Reliable Professional Activities in the Internship of the Technical Nursing Course: Evaluation of Competency Development

Luma Nogueira Soares; Alessandra Arno

DOI: 10.22167/2675-6528-202603211

Article derived from a Course Conclusion Work (TCC), with content based on the student’s original work and adapted to the editorial format of the E&S Magazine with the support of the ResumeAI tool, an artificial intelligence solution developed by Instituto Pecege for textual synthesis and organization.

Summary

The staged evaluation in technical nursing education faces challenges in the fragmentation of criteria and in monitoring student development. The objective was to describe and analyze the creation process of Entrustable Professional Activities (EPAs) as an educational management tool in technical nursing education. A qualitative, applied case study was conducted in a private institution in São Paulo. The research used documentary analysis of institutional records, evaluation rubrics, and materials produced during the construction of the EPAs, between 2023 and 2024, with content analysis. The results revealed that the previous evaluation model presented limitations in the fragmentation of criteria and the absence of explicit progression. The creation of the EPAs was mediated by the coordination, which managed faculty disagreements and defined evaluation criteria. The selection of activities prioritized practical feasibility and observability during internships. The final model organized the evaluation by levels of trust and made the progression explicit, requiring continuous alignment between evaluators and institutional adaptation. It was concluded that the creation of the EPAs was configured as a management process that involved pedagogical mediation, definition of criteria, and adaptation to institutional conditions.

Keywords: Educational assessment; Health education; Nursing internship; School management.

1. Introduction

The training of nursing technicians plays a central role in the organization of the Brazilian health system, representing the largest nursing workforce in the country. The relevance of this category is evidenced by data from the Federal Council of Nursing, which in 2016 indicated approximately 1,907,975 registered nursing technicians, corresponding to about 59.6% of the total professionals in the field in Brazil (COFEN, 2016).

The growth in the training of these professionals is accompanied by the expansion of the supply of technical courses. The National Catalog of Technical Courses, from the Ministry of Education, identified in 2020 a total of 4,179 registered technical nursing courses, distributed across various educational institutions in the country. In the State of São Paulo alone, 939 schools were registered, with 198 of them located in the city of São Paulo (National Catalog of Technical Courses, 2020).

Technical nursing education is part of Professional and Technological Education, being regulated by norms established by the Ministry of Education and the National Education Council. Regulatory frameworks such as the Law of Directives and Bases of National Education (Brazil, 1996), Decree No. 5.154/2004 (Brazil, 2004), and Resolution CNE/CEB No. 6/2012 (Brazil, 2012) guide the curricular organization, workload, and professional competencies to be developed.

The quality of this training is a constant concern, especially considering the mandatory curricular internship, which must be entirely in-person and have a minimum workload of 400 hours for nursing technicians (Cofen, 2026). Supervised practice is central to this process, and competency-based training emerges as a fundamental methodological strategy for developing the clinical skills necessary for professional practice.

The competence-based training approach seeks to integrate knowledge, skills, and attitudes, enabling professionals to respond effectively to the complex demands of practice (Santos, 2011). This perspective, initially disseminated in medicine, has expanded to nursing, contributing to the improvement of professional performance.

In this scenario, Entrustable Professional Activities (EPAs) stand out as units of professional practice that can be delegated to a learner. The condition for this delegation is that the student demonstrates sufficient competence to perform the activities proficiently, even without direct supervision (Kwan, 2016).

Although pedagogical strategies focused on the development of clinical and behavioral competencies are essential for health education (Cate, 2013), traditional assessment methods in nursing internships often present limitations. They are restricted to lists of isolated tasks or subjective rubrics, which do not adequately reflect the student’s readiness for autonomous care practice.

The fragility of these evaluative strategies, which often do not integrate clinical thinking into practice, can compromise the development of critical reasoning and safe decision-making in healthcare (Oliveira, 2019). This gap in the evaluation of technical nursing education stages, characterized by fragmented criteria and difficulty in monitoring student development, points to the need for more integrated and competency-oriented evaluation models.

The implementation of EPAs emerges as a promising solution, as it allows measuring student progression according to their professional responsibilities. This enables an integrated and contextualized analysis of performance, promoting greater patient safety by aligning educational training with the real demands of health services (Alharbi, 2020).

