Development of core entrustable professional activities linked to a competency-based veterinary education framework

Enabling Factors for the Implementation of Competency-Based Curricula in Colleges and Schools of Pharmacy

OBJECTIVES

To review the implementation drivers of competency-based pharmacy education (CBPE) and provide recommendations for enablers.

FINDINGS

Competency-based education is an emerging model in the health professions, focusing on time-variable competency development and achievement compared with a time-bound, course-based, traditional model. CBPE is an outcomes-based organized framework of competencies enabling pharmacists to meet health care and societal needs. However, challenges need to be recognized and overcome for the successful implementation of CBPE. Competency drivers include defining the competencies and roles of stakeholders, developing transparent learning trajectories and aligned assessments, and establishing lifetime development programs for stakeholders. Organization drivers include developing support systems for stakeholders; facilitating connections between all educational experiences; and having transparent assessment plans, policies, and procedures that align with core CBPE precepts, including the sustainability of time-variability. Leadership drivers include establishing growth mindset and facilitating a culture of connection between workplace and educational environments, program advocacy by institutional leaders, accepting failures as part of the process, shifting the organizational culture away from learner differentiation toward competence, and maintaining sufficient administrative capability to support CBPE.

SUMMARY

The successful implementation of CBPE involves enabling the competency, organization, and leadership drivers that will lead to program success. More research is needed in the areas of creation, implementation, and assessment of CBPE to determine success in this model. We have reviewed and provided recommendations to enable the drivers of successful implementation of CBPE.

Examining Competency-Based Education Through the Lens of Implementation Science: A Scoping Review

OBJECTIVES

This study aimed to identify evidence for the implementation and assessment of competency-based education (CBE) in health professions curricula using an implementation science framework.

FINDINGS

Using the PRISMA framework, a systematic review of the literature applying a prespecified and piloted search strategy from 2017 to the present in PubMed and CINAHL was performed. References identified from the search strategy were imported into Covidence for title and abstract screening and full-text review by 2 researchers. A third researcher resolved discrepancies. Data were extracted and synthesized to identify key elements from the article related to implementation science, with a quality appraisal. A total of 25 studies out of 304 initially identified records were included. The studies covered a broad range of health professions and countries. Key findings were limited use of implementation science elements, including variability in CBE implementation, limited fidelity assessment, and partial examination of the process continuum. Programs with a more robust implementation approach have a team-based strategy to lead, implement, and support CBE. Motivation and training of faculty are also key components of successful CBE implementation.

SUMMARY

Competency-based education is implemented differently across institutions, with variation among programs in their choice of elements of implementation science used. Further research is needed to examine CBE from an implementation science perspective and address remaining questions.

Growth Mindset in Veterinary Educators: An International Survey

Carol Dweck's mindset theory describes whether an individual believes that attributes, like intelligence or morality, can be honed (growth mindset) or are innate (fixed mindset). An educator's mindset impacts their approach to teaching, students' learning, participation in faculty development, and wellbeing. Mindset can affect faculty members' openness to curricular change, making the study of veterinary educator mindset timely and salient, as competency-based education is spurring curricular change worldwide. The purpose of this study was to examine the mindsets of veterinary educators internationally. A survey, consisting of demographic questions and mindset items (based on previously published scales), was distributed electronically to veterinary educators internationally, at universities where English is the primary instruction medium. Mindset was evaluated for the following traits: intelligence, clinical reasoning, compassion, and morality. Scale validation, descriptive statistics, and associations to demographic variables were evaluated. Four hundred and forty-six complete surveys were received. Overall, the study population demonstrated predominantly growth mindsets for all traits, higher than population averages, with some variation by trait. There was a small effect on years teaching towards growth mindset. No other associations were found. Veterinary educators internationally who participated in this study demonstrated higher rates of growth mindset than the general population. In other fields, a growth mindset in educators has had implications for faculty wellbeing, teaching and assessment practices, participation in faculty development, and openness to curricular change. Further research is needed in veterinary education to evaluate the implications of these high rates of growth mindset.

Evaluation of veterinary students' confidence and competence with surgical entrustable professional activities after repeated use of low-fidelity training models

BACKGROUND

This study aimed to evaluate whether low-fidelity surgical training models increased veterinary students' surgical confidence and competence and decreased procedural stress related to core surgical entrustable professional activities (EPAs).

