Stakeholder Perceptions and Experiences of Competency-Based Training with Entrustable Professional Activities (SPECTRE): Protocol of a Systematic Review and Thematic Synthesis of Qualitative Research

Stakeholder Perceptions and Experiences of Competency-Based Training with Entrustable Professional Activities (SPECTRE): Protocol of a Systematic Review and Thematic Synthesis of Qualitative Research | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Study protocol Stakeholder Perceptions and Experiences of Competency-Based Training with Entrustable Professional Activities (SPECTRE): Protocol of a Systematic Review and Thematic Synthesis of Qualitative Research Justin Phung, Lindsay Cowley, Lindsey Sikora, Susan Humphrey-Murto, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5218635/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Dec, 2024 Read the published version in BMC Medical Education → Version 1 posted 15 You are reading this latest preprint version Abstract Background : Competency-Based Medical Education (CBME) aims to align educational outcomes with the demands of modern healthcare. Entrustable Professional Activities (EPAs) serve as key tools for feedback and professional development within CBME. With the growing body of literature on EPAs, there is a need to synthesize existing research on stakeholders’ experiences and perceptions to enhance understanding of the implementation and impact of EPAs. In this synthesis, we will address the following research questions: How are Entrustable Professional Activities experienced and perceived by stakeholders in various healthcare settings, and what specific challenges and successes do they encounter during their implementation? Methods : Using Thomas and Harden’s thematic synthesis method, we will systematically review and integrate findings from qualitative and mixed-methods research on EPAs. The process includes a purposive literature search, assessment of evidence quality, data extraction, and synthesis to combine descriptive and analytical themes. Discussion : This study aims to provide insights into the use of EPAs for competency-based education, reflecting diverse contexts and viewpoints, and identifying literature gaps. The outcomes will guide curriculum and policy development, improve educational practices, and set future research directions, ultimately aligning CBME with clinical realities. Trial Registration : Not required Competency Based Education Entrustable Professional Activities Systematic Review Thematic Synthesis Qualitative Research Background Medical education has undergone significant transformations in recent decades, driven by the urgent need to align educational outcomes with the dynamic and complex demands of modern healthcare systems (1,2). Traditional structure- and process-based educational frameworks, prevalent at the turn of the 21st century, have increasingly been deemed inadequate for preparing medical graduates for real-world clinical environments (3). This shift has spurred the global adoption of Competency-Based Medical Education (CBME), an approach emphasizing the attainment of essential competencies for delivering high-quality patient care (3,4). Entrustable Professional Activities (EPAs) are pivotal tools within CBME, serving as practical mechanisms for professional development through feedback and competency-based assessments (5). EPAs, defined as professional responsibilities entrusted to learners once they become clinically competent, translates the broad competencies of CBME’s theoretical frameworks into daily practice (5). Despite their theoretical promise and growing endorsement, the implementation of EPAs faces challenges in its practical application, partly due to stakeholders engagement and resistance (6–8). Although there is an increasing body of literature on EPAs—evidenced by over 1,000 articles and approximately 100 new publications annually—there is a notable gap in synthesizing this extensive work to provide coherent, actionable insights. Most research has focused on the theoretical foundations, development, and curricular integration of EPAs (7,9), neglecting the nuanced context-specific challenges and successes experienced by diverse stakeholders. Furthermore, the rich, in-depth perspectives offered by qualitative research in medical education have not been systematically integrated into a comprehensive synthesis, hindering the ability of educators, policymakers, and researchers to effectively navigate available literature and apply findings to their specific contexts. Addressing this gap is critical. A systematic review of qualitative studies will clarify the multifaceted experiences and perceptions of various stakeholders, providing a holistic understanding of EPAs’ impact on educational outcomes, professional development, and patient care quality (10,11). By synthesizing qualitative findings, we can uncover underlying themes and patterns that quantitative research might overlook, offering deeper insights into the implementation and perception of EPAs across different sociocultural settings (10,12). This synthesis will yield evidence-based recommendations to guide policymaking, educational practice, and future research, ensuring that EPAs fulfill their potential in transforming medical education and ultimately improving patient