The Alice Lee Centre for Nursing Studies (NUS Nursing) is among the first few nursing schools in the world to adopt Entrustable Professional Activities (EPAs) in training undergraduate nurses.
Since April this year, all 1,100 of its nursing undergraduates are being schooled and assessed using this new framework.
Associate Professor Lydia Lau, who led the team in developing the new framework conceived by Professor Emily Ang, said: “The new approach is aimed at inculcating better critical thinking and management skills of nurses to improve patient outcomes and the quality of care.”
EPAs are units of professional practice that are demonstrated through tasks or activities that healthcare supervisors entrust trainees who have achieved adequate levels of competency.
The earlier approach — Continuous Clinical Experience Record (CCER) — has been in use since the 2006 establishment of the Centre’s inaugural undergraduate nursing programme.
CCER is a time-based approach that assesses the multifaceted competencies of student nurses. Historically, such an approach was preferred because it was practical and ensured the necessary skills for clinical practice were picked up.
A Year 1 student, for instance, would be assessed on the ability to perform a set of nursing procedures, which differed from the assessment tasks for a Year 3 student. There were fixed learning objectives for each clinical module.
But a gap remained between simply fulfilling a checklist of competencies for the sake of acing an assessment and effectively applying these skills in real-life situations.
“The clinical environment is dynamic and we need nurses who are not only competent and functional with certain tasks, but who also possess higher-order thinking, such as managing complex clinical situations, and the ability to care for patients holistically,” said A/Prof Lau, Director of Education (Clinical) at NUS Nursing.
She pointed out the various aspects in which the old approach to assessment could cause students’ learning to be assessment- driven and task-oriented.
“In a task-oriented approach where students are assessed on their ability to complete certain tasks, such as tube-feeding, once that checkbox is ticked, students may lose the motivation or incentive to keep practising the same task, even if the patient needs the procedure done another time.”
Such an approach also results in superficial learning. A nursing student may be satisfied with just completing the task of taking a patient’s blood pressure when deeper learning can entail analysing the aspects of the patient’s health condition that could have led to an elevated blood pressure.
“I have encountered a nursing student who did very well academically but when presented with a deteriorating patient, all the student could think of was checking and re-checking the patient’s blood pressure because it was low. Instead, having situational awareness and the ability to make good clinical judgement and decisions, such as calling for help and escalating care should have been the priority,” said A/Prof Lau.
DEVELOPMENT OF NURSING EPAS
In 2016, under the mentorship of Prof Ang, A/Prof Lau and her team took on the huge task of reforming nursing clinical education for the undergraduates at the Centre.
The team developed the new framework after carrying out a literature review to examine EPAs usage here and overseas, reviewing the core competencies required by Singapore Nursing Board and the school, as well as noting emerging healthcare trends.
Ten core nursing EPAs were identified. They are observable and measurable core nursing activities that a student is entrusted to perform at different levels of supervision. In line with the core competencies, the EPA assessment form differed from the old assessment form.
Clinical assessment tools used in the old approach were fragmented because the assessment of skills-based competency in performing certain tasks was segregated from the grading of general attributes such as communication or critical thinking.
The new EPA framework examines the students’ ability to holistically perform the professional activities, which include cognition, psychomotor and character attributes. The supervisors would have to observe how well the students could perform the nursing activities reflecting mastery of the required knowledge, skills, values and attitude, and the consistency of showing the behaviours.
A Year 3 or 4 student would also get more tasks entrusted to them with minimal supervision to give them greater autonomy over their own learning.
The students will be able to achieve the learning objectives based on the context of the clinical placement and opportunities for learning. They are empowered to take charge of their learning activities and monitor their own progress.
For instance, a nursing student who has managed a patient with a cardiac condition can volunteer to switch to another patient with a different condition for a new learning experience.
For skill sets that they have yet to get the opportunity to put into practice in their current clinical placement, they can look for the learning opportunities in future placements instead of having to artificially simulate the scenarios — as was the case in the past in order to complete the stipulated checklist.
ROLLING OUT AN ONLINE SYSTEM
Apart from developing the new framework with nursing EPAs, A/Prof Lau also led another major revamp.
A new online clinical management system was developed in tandem with the framework so that all clinical assessments can be filed and updated online.
In the past, it was all done on paper, making it a cumbersome and inconvenient process. Students received feedback from the clinical instructors only at the end of clinical placements, resulting in insufficient time for improvement or remedial efforts.
Having a real-time online system that students and their instructors can have access to anytime helps in better communication and progress monitoring so that students can respond immediately to the ongoing assessment during their clinical placements.
SHARED MENTAL MODEL
Abroad, similar EPAs are used in the training and assessment of doctors, pharmacists and senior nurses.
In Singapore, NUS postgraduate medical students started using it more than five years ago. Postgraduate nursing students in NUS started adopting it this year. To date, some 1,600 members of the NUS Nursing faculty, students and clinical staff from more than 30 healthcare institutions — including acute and community hospitals and nursing homes which take in NUS Nursing students for clinical placements — have been trained to use the EPA framework.
So far, the outcomes of using the new framework have been positive.
When comparing the scores of a cohort of students over the last two years as they move from the old approach to the new, it was found that their ratings for clinical decision-making and management of patient care rose by 15 per cent, and communication scores increased by 12 per cent.
A/Prof Lau has since published three papers on the development of undergraduate EPAs in two scientific journals.
As more healthcare professionals in Singapore are introduced to EPAs to enhance patient care, A/Prof Lau hopes EPAs will be adopted nationally in time to come.
“It is a paradigm shift for nursing education and care. If all parties use the same assessment framework, we will have a shared mental model with the end goal of providing safe and holistic care with improved patient outcomes.”
