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This issue of CDTL Brief features three Teaching Enhancement Grant projects by colleagues from various departments and faculties.

April 2009, Vol. 12 No. 1 Print Ready ArticlePrint-Ready
An Integrated Simulation Problem-based Learning Activity
Ms Liaw S.Y.; Associate Professor Chen, F.G.; Dr Klainin, P.;
Dr Brammer, Dr O’Brien, A.P. & Dr Samarasekera, D.D.
Alice Lee Centre for Nursing Studies
Yong Loo Lin School of Medicine

The Alice Lee Centre for Nursing (ALCNS) at NUS uses the problem-based learning (PBL) approach for its undergraduate nursing programme. ALCNS has been keen to integrate simulation technology into PBL to provide opportunities for nursing students to apply theories learnt from the PBL session to real life situations. The main focus is to develop students’ clinical competency in providing safe, competent, timely and appropriate patient care during crises.

Nurses need to be competent in identifying patients at risk and implementing immediate interventions to manage crises. Although the clinical laboratory and clinical practicum in the preregistration nursing curriculum provide nursing students with valuable learning experiences, they may not be exposed to clinical crises during such sessions. Technological advancement in nursing education has allowed the use of a human patient simulator, which is able to simulate a variety of patient conditions and create opportunities for students to learn how to manage an unexpected situation in a planned and prescribed way. One of the major strengths of simulation-based learning is thatit provides students with hands-on practice in solving ‘real life’ problems without the fear of harming a ‘real’ patient.

With the support of CDTL’s Teaching Enhancement Grant, a quasi-experimental crossover study was conducted to evaluate the use of a simulated learning activity in teaching nursing students how to identify and manage a crisis. It was hypothesised that the clinical performances of nursing students who had experienced a simulated learning activity during PBL discussion would be superior to those who had only completed conventional PBL discussion.

First year nursing students in the Bachelor of Science (Nursing) programme, who undertook a nursing module on caring for patients with respiratory and cardiovascular disorders, were assigned to either a simulated situation with problem-based discussion (SPBD) or problem-based discussion (PBD) group for their PBL scenarios on respiratory and cardiac cases. Both SPBD and PBD groups worked on the scenarios in a 2-hour brainstorming session where students attempted to identify clinical problems and develop hypotheses and learning issues through group discussion. Students then had time for self-directed learning to research their assigned ‘learning issue’. Group members reconvened during the following week to re-examine the scenarios. The PBD group discussed their learning issues and information to resolve the crisis presented in the scenarios. SPBD students reconvened and went through a hands-on session to manage the crisis using the high-fidelity SimMan patient simulator. This was followed by a debrief in which students discussed findings from the individuals’ learning issues and how the situation might have been managed more effectively.

Following the completion of each case scenario, students were invited to sit for a test on systematic assessment and management of a simulated patient in a crisis. A total of 30 nursing students participated in the first test related to a respiratory scenario and 33 nursing students participated in the second test related to a cardiac scenario. Their performances were scored using validated checklists. The mean scores of students who had gone through SPBD was significantly higher than those who went through the PBD (see Table 1).

Table 1. Comparison of post-test scores for SPBD and PBD

The study supports the use of simulation with problem-based discussion as a more effective way of teaching students how to identify and manage a crisis as compared to the use of problem-based discussion alone. There are several reasons the integration of simulation into problem-based discussion results in superior learning outcomes. One is that simulation provides learners with an opportunity to practise their clinical skills in a realistic and non-threatening environment. This allows them to review and practise their skills as a whole and develop a systematic approach to crisis management (Weller, 2004). Repetitive practice is crucial for clinical skill acquisition as it makes skill demonstration effortless and automatic (Issenberg & Scalese, 2005). In this study, students in the SPBD group were engaged in repetitive practice after their clinical skills laboratory.

In addition, simulation facilitates contextual, constructive and active learning. The transfer of learning from paper to a realistic clinical situation through simulation enhances contextual learning in PBL. The clinical experiences gained from the simulation allowed students to link these experiences to their discussion of the problem. This enabled students to build more personal interpretations of the problem and thus, enhanced the problem-based discussion (Mamede, Schmidt & Norman, 2006). Also, the simulation, which involves a variety of learning strategies such as role play, videos and discussion, enhances the learning outcomes in PBL by engaging students. Jeffries (2002) stated that using a variety of learning strategies in simulation can accommodate students’ diverse learning styles, which is an important pedagogical principle of good teaching. According to Hodgson (1997), learning is deepened when learners are able to perceive the meaning and intrinsic relevance of the subject matter to their own purposes. Immersion into the nursing role through simulation provides students with more valuable insights on the relevance of their clinical skills and knowledge in their field of work.


Hodgson, V. (1997). Lectures and experience of relevance. In F. Marton; D. Hounsell & N.J. Entwistle (eds.). The experience of learning: implications for teaching and studying in higher education (pp. 159–171). Edinburgh: Scottish Academic Press.

Issenberg, S.B. & Scalese, R.J. (2007). Best evidence on high-fidelity simulation: What clinical teachers need to know. The Clinical Teacher, 4(2), 73–77.

Jeffries, P.R. (2002). A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26(2), 96–103.

Mamede, S.; Schmidt, H.G. & Norman G.R. (2006). Innovations in problem-based learning: What can we learn from recent studies? Advances in Health Sciences Education, 11(4), 403–422.

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An Integrated Simulation
Problem-based Learning Activity
Effectiveness of the Classroom Response System in Tutorials
Real-time Feedback/
Teaching System:
Development and Applications