care (11,13). By systematically reviewing and integrating these qualitative findings, we can bridge the current knowledge gap, making the vast and complex literature on EPAs in CBME more accessible and actionable for all stakeholders involved. Research Questions In this synthesis, we will address the following research questions: How are Entrustable Professional Activities experienced and perceived by stakeholders in various healthcare settings, and what specific challenges and successes do they encounter during their implementation? Methods Study Design We will use a qualitative synthesis, a systematic review process that collects, organizes, and analyzes qualitative and mixed-method research data, and then provides comprehensive understanding of complex issues or phenomena (12). We will draw on Thomas and Harden’s principles of thematic synthesis, which entails four steps: systematic search of the literature, assessing quality and relevance of evidence, extracting data, and synthesizing data to integrate descriptive and analytical themes (14). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines will inform the process of completing and reporting this planned review (15). This protocol is reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) statement (16). Eligibility Criteria Study Designs: We will include qualitative studies and qualitative components of mixed-method studies. Participants: Studies involving medical educators (faculty, attendings, clinical teachers), medical learners (medical students, residents), administrators (program directors, competence committee members), and other stakeholders in EPAs across various healthcare settings will be included. Outcomes: Studies that explore the experiences, perceptions, challenges, and successes related to the implementation and use of EPAs. Settings: Any healthcare or educational setting where EPAs are implemented. Language: We will include articles reported in English or French. Information Sources and Search Strategy The following databases were searched by a health sciences librarian (LS): Medline and Medline in Process (Ovid), Embase Classic + Embase (Ovid), APA PsycINFO (Ovid), CINAHL (EBSCOHost), and Education Source (EBSCOHost). A search strategy was developed in Medline and then translated into the other databases as appropriate (see Appendix 1). All databases were searched from dates of inception to August 12, 2024. There were no publication restrictions for the search. All references were entered into an Endnote file for processing (n = 9496), and then were uploaded into Covidence for duplicate removal, and then screening. Database searches (numbers for PRISMA flowchart): Medline in Process and Medline (via Ovid): n = 2206 Embase (via Ovid): n = 2988 APA PsycINFO (via Ovid): n = 254 CINAHL (via EBSCOHost): n = 2010 Education Source (via EBSCOHost): n =2038 Total: n = 9496 Duplicates: n = 2797 Total with duplicates removed: n = 6699 Selection Process Search results will be uploaded to Covidence for screening and data extraction. Two reviewers will screen titles and abstracts independently. Full texts of potentially eligible studies will be retrieved and assessed for inclusion. Disagreements will be resolved through discussion or with a third reviewer if necessary. Data Extraction Using a standardized data extraction form (Appendix 2), two reviewers will extract data on study characteristics, participants, settings, methodologies, interventions, and key findings. A third reviewer will be consulted where discrepancies occur. For the thematic synthesis, all text labelled as “results” or “findings” will be extracted, including participants’ quotes, and entered in NVivo software for analysis. Data Synthesis We will follow Thomas and Harden’s three stages of thematic synthesis, an inductive process involving the systematic coding of data and generating of descriptive and analytical themes (14). The initial stage will begin with line-by-line coding performed independently by two reviewers. Codes will be created inductively to capture the meaning and content of each sentence. All text with a given code will be examined to check for consistency of text interpretation and whether additional levels of coding are needed. In the next stage, descriptive themes will be developed. The reviewers will look for similarities and differences between the codes to group and structure them appropriately, ensuring the meaning of initial coding groups are captured as codes are added and new descriptive themes are developed. The last qualitative synthesis stage involves the generation of analytical themes. Conducted independently then as a group, the reviewers will infer answers from the previously created descriptive themes that address the research questions. Through repetition of this cyclical process, new abstract themes will be generated that sufficiently describe and explain all initial descriptive themes. Evidence-based recommendations can thus be derived from the generated analytical themes. NVivo software will be used to facilitate the entire data coding and synthesis process. Quality appraisal The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research will be used to assess the quality of the include articles (17). Two reviewers will independently evaluate the quality of the included