Understanding Curriculum Implementation with Entrustable Professional Activities Through the Lens of Normalization Process Theory

Competency-based medical education (CBME) is widely adopted in numerous countries, but many programs struggle to translate its conceptual promises into routine educational and clinical practice. Entrustable Professional Activities (EPAs), a key mechanism to operationalize CBME, have been implemented in different ways with substantial variation across contexts. While implementation challenges are well described, the field lacks explanatory approaches to understand why such variation occurs and how it shapes practice. In this Show-and-Tell contribution we apply Normalization Process Theory (NPT), an implementation theory, to analyze how EPA-based curriculum reforms are taken up, enacted, and sustained across settings. We conducted a comparative, theory-informed analysis of implementation experiences from five regions (in Latin America, Asia, North America, Europe) drawing on materials from an international EPA symposium (Barcelona, 2025). Data sources include a pre-symposium survey, invited presentations, transcripts of plenary discussions, and follow-up reflections. Using NPT's four core constructs (coherence, cognitive participation, collective action, and reflexive monitoring), we examined how stakeholders make sense of EPAs, engage with implementation, integrate practices into clinical routines, and adapt them over time. The analysis revealed recurring mechanisms shaping implementation across contexts. Challenges included conceptual ambiguity, variable engagement, workflow pressures, and misalignment with existing practices. At the same time, enabling conditions emerged across settings: clear communication of purpose, phased implementation strategies, coordinated faculty development, leadership support, and context-sensitive adaptation. By foregrounding implementation mechanisms rather than outcomes alone, NPT offers a transferable analytic lens to guide, evaluate, and refine curriculum reforms.