Bridging Competence Gaps: A Mixed‑Methods Needs Assessment to Inform a Simulation‑Based Postgraduate Residency Curriculum

Bridging Competence Gaps: A Mixed‑Methods Needs Assessment to Inform a Simulation‑Based Postgraduate Residency Curriculum | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Bridging Competence Gaps: A Mixed‑Methods Needs Assessment to Inform a Simulation‑Based Postgraduate Residency Curriculum Brekhna Jamil Khan, Zulfiqar Ahmed Bhutta, Jabeen Fayyaz This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8876603/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background: Postgraduate medical training requires competence in emergency care, procedural skills, and patient safety, yet workplace-based learning provides variable exposure, particularly for high-risk, low-frequency events. Simulation-based learning may address these gaps, but evidence for system-level integration in national postgraduate programmes in low- and middle-income countries is limited. This study identified priority simulation needs in Fellow of College of Physicians and Surgeons (FCPS) residency training in Pakistan. Methods: A convergent mixed-methods needs assessment was conducted across three CPSP-accredited tertiary hospitals in Peshawar. A content-validated online survey with good internal consistency (Cronbach’s α = 0.80) was completed by FCPS residents, faculty supervisors, and programme leadership across Medicine & Allied, Surgical & Allied, and Paediatrics (n = 270; response rate = 27%). Competency importance–adequacy gap scores identified priorities. Semi-structured interviews with supervisors and programme directors (n = 12) were analysed using reflexive thematic analysis, with quantitative and qualitative strands equally weighted and integrated using joint displays and narrative weaving. Results: The largest competency gaps were identified in emergency management (55 percentage points) and procedural skills (54 percentage points), followed by clinical decision-making (46), patient safety practices (42), and team-based communication (39). Simulation exposure across programmes was limited, yet organisational support for mandatory simulation-based learning was high (87.8%), indicating readiness for implementation. Qualitative findings explained these gaps through themes of variable clinical exposure, concerns regarding readiness for independent practice, the value of simulation as a safe environment for deliberate practice, gaps in faculty development particularly in debriefing, and the need for formal curricular and assessment integration. Conclusion: Substantial gaps exist between essential postgraduate competencies and current FCPS training. Embedding simulation-based learning as a system-level strategy across curricula, faculty development, and assessment can enhance standardisation, equity, and patient safety in low- and middle-income settings. simulation-based learning postgraduate medical education needs assessment patient safety curriculum development low- and middle-income countries Figures Figure 1 Background Postgraduate medical education must prepare clinicians to safely manage high-risk clinical situations and work effectively within interprofessional teams at the point of independent practice [ 1 ]. However, training systems that rely primarily on workplace-based apprenticeship produce variable learning opportunities and inconsistent attainment of essential competencies, particularly for emergencies, rare procedures, and non-technical skills where exposure is unpredictable and ethically constrained [ 2 – 6 ]. This variability undermines readiness for independent practice, equity of training experiences, and patient safety [ 4 , 6 ]. Educators have widely adopted simulation-based learning to address these limitations by enabling deliberate practice, structured feedback, and reflective learning within psychologically safe environments [ 7 – 9 ]. Increasingly, educators and health systems conceptualise simulation as a translational strategy that links education with healthcare quality improvement, risk mitigation, and standardisation of practice in high-stakes clinical domains [ 10 , 11 ]. In response, simulation scholarship has shifted from demonstrating effectiveness to examining how programmes embed simulation longitudinally within curricula, assessment systems, governance structures, and organisational safety priorities [ 12 , 13 ]. Despite this evolution, educators in low- and middle-income countries (LMICs) continue to face challenges in sustaining system-level simulation integration [ 14 ]. Studies from LMIC contexts identify barriers including limited faculty expertise, high costs, competing service demands, and weak curricular alignment, alongside strong interest in simulation and recognition of its value for patient safety and quality of care [ 14 , 15 ]. These findings highlight the need for context-responsive and needs-driven approaches to simulation integration. Pakistan provides a relevant LMIC context for examining these challenges [ 14 ] The Fellowship of the College of Physicians and Surgeons programme of the College of Physicians and Surgeons Pakistan serves as the national pathway for specialist training across Medicine & Allied, Surgical & Allied, and Paediatrics[ 16 ]. Training occurs predominantly in high-volume hospital environments [ 17 ], where learning experiences vary across institutions due to differences in case mix, supervision quality, protected teaching time, and access to structured educational resources [ 18 , 19 ]. As a result, residents experience inconsistent opportunities to develop emergency management, procedural competence, and team-based skills [ 20 ]. Simulation research in Pakistan has largely focused on undergraduate education, faculty perceptions, or isolated specialty-specific initiatives [ 21 , 22 ] with very limited evaluation of approaches in residency training [ 23 ], leaving postgraduate simulation needs across specialties and stakeholder groups within the FCPS system underexplored [ 14 , 15 , 24 ]. Without system-level needs assessment, simulation risks remaining peripheral rather than functioning as a coordinated strategy for educational quality improvement and patient safety. In this study, we conducted a mixed-methods, multi-specialty needs assessment to inform the development of a competency-aligned simulation-based curriculum for FCPS residency training, guided by Kern’s framework [ 25 ]. We identified priority competency gaps, examined stakeholder perspectives on simulation as a system-level educational and patient-safety strategy, and explored feasibility considerations to support scalable integration within postgraduate training systems. Methods Study Design We conducted a convergent mixed-methods needs assessment, collecting quantitative and qualitative data concurrently with equal priority and integrating findings at interpretation. This approach enabled a comprehensive understanding of postgraduate simulation needs as a system-level educational and patient-safety strategy and aligned with the first two steps of Kern’s six-step curriculum framework [25, 26]. Figure 1 summarises the methodological flow from literature review and CPSP competency requirements through data collection, integration, and curriculum-relevant outputs. Setting We conducted the study across three CPSP-accredited public-sector tertiary hospitals in Peshawar, Khyber Pakhtunkhwa, Pakistan Khyber Teaching Hospital, Hayatabad Medical Complex, and Lady Reading Hospital, which offer FCPS residency programmes in Medicine & Allied, Surgical & Allied, and Paediatrics [16]. These core disciplinary streams encompass diverse procedural, emergency, and non-technical skill requirements, making them suitable for a cross-specialty simulation needs assessment [16]. Institutional variation in case mix, faculty capacity, and educational infrastructure reflected the heterogeneity of FCPS training environments. Although data were collected in Khyber Pakhtunkhwa, the study was designed to inform national FCPS simulation curriculum development and to be relevant to comparable low- and middle-income postgraduate training contexts. Participants and Sampling For the quantitative strand, we used purposive–convenience sampling, targeting FCPS residents and faculty involved in teaching, supervision, assessment, or programme leadership to identify curriculum-relevant gaps [25, 27-29]. The survey was distributed through official institutional channels using a convenience approach appropriate for needs assessments in busy clinical settings where probabilistic sampling is often impractical [30, 31]. Across three institutions, 400 residents and 450 faculty were invited; 270 responses were received (response rate = 27.0%), including 103 residents (25.8%) and 167 faculty (37.1%). Consistent with guidance for multi-site educational needs assessments, this sample was considered sufficient for identifying system-level priorities based on breadth of stakeholder representation and convergence of findings rather than statistical power calculations [27, 32]. For the qualitative strand, we used purposive maximum-variation sampling to recruit faculty members and programme directors for semi-structured interviews [33]. Eighteen individuals were invited, and twelve completed interviews. Sampling was guided by the principle of information power, considering the focused study aim, participant expertise, use of an established framework, and depth of dialogue, with recruitment ceased at thematic sufficiency [25, 34]. Residents were not interviewed because the qualitative focus was on curriculum feasibility, governance, and faculty readiness, and because hierarchical dynamics may constrain candid critique [35, 36]. Resident perspectives were instead captured through anonymous survey responses, with planned engagement during subsequent curriculum co-design and pilot phases [27, 30]. Survey Instrument We developed the needs-assessment survey using a theory- and evidence-informed three-step process [25, 30, 37]. Survey items were mapped to FCPS and CPSP postgraduate competency expectations, including emergency care, procedural skills, patient safety, communication, and clinical decision-making, informed by a targeted review of simulation-based education literature and CPSP curriculum documents [6, 16, 38]. Content validity was established through structured expert review by three senior medical educators and