studies, with discrepancies resolved through discussion or consultation with a third reviewer. Each paper will be categorised as “low” (scores of 0–3), “moderate” (scores of 4–7), or “high” (scores of 8–10) quality. Lower-quality studies will be included in the synthesis process as they may still provide important insights into the phenomena of interest related to the interpretation and reporting of key findings (12). Confidence in Cumulative Evidence We will use the Grading of Recommendations, Assessment, Development and Evaluation – Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach to assess the confidence in the findings from the qualitative evidence synthesis (11,18). This involves evaluating methodological limitations, relevance, coherence, and adequacy of the data. Assessments for each finding will be made through discussion among all authors through team meetings. Ethical Considerations This study will not require ethical approval as it involves secondary analysis of published data. Discussion The results of this systematic review will provide a comprehensive synthesis of qualitative research on the implementation of EPAs within CBME. Thematic synthesis is particularly suited for this context as it allows for a detailed, nuanced understanding of stakeholders' perspective and experiences with EPAs. This method focuses on generating rich, in-depth and actionable insights, offering evidence-based recommendations that are crucial for addressing stakeholder concerns and fostering collaboration among educators, administrators, and policymakers (14). Ultimately, these insights can lead to more effective and sustainable implementation of EPAs, enhancing the quality of medical education and patient care in the CBME era (19). Several practical and operational challenges need to be addressed to ensure the success of this study. Managing the extensive volume of literature requires a comprehensive search strategy across multiple databases. Using Covidence for screening and data extraction helps streamline this process, although there is a risk of missing relevant studies. Additionally, limiting the search to English and French may introduce language and context-related bias. However, we cannot overcome this limitation given the cost of translation and lack of funding for this study. Ensuring consistency among reviewers during screening, extraction, and synthesis is crucial; regular calibration exercises and consensus-building sessions will help mitigate discrepancies (15). Synthesizing qualitative research presents its own set of challenges, such as the variability in study methodologies, quality and reporting. The subjective nature of quality appraisal and thematic synthesis requires careful and iterative processes, including discussion among the research team members (12). Despite these challenges, conducting a thematic synthesis remains essential. It provides a robust framework for integrating qualitative findings from diverse contexts, uncovering deeper insights that might be overlooked with alternate methods (14). Studying the perceptions and experiences of the implementation of EPAs is essential for optimizing educational practices, aligning training with healthcare needs, and informing policy and decision-making (7,9,19). We aim to identify effective practices and context-specific challenges for enhancing competency-based assessments and ensuring graduates are well-prepared for patient care (9). By conducting a robust qualitative evidence synthesis, we can guide resource allocation, address stakeholder concerns, and foster collaboration. Additionally, we will discuss research gaps and promote continuous quality improvement, advancing the field of medical education and ultimately improving the quality of healthcare delivery. Abbreviations CBME: Competency-Based Medical Education EPA: Entrustable Professional Activities GRADE-CERQual : Grading of Recommendations, Assessment, Development and Evaluation – Confidence in the Evidence from Reviews of Qualitative research JBI : Joanna Briggs Institute SPECTRE : S takeholder P erceptions and E xperiences of C ompetency-Based Tr aining with E ntrustable Professional Activities PRISMA : Preferred Reporting Items for Systematic Review and Meta-Analysis PRISMA-P : Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols Declarations Ethics approval and consent to participate Not applicable Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding JP received the Medical Student Education Research Grant (MSERG) Award by the Ontario Medical Students Association. Authors’ contributions All authors contributed to the conceptualization of the study. JP and RK drafted the protocol. All authors provided critical revisions to the protocol. All authors have approved the submitted version and have agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. Acknowledgements Not applicable References Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: Ttransforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923–58. Ludmerer KM, Johns MME. Reforming graduate medical education. Jama. 2005;294(9):1083–7. Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C. Shifting paradigms: From flexner to competencies. Acad Med. 2002;77(5):361–7. Frank JR, Snell LS, Cate O Ten, Holmboe ES, Carraccio C, Swing SR, et al. Competency-based medical education: Theory to practice. Med Teach. 