Entrustable professional activities in nursing education: a scoping review protocol.

INTRODUCTION: Entrustable professional activities were introduced in medical education more than 15 years ago. EPAs define units of professional practice that can be fully entrusted to sufficiently competent professionals. Today, EPAs have been developed and implemented in many health professions, as the concept is useful in bridging the gap between competency-based education and the daily tasks health professions have to deal with in the workplace. While some evidence exists in medical education, the role of EPAs in nursing education is not yet fully understood. Therefore, the overall aim of this scoping review is to describe the current body of evidence regarding EPA implementation in nursing education. METHODS AND ANALYSIS: A two-stage screening process will be used during the search phase, in order to screen retrieved abstracts and titles that focus primarily on the discussion of EPA in nursing education in all languages within the last two decades. The electronic databases, OVID (Embase and PubMed combined) and EBSCOhost (CINHAL and ERIC combined), as well as grey literature will be searched. The search period ranges from 1 January 1995 to 31 December 2021. Data will be extracted according to study design, context (geographical location and type of nursing programme), details of EPAs mentioned (title, specifications, limitations and competency domains), as well as evidence of implementation, outcomes and effect sizes. ETHICS AND DISSEMINATION: Ethical approval is not required as this review will be using previously collected data. Review findings will be published in a peer-reviewed journal and presented at scientific conferences.

A qualitative study applying Bourdieu's concept of field to uncover social mechanisms underlying major curriculum reform.

PURPOSE: Planning committees play a key role in blueprinting major curriculum reform. In this qualitative study, we apply Bourdieu's sociological concept of field to the perceptions of committee members to identify the social mechanisms operating in major curriculum reform. METHOD: A planning committee with 18 members developed a blueprint for major curriculum reform at the Charité Berlin in its transition from a discipline-based programme to a fully integrated undergraduate medical programme. Interviews with 13 members about their experiences were subjected to inductive-deductive content analysis. RESULTS: Viewed through a Bourdieuan lens, the curriculum committee represents a social field of intense competition and conflicts. Groups of committee members struggled for and with different forms of economic, cultural and social capital to maintain and increase their power and social position in the medical programme. In our case, the major reform was accompanied by loss of power within the teaching department group, while the student group gained power. CONCLUSION: Bourdieu's concept of field reveals that a major curriculum reform is substantially shaped by power struggles over various forms of capital and social positions related to the future curriculum. The findings may serve as a complementary guide for those navigating the complexity of major curriculum reform.

What can we expect from medical graduates? Empirical survey on the performance of Core EPAs in the first days of residency.

BACKGROUND: Core Entrustable Professional Activities (EPAs) have been defined to specify the performance expectations for entering residents worldwide. The content of these EPAs was elaborated and validated primarily via medical expert consent approaches. The present study aims to collect empirical information on the actual task performance and supervision level of entering residents as a complementary methodological approach to enhance the content validity of a set of institutional EPAs. METHODS: In the summers of 2017 and 2018, Charité medical graduates (n = 720) received a post-graduation survey by mail. The questionnaire covered the performance of Core EPAs, Core procedures and more advanced EPAs. Graduates were asked how frequently they had performed the respective EPAs since the start of residency and under what level of supervision. We expected the large majority of graduates (> 75%) to have performed the Core EPAs and procedures under at least indirect supervision. RESULTS: In total, 215 graduates (30%) returned the questionnaire, and 131 (18%) surveys could be included in the data analysis. The majority of participants were female (63%) and worked in hospitals (50%) or in university medical centres (30%) across various medical disciplines. Among the Core EPAs, 10 out of 11 tasks had been performed by more than 75% of graduates since the start of residency, 9 under indirect supervision. Regarding the Core procedures, only 3 out of 13 procedures had been performed by the large majority of graduates under indirect supervision, and 10 procedures had not been carried out by at least one-third of participants. Among the 5 advanced EPAs, none of 5 had been performed by more than 75% of the participants since the start of residency, and 4 had been carried out by 50% under indirect supervision. CONCLUSIONS: The results of this study largely and complementarily confirm the validity of the defined Core EPAs representing realistic expectations for entry into residence at our institution. The low actual performance rate of Core procedures serves to stimulate an institutional discussion on their adjustment to better match the workplace reality.

Medical students' ratings of the relevance and actual implementation of interprofessional education and preferences for teaching formats: comparison by gender and prior education.

