Perceptions and experiences of entrustable professional activities implementation in postgraduate medical education: A qualitative evidence synthesis

BACKGROUND: Entrustable professional activities (EPAs) define essential professional tasks and responsibilities that can inform curriculum, teaching, supervision, developmental progression and assessment. Despite widespread implementation in postgraduate medical education, experiences and perceptions of EPAs remain fragmented, raising questions about how they are translated into practice. METHODS: We conducted a systematic review and qualitative evidence synthesis of studies exploring participant experiences and perceptions of EPA implementation in postgraduate medical education. Six databases were searched from inception to August 2024 and updated in April 2025. Eligible studies included qualitative and mixed-methods designs that examined learners, faculty, administrators or other groups involved in EPA use. Data were extracted in duplicate and analysed using Thomas and Harden's thematic synthesis approach. Methodological quality was assessed with the Joanna Briggs Institute checklist, and confidence in findings was appraised with the GRADE-CERQual framework. RESULTS: From 7027 records, 23 studies involving 443 participants were included. Studies spanned Canada, the United States, Europe, and New Zealand across diverse specialties. Thematic synthesis yielded five interrelated themes: design tensions; growth and performance; faculty preparedness, engagement and consistency; psychological climate; and anchoring in institutional scaffolds. Participants valued EPAs for clarifying expectations, structuring feedback and supporting developmental progression. However, many experiences were shaped by assessment-dominant implementation, in which EPAs were encountered primarily through forms, entrustment ratings, completion requirements and progression decisions. Administrative burden, faculty uncertainty, learner anxiety and strategic completion contributed to this narrowed enactment. CONCLUSIONS: EPAs were often experienced less as broad frameworks for organising professional development and more as assessment infrastructure. Future implementation should focus on translating EPAs as intended: essential professional activities that guide curriculum, supervision, feedback and assessment within supportive educational systems.