Fu et al.

BMC Medical Education (2024) 24:705 BMC Medical Education

[Link]

RESEARCH Open Access

Developing an entrustable professional

activity for providing health education
and consultation in occupational therapy
and examining its validity
Chung‑Pei Fu1, Ching‑Kai Huang2, Yi‑Chiun Yang3, Wei‑Sheng Liao4, Shih‑Min Huang5, Wei‑Di Chang6,
Yi‑Ju Chen7, Ming‑Wei Li5, Yi‑Ju Lin8, Chin‑Lung Wu8, Hsin‑Yu Chi5, Chia‑Yi Lee9, Fu‑Mei Chiang10,
Yu‑Lan Chen11, Ching‑Fen Tsou9, Tzu‑Hung Liu12,13, Chia‑Ting Su1, Ai‑Lun Yang14, Nung‑Chen Kuo15* and
Wan‑Ying Chang16*

Abstract
Background Entrustable Professional Activities (EPA)-based assessment is easily and intuitively used in evaluat‑
ing the learning outcomes of competency-based medical education (CBME). This study aimed to develop an EPA
for occupational therapy focused on providing health education and consultation (TP-EPA3) and examine its validity.
Methods Nineteen occupational therapists who had completed online training on the EQual rubric evaluation
participated in this study. An expert committee identified six core EPAs for pediatric occupational therapy. TP-EPA3
was developed following the EPA template and refined through consensus meetings. The EQual rubric, a 14-item,
five-point criterion-based anchor system, encompassing discrete units of work (DU), entrustable, essential, and impor‑
tant tasks of the profession (EEIT), and curricular role (CR), was used to evaluate the quality of TP-EPA3. Overall
scores below 4.07, or scores for DU, EEIT, and CR domains below 4.17. 4.00, and 4.00, respectively, indicate the need
for modifications.
Results The TP-EPA3 demonstrated good validity, surpassing the required cut-off score with an average overall EQual
score of 4.21 (SD = 0.41). Specific domain scores for DU, EEIT, and CR were 3.90 (SD = 0.69), 4.46 (SD = 0.44), and 4.42
(SD = 0.45), respectively. Subsequent revisions clarified observation contexts, enhancing specificity and focus. Further
validation of the revised TP-EPA3 and a thorough examination of its reliability and validity are needed.
Conclusion The successful validation of TP-EPA3 suggests its potential as a valid assessment tool in occupational
therapy education, offering a structured approach for developing competency in providing health education
and consultation. This process model for EPA development and validation can guide occupational therapists in creat‑
ing tailored EPAs for diverse specialties and settings.
Keywords Entrustable Professional Activity, Occupational therapy education, Competency-based medical education

*Correspondence:
Nung‑Chen Kuo
yves7116@[Link]
Wan‑Ying Chang
wanying0928@[Link]
Full list of author information is available at the end of the article

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Fu et al. BMC Medical Education (2024) 24:705 Page 2 of 7