2010;32(8):638–45. Ten Cate O. Nuts and Bolts of Entrustable Professional Activities. J Grad Med Educ. 2013;5(1):157–8. Caverzagie KJ, Nousiainen MT, Ferguson PC, ten Cate O, Ross S, Harris KA, et al. Overarching challenges to the implementation of competency-based medical education. Med Teach. 2017;39(6):588–93. Brydges R, Boyd VA, Tavares W, Ginsburg S, Kuper A, Anderson M, et al. Assumptions About Competency-Based Medical Education and the State of the Underlying Evidence: A Critical Narrative Review. Acad Med. 2021;96(2):296–306. Hawkins RE, Welcher CM, Holmboe ES, Kirk LM, Norcini JJ, Simons KB, et al. Implementation of competency-based medical education: Are we addressing the concerns and challenges? Med Educ. 2015;49(11):1086–102. Cate O Ten, Carraccio C. Envisioning a True Continuum of Competency-Based Medical Education, Training, and Practice. Acad Med. 2019;94(9):1283–8. Carroll C. Qualitative evidence synthesis to improve implementation of clinical guidelines. BMJ [Internet]. 2017;356:4–7. Available from: http://dx.doi.org/doi:10.1136/bmj.j80 Lewin S, Glenton C, Munthe-Kaas H, Carlsen B, Colvin CJ, Gülmezoglu M, et al. Using Qualitative Evidence in Decision Making for Health and Social Interventions: An Approach to Assess Confidence in Findings from Qualitative Evidence Syntheses (GRADE-CERQual). PLoS Med. 2015;12(10):1–18. Soilemezi D, Linceviciute S. Synthesizing Qualitative Research: Reflections and Lessons Learnt by Two New Reviewers. Int J Qual Methods. 2018;17(1):1–14. Mays N, Pope C, Popay J. Systematically reviewing qualitative and quantitative evidence to inform management and policy-making in the health field. J Heal Serv Res Policy. 2005;10(SUPPL. 1):6–20. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8:1–10. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ. 2021;372. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1–9. Lockwood C, Munn Z, Porritt K. Qualitative research synthesis: Methodological guidance for systematic reviewers utilizing meta-aggregation. Int J Evid Based Healthc. 2015;13(3):179–87. Lewin S, Booth A, Glenton C, Munthe-Kaas H, Rashidian A, Wainwright M, et al. Applying GRADE-CERQual to qualitative evidence synthesis findings: Introduction to the series. Implement Sci. 2018;13(Suppl 1):1–10. Touchie C, Ten Cate O. The promise, perils, problems and progress of competency-based medical education. Med Educ. 2016;50(1):93–100. Additional Declarations No competing interests reported. Supplementary Files Appendix.docx Cite Share Download PDF Status: Published Journal Publication published 27 Dec, 2024 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 04 Nov, 2024 Reviewers agreed at journal 03 Nov, 2024 Reviewers agreed at journal 03 Nov, 2024 Reviewers agreed at journal 03 Nov, 2024 Reviews received at journal 02 Nov, 2024 Reviewers agreed at journal 02 Nov, 2024 Reviewers agreed at journal 01 Nov, 2024 Reviewers agreed at journal 31 Oct, 2024 Reviews received at journal 15 Oct, 2024 Reviewers agreed at journal 15 Oct, 2024 Reviewers agreed at journal 13 Oct, 2024 Reviewers invited by journal 11 Oct, 2024 Editor assigned by journal 08 Oct, 2024 Submission checks completed at journal 08 Oct, 2024 First submitted to journal 07 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Traditional structure- and process-based educational frameworks, prevalent at the turn of the 21st century, have increasingly been deemed inadequate for preparing medical graduates for real-world clinical environments\u0026nbsp;(3). This shift has spurred the global adoption of Competency-Based Medical Education (CBME), an approach emphasizing the attainment of essential competencies for delivering high-quality patient care\u0026nbsp;(3,4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEntrustable Professional Activities (EPAs) are pivotal tools within CBME, serving as practical mechanisms for professional development through feedback and competency-based assessments\u0026nbsp;(5). EPAs, defined as professional responsibilities entrusted to learners once they become clinically competent, translates the broad competencies of CBME’s theoretical frameworks into daily practice\u0026nbsp;(5). Despite their theoretical promise and growing endorsement, the implementation of EPAs faces challenges in its practical application, partly due to stakeholders engagement and resistance\u0026nbsp;(6–8).\u0026nbsp;Although there is an increasing body of literature on EPAs—evidenced by over 1,000 articles and approximately 100 new publications annually—there is a notable gap in synthesizing this extensive work to provide coherent, actionable insights. \u0026nbsp;Most research has focused on the theoretical foundations, development, and curricular integration of EPAs\u0026nbsp;(7,9), neglecting the nuanced context-specific challenges and successes experienced by diverse stakeholders. Furthermore, the rich, in-depth perspectives offered by qualitative research in medical education have not been systematically integrated into a comprehensive synthesis, hindering the ability of educators, policymakers, and researchers to effectively navigate available literature and apply findings to their specific contexts.