three clinician-educators with simulation expertise, guiding refinement of item wording and domain coverage [39]. The questionnaire was pilot tested with ten participants (five residents, five faculty), resulting in minor revisions. The final instrument demonstrated acceptable internal consistency (Cronbach’s α = 0.80) and included Likert-scale and open-ended items. The full survey is provided in Supplementary Material 1. Interview Guide We developed a semi-structured interview guide to explore faculty and programme director perspectives on competency gaps, experiences with simulation-based learning, faculty readiness, and curricular integration. The guide was aligned with survey competency domains to support mixed-methods integration and designed to allow flexible probing [26, 40]. It was pilot tested with two faculty members not included in the final sample, and minor refinements were made to wording and sequencing to improve clarity and flow, consistent with qualitative best practice [35, 41]. The final guide is provided in Supplementary Material 2. Data Collection We collected quantitative data using a self-administered online questionnaire (Google Forms) distributed through official institutional channels and WhatsApp groups across CPSP-accredited training institutions [42, 43]. Institutional gatekeepers (programme directors, supervisors, departmental heads) facilitated dissemination [44]. Participation was voluntary, with electronic informed consent obtained prior to completion. Three reminder messages were issued at three-week intervals to maximise response rates [31, 45], yielding 270 responses (103 residents, 167 faculty). Qualitative data were collected through semi-structured interviews conducted online via a secure Zoom® platform by the first author. Gatekeepers identified eligible faculty members and programme directors [44]. With participant consent, interviews were audio-recorded, transcribed verbatim, anonymised, and stored securely in accordance with qualitative research best practice [40, 41]. Data Analysis We analysed quantitative data using descriptive statistics (frequencies and percentages) to summarise participant characteristics, perceived importance and adequacy of postgraduate competencies, and exposure to simulation-based learning. Consistent with the needs-assessment purpose, analyses focused on system-level curriculum prioritisation rather than inferential or subgroup comparisons [25]. Priority training gaps were identified using importance–adequacy gap analysis by calculating the difference between proportions rating each competency as highly important and adequately addressed, with larger gaps indicating greater unmet need [27, 38, 46]. Open-ended survey responses were analysed using content analysis to identify priority scenarios, barriers, and enablers [47]. Qualitative interview data were analysed using inductive reflexive thematic analysis following Braun and Clarke’s six-phase approach [40]. Interviews were audio-recorded, transcribed verbatim, and verified for accuracy. Coding was conducted in NVivo® by the research team and two independent qualitative researchers, with discrepancies resolved through consensus. An audit trail and reflexive memos were maintained [48], and member checking with a subset of participants confirmed the resonance of preliminary themes [49]. Mixed-Methods Integration We integrated quantitative and qualitative findings at interpretation using joint displays and narrative weaving [26]. Qualitative data explained importance–adequacy gaps by illuminating factors such as variable clinical exposure, faculty capacity, and organisational constraints, while elaborating issues of faculty readiness and resources. This integration enabled a comprehensive understanding of postgraduate simulation needs and informed translational simulation design and implementation. Results Participant Characteristics A total of 270 of 500 participants completed the survey (Table 1). Respondents were predominantly male (54.8%), followed by female (42.6%), with 2.6% not reporting gender. FCPS residents comprised 38.3% of respondents, faculty supervisors 36.5%, and programme leadership or senior faculty 25.2%, including programme directors who also participated in qualitative interviews. Participants represented all major FCPS disciplinary streams: Medicine & Allied and Surgery & Allied (each 28.7%), Obstetrics & Gynaecology (22.6%), and Paediatrics (20.0%). Table 1. Demographic Characteristics of Survey Respondents (n = 270) Characteristic Category n % Gender Male 148 54.8 Female 115 42.6 Not reported 7 2.6 Stakeholder Type FCPS Residents 103 38.3 Faculty Supervisors 99 36.5 Programme Leadership* 68 25.2 Specialty Group Medicine & Allied 77 28.7 Surgery & Allied 77 28.7 Obstetrics & Gynaecology 61 22.6 Paediatrics 55 20.0 * Programme leadership includes consultants, programme directors, registrars, fellows, and senior faculty involved in postgraduate training oversight. Across stakeholder groups, emergency management was rated the highest priority competency (93.0%), followed by procedural skills (88.1%), clinical decision-making (85.9%), patient safety (83.7%), and team-based communication (81.9%) (Table 2). In contrast, perceived training adequacy was substantially lower across all domains, particularly for emergency management (38.1%) and procedural skills (34.1%). Importance–adequacy gap analysis identified the largest unmet needs in emergency management (55 percentage points) and procedural skills (54 percentage points), followed by clinical decision-making (46 percentage points). Qualitative findings explained these gaps, highlighting high expectations for independent practice alongside inconsistent preparedness due to variable clinical exposure. Training experiences were perceived as institution-dependent, contributing to inequitable competency development and mirroring the uniformly low adequacy ratings despite high perceived importance. Table 2. Perceived Importance, Adequacy, and Importance–Adequacy Gap for Core FCPS Competencies (n = 270) Rank Competency Rated as Highly Important % (n) Perceived as Adequately Addressed % (n) Importance–Adequacy Gap (pp) 1 Emergency management 93.0 (251) 38.1 (103) 55 2 Procedural skills 88.1 (238) 34.1 (92) 54 3 Clinical decision-making 85.9 (232) 40.0 (108) 46 4 Patient safety practices 83.7 (226) 41.9 (113) 42 5 Team-based communication 81.9 (221) 42.6 (115) 39 Exposure to simulation-based learning was limited and uneven, with most respondents reporting access to task trainers (56.3%) and mannequin-based simulation (43.7%), while exposure to standardised patients (23.7%) and virtual simulation (14.4%) was uncommon. Despite this, strong support emerged for mandatory integration of simulation within FCPS training programmes (87.8%), reflecting recognition of simulation as a means to address gaps not reliably met through workplace learning. Survey and open-ended responses converged on priority simulation scenarios, including acute emergencies, high-risk low-frequency procedures, and communication in emotionally charged or time-critical situations. These priorities aligned with the largest importance–adequacy gaps and were consistent across specialties, supporting the feasibility of a shared, cross-cutting simulation core (Table 3). Table 3. Priority Simulation Scenarios Identified Across FCPS Disciplinary Streams Domain Medicine & Allied Surgery & Allied Obstetrics & Gynaecology / Paediatrics Cross-Cutting Rationale Emergency management Septic shock, acute coronary syndrome, cardiac arrest, acute arrhythmias Polytrauma, massive haemorrhage, peri-operative cardiac arrest Post-partum haemorrhage, eclampsia, neonatal resuscitation, paediatric shock High-risk, low-frequency events with largest importance–adequacy gaps; limited guaranteed exposure in routine training Procedural skills Central venous line insertion, lumbar puncture, airway management Laparoscopic suturing, chest tube insertion, emergency airway Shoulder dystocia manoeuvres, neonatal intubation, assisted vaginal delivery Procedural competence varies by site and supervision; simulation enables deliberate, standardised practice Clinical decision-making Deteriorating patient assessment, escalation of care Intra-operative complications, post-operative deterioration Obstetric emergencies, paediatric deterioration algorithms Requires integration of data under time pressure; difficult to teach explicitly in workplace settings Communication Breaking bad news, goals-of-care discussions Informed consent for high-risk surgery, error disclosure Breaking bad news in obstetrics/paediatrics, counselling families Emotionally charged scenarios inconsistently taught; strong qualitative concern across stakeholders Teamwork & leadership Code blue leadership, ward emergency response Operating theatre crisis management Obstetric emergency drills, neonatal resuscitation teams Non-technical skills critical for patient safety; simulation supports role clarity and closed-loop communication Patient safety & human factors Handover failures, medication errors Surgical safety checklist failures, wrong-site surgery prevention Obstetric safety bundles, escalation delays Limited formal training in safety science; simulation allows systems-focused learning Escalation & systems awareness Recognising limits, timely referral to ICU Escalation to senior surgeon/anaesthesia Escalation in maternal or paediatric emergencies Aligns simulation with governance, risk management, and quality-improvement priorities Simulation was widely viewed as a psychologically safe space for deliberate practice and reflection without patient harm. Faculty supervisors and programme directors emphasised that effective implementation requires trained facilitators, structured debriefing, and formal curricular embedding. Although time, infrastructure, and funding were identified as barriers, these were largely seen as manageable through leadership support, faculty development, low-cost simulation models, and phased implementation. These qualitative insights are summarised in Table 4, which links six interrelated themes to the corresponding importance–adequacy gaps. Collectively, the integrated findings highlight simulation-based learning as a system-level strategy to improve standardisation, equity, and patient safety within FCPS residency training. Table 4. Summary of Qualitative Themes, Illustrative Quotes, and Links to Quantitative