EPAs also favor the direct observation of real activities in patient care, integrating crucial dimensions such as communication, clinical reasoning, and professionalism (Al-Moteri, 2020). Thus, they are configured as a strategic resource to facilitate the transition from the academic environment to autonomous and safe professional practice. Given the need for assessment methods that offer greater reliability to management education, this study aimed to describe and analyze the process of creating EPAs as an educational management tool in technical nursing education, examining the transition from the traditional model to the trust-based model.

2. Material and Methods

The research was characterized as a qualitative case study, of an applied nature and with a documentary approach (Gil, 2022). The study consisted of describing and analyzing the creation process of Trusted Professional Activities (TPAs) as an educational management tool in technical nursing education.

The case study proved adequate for investigating the process of construction and implementation of the EPAs in a specific institutional context. This approach allowed for the analysis of the development path, pedagogical decisions, and strategies adopted for implementation in the curricular internship.

The research was conducted at a private technical education institution in the city of São Paulo (SP). This institution serves approximately 400 students and maintains partnerships with medium and large healthcare facilities for curricular internships. The process of constructing the EPAs, the object of this study, took place between 2023 and 2024.

The construction and analysis committee for the new evaluative model was composed of an intentional sample of 11 nursing professors. The selection of these professionals was based on their performance in field supervision and technical expertise in the nursing curriculum. Periodic meetings, with a minimum frequency of two monthly encounters, were held to define the evaluative activities and verify their feasibility in the internship fields.

For data collection, institutional records from the previous internship evaluation model, which used rubrics, were analyzed. This model consisted of 17 competency attributes, evaluated by criticality level. The previous evaluative scale was structured into three rubrics: needs development (PD), neutral (N), and strong (F).

The new evaluative model, built in 2024, comprised four Entrustable Professional Activities (EPAs), each with up to five competencies. The rubrics for this model were expressed in levels of professional confidence: not reliable to perform alone; reliable for simple cases; reliable for simple and complex cases; and reliable for simple, complex, and emergency cases. The attributes were organized as activities.

Data collection occurred through documentary analysis of digital institutional records. The documents used were produced in the institutional context of the construction of the EPAs, covering the period between the years 2023 and 2024. Access to the data occurred through the digital institutional records of the educational institution itself.

The documents were organized and systematized in the second semester of 2025 for the thematic content analysis. Initially, a floating reading was performed to identify recurring themes. Subsequently, the coding and categorization steps were applied, resulting in analytical axes that enabled the organization of information.

The data analysis followed the content analysis technique proposed by Bardin (2016), structured in the stages of pre-analysis, material exploration, and results treatment. For the organization and systematization of the WBS (Work Breakdown Structure), Microsoft Excel was used.

To ensure the reliability of the findings, data triangulation was used, by comparing institutional pedagogical guidelines, previously used evaluation rubrics, and the theoretical framework of the EPAs. In the pre-analysis stage, two models of rubrics used in previous student evaluations were identified, one for the first and second semester of the internship, and another for the third semester.

In the previous evaluation rubric, the attributes of professional training were organized into three main domains: behavioral (attendance, punctuality, teamwork, commitment, ethical conduct, and initiative); cognitive and technical (care planning, theory-practice correlation, technical knowledge, manual dexterity, professional and patient safety, technical procedures, and medication administration); and communication (quality and excellence in verbal and written communication).

The analysis of these attributes allowed for an understanding of the organization and structuring of competencies in the context of EPA construction. Competencies such as communication, collaboration, professionalism, technical expertise, and situational awareness were incorporated into the EPAs and began to be evaluated through rubrics developed in the new model.

As this is documentary research, with no direct involvement of human participants, submission to the Research Ethics Committee was not required, according to current regulations. Ethical principles were respected, ensuring the confidentiality of institutional information and its exclusive use for academic purposes.

3. Results and Discussion

The initial documentary analysis revealed that the evaluative model previously employed by the institution, although structured in rubrics with 17 objective attributes, presented significant limitations in the integrated assessment of professional competence, especially in the context of care practice. These attributes were organized into behavioral, cognitive-technical, and communicational domains. The fragmentation of criteria was a striking characteristic, manifested in spreadsheets with extensive lists of items evaluated independently, without clear articulation between them or explicit progression throughout the student’s training. This approach hindered the construction of a continuous and linear formative path, concentrating the assessment on specific records and preventing a holistic view of the student’s development.