\u003c/p\u003e\n\u003cp\u003eAddressing this gap is critical. A systematic review of qualitative studies will clarify the multifaceted experiences and perceptions of various stakeholders, providing a holistic understanding of EPAs’ impact on educational outcomes, professional development, and patient care quality\u0026nbsp;(10,11). By synthesizing qualitative findings, we can uncover underlying themes and patterns that quantitative research might overlook, offering deeper insights into the implementation and perception of EPAs across different sociocultural settings\u0026nbsp;(10,12). This synthesis will yield evidence-based recommendations to guide policymaking, educational practice, and future research, ensuring that EPAs fulfill their potential in transforming medical education and ultimately improving patient care\u0026nbsp;(11,13). By systematically reviewing and integrating these qualitative findings, we can bridge the current knowledge gap, making the vast and complex literature on EPAs in CBME more accessible and actionable for all stakeholders involved.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eResearch Questions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn this synthesis, we will address the following research questions: How are Entrustable Professional Activities experienced and perceived by stakeholders in various healthcare settings, and what specific challenges and successes do they encounter during their implementation? \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe will use a qualitative synthesis, a systematic review process that collects, organizes, and analyzes qualitative and mixed-method research data, and then provides comprehensive understanding of complex issues or phenomena\u0026nbsp;(12). We will draw on Thomas and Harden’s principles of thematic synthesis, which entails four steps: systematic search of the literature, assessing quality and relevance of evidence, extracting data, and synthesizing data to integrate descriptive and analytical themes\u0026nbsp;(14).\u003c/p\u003e\n\u003cp\u003eThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines will inform the process of completing and reporting this planned review\u0026nbsp;(15). This protocol is reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) statement \u0026nbsp;(16).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEligibility Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eStudy Designs: We will include qualitative studies and qualitative components of mixed-method studies.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eParticipants: Studies involving medical educators (faculty, attendings, clinical teachers), medical learners (medical students, residents), administrators (program directors, competence committee members), and other stakeholders in EPAs across various healthcare settings will be included.\u003c/li\u003e\n \u003cli\u003eOutcomes: Studies that explore the experiences, perceptions, challenges, and successes related to the implementation and use of EPAs.\u003c/li\u003e\n \u003cli\u003eSettings: Any healthcare or educational setting where EPAs are implemented.\u003c/li\u003e\n \u003cli\u003eLanguage: We will include articles reported in English or French.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eInformation Sources and Search Strategy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe following databases were searched by a health sciences librarian (LS): Medline and Medline in Process (Ovid), Embase Classic + Embase (Ovid), APA PsycINFO (Ovid), CINAHL (EBSCOHost), and Education Source (EBSCOHost). A search strategy was developed in Medline and then translated into the other databases as appropriate (see Appendix 1). All databases were searched from dates of inception to August 12, 2024. There were no publication restrictions for the search. All references were entered into an Endnote file for processing (n = 9496), and then were uploaded into Covidence for duplicate removal, and then screening. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDatabase searches (numbers for PRISMA flowchart): \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMedline in Process and Medline (via Ovid): n = 2206\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEmbase (via Ovid): n = 2988\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAPA PsycINFO (via Ovid): n = 254\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCINAHL (via EBSCOHost): n = 2010\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEducation Source (via EBSCOHost): n =2038\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTotal: n = 9496\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuplicates: n = 2797\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTotal with duplicates removed: n = 6699\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSelection Process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSearch results will be uploaded to Covidence for screening and data extraction. Two reviewers will screen titles and abstracts independently. Full texts of potentially eligible studies will be retrieved and assessed for inclusion. Disagreements will be resolved through discussion or with a third reviewer if necessary.