Findings Theme Core Insight Illustrative Quotations Stakeholder Linked Quantitative Gap (pp) 1. Expectations of competence and readiness Residents are expected to manage high-risk situations independently by programme completion, yet preparedness is inconsistent “By the final year, residents are expected to take charge of emergencies, but many still look for reassurance.” ( R2 ) “They know the theory, but hesitation becomes evident in real emergencies.” ( R4 ) Explains largest importance–adequacy gaps in emergency management (55 pp) and procedural skills (54 pp) 2. Variability in training experiences Competency development depends on institutional context and chance exposure “Some residents see everything; others miss key experiences entirely.” ( R6 ) “Competency should not depend on which hospital you train in.” ( R2 ) Contributes to low adequacy across domains despite high importance: Clinical decision-making: 46 pp 3. Simulation as a safe learning modality Simulation enables deliberate practice for rare, high-risk events without patient harm “Residents can fail, reflect, and try again in simulation.” ( R8 ) “Real settings cannot guarantee repeated exposure to emergencies.” ( R11 ) Explains strong endorsement for simulation addressing gaps in: Emergency management: 55 pp 4. Faculty readiness and development needs Educational value depends on trained facilitators and structured debriefing “Without proper debriefing, simulation becomes just a technical exercise.” ( R1 ) “Most of us were never formally trained to run simulations.” ( R10 ) Linked to gaps in non-technical domains: Team-based communication: 39 pp 5. Need for formal curricular integration Simulation must be embedded and assessed to be prioritised “If simulation is optional, it will never be prioritised.” ( R8 ) “Standardisation through simulation can reduce inequities.” ( R6 ) Reflects persistent gaps in: Patient safety practices: 42 pp 6. Barriers and feasibility considerations Time, infrastructure, and resources are constraints but viewed as manageable “Clinical workload is the main challenge.” ( R9 ) “With leadership support, these barriers are manageable.” ( R5 ) Contextualises gaps across domains Discussion This mixed-methods needs assessment demonstrates a clear misalignment between competencies essential for safe postgraduate practice and the extent to which current FCPS residency training supports their development. Across stakeholder groups and specialties, emergency management, procedural skills, and clinical decision-making were consistently prioritised yet perceived as inadequately addressed (Table 2 ). The convergence of large importance–adequacy gaps with qualitative accounts of variable preparedness and inconsistent clinical exposure indicates a systemic educational challenge rather than isolated programme-level deficiencies (Tables 2 and 4 ). Collectively, these findings support simulation-based learning (SBL) as a curriculum-level, system-aligned strategy rather than a discretionary educational add-on [ 9 , 10 ]. Emergency management and procedural skills emerged as the most critical yet least adequately supported domains. Although over 88% of respondents rated these competencies as highly important, fewer than 40% perceived current training as adequate (Table 2 ). Qualitative findings contextualised these gaps, with faculty and programme directors expressing concern that residents are expected to manage emergencies independently despite limited structured practice (Theme 1, Table 4 ). This mirrors international evidence that apprenticeship-based models alone do not reliably ensure exposure to high-risk, low-frequency events or opportunities for deliberate practice, posing risks to patient safety and readiness for unsupervised practice [ 5 , 6 , 50 ]. Marked variability in training experiences across institutions further explained persistently low adequacy ratings despite high perceived importance. Participants described competency development as dependent on institutional context, case mix, and chance exposure, reinforcing concerns about inequity within workplace-based training systems [ 4 , 6 ]. Simulation was viewed as a mechanism to reduce this variability by ensuring standardised exposure to core scenarios, directly addressing gaps in clinical decision-making and patient safety identified in the quantitative analysis (Table 2 ). Simulation was consistently framed as a psychologically safe modality for deliberate practice of rare and high-risk scenarios without patient harm (Theme 3). This perspective explains the strong support for mandatory SBL integration (87.8%) despite limited current exposure to most simulation modalities and aligns with evidence demonstrating the value of simulation for feedback, repetition, and reflective learning in busy clinical environments [ 7 , 9 , 11 ]. Participants clearly distinguished between ad hoc simulation activities and curriculum-integrated SBL (Theme 5). While task trainers and mannequin-based simulations were available, these were described as sporadic and insufficient to influence competency development meaningfully. This aligns with evidence that isolated simulation initiatives have limited impact unless embedded longitudinally and aligned with curricular goals and assessment strategies [ 51 , 52 ]. The strong consensus for mandatory integration supports a system-level approach consistent with international trends in postgraduate education [ 12 , 13 ]. Faculty readiness emerged as a critical determinant of effective implementation (Theme 4). Although enthusiasm for SBL was high, limited formal training in facilitation and debriefing was acknowledged. This is notable given evidence that educational impact depends more on debriefing quality than simulation fidelity alone [ 53 – 55 ]. Importantly, cost and infrastructure were not viewed as prohibitive barriers. Instead, participants emphasised phased implementation, faculty development, and low-cost or in-situ simulation approaches, which have demonstrated feasibility in resource-constrained settings [ 24 , 56 , 57 ]. This study extends the simulation literature by examining a national, standardised postgraduate training system within a low- and middle-income country context. Inclusion of Medicine & Allied, Surgical & Allied, and Paediatrics captures diverse procedural, emergency, and non-technical skill demands, strengthening relevance for system-level curriculum reform rather than isolated innovation. By triangulating quantitative gaps with qualitative insights from faculty and programme leadership, the study provides actionable evidence to guide sustainable simulation integration, including prioritising safety-critical competencies, aligning scenarios with FCPS competencies and EPAs, staging faculty development, and embedding simulation within assessment and governance structures [ 25 , 27 ]. Limitations and Future Directions This study relied on self-reported perceptions, which may not fully reflect observed competence; however, such perceptions are central to needs assessment and curriculum prioritisation [ 25 , 27 ]. (Grant, 2002; Kern, 2016). Future work should co-design and pilot a simulation-based curriculum within FCPS centres and evaluate impact using objective performance measures, workplace-based assessments, and patient-centred safety indicators. Implications for Practice and Policy At the FCPS and College of Physicians and Surgeons Pakistan level, the findings support a coordinated translational simulation strategy that defines minimum simulation exposure in safety-critical domains, aligns scenarios with national competencies and entrustable professional activities, and embeds simulation standards within accreditation and quality assurance. Institutionally, phased implementation can prioritise high-risk pathways, utilise low-cost and in-situ simulation, and focus faculty development on facilitation and debriefing. The mixed-methods, multi-stakeholder approach offers a transferable model for other low- and middle-income postgraduate systems integrating simulation within quality and risk-management agendas. Conclusion This study identifies safety-critical competence gaps in FCPS residency training and demonstrates strong stakeholder readiness for curriculum-embedded simulation. By linking educational needs with governance, faculty capability, and assessment, the findings provide a blueprint for a national translational simulation strategy to enhance patient safety, equity, and postgraduate training quality in Pakistan and comparable resource-variable settings. Declarations Ethics approval and consent to participate Ethical approval for this mixed-methods needs assessment study was obtained from the Khyber Medical University Ethics Board (Ref No. Dir/KMU-EB/DR/1550). The study involved postgraduate residents and faculty members participating in an educational needs assessment and did not involve real patients or clinical interventions. Participation was voluntary, and written informed consent was obtained from all participants prior to data collection. All procedures were performed in accordance with the ethical principles of the Declaration of Helsinki. Consent for publication Not applicable. This manuscript does not contain any individual person’s data in an identifiable form. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to institutional policies and the educational context of the data but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was supported by Supporting Women In Science Research Grant. The funding body had no role in the study design, data collection, analysis, interpretation of data, or writing of the manuscript. Authors’ contributions BJ conceptualised the study, led the needs assessment design, supervised data collection, and drafted the manuscript. ZAB supervised and mentored this project and contributed to study design, data collection, and analysis. JF supervised and contributed to study design, data collection, and analysis. All authors reviewed and approved the final manuscript and agree to be accountable for all aspects of the work. Acknowledgements The authors would like to acknowledge the postgraduate residents, faculty supervisors, and programme leadership who contributed their time and insights to this needs assessment. We also thank the institutional leadership for supporting this work aimed at strengthening simulation-based postgraduate training. Use of Large Language Models and AI Tools ChatGPT (OpenAI) was used as a supportive tool during manuscript preparation to assist with language refinement, clarity, and organization of text. 