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Practice-based simulation model: a curriculum

innovation to enhance the critical thinking skills of
nursing students

AUTHORS
Mee Young Park Sonja R. Cleary
RN, PhD RN, MN
Lecturer, Director of Clinical Simulation, Discipline of Lecturer, Head of Discipline, Discipline of Nursing
Nursing and Midwifery RMIT University, Melbourne, and Midwifery, RMIT University, Melbourne, Victoria,
Victoria, Australia. Australia.
[email protected] [email protected]

Margaret Anna McMillan Leonie Murphy

RN, PhD, OAM RN, Med
Conjoint Professor, School of Nursing and Midwifery, The Lecturer, Discipline of Nursing and Midwifery, RMIT
University of Newcastle, New South Wales, Australia. University, Melbourne, Victoria, Australia.
[email protected] [email protected]

Jane Frances Conway Sharee Kathleen Griffiths

RN, DEd RN, MN
Conjoint Associate Professor, School of Nursing and Lecturer, Discipline of Nursing and Midwifery RMIT
Midwifery, The University of Newcastle, New South University, Melbourne, Victoria, Australia.
Wales, Australia. [email protected]
[email protected]

KEY WORDS
Nursing, simulation, critical thinking, curriculum development, pedagogy.

ABSTRACT
Objective
The purpose of this paper is to describe the Practice-Based Simulation Model (PBSM) as a pedagogical framework
that enables the integration of simulation in a way that ensures critical thinking skills are explicitly taught as part of
the processes and outcomes of students’ learning.

Setting
The PBSM is an innovative pedagogical strategy that offers greater flexibility; one that can be applied to various
types of educational contexts and delivery modes, while simultaneously ensuring desired learning outcomes.

Primary argument
The use of simulation has been gaining popularity because of its capacity to provide effective experiential learning
as a method of enhancing learners’ critical thinking skills. Despite ample literature that highlights the need for the
integration of simulation into nursing curricula, there are few papers demonstrating simulated learning experiences
that are underpinned by sound pedagogy. This paper asserts that simulated learning experiences need to be
integrated into a curriculum underpinned by sound pedagogy, such as the PBSM, in order to ensure that learning
facilitates the development of the critical thinking abilities deemed essential for nursing.

Conclusion
The PBSM demonstrates an example of effective integration of simulation into a curriculum, and highlights the
importance of the integral relationship of simulation as a key component of curriculum.

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INTRODUCTION
Contemporary health care environments require nurses to possess critical thinking abilities in order to tackle
the complexities of practice – which can often be compounded by increasing patient acuity – advancing
technologies and a growing consumer demand for quality of care (Fero et al 2010). In Australia, as elsewhere,
the importance of critical thinking abilities for registered nurses has been well supported (ANMC 2005). The
National Nursing Competency Standards endorsed by the Australian Nursing and Midwifery Council (ANMC)
includes as one of its four main domains of national nursing competencies, “critical thinking and analysis”;
in addition to “professional practice provision”, “coordination of care”, and “collaborative and therapeutic
practice” (ANMC 2005, p.2). Competency for the purpose of this curriculum reform was defined as “an attribute
of a person which results in effective performance” (Australian Nursing Council 2002, p.1). Since education
providers are obligated to demonstrate that intended graduate outcomes are in line with the ANMC National
Competency Standards (Ryan 2009), Australian nursing curricula must be structured in such a way as to
elicit and make explicit critical thinking behaviours. The challenge is to develop a curriculum model based
on sound pedagogy which results in clinical competency augmented by the ability to think critically in clinical
decision-making and problem-solving processes.

Contemporary approaches in simulation are centred on its capacity to provide effective experiential learning
as a method of enhancing learners’ critical thinking skills (Fero et al 2010; Brannan et al 2008; Rush et
al 2008). Despite recent calls for the integration of simulation into nursing curricula, there is little in the
literature that demonstrates simulated learning experiences underpinned by a sound pedagogy (Parker and
Myrick 2009). This paper describes the main features of the PBSM as a pedagogical framework that enables
the integration of simulation in a way that ensures critical thinking skills are explicitly taught as part of the
processes and outcomes of students’ learning.

