Development of Entrustable Professional Activities for Entry-level Dietitians in Taiwan

doi:10.21203/rs.3.rs-2974007/v1

Background

Entrustable professional activities (EPAs) successfully link competencies with everyday practice in the training of health care professionals. Herein, we report on the nationwide development of EPAs and the competencies of entry-level dietitians receiving postgraduate clinical training programs.

Methods

The consensus process comprised three phases. The approach involved identifying core tasks for entry-level dietitians, holding national workshops and obtaining feedback from experts to form EPA drafts, and conducting a consensus meeting to construct EPAs framework and EPA/competency domain matrix. A total of 101 nutritionists or dietitian educators from teaching hospitals nationwide participated in the workshops (n = 101). Among the participants, experts (n = 31) were invited to join the competency-based medical education taskforce of Taiwan Dietitian Association (TWDA), provide feedback on drafted EPAs, and attend the consensus meeting using the nominal group technique (NGT). During NGT, any proposal for changes of the drafted EPAs or competencies, including adding, removing, and amending, had to be seconded by an additional expert before being further discussed sufficiently and voted on, with rates of agreement of consensus reached being set at ≥ 50%.

Results

We reached a consensus on seven core EPAs for entry-level dietitians. Each EPA was mapped to specific tasks and corresponding core competencies by developing an EPA/competency matrix. Among the seven EPAs, three were related to clinical nutrition care, two were related to the provision of dietetic services, one was related to group education on disease-specific nutrition, and one was related to nutrition care in the residential long-term care of the teaching hospital.

Conclusions

Development of the seven core EPAs as well as the EPA/competency matrix was accomplished by a solid consensus process that would offer goals for the expected progression and augment competency-based training for entry-level dietitians. Future study will be needed to test feasibility of implementing training and assessment of the core EPAs and their efficacy in teaching hospitals of Taiwan.

dietitian

post-graduate clinical training

competency-based medical education

entrustable professional activities (EPAs)

Competency-based medical education (CBME) is an outcome-based approach for designing, implementing, and evaluating educational programs; it utilizes competencies or predefined observable abilities of learners as the outcomes of the curriculum [1]. Recently, there has been a paradigm shift toward an outcome-based medical education framework across health professions rather than a conventional time-based approach [2]. In 2005, Dutch medical education expert Olle ten Cate first proposed [3] the concept of entrustable professional activities (EPAs), which was applied to graduate medical education. The EPAs framework is an educational concept that describes the key activities performed by competent health professionals in a work-based context [4]. EPAs are units of professional practice that can be described as responsibilities or discrete tasks that supervisors entrust to trainees once they have achieved adequate competencies [5]. EPAs set responsibilities and formalize decisions, allowing supervisors to justify the safe assignment of an activity to junior health professionals. The increasing popularity of EPAs has been partially attributed to the transformation of competency standards into observable work-based activities. Additionally, EPAs are valid tools [6] for improving work-based assessments and patient safety.

As the introduction of EPAs is very recent, little information is available regarding their development and implementation for dietitian trainees. However, recent reports have shown that the use of EPA has gradually expanded from postgraduate medicine across multiple medical specialties to nursing, pharmacy, and other allied health professions, such as dietetics [7–13].

The recent establishment of dietetics competency standards addresses the increasing diversity and ensures that graduates are sufficiently cultivated to prosper as opportunities arise. In Australia, the domains of nutrition and dietetics practice, as outlined in the national competency standards for dietitians [14], have been translated into several EPAs to achieve reliable assessment practices among dietetics placement students in clinical settings [15], final-year dietetics students in community and public health [16], graduate dietitian-nutritionists [17], and entry-to-practice dietitians [18].

The interest in competency-based educational programs and workplace-based assessments has increased worldwide. However, these frameworks must be tailored to local contexts for their effective implementation in different countries. To date, few studies have reported on the process of formulating profession-specific and localized EPAs and the corresponding competency framework for dietitian training in Asian countries. In this study, we report the development of a set of EPAs-competencies for entry-level dietitians receiving post-graduate clinical training programs released by the Ministry of Health and Welfare (MOHW) in Taiwan. Due to differences in international standards to become qualified health professionals [19], we defined entry-level as the first four years of practice following initial registration in teaching hospitals in Taiwan.