During the meetings aimed at building Entrustable Professional Activities (EPAs), frequent criticisms arose regarding the difficulty of tracking students’ procedural development. The previous model was perceived as rigid, both in how faculty recorded performance and in students’ ability to clearly understand what they needed to improve. This limitation compromised the formative function of assessment, as students lacked explicit parameters to guide their progress. The rating scale of “Needs Development,” “Neutral,” and “Strength,” with quantitative scoring, reinforced the compartmentalized measurement of skills, without addressing the inherent complexity of clinical practice.

A crucial fragility was identified in the dissociation between the student’s global performance and the safety of the care provided. It was possible for a student to achieve satisfactory performance in various attributes, yet still not demonstrate readiness to act safely and autonomously. This gap in assessment compromised the ability to infer the student’s real competence for professional practice. The literature, as pointed out by Epstein and Hundert (2002), Ten Cate (2005), and Kwan et al. (2016), already discusses how fragmentation compromises the integrated assessment of competence, and the findings of this study corroborate this perspective.

Another critical aspect observed was the variability in the interpretation of evaluative criteria among faculty members, especially in attributes related to behavioral dimensions. Different professors presented distinct levels of tolerance for behaviors considered unprofessional, generating inconsistencies in evaluations. Although there were no formal records of these divergences, the institutional history and the very movement to review the model indicate that such inconsistencies were widely perceived and recognized, both by faculty and by the coordination. This variability highlights that the fragility was not restricted to the instrument, but also to its application, reinforcing the need for greater explicitness of criteria and alignment among evaluators.

The meetings for the construction of the EPAs also revealed significant tensions in defining expectations for each internship period. There were disagreements regarding the scope of student activities and what could be demanded by professors. In these moments, the coordination played a central role in mediating decisions, assuming a more directive stance when consensus among faculty was not reached. This dynamic demonstrated that, despite the collaborative nature of the process, the definition of formative expectations was firmly anchored in the curricular structure and institutional guidelines of the institution.

The distance between the evaluative instruments and real care practice also constituted a relevant limitation of the traditional model. By prioritizing decontextualized attributes, the model presented a low capacity to infer the student’s readiness to act autonomously and safely in patient care. Beyond the instrument’s structure, the absence of an explicit progression logic shared among those involved intensified this distancing, making it difficult to perceive the student’s development and for faculty to support the evaluations.

It is important to emphasize that these limitations were not perceived by a single group, but affected different levels of the institution. Professors, coordination, and students experienced, in distinct ways, the lack of clear criteria and continuous, tangible monitoring of development. For teachers, the difficulty lay in sustaining evaluations; for students, in understanding their own formative journey; and for management, in ensuring greater equity and consistency in the evaluation process. Despite these weaknesses, the model was maintained for a prolonged period, which can be attributed to institutional limitations of time and resources for implementing a new evaluation system.

The reformulation of evaluative practices, as the results indicated, is not restricted to instrumental changes, but involves formative processes, faculty alignment, and curricular reorganization, demanding significant institutional investment. Thus, the criticality model, although representing an attempt at systematization, proved insufficient for the contemporary demands of competency-based training. Its overcoming, therefore, depended not only on the adoption of new instruments but on a broader reconfiguration of evaluative practices, encompassing pedagogical, cultural, and organizational dimensions.

Construction of WBS: criteria, choices, and adaptation to the Brazilian context

The construction of the EPAs in the investigated context was a systematic and deliberative process, which involved a critical analysis of the previous evaluation model and negotiation between different teaching and institutional perspectives on the training priorities in technical nursing education. This process was not limited to a simple transposition of theoretical references, but was marked by the need to contextualize the choices to the curricular reality, the available internship fields, and the legal attributions of the nursing technician profession in Brazil.

The definition of the activities that would comprise the EPAs did not occur linearly, being permeated by discussions among faculty about the relevance, frequency, and feasibility of evaluating practices in the daily routine of internships. Initially, an expanded set of activities was considered, including actions related to cardiopulmonary arrest support and early recognition of risk situations. However, these activities were subsequently excluded, despite being recognized as important and compatible with the scope of practice of the nursing technician.

