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Understanding Curriculum Implementation with Entrustable Professional Activities Through the Lens of Normalization
Marije P Hennus1, Roberta I Ladenheim2, H Carrie Chen3
1Department of Pediatric Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands.
Perspectives on Medical Education
|June 15, 2026
Summary
Competency-based medical education (CBME) implementation faces challenges. Entrustable Professional Activities (EPAs) show varied adoption, but Normalization Process Theory (NPT) explains how to integrate them effectively into practice.
Area of Science:
- Medical Education Research
- Implementation Science
Background:
- Competency-based medical education (CBME) adoption is widespread but faces practical implementation hurdles.
- Entrustable Professional Activities (EPAs) are key to operationalizing CBME, yet their implementation varies significantly across different educational contexts.
Purpose of the Study:
- To analyze the uptake, enactment, and sustainability of EPA-based curriculum reforms using Normalization Process Theory (NPT).
- To understand the mechanisms driving variation in EPA implementation across diverse international settings.
Main Methods:
- A comparative, theory-informed analysis of implementation experiences from five global regions.
- Data collected via pre-symposium surveys, presentations, plenary discussions, and follow-up reflections from an international EPA symposium.
Main Results:
- Implementation challenges included conceptual ambiguity, variable stakeholder engagement, workflow pressures, and misalignment with existing practices.
- Enabling factors for successful EPA implementation comprised clear communication, phased strategies, faculty development, leadership support, and context-specific adaptations.
Conclusions:
- Normalization Process Theory (NPT) provides a valuable framework for analyzing and understanding the complexities of implementing EPA-based CBME reforms.
- Focusing on implementation mechanisms, rather than solely outcomes, offers a transferable approach to guide, evaluate, and refine curriculum innovations in medical education.
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