Study Design

The EPAs for entry-level dietetics practice were developed using a three-phase approach: (1) job analysis and identification of core tasks; (2) formulation of drafts for core EPAs and the domains of competence; (3) consensus meetings for seven core EPAs and corresponding competencies. An overview of each phase of the consensus-building process is presented in Fig. 1. The study was conducted between December 2020 and July 2022. After completion of each phase as mentioned, all data was handled anonymously and retrospectively. Ethical approval was obtained from the Human Ethics Research Committee of the Kaohsiung Medical University Hospital (protocol code: KMUHIRB-E(II)-20220266).

Participants and Recruitment

For participants attending the three workshops (Phase 2), dietitians primarily working as dietitian instructors in teaching hospitals or nutritionists with academic backgrounds were eligible to sign up. Thirty-one workshop participants, who were directors or leaders of the department of nutrition, training program directors, and experienced clinical nutrition instructors from accredited teaching hospitals throughout Taiwan, were invited by the Taiwan Dietitian Association (TWDA) to join the CBME taskforce and attend the consensus meeting for EPAs (phase 3).

Procedures and Data Analysis

An overview of the three phases of the consensus-building process is illustrated in Fig. 1, where the multiphase process used in this study was partially based on the EPAs development reported in medicine in the USA [20] and later in entry-level dietitians in Australia [18]. In the study, the findings of each phase were established and focused on involving the end user in the process to support the implementation of the outcomes in practice and training. The processes of Phases 1, 2, and 3 are as follows:

Phase 1. Job analysis and identification of core tasks. Eleven cores and five competency domains were identified based on a 2-year post-graduate year (PGY) training program for dietitians released by the MOHW of Taiwan and hospital job description booklets of what essential professional doings constituted EPAs for entry-level junior dietitians. An online survey was conducted to obtain agreement rates and formative feedbacks regarding the relevance and importance of each core task [21]. They served as references for nutrition experts to decide the EPAs that should be discussed and drafted while attending the workshops.

Before the workshops (Phase 2), a senior dietitian reviewed the EPAs among healthcare professionals regarding their developmental stages and the specific wording required for building up EPAs. The senior dietitian and a physician educator formulated a standardized EPAs template for the discussion of consensus drafts in the following workshops [22].

Phase 2. Formulation of drafts for core EPAs and the domains of competence. The second phase involved three national workshops (each lasting 200 min) conducted in the northern (Taipei), central (Taichung), and southern (Kaohsiung) major cities across Taiwan. The national workshops were designed to give a 10 min introduction regarding how the 11 core tasks were generated and the ranking of agreements regarding the opinions that seven out of the 11 core tasks should be included as core EPAs for entry-level dietitians [21]. After the introduction, a 90-min presentation to introduce the concepts of CBME and EPAs, the need to establish a shared understanding of entry-level competence, and EPA as potential solutions to assess competency in the workplace was conducted by a physician educator (the corresponding author) with an academic background in medical education. For the remaining 100 min of the workshop, the participants were convened into smaller groups of 4–6 dietitians working on drafting the contents of core EPAs. Each workshop ended with discussions on the contents of the key tasks and the corresponding core competencies of 3–4 EPAs. Three rounds of revision and rewording were then performed, and drafts of the seven core EPAs were created. Approximately 1.5 month before the consensus meeting (Phase 3), these drafts were sent to the CBME taskforce (n = 31) of the TWDA, who critically reviewed and provided feedback for the consensus drafts, and they were invited to attend the subsequent consensus meeting.

Phase 3. Consensus meeting for seven core EPAs and corresponding competencies. Thirty out of 31 dietitian experts of CBME taskforce participated in the consensus meeting. During the consensus, a physician educator (the corresponding author) explained the principles and execution of NGT to achieve a shared mental model among the participants and then applied a standard consensus process for every proposal to moderate the consensus meeting. Drafts of the seven EPAs and five competencies were used for the consensus process. Two consensus face-to-face meetings, lasting 7.5 h each time, were held. During the consensus, the moderator presented each competency, title of the seven EPA, and key tasks of each EPA and asked for any suggestions for change (i.e., adding, removing, and amending proposals). The proposal for change was seconded by an additional expert before being further discussed, voted on, and documented. Voting was done anonymously using Google Docs, and the results were presented immediately after the vote; rates of agreement at which consensus was reached were set above 50% for final approval.

