CIN: Computers, Informatics, Nursing & Vol. 33, No.
o. 7, 278–284 & Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.
F E A T U R E
A R T I C L E
Integrating
Problem-Based
Learning and
Simulation
Effects on Student Motivation and
Life Skills
YOUNG SOOK ROH, PhD, RN
SANG SUK KIM, PhD, RN
Nurse educators must determine the best possible inno-
vative teaching strategies to support quality and safety
education for nurses.1,2 Of these strategies, problem-based
learning (PBL) and simulation are increasingly prevalent in
health profession education, with close links to the prin-
ciples of constructivism and collaborative learning.3 A recent
meta-analysis demonstrated that PBL is more effective
than traditional methods in terms of learning and student
satisfaction, and PBL has a moderate to large effect on the
development of cognitive, affective, and psychomotor skills.4
A meta-analysis also found that technology-enhanced sim-
ulation training, in comparison with other instructional
modalities, is associated with better learning outcomes. Dif-
ferences were significant for satisfaction, knowledge, pro-
cess skills, and product skills.5
Although PBL and simulation in isolation have educa-
tional merit, merging these pedagogies has the scope to
link aspects of learning that further enhance and trans-
form knowledge.6 However, some studies have revealed
Author Affiliation: Red Cross College of Nursing, Chung-Ang University
(CAU) Seoul, Korea.
Ethical approval was granted by the institutional review board.
The authors have disclosed that they have no significant relation-
ship with, or financial interest in, any commercial companies pertaining
to this article.
Corresponding author: Sang Suk Kim, PhD, RN, 84 Heukseouk-Ro,
Dongjak-Gu, Seoul, 156-861, Korea (kss0530@cau.ac.kr).
DOI: 10.1097/CIN.0000000000000161
278 CIN: Computers, Informatics, Nursing & July 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Previous research has suggested that a teaching
strategy integrating problem-based learning and
simulation may be superior to traditional lecture.
The purpose of this study was to assess learner
motivation and life skills before and after taking a
course involving problem-based learning and
simulation. The design used repeated measures
with a convenience sample of 83 second-year
nursing students who completed the integrated
course. Data from a self-administered question-
naire measuring learner motivation and life skills
were collected at pretest, post–problem-based
learning, and post-simulation time points. Repeated-
measures analysis of variance determined that the
mean scores for total learner motivation (F = 6.62,
P = .003), communication (F = 8.27, P G .001),
problem solving (F = 6.91, P = .001), and self-
directed learning (F = 4.45, P = .016) differed
significantly between time points. Post hoc tests
using the Bonferroni correction revealed that total
learner motivation and total life skills significantly
increased both from pretest to postsimulation and
from post–problem-based learning test to post-
simulation test. Subscales of learner motivation
and life skills, intrinsic goal orientation, self-efficacy
for learning and performance, problem-solving
skills, and self-directed learning skills significantly
increased both from pretest to postsimulation test
and from post–problem-based learning test to
post-simulation test. The results demonstrate that
an integrating problem-based learning and sim-
ulation course elicits significant improvement in
learner motivation and life skills. Simulation plus
problem-based learning is more effective than
problem-based learning alone at increasing in-
trinsic goal orientation, task value, self-efficacy for
learning and performance, problem solving, and
self-directed learning.
KEYWORDS
Motivation & Patient simulation &
Problem-based learning & Problem solving &
Self-directed learning
that learning is enhanced with the use of simulation
compared with PBL. Steadman et al7 found that simula-
tion led to improved acquisition of assessment and man-
agement skills compared with PBL in medical students.
