When I presented my work on evaluating entrustable professional activities (EPAs) in undergraduate physiotherapy at the Ottawa Conference on the Assessment of Competence in Medicine and the Healthcare Professions in 2024, I was excited by the tremendous interest in this assessment. Some colleagues were developing EPAs for their professions, others argued for them as credentialing standards and a few, like me, were sharing implementation stories.
What are EPAs?
Entrustable professional activities are tasks that learners can be entrusted to perform unsupervised, once they demonstrate a certain level of competence. While competencies remain the cornerstone of physiotherapy training, they alone do not capture the real-world supervision decisions clinicians make daily – especially with undergraduates unfamiliar with clinical risks.
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We have to balance risk and autonomy in clinical training. EPAs facilitate this balance, allowing the student to make the decisions. We use observed performance, discussions and case notes documentation to support them in this process. Ultimately, assessments will come down to judgement about the level of supervision a student needs and their readiness for independent practice.
First conceptualised by Olle ten Cate in 2005 for medical residency, EPAs have gained momentum only in the past decade, and are now used across undergraduate health professions training.
My EPAs experience
In 2020, my institution introduced EPA assessments into undergraduate physiotherapy clinical placements alongside our existing competency tool, following a national training standards review. As then-clinical placement education lead, I contributed to their development and, subsequently, led implementation.
Five years and three implementation cycles later, my relationship with them is maturing. At the conference, I sensed in new adopters a combination of apprehension and conviction, emotions I know well. After all, entrustment-based supervision and assessment is a paradigm shift. I wish that I had had input from designers experienced in the process back then, but my institution was the first mover, globally, in physiotherapy EPAs. The journey was arduous but worth every anxiety and effort. Here, I hope to alleviate doubts and persuade those new to the idea to persist. Here’s what to consider.
Developing entrustable professional activities
1. Designers assemble!
It’s important to strike a balance of seniority, clinical domain expertise, workplace setting, leadership roles and academia to ensure diverse representation, but this can be difficult to do without bloating the working committee. One critical member is the university’s clinical placements coordinator/lead. Get them involved early on in the process to sharpen implementation plans. I was drawn into development discussions relatively late to confirm suitable numbers and types of evidence at placements, and I wish my entry point had been earlier, for a deeper understanding of EPAs.
Upon reflection, I might have been hasty with development decisions. Lacking full understanding of how entrustment-based decisions operate through evidence, I had set a burdensome amount of evidence pieces. My decision compromised meaningful time meant for student supervision and evoked discontent from workplace supervisors and students.
2. Right EPAs, right purpose
Should you write EPAs for specific conditions, settings or patient populations? Undergraduate EPAs should reflect the core work of entry-level practitioners – tasks fundamental to the profession across conditions and settings. Appropriate EPAs align with the purpose of the assessment while minimising the administrative burden, so take time to select the right ones.
3. Gain faculty buy-in
Seek faculty suggestions and consensus when implementing EPAs. This not only validates the development process but also expands capacity for implementation. When my colleagues and I engaged in debate about EPAs, it helped to reinforce my belief that they can advance workplace-based assessments. As faculty support students and clinical educators at placements, their support creates a lasting cohesive implementation network.
Implementing EPAs
Author Simon Sinek reminds us that people do not fear change, but sudden change. Make implementation gradual, participatory and responsive.
1. Start small with pilots
Before mass training, my team first engaged clinician leaders. Then we piloted only two of the five activities with a handful of hospital teams. These leaders became advocates, encouraging their workplace supervisors to adapt to the new system.
2. Simple documentation, happy supervisors
Clinical educators often cited paperwork as a barrier, diverting time from student coaching. In response, we streamlined multiple forms of evidence into a single checklist integrating EPAs, sources of evidence and feedback. By the second implementation cycle, the assessment burden was lighter and satisfaction was higher. Consider investing in an online EPA platform to ease data entry and analysis.
3. Train, calibrate and listen
We began training and calibration of clinical educators on EPA assessment with the “why” (another of Sinek’s recommendations). We refreshed clinical educators at every placement block. Because EPA assessments were used alongside our competency assessment tool, we embedded entrustment language into existing rubrics to reduce redundancy. Many educators found the two assessment systems complemented each other, especially in supporting pass/fail decisions for borderline students.
We actively sought feedback – even when unconstructive – to improve processes. Using a plan-do-check-act cycle, we iterated improvements across three rounds. Today, fewer complaints, greater supervisors’ and students’ acceptance and smoother operations signal that our socialisation of EPAs has been successful.
At Ottawa, I shared that EPA assessments met four of the seven Ottawa criteria for good systems of assessments, such as purpose-driven, coherent, feasible and acceptable, with end entrustment level corresponding to indirect supervision. Work is ongoing for the other three criteria: transparency, continuous and comprehensive.
My experience shows that EPA adoption will never be perfect but continuous dialogue and flexibility should suffice. Development needs the right mix of voices; implementation thrives on advocacy, simplification and responsiveness to feedback. Five years on, EPAs have transformed how physiotherapy students are assessed and supported on their journey toward professional autonomy.
Over to you.
Rahizan Zainuldin is associate professor of health and social sciences at Singapore Institute of Technology.
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