The main justification for excluding these activities was the impossibility of ensuring that all students were exposed to these situations equitably, as well as the limitation of repeating these practices, a condition considered essential for assessing performance progression. This movement highlighted that the selection criteria were not restricted solely to the clinical relevance of the activities, but also incorporated pedagogical and operational aspects, such as the possibility of direct observation, repetition, and longitudinal follow-up. Thus, four central EPAs were defined.

The four EPAs defined were: measurement of vital signs and capillary glycemia; performance of hygiene and comfort measures; performance of basic procedures and handling of devices related to care; and administration of medications. This selection reflected an intentional strategy of prioritizing high-frequency and broadly distributed activities in the internship fields, aiming to ensure greater evaluative consistency and equitable learning opportunities for all students. The choice of these fundamental activities ensures that students develop essential and observable competencies.

The decision-making process, although collaborative, was not horizontal. Discussions actively involved the faculty, but the coordination played a central role in mediating decisions, ensuring alignment with the institutional regulations and the course’s curricular structure. This action was fundamental, especially in moments of divergence, when different understandings of what should be evaluated emerged among the professors. The resolution of these tensions occurred through the prioritization of institutional and pedagogical criteria, reinforcing the management’s role in consolidating the evaluation model.

The definition of the competencies that make up the WBS was not configured as a mere adoption of theoretical references, but as a construction from the articulation between the technical demands of professional practice and the behavioral dimensions valued by the institution and the labor market. Competencies such as communication, professionalism, technical expertise, and situational awareness emerged from this interface between theory and practice. The competence of collaboration was incorporated in a more contextualized way, linked only to activities that demanded direct interaction with the team.

This process reinforces that the construction of the EPAs was anchored in a situated logic, in which decisions were made based on multiple legal, curricular, pedagogical, and institutional conditions, and not exclusively based on international models. The adaptation to Brazilian technical education required the redefinition of the scope of activities, considering that, according to Law No. 7.498/1986 (Brazil, 1986), the nursing technician works under supervision, focusing on the execution of direct care and technical procedures. This contrasts with the predominant application of EPAs in higher education, especially in medical training in other countries.

International literature highlights that the adaptation of EPAs for different training levels requires the explicit definition of autonomy and supervision limits, an essential condition for the validity of the assessment instrument (Ten Cate et al., 2018; Kwan et al., 2016). In the present context, this adaptation materialized both in the selection of activities and in the way progression through trust levels was structured, maintaining the principle of progressive autonomy, but anchored in a scope of practice compatible with technical training. Collaborative construction in the implementation of educational innovations is a relevant aspect, as highlighted by Frank et al. (2010).

Thus, the results indicate that the construction of the EPAs was not limited to the transposition of theoretical models, but constituted a contextualized process, which considered the institutional, legal, and pedagogical specificities of technical nursing education, configuring itself as a relevant contribution to the field. This process of adaptation and negotiation was crucial to ensure the acceptance and viability of the new evaluative model within the institution, promoting a more effective alignment between theory and professional practice.

Progression by confidence levels and development of autonomy

The adoption of EPAs allowed the structuring of an evaluative system based on progressive levels of confidence, replacing the traditional classificatory logic, and orienting towards the development of student autonomy. The four-level confidence scale was established: “unreliable to perform alone”, “reliable for simple cases”, “reliable for simple and complex cases”, and “reliable for simple, complex, and emergency cases”. This scale establishes a direct relationship between observed performance and the degree of supervision required, in line with the model proposed by Cate (2005), in which confidence plays a central role in pedagogical decision-making.

The prediction of progression for the EPAs was detailed throughout the course semesters. For EPA 1 (Measure Vital Signs and Capillary Glycemia), the expectation is that in the second semester the student will be “reliable for simple cases”, progressing to “reliable for simple and complex cases” in the third semester, and reaching “reliable for simple, complex, and emergency cases” in the fourth semester. This same progression logic applies to the other EPAs, such as EPA 2 (Perform Hygiene and Comfort Measures), EPA 3 (Perform basic procedures and handle devices related to care), and EPA 4 (Administer Medications), with the level of confidence increasing according to the complexity of the cases and the expected autonomy.

