Supervising for trust in an EPA based curriculum: a focused ethnography of supervisors' entrustment decisions in dental education

Dental education prepares students for independent practice, handling both predictable and unpredictable challenges. This necessitates a prospective approach to supervision and assessment, as such an approach not only evaluates current performance but also anticipates future behaviour. Entrustable Professional Activities (EPAs) offer a structured framework to develop and assess trust in students, supporting this prospective perspective. Although EPAs were originally designed for postgraduate training, they are increasingly used in undergraduate programs. While existing literature outlines factors influencing entrustment decisions, little is known about how these factors operate within dental education. This study explores how entrustment is enacted in dentistry and examines its potential link to adaptive expertise, which further promotes a prospective approach to supervision and assessment. A focused ethnography was conducted to gain in-depth insight into entrustment decision-making, based on observations and interviews during clinical practice and academic clinical reasoning sessions, and interviews reflecting on these observations. Data collection was followed by template analysis, using a theoretical background based on literature on ad hoc and summative entrustment decisions, retrospective and prospective entrustment, the A RICH framework, and conceptualisations and operationalisations of adaptive expertise. Throughout every phase of the study, an iterative process took place involving the entire research team. Data collection involved 56 h of observations and 9 interviews with dental supervisors. Ad hoc entrustment decisions are made daily by supervisors. All factors known from the literature to influence entrustment decisions were observed, including the A RICH features of students and students’ adaptive expertise and adaptive performance. The patient as an actor emerged as an additional factor influencing entrustment. This study highlights the increasing applicability of EPAs in dental education. It confirms the factors influencing entrustment decisions, adds the patient as a sixth factor, and supports the relevance of the A RICH framework. The findings emphasize a paradigm shift toward trust-based dialogue. However, conversations about entrustment rarely address trainee qualities beyond technical skills explicitly. To enable prospective assessment, curriculum design is crucial: a longitudinal EPA-based curriculum provides essential conditions for supervisors’ entrustment decisions. Further research into key curriculum factors is important to facilitate EPA-based curricula in dental education.