Bridging competence and practice: The role of Entrustable Professional Activities (EPAs) in optometric education

Abstract

Background

Competency‐based education (CBE) has gained prominence in health profession education, emphasising the assessment of learners based on their ability to perform essential tasks in clinical practice. Entrustable Professional Activities (EPAs) operationalise competency assessment by translating broad competencies into specific tasks that learners must be trusted to perform independently before transitioning into professional practice. While EPAs are widely integrated into medical education, their application in optometry remains limited.

Aim

This narrative explores the role of EPAs in optometric education, examining their potential to enhance competency assessment and support the transition from training to independent practice.

Method

A narrative review was conducted, focusing on EPAs in health profession education, with a particular emphasis on their application in optometry. Peer‐reviewed journal articles, institutional reports and policy documents were analysed to identify trends, challenges and best practices.

Results

The review highlights a growing recognition of EPAs in optometric education, particularly in operationalising core competencies and supporting structured, workplace‐based assessments. However, challenges such as limited optometry‐specific EPA examples, a need for faculty development and suitable assessment tools hinder broader adoption. Lessons from other health professions suggest that structured EPA frameworks improve learner readiness and enhance patient safety.

Conclusion

EPAs offer a structured approach to competency assessment in optometric education, fostering clinical preparedness. Their integration requires curriculum alignment, faculty development and robust assessment strategies.

Contribution

This review provides insights into the potential adoption of EPAs in optometric education, contributing to advancing competency‐based training and assessment strategies.

Key points.

• Entrustable Professional Activities offer a practical approach to assessing real‐world clinical readiness by linking professional responsibilities with observable, trusted performance in clinical education.

• This review highlights the lack of systematic application of Entrustable Professional Activities in optometric education and identifies opportunities for their integration into clinical training.

• A clearer understanding of Entrustable Professional Activities can help educators design more meaningful assessments that better prepare optometry students for independent, patient‐centred care.

INTRODUCTION

The field of optometry is evolving rapidly, driven by advances in technology, changing patient demographics and expanding scope of practice. To meet these demands, optometric education must equip students not only with theoretical knowledge but also practical skills and professional behaviours. Competency‐based education (CBE) has emerged as a paradigm shift, emphasising measurable outcomes that align with real‐world responsibilities. ¹

Within CBE, Entrustable Professional Activities (EPAs) have become central to bridging the gap between competence and clinical practice. In the context of optometry, EPAs have been proposed as a potential approach to assess clinical competence; however, no published evidence of their implementation currently exists. ² , ³ EPAs are units of professional practice that can be entrusted to students once they demonstrate sufficient competence to perform them with decreasing levels of supervision. ⁴ Rather than serving as assessment tools in themselves, EPAs provide a framework for assessing learners' readiness for unsupervised practice by linking discrete competencies to meaningful clinical tasks. ⁵ This task‐based approach supports more holistic, authentic assessment, addressing limitations of traditional skill‐based or knowledge‐based evaluations. ⁵ , ⁶

EPAs are also closely tied to professional identity formation by scaffolding learners' development towards autonomy and responsibility. Entrustment decisions reflect a supervisor's confidence in the learner's ability to integrate knowledge, skill and professional behaviour—a crucial step in the transition from student to health professional. ⁵ In this way, EPAs not only assess performance but also support the formation of clinical judgement and self‐regulation.

Although EPAs have been increasingly implemented in medicine and other health professions, there is limited published evidence regarding formal application in optometry. This does not necessarily imply an absence of use, but rather a lack of structured frameworks, published evaluations or discipline‐specific guidance. ² Given optometry's evolving practice landscape, there is a clear need to explore how EPAs can be adapted to support competency‐based training in this field.

This narrative review aims to examine the conceptual foundation of EPAs, explore their implementation across health professions and analyse their potential contribution to bridging competence and practice in optometric education.