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BMC medical research methodology 2016, 16(1):146.https://doi.org/10.1186/s12874-016-0242-z Artino Jr AR, La Rochelle JS, Dezee KJ, Gehlbach H: Developing questionnaires for educational research: AMEE Guide No. 87. Medical teacher 2014, 36(6):463-474.https://doi.org/10.3109/0142159X.2014.889814 VanGeest JB, Johnson TP, Welch VL: Methodologies for improving response rates in surveys of physicians: a systematic review. Evaluation & the health professions 2007, 30(4):303-321.https://doi.org/10.1177/0163278707307 Thomas C, Comfort P, Jones PA, Dos' Santos T: Strength and conditioning for netball: A needs analysis and training recommendations. Strength & Conditioning Journal 2017, 39(4):10-21 Nyimbili F, Nyimbili L: Types of purposive sampling techniques with their examples and application in qualitative research studies. 2024 Malterud K, Siersma VD, Guassora AD: Sample size in qualitative interview studies: guided by information power. 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Education in medicine journal 2019, 11(2):49-54.https://doi.org/10.21315/eimj2019.11.2.6 Braun V, Clarke V: Toward good practice in thematic analysis: Avoiding common problems and be (com) ing a knowing researcher. International journal of transgender health 2023, 24(1):1-6 Kallio H, Pietilä AM, Johnson M, Kangasniemi M: Systematic methodological review: developing a framework for a qualitative semi‐structured interview guide. Journal of advanced nursing 2016, 72(12):2954-2965.https://doi.org/10.1111/jan.13031 Keat WOL, Gauhar V, Castellani D, Teoh JY-C: Tips and pitfalls in using social media platforms for survey dissemination. Société Internationale d’Urologie Journal 2023, 4(2):118-124 o’Doherty D, Dromey M, Lougheed J, Hannigan A, Last J, McGrath D: Barriers and solutions to online learning in medical education–an integrative review. BMC medical education 2018, 18(1):130.https://doi.org/10.1186/s12909-018-1240-0 Singh S, Wassenaar DR: Contextualising the role of the gatekeeper in social science research. South African Journal of Bioethics and Law 2016, 9(1):42-46 Dillman DA, Hao F, Millar MM: Improving the effectiveness of online data collection by mixing survey modes. The SAGE handbook of online research methods 2017:220-238 Omer MM, Rahman RA, Fauzi MA, Almutairi S: Key competencies for identifying construction activities that produce recyclable materials: a competency gap analysis. Built Environment Project and Asset Management 2025, 15(3):699-716.https://doi.org/10.1108/BEPAM-10-2023-0181 Özden M: Content and thematic analysis techniques in qualitative research: Purpose, process and features. Qualitative Inquiry in Education: Theory & Practice 2024, 2(1):64-81.https://doi.org/10.59455/qietp.20 Enworo OC: Application of Guba and Lincoln's parallel criteria to assess trustworthiness of qualitative research on indigenous social protection systems. Qualitative research journal 2023, 23(4):372-384.https://doi.org/10.1108/QRJ-08-2022-0116 McKim C: Meaningful member-checking: A structured approach to member-checking. American Journal of Qualitative Research 2023, 7(2):41-52 Issenberg SB, Scalese RJ: Simulation in health care education. Perspectives in biology and medicine 2008, 51(1):31-46.10.1353/pbm.2008.0004 McCarthy DM, Powell RE, Cameron KA, Salzman DH, Papanagnou D, Doty AM, Leiby BE, Piserchia K, Klein MR, Zhang XC: Simulation-based mastery learning compared to standard education for discussing diagnostic uncertainty with patients in the emergency department: a randomized controlled trial. BMC medical education 2020, 20(1):49.https://doi.org/10.1186/s12909-020-1926-y Brydges R, Hatala R, Zendejas B, Erwin PJ, Cook DA: Linking simulation-based educational assessments and patient-related outcomes: a systematic review and meta-analysis. Academic Medicine 2015, 90(2):246-256.10.1097/ACM.0000000000000549 Rudolph JW, Simon R, Rivard P, Dufresne RL, Raemer DB: Debriefing with good judgment: combining rigorous feedback with genuine inquiry. Anesthesiology clinics 2007, 25(2):361-376.https://doi.org/10.1016/j.anclin.2007.03.007 Cheng A, Morse KJ, Rudolph J, Arab AA, Runnacles J, Eppich W: Learner-centered debriefing for health care simulation education: lessons for faculty development. Simulation in Healthcare 2016, 11(1):32-40.10.1097/SIH.0000000000000136 Cheng A, Palaganas J, Eppich W, Rudolph J, Robinson T, Grant V: Co-debriefing for simulation-based education: a primer for facilitators. Simulation in Healthcare 2015, 10(2):69-75.10.1097/SIH.0000000000000077 Kerins J, Ralston K, Stirling SA, Simpson N, Tallentire VR: Training as imagined? A critical realist analysis of Scotland’s internal medicine simulation programme. Advances in Simulation 2024, 9(1):27.https://doi.org/10.1186/s41077-024-00299-y Lateef F: Simulation-based learning: Just like the real thing. Journal of emergencies, trauma, and shock 2010, 3(4):348-352.10.4103/0974-2700.70743 Additional Declarations No competing interests reported. Supplementary Files S1SBLNeedsAssessmentSurvey.docx S2SBLInterviewGuide.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 23 Feb, 2026 Editor assigned by journal 23 Feb, 2026 Editor invited by journal 18 Feb, 2026 Submission checks completed at journal 17 Feb, 2026 First submitted to journal 17 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8876603","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":596421048,"identity":"b7d4d3a7-4af0-47af-866d-825adf5993d7","order_by":0,"name":"Brekhna Jamil Khan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYBACAwYGZmYgDcSMjQc+HIAJMiQQpaXh4AxStIDBYR5itJhLHz5sXLjDjp1/2uGGwzZntiU2sDdvk2DckYZTi2VfWnLyzDPJzBK3ExsO59wAkjzHyiQYz+TgdtgZHuPDvG1Ax4G1fACSEjlmEoxtFXi08H8GaqlnlgdpsQBpkX9DSAsPczJv22FmA5AWBpDDJHhAWnA7zLKHzdiYt+04syFQ8cGeM7eN23jSii0Sz+D2vjkP82Np3rbqZLnb6Q8f/Dh2W7af/fDGGx93JOPUAgMIFWwgIrGBoA4GO1QuIxFaRsEoGAWjYMQAADbSWhWaMSv5AAAAAElFTkSuQmCC","orcid":"","institution":"Khyber Medical University","correspondingAuthor":true,"prefix":"","firstName":"Brekhna","middleName":"Jamil","lastName":"Khan","suffix":""},{"id":596421049,"identity":"9cf6c857-30fe-48be-a3c4-6bac7817abf7","order_by":1,"name":"Zulfiqar Ahmed Bhutta","email":"","orcid":"","institution":"Institute for Global Health and Development, The Aga Khan University, South-Central Asia, East Africa, and United Kingdom","correspondingAuthor":false,"prefix":"","firstName":"Zulfiqar","middleName":"Ahmed","lastName":"Bhutta","suffix":""},{"id":596421050,"identity":"09fde695-9a2c-4906-b9ba-358cc3255b39","order_by":2,"name":"Jabeen Fayyaz","email":"","orcid":"","institution":"Department of Pediatrics, University of Toronto, Canada","correspondingAuthor":false,"prefix":"","firstName":"Jabeen","middleName":"","lastName":"Fayyaz","suffix":""}],"badges":[],"createdAt":"2026-02-14 03:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8876603/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8876603/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103574741,"identity":"a0063b10-914f-4153-ad67-d2730ad35cad","added_by":"auto","created_at":"2026-02-27 09:05:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1130131,"visible":true,"origin":"","legend":"\u003cp\u003e\u0026nbsp;See image above for figure legend.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8876603/v1/b9ae63eb95d60151d9bf5ae1.png"},{"id":104398831,"identity":"08dc0637-a7f8-4c70-921f-fc565a895dcf","added_by":"auto","created_at":"2026-03-11 12:03:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2539250,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8876603/v1/89206cf5-b504-4bac-bfd9-ff3f4061451a.pdf"},{"id":103574742,"identity":"7627f32f-abe1-4c30-9dc2-702ef6759b68","added_by":"auto","created_at":"2026-02-27 09:05:41","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":33667,"visible":true,"origin":"","legend":"","description":"","filename":"S1SBLNeedsAssessmentSurvey.docx","url":"https://assets-eu.researchsquare.com/files/rs-8876603/v1/4d762ddfede01763394235da.docx"},{"id":103574740,"identity":"e673cb62-fd67-43b4-986a-71615f724054","added_by":"auto","created_at":"2026-02-27 09:05:40","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20160,"visible":true,"origin":"","legend":"","description":"","filename":"S2SBLInterviewGuide.docx","url":"https://assets-eu.researchsquare.com/files/rs-8876603/v1/83733dd3c3b97958382eb95f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Bridging Competence Gaps: A Mixed‑Methods Needs Assessment to Inform a Simulation‑Based Postgraduate Residency Curriculum","fulltext":[{"header":"Background","content":"\u003cp\u003ePostgraduate medical education must prepare clinicians to safely manage high-risk clinical situations and work effectively within interprofessional teams at the point of independent practice [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, training systems that rely primarily on workplace-based apprenticeship produce variable learning opportunities and inconsistent attainment of essential competencies, particularly for emergencies, rare procedures, and non-technical skills where exposure is unpredictable and ethically constrained [\u003cspan additionalcitationids=\"CR3 CR4 CR5\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This variability undermines readiness for independent practice, equity of training experiences, and patient safety [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEducators have widely adopted simulation-based learning to address these limitations by enabling deliberate practice, structured feedback, and reflective learning within psychologically safe environments [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Increasingly, educators and health systems conceptualise simulation as a translational strategy that links education with healthcare quality improvement, risk mitigation, and standardisation of practice in high-stakes clinical domains [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In response, simulation scholarship has shifted from demonstrating effectiveness to examining how programmes embed simulation longitudinally within curricula, assessment systems, governance structures, and organisational safety priorities [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite this evolution, educators in low- and middle-income countries (LMICs) continue to face challenges in sustaining system-level simulation integration [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Studies from LMIC contexts identify barriers including limited faculty expertise, high costs, competing service demands, and weak curricular alignment, alongside strong interest in simulation and recognition of its value for patient safety and quality of care [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. These findings highlight the need for context-responsive and needs-driven approaches to simulation integration.