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

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.