In other research, pharmacy students in the simulation
group showed significantly better improvements in postquiz
scores compared with the PBL group. The simulation-based
learning group performed at least 15% better in clinical
assessment and critical-thinking skills involving problem lists,
pharmacotherapy plans, and monitoring plans.8 PharmD
students receiving simulation-based learning, compared with
those receiving modified PBL and standardized patients,
performed better on knowledge-based quizzes and had
higher levels of satisfaction.9 A simulation-based learning
group showed significantly higher scores on two postin-
tervention scenarios concerning structure and time than
a PBL group among 45 fourth-year medical students.10
Integration of simulation exercises into the educational
curriculum is an essential feature for their effective use.11
Some studies have demonstrated the beneficial effects of
merging PBL and simulation. One study reported the de-
velopment of a model incorporating PBL in a simulated
clinical environment to support the translation of theore-
tical knowledge into practical skills.12 Incorporation of
simulation learning activities into problem-based discus-
sion appears to be an effective educational strategy for
teaching nursing students to assess and manage crisis events.3
Nursing students in a 9-week fundamental nursing course
integrating PBL and simulation reported significant in-
creases in problem-solving and self-directed learning com-
petency, compared with a traditional curriculum group.13
Nursing students reported favorable perceptions related
to competence and small-group learning and had a favor-
able view of PBL plus simulation, irrespective of their course
grade.14 One study demonstrated that assessors’ scores
showed a mean improvement in patient assessment, clin-
ical decision making, technical and communication skills,
and overall performance after participating in three cycles
of PBL and associated simulations.15 After participation
in a multifaceted educational session using PBL and sim-
ulation, nurses perceived that the education provided an
excellent opportunity to increase their knowledge, whereas
the simulation experience allowed them to practice their
competencies.16 A recent study also reported the positive
impact of PBL and a combined learning method among
nursing students. The PBL group and the group receiving
combined simulation and PBL had higher knowledge and
confidence in skill performance scores than did the tradi-
tional learning method group.
Curricula must not only provide students with the re-
quisite knowledge, skills, and practice, but also foster
learner motivation and life skills.17 While research is needed
to examine the practicality and feasibility of merging two
well-known pedagogies, PBL and simulation, there is rel-
atively little empirical evidence on the motivation and life
skills of nursing students taking part in an integrated course
of PBL with simulation. Thus, there is a need to further ex-
plore whether learner motivation and life skills differ or
change with different self-directed learning strategies. Such
CIN: Computers, Informatics, Nursing & July 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
findings could provide evidence demonstrating the efficacy
of courses integrating PBL and simulation for nursing students.
Purpose
The purpose of this study was to assess learner motivation
and life skills in second-year nursing students taking a
course with integrated PBL and simulation.
METHODS
Design
This study was a repeated-measures design with data col-
lected from nursing students via questionnaires adminis-
tered at baseline (pretest), after PBL (post-PBL), and after
simulation (post-simulation) (Figure 1).
Participants
Regarding sample size, we used G*Power 3 (Heinrich
Heine Universitat, Dusseldorf, Germany) to determine that
60 participants were required for a suitable effect size (d =
0.6) with 95% power and a significance level of .05, using
one-way repeated-measures analysis of variance (ANOVA).18
This effect size estimate was based on a pooled effect size
of 0.62 for multiple learning strategies as reported in a
systematic review and meta-analysis of the comparative
effectiveness of instructional design features in simulation-
based education.19 A nonrandom convenience sample of
second-year nursing students enrolled in an adult health
nursing course in the second semester of 2012 (n = 90)
were invited to participate in the study. After the exclusion
of seven questionnaires because of incomplete data, 83
questionnaires (92%) were used in the final analysis. Of
the 83 participants, approximately 90% were women. They
ranged in age from 19 to 40 years with a mean age of 22.1
(SD, 4.13) years.
Measures
Learners’ motivation was measured using the Korean version
of the Motivated Strategies for Learning Questionnaire
(MSLQ), a self-report instrument designed to assess college
students’ motivational orientations toward a college
course.20,21 A total of 31 questions, each using a 7-point
scale (1 = not true, 7 = very true), make up the six moti-
vation subscales: self-efficacy (eight items), task value be-
liefs (six items), test anxiety (five items), intrinsic goal
orientation (four items), extrinsic goal orientation (four
items), and control of learning beliefs (four items). In the
development and validation studies of the MSLQ,21,22
Cronbach’s ! for the total and domain scores ranged from
.92 to .97. In the current study, Cronbach’s ! for the MSLQ
total and domain scores ranged from .90 to .97.
279
FIGURE 1. Research design.
Life skills were measured using the Life Skills Ques-
tionnaire for Korean college students and adults.23 It con-
sists of three subscales: communication skills (49 items),
problem-solving skills (45 items), and self-directed learn-
ing skills (45 items). Each item is scored on a 5-point Likert-
type scale, from 1 (very uncommon) to 5 (very frequent),
with higher scores indicating a higher level of life skills.
Alpha coefficients reported for the Life-Skills subscales
are .80 for the communication skills subscale, .94 for the
problem-solving skills subscale, and .93 for the self-directed
learning skills subscale.23 In the current study, ! coeffi-
cients for the Life-Skills subscales ranged from .84 to
.91 for the communication skills subscale, from .93 to
.96 for the problem-solving skills subscale, and from .92
to .95 for the self-directed learning skills subscale.
