Entrustable professional activities, entrustment, and the conceptualization of competence in the health professions

Abstract

The use of entrustable professional activities (EPAs) and entrustment decision-making in health professional education was proposed to operationalize competency-based education. To ground its use, a common conceptualization of 'competence' is needed. Based on theoretical notions of epistemology (distinguishing propositional, procedural, and experiential knowledge) and inspired by the theoretical insights of Vygotsky, Maslow, Billett, and others, the authors elaborate a three-layered model that includes canonical competence (what every professional should have mastered, independent of context), contextual competence (the ability to work in relevant contexts and apply canonical competence), and personalized competence (the individual approach to high-level practice). The model aligns well with curricula that stress knowing, doing, and being, combining competencybased standards with professional identity formation. EPAs and entrustment decision-making typically regard the contextual layer of competence. This is because entrustment decisions, to support trainees in their progressive, professional autonomy, happen in clinical contexts where canonical, context-independent knowledge and skill are necessary but insufficient. Passing the threshold of entrustment with clinical responsibilities draws on both canonical competence and the ability to work in clinical contexts, responding to the needs of patients, of collaborators, and working within the rules and habits of the local environment. Once a trainee is entrusted with clinical responsibilities, and feels confident about the first two layers of competence, personalized competence can emerge more prominently, leading to integrated professional and personal identity formation. The three layers of competence together establish the conditions to think, act, and feel like a health professional: the knowing, the acting, and the being.