METHODS

This narrative review employed a structured approach to identify, select and synthesise literature relevant to the application of Entrustable Professional Activities (EPAs) in optometric education. A broad search of peer‐reviewed articles, grey literature and professional guidelines was conducted using electronic databases including PubMed, Scopus, ERIC and Google Scholar. Search terms included combinations of ‘Entrustable Professional Activities’, ‘EPAs’, ‘optometric education’, ‘competency‐based education’, ‘assessment’ and ‘clinical training’.

CONCEPTUAL FRAMEWORK OF EPAs

Definition and principles

EPAs were first conceptualised in medical education as a way to operationalise competency assessment by linking theoretical competencies to real‐world professional tasks that can be observed and evaluated in clinical settings. ⁶ According to the ‘An International Association for Medical Education (AMEE)’ Guide 140, an EPA is defined as a key task of a discipline that can be entrusted to a sufficiently competent trainee. These activities are observable, measurable and require the integration of multiple competencies to be performed safely and effectively without direct supervision. ⁶ , ⁷

EPAs connect the competencies learners require (e.g., clinical reasoning, communication and procedural skills) with the professional tasks they will be expected to be entrusted to perform independently. ⁶ For instance, an EPA in optometry might include ‘Managing a patient with contact lenses’, which requires integrating knowledge, skills and attitudes across domains. ² These ‘units’ represent essential professional tasks that are appropriate for evaluation and decision‐making in educational progression and licensure processes (i.e., credentialing), where formal confirmation of a learner's readiness for unsupervised practice is required. ⁸

Entrustment decisions are inherently linked to levels of supervision. The degree of trust placed in a learner is reflected in the level of supervision deemed necessary for safe and effective performance. This is often evaluated using an entrustment‐supervision scale (Table 1), which prompts assessors to determine how independently a learner can be expected to carry out a specific EPA. ⁷

TABLE 1.

The five levels of entrustment based on the degree of autonomy granted to students.

The student is not permitted to perform the EPA and may only observe. The student is allowed to perform the EPA but only under direct and proactive supervision. The student may carry out the EPA under indirect or on‐demand supervision, where assistance is available if needed. The student is entrusted to perform the EPA independently, with or without periodic monitoring. The student is competent not only to perform the EPA independently but also to supervise and guide others in its practice.

The literature identifies particular characteristics, both structural and conceptual, that a task must exhibit to qualify as an EPA. ⁹ As the EPA must be an observable, quantifiable and professional responsibility that requires training to carry out, it is suitable for delegation and can be executed autonomously. ⁶ , ⁹ EPAs are grounded in several essential principles guiding their competency‐based education implementation. One fundamental principle is the integration of competencies. Unlike traditional assessments that evaluate isolated skills or knowledge areas, EPAs take a holistic approach, requiring students to demonstrate the application of multiple competencies in a real‐world professional setting. ¹⁰ In optometry, clinical tasks require the integration of multiple competencies, including clinical knowledge, patient communication, technical skills and ethical decision‐making. For example, conducting comprehensive eye examinations is not just about performing individual tests such as visual acuity, refraction or slit‐lamp biomicroscopy. ¹¹ Instead, the optometrist must synthesise findings, interpret diagnostic results, communicate effectively and formulate an appropriate management plan. ¹¹

Another key principle of EPAs is that they are context‐specific—each EPA should reflect the profession's real‐world responsibilities and be adaptable to different practice environments. In optometry, while the core competencies remain consistent, the scope, autonomy and available resources may vary depending on the setting. Therefore, EPAs must be written in a way that accommodates these contextual differences while ensuring that the essential skills and behaviours required for safe and effective practice are maintained. This approach enhances the relevance and transferability of EPAs and ensures that assessments accurately reflect a graduate's readiness for independent clinical practice across diverse professional contexts.