Procedure
An integrated circulorespiratory course was designed based
on the framework of PBL combined with simulation.24 This
course aimed to improve core nursing competence in
the circulorespiratory (ie, cardiovascular and hematologic
care in respiratory system) nursing care area through in-
tegration of PBL and simulation. The three-credit course
consisted of two credits of lectures (30 hours) and one
credit of small-group sessions (15 hours), based on the credit
regulation of the school of nursing. The course was de-
livered as a 4-hour lecture and a 2-hour small-group tutorial
each week. The nursing students were assigned to three
teams of 30 students each. Each team had five groups with
five or six students each. Nursing students were assigned to
a team based on random selection by choosing a number,
and they were informed that their team assignments would
remain the same throughout the course. Two faculty mem-
bers acted as tutors for the three teams.
280 CIN: Computers, Informatics, Nursing & July 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Problem-based learning. Four PBL sessions (2 hours
per session per week) were held for students to gain core
competence in nursing care of patients with chest pain and
dysrhythmia. Problem-based learning scenarios were de-
veloped using actual patient situations at a cardiovascular
intensive care unit of a university hospital in Korea. The
PBL scenario was evaluated by two experienced clinical
nurses who served as subject matter experts. The scenarios
included a 65-year-old male patient with chest pain and a
diagnosis of acute myocardial infarction.
Simulation-based learning. After the PBL session, six
simulation sessions (2 hours per session per week) were
led by two faculty members to help the students acquire
cardiopulmonary resuscitation (CPR) skills. Participants
had a 4-hour ‘‘hands-on’’ session of instructor-led CPR
skills training before a weeklong session of simulation
testing in November 2012. Instructor-led CPR skills train-
ing was defined in the study as simulation-based resusci-
tation training in patient assessment, chest compressions,
ventilations, defibrillation, medication, and other actions
necessary to treat a patient with cardiac arrest due to ventric-
ular fibrillation. Participants were given time to practice
protocols and procedures and received structured educa-
tion from two experienced instructors. All sessions took place
in a nursing simulation center at a college of nursing. The
2-hour testing session was followed by a three-step simula-
tion process consisting of briefing, simulation, and debriefing.
A team of four nursing students was tested at each session.
While one student directed resuscitation efforts, another
student performed CPR or other tasks on the human patient
simulator, SimMan (Laerdal, Stavanger, Norway). As described
in the Advanced Cardiovascular Life Support guidelines,
nursing students were expected to (1) obtain a history, (2)
perform a physical examination, (3) attach noninvasive mon-
itoring, (4) administer medications, (5) perform procedures
and tests, and (6) direct the resuscitative efforts of other
participants.
Institutional review board approval was obtained. Par-
ticipants provided informed consent prior to the baseline
assessment. Students were also informed that they could
refuse to participate or withdraw from participation in
the survey at any time without penalty to them or their
course grade. Nursing students who consented completed
the self-administered questionnaire at baseline, post-PBL,
and postsimulation.
Data Analysis
Descriptive statistics were obtained, and one-way repeated-
measures ANOVAs with post hoc tests (Bonferroni correc-
tion) were conducted on each of the subscales and total
scales using the SPSS version 21.0 program (SPSS Inc,
Chicago, IL). The level of significance was set at .05 for all
tests. In preparation for the single-group analyses, the data
were examined for violations of the statistical assumptions
(independence, normality, sphericity) underlying repeated-
measures ANOVA. A Kolmogorov-Smirnov test revealed
that the distribution of the sample was normal. Mauchly’s
tests indicated that the assumption of sphericity was met
only in the extrinsic goal orientation subscale (# 22 = 2.66,
P = .265), test anxiety subscale (# 22 = 1.13, P = .569), total
life skills scale (# 22 = 5.66, P = .059), communication skills
subscale (# 22 = 1.19, P = .552), and the problem-solving
skills subscale (# 22 = 5.15, P = .076). The Huynh-Feldt
correction was used when the variables violated the assump-
tion of sphericity.
RESULTS
A repeated-measures ANOVA determined that the mean
scores for total learner motivation scale (F = 6.62, P = .003)
and total life skills scale (F = 8.89, P G .001) differed signif-
icantly between time points. Subscale analysis of learner
motivation scale showed that intrinsic goal orientation
(F = 6.90, P = .002), task value (F = 5.20, P = .009),
control of learning beliefs (F = 7.41, P = .001), and self-
efficacy for learning and performance (F = 5.08, P = .010)
differed significantly between time points. Subscale anal-
ysis of life skills scale showed that communication skills
(F = 8.27, P G .001), problem-solving skills (F = 6.91, P =
.001), and self-directed learning skills (F = 4.45, P = .016)
differed significantly between time points (Table 1).
