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

Using the ‘Answer Until Correct’ Assessment Method to Enhance Learning

by Zemen Habtemariam, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

Ultimately the goal of teaching is for students to learn.  Not simply for purposes of doing well on a test or getting a good grade, but to encourage students to engage in learning, to see more than one interpretation of the answer, and to improve retention. However, in my experience, how we are assessed in the classroom is not always reflective of what we are supposed to learn or what we actually have learned. Therefore, using a method of assessment that effectively reflects the desired goal – that is learning — is attractive to me.

Let’s look at an example. In my pharmacy school, a common method of assessment is the multiple choice examination (MCE).  Indeed, it's the most widely used form of assessment at many schools.  During a MCE, students are presented with a series of questions and they are asked to pick the one best answer. While these tests have been used for a very long time and are “objective” measures of knowledge, they have their flaws – and may actually discourage learning. For starters, multiple choice examinations foster the short memorization of facts and not the long term retention of concepts. They often foster “binge and purge” behaviors. In addition, MCEs can provoke anxiety because the learner is often forced to deliberate between two arguably good choices. I know these flaws all too well.

However, MCEs are not the only testing method available. Another testing method that might effectively addresses the “flaws” of the MCE is the Answer-Until-Correct (AUC) method. Under the AUC procedure, examinees can select an option for the multiple-choice question.  If the selected answer is not the best choice, the students is permitted to select another answer.  And they can continue to select other answer choices until the best answer is revealed. This type of testing often awards more points for selecting the best response first and awards fewer points as the students additional choices. This method of testing can enhance learning principally by providing formative feedback. Formative assessment is an approach whereby students receive immediate feedback on their work. This can be a critical element for students to achieve deeper learning.¹ Epstein and colleagues² developed a tool using the AUC method on three multiple-choice examinations in an introductory psychology course. Not only did the study find that students taking these types of exams performed better on the course’s final examination, but students would have received higher scores (when compared to students who had previously taken the course) even if a traditional MCE approach had been used. In this manner, the AUC approach actually helped students to retain their knowledge.

In addition to improving student learning, the AUC method may also reduce test anxiety – something many students experience. One study examined the effect of anxiety on student performance during a series of tests of varying levels of difficulty.³ The study found that although highly anxious students tended to do poorly on examinations, students who were prone to anxiety who received positive feedback from their examinations tended to have big gains in their performance, especially on exams of low difficulty (“easy”). The authors highlighted how items or questions of optimal difficulty on an examination often induced anxiety.  But that’s a Catch-22.  Students can only perform at their optimum when their anxiety is reasonably low.  The take-home message from this study is that students can show improvement in their test performance when anxiety is not highly apparent. Therefore, a testing approach that reduces the risk of selecting a wrong answer and utilizes immediate feedback can be expected to reduce anxiety.  This, in turn, allows learns to perform at their best.

Now that we have covered how the AUC method works and its potential benefits, one may be curious as to when and where it can be applied. Health professionals must be able to perform well on a test, but also be able to apply that knowledge to patient care or in the work environment. A good application of the AUC method would be a pharmacy law course. Pharmacy law, not unlike many topics in a pharmacy school curriculum, is important because every pharmacist must understand and adhere to the laws and regulations that govern pharmacy practice and the sale of medications. Traditional testing methods often require long periods of time to score or grade them.  Thus, students won’t know what answers they got wrong until they get their exam back some days or even weeks later.¹ Thus, students are forced to progress to the next topic in the course without having mastered the previous material and don’t have the opportunity to learn from their mistakes. Thus, educators can apply the AUC method by having students take law exams and answer each question until they reach the correct response. This not only teaches them what the correct answers are, but perhaps more importantly, students begin to learn why the other answers are not correct.

Students and educators will benefit from using the AUC method. This assessment technique has been shown to improve academic performance, alleviate anxiety that can hinder students from learning and test-taking, and addresses some of the limitations inherent in more traditional multiple choice exam formats.

References

1. Persky A, Pollack G. Using Answer-Until-Correct examinations to provide immediate feedback to students in a pharmacokinetics course. Am J Pharm Educ. 2008; 72(4): Article 83.

2. Epstein M, Epstein B, Brosvic G. Immediate feedback during academic testing. Psychological Reports. 2001; 88: 889-94.

3. Rocklin T, Thompson J. Interactive effects of test anxiety, test difficulty, and feedback. Journal Of Educational Psychology. 1985; 77(3): 368-72.  [accessed April 21, 2015]

Saying What the Learner May Not Want to Hear – Providing Feedback

by Regina Ulis, PharmD, PGY1 Pharmacy Practice Resident, Medstar Georgetown University Hospital

Every preceptor will inevitably encounter a learner who must be given “corrective” feedback regarding a less than optimal performance. While it is easy to give praise and reward learners for good behavior, it can be quite difficult to formulate criticism and deliver it in an effective manner. Such criticism may be necessary to help the learner grow professionally or perhaps personally, to protect patients’ health, or for a variety of other reasons.¹ However, it is important to understand that the recipient may see this feedback as a personal attack or may shy away from the learning experience instead of taking the advice in stride and taking action to make a behavior change. So how, then, do preceptors deliver feedback in a positive manner that promotes the learner’s growth?

