themes were interpreted from the data: 1) Frameworks such as the APP are needed to work towards elimination of restrictive practices; 2) APP-EPAs afford an opportunity to set the standard for practice; and 3) 'who watches the watchers', were identified by the experts as well as areas to enhance EPAs prior to introduction into practice. CONCLUSIONS: EPAs address a practice-gap and offer a framework to assist movement towards elimination of restrictive practices, while prompting best-practice, self-reflection and practice improvement guidance.

Faculty Decision Making in Ad Hoc Entrustment of Pediatric Critical Care Fellows: A National Case-Based Survey.

Phenomenon: Ad hoc entrustment decisions reflect a clinical supervisor's estimation of the amount of supervision a trainee needs to successfully complete a task in the moment. These decisions have important consequences for patient safety, trainee learning, and preparation for independent practice. Determinants of these decisions have previously been described but have not been well described for acute care contexts such as critical care and emergency medicine. The ad hoc entrustment of trainees caring for vulnerable patient populations is a high-stakes decision that may differ from other contexts. Critically ill patients and children are vulnerable patient populations, making the ad hoc entrustment of a pediatric critical care medicine (PCCM) fellow a particularly high-stakes decision. This study sought to characterize how ad hoc entrustment decisions are made for PCCM fellows through faculty ratings of vignettes. The authors investigated how acuity, relationship, training level, and task interact to influence ad hoc entrustment decisions. Approach: A survey containing 16 vignettes that varied by four traits (acuity, relationship, training level, and task) was distributed to U.S. faculty of pediatric critical care fellowships in 2020. Respondents determined an entrustment level for each case and provided demographic data. Entrustment ratings were dichotomized by "high entrustment" versus "low entrustment" (direct supervision or observation only). The authors used logistic regression to evaluate the individual and interactive effects of the four traits on dichotomized entrustment ratings. Findings: One hundred seventy-eight respondents from 30 institutions completed the survey (44% institutional response rate). Acuity, relationship, and task all significantly influenced the entrustment level selected but did not interact. Faculty most frequently selected "direct supervision" as the entrustment level for vignettes, including for 24% of vignettes describing fellows in their final year of training. Faculty rated the majority of vignettes (61%) as "low entrustment." There was no relationship between faculty or institutional demographics and the entrustment level selected. Insights: As has been found in summative entrustment for pediatrics, internal medicine, and surgery trainees, PCCM fellows often rated at or below the "direct supervision" level of ad hoc entrustment. This may relate to declining opportunities to practice procedures, a culture of low trust propensity among the specialty, and/or variation in interpretation of entrustment scales.

What influences general surgery residents' prospective entrustment and operative time in robotic inguinal hernia repairs.

INTRODUCTION: Teaching residents robotic-assisted inguinal hernia repair (RIHR) is an increasingly common extension of contemporary surgical training. This study sought to investigate what variables would influence operative time (OT) and resident prospective entrustment in RIHR cases. METHODS: We prospectively collected 68 resident RIHR operative performance evaluations with a validated instrument. Outpatient RIHR cases performed by 11 general surgery residents during 2020-2022 were included. The overall OT of matched cases was extracted from hospital billing; matched procedural step-specific OT was obtained from Intuitive Data Recorder (IDR). Statistical analysis was performed using Pearson correlation and one-way ANOVA. RESULTS: The evaluation instrument reliably assessed residents' RIHR performance (Cronbach's α = 0.93); residents' prospective entrustment strongly correlated with overall guidance provided by attending surgeon (r = 0.86, p < 0.0001) and operative plan and judgment (r = 0.85, p < 0.0001). The overall OT was significantly associated with resident's team management (r = - 0.35, p = 0.011). Procedural step-specific OT was significantly associated with residents' step-specific skill (r = - 0.32, p = 0.014). On average, RIHR cases with the highest level of prospective entrustment (Resident can teach junior) showed the shortest step-specific OT. Entrustment level 3 (Reactive guidance needed) was the turning point of all four RIHR procedural step-specific OT. CONCLUSIONS: Our findings suggest that in RIHR, attending guidance, resident operative plan and judgment, and resident technical skill contribute to resident prospective entrustment; resident team management, technical skill, and attending guidance influence operative time, which in turn impacts attendings' determination of resident prospective entrustment. Future studies with a larger sample size are needed to further validate the findings.

Which Entrustment-Supervision Scale is Right for Pharmacy Education?

Entrustable professional activities (EPAs) are an outgrowth of the competency-based educational model to support workplace-based learner assessments and evaluation. A learner's performance of EPAs is assessed by the degree of provided entrustment and required supervision rather than by a score, percentage, or letter grade typically assigned in traditional academic coursework. Entrustment-supervision (ES) scales are used to document learner progression and steer learner development over time. The purpose of this article is to critique various ES tools in health professions education for utilization within an EPA framework for learner assessment in workplace-based settings and to determine which will best suit pharmacy education. Exploring the advantages and disadvantages across all types of ES scales is a critical step in determining the most useful ES tool for use within a specific pharmacy institution and across the Academy. An ES scale with the traditional 5 levels, a prospective assessment frame, and increased stratification at lower levels should be recommended by the Academy and utilized in workplace-based settings for formative and summative assessment to provide more valid assessment of learners, support the ideal of life-long learning, and give more meaning for pharmacy faculty and learners within assessment.

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?

An Innovative Undergraduate Medical Curriculum Using Entrustable Professional Activities.