Post hoc tests using the Bonferroni correction revealed that
total learner motivation (P = .009), intrinsic goal orientation
(P = .008), task value (P = .042), self-efficacy for learning
and performance (P = .004), total life skills (P G .001),
communication skills (P G .001), problem-solving skills
(P G .001), and self-directed learning skills (P = .001) sig-
nificantly increased from pretest to postsimulation test.
Total learner motivation (P = .001), intrinsic goal orien-
tation (P = .001), task value (P = .002), control of learning
beliefs (P = .001), self-efficacy for learning and performance
(P = .003), total life skills (P = .005), problem-solving skills
(P = .003), and self-directed learning skills (P = .029)
also increased significantly from post-PBL test to postsimu-
lation test.
DISCUSSION
The present study assessed the effects of a teaching strat-
egy integrating PBL with simulation on learner motiva-
tion and life skills among second-year nursing students in
Korea. The integrated nursing course resulted in a signif-
icant improvement in learner motivation and life skills.
To our knowledge, this is the first report examining the
effects of integrating PBL with simulation on learner
motivation and life skills in a nursing course.

T a b l e 1
Effects of PBL With Simulation on Learner Motivation and Life Skills (n = 83)
Bonferroni
Variable Baseline (A) Post-PBL (B) Post-simulation (C) F P Correction
Learner motivation 5.03 T 0.63 4.88 T 0.96 5.21 T 0.77 6.62a .003 A, B G C
Intrinsic goal orientation 4.94 T 0.97 4.83 T 1.06 5.27 T 0.92 6.90a .002 A, B G C
Extrinsic goal orientation 5.25 T 0.99 5.05 T 1.00 5.29 T 1.01 2.53b .079
Task value 5.28 T 0.85 5.11 T 1.11 5.45 T 0.90 5.20a .009 A, B G C
Control of learning beliefs 5.18 T 0.70 4.87 T 1.14 5.26 T 0.82 7.41a .001 BGC
Self-efficacy for learning and performance 5.06 T 0.89 4.97 T 1.16 5.30 T 0.98 5.08a .010 A, B G C
Test anxiety 4.48 T 1.04 4.42 T 1.07 4.59 T 0.96 1.23b .294
Life skills 3.43 T 0.32 3.46 T 0.41 3.57 T 0.40 8.89b G.001 A, B G C
Communication skills 3.42 T 0.29 3.50 T 0.36 3.57 T 0.39 8.27b G.001 A G C
Problem-solving skills 3.44 T 0.42 3.45 T 0.52 3.61 T 0.45 6.91b .001 A, B G C
Self-directed learning skills 3.44 T 0.45 3.45 T 0.52 3.55 T 0.48 4.45a .016 A, B G C
a
When the sphericity assumption for the variance was not satisfied, the corrected F test (Huynh-Feldt) was applied.
b
When sphericity assumption for the variance was satisfied, the F test was used.

CIN: Computers, Informatics, Nursing & July 2015 281

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 In this study, learner motivation significantly increased from
pretest to postsimulation and from post-PBL to postsimulation.
One previous study has demonstrated that, compared with
baseline, intrinsic goal orientation, control of learning
beliefs, and self-efficacy for learning and performance
improved after a learner-centered pharmacology course.25
The reason for the improvement of learning motivation
associated with simulation was thought to be the expe-
riential learning afforded in the simulation method com-
pared with PBL alone. In our course, a blended approach
integrating PBL and simulation was applied. Experiential
learning provides a useful model for simulation training.
Experience provides the main motivation for learning,
and new knowledge is established from reflection on expe-
rience. The model of learning from experience includes
concrete experience with abstract conceptualization as a
means of perceiving the experience, as well as critical re-
flection and active experimentation as a means of trans-
forming the experience.26 Engaging nursing students in
CPR skills training using simulation provides both the
realism and the time with which to analyze and interpret
scenarios and their outcomes. The experiential learning
process using simulation techniques allows learners to re-
flect critically on how they felt during the simulation. They
could then begin to formulate concepts and hypotheses con-
cerning the experience through discussion and reflec-
tion. Further experimentation with newly formed concepts
and experiences could then lead to further reflection on
experimentation.26
Learner motivation is essential for enhancing students’
academic achievement. Studies have shown associations
between motivation measures and course grades,27,28 per-
sistence, and self-directedness.28 Among medical residents,
total MSLQ scores have shown significant positive asso-
ciations with posttest knowledge scores, and the strongest
domain-specific relationships were between self-efficacy and
control of learning belief scores and knowledge scores.29
Thus, our results provide nursing educators with evidence
demonstrating the usefulness of integrating PBL and simu-
lation to improve learner motivation.
