Entrustable Professional Activities: Building Core Skills and Expectations

By Andrew Mays, PharmD, CNSC, Clinical Pharmacy Specialist, University of Mississippi Medical Center

As a preceptor for student pharmacists, pharmacy residents, and medical fellows, I sometimes ask myself if I am providing my trainees the best training to prepare them for practice.  While each individual has different professional goals, it is my responsibility to ensure that each trainee has been adequately prepared for the professional roles they will have in the future.  Sometimes, my perspective is clouded by a trainee’s background or career ambitions.  Precepting trainees from multiple professional programs often make it difficult to meet each institution’s unique requirements.  This can leave preceptors with questions about what each student’s experience must include or what to skills to focus on.  Entrustable professional activities (EPAs) provide preceptors a common structure for practice-based experiences.¹

Healthcare is constantly evolving and training programs for each healthcare profession must change to meet the needs of patients. This evolution also impacts the education of students within professional programs.  To maintain consistency, leaders within health professions education must determine how to evaluate student progression and determine when a trainee is ready for practice.  EPAs give preceptors a set of expectations and leads to appropriate and effective feedback.  EPAs also address potential differences between schools and postgraduate training programs.  EPAs can be leveraged to determine trainee competency in “real-life” clinical settings.^1,2

The American Association of Colleges of Pharmacy’s Academic Affairs Standing Committee recently developed the Core Entrustable Professional Activities (EPAs) for New Pharmacy Graduates.³ EPAs are units of professional practice and descriptors of work that are independently executable, observable, and measurable in process and outcome.  These core EPAs were identified as activities or tasks that all new pharmacy graduates must be able to perform without direct supervision when entering practice or post-graduate training.⁴

Recently published research in the American Journal of Health-System Pharmacy looked at the validity of the Core EPAs for New Pharmacy Graduates.⁵ This prospective study asked experienced pharmacy preceptors to complete a 28-item survey that included questions regarding the Core EPAs, the EPA role categories, and respondent demographics. These practitioners supervised students on introductory and advanced pharmacy practice experiences.  To be eligible for the study, the respondents must have supervised at least 6 students over the previous 24 months. The participants in this study represented diverse backgrounds and practice settings. Respondents were full-time, part-time, and volunteer/adjunct faculty and practiced in acute care, long-term care, ambulatory care, and other diverse pharmacy practice settings.

Respondents consistently agreed (>75%) that the EPA statements were pertinent to pharmacy practice and reflected activities that pharmacists are supposed to do in every pharmacy practice setting.

The results of this study show that experienced highly-credentialed preceptors agree that the EPA statements are valid expectations.  Moreover, the EPA statements are focused, observable, and transferable to multiple settings.  However, this study did not survey new practitioner, staff pharmacists, or administrators – groups that might have different opinions about the relevance and applicability of the EPAs.  Also, students and residents were not included in this study.  The viewpoint of pharmacy students or residents may give important information in order to determine the feasibility of the EPAs during training.

EPAs describe the activities that encompass the day to day activities of healthcare professionals.  One important element that has not been adequately addressed is the concept of “trust.”  How will preceptors determine whether a trainee can be “entrusted” to perform these activities?  And if trainees do not demonstrate an adequate level of ability, what is an appropriate intervention?

Along with identifying the critical skills needed to care for patients, EPAs empower preceptors to tailor rotations to better prepare students for practice.  As the use of EPAs increases and students are more consistently prepared for practice, postgraduate training programs should witness a more consistent baseline of knowledge and skill for entering residents.  This will not eliminate students having variations in clinical experiences, but it will allow for post-graduate training programs to build on the expected core.

References

1. Pittenger AL, Chapman SA, Frail CK, et al. Entrustable Professional Activities for Pharmacy Practice. Am J Pharm Educ. 2016 May 25;80(4): Article 57.
2. Association of American Medical Colleges. Core Entrustable Professional Activities for Entering Residency: Curriculum Developers’ Guide. https://members.aamc.org/eweb/upload/Core%20EPA%20Curriculum%20Dev%20Guide.pdf (accessed October 15, 2018).
3. Haines ST, Pittenger AL, Stolte SK, et al. Core Entrustable Professional Activities for New Pharmacy Graduates. Am J Pharm Educ. 2017 25;81(1): Article S2.
4. American Association of Colleges of Pharmacy. Core EPA Domains and Example Supporting Tasks (Appendix1).
   
   https://www.aacp.org/resource/entrustable-professional-activities-epas (accessed October 8, 2018).
5. Haines ST, Pittenger AL, Gleason BL, et al. Validation of the entrustable professional activities for new pharmacy graduates. Am J Health-Syst Pharm. 2018;75: e661-8.

Time-Variable, Competency-Based Education: Benefits and Challenges

by Kelsey Dearman Beatrous, PGY-1 Pharmacy Practice Resident, University of Mississippi Medical Center

Health professions education has traditionally used time, along with practice-experiences and exams, to determine when a student “graduates” and is deemed ready for practice.  Time — measured in semesters and credit hours — sets the pace of learning for students.  But does time and credit hours assure that all learners are ready for practice?  Clearly not.  Is there a better way?  In contrast, competency-based education (CBE) assesses how much students have learned before they progress forward in the curriculum instead of focusing on the amount of time spent completing formal instruction.¹ Competency-based learning allows the student to progress at his or her own pace.  The student completes the degree by demonstrating that he or she has mastered the knowledge, skills, and attitudes necessary to become a health professional.