The need to educate medical professionals in changing medical organizations has led to a revision of the Radboudumc's undergraduate medical curriculum. Entrustable professional activities (EPAs) were used as a learning tool to support participation and encourage feedback-seeking behavior, in order to offer students the best opportunities for growth. This paper describes the development of the Radboudumc's EPA-based Master's curriculum and how EPAs can facilitate continuity in learning in the clerkships. Four guiding principles were used to create a curriculum that offers possibilities for the students' development: (1) working with EPAs, (2) establishing entrustment, (3) providing continuity in learning, and (4) organizing smooth transitions. The new curriculum was designed with the implementation of EPAs and an e-portfolio, based on these 4 principles. The authors found that the revised curriculum corresponds to daily practice in clerkships. Students used their e-portfolios throughout all clerkships, which stimulates feedback-seeking behavior. Moreover, EPAs promote continuity in learning while rotating clerkships every 1 to 2 months. This might encourage curriculum developers to use EPAs when aiming for greater continuity in the development of students. Future research needs to focus on the effect of EPAs on transitions across clerkships in order to further improve the undergraduate medical curriculum.

Integrated immediate postmortem and acute bereavement care: Competency-based entrustable professional activities for nursing.

BACKGROUND: Integrated immediate postmortem and acute bereavement care alleviates emotional distress due to losing a loved one; however, the provision of effective nursing care remains insufficient. Therefore, preparing nursing students with such skills is essential in end-of-life care education, and entrustable professional activities (EPAs) offer potential to address this gap. OBJECTIVES: To establish EPAs concerning immediate postmortem and acute bereavement care with a seven-category description for EPAs, milestones, and assessment tools. DESIGN: We used a modified Delphi method and four-step consensus-building approach to i) identifying the list of possible EPA items related to immediate postmortem and acute bereavement care based on a literature review and clinical experiences, ii) select an expert panel, iii) pool, review, and revise the EPAs, and iv) validate EPA quality using the Queen's EPA Quality rubric. Data analysis was performed via modes and quartile deviations. RESULTS: The following four major EPA components were identified: i) cultural and religious ritual assessment; ii) death preparation; iii) postmortem care; and iv) acute bereavement care. Three essential competencies were identified as highly correlated: general clinical skills, communication and teamwork capabilities, and caring. Consensus was achieved after three survey rounds. A 100 % questionnaire response rate was obtained. In the third round, all items received 4 or 5 points from >95 % of the panel members and were found to meet the quartile deviation cutoff score of <0.6, indicating that a high consensus level was established. The average Queen's EPA Quality rubric score was 62.5, with an average item score of 4.46, which was higher than the cut-off score of 4.07. Three major parts of EPAs were developed: task descriptions, milestones, and the assessment tool. CONCLUSION: The development of EPAs assessments concerning immediate postmortem and acute bereavement care may guide nursing curricula planning to bridge the gap between competencies and clinical practice.

Entrustment decision-making in genetic counseling supervision: Exploring supervisor and student perspectives to enhance training practices.

Entrustment decisions are an essential part of genetic counseling supervision and have the potential to influence a student's progression toward autonomy. However, there is often uncertainty among supervisors regarding how and when to make these decisions and very few studies have examined the impact of these decisions on students. This study utilized a mixed methods approach including surveys of genetic counseling supervisors (n = 76) and students (n = 86) as well as qualitative interviews with genetic counseling supervisors (n = 20) and students (n = 20) that explored factors that influence the entrustment decisions of genetic counseling supervisors and their effect on genetic counseling students. Genetic counseling supervisors and students were recruited from various organizations across the United States and Canada and represented a range of geographic regions, hospital systems, and genetic counseling programs. A hybrid process of deductive and inductive coding and thematic analysis was used to evaluate and interpret transcripts from the supervisor and student interviews. All participants identified advantages of increased autonomy during training. However, many supervisors reported low entrustment, seldom allowing students to complete unsupervised sessions or supervised cases without interruption. Entrustment decisions were heavily influenced by student ability and confidence, as well as patient feedback. Students emphasized the negative impact of decreased entrustment on their confidence and described clear benefits to increased autonomy before, during, and after the genetic counseling appointment. Supervisors identified various barriers to entrustment pertaining to the student, clinical setting, and the patient, whereas students more often emphasized barriers pertaining to themselves. Our results highlight a tension between the clear advantages of increased entrustment and autonomy and various barriers to the provision of these opportunities. Additionally, our data suggest several ways to enhance the supervisor-student relationship and promote additional learning opportunities to support student-centered supervision.

Preceptors' considerations when entrusting professional activities to postgraduate nursing students: A qualitative study.

BACKGROUND: Nurse-preceptors regularly struggle to evaluate students' readiness to take care of patients unsupervised, even with sophisticated workplace-based assessment tools. Preceptors' gut feelings are not always captured well, but are critical for judgement of readiness for learner entrustment with care tasks. Studies in medical education report features that clinicians consider important when trusting students with clinical responsibilities that might also apply in nursing. OBJECTIVES: To unravel preceptors' considerations when entrusting professional activities to postgraduate nursing students. The findings may contribute to the improvement of workplace-based assessments and the training of preceptors. METHODS: Thematic analysis of semi-structured interviews with sixteen nurse-preceptors from three postgraduate nursing specialisations in Dutch hospitals. RESULTS: Three themes emerged: CONCLUSIONS: For preceptors of postgraduate nursing students, entrustment requires more than merely insight into objectively measurable competencies. Entrusting is accompanied by subjectivity related to what preceptors expected of students. These expectations are in line with suggested factors in the literature-capability, integrity, reliability, agency, and humility-considered before entrusting students with clinical responsibilities identified in medical training. Entrusting is also accompanied by what preceptors realise about their own role in entrustment decisions. Combining different information sources made assessment more transparent and the implicit more explicit.