Three workshops were held from December 2020 to April 2021. Preliminary drafts of seven EPA titles and descriptions of the key tasks of each EPA and their corresponding core competencies were discussed and formulated for at least two rounds at workshops (Figure 1). The preliminary drafts were sent to obtain comments via an online survey from experts on the CBME taskforce of the TWDA (n=30). The feedbacks were sorted into three categories: “adding,” “removing,” and “amending” and formative feedbacks prior to the consensus meeting.

In October and November 2021, 30 experts from the CBME taskforce of the TWDA attended two consensus meetings to achieve consensus on EPAs and the corresponding core competencies. The characteristics of the experts in relation to their teaching experience are listed in Table 1. All experts were female, with 53.3% (n = 16) from teaching hospitals in medical centers, 40.0% (n = 12) from regional teaching hospitals, one employed as an academic, and one as a long-term care dietician (n = 2, 6.7%). The majority (20/30, 66.7%) of the attendees were directors or session leaders of the nutrition and dietetics department, and 86.7% (26/30) were currently clinical instructors with teaching responsibilities. The distributions of practice at < 10 years, 11–20 years, 21–30 years, and > 30 years were 6.7% (n = 2), 23.3% (n = 7), 50.0% (n = 15), and 6% (19.4%), respectively.

The results of the NGT consensus process are presented in Figure 2. During the NGT process, two competencies and nine descriptions of key tasks were agreed upon by most experts and were finalized without the need for changes. For changes, 55 suggestions were proposed, including 46 amendments, 5 additions, and 4 removals. Among the 46 amending proposals, three competencies, six EPA titles, and 34 descriptions of key tasks of EPAs achieved a consensus for change, with the remaining one EPA title and two descriptions of key tasks remaining unchanged. For adding proposals, one newly added competency and four key task descriptions were approved. For removing proposals, four task descriptions from the EPAs were deleted.

Finally, seven EPAs with task descriptions and relevant competencies for entry-level dietitians were approved during the consensus process. During the NGT consensus process, two core competencies: interpersonal and communication skills and professionalism, of the initial draft were agreed upon by most experts and were finalized without any proposals for change. The agreement rates of the four competencies (nutrition knowledge, nutrition care, practice-based learning and improvement, and management strategy and resource utilization), including three amending proposals and one added proposal, ranged from 60% to 100% (Table 2).

The agreement rates of the consented seven EPAs and their task descriptions are presented in Table 2. All titles of the seven EPAs were proposed for change, and the voted agreement rates ranged from 63.3% to 100.0%. Among the task descriptions of the seven EPAs, nine were agreed on without changes, 36 task descriptions had proposals for amending, four for adding, and four for removal (Figure 2). The agreement rates for those (task description of seven EPAs) with amending, adding, or removing proposals were (Table 2): 66.7%–100% for nutritional care for inpatients with common diseases (EPA1); 53.3%–100% for nutritional care for outpatients with common chronic diseases (EPA2); 53.3%–100% for nutritional care in critical care units (EPA3); 80%–100% for hospital plate-meal preparation and supervision (EPA4); 73.3%–100% for meal design and cost management (EPA5); 86.2%–100% for Group education for disease-specific nutrition (EPA6); 72.4%–100% for nutritional care in residential long-term care institutions (EPA7). In this study, EPAs were mapped to six competencies by developing an EPA/competency matrix, as shown in Table 3.

This study is the first attempt to build and search for EPAs for entry-level dietitians working in hospitals in Asian countries. The establishment of seven EPAs and their corresponding domains of competence in clinical nutrition care and dietetics education could enable practitioners, instructors, and academics to share their understanding for assessments of the key tasks of each EPA of entry-level dietitians in nationwide teaching hospitals in Taiwan. During the development of building up EPAs, the use of NGT with anonymous real-time voting and immediate display of voting results enabled effective iterative exchanges of expert opinions and an immediate consensus process to build and facilitate a common understanding of the minimum core EPAs of entry-level dietitians with associated descriptive performance levels.