Regarding the effects on life skills, post hoc tests using
the Bonferroni correction revealed that communication and
self-directed learning scores significantly increased from
pretest to postsimulation. Problem-solving scores signif-
icantly increased from pretest to postsimulation and from
post-PBL to postsimulation. The finding that students with
simulation-based learning demonstrated higher competen-
cies than observed with PBL alone is certainly consistent
with many reports.7–10 This result supports the finding that
nursing students in a 9-week fundamental nursing course
with integrated PBL and simulation reported significant
increases in problem solving and self-directed learning, com-
pared with a traditional curriculum group.13Self-directed
learning is a method of instruction that can be defined in
terms of the amount of responsibility the learner accepts
282 CIN: Computers, Informatics, Nursing & July 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
for his/her own learning.30 Evidence suggests that self-
directed learning in education for health professionals is
more effective than lectures in the acquisition of knowl-
edge31 and that simulation is a good way to introduce ac-
tive learning.
Our study demonstrates that simulation plus PBL is more
effective than PBL alone at increasing learner motivation,
problem solving, and self-directed learning. A possible ex-
planation for this result is the greater feedback and learning
time, group work, and lesser extraneous cognitive load asso-
ciated with simulation versus the comparison intervention.5
Williams and Beattie32 contended that PBL provides a
practical clinical teaching approach to guide students in
the acquisition of critical reasoning and practical skills.
However, this approach alone does not replicate the real-
world environment, whereas simulation is the vehicle for
translating classroom knowledge into practice in a safe
learning environment.33 Integrating PBL and simulation
enables students to think aloud and generate knowledge
related to a patient problem in tutorial groups (PBL) and
then practice how they would manage that problem in a
controlled environment (simulation).6 Integrative approaches
that encourage discussion, problem solving, and performance-
based assessment require a commitment to small-group work,
expert facilitation, and a move away from the delivery of
content to the development of integrative competencies.15
Through training that merges PBL and simulation, nurs-
ing students may be able to more efficiently and effectively
develop the necessary competencies for the quality and safety
of patient care.
Instructional design should be based on conceptions of
how students learn and what it means to learn. To comply
with these principles, we designed and implemented a course
merging PBL and simulation based on several educational
principles and models, including adult learning theory, con-
structivism, and reflective practice. Regarding adult learning
principles, adult learners have a readiness to learn what they
perceive to be beneficial for coping effectively in real-life
situations. Students can use high-level activities appropri-
ate for achieving the intended outcomes, resulting in a deep
approach to learning.34 It is crucial for educators to struc-
ture and sequence the PBL and simulation so that the learners’
confidence, critical thinking, and problem-solving skills can
evolve in a coordinated, supported context.6 Cardiopulmo-
nary resuscitation skills are an essential nursing competency
as nurses are frequently first responders in hospital emergency
situations. During orientation, teachers can address the im-
portance of CPR skills by noting the association between
early initiation of resuscitation and positive patient outcome
and, in this way, motivate students who understand that par-
ticipating in the training session may help them cope effec-
tively as nurses in real emergency situations.
This study has a number of limitations worthy of dis-
cussion. Repeated-measures designs are widely used because
they have advantages over cross-sectional designs. For
instance, collecting repeated measurements of key var-
iables can provide a more definitive evaluation of within-
person change across time. Moreover, collecting repeated
measurements can simultaneously increase statistical power
for detecting changes while reducing the costs of conduct-
ing a study.35 However, despite the advantages over cross-
sectional designs, repeated-measures designs complicate the
crucial process of selecting a sample size. Furthermore, the
extent of improvement demonstrated is all that could result
from a single semester of an adult health nursing course,
and intrinsic self-rating scales may affect the validity of
the findings.
CONCLUSION
Curricula must not only provide students with knowledge,
skills, and practice, but also foster learner motivation and
life skills. In this study, a nursing course with integrated
PBL and simulation elicited a significant improvement in
learner motivation and life skills. Simulation plus PBL is a
more effective teaching strategy than PBL alone at increas-
ing intrinsic goal orientation, task value, self-efficacy for
learning and performance, problem solving, and self-
directed learning. This evidence is valuable in helping
nurse educators consider the best possible innovative teach-
ing strategies to support the quality and safety education
of nurses.
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