METHODS

Final-year veterinary students repeatedly performed one of three surgical EPAs on a low-fidelity surgical training model (canine castration, subcutaneous lump removal and eyelid laceration repair) and completed a survey at set time points. In addition, a grading rubric was used to assess participants' competence in performing the assigned EPA at two different time points. Survey results and competency gradings were compiled and analysed.

RESULTS

Students' self-assessed confidence significantly increased, and stress significantly decreased, between assessment points on all three EPA surgical training models. Graded competence significantly improved between the assessment points on all training models, and most students deemed the models to be realistic and helpful for student practices.

LIMITATIONS

Limitations relate to the study involving a single cohort from a single institute and the reliance on student self-assessment.

CONCLUSIONS

Repeated exposure to low-fidelity surgical training models increased final-year students' surgical confidence and competence and reduced procedural stress related to three key surgical EPAs. Assessment of competence using a grading rubric was successful and could be incorporated into a competence-based veterinary education assessment framework to allow screening of competence prior to graduation.

Establishing the Most Important Clinical Skills for New Graduate Veterinarians by Comparing Published Lists with Regional Stakeholder Expectations: A Bangladesh Experience

Veterinary clinical skills training is evolving rapidly around the world and there is increasing interest in Bangladesh in opening clinical skills laboratories and using models in teaching. The first clinical skills laboratory was opened at Chattogram Veterinary and Animal Sciences University in 2019. The current study aimed to identify the most important clinical skills for veterinarians in Bangladesh to inform the further development of clinical skills laboratories and ensure resources are deployed effectively and efficiently. Lists of clinical skills were collated from the literature, national and international accreditation standards, and regional syllabi. The list was refined through local consultation, focused on farm and pet animals, and was disseminated via an online survey to veterinarians and final-year students who were asked to rate the level of importance of each skill for a new graduate. The survey was completed by 215 veterinarians and 115 students. A ranked list was generated with injection techniques, animal handling, clinical examination, and basic surgical skills among the most important. Some techniques requiring specific equipment and some advanced surgical procedures were considered less important. As a result of the study, the most important clinical skills for a new graduate in Bangladesh have been identified for the first time. The results will inform the development of models, the use of clinical skills laboratories, and the design of clinical skills courses for veterinary training. Our approach of drawing upon existing lists followed by local stakeholders consultation is recommended to others to ensure clinical skills teaching is regionally relevant.

Development of entrustable professional activities for post-doctorate pediatric dentistry education

PURPOSE

To identify the core components of pediatric dentistry defining entrustable professional activities (EPAs) representing the profession.

METHODS

Potential core components of pediatric dentistry and corresponding domains were identified through review of literature and existing pediatric dentistry standards. A modified Delphi technique was utilized to rate these candidate EPAs to achieve consensus around prioritized EPAs.

RESULTS

Eleven participants participated in all three rounds of the Delphi. After three rounds, 16 candidate EPAs reached consensus for pediatric dentistry. Each EPA fell into one of four domains: "assessment and planning," "provision of care," "behavior guidance," and "professional development." An original candidate EPA focused on non-pharmacological behavior guidance was deemed too broad by the Delphi. This EPA was subsequently developed into three separate components on nitrous oxide analgesia, moderate sedation, and general anesthesia.

CONCLUSIONS

Prioritized EPAs will help define the essential activities of the profession and provide a framework for creating assessments to ensure that graduating pediatric residents are ready for unsupervised practice.