\u003c/p\u003e \u003cp\u003ePakistan provides a relevant LMIC context for examining these challenges [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] The Fellowship of the College of Physicians and Surgeons programme of the College of Physicians and Surgeons Pakistan serves as the national pathway for specialist training across Medicine \u0026amp; Allied, Surgical \u0026amp; Allied, and Paediatrics[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Training occurs predominantly in high-volume hospital environments [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], where learning experiences vary across institutions due to differences in case mix, supervision quality, protected teaching time, and access to structured educational resources [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. As a result, residents experience inconsistent opportunities to develop emergency management, procedural competence, and team-based skills [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSimulation research in Pakistan has largely focused on undergraduate education, faculty perceptions, or isolated specialty-specific initiatives [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] with very limited evaluation of approaches in residency training [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], leaving postgraduate simulation needs across specialties and stakeholder groups within the FCPS system underexplored [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Without system-level needs assessment, simulation risks remaining peripheral rather than functioning as a coordinated strategy for educational quality improvement and patient safety.\u003c/p\u003e \u003cp\u003eIn this study, we conducted a mixed-methods, multi-specialty needs assessment to inform the development of a competency-aligned simulation-based curriculum for FCPS residency training, guided by Kern\u0026rsquo;s framework [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. We identified priority competency gaps, examined stakeholder perspectives on simulation as a system-level educational and patient-safety strategy, and explored feasibility considerations to support scalable integration within postgraduate training systems.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a convergent mixed-methods needs assessment, collecting quantitative and qualitative data concurrently with equal priority and integrating findings at interpretation. This approach enabled a comprehensive understanding of postgraduate simulation needs as a system-level educational and patient-safety strategy and aligned with the first two steps of Kern\u0026rsquo;s six-step curriculum framework [25, 26]. Figure 1 summarises the methodological flow from literature review and CPSP competency requirements through data collection, integration, and curriculum-relevant outputs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003c/strong\u003e\u003cstrong\u003eSetting\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted the study\u0026nbsp;across three CPSP-accredited public-sector tertiary hospitals in Peshawar, Khyber Pakhtunkhwa, Pakistan Khyber Teaching Hospital, Hayatabad Medical Complex, and Lady Reading Hospital, which offer FCPS residency programmes in Medicine \u0026amp; Allied, Surgical \u0026amp; Allied, and Paediatrics [16]. These core disciplinary streams encompass diverse procedural, emergency, and non-technical skill requirements, making them suitable for a cross-specialty simulation needs assessment [16]. Institutional variation in case mix, faculty capacity, and educational infrastructure reflected the heterogeneity of FCPS training environments. Although data were collected in Khyber Pakhtunkhwa, the study was designed to inform national FCPS simulation curriculum development and to be relevant to comparable low- and middle-income postgraduate training contexts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants and Sampling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor the quantitative strand, we used purposive\u0026ndash;convenience sampling, targeting FCPS residents and faculty involved in teaching, supervision, assessment, or programme leadership to identify curriculum-relevant gaps [25, 27-29]. The survey was distributed through official institutional channels using a convenience approach appropriate for needs assessments in busy clinical settings where probabilistic sampling is often impractical [30, 31]. Across three institutions, 400 residents and 450 faculty were invited; 270 responses were received (response rate = 27.0%), including 103 residents (25.8%) and 167 faculty (37.1%). Consistent with guidance for multi-site educational needs assessments, this sample was considered sufficient for identifying system-level priorities based on breadth of stakeholder representation and convergence of findings rather than statistical power calculations [27, 32].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the qualitative strand, we used purposive maximum-variation sampling to recruit faculty members and programme directors for semi-structured interviews [33]. Eighteen individuals were invited, and twelve completed interviews. Sampling was guided by the principle of information power, considering the focused study aim, participant expertise, use of an established framework, and depth of dialogue, with recruitment ceased at thematic sufficiency [25, 34]. Residents were not interviewed because the qualitative focus was on curriculum feasibility, governance, and faculty readiness, and because hierarchical dynamics may constrain candid critique [35, 36]. Resident perspectives were instead captured through anonymous survey responses, with planned engagement during subsequent curriculum co-design and pilot phases [27, 30].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurvey Instrument\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe developed the needs-assessment survey using a theory- and evidence-informed three-step process [25, 30, 37]. Survey items were mapped to FCPS and CPSP postgraduate competency expectations, including emergency care, procedural skills, patient safety, communication, and clinical decision-making, informed by a targeted review of simulation-based education literature and CPSP curriculum documents [6, 16, 38]. Content validity was established through structured expert review by three senior medical educators and three clinician-educators with simulation expertise, guiding refinement of item wording and domain coverage [39]. The questionnaire was pilot tested with ten participants (five residents, five faculty), resulting in minor revisions. The final instrument demonstrated acceptable internal consistency (Cronbach\u0026rsquo;s \u0026alpha; = 0.80) and included Likert-scale and open-ended items. The full survey is provided in Supplementary Material 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterview Guide\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe developed a semi-structured interview guide to explore faculty and programme director perspectives on competency gaps, experiences with simulation-based learning, faculty readiness, and curricular integration. The guide was aligned with survey competency domains to support mixed-methods integration and designed to allow flexible probing [26, 40]. It was pilot tested with two faculty members not included in the final sample, and minor refinements were made to wording and sequencing to improve clarity and flow, consistent with qualitative best practice [35, 41]. The final guide is provided in Supplementary Material 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe collected quantitative data using a self-administered online questionnaire (Google Forms) distributed through official institutional channels and WhatsApp groups across CPSP-accredited training institutions [42, 43]. Institutional gatekeepers (programme directors, supervisors, departmental heads) facilitated dissemination [44]. Participation was voluntary, with electronic informed consent obtained prior to completion. Three reminder messages were issued at three-week intervals to maximise response rates [31, 45], yielding 270 responses (103 residents, 167 faculty).\u003c/p\u003e\n\u003cp\u003eQualitative data were collected through semi-structured interviews conducted online via a secure Zoom\u0026reg; platform by the first author. Gatekeepers identified eligible faculty members and programme directors [44]. With participant consent, interviews were audio-recorded, transcribed verbatim, anonymised, and stored securely in accordance with qualitative research best practice [40, 41].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe analysed quantitative data using descriptive statistics (frequencies and percentages) to summarise participant characteristics, perceived importance and adequacy of postgraduate competencies, and exposure to simulation-based learning. Consistent with the needs-assessment purpose, analyses focused on system-level curriculum prioritisation rather than inferential or subgroup comparisons [25]. Priority training gaps were identified using importance\u0026ndash;adequacy gap analysis by calculating the difference between proportions rating each competency as highly important and adequately addressed, with larger gaps indicating greater unmet need [27, 38, 46]. Open-ended survey responses were analysed using content analysis to identify priority scenarios, barriers, and enablers [47].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQualitative interview data were analysed using inductive reflexive thematic analysis following Braun and Clarke\u0026rsquo;s six-phase approach [40]. Interviews were audio-recorded, transcribed verbatim, and verified for accuracy. Coding was conducted in NVivo\u0026reg; by the research team and two independent qualitative researchers, with discrepancies resolved through consensus. An audit trail and reflexive memos were maintained [48], and member checking with a subset of participants confirmed the resonance of preliminary themes [49].