A crucial aspect of EPAs is the concept of entrustment decisions. Rather than simply measuring proficiency through traditional assessments, EPAs emphasise the ability to determine whether a student can be trusted to perform a given activity independently and safely. In optometric education, entrustment decisions revolve around determining whether a student is ready to perform a given procedure independently or make clinical decisions without supervision. ² , ³ For example, a student in clinical training may initially require close supervision when performing tonometry to measure intraocular pressure, as errors in technique could lead to inaccurate readings or patient discomfort. Over time, as they demonstrate consistency, accuracy and the ability to manage patient responses effectively, their clinical supervisor may determine that they are ready to perform the procedure independently. Entrustment decisions also extend to more complex tasks, such as whether a student can safely diagnose and initiate treatment for conditions such as glaucoma or keratoconus without requiring immediate oversight from a senior optometrist. This ‘trust’ acts as a gatekeeper between the student's level of participation and responsibility in the workplace. ¹² The levels of entrustment are divided into five categories on the basis of the degree of autonomy granted to students (Table 1).

The five‐level supervision scale proposed by Chen et al. ¹³ offers a structured framework for translating trust‐based decisions into observable, progressive stages of student autonomy. This model has been widely adopted across health profession education to guide educators in determining appropriate levels of supervision based on a student's readiness and demonstrated competence.

Building on this foundational model, ten Cate et al. ¹⁴ provided additional granularity to supervision levels within undergraduate settings, notably in the Utrecht medical curriculum. Their adaptations refined levels 2 through 4 to capture better the variations in clinical oversight required during student development:

Level 2—Direct, proactive supervision: The student is permitted to perform the EPA under the direct observation of a supervisor who is physically present. This can involve:

1. Performing the activity jointly with the supervisor (co‐activity), or

2. Performing the EPA independently while the supervisor remains in the room, ready to intervene.

Level 3—Indirect, reactive supervision: The student may carry out the EPA without continuous observation, although the supervisor remains readily available. Variants of this level include:

1. The supervisor re‐performing the EPA post hoc.

2. Verification of critical findings or decisions by the supervisor.

3. Review of the student's work within a defined time frame (e.g., within 24 h or upon request).

Level 4—Supervised autonomy: The student is entrusted to perform the EPA without direct oversight. While this level typically exceeds expectations for inexperienced learners in some contexts, it is defined by:

1. The supervisor is available for consultation if required, or

2. The student functions independently, with the supervisor providing retrospective feedback and ongoing monitoring as appropriate.

Although Level 5—the ability to supervise and guide others—is part of the broader entrustment scale, it is generally considered optional for professional training. This level represents a threshold beyond independent practice, where the individual is deemed competent not only to perform the EPA autonomously, but also to mentor or oversee others. In the context of entry‐level optometric education, attainment of Level 5 may not be expected uniformly. However, exposure to leadership and peer‐teaching opportunities can serve as a foundation for future professional roles that include supervision, clinical instruction or preceptorship.

This tiered entrustment model provides educators with a defensible mechanism to assess and document progression towards independent practice while simultaneously safeguarding patient care. ¹⁵ Within optometric education, its application can enhance clarity around student readiness for practice and ensure alignment with professional responsibilities at the point of graduation.

Finally, a fundamental advantage of using EPAs is that they support the structured development of progressive autonomy. In optometric education, students are expected to transition gradually from observation to supervised practice, and eventually to independent clinical responsibility. ¹⁶ This progression is scaffolded through increasingly complex and integrated clinical tasks. For example, refraction can be framed as an EPA in its own right, as it represents a core unit of professional activity that optometrists are expected to perform independently upon graduation. A first‐year student may begin by observing senior clinicians perform refraction techniques as part of a comprehensive eye examination. In subsequent years, they practise those techniques under supervision, receiving feedback on both technical execution and clinical decision‐making. By their final year, students should be able to competently perform and interpret refraction independently, incorporating it into the broader context of patient care. This illustrates how EPAs encompass both technical skills and clinical reasoning and how competency develops through structured experiential learning.