Objectives: Interprofessional education is becoming increasingly important for collaboration in patient care. In the national context, there are few empirical studies on the assessment of medical students as important stakeholders in their education. Method: Students (N=2,974) participated in a semester-wide online evaluation of the modular curriculum of medicine at the Charité Berlin. Socio-demographic data (including gender, completion of prior education/studies), assessments of the relevance and extent of interprofessional collaboration and preferences for interprofessional education in various teaching formats were collected. Results: In total, data from 1,019 students were included in the evaluation. The relevance of interprofessional collaboration was considered high by medical students. Female students rated the relevance higher than male students. The completion of pre-education (vocational training or study) had no additional influence. The actual implementation of interprofessional education was rated equally low by female and male students. Medical students rated patient-centred, interactive small group formats as particularly suitable for interprofessional education. There were no gender differences, but the effect was more pronounced among students with vocational training. Conclusion: The assessments of female and male students show a large difference between the perceived relevance and the actual implementation of interprofessional collaboration in the modular curriculum of medicine. This study provides an empirical basis for the actual implementation of interprofessional collaboration and students' views on suitable teaching formats for interprofessional education.

The modular curriculum of medicine at the Charité Berlin - a project report based on an across-semester student evaluation.

Aim: The introduction of a reform clause into the German licensing laws for medical doctors has enabled German faculties to pilot alternative designs for medical degree programmes. The aim of this project report is to outline the curricular features of the modular curriculum of medicine (MCM) at the Charité and to assess the results of its implementation based on a student evaluation across semesters. Project outline: The MCM was planned and implemented in a competency- and outcome-based manner from 2010-2016 in a faculty-wide process. The curriculum is characterised by a modular structure, longitudinal teaching formats and the integration of basic and clinical science. In the winter semester 2017, evaluations by students in semesters 1-10 were carried out. The results were analysed descriptively, and the coverage of overarching learning outcomes was compared to the results of a survey carried out amongst students on the traditional regular curriculum of medicine track in 2016. Results: A total of 1,047 students participated in the across-semester evaluation (return rate 35%). A high percentage of the respondents positively rated the achieved curricular integration and longitudinal teaching formats. The majority of the respondents agreed with the relevance of the overarching learning outcomes. Students' evaluations of the coverage of learning outcomes showed a differentiated picture for the MCM. Compared to the regular curriculum track, the coverage in the MCM programme showed substantial improvements in all aspects. Students found themselves to be better prepared for the M2 state examination and the practical year. The students' overall satisfaction with their decisions to study in the MCM was high. Conclusions: The results of the student evaluation show that a significant improvement in medical education has been achieved at the Charité with the new integrated, outcome-oriented design and the implementation of the MCM. At the same time, ongoing weaknesses have been revealed that serve as a basis for the continued development of the curriculum. This report aims to contribute to the discussion of the future of undergraduate medical education in Germany.

Exploring the introduction of entrustment rating scales in an existing objective structured clinical examination.

BACKGROUND: The concept of EPAs is increasingly applied to assess trainees' workplace performance by means of entrustment ratings. OSCEs assess performance in a simulated setting, and it is unclear whether entrustment ratings can be integrated into these exams. This study explores the introduction of an entrustment rating scale into an existing OSCE. METHODS: A 6-point entrustment scale was added to the standard ratings in an OSCE administered prior to students' final clerkship year in an undergraduate medical programme. Standard OSCE ratings assess clinical and communication skills. Assessors (n = 54) rated students' performance (n = 227) on a diverse set of clinical tasks and evaluated the addition of entrustment scales to OSCEs. Descriptive and inferential statistics were calculated for analyses. RESULTS: Student performance varied across the stations, as reflected in both the standard OSCE ratings and the added entrustment ratings. Students received generally high standard OSCE ratings, whereas entrustment ratings were more widely distributed. All students passed the OSCE, and only a small proportion of students did not reach the expected pass threshold of 60% on the standard ratings in the single stations. The proportion of students who did not reach the expected entrustment level in the respective stations was noticeably higher. Both the clinical and communication skill ratings were related to the entrustment rating in most OSCE stations. A majority of the assessors positively evaluated the addition of entrustment ratings into the OSCE. DISCUSSION: The findings provide an empirical basis to broaden our understanding of the potential use of entrustment ratings in existing OSCEs. They provide directions for future, more specific studies. The ratings might be used for formative feedback on students' readiness for workplace practice.