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Extraction\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing a standardized data extraction form (Appendix 2), two reviewers will extract data on study characteristics, participants, settings, methodologies, interventions, and key findings. A third reviewer will be consulted where discrepancies occur. For the thematic synthesis, all text labelled as “results” or “findings” will be extracted, including participants’ quotes, and entered in NVivo software for analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Synthesis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe will follow Thomas and Harden’s three stages of thematic synthesis, an inductive process involving the systematic coding of data and generating of descriptive and analytical themes\u0026nbsp;(14).\u0026nbsp;The initial stage will begin with line-by-line coding performed independently by two reviewers. Codes will be created inductively to capture the meaning and content of each sentence. All text with a given code will be examined to check for consistency of text interpretation and whether additional levels of coding are needed. In the next stage, descriptive themes will be developed. The reviewers will look for similarities and differences between the codes to group and structure them appropriately, ensuring the meaning of initial coding groups are captured as codes are added and new descriptive themes are developed. The last qualitative synthesis stage involves the generation of analytical themes. Conducted independently then as a group, the reviewers will infer answers from the previously created descriptive themes that address the research questions. Through repetition of this cyclical process, new abstract themes will be generated that sufficiently describe and explain all initial descriptive themes. Evidence-based recommendations can thus be derived from the generated analytical themes. NVivo software will be used to facilitate the entire data coding and synthesis process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality appraisal\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research will be used to assess the quality of the include articles\u0026nbsp;(17). Two reviewers will independently evaluate the quality of the included studies, with discrepancies resolved through discussion or consultation with a third reviewer. Each paper will be categorised as “low” (scores of 0–3), “moderate” (scores of 4–7), or “high” (scores of 8–10) quality. Lower-quality studies will be included in the synthesis process as they may still provide important insights into the phenomena of interest related to the interpretation and reporting of key findings\u0026nbsp;(12).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConfidence in Cumulative Evidence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe will use the Grading of Recommendations, Assessment, Development and Evaluation – Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach to assess the confidence in the findings from the qualitative evidence synthesis\u0026nbsp;(11,18).\u0026nbsp;This involves evaluating methodological limitations, relevance, coherence, and adequacy of the data. Assessments for each finding will be made through discussion\u0026nbsp;among all authors through team meetings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study will not require ethical approval as it involves secondary analysis of published data.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of this systematic review will provide a comprehensive synthesis of qualitative research on the implementation of EPAs within CBME. Thematic synthesis is particularly suited for this context as it allows for a detailed, nuanced understanding of stakeholders' perspective and experiences with EPAs. This method focuses on generating rich, in-depth and actionable insights, offering evidence-based recommendations that are crucial for addressing stakeholder concerns and fostering collaboration among educators, administrators, and policymakers\u0026nbsp;(14). Ultimately, these insights can lead to more effective and sustainable implementation of EPAs, enhancing the quality of medical education and patient care in the CBME era\u0026nbsp;(19).\u003c/p\u003e\n\u003cp\u003eSeveral practical and operational challenges need to be addressed to ensure the success of this study. Managing the extensive volume of literature requires a comprehensive search strategy across multiple databases. Using Covidence for screening and data extraction helps streamline this process, although there is a risk of missing relevant studies. Additionally, limiting the search to English and French may introduce language and context-related bias. However, we cannot overcome this limitation given the cost of translation and lack of funding for this study. Ensuring consistency among reviewers during screening, extraction, and synthesis is crucial; regular calibration exercises and consensus-building sessions will help mitigate discrepancies\u0026nbsp;(15). Synthesizing qualitative research presents its own set of challenges, such as the variability in study methodologies, quality and reporting. The subjective nature of quality appraisal and thematic synthesis requires careful and iterative processes, including discussion among the research team members\u0026nbsp;(12). Despite these challenges, conducting a thematic synthesis remains essential. It provides a robust framework for integrating qualitative findings from diverse contexts, uncovering deeper insights that might be overlooked with alternate methods\u0026nbsp;(14).