Theoretical perspectives

EPAs represent a conceptual shift in health profession education, focusing on real‐world professional tasks and the level of trust placed in a learner's ability to perform them independently. Traditionally, clinical competence in health profession education has been evaluated using fragmented assessments—such as multiple‐choice examinations, Objective Structured Clinical Examinations or skill checklists—that isolate specific knowledge areas or technical skills. These approaches are rooted in a positivist epistemology, which assumes that competence is an objective trait that can be measured by breaking it down into discrete, observable components. However, this perspective often fails to capture the complexity of real‐world clinical performance. In contrast, the EPA framework aligns with a post‐positivist or constructivist orientation, where competence is understood as holistic, context‐dependent and shaped by interpersonal dynamics, clinical judgement and evolving trust relationships. ¹⁷ EPAs thus emphasise the integration of knowledge, skills and professional behaviours in authentic clinical contexts, recognising that readiness for independent practice emerges through meaningful participation and guided entrustment in real‐world tasks. ¹⁸ This theoretical lens positions EPAs as more than mechanisms for assessing how one evaluates students—they challenge the understanding of an assessment to be an integrated, interpretive judgement about readiness for professional responsibility. This shift also has significant implications for faculty development, as educators must grapple with subjectivity, context and the relational dimension of ‘trust’ when making entrustment decisions. ¹⁹

The EPA framework aligns with multiple educational theories and models. It builds directly upon Miller's Pyramid of Clinical Competence, which describes four levels of performance assessment: ‘knows’, ‘knows how’, ‘shows how’ and ‘does’. ²⁰ EPAs are situated at the ‘does’ level—where learners demonstrate competence in real‐world settings. However, ten Cate has proposed extending Miller's framework by adding a fifth level: ‘trusted to act independently’. ²¹ This addition captures the core of entrustment decisions and reflects the developmental aim of competency‐based education: To determine when learners are ready to take on professional responsibilities without direct supervision. ²¹

A central tenet of EPA‐based education is the promotion of authentic assessment. Authentic assessment involves evaluating learners in tasks that closely resemble real‐world practice, thereby fostering not only clinical competence but also professional identity and employability. ²² For instance, assessing a student's ability to manage a patient with ocular hypertension requires integration of clinical reasoning, technical skill, patient communication and ethical decision‐making—hallmarks of authentic professional performance. Authentic assessments—those that closely mirror real‐life clinical tasks and responsibilities—enhance the relevance of learning by ensuring that students are assessed on what they will actually do in practice. They also promote fairness, as assessments are grounded in meaningful contexts rather than abstract scenarios, and increase utility by providing actionable insights into a learner's readiness for independent professional practice.

The concept of entrustment itself is deeply rooted in sociocultural and workplace‐based learning theories, particularly cognitive apprenticeship. These theories emphasise learning through guided participation, mentorship and situated practice in authentic settings. ¹⁸ Within these frameworks, learners begin as novices under close supervision and gradually gain autonomy through scaffolded experiences. Entrustment decisions, therefore, are relational and context‐sensitive judgments based not only on performance but also on traits like reliability, integrity and capacity for self‐regulation. ²³ The entrustment process reflects a social contract: The supervisor entrusts the learner with patient care responsibilities, balancing educational needs with patient safety.

Moreover, EPAs align with self‐determination theory (SDT), which posits that human motivation is fostered by the fulfilment of three psychological needs: autonomy, competence and relatedness. ²⁴ EPAs support autonomy by promoting progressively independent practice; they build competence by clearly defining expectations and required standards for professional tasks, and they enhance relatedness by fostering meaningful engagement between learners and supervisors. Through this lens, EPAs serve as motivational and developmental tools, helping students internalise professional values and progress towards independent clinical practice.

In summary, EPAs are supported by a rich theoretical foundation that includes assessment theory, workplace‐based learning models, sociocultural perspectives and motivational psychology. Their use in optometric education—though still emerging—offers a way to align assessment with the realities of professional practice, moving beyond fragmented evaluations towards holistic, longitudinal judgements of clinical readiness and trustworthiness.