Photo by Nubia Navarro (nubikini) from Pexels

CBE can also be applied to post-graduate training such as residency and fellowship programs. Currently, practice experiences within residency programs are typically limited to one calendar month and residents move forward each month to a new learning experience, even if they have not mastered the intended outcomes. Introducing CBE would require the resident to master the necessary competencies before “moving on.”  In theory, this is what should happen and what every program should strive for, right?

One program that has adopted a CBE curriculum is The University of Wisconsin-Milwaukee College of Nursing Bachelor of Science Nursing degree option, the UW Flexible Option BSN.² This program permits nursing students to complete their nursing degree by demonstrating their knowledge and skills instead of acquiring course credits.  Students are required to complete a variety of competency-based activities.  Successful completion can take as little or as much time as needed.

While CBE is intuitively attractive, it presents unique shortcomings that may make implementing it across health professional curriculums problematic. As Melissa Medina, Ed.D at the University of Oklahoma Health Sciences Center points out, scheduling introductory pharmacy practice experiences (IPPEs) and advanced pharmacy practice experiences (APPEs) is potentially problematic in CBE.³ These issues are not unique to pharmacy education, but apply to any professional degree program that requires rotations or practice-based experiences before graduation. In CBE programs, students will be ready to advance to their practice experiences at different times throughout the year. A student may be ready to begin a practice experience in June, for example, but without advanced planning, none of the practice sites affiliated with the college/school may be able to accommodate the student, regardless of how ready the student might be. In a CBE curriculum, practice experiences are also competency-based, and some students will likely need more time (or some less) at a practice site before being deemed “competent” by the preceptor to move forward. Although practice experiences are often completed in the later part of a curriculum, scheduling students for experiences that could start at any time during the year and would last for variable durations would be very challenging. It would be extremely difficult for school administrators to assign, accommodate, and predict the length of time students need to complete these experiences. Practice sites cannot accept an unlimited number of students and preceptors might be limited by specific student-preceptor ratio laws. This remains the biggest challenge to implementing CBE within degree programs.

Another potential drawback is that CBE may not suit all students.  Some students prefer lectures in traditional classroom settings.  Students who are less self-directed or require more assistance may fall behind in a competency-based program.  It might be more difficult for faculty to identify students who are performing poorly.

In the UW Flex BSN program, they have found a potential solution by providing adequate support to all students to ensure no one is left behind. Each student is assigned an academic success coach (ASC) when admitted to the program. The ASC guides the student through the entire program until graduation.² ASCs support their students in various ways including academic advising, general tutoring, and mentoring at least once a week as the student progresses through the program.

Another potential problem with CBE is the potential for a large gap in time between completion of the degree requirements and starting residency training. Currently, residency programs start on (or around) July 1st. In a CBE curriculum, if students complete their degree at their own pace, there may be large gaps between degree completion (in September, for example) and residency program entry. On one hand, it would give recent graduates more time to complete board exams and take time off before furthering their training. However, this may be less desirable for many recent graduates aiming to start and complete training as quickly as possible in order to earn a salary (and pay back student loans!). If CBE becomes commonplace, residency programs would have to be open to accepting and graduating residents at various times of the year.

Oregon Health and Science University (OHSU) is currently designing a medical education and residency program called Program to Accelerate Competency-based Education (PACE).  The school plans to enroll students in PACE in 2019.⁴ Students in PACE can begin an OHSU residency program in different specialties outside of the National Match process. Medical students would be allowed to graduate in any semester (spring, summer, fall, or winter) and then enter one of the various residency programs at OHSU at any point during the year. This program requires coordination between the professional degree program and residency training to accommodate trainees at various times throughout the year.

Several health professional degree programs want to move toward a CBE curriculum. Piloting competency-based principles in the earlier courses in a curriculum may be a place to start in degree programs that wish to convert to CBE. Hiring and training adequate personnel to ensure oversight of student performance and provide personalized attention will be necessary to meet the program’s and student’s needs. Professional programs that are closely associated with academic medical centers can work together to provide off-cycle clerkship and residency start dates like OHSU PACE program. However, planning and accommodating students for their practice experiences will remain a critical barrier to fully implementing CBE. For the time being, I believe that the didactic portion of the curriculum could be competency-based but practice experiences will still need to be planned and scheduled based on well-defined start and end dates. None-the-less, enhancing health professional curricula with competency-based elements in the didactic portion of the degree program can help ensure students meet the necessary competencies prior to beginning their practice experiences.

[Editor's Note:  For more information on this timely topic, check out the March 2018 Supplement to the journal Academic Medicine (open access):  Competency-based, Time-Variable Education in the Health Professions. There are a number of articles in this themed issue.] 

References:

1. Ten Cate O, Gruppen LD, Kogan JR, Lingard LA, Teunissen PW. Time-Variable Training in Medicine. Academic Medicine. 2018;93:S6-11. doi:10.1097/acm.0000000000002065
2. Litwack K, Brower AM. The University of Wisconsin–Milwaukee Flexible Option for Bachelor of Science in Nursing Degree Completion. Academic Medicine. 2018;93:S37-41. doi:10.1097/acm.0000000000002076
3. Medina M. Does Competency-Based Education Have a Role in Academic Pharmacy in the United States? Pharmacy. 2017;5(4):13. doi:10.3390/pharmacy5010013
4. Mejicano GC, Bumsted TN. Describing the Journey and Lessons Learned Implementing a Competency-Based, Time-Variable Undergraduate Medical Education Curriculum. Academic Medicine. 2018;93:S42-48. doi:10.1097/acm.0000000000002068