Case scenario

A carer presents a prescription for cefalexin oral liquid for their child, who has mild cellulitis. The intern asks if they could be assessed on EPA dispensing. You agree and ask the intern to talk through their thoughts as you observe them process the prescription and reconstitute the antibiotic.

Learning objectives 

After reading this article, pharmacists should be able to:

  • Define what entrustable professional activities are
  • Discuss the purpose of entrustable professional activities in assessment of intern readiness to practise
  • List sources of information that can be used to inform entrustment decisions
  • Outline key recommendations for application of entrustable professional activities in pharmacy workplaces.

Competencies addressed (2016): 1.4, 1.5, 1.6, 2.3, 4.1, 4.3, 4.6, 4.7, 5.

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Introduction 

Preceptors and supervising pharmacists are responsible for making decisions about the ability of pharmacy interns to complete tasks independently as they progress through the supervised practice period. As an intern gains confidence over time, a supervisor will generally allow them to carry out certain tasks with increasing independence while providing appropriate supervision to safeguard patient safety.

Entrustable professional activities (EPAs) provide a framework for evaluating the progressive increase in responsibility and autonomy of a trainee in carrying out the activity. In this way, EPAs mirror what already occurs in pharmacy workplaces and the day-to-day work of supervisors.

EPAs have been introduced in all intern training programs (ITPs) and form part of a suite of workplace-based assessment (WBA) tools that support learning and assessment of pharmacy intern readiness to practice.1,2 This article seeks to provide preceptors and supervising pharmacists with a deeper understanding of the principles underpinning EPAs to support their use in pharmacy intern training.2 It builds on our first article, ‘Workplace-based assessment for intern pharmacists’, published in the April 2023 issue of AP.

The APC has developed videos, exemplars and guidelines to help interns and their supervisors in the understanding of EPAs – visit this page to learn more. 

Description and purpose of entrustable professional activities

An EPA is defined as ‘a unit of professional practice (a task or group of tasks) that can be fully entrusted to a trainee, as soon as he or she has demonstrated the necessary competence to execute this activity unsupervised’.3

EPAs have become increasingly popular in several health profession education programs.4-7 While relatively new in pharmacy education,8 EPAs provide an opportunity to operationalise a competency-based approach to pharmacy intern training.9,10

EPAs relate to tasks that can be readily observed and collectively define the professional work of a discipline.3,4 In pharmacy, EPAs constitute what pharmacists are trusted to do, such as dispensing, vaccination and providing patient advice. These professional tasks can be fully entrusted to a pharmacy intern when they have demonstrated the necessary competence to carry out the tasks independently, subject to regulatory requirements.

More recently it has been suggested that registration of a healthcare professional should not only be based on what we observe them do in practice but also on the level of trust we have that they can perform future tasks unsupervised.11

EPAs provide a framework for collecting information about current performance to inform decisions about trust in an intern’s future performance.1

Trust, the central concept of entrustable professional activities

Trust is the underpinning principle of EPAs. Patients trust healthcare providers to deliver safe and effective care, and providers must trust one another to collaborate effectively for better patient outcomes.13-15

In training settings, supervisors decide when and for what tasks they entrust trainees to assume responsibility.13-15

EPAs build on this concept of trust to link competence to the work of professionals. When EPAs are the focus of assessment, the key question is: can we trust this trainee to execute the EPA safely?13 The answer is a point-in-time decision (an entrustment decision) made by the supervisor that translates to the level of supervision the trainee will require to continue to practise the EPA.13 Such decisions happen in the workplace every day on an ad hoc basis.16

EPAs incorporate five levels of supervision, outlining a gradual increase in responsibility and autonomy. However, for pharmacy intern assessment, only Levels 1 to 41 are applicable as outlined in Table 1. Note that even when an intern has been deemed entrustable at Level 4, Pharmacy Board requirements for supervision while the intern is provisionally registered still apply, and the supervising pharmacist always remains responsible for the actions of the intern under their supervision.1

Table 1 – Levels of supervision and descriptions of their meaning

Level of supervision Description
Level 1 Observe only, even with direct supervision
Level 2 Perform with direct, proactive supervision and intervention
Level 3 Perform with indirect proximal (nearby) supervision, on request and quickly available
Level 4 Perform with minimal supervision, available if needed, essentially independent performance
Level 5 Supervise more junior colleagues (outside scope of the intern year)

References:Australian Pharmacy Council1, Olle ten Cate16

Making entrustment decisions 

Entrustment decisions are future-focused: supervisors make a risk-based decision about the transfer of responsibility to a learner to perform a given task. As it is not possible for a learner to be exposed to all possible scenarios, assessment of learners should be focused on the ability to execute the task safely. They should also be able to adapt to any unexpected circumstances that may arise during the execution of a task in future practice.16

Supervisors must therefore gather evidence from several sources to support their entrustment decisions. One way of doing this is by observing the intern perform the EPA,3 referred to as a short practice observation (SPO). An entrustment discussion between an intern and their  supervisor following an SPO facilitates intern self-reflection and helps supervisors understand learning needs.3,16 During the entrustment discussion, the supervisor should probe how the pharmacy intern would act in different circumstances using ‘what if’ questions.16 These alternative scenarios allow a learner to consider a broader range of situations than what was encountered. Entrustment decision- making is also informed by a learner’s insight and acknowledgement of their ability to adapt to new scenarios and contexts.

Other sources of information that should be used to inform entrustment decisions include14-16:

  • Previous observations of the intern
  • Feedback from other supervisors, healthcare professionals and consumers 
  • Documentation, such as medicine dispensing/error logs 
  • Other workplace activities such as case-based discussions.

