When using entrustable professional activities thwarts basic psychological needs: A case study of residents' experience.

BACKGROUND

Entrustable professional activities (EPAs) were introduced to link competencies with clinical work and support residents' professional and competence development. Yet their implementation has raised concerns about burdensome documentation and limited educational value. Drawing on Self-Determination Theory (SDT), we examined how residents experienced EPAs in relation to their needs for autonomy, competence, and relatedness-needs essential for optimal motivation and professional development.

METHODS

We conducted an instrumental case study in a Canadian internal medicine residency program. Fourteen residents participated in semi-structured interviews. We used Braun and Clarke's six-phase thematic analysis, with SDT guiding our interpretation of how participants' narratives reflected their experiences of autonomy, competence, and relatedness.

RESULTS

Residents experienced EPAs as compliance exercises disconnected from meaningful professional development. Four interrelated themes captured how these experiences related to residents' basic psychological needs: (1) A Documentation Imperative demonstrated how external pressures to accumulate observation forms constrained residents' autonomy and discouraged formative use of feedback, undermining competence; (2) Fleeting Convergences captured how EPAs and competence development operated on largely separate trajectories, with only occasional moments of alignment; (3) Electronic Barriers highlighted how documentation platforms replaced feedback dialogue with impersonal transactions, weakening relatedness while reducing opportunities for autonomous engagement and understanding performance gaps, if any; and (4) A Binding Burden showed that shared bureaucratic struggles fostered peer solidarity among participants, though this relatedness centered on coping rather than collaborative learning.

CONCLUSIONS

Current use of EPAs often fails to support the conditions necessary for meaningful engagement with EPAs and, in some cases, actively thwarts them. Documentation burdens constrained autonomy, competence was weakly supported, and relatedness was strained by transactional processes-a drift from EPAs as professional activities to fragmented assessment tasks. Addressing these challenges is essential if EPAs are to function as intended: units of professional practice to be entrusted to residents.