Several methods have been proposed for giving effective feedback to learners. One of the most frequently used methods is the “Feedback Sandwich”.² A Feedback Sandwich is essentially a negative critique “sandwiched” between positive statements. For example, if a learner needs to be more assertive, the preceptor might say, “You made several excellent recommendations to change the patient’s medication regimen. However, I don’t think you communicated them to the team very effectively.  You seemed unsure of yourself and people could barely hear you. I think that one of your goals for this rotation should be to become more confident in making recommendations to the team. That way the team can take advantage of your clinical knowledge and this will lead to improved patient care.”

The entire purpose of this method is to make the delivery of negative feedback more palatable. This method can be effective because it builds trust, improves comfort, and increases the receptiveness of the listener to the criticisms that are delivered. It has also been documented to increase motivation and engagement²; these qualities are necessary to maximize learning. There are also variations to this technique, such as the “open-face” sandwich, which pairs a negative statement followed by a positive one. Different situations may call for different varieties of “sandwiches,” and it may also become necessary to vary the technique because the learner may begin to anticipate that good feedback is always followed by a negative comment.²

Studies have been conducted to see the effects of the Feedback Sandwich on learning including studies with medical students.²  These results should be applicable to student pharmacists and other health professionals as well. Overall, these studies have shown that this method enhances the learner’s self-esteem. Additionally, using this method allows for more individualized comments, which increases performance even though it may not increase the student's short-term satisfaction. Other results indicated that the number of positive comments provided to a learner predict successful future performance.² This may be a reason why it may be helpful to give positive feedback alongside the negative.

Another common method of giving feedback is the “reflective feedback” technique which focuses on content and its relationship to the receiver. In other words, this message focuses on the message to be delivered and how important it is to the person receiving it. This method consists of a series of 3 steps:³

1.  Ask questions that are clarifying and connected to what was observed
2. Explain the value or potential value to the learner who is receiving feedback
3. Ask a reflective question or put forth a potential action to stimulate thought

The goal of these steps is to make underlying assumptions explicit (step 1), make the recipient feel valued (step 2), and request a response from the recipient and allow them to see others’ point of view (step 3).  One of the positive attributes of reflective feedback technique is that it is intended to come off as less judgmental and more focused on growth and development. Following these three steps opens a conversation between the teacher and learner and allows for a discussion, including justifications and possible observations that each party has made.³

Although these are but two methods that may be used to deliver feedback to learners, both are documented to be effective. They allow for growth and development – often of both parties.^1,3 In health professional education, using these techniques may also lead to improvements in patient care. It is important to note, that many other strategies for delivering feedback exist, and that every situation is unique.  It is important to have a plan prepared for when you have to say what your learner may not want to hear.

References

1.   Hoon A, Olver E et al. Use of the “Stop, Start, Continue” method is associated with the production of constructive qualitative feedback by students in higher education. Assess Eval Higher Educ 2015; 40(5): 755-767.

2.   Parkes J, Abercrombie S, McCarty T. Feedback sandwiches affect perceptions but not performance. Adv Health Sci Educ Theory Pract 2013; 18(3):397-407.

3.   Reilly M. Saying what you mean without being mean. Educational Leadership 2015; 73(4): 36-40.

Teaching Team Work and Cooperation: Critical Skills in Healthcare Today

by Matthew Levit, Doctor of Pharmacy Candidate, Class of 2018, University of Maryland School of Pharmacy

Traditional instructional models stress the importance of individualism, but many educators and schools have begun to emphasize cooperative learning methods.¹ Cooperative learning is an integrative learning model that seeks to educate students through activities that promote social learning and leadership experiences.^2,3 Cooperative learning has its origins in social interdependence theory. According to this theory, the learning outcomes of an individual are determined by their own actions as well as the actions of others.³ Cooperative learning builds on this theory by postulating that learning occurs best through social engagement.⁴

Picture from collegestar.org

Cooperative learning is more than just working together in a group. Students learn by using their social and interpersonal skills to achieve an academic goal.¹ Cooperative learning is commonly used in a variety of practice-based settings including service learning, integrative internships, and continuing education (CE) seminars.⁵ In some of these settings, students receive academic credit and solve real-world problems.⁵ For example, students rotating on an interprofessional team may encounter a patient that suffers from multiple comorbidities (e.g. diabetes, hypertension, and neuropathic pain). One student in the group may be adept at diabetes management.  Another may have experience managing patients with high blood pressure.  And another may be very knowledgeable about neuropathic pain. Collectively, the students learn from each other and are more likely to successfully complete the academic exercise.