Knowledge to practice 

Experiences in the implementation of EPAs from other health programs can support their use in pharmacy workplaces.17-19

  • Entrustment decisions should be made by those directly supervising the learner. There may be multiple individuals providing supervision to an intern, each making their own entrustment decisions.
  • Supervisors should use all available information sources to inform entrustment decisions, as well as acknowledging gut feelings about learner readiness for more autonomy. 
  • It is important that the intern has been observed across a broad range of scenarios with supervisors, if possible. This allows sufficient opportunity for the intern to demonstrate capability, agency, reliability, integrity and humility to limit risk of future unsupervised practice. 
  • Trust is not static but context specific. A supervisor may trust an intern to work with more independence with simple activities, but when more complex tasks arise, more proactive supervision may be needed.
  • Empower learners to take ownership of the assessment process. Encourage learners to reflect on the activities they complete, including areas for improvement and planning how they will work on these areas.

Conclusion 

Supervisors can use EPAs to provide real-time feedback on intern performance. Assessment of an EPA results in entrustment decisions that outline the independence the intern has to continue practising the EPA. As trust and responsibility increases, the level of supervision required for successful performance of that activity decreases.

Case scenario continued 

You note the intern gathered allergy history and patient weight but not for other medicines or medical conditions. The intern seeks your opinion on the appropriateness of the antibiotic after reviewing Therapeutic Guidelines. You also observe that the intern forgets to use ancillary labels.

It’s getting busy, so you show the intern the correct ancillary labels and ask them to join you as you speak with the carer. Later, you gather away from the dispensing area and engage in an entrustment discussion. You ask the intern to reflect on the SPO and share their self-assessment. You help them identify areas for improvement and ask ‘what if’ questions to probe what they would do in different circumstances. You explain that your entrustment decision is at Level 3 and provide the rationale for your decision. Finally, you complete the ‘Assessment of EPA’ form, and the intern documents their reflection and development plan.

Key points 

  • EPAs are professional activities or tasks that can be entrusted to an intern once they are deemed competent and which they will be expected to carry out independently once registered as a pharmacist.
  • EPAs are not behaviours or competencies. Successful performance of an EPA may, however, require demonstration of more than one competency and or professional behaviour. 
  • Even when an intern has been deemed entrustable at Level 4, the Pharmacy Board requirements for supervision while the intern is provisionally registered still apply.

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References

  1. Australian Pharmacy Council. Assessing intern performance and readiness to practise using entrustable professional activities (EPAs). 2022. At: pharmacycouncil.org.au/workplace-based- assessment/
  2. Australian Pharmacy Council. Intern workplace-based assessment. At: pharmacycouncil.org.au/workplace-based-assessment/
  3. Ten Cate O. Entrustability of professional activities and competency-based training. Med Educ 2005 Dec;39(12):1176–7.
  4. Ten Cate O, Taylor DR. The recommended description of an entrustable professional activity: AMEE Guide No 140. Medical Teacher 2021;43(10):1006–114.
  5. Ten Cate O, Scheele F. Competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med 2007;82(6):542–7.
  6. Bramley AL, McKenna L. Entrustable professional activities in entry-level health professional education: A scoping review. Med Educ 2021;55(9):1011–32.
  7. Shorey S, Lau TC, Lau ST, et al. Entrustable professional activities in health care education: a scoping review. Med Educ 2019;53(8):766–77.
  8. Abeyaratne C, Galbraith K. A Review of entrustable professional activities in pharmacy education. Am J Pharm Educ. Epub 2021 Dec 15.
  9. Smith C, Stewart R, Smith G, et al. Developing and implementing an entrustable professional activity assessment for pharmacy practice experiences. Am J Pharm Educ 2020 Sep;84(9):ajpe7876.
  10. Pittenger AL, Chapman SA, Frail CK, et al. Entrustable professional activities for pharmacy practice. Am J Pharm Educ 2016;80(4):57.
  11. Ten Cate O, Carraccio C, Damodaran A, et al. Entrustment decision making: extending Miller’s pyramid. Acad Med 2021;92(2):199–204.
  12. Witheridge A, Ferns G, Scott-Smith W. Revisiting Miller’s pyramid in medical education: the gap between traditional assessment and diagnostic reasoning. Int J Med Educ 2019;10:191–2.
  13. Ten Cate O. Nuts and bolts of entrustable professional activities. J Grad Med Educ 2013 5(1):157–8.
  14. Ten Cate O, Hart D, Ankel F, et al. Entrustment decision making in clinical training. Academic Medicine 2016;91(2):191–8.

Our Authors 

DR HAYLEY CROFT (she/her) PhD, BPharm, GradCertDiabetes, AACPA, MPS is an accredited consultant pharmacist and teaching and research academic at the University of Newcastle.

SALLY MAROTTI (she/her) BPharm, MClinPharm, AdvPractPharm is the lead pharmacist for experiential learning, training and research for SA Pharmacy, SA Health. 

JOSEPHINE MAUNDU (she/her) BPharm (Hons), MPH, PharmD, MPS is currently Director of Policy and Projects at the Australian Pharmacy Council.

ACKNOWLEDGEMENT

STEVEN WALKER (he/him) BPharm (Hons), MClinPharm, Monash University

OUR REVIEWER

CLARA FITTLER (she/her) BPharm, GradCert AppPharmPrac, CertIV TAE, MPS is a PSA Professional Practice Pharmacist.

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