Would I Trust or Will I Trust? The Gap between Entrustment Determinations and Entrustment Decisions for Trainees in Pharmacy and Other Health Professions

Abstract

Entrustable Professional Activities (EPAs) and entrustment decision making are rapidly becoming mainstream in competency-based education in the health professions. EPAs are the units of professional practice to entrust graduates with once they have developed the required competencies. They were conceived to enable a gradual increase in professional autonomy during training, by allowing trainees to practice activities in which they have demonstrated they have mastered well, with decreasing supervision. However, practicing health care unsupervised generally requires licensure. The question for pharmacy education, as well as for undergraduate medical education, is can students be given any autonomy in practice, even when they have fully mastered an EPA yet remain unlicensed? While entrustment decisions for licensed practitioners have autonomy consequences, some educators in undergraduate programs speak of ‘entrustment determinations’, to avoid decisions about students that affect patient care, in other words saying, we would trust you, rather than we will trust you. However, graduating learners without the experience of responsibility and reasonable autonomy creates a gap with full practice responsibilities, which may jeopardize patient safety after training. What can programs do to retain the power of using EPAs while at the same time guarding patient safety?

Assessment of Entrustable Professional Activities Among Dutch Endocrine Supervisors

“…Videos would be less useful, as they only capture observations on single moments. We called the ratings “entrustment determinations” rather than entrustment decisions, as those would require observations of live situations and the option to actually decide on entrustment with a health care task [ 21 ]. Despite these limitations, raters expressed high confidence in the EPA levels they assigned, demonstrating that the case description provided the most important details to come to a justified conclusion.…”

“…The introduction of the mini clinical evaluation exercise or miniCEX [ 16 , 17 ] was an early example, followed by tools for direct observation of technical skills [ 18 ], case-based discussions [ 19 ], 360 degree evaluation [ 20 ] and many more [ 22 ]. The worldwide movement of competency-based medical education with its focus on standardised outcomes of training [ 21 , 22 ], largely since the turn of the century, has not only further stimulated WBA but reinforced the need for standards of validity [ 23 ]. With the introduction of EPAs in postgraduate training [ 3 ] the focus of WBA shifted from retrospective observed proficiency to prospective entrustment decision-making.…”

Do summative entrustment decisions actually lead to entrustment?

“…This would also allow them to deviate from a general CBME policy and to make 'entrustment decisions' on paper without increase of autonomy in practice. 13 'Seniorisation' of patient care in teaching hospitals may not only serve patient safety but also interfere with the trainee's opportunity to build experience.…”

“…Supervising clinicians have the authority to determine when, and to what extent, trainees are allowed to work with or without their supervision. This would also allow them to deviate from a general CBME policy and to make ‘entrustment decisions’ on paper without increase of autonomy in practice 13 …”