EPAs IN OPTOMETRIC EDUCATION

Defining core EPAs for optometry

To develop EPAs for optometry, it is essential to identify core activities that optometrists must be trusted to perform independently upon entering professional practice. While specific tasks may vary depending on national or regional scopes of practice, a common foundation of responsibilities can be identified across jurisdictions. These EPAs represent critical units of professional practice that ensure readiness for unsupervised clinical work and can serve as the building blocks for curriculum design and workplace‐based assessment in optometric education.

While specific EPAs for optometry have yet to be developed or validated systematically, preliminary efforts can be informed by existing scope of practice frameworks. For instance, the World Council of Optometry (WCO) defines core areas of optometric practice that may provide a foundational reference point. ²⁵ However, in line with AMEE Guide No. 140, any attempt to formulate EPAs must involve a rigorous process, including stakeholder consultation, iterative refinement and testing for clarity, entrustability and alignment with professional expectations. As such, the development of profession‐specific EPAs for optometry remains an area for future research and curriculum innovation. ⁶ , ²⁵

Benefits of EPAs in optometric education

The use of EPAs in optometric education offers several potential benefits in enhancing clinical competence, structuring assessment and aligning training with professional expectations. The advantages of integrating EPAs include:

1. Authentic assessment: EPAs provide a means to assess learners in the context of real clinical practice, ensuring alignment between what students are taught and what they are expected to do in professional settings. This promotes the application of knowledge and skills in realistic scenarios, moving beyond traditional theoretical evaluations. ²²

2. Integrated competency evaluation: Each EPA encapsulates multiple domains of competence—such as knowledge, clinical skills, communication and professional behaviours—providing a holistic framework to assess the integration of competencies rather than fragmented components. ⁶

3. Structured feedback and supervision: EPAs support the provision of specific, actionable feedback based on discrete professional tasks. Educators can use entrustment‐supervision scales to determine the level of oversight needed for each student, enhancing the quality of formative and summative feedback. ²⁶

4. Progressive autonomy and readiness for practice: EPAs explicitly outline the expected level of supervision for each activity, facilitating the learner's gradual shift from dependency to autonomy. This scaffolding supports clinical confidence, self‐regulation and independence. ²⁶

5. Alignment with professional standards: When aligned with national and international optometric competency frameworks, EPAs ensure that training programmes focus on activities that reflect the realities and expectations of professional practice. This assumes, of course, that professional standards are themselves current, comprehensive and well articulated. ⁶

6. Improved patient safety and care quality: By clearly defining what tasks can be entrusted to whom and under what conditions, EPAs contribute to safeguarding patients by ensuring that only sufficiently competent individuals perform critical clinical procedures. ²⁷ , ²⁸

7. Support for interprofessional collaboration: Many EPAs involve teamwork and communication with other healthcare providers. By embedding collaborative tasks into assessment frameworks, EPAs can promote interprofessional learning and practice. ²⁹

8. Curriculum development and transparency: EPAs provide a structured framework that can inform curriculum design, helping institutions to clearly articulate learning outcomes, teaching methods and assessment strategies that are directly tied to clinical work. This transparency benefits both educators and students. ³⁰ , ³¹

While some might argue that current optometry graduates are already ‘fit for practice’, EPAs represent a shift towards explicitly articulating and evidencing that fitness through workplace‐based entrustment decisions. Rather than questioning students' readiness abstractly, EPAs make the expectations for unsupervised practice explicit, measurable and evidence‐informed. They could serve to strengthen confidence among faculty, employers, regulators and patients that newly qualified optometrists can competently and safely deliver care.

Implementation strategies

The implementation of EPAs in optometric education requires a well‐structured and strategic approach to ensure their effectiveness in enhancing clinical competence. A crucial first step is to clearly describe and define the specific EPAs that reflect the real‐world responsibilities and scope of the optometric profession. This involves engaging with relevant stakeholders, including faculty, practising optometrists, regulatory bodies and students, to ensure that EPAs reflect the realities of professional practice. ⁶ According to ten Cate and Taylor, stakeholder collaboration is vital for creating EPAs that are relevant, feasible and aligned with competency frameworks. ⁶ Kitto et al. ³² stated that initial EPAs are formulated through consultations with relevant stakeholders and literature reviews, and then refined through several rounds of stakeholder engagements and discussions. Techniques such as nominal group techniques and Delphi methods may be used to validate EPAs rigorously. Each EPA should be clearly defined, with specific competencies, expected outcomes and entrustment criteria, ensuring alignment with professional standards. ³³