Student participation in the development of interprofessional education courses: Perceptions and experiences of faculty members and the students.

Introduction: Student participation has shown positive effects on the curriculum development process for a single health profession. This qualitative study explores faculty members' and students' perceptions and experiences regarding student participation in interprofessional course development.Methods: Interprofessional courses were developed and implemented by interprofessional teams of faculty members and students. Two focus group discussions were carried out: one with faculty members and one with students.Results: Students contributed to both the process and the results of interprofessional course development in a complementary manner. Student participation was facilitated via motivation for and through work on interprofessional education, a balance between clarity on tasks and students' autonomy, and a low-hierarchy team atmosphere. Students developed professionally, and faculty members saw them as future ambassadors for interprofessional collaboration.Conclusions: This study provides multiple qualitative evidence for a positive, complementary role of student participation in interprofessional course development. A number of factors were identified that should be nurtured to facilitate this effect. Our findings may stimulate and guide other schools to actively involve students in the development of interprofessional education.

Introducing an assessment tool based on a full set of end-of-training EPAs to capture the workplace performance of final-year medical students.

BACKGROUND: While literature on the theoretical value of entrustable professional activities (EPAs) for assessment is rapidly expanding, little experience exists on its application. The aims of this study are to develop and explore the utility of an EPA-based assessment tool for capturing the workplace performance of final-year medical students based on a full set of end-of-training EPAs. METHODS: The tool was developed in a systematic iterative process. Twelve 12 end-of-undergraduate medical training EPAs were nested into 72 smaller EPAs and cross-mapped onto a 6-point supervision level scale, both adjusted to the context of final-year clerkships. One version was created for students' self-assessment of their ability to carry out tasks and their history of carrying out tasks, and another version was created for supervisors' assessment of students' ability to carry out tasks. The tool was administered to final-year clerkship students and their clinical supervisors to explore its utility as an assessment approach. The results were analysed using descriptive and interferential statistics. RESULTS: We enrolled a total of 60 final-year medical students. For 33 students, ratings were provided from one supervisor and for 27 students from two supervisors. With regard to the reliability and validity of the tool, students' and supervisors' ratings showed an overall good internal consistency as well as variability between and within the EPAs. Over the full EPA range, students rated their ability to perform a task slightly higher than their task performance history and slightly lower than the supervisors' ratings. Students' self-ratings of their ability to perform a task correlated with their history in performing the task. Supervisors' ratings correlated among supervisors and not with students' ratings. Concerning educational outcomes, supervisors' average rating of students' ability to perform the EPAs without direct supervision was 64%, and key findings being double-checked. CONCLUSIONS: This study introduces a tool that is adjusted to the final-year clerkship context and can assess the workplace performance of trainees based on a full set of end-of-training EPAs. Its utility characteristics suggest that the tool may be employed as a formative and outcome-aligned approach to the assessment of final-year students before entering into residency.

Development of Entrustable Professional Activities for entry into residency at the Charité Berlin.

Background: Entrustable Professional Activities (EPAs) have emerged as a new approach to operationalise the workplace performance expectations for the transition from under- to postgraduate medical training. However, the transferability of such EPAs from one context to another appears limited. In this article, we report on the results of our approach to define a full set of core EPAs for entry into residency with the expectation to be performed under distant supervision. Methods: The EPA development involved a modified, three round Delphi study, conducted at the Charité - Universitätsmedizin Berlin. The supervision level was operationalised as supervisor being distantly available and findings being reviewed. The threshold for consent was reaching a content validity index of a least 80%. The Delphi study involved experienced physicians (n=45) and resulted in a set of core EPAs with the descriptions of the categories: title, specification/limitations, conditions and implications of entrustment decision, knowledge, skills, and attitude, link to competencies and assessment sources. Results: The response rates were 76-80% in the Delphi rounds. Key to the content validation process for the performance expectation was deciding on "to act under distant supervision". The results are full descriptions of 12 core EPAs, organised into 5 overarching EPA domains. Conclusions: Our systematic approach yielded the definition of 12 core EPAs for entry into residency at the level of "act with distant supervision" according to the practice in our context. This report may support other medical schools who plan to implement EPAs into their curricula.

Doctors on the move: a qualitative study on the driving factors in a group of Egyptian physicians migrating to Germany.