Critical Thinking and Simulation

Martin’s (2002) definition of critical thinking, the “thought process used by nurses for clinical decision-
making” (p. 243) is utilised for the purpose of this curriculum model development. While it is necessary to
acknowledge that critical thinking is needed for problem-solving and complex decision-making, it is also
essential to recognise that critical thinking is not an independent skill, but rather one that develops in the
context of domain knowledge. Learners’ abilities in decision-making and problem-solving are best improved
through repeated experiences, or practice with thinking as it relates to specific knowledge domains (Rush
et al 2008).

Although clinical placement provides the best opportunity for students in repeated exposure to practice, the
efficacy of current approaches to clinical education has been frequently questioned. It is acknowledged that
given the increasing dynamics of health settings, the likelihood that student nurses develop competence and
critical thinking skills for practice in those environments is limited (Lunney 2008; Jeffries 2007; Watson et al
2002). Simulation, on other hand, enables the repetition of clinical experiences that are considered infrequent
but critical, or events where students are unable to participate due to patient safety concerns. Simulation as
an educational method provides an opportunity to structure learning systematically to help students acquire
deep content knowledge and to facilitate the development of critical thinking processes (Brannan et al, 2008;
Schumacher 2004). Simulation contextualises various types of clinical practice situations, the most common
being to provide an opportunity to present patients with deteriorating conditions. This requires learners to
recognise, interpret and integrate new information with their previous knowledge so as to make decisions about
the course(s) of action to follow (Liaw et al 2011; Watson et al 2002). Following the simulation, debriefing
allows learners to be challenged and to critically review their decision-making processes and performances

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and to identify further learning needs. Therefore, it is argued that simulation learning experiences encourage
the development of critical thinking skills and help learners become more competent in the care of patients
and complex conditions (Decker et al 2011; McGaghie et al 2010).

Despite the overwhelming expectation of simulation effects on learners’ critical thinking skills, the evidence
to support this expectation seems insufficient. Recent experimental studies (Massias 2010; Brown and
Chronister 2009; Ravert 2008) have failed to prove whether simulation-assisted learning is more effective
than non-simulation-assisted learning in improving learners’ critical thinking skills. Lapkin et al (2010), in
their systematic review of the literature, also report mixed findings. This current literature review found only
two experimental studies (Howard 2007; Schumacher 2004) which showed significant improvement in the
critical thinking abilities of nursing students after exposure to simulation activities. Another study, by Fero et
al (2010) examined the relationship between critical thinking skills and simulation-based performance using
videotaped vignettes and a high-tech patient simulator. This study employed the California Critical Thinking
Disposition Inventory and the California Critical Thinking Skills Test, and reported a statistically significant
correlation between performance in simulation and overall critical thinking disposition scores. Despite
these recent studies suggesting a positive correlation, the methodological limitations of these studies, such
as small sample size and use of convenience sampling, has resulted in insufficient evidence to support a
concrete correlation between the uses of simulation and improved critical thinking skills. The difficult task of
demonstrating the effectiveness of simulation in improving critical thinking skills with significant randomised
sample sizes has been deemed impractical (Lapkin et al 2010). In addition, designing experimental studies
that require extensive periods of time and allow sufficient exposure to simulation before testing is challenged
by the difficulty related to meeting ethical underpinnings of research and those principles of assessment that
centre on equity for all students.

This paper argues that simulation, when incorporated into structured learning, creates an opportunity for
educators to provide a framework to enable students to develop a full suite of skills; to be team players, to
work collaboratively with others, to engage in determining solutions in particularly challenging situations, to
make decisions based on sound judgments, and to develop critical thinking in a safe supportive environment.
However, it is important to note that as not all experiences lead to meaningful learning, and that learners’
exposure to simulation does not always result in the desired learning outcomes, including critical thinking
skills. Critical thinking is best developed through repeated exposures to practice where learners’ thinking
processes are supported by integrated contextual knowledge, skills, and behaviours (Helsdingenet al 2011;
Simpson and Courtney 2002). Simulation, therefore, that is integrated into a curriculum based on sound
pedagogy will ensure that learning facilitates the development of the critical thinking abilities.

