Understanding entrustment decisions in entrustable professional activities

To the Editor, Entrustable professional activities (EPAs) play a defining role in the acquisition of essential skills and competencies that are necessary for independent clinical practice.[1] These activities provide a structured framework to translate subject-specific competencies into observable and measurable actions, enabling teachers to assess the performance of students and thereby make a decision regarding their proficiency.[2] In competency-based medical education, EPAs predominantly focus on the real-world activities that students are expected to encounter upon completion of their training period and also provide specific criteria to assess the competence levels of medical students.[3] The relationship between specific learning objectives, competencies, and EPAs is shown in Figure 1.Figure 1: Relationship between specific learning objectives, competency, and entrustable professional activities. K: Knowledge, S: Skills, A: AffectiveIn the medical field, entrustment refers to the process, in which students are permitted to perform specific activities independently after they have demonstrated the desired level of competence and readiness in authentic settings.[3] This happens only when students gain the trust of their teachers or assessors to perform activities (which essentially involves assessment of knowledge, skills, attitude, and behavior of students about the EPA that is being observed) in the absence of direct supervision.[3,4] In the broader sense, entrustment indicates a transition from being dependent toward autonomy, which ensures that students gradually become more responsible and competent in performing specific professional activities.[1,3,4] To enable an assessor to decide about entrustment concerning specific tasks, many components need to be observed in the planned assessments.[1,2] This begins with observing the performance of students in real or simulated scenarios depending on the EPA, using a suitable assessment tool (such as checklist, global rating scale, and workplace-based assessment.)[3] Medical students have to be assessed on the basis of predefined criteria and the set benchmarks for the specific task, while the level of supervision will depend on the extent of readiness and proficiency demonstrated by individual students.[3,4] In addition, the entrustment decision will also take into account the ethics, professional approach, communication skills, and interpersonal skills demonstrated by students while performing the given task, if relevant.[4,5] Finally, it is crucial that all the records pertaining to entrustment decisions are properly documented and maintained to enhance accountability.[2,3] By all means, entrustment decisions play a vital role in making an evidence-driven decision about the competence and learning progression of the student.[5] In other words, these decisions consider the readiness of students to practice independently and safely for real-world practice.[4,5] Once a teacher entrusts a student with any specific activity, it is an indication that their performance has been validated and meets the set expectations and standards.[3] This does not happen in a day; rather, entrustment allows students to gradually progress from being under strict supervision to no supervision, and in the process, students also become autonomous.[3,6] This obviously aids in the acquisition of knowledge and skills, the development of professional identity, and the confidence to perform the assigned task.[6,7] Moreover, entrustment decisions are pivotal in bringing about patient safety and improving quality assurance both in the field of education and healthcare delivery.[3,4] On realizing the importance of entrustment decisions, we must adopt a systematic process to make this entrustment decision.[3,8] This begins with the identification of specific activities that are suitable for entrustment depending on their relevance to the responsibilities of the student. This has to go along with the formulation of specific criteria which will aid in assessing the competence of students in the identified tasks.[8] At the same time, an appropriate assessment tool should also be selected through which student performance will be assessed in different settings.[3,4] The assessment must be followed by the delivery of constructive feedback to the students and encouragement of reflection, both activities aiming toward the identification of strengths and the areas that need improvement.[2,4] Depending on the improvement in the performance of the student (namely, Grade 1 – only knowledge, Grade 2 – requires strict supervision, Grade 3 – requires lose supervision, Grade 4 – independently do, and Grade 5 – teach others), the level of supervision should also change, but then, we must take into account the complexity of the task and patient safety.[8] It is extremely important that this entire process of monitoring and learning progression is systematically documented to help teachers make rational decisions.[3] Further, it is always a healthy practice to involve a number of assessors in the process and test the students across different learning environments. Finally, there has to be a mechanism to periodically review and evaluate the process of entrustment decision to assess the overall effectiveness of the entrustment decision process.[4,5] Entrustment decisions are not made in isolation; rather, a number of parameters such as the complexity of the activity, level of student proficiency, learning context, and patient safety must be given due importance.[9] The faculty member assesses the depth of understanding (knowledge component), proficiency in clinical skills about the task, communication skills, and demonstration of ethical and professional behavior.[2,3] In addition, students are also assessed for their clinical judgment (namely, whether they can make sound clinical decisions depending on the needs of the patient), consistency (in terms of their performance in different settings), problem-solving skills, and adaptability depending on the changes in patient parameters or resources availability in the local environment.[1-4] Further, students are also assessed for their ability to collaborate with their team members from different professions and their ability to engage in teamwork.[10] In addition, students should be receptive to the given feedback and make efforts to incorporate them into their future set of practice.[11] At the same time, students should be willing to engage in self-assessment and reflection, as these efforts will help them to continuously improve and move forward in the direction of attainment of learning competencies.[1-3] Making entrustment decisions in medical education is a challenging task, and as assessors, faculty members must be aware of them. These challenges include the scope of being subjective in assessment, as the way one faculty assesses a student might be different from another one, which also influences the consistency and reliability of such decisions.[12] The presence of a limited number of validated assessment tools can also emerge as a big challenge to evaluate the competence of students.[13] Further, contextual factors (such as patient attributes or settings of assessment) can also impact the perceived readiness for entrustment. Moreover, untrained faculty members or too much assessment can bring about assessment fatigue, and these issues must be looked into.[14] From students’ perspective, variability in their readiness or learning curve, and personal factors can definitely influence their ability to demonstrate competence on a regular basis.[15] Finally, we must maintain a balance between ethical parameters (such as maintaining patient confidentiality and obtaining informed consent) and entrustment decisions.[12-14] On realizing the potential concerns, we must adopt specific measures to improve the accuracy of assessments of students.[16] The most essential strategy is to organize a series of faculty development workshops to empower them to use different assessment tools and the ways by which these tools can be used in a valid and reliable manner.[16,17] Teachers should develop and/or use the existing standardized assessment tools to bring about consistency in the assessment.[3] We must define clear criteria (that are in alignment with the learning objectives) and benchmarks for entrustment decisions.[16-18] For each of the assessment tools, it is a better practice to develop rubrics of milestones to eliminate the possibility of subjectivity.[17,19] It is a positive practice to involve multiple assessors in multiple settings to reduce the probability of interassessor variability.[16,17] Further, as mentioned earlier, all assessments should be properly documented and due consideration to be given to contextual factors.[18-20] Finally, teachers must adhere to ethical guidelines and professional standards in making entrustment decisions.[4] EPAs are of paramount importance in informing entrustment decisions regarding the ability of students to independently practice. However, there are a number of factors that influence entrustment decisions, and we must take specific measures to enhance the validity and reliability of the assessment process and thereby improve entrustment decisions. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Ethical conduct of research This study was done according to the reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. Approval from the Ethics/Institutional Review Board is not required for short communication.