Introduction Methods
Competency-based medical education (CBME) repre- This study was approved by the institutional review
sents a strategic evolution in the methodology of medi- boards of Fu Jen Catholic University (C110093) and
cal training, emphasizing the development of specific Taipei Hospital, Ministry of Health and Welfare
competencies essential for effective clinical practice (TH-IRB-0022–0027).
[1, 2]. Although competency frameworks have been
developed by the Accreditation Council for Graduate Participants
Medical Education (ACGME) and Canadian Medical Nineteen occupational therapists (11 females, 8 males),
Education Directives for Specialists (CanMEDS), their who had completed online training on the EQual rubric
implementation in clinical practice has been limited. evaluation, rated the 6 core EPAs in pediatric occupa-
Entrustable professional activities (EPAs) and mile- tional therapy on the EQual rubric. Their age distribu-
stones have emerged to bridge the gap between com- tion was as follows: 21.1% were aged 31–40 years; 63.2%,
petency frameworks and assessment and training in 41–50 years; and 15.8%, 51–60 years. Their workplaces
clinical practices [3–5]. were medical centers (42.1%), regional teaching hospitals
EPAs are discrete clinical activities that require the (47.4%), and district teaching hospitals (5.3%). Their posi-
integration of various competencies and represent an tions were chiefs of occupational therapy (26.3%), chiefs
activity associated with a specific clinical event [6, 7], of pediatric occupational therapy (15.8%), teaching direc-
whereas milestones refer to observable markers along a tors of occupational therapy (26.3%), clinical teachers
continuum of progress [8]. However, the application of (57.9%), and university teachers. The average duration of
milestones as evaluative tools for trainees’ competency their work experience was 20.2 years (SD = 6.7), whereas
faces challenges due to their sheer number, the exten- that as clinical teachers was 15.6 years (SD = 7.8).
sive and complex training required, and the necessity
for full participation in the learning process [9]. There- Procedure
fore, EPA-based assessment is easier and more intui- This study comprised two stages: the development of TP-
tive to use in evaluating the learning outcomes of the EPA3, and an examination of the structure and quality of
CBME [10, 11]. TP-EPA3.
EPAs have been well developed in many medical pro- In the first stage, six topics for the core EPAs were
fessions, such as medicine of various specialties [12–18], identified by expert committee using the nominal group
dentistry [19], nursing [20], pharmacy [21, 22], radiology technique and survey questionnaires distributed to 131
[23–25], physical therapy [26], and occupational therapy teaching hospitals in Taiwan [29]. The expert commit-
[27, 28]. While EPAs tailored to occupational therapy tee included two university teachers from departments
have been established in Singapore, they primarily focus of occupational therapy, 24 clinical teachers of pediat-
on undergraduate education during the earlier years ric occupational therapy in teaching hospitals, and one
of study, emphasizing fundamental professional activi- external expert developing EPAs in family medicine in
ties crucial for early-stage clinical education. However, Taiwan. The nominal group technique and survey ques-
it is crucial to develop EPAs specific to the final year of tionnaires were chosen to ensure a comprehensive and
undergraduate clinical training and post-graduate clini- systematic collection of expert opinions and have been
cal training. During this phase, occupational therapy detailed in previous studies [30, 31]. The survey was dis-
students are exposed to four major domains: physical, tributed to 131 teaching hospitals in Taiwan, providing a
mental, pediatric, and community. Each domain encom- broad basis for the identification of core EPAs [29].
passes unique core competencies and professional activi- The Taiwan Occupational Therapy Association made
ties. Thus, developing EPAs tailored to each domain of only minor textual refinements to the titles of the six
occupational therapy is essential. Accordingly, the pur- core EPAs: EPA1, “Providing evaluations in occupational
pose of this study was to delineate the process of devel- therapy”; EPA2, “Providing interventions in occupational
oping an EPA in pediatric occupational therapy, using the therapy”; EPA3, “Providing health education and consul-
EPA3 Providing Health Education and Consultation in tation” (TP-EPA3); EPA4, “Writing occupational therapy
occupational therapy (TP-EPA3) serving as an example, medical records”; EPA5, “Providing transdisciplinary col-
and to examine its validity. While we developed six EPAs laboration healthcare”; and EPA6, “Providing services
in pediatric occupational therapy, this study focuses of splints or assistive devices”, without altering the core
exclusively on TP-EPA3 as a representative example due competencies or the content of the EPAs themselves.
to its broad applicability across the four major domains The draft of TP-EPA3 was written by two pediatric occu-
of occupational therapy: physical, mental, pediatric, and pational therapy clinical teachers (corresponding and
community. co-corresponding authors) from two teaching hospitals

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Fu et al. BMC Medical Education (2024) 24:705 Page 3 of 7