Integrating EPAs into the curriculum requires careful mapping across both vertical and horizontal axes to provide a cohesive learning experience. ³¹ Students should encounter EPAs incrementally, progressing from foundational knowledge and skills to more complex, integrated tasks. Interprofessional education is essential, as it allows students to collaborate with other healthcare professionals, reflecting the team‐based nature of modern patient care. Longitudinal learning opportunities further ensure that students build confidence and competence over time. ⁶ Faculty training is equally critical; educators must be equipped to design, teach and assess EPAs effectively. This involves workshops, peer mentoring and access to resources that clarify EPA frameworks and entrustment processes. ²⁶ Similarly, students should be introduced to the concept of EPAs early in their education to understand their role in professional development and readiness for clinical practice. ³⁴

Robust assessment strategies are integral to EPA implementation, as they ensure that students are evaluated in a manner that mirrors real‐world clinical practice. Workplace‐based assessments, such as mini‐clinical evaluation exercises (mini‐CEX), direct observation of procedural skills (DOPS) and multisource feedback (MSF), are particularly effective. ³⁵ These methods enable direct evaluation of students' performance in authentic clinical settings. Entrustment decision‐making, supported by entrustment scales, provides a structured means to assess the level of supervision required for each EPA, ranging from direct supervision to independent practice. ⁶ , ³⁵ Students can compile portfolios as evidence of their competence in performing EPAs, incorporating reflections, case studies and supervisor evaluations. ²⁶ Additionally, digital platforms can be leveraged to document, track and analyse progress in achieving EPA milestones. ²⁶

Providing structured and actionable feedback is another essential aspect of implementing EPAs. ²⁶ Regular feedback sessions aligned with EPA criteria enable students to understand their strengths and areas for improvement. Encouraging reflective practice further helps students critically analyse their performance and identify steps for development. ²¹ To ensure successful implementation, programmes must establish mechanisms to monitor and evaluate the integration of EPAs. This includes regular quality assurance processes to review and refine EPA descriptors, teaching methods and assessment tools based on feedback from faculty and students. Impact analyses are also necessary to evaluate the effects of EPAs on student competence, patient care and alignment with professional standards. ²¹

Implementing EPAs in optometric education would be an iterative process involving a framework comprising interconnected phases or components, each addressing a critical aspect of EPA development, integration and evaluation. Figure 1 represents the implementation of EPAs in optometric education visually.

FIGURE 1.

A visual representation of the implementation of Entrustable Professional Activities (EPAs) in optometric education—designed by the author based on ten Cate and Taylor. ⁶

PROGRAMME EVALUATION

The development and implementation of EPAs in health profession education must be accompanied by rigorous programme evaluation to ensure their validity, utility and alignment with established definitions and features. Effective evaluation determines whether EPAs enable valid and reliable entrustment decisions, support learner development and allow for appropriate remediation or revision where needed. ³⁶

Despite increasing adoption of EPAs across health disciplines, the literature reflects variability in how EPAs are developed, validated and evaluated. This highlights a need for standardised, evidence‐based tools to assess the quality of EPA design and implementation. Several such tools have emerged to address this gap.

One early tool, the Quality of Entrustable Professional Activities (QUEPA) instrument, was developed by Post et al. ³⁷ to assess internal medicine EPAs at the Mayo Clinic. The QUEPA tool is based on seven essential features of a high‐quality EPA: focus, observability, clarity of intention, realism, articulation of trustworthiness, applicability across settings and integration of multiple competencies. These features are rated on a 5‐point Likert scale. While the QUEPA demonstrated initial validity, several limitations were noted. These included a lack of descriptive rating anchors, the absence of cut‐off scores for acceptable quality and lower reliability for knowledge‐focused EPAs. Furthermore, the development and validation were conducted by the same group of experts, raising concerns about potential bias and generalisability.

