Table 1
The entrustment scale used at South Australia Health in the intern training year.
| LEVEL OF ENTRUSTMENT | |
|---|---|
| Level 1 | The learner is able to thoughtfully observe |
| Level 2a | The learner is able to perform the task with regular direct supervision and proactive guidance |
| Level 2b | The learner is able to perform the task with occasional direct supervision and proactive guidance |
| Level 3 | The learner is able to perform the tasks independently with reactive supervision |
| Level 4 | The learner can perform the task in complex populations and environments |
| Level 5 | The learner is able to supervise more junior colleagues |
Table 2
Intern pharmacists’ (n = 17) self-reported entrustment ratings at performing different entrustable professional activities across three time points in the intern training year and the corresponding changes in self-reported readiness for entrustment.
| ENTRUSTABLE PROFESSIONAL ACTIVITY | MEDIAN SELF-REPORTED READINESS FOR ENTRUSTMENT T1*: JAN–MAR | MEDIAN SELF-REPORTED READINESS FOR ENTRUSTMENT T2**: APR–JUL | MEDIAN SELF-REPORTED READINESS FOR ENTRUSTMENT T3***: AUG–NOV | PAIRWISE COMPARISON OF T1 TO T2 | PAIRWISE COMPARISON OF T1 TO T3 | PAIRWISE COMPARISON OF T2 TO T3 | OVERALL COMPARISON OF THE THREE TIME POINTS (T1, T2, AND T3) |
|---|---|---|---|---|---|---|---|
| p VALUE° | p VALUE° | p VALUE° | p VALUE‡ | ||||
| EPA1: Dispensing medications | 3 | 4 | 3 | .473 | .492 | .163 | .505 |
| EPA 2: Taking a medication history | 3 | 3 | 3 | .024 | .024 | 1 | .031 |
| EPA 3: Conducting a chart annotation, clinical review, and assessment of medication management | 2b | 3 | 3 | .016 | .070 | .287 | .001 |
| EPA 4: Conducting therapeutic drug monitoring | 2b | 2b | 3 | .003 | .000 | .310 | .001 |
| EPA 5: Facilitating patient discharge or transfer | 2b | 3 | 3 | .015 | .015 | .219 | .001 |
| EPA 6: Providing specific patient education on inhaler technique, anticoagulation counselling, oral cancer therapy education etc) | 2b | 3 | 3 | .013 | .001 | .287 | .001 |
| EPA 7: Initiation of clozapine | 2a | 2a | 2b | .021 | .001 | .169 | .024 |
| EPA 8: Participating in an interprofessional ward round | 2a | 2b | 2b | .001 | .001 | .024 | .021 |
| EPA 9: Providing regional cancer services – related tasks (i.e ordering and receiving cancer therapies) | 1 | 1 | 1 | .132 | .132 | 1 | .182 |
| EPA 10: Conducting Partner Pharmacist Medication Charting (PPMC) | 1 | 1 | 1 | .545 | .034 | .106 | .057 |
| *T1 = Time point 1 | |||||||
| **T2 = Time point 2 | |||||||
| ***T3 = Time point 3 |
[i] ° p value from the Dunn test with the Bonferroni adjustment comparing changes in intern pharmacists’ self-reported median entrustment to perform different entrustable professional activities between each of the three different time points. Bolded results are statistically significant differences between the different groups with a p value of < 0.05.
‡ p value from the Kurskal-Wallis test comparing changes in intern pharmacists’ self-reported median entrustment to perform different entrustable professional activities across the three different time points. Bolded results are statistically significant differences between the different groups with a p value of < 0.05.
Figure 1
Longitudinal changes in intern pharmacists’ (n = 17) attitudes and perceptions of Entrustable Professional Activities across the pharmacy internship.
Table 3
Themes, contextual insights, and representative quotes illustrating intern pharmacists’ experiences of entrustment progression across the internship year
| THEME | SUBTHEME AND CONTEXT | DESCRIPTION OF CONTEXT | REPRESENTATIVE QUOTES |
|---|---|---|---|
| Entrustment as a time and task-dependent marker of competence, readiness, and autonomy, with EPAs providing structured learning and goal setting | Confidence-building in task-related activities | As trainees achieve successive levels of entrustment, they internalize trust from supervisors as confidence in their own abilities, promoting readiness to manage tasks with greater autonomy | “For me, a big takeaway from having done all of my EPAs is now having the confidence to figure out a plan of what to do if I’m faced with a task where I’m not too sure.” – Intern 5 |
| Independence in decision-making | Autonomy through accountable decision-making within a collaborative team context | “You’re still working within a team, and you’re still getting help from other people. But I think that’s where the independent kind of phrase comes in, independent in decision making.” – Intern 10 | |
| Benchmark of demonstrated accomplishment and autonomy | Entrustment through EPAs were regarded as departmental markers of practice readiness | “Essentially, it was kind of viewed that once you had completed an EPA ten times at level 3, pharmacists were more than happy to kind of, trust you to go and perform those activities without supervision.” – Intern 3 | |
| Establishing structured learning goals | EPAs helped establish clear learning goals for the trainees and the expectations throughout training | “I feel like EPAs were very useful for our development. They gave us an aim to work towards, so we knew what we were doing and what we were aiming for, and that really helped us set goals for ourselves throughout the year.” – Intern 12 “It’s a learning tool, and the tool that’s being used to show, I guess, your skills and to develop them to the point where you are trusted to do the activity independently.” – Intern 4 | |
| Longitudinal tracking of growth and autonomy | EPAs allowed both trainees and supervisors to monitor the growth of the trainee throughout the intern year | “An EPA over time is like a journey that records our improvement to the point where an employer can say, ‘yes, you can do these tasks independently,’ and it provides a record of that progression.” – Intern 14 “That’s not necessarily measured every time, but it starts to reflect that you are being more self-directed, and that you can be more independent in doing different activities.” – Intern 2 | |