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMixed-Methods Integration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe integrated quantitative and qualitative findings at interpretation using joint displays and narrative weaving [26]. Qualitative data explained importance\u0026ndash;adequacy gaps by illuminating factors such as variable clinical exposure, faculty capacity, and organisational constraints, while elaborating issues of faculty readiness and resources. This integration enabled a comprehensive understanding of postgraduate simulation needs and informed translational simulation design and implementation.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 270 of 500 participants completed the survey (Table 1). Respondents were predominantly male (54.8%), followed by female (42.6%), with 2.6% not reporting gender. FCPS residents comprised 38.3% of respondents, faculty supervisors 36.5%, and programme leadership or senior faculty 25.2%, including programme directors who also participated in qualitative interviews. Participants represented all major FCPS disciplinary streams: Medicine \u0026amp; Allied and Surgery \u0026amp; Allied (each 28.7%), Obstetrics \u0026amp; Gynaecology (22.6%), and Paediatrics (20.0%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Demographic Characteristics of Survey Respondents (n = 270)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e54.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e42.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eStakeholder Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFCPS Residents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003eFaculty Supervisors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e36.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003eProgramme Leadership*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e25.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpecialty Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMedicine \u0026amp; Allied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003eSurgery \u0026amp; Allied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e28.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003eObstetrics \u0026amp; Gynaecology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e22.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 182px;\"\u003e\n \u003cp\u003ePaediatrics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e* Programme leadership includes consultants, programme directors, registrars, fellows, and senior faculty involved in postgraduate training oversight.\u003c/em\u003e\u003cem\u003e\u003cbr\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAcross stakeholder groups, emergency management was rated the highest priority competency (93.0%), followed by procedural skills (88.1%), clinical decision-making (85.9%), patient safety (83.7%), and team-based communication (81.9%) (Table 2). In contrast, perceived training adequacy was substantially lower across all domains, particularly for emergency management (38.1%) and procedural skills (34.1%). Importance\u0026ndash;adequacy gap analysis identified the largest unmet needs in emergency management (55 percentage points) and procedural skills (54 percentage points), followed by clinical decision-making (46 percentage points).\u003c/p\u003e\n\u003cp\u003eQualitative findings explained these gaps, highlighting high expectations for independent practice alongside inconsistent preparedness due to variable clinical exposure. Training experiences were perceived as institution-dependent, contributing to inequitable competency development and mirroring the uniformly low adequacy ratings despite high perceived importance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Perceived Importance, Adequacy, and Importance\u0026ndash;Adequacy Gap for Core FCPS Competencies (n = 270)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRank\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCompetency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRated as Highly Important % (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePerceived as Adequately Addressed % (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eImportance\u0026ndash;Adequacy Gap (pp)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEmergency management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e93.0 (251)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38.1 (103)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eProcedural skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e88.1 (238)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34.1 (92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eClinical decision-making\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e85.9 (232)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40.0 (108)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePatient safety practices\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e83.7 (226)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41.9 (113)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTeam-based communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e81.9 (221)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42.6 (115)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eExposure to simulation-based learning was limited and uneven, with most respondents reporting access to task trainers (56.3%) and mannequin-based simulation (43.7%), while exposure to standardised patients (23.7%) and virtual simulation (14.4%) was uncommon. Despite this, strong support emerged for mandatory integration of simulation within FCPS training programmes (87.8%), reflecting recognition of simulation as a means to address gaps not reliably met through workplace learning.\u003c/p\u003e\n\u003cp\u003eSurvey and open-ended responses converged on priority simulation scenarios, including acute emergencies, high-risk low-frequency procedures, and communication in emotionally charged or time-critical situations. These priorities aligned with the largest importance\u0026ndash;adequacy gaps and were consistent across specialties, supporting the feasibility of a shared, cross-cutting simulation core (Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Priority Simulation Scenarios Identified Across FCPS Disciplinary Streams\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" width=\"633\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDomain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMedicine \u0026amp; Allied\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSurgery \u0026amp; Allied\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eObstetrics \u0026amp; Gynaecology / Paediatrics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCross-Cutting Rationale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEmergency management\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSeptic shock, acute coronary syndrome, cardiac arrest, acute arrhythmias\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePolytrauma, massive haemorrhage, peri-operative cardiac arrest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePost-partum haemorrhage, eclampsia, neonatal resuscitation, paediatric shock\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHigh-risk, low-frequency events with largest importance\u0026ndash;adequacy gaps; limited guaranteed exposure in routine training\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eProcedural skills\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCentral venous line insertion, lumbar puncture, airway management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLaparoscopic suturing, chest tube insertion, emergency airway\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eShoulder dystocia manoeuvres, neonatal intubation, assisted vaginal delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eProcedural competence varies by site and supervision; simulation enables deliberate, standardised practice\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eClinical decision-making\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eDeteriorating patient assessment, escalation of care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIntra-operative complications, post-operative deterioration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eObstetric emergencies, paediatric deterioration algorithms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRequires integration of data under time pressure; difficult to teach explicitly in workplace settings\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCommunication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eBreaking bad news, goals-of-care discussions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eInformed consent for high-risk surgery, error disclosure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eBreaking bad news in obstetrics/paediatrics, counselling families\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEmotionally charged scenarios inconsistently taught; strong qualitative concern across stakeholders\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTeamwork \u0026amp; leadership\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCode blue leadership, ward emergency response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eOperating theatre crisis management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eObstetric emergency drills, neonatal resuscitation teams\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNon-technical skills critical for patient safety; simulation supports role clarity and closed-loop communication\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePatient safety \u0026amp; human factors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHandover failures, medication errors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSurgical safety checklist failures, wrong-site surgery prevention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eObstetric safety bundles, escalation delays\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLimited formal training in safety science; simulation allows systems-focused learning\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEscalation \u0026amp; systems awareness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRecognising limits, timely referral to ICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEscalation to senior surgeon/anaesthesia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEscalation in maternal or paediatric emergencies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAligns simulation with governance, risk management, and quality-improvement priorities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSimulation was widely viewed as a psychologically safe space for deliberate practice and reflection without patient harm. Faculty supervisors and programme directors emphasised that effective implementation requires trained facilitators, structured debriefing, and formal curricular embedding. Although time, infrastructure, and funding were identified as barriers, these were largely seen as manageable through leadership support, faculty development, low-cost simulation models, and phased implementation.