To address these shortcomings, Taylor et al. ³⁶ developed the Queen's EPA Quality (EQual) Rubric, grounded in the original EPA criteria proposed by ten Cate et al. The EQual rubric offers improved psychometric properties, including the use of descriptive anchors for each criterion, clear thresholds for quality and options for rater training. It can be applied by both clinical and non‐clinical stakeholders, facilitating broader engagement in EPA evaluation. In addition to assessing whether EPAs meet definitional criteria, the EQual rubric can identify areas requiring revision and strengthen the overall structure of EPA frameworks. ³⁶

Another approach, introduced by van Bruggen et al., ³⁸ evaluated EPAs for academic teaching in higher education using expert consensus across four criteria: clarity (including accessibility for novice users), relevance to the educational context, comprehensiveness and usefulness in teaching qualification programmes. This framework was operationalised through an 8‐point scale and iterative expert input to reach consensus. In some applications, an additional criterion—contextual applicability—has been added to ensure local relevance.

Programme evaluation is distinct from routine quality assurance or curriculum monitoring. It provides a structured and evidence‐based means of determining whether EPAs fulfil their intended educational function and remain responsive to evolving professional demands. As optometric education seeks to implement EPAs, integrating formal evaluation mechanisms, such as the EQual rubric or similar context‐sensitive tools, will be critical to ensure ongoing improvement, stakeholder confidence and the credibility of entrustment decisions.

CHALLENGES AND OPPORTUNITIES FOR IMPLEMENTING EPAs IN OPTOMETRIC EDUCATION

The implementation of EPAs in optometric education presents numerous challenges and opportunities that require careful consideration to ensure successful curricular integration. One of the primary challenges is cultural resistance to change. ³² Transitioning from traditional, time‐based curricula to a competency‐based model centred on EPAs often encounters resistance from both faculty and students. ³⁹ Faculty accustomed to conventional assessment models may find it difficult to embrace the more dynamic and learner‐centred nature of EPAs. Similarly, students may struggle with the shift from discrete, time‐limited assessments—such as OSCEs—towards a more continuous and holistic evaluation of clinical competence. ² Encandela et al. ⁴⁰ suggested that addressing these cultural barriers requires cultivating a shared understanding of the value and benefits of EPAs across all stakeholders, including students, clinical educators and regulatory bodies.

Philosophical considerations also surface in the shift towards EPA‐based models. EPAs reflect a deeper reorientation in assessment philosophy—from viewing assessment as a summative measure of knowledge acquisition to a formative, workplace‐based judgement of trustworthiness in practice. Depending on one's epistemological stance (e.g., positivist vs. post‐positivist), the concept of entrustment may be embraced as a valid indicator of competence or critiqued for its subjectivity and contextual variability. Moreover, as competence‐based models gain traction, there is concern about the loss of traditional educational rituals or ‘rites of passage’—such as final year examinations or clinical sign‐offs—that historically marked learners' transition to professional identity. ⁴¹ This shift may require reimagining how professional identity formation is supported in the absence of these established benchmarks.

Logistical and operational challenges are also significant. The adoption of EPAs necessitates substantial institutional investment in time, technology and personnel. For instance, the infrastructure required to track EPA progress—such as digital platforms, workplace‐based assessments and portfolio systems—may not be readily available or affordable for many institutions. ³⁹ Scheduling consistent, high‐quality workplace‐based learning experiences across diverse clinical environments also presents logistical complexity. Furthermore, ensuring sufficient observation opportunities for faculty to make robust entrustment decisions is difficult when clinical settings are resource‐constrained or overburdened.

