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this is the discussion form the article .The overall impact of SBE remains unclear. The veracity of positive findings in this review is questionnable. The extraction and synthesis of SBE study findings in this systematic review exposed a body of evidence unsuitable for meta-analysis as a consequence of heterogeneity in outcome measures and poor quality study design. Findings associated with data synthesis revealed primarily positive trends in SBE outcomes with similar effect sizes in knowledge or skills based outcomes and a trend toward larger effect sizes in attitudinal outcome measures. Design flaws in the process and implementation of randomization were a consistent feature impacting on quality and risk of bias. Despite the frequency of positive effects associated with SBE interventions when compared to traditional modes of education, the evidence to indicate SBE was of tangible benefit for knowledge improvement, skill development or attitude adjustment in undergraduate nursing students is limited. Lapkin, Levett-Jones, Bellchambers, and Fernandez (2010) conducted a systematic review examining the effect of human patient simulation manikins in teaching clinical reasoning, and Levett-Jones and Lapkin (2014) conducted a systematic review of the effectiveness of simulation debriefing in health professional education. Both reviews identified a similar trend in design and trial conduct, including a lack of rigorous randomization, poor allocation concealment, and a lack of tested instruments used to collect outcomes data. In addition, these authors raised concerns regarding th

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