\u003c/p\u003e\n\u003cp\u003eThese qualitative insights are summarised in Table 4, which links six interrelated themes to the corresponding importance\u0026ndash;adequacy gaps. Collectively, the integrated findings highlight simulation-based learning as a system-level strategy to improve standardisation, equity, and patient safety within FCPS residency training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Summary of Qualitative Themes, Illustrative Quotes, and Links to Quantitative Findings\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" width=\"671\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCore Insight\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIllustrative Quotations\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eStakeholder\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLinked Quantitative Gap (pp)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1. Expectations of competence and readiness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003eResidents are expected to manage high-risk situations independently by programme completion, yet preparedness is inconsistent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;By the final year, residents are expected to take charge of emergencies, but many still look for reassurance.\u0026rdquo; (\u003c/em\u003e\u003cem\u003eR2\u003c/em\u003e\u003cem\u003e)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;They know the theory, but hesitation becomes evident in real emergencies.\u0026rdquo; (\u003c/em\u003e\u003cem\u003eR4\u003c/em\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003eExplains largest importance\u0026ndash;adequacy gaps in\u003cstrong\u003e\u0026nbsp;\u003cstrong\u003eemergency management (55 pp)\u003c/strong\u003e\u0026nbsp;\u003c/strong\u003eand \u003cstrong\u003eprocedural skills (54 pp)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2. Variability in training experiences\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003eCompetency development depends on institutional context and chance exposure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Some residents see everything; others miss key experiences entirely.\u0026rdquo; (\u003c/em\u003e\u003cem\u003eR6\u003c/em\u003e\u003cem\u003e)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Competency should not depend on which hospital you train in.\u0026rdquo; (\u003c/em\u003e\u003cem\u003eR2\u003c/em\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003eContributes to low adequacy across domains despite high importance: Clinical decision-making: 46 pp\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3. Simulation as a safe learning modality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003eSimulation enables deliberate practice for rare, high-risk events without patient harm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Residents can fail, reflect, and try again in simulation.\u0026rdquo; (\u003c/em\u003e\u003cem\u003eR8\u003c/em\u003e\u003cem\u003e)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Real settings cannot guarantee repeated exposure to emergencies.\u0026rdquo; (\u003c/em\u003e\u003cem\u003eR11\u003c/em\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003eExplains strong endorsement for simulation addressing gaps in: Emergency management: 55 pp\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4. Faculty readiness and development needs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003eEducational value depends on trained facilitators and structured debriefing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Without proper debriefing, simulation becomes just a technical exercise.\u0026rdquo; (\u003c/em\u003e\u003cem\u003eR1\u003c/em\u003e\u003cem\u003e)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Most of us were never formally trained to run simulations.\u0026rdquo; (\u003c/em\u003e\u003cem\u003eR10\u003c/em\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003eLinked to gaps in non-technical domains: Team-based communication: 39 pp\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5. Need for formal curricular integration\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003eSimulation must be embedded and assessed to be prioritised\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;If simulation is optional, it will never be prioritised.\u0026rdquo; (\u003c/em\u003e\u003cem\u003eR8\u003c/em\u003e\u003cem\u003e) \u0026ldquo;Standardisation through simulation can reduce inequities.\u0026rdquo; (\u003c/em\u003e\u003cem\u003eR6\u003c/em\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003eReflects persistent gaps in: Patient safety practices: 42 pp\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6. Barriers and feasibility considerations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003eTime, infrastructure, and resources are constraints but viewed as manageable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Clinical workload is the main challenge.\u0026rdquo; (\u003c/em\u003e\u003cem\u003eR9\u003c/em\u003e\u003cem\u003e)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;With leadership support, these barriers are manageable.\u0026rdquo; (\u003c/em\u003e\u003cem\u003eR5\u003c/em\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003eContextualises gaps across domains\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis mixed-methods needs assessment demonstrates a clear misalignment between competencies essential for safe postgraduate practice and the extent to which current FCPS residency training supports their development. Across stakeholder groups and specialties, emergency management, procedural skills, and clinical decision-making were consistently prioritised yet perceived as inadequately addressed (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The convergence of large importance\u0026ndash;adequacy gaps with qualitative accounts of variable preparedness and inconsistent clinical exposure indicates a systemic educational challenge rather than isolated programme-level deficiencies (Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Collectively, these findings support simulation-based learning (SBL) as a curriculum-level, system-aligned strategy rather than a discretionary educational add-on [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEmergency management and procedural skills emerged as the most critical yet least adequately supported domains. Although over 88% of respondents rated these competencies as highly important, fewer than 40% perceived current training as adequate (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Qualitative findings contextualised these gaps, with faculty and programme directors expressing concern that residents are expected to manage emergencies independently despite limited structured practice (Theme 1, Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). This mirrors international evidence that apprenticeship-based models alone do not reliably ensure exposure to high-risk, low-frequency events or opportunities for deliberate practice, posing risks to patient safety and readiness for unsupervised practice [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMarked variability in training experiences across institutions further explained persistently low adequacy ratings despite high perceived importance. Participants described competency development as dependent on institutional context, case mix, and chance exposure, reinforcing concerns about inequity within workplace-based training systems [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Simulation was viewed as a mechanism to reduce this variability by ensuring standardised exposure to core scenarios, directly addressing gaps in clinical decision-making and patient safety identified in the quantitative analysis (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSimulation was consistently framed as a psychologically safe modality for deliberate practice of rare and high-risk scenarios without patient harm (Theme 3). This perspective explains the strong support for mandatory SBL integration (87.8%) despite limited current exposure to most simulation modalities and aligns with evidence demonstrating the value of simulation for feedback, repetition, and reflective learning in busy clinical environments [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eParticipants clearly distinguished between ad hoc simulation activities and curriculum-integrated SBL (Theme 5). While task trainers and mannequin-based simulations were available, these were described as sporadic and insufficient to influence competency development meaningfully. This aligns with evidence that isolated simulation initiatives have limited impact unless embedded longitudinally and aligned with curricular goals and assessment strategies [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. The strong consensus for mandatory integration supports a system-level approach consistent with international trends in postgraduate education [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFaculty readiness emerged as a critical determinant of effective implementation (Theme 4). Although enthusiasm for SBL was high, limited formal training in facilitation and debriefing was acknowledged. This is notable given evidence that educational impact depends more on debriefing quality than simulation fidelity alone [\u003cspan