The Development and Implementation of a National Veterinary Graduate Development Programme (VetGDP) to Support Veterinarians Entering the UK Workforce

The UK veterinary profession is facing significant challenges, including high rates of veterinarians leaving the profession amidst workforce shortages, alongside high levels of dissatisfaction, stress, and poor mental health. The highest rates of attrition are associated with veterinarians who have recently graduated and are at an early stage in their careers. Although there may be many contributory factors, a lack of adequate support during the transition from vet school into their first professional role following graduation may be one important cause. Consequently, it has never been more important to develop an effective system for supporting new graduates, which is accessible to all. A new Veterinary Graduate Development Programme (VetGDP) has been developed, using a framework of professional activities that are sufficiently flexible to create a bespoke, individualized program for each graduate depending on the role they enter. Each new graduate is assigned a dedicated coach (Adviser) within their workplace, who has been trained to provide effective support and has committed to doing so throughout the program. VetGDP has been implemented on a national scale in the UK; engagement is assured through the RCVS Code of Professional Conduct and quality assurance is in place. VetGDP has been developed using established educational, sociocultural, and behavioral theories, and the latest research in coaching and feedback within medical education. These methods, which aim to ensure there is the best possible impact on graduates' professional development, and the creation of a positive learning culture within the workplace, are taught to all Advisers via an e-learning package.

The Current State of Veterinary Toxicology Education at AAVMC Member Veterinary Schools

This study assessed the depth, breadth, and perception of toxicology education in curricula at Association of American Veterinary Medical Colleges (AAVMC) member veterinary schools. An online questionnaire was sent twice to all 54 AAVMC members and sent once to a veterinary toxicology list serve. The survey covered areas related to instructor demographics, the depth and extent of toxicology taught, and the respondent's perceptions of their student's ability to perform entrustable professional activities (EPA). Results were analyzed using descriptive statistics. Our survey resulted in a 44% response rate. All responding schools included toxicology in their curriculum, and it was a required course in 23 programs. Contact hours in stand-alone veterinary toxicology courses ranged from 14 to 45 h. Most respondents indicated that the current time allotted for toxicology was inadequate, despite indicating that most of their students could perform most EPAs autonomously. One exception related to the ability of students to analyze toxicology data. We found small variations in teaching methods and curriculum content. The results of our study can assist veterinary schools in evaluating their curricula to better prepare new graduates for the management of toxicology issues they may face in their veterinary careers.

Investigating the Relationship between Multiple Mini-Interview Communication Skills Outcomes and First-Year Communication Skills Performance and Reflections in Students at the Ontario Veterinary College

An important outcome for veterinary education is ensuring that graduates can provide an appropriate level of care to patients and clients by demonstrating core competencies such as communication skills. In addition, accreditation requirements dictate the need to assess learning outcomes and may drive the motivation to incorporate relevant and appropriate methods of entry assessments for incoming students. Predicting the success of Doctor of Veterinary Medicine (DVM) students based on entry assessment performance has been scantly investigated and can be challenging. Specifically, no research presently exists on predicting DVM students' first-year performance in relation to communication skills at the time of program entry. Objectives of this exploratory study were to investigate (a) the relationship between communication skills outcomes from multiple mini-interview (MMI) data and first-year academic performance related to communication and (b) the relationship between communication skills outcomes from MMI data and self-reported first-year communication reflections. A retrospective single-class study was conducted. Data were analyzed using descriptive statistics, correlation statistics, regression models, and paired t-tests to identify relationships among variables. Paired t-tests showed that students felt more prepared to meet second-year expectations over first-year expectations. Spearman's correlation revealed an association between MMI communication scores and one pre-year 1 survey question related to professionalism. Noo relationships were observed between MMI communication scores and marks from a self-reflection assignment in a communications course, or grades from a clinical medicine course that included clinical communication. The merit for further exploration of the relationship between communication competencies and student performance is discussed.

Veterinary students' views on surgical entrustable professional activities and the impact of COVID-19 on clinical competence development

Background

The primary purpose of this study was to understand veterinary students’ views on the described key surgical entrustable professional activities (EPAs) and to understand how COVID‐19 restrictions have impacted their clinical skill and competence development.

Methods

Final‐year veterinary students at a single institute completed a web‐based survey distributed by email. The survey aimed to characterise five constructs regarding EPAs, and a specific five‐point Likert‐like scale was created asking explicitly worded questions for each construct.

Results

One hundred and ten students responded. The cohort agreed that the previously described key surgical EPAs were clinically important and relevant, but over 50% of the respondents felt that they had no substantial experience with them and were not confident or comfortable performing them. Additionally, most students (95%) felt their clinical development was negatively impacted by COVID‐19.

