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Making a Case for Entrustable Professional Activities for Nurse Practitioners in Emergency Care

Hoyt, K. Sue PhD, RN, FNP-BC, ENP-C, CEN, FAEN, FAANP, FAAN; Ramirez, Elda G. PhD, RN, FNP-BC, ENP-C, FAEN, FAANP; Proehl, Jean A. RN, MN, CEN, CPEN, TCRN, FAEN, FAAN

Editor(s): Hoyt, K. Sue; Proehl, Jean A.

Author Information
Advanced Emergency Nursing Journal: April/June 2017 - Volume 39 - Issue 2 - p 77-80
doi: 10.1097/TME.0000000000000146
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The word “trust” is a belief in the ability, reliability, and/or strength of an individual. Trust in a provider is an important element for safe patient care. Patients need to trust their providers, and health care providers need to trust each other when practicing in a collaborative environment such as emergency care. In teaching settings, for example, preceptors must decide when and for what tasks they entrust nurse practitioner (NP) students, postgraduate NP fellows, and novice NPs to assume clinical responsibilities with heavy to light supervision or no supervision at all.


The Association of American Medical Colleges established a taxonomy of competency domains (entrustable professional activities [EPAs]) that are applicable for other health care providers, including nursing (Englander et al., 2013). Entrustable professional activities are a conceptual methodology/framework that allows preceptors/faculty to make competency-based decisions regarding the level of supervision required by the provider (ten Cate, 2013).

Entrustable professional activities are specific tasks and/or responsibilities entrusted to a student NP/novice NP once that individual has attained a specific competence at an acceptable level (ten Cate, 2013). For example, an individual could be entrusted to perform unsupervised activities once he or she has attained a sufficient level of competence.

Entrustable professional activities are independently executable and therefore suitable for entrustment decisions. Sequencing EPAs with regard to increasing difficulty, risk, or sophistication can serve as a backbone both for graduate nursing education and for clinical practice (ten Cate, 2013).

The American Association of Colleges of Nursing (2015) in its recent “White Paper: Re-envisioning the Clinical Education of Advanced Practice Registered Nurses” mentions EPAs as a way for nursing educators to standardize core competencies and assessment tools to consider similar evaluative approaches of advanced practice registered nurses.


Competencies are observable and measurable actions based on the ability to integrate knowledge, behaviors, skills, values, and attitudes. Emergency care competencies are specialty competencies intended to supplement the core competencies for all family NPs according to the Consensus Model document (i.e., population-focused competencies) while providing a model for practice in emergency care (Emergency Nurses Association, 2010).

Competency-based education focuses on standardized levels of proficiency to guarantee that all NP students have a sufficient level of proficiency at the completion of their training. The Accreditation Council for Graduate Medical Education and the Royal College of Physicians and Surgeons of Canada (CanMEDS) competencies comprise a framework delineating professional qualities. This framework gives generalized descriptions to assist learners, their supervisors, and institutions in teaching and assessment. But these frameworks must translate into practice. Entrustable professional activities were established to facilitate this translation, “addressing the concern that competency frameworks would otherwise be too theoretical to be useful for training and assessment in daily practice” (ten Cate, 2015).


Entrustable professional activities are not an alternative for competencies; they merely represent a way to translate competencies into clinical practice (ten Cate, 2013). Competencies are descriptors of providers; EPAs are descriptors of work. Entrustable professional activities usually require multiple competencies, and various EPAs require proficiency in several competency domains such as those in emergency care. It is important to note that an EPA must be described at a sufficient level of detail to set forth expectations for the NP student/novice NP and to guide a preceptor's/faculty's assessment and entrustment decisions (ten Cate, 2013).


Milestones are important touch points (behaviors) that mark a level of performance for a given competency. Milestones are the stages in the development of specific competencies. For example, at the first milestone, the new NP student would demonstrate “critical deficiencies” because he or she is a registered nurse (RN) without any clinical/academic NP training. During the second milestone, the new NP student would require “heavy supervision.” In a normal situation, this student should progress onto “light supervision.” At the next level, the NP would demonstrate all of the milestones learned in an NP program (and the respective clinical settings) and may have achieved a level of “no supervision.” In the final level, the NP would demonstrate “aspirational abilities/qualities” and would become the role model or teacher. In sum, milestones may link to a preceptor's/faculty's EPA decisions (e.g., direct proactive supervision vs. distant supervision).