Faculty development is another critical factor. Educators must be supported to develop the knowledge and skills needed to assess students on the basis of entrustment, provide actionable feedback and contribute to students' professional growth. ³² , ⁴² Without comprehensive and ongoing faculty development initiatives, the reliability and validity of EPA‐based assessments risk being undermined by assessor subjectivity or lack of familiarity with entrustment frameworks. ⁴³

Balancing standardisation and contextual flexibility is also complex. While EPAs should align with overarching professional standards and core competencies, they must also be adaptable to specific institutional, cultural and clinical contexts. ³⁹ , ⁴⁰ This balance is essential to ensure relevance and feasibility in diverse training environments. ⁶ In addition, assessment challenges persist. Workplace‐based assessment is inherently subjective and, without structured tools, such as entrustment‐supervision scales and rater training, variability in assessments may compromise fairness and comparability. ⁴⁴

Despite these challenges, EPAs present transformative opportunities for optometric education. They provide a more authentic bridge between theoretical learning and clinical practice, potentially enhancing clinical readiness and decision‐making capabilities. ¹⁸ For example, mastering EPAs such as conducting comprehensive eye examinations or managing refractive errors supports both confidence and competence in emerging professionals. ² They also support student‐centred learning, enabling personalised progression based on competence rather than time. ³ This encourages learners to take ownership of their development, focusing on areas needing growth and engaging more meaningfully with feedback. ⁴

EPAs also promote interprofessional collaboration, equipping students to work in team‐based healthcare environments. Coordinating care with ophthalmologists, primary care providers or other health professionals mirrors real‐world practice and aligns with the WCO's emphasis on integrated care. ²⁵ Furthermore, EPAs offer a standardised yet flexible assessment framework, allowing institutions to evaluate clinical competence in ways that are both rigorous and adaptable. ⁴⁵

Importantly, while there is optimism regarding the benefits of EPAs, evidence of their long‐term impact on patient outcomes and workforce readiness remains limited. Caution is warranted in making strong claims about their effectiveness without more comprehensive evaluation data. A strategic and iterative approach is needed—one that includes investment in faculty development, stakeholder engagement and infrastructure, as well as ongoing feedback and evaluation loops. Through such an approach, EPAs can become a powerful tool for fostering competent, adaptable and reflective graduates ready to deliver high‐quality, patient‐centred eye care.

CONCLUSION AND RECOMMENDATIONS

The integration of EPAs into optometric education offers a transformative approach to competency‐based learning, offering a structured framework that aligns clinical training with real‐world professional responsibilities. By emphasising progressive autonomy, EPAs acknowledge that students develop their skills over time through structured progression. This scaffolding approach ensures that students transition from observation to supervised practice and ultimately to independent clinical decision‐making.

The theoretical foundations of EPAs further strengthen their applicability to optometric education. Drawing from Miller's pyramid of clinical competence, EPAs operate at the highest level—‘does’—ensuring that students are assessed on the basis of their ability to perform real‐world clinical tasks. Their integration into clinical education enables ongoing evaluation of student competence through methods such as direct observation, self‐reflection and case‐based discussions over time. By emphasising authentic assessment methods, the EPAs can align student learning with accreditation and regulatory requirements, fostering fairness, employability and the development of critical skills.

EPAs remain underutilised in optometric education. Future research and pilot implementations are needed to explore their feasibility, refine their structure and assess their impact on student preparedness for independent practice. As the field of optometry continues to evolve in response to changing patient needs, embracing EPAs could bridge the gap between theoretical education and clinical competency, ultimately enhancing both professional development and patient outcomes.

AUTHOR CONTRIBUTIONS

Sanele Buthelezi: Conceptualization (lead); data curation (lead); formal analysis (lead); methodology (lead); writing – original draft (lead); writing – review and editing (lead).

FUNDING INFORMATION

This research received no specific grant from any funding agency in the public, commercial or not‐for‐profit sectors.

CONFLICT OF INTEREST STATEMENT

There are no competing interests to declare.

CONSENT TO PUBLICATION

Not applicable.

Buthelezi S. Bridging competence and practice: The role of Entrustable Professional Activities (EPAs) in optometric education. Ophthalmic Physiol Opt. 2025;45:2063–2071. 10.1111/opo.13562