In Taiwan, the educational pathway to become a certified dietitian includes successful completion of a bachelor’s degree in Nutrition and Dietetics and a dietetics internship. Upon completion of internships of 64-h basic nutrition, 128-h food preparation and supply, 192-h clinical nutrition, and 64-h community nutrition, the last-year dietetic students are eligible to take a board registration examination that qualifies them as registered dietitians [23]. Thus, nutrition graduates in Taiwan advance to the next stage of training as entry-level dietitians primarily based on the time they spend in the roles and not on whether they are qualified with the required competencies of certain practicing areas. A potential approach to address this issue would be to change the time-based training and adopt the CBME framework [24]. The decision of the Taiwan Dietician Association to use EPAs as a CBME framework for entry-level dietitians was made based on the fact that the EPAs have been suggested to bridge the gap between the theoretical parts of CBME and practical clinical work by focusing on observable and measurable activities, instead of person-based descriptors that are difficult to evaluate [25]. In hospital settings, typical practice areas for entry-level dieticians include the provision of outpatient and inpatient nutrition counseling, therapeutic food service management, and health promotion activities. The task job descriptions of the seven core EPAs developed in this study appeared to be consistent with those practicing areas and are expected to strengthen and improve the clinical training of entry-level dietitians in Taiwan.

Although EPAs have gained rapid acceptance in postgraduate medical education, little is known about their applications and use by entry-level health professionals. Since 2007, the MOHW in Taiwan has provided support in implementing training for post-graduate medical personnel through the “Instruction Fee Reimbursement Programs for Teaching Hospitals,” also releasing a post-graduate clinical training system that encompasses information on training targets, duration, and evaluation standard options [26]. This study proposes the first EPA/competency matrix for entry-level dietitians working in the nutrition sector of hospitals, which could serve as the driving force to revise the post-graduate training program and accelerate the implementation of CBME for dietitian training in teaching hospitals, and possibly extend this to other workplaces. Additionally, our developmental process may serve as a model for other countries to establish generic and local CBME programs.

This first version of shared understanding in EPAs for entry-level dietitians provides precision for decisions on training quality assessment across teaching hospitals in Taiwan. However, it is necessary to continuously cultivate instructors involved in implementing competency-based assessments [27]. By incorporating these new frameworks into a training plan without satisfactorily trained instructors, multiple parts of the assessment evidence to be evaluated to decide whether a trainee is entrusted to practice the elements of each EPA may lead to inappropriate assessment decisions. Additionally, establishing EPAs can be of little value unless they are accompanied by an optimal setting that allows trainees to learn effectively and trainers or instructors to provide comprehensive judgments of performance [28].

Limitations

This study had some limitations. First, EPAs and their corresponding competence domains have not been tested for implementation or acceptability by instructors in hospital settings. Without building an e-assessment and portfolio system, gathering evidence on trainees’ learning effectiveness may become difficult. Second, a multistage and iterative process was applied to develop the EPAs; only a small number of experts participated in the workshops to work on the drafts of the EPAs and consent the EPAs. The representation of our experts may be somewhat restricted, and the expansion of workshops or experts may introduce other suggestions or opinions during the development process. As we held workshops and consensus meetings, up to 85% of the participants and experts were engaged in teaching as instructors or program directors from nationwide teaching hospitals, despite the small sample size. Third, the developed EPAs are only suitable for entry-level registered dietitians working in clinical hospitals; the generalization of these EPAs to countries with different education or registration systems for becoming certified dieticians may be limited.

This is the first study to report on the establishment of EPAs and their corresponding competencies for entry-level dietitians in Asia. The establishment of EPAs can transform competencies into the authorization of clinical nutrition work in teaching hospitals and may facilitate improvement in the quality of medical nutritional services. Describing the work tasks of an entry-level dietitian could also provide insights into supporting entry-level competence assessment decisions and affirm the focus on entry-level eagerness [18]. The development of the seven core EPAs and the EPA/competency matrix was accomplished by a solid consensus process that would offer goals for the expected progression and augment competency-based training for entry-level dietitians. However, generalization of these EPAs to other Asian countries may be limited due to different education or registration systems. In the future, our EPAs and corresponding competence domains are surely needed to be tested for implementation in hospital settings.