Entrustment decisions involve clinical skills and abilities, as well as more general facets of competence such as understanding one's own limitations and knowing when to ask for help. Making entrustment decisions for unsupervised practice requires observed proficiency, usually on multiple occasions. In practice, entrustment decisions are affected by four groups of variables: (1) attributes of the NP student/novice NP (e.g., level of training); (2) attributes of the supervisors (e.g., lenient or strict); (3) context (e.g., time of the day, facilities available); and (4) the nature of the EPA (e.g., easy, difficult).

Entrustment decisions can be further distinguished as “ad hoc” (e.g., occur at a certain time of day–night shift), or they can be further delineated as structural (e.g., establishing the recognition that an NP may now perform this activity at a specific level of supervision). In the clinical setting, many ad hoc entrustment decisions occur every day. Structural (formal) entrustment decisions mean that an NP student/novice NP has attained a certain milestone that would translate into decreased supervision. The award is known as a statement of awarded responsibility (STAR). Linking an EPA with a competency framework emphasizes essential competency domains when observing an individual performing the EPA (ten Cate, 2013).


Utilizing the EPA model in academics is a model that has come full circle. In academic nursing, the Competency Outcomes and Performance Assessment (COPA) was utilized in the 1990s as an integrated outcomes-oriented system based on concepts related to creating practice competency categories, implementing interactive learning methods and key psychometric concepts that support performance assessment methods. Such a framework is useful to educators in both academic and service settings for promoting competence and accountability. Although this model was acceptable for evaluation of the baccalaureate nursing student's progression, it would not be acceptable at the graduate level. The EPAs of an NP do not parallel those of an RN. A different level of “trust” is assigned to an NP (e.g., rendering a final diagnosis). In other words, the role as an NP is a more decision-based practice. Thus, EPAs can work seamlessly for an NP evaluation methodology in the academic setting. Emergency nurse practitioner (ENP) faculty need to prepare the faculty to provide EPA-based assessments. Academicians must use structural entrustment decisions as a way for these students to execute EPAs with distant supervision.

Regarding clinical practice, EPAs are inclusive of specific actions unique to the emergency provider. These actions are directed toward maturity and decisiveness of the provider whether in training or in practice. Thus, EPAs will define ability to grow and be successful in a clearer model. The provider now has a pathway to follow when evaluating a student; the faculty member can now measure the evolution and development of skills while tangibly directing or redirecting the student. Utilizing EPAs makes evaluation objective. Nurse practitioner instructors will need to decide how many EPAs are useful for training. Entrustable professional activities can be the focus of assessment. The key question is: “Can we trust this NP student to execute this EPA?”

Although there are many EPAs that will serve to make ad hoc entrustment decisions, EPAs that lead to structural entrustment decisions (i.e., certification or STARs) should involve broad based responsibilities and be limited in number. For a graduate NP education program, no more than 20–30 EPAs are recommended.

Finally, ENPs will need to examine the specialty requirements and milestones and work collaborative with organizations such as the ENA, the American Association of Nurse Practitioners, the American Association of Emergency Nurse Practitioners, the American Academy of Nurse Practitioners Certification Board, and other professional organization to identify EPAs. Entrustable professional activities will evolve seamlessly in the context of NP practice because the actions performed will be parallel to the medical model. Academic evaluation models can be easily transitioned with utilization of EAPs specific to the population and specialty. This is our future as ENPs.

—Elda G. Ramirez, PhD, RN, FNP-BC, ENP-C, FAEN, FAANP
—Jean A. Proehl, RN, MN, CEN, CPEN, TCRN, FAEN, FAAN


American Association of Colleges of Nursing. (2015). White Paper: Re-envisioning the clinical education of advanced practice registered nurses. Retrieved from
Emergency Nurses Association. (2010). Nurse practitioner Delphi study: Competencies for practice in emergency care. Journal of Emergency Nursing, 36(5), 439–444.
Englander R., Cameron T., Ballard A., Dodge J., Bull J., Aschenbrener C. (2013). Toward a common taxonomy of competency domains for the health professions and competencies for physicians. Academic Medicine, 88(8), 1088–1094.
ten Cate O. (2013). Nuts and bolts of entrustable professional activities. Journal of Graduate Medical Education. Retrieved from
ten Cate O. (2015). Entrustable professional activities as a framework for the assessment of residents. Retrieved from
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