There is a dearth of literature demonstrating the integration of simulated learning experiences in nursing
curricula underpinned by a pedagogy (Schlairet 2011; Parker and Myrick 2009). A number of authors have
suggested merging simulation into an integrated Problem Based Learning (PBL) curriculum (Murphy et al
2010; Park et al 2009; Wong et al 2008). PBL has long been recognised as a mechanism to provide an
integrated approach to acquiring the knowledge, skills, and behaviours required for effective clinical practice,
and therefore having the potential to enhance critical thinking skills (Oja 2011); however, many models of
PBL do not achieve this outcome (Hmelo-Silver et al 2007). A totally integrated PBL curriculum, focusing
mainly on the classroom activities is impractical, particularly when considering the competing challenges
associated with the shortage of nursing academics and increasing student enrolment, challenges which have
driven an emphasis on cost-effectiveness in educational delivery and an emerging on-line presence (Howard
et al 2011). Therefore, there is a need for an innovative pedagogical strategy that offers greater flexibility;
one that can be applied to various types of educational contexts and delivery modes, while simultaneously
ensuring desired learning outcomes.

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The Practice-Based Simulation Model (PBSM)

The Practice-Based Simulation Model was initially conceptualised by the first author, drawing both on the
literature and professional expertise gained through leading the development, implementation and evaluation
of the Simulation-Problem Based Learning (S-PBL) curriculum in Korea (Park et al 2009). The PBSM was then
further refined through an action based project involving a series of trials and modification of the model during
2009-2010 by the authors at one Australian university. The PBSM is currently employed in five undergraduate
courses in a Bachelor of Nursing program, and within two postgraduate nursing programs. The results of the
evaluation study of the PBSM implementation is being prepared for later publication.

The PBSM is based on constructivist learning theory which asserts that knowledge is not passively transferred
from educator to learner, but constructed by the individual learner through the processing of experiences and
interactions with their environment (Parker and Myrick 2009). Constructivist learning theory is operationalised
through valuing concepts of active learning, authentic or situated learning, and collaborative learning (Pritchard
and Woollard 2010).

The PBSM is a learner-centred curriculum model that was developed with the aim of achieving effective
simulation integration, and to clearly demonstrate the integral relationship of simulation as a potentially
key component of curriculum. The learning of critical thinking skills is explicit to the PBSM as linked to the
process of planning, implementation and evaluation of curriculum in order to achieve these skills as part of
the desired outcomes.

Elements of the Practice-Based Simulation Model

The PBSM as a curriculum model is composed of a series of learning modules. Each learning module is
organised around one practice situation, which is carefully selected to represent a cluster of key learning
concepts. One or two learning modules collectively form a subject and these are mapped out to reflect
achievement of the desired outcomes of the entire curriculum. The PBSM has five elements: practice situation,
simulation, structured learning, inquiry process, and assessment. All of these elements are interlinked and
work together, as shown in figure 1, to systematically guide and effectively drive the learners’ knowledge
construction. This section provides the rationale for each element and elaborates their role within the Practice-
Based Simulation Model.

Figure 1:
The interlinking of elements in
the Practice-Based Simulation
Model.

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Practice Situation
The practice situation is the core of curriculum design and the main thread holding each of the elements
together. It provides the focus for learning and assures the clear integration of learning concepts within the
framework of nursing professional practice (Conway et al 2000). To develop an effective PBSM learning
module, a quality practice situation must be designed and integrated into the curriculum. The quality design
of practice situation and aligned simulation learning experiences ‘integrate thinking and doing’ during
learning processes and inform action-oriented decision-making by learners. The materials replicating practice
situations should: be authentic and reflect real world practices; provide specificity and direction for learners
around time, place and role; include social, political, and ethical components; and recognise the potential
for multimedia to enhance the fidelity of simulation (PROBLARC 2000).

A practice situation is often referred to as a case and involves a ‘problem’, a ‘patient case’, or a ‘scenario’
depicting various people and/or situations. In the PBSM, the term ‘practice situation’ is used to emphasise
the point that the stimulus material should not merely be a patient case, but should include practice context
surroundings in which the patient and the nurse are physically, socially, and emotionally located (Fero et al
2009). Even a quality practice situation taken from real-world practice often requires re-structuring to guide
the learning process. This re-structuring includes situation descriptions, formulation of relevant cues, and
their effect on priorities. During this process, clinicians’ involvement is critical to ensure the similarity to real-
world situations in content, importance, and direction of the relationships (Chiarella et al 2008).