CBME

Competency-based Medical Education

EPAs

Entrustable Professional Activities

MOHW

Ministry of Health and Welfare

NGT

Nominal Group Technique

PGY

Postgraduate Year

TWDA

Taiwan Dietitian Association

Ethics Approval and Consent to Participate

The study was conducted in accordance with the guidelines of the Declaration of Helsinki. The data collection took place on a voluntary basis, and anonymous voting was performed to obtain consensus. With approval by the Institutional Review Board of Kaohsiung Medical University Hospital (protocol code: KMUHIRB-E(II)-20220266), informed consents were waived and all data was handled anonymously and analyzed retrospectively. The research involved no more than minimal risk to the participants, and waiver of informed consent would not adversely affect the rights and welfare of the participants.

Consent for Publication

Not applicable.

Availability of Data and Materials

The datasets used and/or analyzed during the study are available from the corresponding author upon reasonable request.

Competing Interests

The authors declare that they have no competing interests.

Funding

The study was partially sponsored by research grants from the National Science and Technology Council of Taiwan (MOST 11-2628-H-002-011-MY3) and Kaohsiung Medical University Hospital (KMUH 110-0R85).

Authors' Contributions

Meng-Chuan Huang contributed to the research design, coordinated research resources, interpreted the data, and wrote the manuscript. Su-E Kuo and Huei-Min Chin coordinated research resources and assisted in data interpretation. Hui-Ping Chang assessed and interpreted data. Chiao-I Chang assisted in collecting, organizing, and analyzing the participants’ qualitative and quantitative data. Chih-Wei Yang contributed to the conception and design of the research and review and editing of the manuscript. All the authors have read and approved the final version of the manuscript.

Acknowledgments

The authors thank the Taiwan Dietitian Association (TWDA) for their financial and administrative support. The members of the CBME taskforce of the TWDA were also extended.

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Table 1. Demographics and characteristics EPAs development team dieticians attending national workshops and consensus meeting (n=30)

	N (%)
Practice setting
Medical center	16 (53.3)
Regional hospital	12 (40.0)
Nutrition Clinics	2 (6.7)
Years of practice (year)
<10	2 (6.7)
11–20	7 (23.3)
21–30	15 (50.0)
>30	6 (19.4)
Department director or session leader
Yes	20(66.7)
No	10(33.3)
Clinical Teaching instructor
Yes	26(86.7)
No	4 (13.3)