Conclusions

The results of this study show that the key EPAs proposed are considered important skills by the undergraduate cohort described and that experience levels when entering the final year are lacking, potentially due to reduced exposure to clinical cases influenced by the COVID‐19 pandemic.

Active learning for an evidence-based veterinary medicine course during COVID-19

Epidemiology is often a challenging course that is not well appreciated by many students learning veterinary medicine. The curriculum for this topic can sometimes be dry, difficult for students to contextualize, and heavy with statistics and mathematical concepts. We incorporated the concepts of epidemiology that are most important for practicing veterinarians and combined these with evidence-based veterinary medicine principles to create a practical course for second-year undergraduate veterinary students. We share the structure of our course and the different learning components, which also included incorporating graduate student mentors for journal clubs and an assignment that culminated in some students publishing their review findings. Anecdotal responses from students suggest they enjoyed the course and learned skills they felt would be useful in veterinary practice to help them make evidence-based clinical decisions.

A Novel Canine Otoscopy Teaching Model for Veterinary Students

Otoscopic evaluation using an otoscope is an important tool among the diagnostic modalities for otitis externa and is considered a core component of a canine patient's complete physical examination. Traditionally, otoscopic training in veterinary school involves using live dogs (i.e., laboratory dogs or dogs that are patients of the veterinary teaching hospital). While this approach has its advantages, performing otoscopic examination on live dogs presents several challenges: it requires adequate patient restraint, can cause stress to the dog, and can potentially cause trauma and/or injury to the dog's ear canal when performed by an inexperienced individual. Using an alternative teaching tool for otoscopic evaluation could overcome these challenges and improve veterinary students' learning experience. In this study, we investigated student perceptions of a novel canine teaching model for otoscopic evaluation in first-year veterinary students. The Elnady preservation technique was employed to create a realistic, durable, and flexible model for otoscopic training in a dermatology laboratory session in a first-year veterinary course. Student feedback was assessed on a Likert scale, and overall feedback indicated that students felt that the model was beneficial for skill building and removed many of the stressors incurred with using live animals when training in clinical skills. Most students stated that they would like to have additional similar models incorporated into training and would recommend these models to other students.

Breaking barriers: The landscape of human and veterinary medical anatomy education and the potential for collaboration

Despite human (HUM) and veterinary (VET) medical institutions sharing the goal of educating future clinicians, there is little collaboration between them regarding curricular and pedagogical practices during the preclinical/basic science training years. This may be, at least in part, due to a lack of understanding of each type of curriculum. This study presents data about curricula, student populations, pedagogical methodologies applied, and anatomy educators' training at both HUM and VET institutions. Preclinical curricula, admissions criteria, and student demographics were analyzed for 21 institutions in the United States having both HUM and VET schools. This dataset was augmented by a questionnaire sent to anatomists internationally, detailing anatomy curricula, pedagogies applied, and anatomy educators' training. Many curricular similarities between both training programs were identified, including anatomy education experiences. However, VET programs were found to include more preclinical coursework than HUM programs. Students who matriculate to VET or HUM schools have similar academic records, including prerequisite coursework and grade point average. Median HUM class size was significantly larger, and the percentage of women enrolled in VET institutions was significantly higher. Training of anatomy educators was identical with one exception: VET educators are far more likely to hold a clinical degree. This study elucidates the substantial similarities between VET and HUM programs, particularly in anatomy education, underscoring the potential for collaboration between both types of programs in areas such as interprofessional education, bioethics, zoonotic disease management, and postgraduate training.

Effective Veterinary Clinical Teaching in a Variety of Teaching Settings

This review explores different modalities for clinical teaching of veterinary learners globally. Effective clinical teaching aims to prepare graduates for a successful career in clinical practice. Unfortunately, there is scant literature concerning clinical teaching in veterinary medicine. Our intent for this review is to stimulate and/or facilitate discussion and/or research in this important area. We discuss the different forms that veterinary clinical teaching can take, depending on their setting, which can be university-based clinical activities, work-based in commercial clinical practices, or in a traditional academic setting with little to no real-time exposure to clients and patients. We suggest that each of these modalities has a place in clinical teaching of veterinary learners at any point in the curriculum but that a mix of these approaches will likely provide an improved experience for the learner. Further, we discuss strategies to improve clinical teaching in these different settings. Potential strategies related to the teaching skills of clinical instructors could include training in delivery of clinical teaching in a variety of learning settings, and instructors’ official recognition, including opportunities for career progression. Potential strategies to improve clinical teaching in different teaching settings would vary with the learning settings. For example, in traditional academic settings, case-based learning with incorporation of simulation models is one proposed strategy. The involvement of learners in ‘teach-others’ is a strategy for both traditional academic and clinical settings. Finally, clearly addressing Day One competencies is required in any clinical teaching setting.