additionalcitationids=\"CR54\" citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Importantly, cost and infrastructure were not viewed as prohibitive barriers. Instead, participants emphasised phased implementation, faculty development, and low-cost or in-situ simulation approaches, which have demonstrated feasibility in resource-constrained settings [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study extends the simulation literature by examining a national, standardised postgraduate training system within a low- and middle-income country context. Inclusion of Medicine \u0026amp; Allied, Surgical \u0026amp; Allied, and Paediatrics captures diverse procedural, emergency, and non-technical skill demands, strengthening relevance for system-level curriculum reform rather than isolated innovation. By triangulating quantitative gaps with qualitative insights from faculty and programme leadership, the study provides actionable evidence to guide sustainable simulation integration, including prioritising safety-critical competencies, aligning scenarios with FCPS competencies and EPAs, staging faculty development, and embedding simulation within assessment and governance structures [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Future Directions\u003c/h2\u003e \u003cp\u003eThis study relied on self-reported perceptions, which may not fully reflect observed competence; however, such perceptions are central to needs assessment and curriculum prioritisation [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. (Grant, 2002; Kern, 2016). Future work should co-design and pilot a simulation-based curriculum within FCPS centres and evaluate impact using objective performance measures, workplace-based assessments, and patient-centred safety indicators.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Practice and Policy\u003c/h2\u003e \u003cp\u003eAt the FCPS and College of Physicians and Surgeons Pakistan level, the findings support a coordinated translational simulation strategy that defines minimum simulation exposure in safety-critical domains, aligns scenarios with national competencies and entrustable professional activities, and embeds simulation standards within accreditation and quality assurance. Institutionally, phased implementation can prioritise high-risk pathways, utilise low-cost and in-situ simulation, and focus faculty development on facilitation and debriefing. The mixed-methods, multi-stakeholder approach offers a transferable model for other low- and middle-income postgraduate systems integrating simulation within quality and risk-management agendas.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study identifies safety-critical competence gaps in FCPS residency training and demonstrates strong stakeholder readiness for curriculum-embedded simulation. By linking educational needs with governance, faculty capability, and assessment, the findings provide a blueprint for a national translational simulation strategy to enhance patient safety, equity, and postgraduate training quality in Pakistan and comparable resource-variable settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this mixed-methods needs assessment study was obtained from the Khyber Medical University Ethics Board (Ref No. Dir/KMU-EB/DR/1550). The study involved postgraduate residents and faculty members participating in an educational needs assessment and did not involve real patients or clinical interventions. Participation was voluntary, and written informed consent was obtained from all participants prior to data collection. \u003cstrong\u003eAll procedures were performed in accordance with the ethical principles of the Declaration of Helsinki.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This manuscript does not contain any individual person\u0026rsquo;s data in an identifiable form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to institutional policies and the educational context of the data but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by \u003cstrong\u003eSupporting Women In Science Research Grant.\u0026nbsp;\u003c/strong\u003eThe funding body had no role in the study design, data collection, analysis, interpretation of data, or writing of the manuscript.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBJ\u003c/strong\u003e conceptualised the study, led the needs assessment design, supervised data collection, and drafted the manuscript.\u0026nbsp;\u003cstrong\u003eZAB\u003c/strong\u003e supervised and mentored this project and contributed to study design, data collection, and analysis. \u0026nbsp;\u003cstrong\u003eJF\u0026nbsp;\u003c/strong\u003esupervised and\u0026nbsp;contributed to study design, data collection, and analysis.\u0026nbsp;All authors reviewed and approved the final manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge the postgraduate residents, faculty supervisors, and programme leadership who contributed their time and insights to this needs assessment. We also thank the institutional leadership for supporting this work aimed at strengthening simulation-based postgraduate training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUse of Large Language Models and AI Tools\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChatGPT (OpenAI) was used as a supportive tool during manuscript preparation to assist with language refinement, clarity, and organization of text. All content generated with the assistance of the LLM was critically reviewed, edited, and validated by the authors, who retain full responsibility for the accuracy, originality, and integrity of the work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSung T-C, Hsu H-C: Improving critical care teamwork: Simulation-Based interprofessional training for enhanced communication and safety. \u003cem\u003eJournal of Multidisciplinary Healthcare \u003c/em\u003e2025:355-367.https://doi.org/10.2147/JMDH.S500890\u003c/li\u003e\n\u003cli\u003eRobbrecht M: Optimising workplace learning in postgraduate medical education: towards supporting residents and supervisors in clinical practice. University of Antwerp; 2024\u003c/li\u003e\n\u003cli\u003eEraut M: Transfer of knowledge between education and workplace settings. 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A critical realist analysis of Scotland\u0026rsquo;s internal medicine simulation programme. \u003cem\u003eAdvances in Simulation \u003c/em\u003e2024, 9(1):27.https://doi.org/10.1186/s41077-024-00299-y\u003c/li\u003e\n\u003cli\u003eLateef F: Simulation-based learning: Just like the real thing. \u003cem\u003eJournal of emergencies, trauma, and shock \u003c/em\u003e2010, 3(4):348-352.10.4103/0974-2700.70743\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"simulation-based learning, postgraduate medical education, needs assessment, patient safety, curriculum development, low- and middle-income countries","lastPublishedDoi":"10.21203/rs.3.rs-8876603/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8876603/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003ePostgraduate medical training requires competence in emergency care, procedural skills, and patient safety, yet workplace-based learning provides variable exposure, particularly for high-risk, low-frequency events. Simulation-based learning may address these gaps, but evidence for system-level integration in national postgraduate programmes in low- and middle-income countries is limited. This study identified priority simulation needs in Fellow of College of Physicians and Surgeons (FCPS) residency training in Pakistan.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA convergent mixed-methods needs assessment was conducted across three CPSP-accredited tertiary hospitals in Peshawar. A content-validated online survey with good internal consistency (Cronbach’s α = 0.80) was completed by FCPS residents, faculty supervisors, and programme leadership across Medicine \u0026amp; Allied, Surgical \u0026amp; Allied, and Paediatrics (n = 270; response rate = 27%). Competency importance–adequacy gap scores identified priorities. Semi-structured interviews with supervisors and programme directors (n = 12) were analysed using reflexive thematic analysis, with quantitative and qualitative strands equally weighted and integrated using joint displays and narrative weaving.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The largest competency gaps were identified in emergency management (55 percentage points) and procedural skills (54 percentage points), followed by clinical decision-making (46), patient safety practices (42), and team-based communication (39). Simulation exposure across programmes was limited, yet organisational support for mandatory simulation-based learning was high (87.8%), indicating readiness for implementation. Qualitative findings explained these gaps through themes of variable clinical exposure, concerns regarding readiness for independent practice, the value of simulation as a safe environment for deliberate practice, gaps in faculty development particularly in debriefing, and the need for formal curricular and assessment integration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eSubstantial gaps exist between essential postgraduate competencies and current FCPS training. Embedding simulation-based learning as a system-level strategy across curricula, faculty development, and assessment can enhance standardisation, equity, and patient safety in low- and middle-income settings.\u003c/p\u003e","manuscriptTitle":"Bridging Competence Gaps: A Mixed‑Methods Needs Assessment to Inform a Simulation‑Based Postgraduate Residency Curriculum","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-27 09:05:35","doi":"10.21203/rs.3.rs-8876603/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-02-23T17:12:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-23T17:04:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-18T12:55:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-17T21:39:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-02-17T21:34:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"879f4670-e80f-4925-806a-f0a141ca13e3","owner":[],"postedDate":"February 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-27T09:05:36+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-27 09:05:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8876603","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8876603","identity":"rs-8876603","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}