Beyond the Numbers: Exploring Tensions Between Formal Entrustment and Trainee Readiness in Internship Training - A Mixed-Methods Study.

Purpose: Entrustment decision-making is shaped by both supervisor and trainee. Existing research has focused largely on supervisor decision-making; however, less is known about how trainees experience and internalize entrustment. This study explores how trainee entrustment develops over a pharmacy internship and examines lived experiences that influence progression toward unsupervised practice. Methods: A convergent mixed-methods design explored the entrustment journey of provisionally registered (intern) pharmacists in Australia. Quantitative data were collected via self-administered questionnaires at three time points (beginning, middle, end of internship), capturing perceptions of entrustable professional activities (EPA) utility and self-perceived readiness for entrustment across ten EPAs. At year-end, focus groups explored pharmacy interns' perceptions of the EPA framework and how they interpreted and internalized it in relation to their development. Qualitative data were analyzed using reflexive thematic analysis and triangulated with quantitative findings to examine convergence and divergence over time. Results: Seventeen pharmacy interns completed questionnaires; 16 of these participated in focus groups. Self-perceived readiness for entrustment increased significantly across most EPAs, with median entrustment ratings reaching level 3 (independent with reactive supervision) by the end of internship. Pharmacy interns described that being entrusted supported confidence development, particularly when paired with structured feedback and reflective practice. Some noted that an emphasis on meeting numeric benchmarks risked reducing the process to a "numbers game," overshadowing diverse and complex learning opportunities, and diminishing feedback opportunities once level 3 was achieved. At times, this created asymmetry between being entrusted by a supervisor and the interns' own sense of readiness for more complex practice. Conclusion: EPAs support trainees' progression toward autonomy by embedding structure, feedback, and self-reflection that affirms competence and guides development. When entrustment decisions are tied to achieving a predetermined number of EPA observations, there is a risk that entrustment may be conferred prematurely, thereby reducing the depth of feedback and reflection that follows. When framed as assessments