BACKGROUND: Migration of physicians has become a global phenomenon with significant implications for the healthcare delivery systems worldwide. The motivations and factors driving physician's migration are complex and continuously evolving. Purpose of this study is to explore the driving forces in a group of Egyptian physicians and final-years medical students preparing to migrate to Germany. METHODS: A qualitative study was conducted based on social constructivism epistemology. In five focus group discussions, there participated a total 12 residents and 6 final-year medical students from 7 different training and workplace locations in Egypt. The participants provided information about their motivation and planning for migration. We applied a coding framework based on the concept of push/pull factors and barriers/facilitators for migration, and used Atlas.ti software for analysis. RESULTS: The thematic analysis indicated that the migration within the study's participants results from a specific weighting of push and pull factors. Push factors are considered to be more important than pull factors. Factors related to professional development play a leading role. The route of migration towards Germany is mainly determined by the low hurdle registration and licensing requirements in this destination country compared to other countries. In some cases, Germany is regarded as a "transit country", a step on the road to other European countries. The intent, planning and preparation of migration is assisted considerably by the local formation of a community and culture of migration with multiple ways for information exchange, identity building and social support through face-to-face and online channels. CONCLUSIONS: This study specifies - in a group of Egyptian physicians and final-year medical students - the perceived push and pull factors which influenced their intent to migrate to Germany. In addition to the general wealth gap, their particular route of migration is mainly determined by the requirements in licensing and registration procedures for foreign physicians in the potential destination country. The planning and preparation of a move is substantially facilitated by their joining a social network and a community of migrating physicians.

Moving a mountain: Practical insights into mastering a major curriculum reform at a large European medical university.

AIM: Undergraduate medical education is currently in a fundamental transition towards competency-based programs around the globe. A major curriculum reform implies a dual challenge: the change of the curriculum and the delivering organization. Both are closely interwoven. In this article, we provide practical insights into our approach of managing such a fundamental reform of the large undergraduate medical program at the Charité - Universitätsmedizin Berlin. METHODS: Members of the project management team summarized the key features of the process with reference to the literature. RESULTS: Starting point was a traditional, discipline-based curriculum that was reformed into a fully integrated, competency-based program. This change process went through three phases: initiation, curriculum development and implementation, and sustainability. We describe from a change management perspective, their main characteristics, and the approaches that were employed to manage them successfully. CONCLUSIONS: Our report is intended to provide practical insights and guidance for those institutions which are yet considering or have already started to undergo a major reform of their undergraduate programs towards competency medical education.

Welcome, Orientation, Language Training: a project at the Charité for new international medical students.

Objective: A comprehensive, integrated support programme for new international students of medicine has been developed, implemented and evaluated at the Charité. The objectives of the programme were improved social integration, orientation on the study program and Charité campus, as well as qualification in medical specialist language. Project outline: The "Charité Orientation Module for International Students" (ChOIS) was designed by a working group with a variety of expertise in the field of international students. The programme has three stages: Recruitment (specific invitation on matriculation); Orientation week before semester start; and Parallel events during the first semester. ChoOIS was piloted in the Winter Semester 2015/16 and, following evaluation, continued in a modified form in the Summer Semester 2016. Key features were: Welcome and social integration by faculty welcome-events and student group activities; Orientation on the study program, on teaching infrastructures at the Charité and on student life in Berlin by senior medical students; and Training in language for medical communication and bedside teaching by professional lecturers. Results: Results of evaluations conducted after the orientation weeks, at the end of the semester and retrospectively in the 3rd semester produced high approval ratings of the individual features of the ChOIS-programme and of the programme as a whole by participating students. Discussion: A comprehensive, integrated support programme for new international students of medicine has been developed and implemented. The ChOIS-programme can serve as a practice model to guide other medical faculties. In future, a programme that goes beyond the start of the course and includes more involvement by senior students would be desirable.

Medical students' preparedness for professional activities in early clerkships.

