Entrustable professional activities versus competencies and skills: Exploring why different concepts are often conflated

Abstract

Despite explanations in the literature, a returning question in the use of entrustable professional activities (EPAs) is how to distinguish them from competencies and skills. In this article, we attempt to analyze the causes of the frequent confusion and conflation of EPAs with competencies and skills, and argue why the distinction is important for education, qualification and patient safety. ‘Tracheotomy’, ‘lumbar puncture’, ‘interprofessional collaboration’ for example are colloquially called ‘skills’, but its is a person’s ability to perform these activities that is the actual skill; the EPA is simply the activity itself. We identify two possible causes for the confusion. One is a tendency to frame all educational objectives as EPAs. Many objectives of medical training can be conceptualized as EPAs, if ‘the ability to do X’ is the corresponding competency; but that does not work for all. We offer ways to deal with objectives of training that are not usefully conceptualized as EPAs. A more fundamental cause relates to entrustment decisions. The permission to contribute to health care reflects entrustment. Entrustment decisions are the links or pivots between a person’s readiness for the task and the actual task execution. However, if entrustment decisions do not lead to increased autonomy in the practice of health care, but only serve to decide upon the advancement to a next stage of training, EPAs can become the tick boxes learners feel they need to collect to ‘pass’. Gradually, then, EPAs can loose their original meaning of units of practice for which one becomes qualified.

The logic behind entrustable professional activity frameworks: A scoping review of the literature

“…We do not dispute the importance of these objectives for training, but they should be incorporated in training in a different way than stand-alone EPAs. Several ways to deal with objectives of training that are not usefully conceptualised as EPAs were recently provided by ten Cate and Schumacher 32.…”

Supervising the senior medical resident: Entrusting the role, supporting the tasks

“…Five participants were in their first 5 years of practice, nine had been in practice for 6-10 years and the remaining five participants had more than 15 years of experience as supervising physicians. Most participants (16) supervised on a clinical teaching unit at a tertiary care site, two participants supervised on both a teaching unit and in a community setting and one participant worked exclusively at a community site.…”

“…As has been noted elsewhere, in the Canadian CBME context, entrustment decisions lead to progression to the next stage of training, are granted by the system and do not lead to unsupervised practice. 8,16 These constraints may have limited our participants' perspective on entrustment to the scope of the senior resident role.…”

Developing entrustable professional activities for doctoral graduates in health professions education: obtaining a national consensus in Iran

“…Competencies were used to address the challenge by integrating knowledge, skills and attitude. However, both educational objectives and competencies are attributes of individuals and are invisible until they are being used while the individual is performing tasks or activities [ 14 ]. On the other hand, EPAs describe activities of a profession that are performed by qualified persons, independently and proficiently; requiring integrated competencies in different areas in order to perform activities effectively [ 15 ].…”