Comparing Entrustment and Competence: An Exploratory Look at Performance-Relevant Information in the Final Year of a Veterinary Program

Workplace-based assessments and entrustment scales have two primary goals: providing formative information to assist students with future learning; and, determining if and when learners are ready for safe, independent practice. To date, there has not been an evaluation of the relationship between these performance-relevant information pieces in veterinary medicine. This study collected quantitative and qualitative data from a single cohort of final-year students (n = 27) across in-training evaluation reports (ITERs) and entrustment scales in a distributed veterinary hospital environment. Here we compare progression in scoring and performance within and across student, within and across method of assessment, over time. Narrative comments were quantified using the Completed Clinical Evaluation Report Rating (CCERR) instrument to assess quality of written comments. Preliminary evidence suggests that we may be capturing different aspects of performance using these two different methods. Specifically, entrustment scale scores significantly increased over time, while ITER scores did not. Typically, comments on entrustment scale scores were more learner specific, longer, and used more of a coaching voice. Longitudinal evaluation of learner performance is important for learning and demonstration of competence; however, the method of data collection could influence how feedback is structured and how performance is ultimately judged.

Using the Five Core Components of Competency-Based Medical Education to Support Implementation of CBVE

In recent years, veterinary education has begun the transition to competency-based models, recognizing that, like medical education, our goals include improved patient and client outcomes and the importance of learner-centered methods in education. Given that implementation of competency-based veterinary education (CBVE) is still in its relative infancy across many veterinary programs, we stand to gain from a unified approach to its implementation. As a guideline, the five core components of competency-based medical education (CBME) should serve to ensure and maintain fidelity of the original design of outcomes-based education during implementation of CBVE. Identified the essential and indispensable elements of CBME which include 1) clearly articulated outcome competencies required for practice, 2) sequenced progression of competencies and their developmental markers, 3) tailored learning experiences that facilitate the acquisition of competencies, 4) competency-focused instruction that promotes the acquisition of competencies, and 5) programmatic assessment. This review advocates the adoption of the principles contained in the five core components of CBME, outlines the approach to implementation of CBVE based upon the five core components, and addresses the key differences between veterinary and medical education which may serve as challenges to ensuring fidelity of CBVE during implementation.

Clarifying essential terminology in entrustment

With the rapid uptake of entrustable professional activties and entrustment decision-making as an approach in undergraduate and graduate education in medicine and other health professions, there is a risk of confusion in the use of new terminologies. The authors seek to clarify the use of many words related to the concept of entrustment, based on existing literature, with the aim to establish logical consistency in their use. The list of proposed definitions includes independence, autonomy, supervision, unsupervised practice, oversight, general and task-specific trustworthiness, trust, entrust(ment), entrustable professional activity, entrustment decision, entrustability, entrustment-supervision scale, retrospective and prospective entrustment-supervision scales, and entrustment-based discussion. The authors conclude that a shared understanding of the language around entrustment is critical to strengthen bridges among stages of training and practice, such as undergraduate medical education, graduate medical education, and continuing professional development. Shared language and understanding provide the foundation for consistency in interpretation and implementation across the educational continuum.