within the expert committee, based on the EPA template trainee’s level of entrustment using the following ques-
[11]. Following three rounds of consensus meetings, the tion: "If you were to supervise this trainee again in a
expert committee finalized the description of TP-EPA3, similar professional task and situation, which of the fol-
as shown in Appendix 1. lowing statements aligns with how you would assign the
In the second stage, 16 committee members from the task?" This question was used to guide the clinical teach-
stage one expert committee, along with 3 non-committee ers’ entrustment decisions. The entrustment and super-
occupational therapy experts with EPA experience, rated vision scale comprised 5 levels, with level 1 and level 2
TP-EPA3. All raters had completed the online training being further divided into two sublevels, and level 3
of the EQual rubric evaluation and assessed TP-EPA3 being divided into three sublevels (Appendix 2). The defi-
according to the EQual rubric. nition of level 1a was “Not allowed to observe practicing
the EPA”. Level 1b was “Not allowed to practice the EPA;
Measure allowed to observe”. Level 2a was "Allowed to practice the
The EQual rubric is a 14-item evaluation utilized to EPA only under proactive, full supervision as co-activity
assess the quality of EPAs [32]. This rubric measures with supervisor”. Level 2b was “Allowed to practice the
the constructs of EPAs across 3 domains, including dis- EPA only under proactive, full supervision with super-
crete units of work (DU) (items 1–6), entrustable, essen- vision in room ready to step in as needed”. Level 3a was
tial, and important tasks of the profession (EEIT)(items “Allowed to practice the EPA only under reactive/on-
7–10), and curricular role (CR) (items 11–14) [32]. Each demand supervision with supervisor immediately avail-
item is scored using a five-point criterion-based anchor able, all findings double-checked”. Level 3b was “Allowed
system [32], and an online training video is available for to practice the EPA only under reactive/on-demand
scoring [33]. A cut-off score of 4.07 determines whether supervision with supervision immediately available, key
a given EPA requires modification, with an average over- findings double-checked”. Level 3c was “Allowed to prac-
all EQual score below 4.07 indicating that it does [32]. tice the EPA only under reactive/on-demand supervision
Moreover, the cutoff scores for the DU, EEIT, and CR with supervisor distantly available, findings reviewed”.
domains are 4.17, 4.00, and 4.00, respectively [34]. The Level 4 was “Allowed to practice the EPA unsupervised”.
EQual rubric evaluation has been found to be reliable, Level 5 was “Allowed to supervise others in practice of
valid and useful in EPA development [32, 34, 35]. the EPA”.

Data analysis Results of the EQual rubric

Data analyses were performed in Microsoft Excel 16.75 Eighteen occupational therapists rated the TP-EPA3
for Mac. We calculated mean and standard deviation for according to the EQual rubric. The response rate was
the EQual rubric score and three domain scores to deter- 94.7%. The EQual item, domain, and overall scores for
mine whether the EPA needs modification. The EQual the TP-EPA3 are listed in Table 1. The average scores
rubric score represented the average of all 14 items, and of the individual items on the Equal rubric ranged from
domain scores for DU, EEIT, and CR were calculated 3.17 to 4.83. The average overall EQual score was 4.21
from items 1–6, 7–10, and 11–14, respectively [32, 34, (SD = 0.41), which was higher than the cut-off score,
35]. Additionally, the scatter plot was used to examine 4.07. The domain scores for DU, EEIT, and CR were 3.90
the dispersion of scores across the three domains. (SD = 0.69), 4.46 (SD = 0.44), and 4.42 (SD = 0.45), respec-
tively. Only the domain score for DU (3.90) was lower
Results than the domain cut-off score (4.17). The scatter plot of
Development of EPA3, providing health education the three domain scores of the EQual is shown in Fig. 1.
and consultation (TP‑EPA3)
The description of TP-EPA3 is shown in Appendix 1. Discussion
The EPA comprises 8 parts: title; specifications and limi- To the best of our knowledge, this study was the first to
tations; potential risks in case of failure; most relevant illustrate the development process of EPAs in pediatric
competency domains; required knowledge, skills, atti- occupational therapy, specifically tailored for use in the
tude and experiences; assessment information sources final year of undergraduate clinical training and post-
to assess progress and ground a summative entrustment graduate clinical training in the pediatric domain. The
decision; entrustment for which level of supervision is to EPAs developed in this study can complement those
be reached at which stage of training; and expiration date. developed in Singapore [27, 28], which are utilized dur-
The entrustment and supervision scale for TP-EPA3 ing the earlier years of undergraduate education. Early
adopted Chen’s entrustment and supervision scale [36]. exposure to EPAs in undergraduate education can
Specifically, clinical teachers were asked to assess the enhance students’ understanding of the EPA concept,

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Fu et al. BMC Medical Education (2024) 24:705 Page 4 of 7

Table 1 EQual rubric item, domain, and overall scores for the TP-EPA3
Item Mean (SD) Median Mode