The internship schedule was also aligned with this progression, with the second and third semesters focused on “Assistance Practice I” and “Assistance Practice II”, respectively, culminating in the fourth semester with the performance in “Critical Patients”. This structure ensures that the student is exposed to scenarios of increasing complexity, allowing for the gradual development of skills and the building of the confidence necessary for autonomous and safe professional practice. The semester progression is anchored in the course curriculum and the increasing complexity of practice scenarios.

In the first internship period, corresponding to the assistant training level, students are placed in settings such as Basic Health Units and public hospitals, focusing on the care of low-complexity patients, with the expectation of developing initial competencies and basic levels of confidence. In the second period, the consolidation of fundamental nursing care is assumed, allowing for expanded practice in contexts of greater complexity and with greater responsibility. In the final internship, the student is expected to be able to provide assistance to critically ill patients, requiring higher levels of autonomy and decision-making.

Progression does not occur automatically, being conditioned to reaching the expected confidence levels for each stage. When these levels are not met, the student fails and must fully repeat the internship period, as provided for in institutional regulations. This highlights the understanding that the development of competencies demands time and adequate exposure to practices. This aspect reinforces the need for an evaluative system that continuously monitors the student, reducing the risk of failure being perceived as an unexpected event. During the construction of the EPAs, the importance of making the evaluative criteria more transparent throughout the formative path was widely discussed among the faculty.

Compared to the previous model, based on static and difficult-to-sustain rubrics, the new model based on EPAs addresses previously identified weaknesses, such as the absence of clear criteria and the difficulty in justifying the evaluations performed. By structuring activities into EPAs and linking them to competencies and confidence levels, the possibility of identifying learning gaps in real-time is expanded, while also promoting greater transparency and consistency in the evaluation process. This approach allows for more precise monitoring of student development, facilitating targeted pedagogical interventions.

The implementation of this model demands specific institutional conditions for its sustainability, such as continuous alignment among faculty, clarity of educational objectives, and the guarantee of internship fields that offer sufficient opportunities for the practice and evaluation of the proposed activities. In this sense, the role of pedagogical leadership proves central in the transition from a culture based on grade assignment to a culture oriented towards building trust, in which explicit criteria, continuous monitoring, and shared responsibility between faculty and students become structuring elements of the educational process.

The construction process was marked by intense faculty participation, with periodic meetings that enabled collective validation of choices and conceptual alignment among evaluators. This aspect reinforces the importance of collaborative construction in the implementation of educational innovations, as highlighted by Frank et al. (2010). Thus, the results indicate that the construction of the EPAs was not limited to the transposition of theoretical models, but constituted a contextualized process, which considered the institutional, legal, and pedagogical specificities of technical nursing education, configuring itself as a relevant contribution to the field of health education.

Implications for the management of the evaluation process

The analysis of institutional documents showed that the implementation of EPAs went beyond the merely pedagogical dimension, assuming the contours of an educational management strategy with direct repercussions on the organization of the evaluation process. The records of pedagogical meetings indicate the active role of the coordination in mediating the process, especially in defining evaluation criteria and in conducting discussions among teachers about assigning confidence levels. This movement dialogues with the understanding of pedagogical leadership as a structuring element of educational quality, as it articulates formative and decision-making processes in the institutional daily life.

Another critical aspect refers to the consistency of evaluations among different instructors. Models based on professional judgment are subject to variations arising from greater or lesser rigor of the evaluators, which can compromise the fairness of the process. In the previous model, this fragility was evident in the difficulty of explicitly stating the criteria used, resulting in questions from students and limitations in supporting evaluative decisions. The EPA-based proposal sought to mitigate this variability through the definition of structured rubrics and investment in instructor alignment processes.

The intensification of internship orientation meetings, with detailed criteria, rules, and regulations, was configured as a central strategy to promote greater equivalence in evaluations. Furthermore, the use of a monitoring system allows for greater proximity of the coordination in monitoring the evaluations carried out. This movement is supported by the literature on competency-based assessment, which emphasizes the need for alignment between evaluators to ensure greater reliability of judgment (Cate, 2007; Cate, 2013). The coordination, by mediating these discussions, ensured that decisions were aligned with institutional and curricular guidelines.