| Embedding the constant presence of the supervisor in training | The structure of entrustment through observation from a supervisor ensured trainees were supported by the presence of a supervisor | “In terms of development, it is a good tool to ensure that a pharmacist is with you so you’re not practicing on your own.” – Intern 6 “The EPA system almost ensured that we had a supervisor with us to support us at different stages of training….I know that’s not always the case but having that almost mandated because of the system was beneficial to my development.” – Intern 8 | |
| Feedback and self-reflection as drivers of trainee development | Embedding and fostering intentional reflective practice | EPAs and entrustment discussions supported trainees in regularly self-reflecting on their performance, progress, and learning requirements | “I believe if we there were no EPAs and with the amount of work we have and how busy we are, I don’t think we would get that much time to sit there and self-reflect if the EPAs were not there.” – Intern 12 “It allowed you to track your progress throughout the year based on what was documented. It wasn’t necessarily completely objective, but I could look back and see whether I had stagnated or progressed in certain areas. That helped me to reflect on my development, especially with the more specific tasks.” – Intern 5 |
| Self-calibration of progress | Entrustment discussions helped trainees improve their self-awareness and focus their developmental goals | “It also helps me, if say, I moved on to a new clinical rotation, and I look back on what I didn’t do so well in a previous rotation, I’m able to work on that, or perhaps reflect on that again and see how I’m tracking.” – Intern 13 | |
| Supervisor feedback as a central mechanism to trainee development | Trainees placed more value on the feedback itself than on the entrustment level assigned to them by their respective supervisors | “I think ultimately, the benefit that I got from the EPA was the word feedback or the written feedback from my preceptor. I would take, I guess, more away from that than the entrustment scale, or where they decided to tick for me.” – Intern 13 “EPAs encouraged discussions with my preceptor that probably wouldn’t have happened otherwise. While there would still have been some dialogue without EPAs, it wouldn’t have been to the same extent as what the EPA process provided.” – Intern 6 “It didn’t matter what level (of entrustment) was achieved, it was the act of self-reflection and feedback that supported learning…” – Intern 3 | |
| Sustaining feedback practice | Trainees received less feedback over time as they progressed through the intern year and were granted greater autonomy in practice | “It reduces the amount of feedback we would be getting as we’re being entrusted more…so there will be no sort of feedback involved in there when you’re doing a task independently, I guess.” – Intern 7 | |
| Mismatch between formal entrustment and the trainees’ self-perceived readiness | Self-perceived readiness gaps | Trainees revealed gaps between entrustment and self-perceived readiness, characterised by feeling overwhelmed by expectations and doubts about the credibility of ratings | “Entrustment at level 3 prior to readiness overwhelmed some interns. Once you get level three, you’re on your own, and then that sort of scared me a little bit.” – Intern 4 “It still doesn’t mean I’m confident managing high-risk cases, but I’ve been signed off. From my experience, once pharmacists knew I was fully signed off for reviews, discharges, and histories, they didn’t even want to co-sign anymore — it was like, ‘oh, you’re independent now, you can do it.’” – Intern 9 |
| Premature and rushed entrustment decisions | Formal entrustment level by supervisor after a certain number of observations not reflecting the trainee’s self-perceived capabilities to manage the variety of cases | “I was signed off on ten level 3 discharge EPAs, but in retrospect they were all simple cases – patients going home with just one or two medicines. Later in my intern year, I started encountering more complex discharges, like Webster packs, nursing homes, hospital transfers, and interstate cases. Technically, I had already been signed off by the EPA, but I was nowhere near competent to manage those kinds of discharges.” – Intern 13 | |
| Perceptions and implications upon reaching a finite numerical target leading to autonomy in practice | Transferability of entrustment across different settings and contexts | Misalignment between entrustment level and self-perceived capability | “When I rotated to a ward with more complex patients, I suddenly felt I needed more supervision because the cases were so different. I actually wanted closer support, but it wasn’t provided as readily since I had already been signed off.” – Intern 3 “I think, for example, if you’ve done ten discharge EPAs at level 3, but they’re all for patients going back to the same nursing home – where the requirements are the same and the patients are similar – that’s very different from, say, a clozapine discharge or something more complex. So even if you’ve been signed off in the area of ‘discharges’ overall, it might not really reflect how competent you are across the full range of discharge scenarios.” – Intern 14 |
| Reality of un-encountered complexities | Transitioning to greater autonomy safely, requires recognition that there will still be uncertainties | “Even once I’m fully registered and practicing as a pharmacist, there will still be complex discharges I’ll need to manage. So the entrustment level alone doesn’t necessarily mean I’m ready for every situation”. – Intern 7 “I don’t know if putting a strict number on it, like saying you must do ten level 3 entrustment observations before you can progress, is the best approach. I think it should be more about doing a few at each level, and then actually monitoring your growth throughout the intern year. Because if you’re not showing growth over time, that’s when you can identify that something isn’t right.” – Intern 11 |
Figure 2
Visual synthesis of the thematic analysis depicting trainees’ perceived journey toward unsupervised practice, represented as a wooden bridge with each subtheme illustrated as an individual wooden plank.