1 This EPA has a clearly defined beginning and 3.17 (1.42) 3 3,4,5
end
2 This EPA is independently executable to 4.06 (1.0) 4 4
achieve a defined clinical outcome
3 This EPA is specific and focused 3.94 (0.94) 4 4,5
4 This EPA is observable in process 4.17 (0.51) 4 4
5 This EPA is measurable in outcome 4.05 (0.64) 4 4
6 This EPA is clearly distinguished from other 4.00 (0.69) 4 4
EPAs in the framework
7 This EPA describes work that is essential and 4.72 (0.46) 5 5
important to the profession
8 Performing this EPA leads to recognized output 4.28 (0.83) 4.5 5
or outcome of labor
9 The performance of this EPA in clinical practice 4.00 (0.97) 4 5
is restricted to qualified personnel
10 This EPA addresses professional work that is 4.83 (0.38) 5 5
suitable for entrustment
11 This EPA requires the application of knowledge, 4.39 (0.50) 4 4
skills, and/or attitudes (KSAs) acquired through
training
12 This EPA involves application and integration 4.67 (0.49) 5 5
of multiple domains of competence
13 The EPA title describes a task, not qualities or 4.33 (0.49) 4 4
competencies of a learner
14 This EPA describes a task and avoids adjectives 4.28 (0.75) 4 5
(or adverbs) that refer to proficiency
Domain 1: Discrete units of work (average score of 3.90 (0.69)
Item 1 to item 6) (cut-off score: 4.17)
Domain 2: Entrustable, essential, and important tasks 4.46 (0.44)
of the profession (average score of item 7 to item 10) (cut-off score: 4.00)
Domain 3: Curricular role (average score of item 11 4.42 (0.45)
to item 14) (cut-off score: 4.00)
Average overall EQual score (cut-off score: 4.07) 4.21 (0.50)
EPA Entrustable Professional Activity

increase clinical engagement, foster a stronger sense of EQual domain scores for DU than for the other domains.
professional identity, bridge the gap between theoretical Notably, the average scores for item 1 (“This EPA has a
knowledge and clinical practice, and facilitate compre- clearly defined beginning and end”) and item 3 (“This
hension of future practice expectations during condi- EPA is specific and focused”) were the lowest (Table 1).
tional registration [28, 37, 38]. Using EPAs in pediatric In pediatric occupational therapy, health education and
occupational therapy during the final year of undergradu- consultations frequently occurred during various interac-
ate clinical training and post-graduate clinical training tions with parents, such as following screenings, assess-
can assess students’ advanced clinical skills in pediatric ments, interventions, cessation of interventions, or even
occupational therapy domain, enable students to engage during casual conversations about the child’s recent
in self-directed learning to address their weakness, as behaviors or challenges. Therapists often used these
well as determine their readiness to become independent opportunities to recommend home program, activity
pediatric occupational therapists [39, 40]. adjustments, environmental modifications, or changes in
The overall EQual score of TP-EPA3 (4.21), being parenting strategies. Due to the nature of these interac-
higher than the cut-off score of 4.07, indicated good tions, it would be challenging to identify a clear begin-
validity and quality. However, the EQual domain score ning and end for providing consultations and health
for DU (3.90), below the cut-off score of 4.17, indicated education. This might explain why items 1 and 3 received
a need for further revisions of the items within this lower scores. Consequently, the observation contexts of
domain. The scatter plot revealed greater variability in TP-EPA3 were refined to focus on four specific contexts:

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Fu et al. BMC Medical Education (2024) 24:705 Page 5 of 7

Fig. 1 Scatter plot of the three EQual domain scores of TP-EPA3: Providing Health Education and Consultation in pediatric occupational
therapy in Taiwan. Note: EPA = entrustable professional activity. DU = Discrete units of work. EEIR = Entrustable, essential, and important tasks
of the profession. CR = Curricular role