Simulation
Although various types of simulation technologies are employed in the clinical laboratory sessions, simulation
as an element of this model refers to a form of immersive simulation where learners are required to take
the role of a clinician within a replication of real practice situation. The learners are required to analyse
the clinical situation, to formulate appropriate care, to prioritise and to deliver the care within the real-time
practice environment. Simulation in this model, therefore, provides a venue for training learners’ ability to
think critically and engage in clinical reasoning.
The “practice situation” in the PBSM provides a full description of a nurse-patient encounter, while the simulation
scenario represents a snap shot of a particular portion of that situation. Depending upon the purpose of
the learning module, one or a series of snap shots can be taken and employed as simulation scenarios in a
learning module. The scenarios are usually sequential in order to imitate the changing, contingent situations
of a nurse-patient encounter. These sequential multiple encounters enable and reinforce learners’ ability to
recall previous knowledge and to apply this to new experiences. This allows learners to construct a deeper
level of processing, therefore improving their clinical reasoning skills (Hoffman et al 2011).

A typical immersive simulation session within this model includes a process of 10-15 minutes of pre-briefing,
10-15 minutes of simulation encounter, and 20-30 minutes of debriefing. A remedial follow-up is arranged
when considered necessary. Debriefing allows a venue for the teaching of critical thinking skills in the context
of specific subject matter (Dreifuerst 2010). The debriefing process involves a learner’s critical review and
discussion of the decision-making process within the simulation encounter and a reflection of the learners’
own cognitive strategy. This is considered as a typical, but very effective mode for the instruction of critical
thinking skills (Helsdingen et al 2011).

The PBSM suggests that various forms of debriefing be used, according to the learner’s level of preparation, and
in order to meet the objectives of the learning module. A facilitator guided debriefing is useful for beginners to
be trained in learning from reflection. The debriefing facilitator encourages learners to collaboratively engage
in constructive processing by redirecting their attention, pushing them to think deeply, and modelling the

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clinical reasoning process that clinicians would perform in real practice (Dreifuerst 2010; Hmelo-Silver et al
2007). Peer debriefing in the PBSM is used to promote learners’ engagement in structured observation, to
critically evaluate, and to provide peer feedback, in a professionally appropriate manner. A written form of
debriefing is particularly useful in providing learners with time to reflect on their performances and emotions.
This allows educators to have access to the individual learner’s perceived learning through the simulation
(Petranek 2000).

Practice situation and simulation are the elements of the PBSM emphasising the goals of authenticity. The
PBSM employs real-world practice situations as the focal point of all learning and assessment strategies, and
further reinforces authenticity through the use of immersive simulation. This approach then locates learners’
performance within a realistic encounter with an imitated practice situation. Therefore, the PBSM increases
the chance of transferability of on-campus learning to clinical settings.

Structured Learning
Structured learning in this model refers to that element concerned with the way the learning of the essential
content of a curriculum is achieved. It is important that educators achieve a consensus on the essential
learning content of the profession and how this can be best transferred to their learners. The PBSM includes
regular, structured learning sessions such as lectures, tutorials, clinical skill labs, and web-based interactive
learning sessions. One criticism of constructivist learning approaches, such as PBL and Inquiry Based Learning
(IBL), has been that certain models used by these approaches place too much emphasis on the discovery
journey of learning, but provide minimal instructional support. Such an approach has been reported to be less
effective and efficient than conventional instructional approaches that provide sufficient guidance to student
learning process (Kirschner et al 2006). While the importance of learners being engaged in the self-directed
and collaborative construction of knowledge is still valued, the PBSM endeavours to reduce excessive cognitive
loading for the learners by providing a more focused approach through the use of various types of direct and
indirect instructions. The PBSM supports the inclusion of direct instruction such as regular lecture sessions,
but these must be provided in a timely manner; generally once learners have identified their learning gaps
and understand the relevance of the information through analysing the practice situation.