Picture from viewinghistorythroughthedigitallens.com

There are five key elements to the cooperative learning model. These include positive interdependence, individual and group accountability, face-to-face promotive interaction, interpersonal and small group skills, and group processing.^1,6 Positive interdependence requires that every member of the group value each other’s contributions.¹ Interprofessional healthcare teams must have positive interdependence in order to fully utilize each member’s unique contributions to the patient’s care. Individual and group accountability requires that each member of the group is accountable for one’s actions and all must contribute to the completion of the assigned task.⁶ An evaluator should discipline students who do not contribute because it is detrimental to the group’s overall success. Interpersonal and small group skills include effective leadership and communication, building trust, making clear decisions, and managing potential conflicts.¹ Face to face promotive interactions require learners to share resources as well as support and encourage their teammates success.⁶ Group processing requires communication among group members. Members should be encouraged to express any concerns they have with each other for the overall benefit of the group.⁶

One example of an instructional method that uses the five key elements of the cooperative learning model is the jigsaw technique.^3,5 In this method, students are assigned a topic and placed into two groups: a home group and an expert group. Students in the home group go to the expert group to learn a particular topic and then go to another group to teach that particular subject.³ This technique promotes contributions from each member of the group (positive interdependence and face to face interaction) as well as accountability for each member’s actions (individual and group accountability). Educators that use this model expect their students to support each other’s learning as well as understand that each member of the group must be able to teach a piece of the subject matter to others. In addition, students are expected to communicate effectively with each other using verbal and non-verbal communication (interpersonal and small group talks and group processing).^3,5  This certain isn’t the only example of cooperative learning.  Several other cooperative learning methods exist [See previous blog essay regarding the Processed Oriented Guided Inquiry Learning (POGIL) method].

Picture from flipclass.com

In healthcare today, interprofessional healthcare teams are practicing cooperative learning.⁷ In the past, different specialties would work independently and had little appreciation or understanding regarding the unique contribution that other members of the health care team could make.  If students start collaborating in the classroom with their peers, then perhaps this will translate to working with other healthcare professionals.⁷ Health professions educators have an important role in helping students become effective members of a team. In order to implement cooperative learning, educators must promote instructional methods that use the 5 key elements of the cooperative learning model. For example, in the classroom setting, an educator can design case-based group exercises (interpersonal and small group skills and group processing). Students should be encouraged to work in small groups so that everyone has a chance to participate (face-to-face promotive interaction) and learn from each other. During these clinical exercises, the instructor can require that each student to write a reflection on how they contributed to the group’s work as well as evaluate peers (positive interdependence and individual and group accountability). This reflection will allow the educator to see how well collaborative learning is working and student comments can be used to make changes. In practice-based settings, preceptors and other healthcare instructors can encourage interprofessional healthcare teams to use this model of learning when “rounding” in the hospital or during interprofessional meetings in clinic.^4,7 Evaluations of their experiences can be used to individualize students’ needs and provide an overall framework for future collaborative work. The ultimate goal every educator should stress when using cooperative learning strategies in healthcare is to promote optimal patient care.

Picture from dental.nyu.edu

Cooperative learning is a model for developing and implementing instructional activities that helps students to develop social learning and leadership skills. ^2,3 Educators and students in the health professions must become proficiency in these skills in order to effectively manage complex patients through team-based collaborations.^4,7

References

1. Salam T, Greenberg H, Pitzel M, Cripps D. Interprofessional education internships in schools: Jump starting change. Journal of Interprofessional Care. 2010; 24(3): 251 – 263.
2. Stavenga de Jong JA, Wierstra RF, Hermanussen J. An exploration of the relationship between academic and experiential learning approaches in vocational education. British Journal of Educational Psychology 2006; 76(1): 155-169.
3. Johnson DW, Johnson RT. An Educational Psychology Success Story: Social Interdependence Theory and Cooperative Learning. Education Educational Res 2009; 38(5): 365 – 379.
4. Budgen C, Gamroth L. An overview of practice education models. Nurse Education Today 2008; 28(1): 273 – 283.
5. Schul JE. Revisiting an Old Friend: The Practice and Promise of Cooperative Learning for the Twenty-First Century. Soc Studies 2011; 102(1): 88 – 93
6. Basak T, Yildez D. Comparison of the effects of cooperative learning and traditional learning methods on the improvement of drug-dose calculation skills of nursing students undergoing internships. Education Educational Res 2014; 73(3): 341 – 350.
7. Mitchell P, Wynia M, Golden R, et al. Core principles and values of effective team based health care. 2012; Discussion Paper, Institute of Medicine, Washington, DC.