Day-1 Competencies for Veterinarians Specific to Health Informatics

In 2015, the American Association of Veterinary Medical Colleges (AAVMC) developed the Competency-Based Veterinary Education (CBVE) framework to prepare practice-ready veterinarians through competency-based education, which is an outcomes-based approach to equipping students with the skills, knowledge, attitudes, values, and abilities to do their jobs. With increasing use of health informatics (HI: the use of information technology to deliver healthcare) by veterinarians, competencies in HI need to be developed. To reach consensus on a HI competency framework in this study, the Competency Framework Development (CFD) process was conducted using an online adaptation of Developing-A-Curriculum, an established methodology in veterinary medicine for reaching consensus among experts. The objectives of this study were to (1) create an HI competency framework for new veterinarians; (2) group the competency statements into common themes; (3) map the HI competency statements to the AAVMC competencies as illustrative sub-competencies; (4) provide insight into specific technologies that are currently relevant to new veterinary graduates; and (5) measure panelist satisfaction with the CFD process. The primary emphasis of the final HI competency framework was that veterinarians must be able to assess, select, and implement technology to optimize the client-patient experience, delivery of healthcare, and work-life balance for the veterinary team. Veterinarians must also continue their own education regarding technology by engaging relevant experts and opinion leaders.

Key Assumptions Underlying a Competency-Based Approach to Medical Sciences Education, and Their Applicability to Veterinary Medical Education

This perspective explores six key assumptions of a competency-based approach to medical-sciences education, as they relate to veterinary medical education. Those assumptions, derived from characteristics of competency based medical education (CBME) identified by CBME proponents are: (1) There are sufficient shortcomings in the medical competence of graduate veterinarians that solutions are necessary, and changes in the way we teach veterinarians will address those problems. (2) It is feasible to identify generally accepted core competencies in veterinary medical practice. (3) Teaching to defined learning outcomes will produce greater achievement for learners than approaches that do not emphasize clearly defined outcomes. (4) In veterinary medical education, it is possible to articulate the development of competence sequentially in a manner that is relatively consistent across learners, and carefully planning and sequencing learning activities will produce better learning outcomes. (5) Competency-focused instruction, which tailors the pace and progression of instruction to learners, is feasible in veterinary medical education, and will produce better outcomes than instruction that moves all students through an equivalent process in a set time frame. (6) Programmatic Assessment, including numerous direct observations with feedback, will improve learning outcomes, and is feasible in veterinary medical education. While available research does not unequivocally support all six assumptions, overall the potential benefits of adopting a competency-based approach seem promising for veterinary medical education.

Collaborative Development of Core Entrustable Professional Activities for Veterinary Education

Entrustable professional activities (EPAs) have been proposed as a practical framework for the implementation of competency-based education. As veterinary education moves toward a competency-based approach, core EPAs provide a context for assessment of workplace activities. This article reports on the development of eight core clinical EPAs for veterinary education created through multi-institutional collaboration, with international input from veterinary educators and veterinary educational leaders. These core EPAs are intended as minimal expectations for clinical activities that should be assessed for every graduate of Association of American Veterinary Medical Colleges member institutions. Adoption of the core EPAs and the associated Competency-Based Veterinary Education (CBVE) framework by veterinary schools is intended to promote Day One graduate competence and thereby enhance patient care and client service.

The One Note System: Implementation and Initial Perceptions of Student Documentation in the Electronic Health Records Under the New Centers for Medicare and Medicaid Services Guidelines

Introduction

Medical students have been documenting notes in the electronic health records (EHR) for many years but often wrote separate notes from housestaff and faculty because licensed providers (LPs) could not bill the Centers for Medicare and Medicaid Services (CMS) for Evaluation and Management (E/M) services. However, in 2018, CMS updated its policy to allow LPs to simply verify any component of an E/M service under appropriate supervision, allowing LPs to bill a full medical student note.

Methods

At Virginia Commonwealth University Health Systems (VCUHS), a task force was formed to develop and pilot the One Note System (ONS), a system that incorporates the new CMS guidelines for certain note types. In June 2019, or 10 months after implementation of the ONS, the authors developed and distributed a survey that explored perceptions regarding the ONS among medical students, housestaff (residents and fellows), and faculty.

Results

The results showed that most participants were aware of the ONS and preferred email as the form of training. Overall, the ONS had a positive impact on faculty and housestaff workflow, improved self-reported faculty wellbeing, and increased meaning in student work. Only a minority reported barriers to implementing the ONS.

Conclusions

The One Note System was successfully implemented at VCUHS and positively received. Other outcomes to measure include impact of the ONS on student and trainee education, compliance and billing, quality and quantity of documentation, and faculty and housestaff burnout rates.