\u003c/p\u003e\n\u003cp\u003eStudying the perceptions and experiences of the implementation of EPAs is essential for optimizing educational practices, aligning training with healthcare needs, and informing policy and decision-making\u0026nbsp;(7,9,19). We aim to identify effective practices and context-specific challenges for enhancing competency-based assessments and ensuring graduates are well-prepared for patient care\u0026nbsp;(9). By conducting a robust qualitative evidence synthesis, we can guide resource allocation, address stakeholder concerns, and foster collaboration. Additionally, we will discuss research gaps and promote continuous quality improvement, advancing the field of medical education and ultimately improving the quality of healthcare delivery.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eCBME:\u0026nbsp;\u003c/strong\u003eCompetency-Based Medical Education\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEPA:\u0026nbsp;\u003c/strong\u003eEntrustable Professional Activities\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGRADE-CERQual\u003c/strong\u003e: Grading of Recommendations, Assessment, Development and Evaluation – Confidence in the Evidence from Reviews of Qualitative research \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJBI\u003c/strong\u003e: Joanna Briggs Institute \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSPECTRE\u003c/strong\u003e: \u003cstrong\u003eS\u003c/strong\u003etakeholder \u003cstrong\u003eP\u003c/strong\u003eerceptions and \u003cstrong\u003eE\u003c/strong\u003experiences of \u003cstrong\u003eC\u003c/strong\u003eompetency-Based \u003cstrong\u003eTr\u003c/strong\u003eaining with \u003cstrong\u003eE\u003c/strong\u003entrustable Professional Activities\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePRISMA\u003c/strong\u003e: Preferred Reporting Items for Systematic Review and Meta-Analysis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePRISMA-P\u003c/strong\u003e: Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJP received the Medical Student Education Research Grant (MSERG) Award by the Ontario Medical Students Association.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the conceptualization of the study. JP and RK drafted the protocol. All authors provided critical revisions to the protocol. All authors have approved the submitted version and have agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eFrenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: Ttransforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923\u0026ndash;58.\u003c/li\u003e\n \u003cli\u003eLudmerer KM, Johns MME. Reforming graduate medical education. Jama. 2005;294(9):1083\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eCarraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C. Shifting paradigms: From flexner to competencies. Acad Med. 2002;77(5):361\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eFrank JR, Snell LS, Cate O Ten, Holmboe ES, Carraccio C, Swing SR, et al. Competency-based medical education: Theory to practice. Med Teach. 2010;32(8):638\u0026ndash;45.\u003c/li\u003e\n \u003cli\u003eTen Cate O. Nuts and Bolts of Entrustable Professional Activities. J Grad Med Educ. 2013;5(1):157\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eCaverzagie KJ, Nousiainen MT, Ferguson PC, ten Cate O, Ross S, Harris KA, et al. Overarching challenges to the implementation of competency-based medical education. Med Teach. 2017;39(6):588\u0026ndash;93.\u003c/li\u003e\n \u003cli\u003eBrydges R, Boyd VA, Tavares W, Ginsburg S, Kuper A, Anderson M, et al. Assumptions About Competency-Based Medical Education and the State of the Underlying Evidence: A Critical Narrative Review. Acad Med. 2021;96(2):296\u0026ndash;306.\u003c/li\u003e\n \u003cli\u003eHawkins RE, Welcher CM, Holmboe ES, Kirk LM, Norcini JJ, Simons KB, et al. Implementation of competency-based medical education: Are we addressing the concerns and challenges? Med Educ. 2015;49(11):1086\u0026ndash;102.\u003c/li\u003e\n \u003cli\u003eCate O Ten, Carraccio C. Envisioning a True Continuum of Competency-Based Medical Education, Training, and Practice. Acad Med. 2019;94(9):1283\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eCarroll C. Qualitative evidence synthesis to improve implementation of clinical guidelines. BMJ [Internet]. 2017;356:4\u0026ndash;7. Available from: http://dx.doi.org/doi:10.1136/bmj.j80\u003c/li\u003e\n \u003cli\u003eLewin S, Glenton C, Munthe-Kaas H, Carlsen B, Colvin CJ, G\u0026uuml;lmezoglu M, et al. Using Qualitative Evidence in Decision Making for Health and Social Interventions: An Approach to Assess Confidence in Findings from Qualitative Evidence Syntheses (GRADE-CERQual). PLoS Med. 2015;12(10):1\u0026ndash;18.\u003c/li\u003e\n \u003cli\u003eSoilemezi D, Linceviciute S. Synthesizing Qualitative Research: Reflections and Lessons Learnt by Two New Reviewers. Int J Qual Methods. 2018;17(1):1\u0026ndash;14.\u003c/li\u003e\n \u003cli\u003eMays N, Pope C, Popay J. Systematically reviewing qualitative and quantitative evidence to inform management and policy-making in the health field. J Heal Serv Res Policy. 2005;10(SUPPL. 