Indirect instruction is presented during tutorials, clinical laboratory sessions, and online interactive activities,
as a type of scaffolding activity. For example, clinical laboratory sessions in the PBSM are designed to a foster
collaborative learning environment using vignettes and multimedia content. The educator acts as a facilitator
to discuss a vignette – often one that directly relates to the practice situation – so that skills are taught
within the context of the practice situation. Ideally learners will have access to computers to retrieve relevant
information and to learn collaboratively with their peers. The facilitator assists learners’ understanding and
development by prompting learners to explain or identify the limits of their knowledge and skills. Direct skill
demonstration is given once the collaborative learning is undertaken and considered necessary to articulate
complicated procedures. Such timely direct and indirect instruction promotes knowledge construction in a
way that makes knowledge available for future use in relevant contexts (Edelson 2001). Structured learning
sessions in the PBSM aim to encourage learners to move beyond their limitations and engage in complex
tasks that would otherwise be beyond their current abilities (Hmelo-Silver et al 2007).

Inquiry Process
Concurring with Facione’s (2011) views on critical thinking as a vital tool for inquiry, the inquiry process in
this model is an element which focuses on enhancing learners’ critical thinking skills and preparing them to
be life-long learners. The strategies to promote learners’ inquiry processes are distributed in each element
of the PBSM and across the curriculum, so as to focus on gradual improvement in learners’ critical thinking

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skills. For example, the choice of appropriate debriefing method directly relates to elements of the inquiry
process. The selection and design of inquiry process strategies are guided by a set of core critical thinking
skills and sub-skills identified by an international group of experts in critical thinking through a Delphi study
conducted by Facione (Facione 2011, 1990); this is outlined in table 1.

Table 1: Core Critical Thinking Skills and Sub-skills, adapted from Facione (2011)

Core critical thinking skills Sub-skills

Interpretation Categorise, decode significance and clarify meaning
Analysis Examine ideas, identify arguments, and identify reasons and claims
Inference Query evidence, conjecture alternatives, and draw conclusion using inductive
or deductive reasoning
Explanation State results, justify procedures, and present arguments
Self-regulation Self-monitor and self-correct

One of the main features of the PBSM model is its use of pre- and post-concept mapping as a mean to aid
learners’ self-evaluation of their learning needs and outcomes. Concept mapping has been reported as an
effective tool in helping learners develop problem solving and critical thinking skills (Hsu and Hsieh 2005;
Wheeler and Collins 2003). Pre-concept mapping assists learners in the engagement of cognitive processes
such as organising, categorising, analysing, evaluating, and reasoning critically (Taylor and Wros 2007;
Rafferty and Fleschner 1993). During pre-concept mapping, learners’ decisions are based on the recognition
of aspects of the practice situation, matching recognised aspects with previous knowledge and experiences.
The learners are required to formulate set of care decisions to manage the situation. These decisions are often
incomplete or inconsistent because of missing information, insufficient evidence, and unproven assumptions
(Helsdingen et al 2011). The result of pre-concept mapping therefore reinforces learners’ impetus towards
identifying their learning needs and motivates their seeking for further information. Pre-concept mapping
aims to foster the core critical thinking skills of interpretation, analysis, and inferences (table 1).

Post concept mapping aims to promote learners’ self-reflection on ‘knowing’ and the ‘process of knowing’ by
allowing learners to revisit the practice situation and compare their pre- and post-concept maps. This process
allows learners to engage in the core critical thinking skill of explanation (table 1). A ‘reflective summary’ –
an individual written assignment – replaces the post-concept mapping for experienced learners. Towards
the close of a module, following an immersive simulation and debriefing, learners are required to revisit the
practice situation and reflect upon their decisions, decision making processes and performances, and to
rationalise or critique their decisions based on scientific evidence. Therefore, a reflective summary aims to
foster learners’ self-reflection on ‘knowing and doing’ and provides opportunities to learn the core critical skill
of self-regulation (table 1). The authors suggest that educators make explicit the objectives of the strategies
to learners during the implementation of inquiry process, so that the value of the activities is well-accepted
in order to motivate learners’ participation, particularly when the strategies are not incorporated as part of
formal assessment.

Assessment
Assessment as one of the five elements of the PBSM displays close links to the practice situation so learning
is re-directed to the specific context. Assessment, and assessment strategies that direct students’ learning,
must be congruent with the goal of the curriculum (which in the case of undergraduate nursing education is
most often the achievement of professional competency as provided by the registration body) (Ryan 2009).
Competency builds on a foundation of basic clinical skills, scientific knowledge, moral development, and
cognitive functions, such as critical thinking (Epstein 2007). As Epstein (2007) emphasises, it is vital to have

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multiple methods of assessment to cover all dimensions of competency, particularly by using a longitudinal
approach within a curriculum and so avoid excessive testing at any one point in time. This will allow educators
to monitor gradual improvement of learning outcomes and learners’ knowledge base, and assess improvements
in levels of skill against criteria informed by statements and standards within a suite of nursing competencies.

