Entrustment–supervision progression across core entrustable professional activities in undergraduate nursing clinical rotations: a prospective longitudinal study

Abstract

Entrustable professional activities (EPAs) operationalize competency-based education by linking assessment to observable clinical tasks and supervision decisions. Although EPAs are widely implemented in postgraduate and advanced nursing education, quantitative evidence describing entrustment progression in undergraduate nursing clinical rotations remains limited. Understanding how entrustment–supervision levels evolve across consecutive clinical rotations may inform supervision practices and curriculum design. This prospective observational study included 119 third-year undergraduate nursing students enrolled in two consecutive three-week full-time medical–surgical nursing clinical rotations at a university in eastern Taiwan. Five core EPAs were developed through expert consensus and evaluated with the EQual rubric tool. Clinical supervisors assessed students weekly using a five-level entrustment–supervision scale. Interrater reliability was examined using intraclass correlation coefficients (ICCs). Changes in entrustment–supervision levels across weeks were analyzed using generalized estimating equations with linear trend testing. The five EPAs demonstrated EQual scores of 4.77–4.87 and ICCs greater than 0.90 under standardized video-based conditions. A total of 1,504 entrustment–supervision ratings were recorded across both clinical rotations (Medical–Surgical Nursing Practicum I and II). During Practicum I, mean entrustment–supervision levels increased significantly across Weeks 1–3 for all five EPAs (all linear trends p < 0.001), progressing from observation or direct supervision toward indirect supervision. However, handover and interpretation of laboratory values did not consistently reach Level 3 by Week 3. In Practicum II, all EPAs again demonstrated significant week-by-week progression (all linear trends p < 0.001). By the final week, the mean rating for each EPA was at least Level 3, corresponding at the group level to performance under indirect supervision. Distribution analyses showed a shift toward higher entrustment–supervision levels in Practicum II, with fewer Level 1 ratings and increased Levels 3–4 ratings across all activities. EPA-based assessment was successfully implemented and captured short-term increases in entrustment–supervision ratings across consecutive clinical rotations. Entrustment trajectories varied by task and clinical context, suggesting that supervision decisions reflect both learner development and context-sensitive calibration. These findings provide quantitative support for implementing EPAs to guide longitudinal assessment and supervision in undergraduate nursing programs.