1):6\u0026ndash;20.\u003c/li\u003e\n \u003cli\u003eThomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8:1\u0026ndash;10.\u003c/li\u003e\n \u003cli\u003ePage MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ. 2021;372.\u003c/li\u003e\n \u003cli\u003eMoher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eLockwood C, Munn Z, Porritt K. Qualitative research synthesis: Methodological guidance for systematic reviewers utilizing meta-aggregation. Int J Evid Based Healthc. 2015;13(3):179\u0026ndash;87.\u003c/li\u003e\n \u003cli\u003eLewin S, Booth A, Glenton C, Munthe-Kaas H, Rashidian A, Wainwright M, et al. Applying GRADE-CERQual to qualitative evidence synthesis findings: Introduction to the series. Implement Sci. 2018;13(Suppl 1):1\u0026ndash;10.\u003c/li\u003e\n \u003cli\u003eTouchie C, Ten Cate O. The promise, perils, problems and progress of competency-based medical education. Med Educ. 2016;50(1):93\u0026ndash;100.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Competency Based Education, Entrustable Professional Activities, Systematic Review, Thematic Synthesis, Qualitative Research ","lastPublishedDoi":"10.21203/rs.3.rs-5218635/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5218635/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eCompetency-Based Medical Education (CBME) aims to align educational outcomes with the demands of modern healthcare. Entrustable Professional Activities (EPAs) serve as key tools for feedback and professional development within CBME. With the growing body of literature on EPAs, there is a need to synthesize existing research on stakeholders’ experiences and perceptions to enhance understanding of the implementation and impact of EPAs. In this synthesis, we will address the following research questions: How are Entrustable Professional Activities experienced and perceived by stakeholders in various healthcare settings, and what specific challenges and successes do they encounter during their implementation?\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eUsing Thomas and Harden’s thematic synthesis method, we will systematically review and integrate findings from qualitative and mixed-methods research on EPAs. The process includes a purposive literature search, assessment of evidence quality, data extraction, and synthesis to combine descriptive and analytical themes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThis study aims to provide insights into the use of EPAs for competency-based education, reflecting diverse contexts and viewpoints, and identifying literature gaps. The outcomes will guide curriculum and policy development, improve educational practices, and set future research directions, ultimately aligning CBME with clinical realities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eNot required\u003c/p\u003e","manuscriptTitle":"Stakeholder Perceptions and Experiences of Competency-Based Training with Entrustable Professional Activities (SPECTRE): Protocol of a Systematic Review and Thematic Synthesis of Qualitative Research","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-27 10:10:37","doi":"10.21203/rs.3.rs-5218635/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-04T14:13:45+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"245755775413670008212072797359637961382","date":"2024-11-03T15:18:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"84768098961095952239410389204256652225","date":"2024-11-03T12:43:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"334928739139753934980124060417040493584","date":"2024-11-03T10:50:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-03T01:37:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"64654111269456916260159791931960258980","date":"2024-11-02T17:22:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"210186563803607064059950263760178741903","date":"2024-11-01T06:23:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"98419120627535247174306764499743900085","date":"2024-11-01T02:26:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-15T22:17:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"316116618087064437296645687766905969320","date":"2024-10-15T21:54:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"334651946822016459021001861394529245666","date":"2024-10-13T22:27:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-11T13:40:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-08T11:24:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-08T11:21:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2024-10-07T13:39:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"11a1a1d5-f586-41fc-853e-c0ab95508102","owner":[],"postedDate":"November 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-30T16:04:23+00:00","versionOfRecord":{"articleIdentity":"rs-5218635","link":"https://doi.org/10.1186/s12909-024-06508-6","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2024-12-27 15:57:15","publishedOnDateReadable":"December 27th, 2024"},"versionCreatedAt":"2024-11-27 10:10:37","video":"","vorDoi":"10.1186/s12909-024-06508-6","vorDoiUrl":"https://doi.org/10.1186/s12909-024-06508-6","workflowStages":[]},"version":"v1","identity":"rs-5218635","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5218635","identity":"rs-5218635","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}