after screening, after evaluation, after intervention, and TP-EPA3. The key point in determining the summa-
intervention discontinuation. These specifications were tive entrustment and supervision levels for EPAs is to
revised in alignment with the definitions, sequences, and thoroughly consider the outcomes of multiple assess-
crucial observation points related to providing health ment methods and assessments. This approach prevents
education and consultation. The revised version of the trainees from being unfairly labeled as “under proactive”
TP-EPA3 is provided in Appendix 3. based solely on one performance or poor performance on
The TP-EPA3 presented in this paper may not be uni- severe patients [41].
versally applicable to all occupational therapy fields, such Since our EPAs were designed to evaluate both UGY
as physical, mental, and community settings, or at differ- and PGY trainees, Chen’s prospective entrustment and
ent levels of hospitals or community agencies, or in all supervision scale [36] was adopted for two main rea-
countries. However, occupational therapists can employ sons. First, the prospective nature of Chen’s scale could
the EPA topic development process [29] and EPA con- reduce the influence of contextual factors such as time of
tent development process in this paper to develop their observation and work load, as well as task factors such as
core EPAs tailored to their respective fields, hospitals or complexity of patient’s conditions [41]. Second, Chen’s
community agencies, or countries. In cases where occu- scale expands the lower levels of the scale to include
pational therapy units provide specialized services or finer gradation of supervision, making it more suitable
interventions, specialized EPAs may also be developed by for assessing the performances of UGY trainees [36].
following this EPA development process. For instance, if Thus, the scale offers a more comprehensive framework
an occupational therapy unit specializes in telemedicine for evaluating the trainees’ performances at different
or screening, specialized EPAs can be developed. Moreo- stages of training, allowing more detailed analysis of their
ver, if only certain components of the professional tasks progress.
of the EPAs can be performed due to the size or other
constraints, nested EPAs [11], which are smaller units of Limitations and suggestions
the original EPA, can be considered. This study had four major limitations. First, although
The assessment information sources utilized in evalu- the overall EQual score of the initial TP-EPA3 indi-
ating progress and grounding a summative entrust- cated acceptable content validity, the revised TP-EPA3
ment decision for the TP-EPA3, as presented in this still needs to be examined to determine whether the
study, encompass all the assessment methods typically DU domain score has been improved. Second, since
employed to evaluate trainees’ capabilities. Occupa- only the content validity of TP-EPA3 was examined,
tional therapy clinical teachers can select the assessment its inter-rater and intra-rater reliability, convergent
methods they already utilize from those provided in the and discriminant validity, and responsiveness should

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Fu et al. BMC Medical Education (2024) 24:705 Page 6 of 7