Regarding institutional culture, the analyzed records suggest a gradual movement from a grade-centered model to an approach focused on monitoring student development. Feedback reports and records indicate a greater appreciation for qualitative aspects of student performance, as well as the incorporation of feedback as a structuring part of the evaluative process. This change, although not homogeneous among all faculty members, approaches the conceptions of formative assessment discussed by Luckesi (2023), for whom the focus of assessment should shift from classification to monitoring learning.

The documents also show that the adoption of EPAs promoted a closer relationship between the evaluation process and the demands of clinical practice. The explicit definition of performance criteria and the use of instruments based on concrete professional activities contributed to greater clarity in educational expectations, as indicated in the student evaluation and monitoring records. This finding converges with the literature that understands EPAs as devices that articulate training and practice, favoring decision-making based on professional confidence (Cate, 2005; Cate, 2013).

From a management perspective, the findings allow for the identification of institutional conditions that favored the implementation of the model. These include the existence of formal spaces for pedagogical discussion, the continuous action of coordination in mediating conflicts and alignments, and the institutional availability for reviewing instruments and processes. Such conditions reinforce the idea that changes in evaluation models depend on organizational support and an institutional culture that values collaborative and reflective processes. The articulation between pedagogical leadership, institutional support, and teacher collaboration contributed to the consolidation of the evaluation model by EPAs.

From these elements, it is interpreted that the adoption of EPAs implies the need to reconfigure the management of the evaluation process, requiring greater investment in teacher training, pedagogical mediation, and continuous monitoring. More than the adoption of a new instrument, it is about incorporating an evaluative logic that demands articulation between institutional actors and organizational support. In this sense, although the results point to the potential for replicating the model, its implementation in other contexts will depend on the presence of institutional conditions similar to those identified in this study, as well as on the recognition, already indicated in the literature, that evaluation processes based on trust require time, negotiation, and institutional maturity (Cate, 2007; Luckesi, 2023).

In summary, the research demonstrated that the transition to the EPA assessment model at the studied institution was a complex and multifaceted process. It involved overcoming the limitations of the traditional model, carefully defining reliable professional activities based on feasibility and observability criteria, and structuring a progression through levels of trust. Pedagogical coordination played a central role in mediation and alignment, transforming the implementation of EPAs into a strategic educational management tool that promotes greater clarity, consistency, and integration between theoretical training and clinical practice, directly responding to the objective of describing and analyzing this creation process.

4. Conclusion

This study described and analyzed the process of creating Entrustable Professional Activities (EPAs) as an educational management tool in nursing technical education, examining the transition from a traditional model to a trust-based approach. It was found that the previous evaluation model presented significant limitations, characterized by fragmentation of criteria, absence of explicit progression, and difficulty in integrating the assessment of professional competence into care practice. The construction of EPAs was configured as a systematic and deliberative process, mediated by pedagogical coordination, which managed faculty disagreements and defined evaluation criteria. The selection of the four central EPAs – measurement of vital signs and capillary glycemia; performance of hygiene and comfort measures; performance of basic procedures and handling of care-related devices; and administration of medications – prioritized practical feasibility and observability in internship settings. The resulting model organized the evaluation by levels of trust and made explicit the student’s progression throughout the semesters, aligning it with the increasing complexity of practice scenarios. This reconfiguration of the evaluation process represents a managerial and pedagogical contribution by promoting greater clarity, consistency, and alignment between theoretical training and the real demands of care practice.

However, the study acknowledges limitations, such as conducting the research in a single institution, which restricts the generalization of findings to other contexts. Furthermore, the investigation focused on the process of constructing the WBS, without delving deeper into the analysis of its application with students, and the researcher’s insertion into the field may have influenced data interpretation. Therefore, it is suggested that the implementation of the WBS be accompanied by structured spaces for pedagogical discussion and continuous institutional mediation, with investment in teacher training for the alignment of evaluation criteria and the adequate use of the model. Future studies are recommended to analyze the application of the WBS in different institutional contexts, as well as investigations that explore its developments in the formative process and its direct impact on student performance and perception.

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Article originating from the Course Conclusion Work of the Specialization in School Management of the MBA USP/Esalq

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