The PBSM advocates the use of simulation in assessing the clinical component of the curriculum as it allows
educators to formatively assess in ways that are consistent with the knowledge, skills, and attitudes underpinning
competent performance. Epstein and Hundert (2002) argue that conventional methods of assessment may
“underemphasise some important domains of professional practice, including interpersonal skills, life-long
learning, professionalism, and integration of core knowledge into clinical practice” (p. 226). Most on-campus
assessment methods in health professional education still evaluate a single dimension of competency, such
as knowledge or skills, rather than integrating both and explicitly assessing the processes which underpin
them (Epstein 2007; Epstein and Hundert 2002). Simulation has been recognised as a desirable method for
assessing competency as it allows for the evaluation of learners’ performance in real-time and in a realistic
practice situation (Decker et al 2011; Scalese et al 2008). Simulation-based assessment allows educators
to simultaneously examine numerous learners, all exposed to identical scenario conditions, that can be
reproduced over time and are highly realistic; thereby creating fairer grounds for assessment, while at the
same time eliminating threats to patient safety (Spunt 2007; Boulet et al 2003).

Although simulation has been reported as an effective way of assessing learners’ practical skills and other
non-vocational qualities, scepticism towards using clinical simulation in learner assessment still exists
(Donoghue et al 2009; Ryan 2009; Brannan et al 2008). Boulet et al (2003) criticise the reliability of simulation
assessment as being strongly influenced by the types and number of simulation encounters. Thus, in the PBSM
it is advocated that accommodations be made for multiple simulated encounters to encompass a broader
range of practice domains in order to effectively and accurately assess learners’ abilities in clinical settings.
Although the PBSM actively utilises various forms of simulation for formative assessment and feedback for
students across the curriculum, the use of immersive simulation as a summative assessment is recommend
only in the final year of a program. This is to ensure that learners have had sufficient exposure to simulation
and spent adequate time to prepare for a fair and accurate appraisal of their readiness for transition to the
workforce. It is also essential to create reasonable expectations about the demands of these assessment
tasks for both educators and learners.

There is an ongoing need for staff development in all aspects of the PBSM, but particular emphasis needs to
be focused on assessing the processes that learners develop during a program. Unless nurse educators are
able to agree on behaviours that reflect critical thinking and to design assessment activities that elicit both the
process of developing critical thinking and the outcomes of its application to nursing practice, the evidence
that nurses can and do think critically will continue to be questioned. In times of diminishing resources within
universities there has been a tendency to rationalise assessment methods to product-oriented, summative
assessment, such as written assignments or essays, knowledge tests, or observation of performance of
clinical procedures. Those involved in nurse education need to develop valid, reliable, efficient, and effective
tools for assessing critical thinking as a process integral to both practice and learning.

CONCLUSION
In summary, the Practice-Based Simulation Model is an innovative curriculum model underpinned by
constructivist pedagogy that is designed in such a way as to ensure critical thinking skills are explicitly

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taught as part of the processes and outcomes of students’ learning. The interlinking of five elements of this
model – practice situation, simulation, structured learning, inquiry process, and assessment – provides a
framework for educators to use in the process of design, implementation and evaluation of a curriculum and
to systematically assist knowledge construction of learners.

The PBSM demonstrates an example of effective integration of simulation into a curriculum, and highlights the
importance of the integral relationship of simulation as a key component of curriculum. The authors assert
that simulated learning experiences need to be integrated into a curriculum underpinned by sound pedagogy,
such as the PBSM, in order to ensure that learning facilitates the development of the critical thinking abilities
deemed essential for nursing.

One of the critical features of this model is its flexibility to be applied into various types of educational contexts
and delivery modes. Since its development in 2010, the PBSM has been utilised for various courses and
programs of undergraduate, postgraduate, and clinical education. The informal and formal evaluations of these
efforts strongly support its value and usefulness for simulation integrated teaching and learning practice. A
longitudinal study examining the effect of the PBSM is needed to support the correlation between the use
of simulation and enhanced learners’ critical thinking skills.

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