be further investigated. Third, the target entrustment Acknowledgements

We gratefully appreciate the Taiwan Occupational Therapy Association, the
and supervision levels of UGY and PGY trainees were President, Dr. Ching-Yi Wu, the Chair of the Professional Quality Committee,
recommended by the expert committee. Future stud- Dr. I-Ping Hsueh, and Yi-Fang Wu for their support of our research. We also
ies should investigate the perspectives of occupa- acknowledge the non-committee occupational therapy experts for their help
in examining the validity of the EPAs.
tional therapy clinical teachers on these target levels.
Fourth, a potential limitation of our study is the over- Authors’ contributions
lap of committee members across the development and C.P.F: co-principal investigator, wrote manuscript, designed research, collected
and analyzed data, one of the expert committee members. C.K.H., Y.C.Y., W.S.L.,
evaluation phases of TP-EPA3. Sixteen of the nineteen S.M.H., W.D.C., Y.J.C., M.W.L., YJ.L., C.L.W., H.Y.C., C.Y.L., F.M.C., Y.L.C., C.F.T.: expert
experts who assessed TP-EPA3 using the EQual rubric committee members, assisted in research execution, EPAs lead authors. T.H.L.:
evaluation were involved in the initial development. Taught the concepts and framework of competency-based medical education
and entrustable professional activities to the expert committee, guided the
Despite all raters being trained using the EQual rubric, occupational therapy expert committee to develop EPAs, assisted in design‑
their prior involvement could introduce unintentional ing research, assisted in writing manuscripts, shared EPAs developmental
rater bias, potentially influencing the impartiality of experiences in family medicine. C.T.S.: edited manuscripts, one of the expert
committee members. A.L.Y.: shared EPAs development experiences in physical
their assessments. therapy, external experts, edited manuscripts. Corresponding author N.C.K.:
lead author of the TP-EPA3 for providing health education and consultation in
occupational therapy, which is presented in this manuscript, one of the expert
committee members, assisted in research execution. Co-corresponing author
Conclusion W.Y.C.: principal investigator, lead author of the TP-EPA3 which is presented in
EPAs provide a time-efficient, feedback-oriented, and this manuscript, one of the expert committee members, assisted in research
workplace-based assessment for evaluating whether execution.
trainees can perform clinical professional tasks com- Funding
petently without supervision. The EPA development This study was supported by research grants from the Taipei Hospital, Ministry
process outlined in this study can help occupational of Health and Welfare (Project No. 202315).
therapists develop core EPAs, specialized EPAs, or nested Availability of data and materials
EPAs tailored to their specific fields, hospitals or com- Data is available upon reasonable request from corresponding author. The
munity agencies, or countries. In conclusion, EPAs are e-mail of the corresponding author is yves7116@[Link] and wany‑
ing0928@[Link] .
not only easy and intuitive for assessing the learning
outcomes of CBME but also support clinical teachers in
Declarations
evaluating trainee independence in significant clinical
professional activities and in curriculum design. Further- Ethics approval and consent to participate
more, EPAs help trainees prepare for clinical professional This study was approved by the institutional review boards of Fu Jen Catholic
University (C110093) and Taipei Hospital, Ministry of Health and Welfare (TH-
activities. Specifically, the TP-EPA3, which focus on pro- IRB-0022–0027). Informed consent was obtained from all participants.
viding health education and consultation in pediatric
occupational therapy in Taiwan, has been validated using Consent for publication
Not applicable.
the EQual rubric, paving the way for the development of
additional core EPAs using the process described. Competing interests
The authors declare no competing interests.
Abbreviations
EPA Entrustable Professional Activity Author details
CBME Competency-based medical education 1
Department of Occupational Therapy, College of Medicine, Fu Jen Catholic
TP-EPA3 EPA3 for occupational therapy focused on providing health edu‑ University, New Taipei City, Taiwan. 2 Department of Rehabilitation, Occu‑
cation and consultation pational Therapy, Linkuo Chang Gung Memorial Hospital, Taoyuan, Taiwan.
DU Discrete units of work 3
Department of Rehabilitation, Lotung Poh-Ai Hospital, Yilan, Taiwan. 4 Depart‑
EEIT Entrustable, essential, and important tasks of the profession ment of Rehabilitation, Taipei Medical University Hospital, Taipei, Taiwan.
CR Curricular role 5
Department of Rehabilitation, Sijhih Cathay General Hospital, New Taipei City,
ACGME Accreditation Council for Graduate Medical Education Taiwan. 6 Department of Rehabilitation, Mackay Memorial Hospital, Taipei, Tai‑
CanMEDS Canadian Medical Education Directives for Specialists wan. 7 Department of Rehabilitation, Kaohsiung Chang Gung Memorial Hos‑
UGY​ Undergraduate year pital, Kaohsiung, Taiwan. 8 Department of Rehabilitation, Changhua Christian
PGY Post-graduate year Hospital, Changhua, Taiwan. 9 Department of Rehabilitation, Cathay General
Hospital, Taipei, Taiwan. 10 Department of Physical Medicine and Rehabilitation,
National Taiwan University Hospital, Taipei, Taiwan. 11 Department of Physical
Supplementary Information Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan.
The online version contains supplementary material available at [Link] 12
Department of Family Medicine, Taipei Tzu Chi Hospital, New Taipei City, Tai‑
org/​10.​1186/​s12909-​024-​05670-1. wan. 13 School of Medicine, Tzu Chi University, Hualien City, Taiwan. 14 Institute
of Sports Sciences, University of Taipei, Taipei, Taiwan. 15 Department of Occu‑
Supplementary Material 1. pational Therapy, Taoyuan General Hospital, Ministry of Health and Welfare,,
No. 1492, Zhongshan Rd.,Taoyuan Dist., Taoyuan 330, Taiwan. 16 Department
Supplementary Material 2. of Physical Medicine and Rehabilitation, Taipei Hospital, Ministry of Health
Supplementary Material 3. and Welfare, No. 127, Su‑Yuan Rd., Hsin‑Chung Dist., New Taipei City, Taiwan.

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Fu et al. BMC Medical Education (2024) 24:705 Page 7 of 7

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