Table 2. Agreement rates of change proposals for the competency, EPAs and task description for entry-level dietitians in Taiwan (n=30)
Domains of competence	Agreement of changes
A. Nutrition knowledge	90.0%
B. Interpersonal and communication skills^b	-
C. Nutritional care	60.0%
D. Professionalism^b	-
E. Practice-based learning and improvement	100.0%
F. Management strategy and resource utilization	66.7%
Core EPA	Agreement of changes	EPA task description	Agreement of changes
EPA 1. Nutritional care for inpatients with common diseases	96.7%	✓ Identify nutritional care needs and communicate with healthcare team if necessary.	93.3%
		✓ Collect objective information for nutritional assessment.	100.0%
		✓ Identify patients in accordance with hospital regulations and introduce yourself to patients	100.0%
		✓ Conduct interviews to assess nutritional intake and care resources.	66.7%
		✓ Determine nutritional diagnosis.	100%
		✓ Formulate nutritional treatment goals and provide nutritional intervention plans.	66.7%
		✓ Complete nutritional medical records.	86.7%
EPA 2. Nutritional care for outpatients with common chronic diseases	70.0%	✓ Check the patient's identity according to hospital regulations.	53.3%
		✓ Confirm medical needs and communicate with the medical team if necessary.	93.3%
		✓ Collect objective information for nutritional assessment.	100.0%
		✓ Conduct interviews to assess dietary content and lifestyle.	96.7%
		✓ Determine nutritional diagnosis.	93.3%
		✓ Work with patients to formulate goals, provide individual diet plans, nutrition counseling, and education.	80.0%
		✓ Complete nutritional medical records.	63.3%
EPA 3. Nutritional care in critical care units	63.3%	✓ Identify nutritional care needs and communicate with healthcare team if necessary.	100.0%
		✓ Collect objective information for nutritional assessment.	100.0%
		✓ Identify patients in accordance with hospital regulations and introduce yourself to patients.	53.3%
		✓ Assess nutritional support routes and dietary intake status.	100.0%
		✓ Determine nutritional diagnosis.	96.7%
		✓ Discuss with the medical team to formulate nutritional treatment goals and intervention plans.	86.7%
		✓ Complete nutritional medical records.	100.0%
EPA 4. Hospital plate-meal preparation and supervision	63.3%	✓ Confirm the catering staff's clothing and appearance, hand hygiene, and safety during the catering process.^b	-
		✓ Confirm the menu, quality, and quantity of cooked meals for each food category.	100.0%
		✓ Verify that the catering equipment is clean and functioning properly.	100.0%
		✓ Confirm the reserved samples of the cooked meals.^b	-
		✓ Check the meal card with the contents of the meal order and make sure the plate is clean.	80.0%
		✓ Make sure all meals are delivered on time.	96.7%
		✓ Confirm the disposal of leftovers after catering, return of items, and cleaning the kitchen.	93.3%
		✓ Complete meal records, handle wrong meals and customer complaints if necessary.	86.7%
EPA 5. Meal design and cost management	100.0%	✓ Complete the meal plans.^b	-
		✓ Design cycle menus.^b	-
		✓ Collect market information on food supply prices, quality specifications, transportation, and storage.	86.7%
		✓ Menu cost analysis and correction.	96.7%
		✓ Communicate with chefs for menu content and revision as needed.	73.3%
		✓ Calculation of purchase quantity based on menu.	100.0%
EPA 6. Group education for disease-specific nutrition^a	89.7%	✓ Confirm the type of application, target of health education, and available resources.	100.0%
		✓ Complete education activity design.	86.2%
		✓ Make teaching materials or teaching aids that match the theme.	100.0%
		✓ Carry out event promotion and on-site arrangements.	100.0%
		✓ Practical implementation of group nutrition education.	93.1%
		✓ Activity analysis review.	100.0%
EPA 7. Nutritional care in residential long-term care institutions^a	93.1%	✓ Identify high-risk cases of malnutrition.	72.4%
		✓ Collect objective information for nutritional assessment.^b	-
		✓ Identify individual cases in accordance with institutional regulation and identify themselves.	100.0%
		✓ Conduct visits to assess nutritional intake and care needs.	100.0%
		✓ Determine nutritional diagnosis.^b	-
		✓ Formulate nutrition intervention goals and provide nutrition improvement programs.^b	-
		✓ Develop a follow-up visit plan.^b	-
		✓ Complete nutritional care record.^b	-
Agreement was %. ^aThere were twenty-nine nutrition experts participating in the consensus process, one expert was sick and did not attend the consensus meeting. ^bTask descriptions were agreed on by most members of the competence-based medical education (CBME) taskforce and were finalized without the need of amendments.

Table 3. EPAs-competency matrix for entry-level hospital dietitians in Taiwan
EPAs task	Competencies
EPAs task	A. Nutrition knowledge	B. Interpersonal and communication skills	C. Nutritional care	D. Professionalism	E. Practice based learning and improvement	F. Management strategy and resource utilization
EPA 1. Nutritional care for inpatients with common diseases	V	V	V	V	V
EPA 2. Nutritional care for outpatients with common chronic diseases	V	V	V	V	V
EPA 3. Nutritional care in critical care units	V	V	V	V	V
EPA 4. Hospital plate-meal preparation and supervision	V	V			V	V
EPA 5. Meal design and cost management	V	V		V	V	V
EPA 6. Group education for disease-specific nutrition	V	V		V	V	V
EPA 7. Nutritional care in residential long-term care institutions	V	V	V	V

No competing interests reported.

Development of Entrustable Professional Activities for Entry-level Dietitians in Taiwan

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Abstract

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Background

Methods

Participants and Recruitment

Procedures and Data Analysis

Results

Discussion

Limitations

Conclusion

Abbreviations

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References

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