BACKGROUND: Sufficient preparedness is important for transitions to workplace participation and learning in clinical settings. This study aims to analyse medical students' preparedness for early clerkships using a three-dimensional, socio-cognitive, theory-based model of preparedness anchored in specific professional activities and their supervision level. METHODS: Medical students from a competency-based undergraduate curriculum were surveyed about preparedness for 21 professional activities and level of perceived supervision during their early clerkships via an online questionnaire. Preparedness was operationalized by the three dimensions of confidence to carry out clerkship activities, being prepared through university teaching and coping with failure by seeking support. Factors influencing preparedness and perceived stress as outcomes were analysed through step-wise regression. RESULTS: Professional activities carried out by the students (n = 147; 19.0%) and their supervision levels varied. While most students reported high confidence to perform the tasks, the activity-specific analysis revealed important gaps in preparation through university teaching. Students regularly searched for support in case of difficulty. One quarter of the variance of each preparedness dimension was explained by self-efficacy, supervision quality, amount of prior clerkship experience and nature of professional activities. Preparedness contributed to predicting perceived stress. CONCLUSIONS: The applied three-dimensional concept of preparedness and the task-specific approach provided a detailed and meaningful view on medical students' workplace participation and experiences in early clerkships.

Applying occupational and organizational psychology theory to entrustment decision-making about trainees in health care: a conceptual model.

In medical contexts around the world, supervising physicians continuously decide what degree of supervision to apply as trainees carry out professional activities. Although the implications for patients can be far-reaching, little is known about how these entrustment decisions are formed. The concept of 'Entrustable Professional Activities' has initiated interest and valuable research on factors that may influence the entrustment decision process.The aim of the current article is to link models of entrustment developed in the fields of occupational and organizational psychology and military psychology to medical education studies that have explored the factors influencing physicians' entrustment decisions. We provide a conceptual framework of the entrustment decision-making process, which we suggest will contribute to the understanding of how supervising physicians arrive at the decision to entrust a medical trainee with a professional activity.

Berlin in Motion: Interprofessional teaching and learning for students in the fields of medicine, occupational therapy, physiotherapy and nursing (INTER-M-E-P-P).

AIM: The Berlin project "Interprofessional teaching and learning in medicine, occupational therapy, physiotherapy and nursing" (INTER-M-E-P-P) pursues the goal of developing and testing interprofessional courses in an exemplary manner, and then implement these into their regular study programs. METHOD: Under the direction of a steering committee of the participating institutions, professions and status groups, interprofessional courses were designed, carried out and evaluated. Specific to this project are the participation of students in the steering committee, and the accompanying of external supervision. The evaluation integrates the perspectives of all project participants, and combines quantitative and qualitative methods. RESULTS: INTER-M-E-P-P established cooperative structures between the participating universities and programs. Three courses were designed, taught and evaluated in an interprofessional manner. The various curricula, organizational patterns and locations of the study paths led to a great need for resources in regard to planning and implementation. This process can be made difficult by any stereotypes or preconceptions inherent to those doing the planning; however, under external supervision, the individual professional viewpoints can still be broadened and enriched. CONCLUSION: A sustainable implementation of interprofessional education into the curricula of health science study programs is currently complicated by barriers such as different geographical locations and differing university regulations concerning study and testing. Implementation will require long-term support at the university as well as at political levels.

[High utilization of health insurance services by the elderly--analysis of hospital and drug utilization data]. / Vielnutzung von Krankenversicherungsleistungen im Alter--eine Analyse von Krankenhaus- und Arzneimitteldaten.

The present contribution discusses the utilization of the healthcare system by elderly patients in Germany. First, the paper focuses on the detailed characterization of a group of people aged 60 years or more (N = 73,454). Second, the objective is to analyze the data for high utilization of healthcare services by older men and women. The analysis is based on data regularly recorded by a German health insurance agency for the year 2000. High utilization is operationalized by a 10% cutoff for users with the highest number of treatments, highest costs and/or other criteria depending on the respective health service sector. The insured group investigated received approximately 1.4 million prescriptions, producing costs of 42 million E. High utilizers account for 32% of all prescriptions and 44% of the costs, respectively. At the same time, the age groups with the highest prescription rates do not cause the highest costs: So the relationship between age and prescription drug expenses as well as between age and prescription rates does not display an arithmetically increasing pattern. Within the timeframe investigated 26,000 hospital treatments were accounted for by 21.75% of the elderly under research. In total, they caused expenses of 88 million E. High utilization in the hospital sector was operationalized by four criteria. Sex- and age-specific analysis of high utilization of hospital treatment revealed that the four different criteria apply to different insured groups. In summary, the high utilization of healthcare services appears to be a multidimensional phenomenon.