Thai nursing students’ formative experiences of simulation-based learning: Implications for facilitation and debriefing

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Methods: A qualitative descriptive study was conducted as the qualitative strand of a broader mixed-methods project in an undergraduate nursing programme in Eastern Thailand. Between August and October 2024, 24 third- and fourth-year students participated in in-depth, semi-structured interviews in Thai (face to face or via Zoom). Interviews lasted 45–60 minutes, were transcribed verbatim, and analysed using reflexive thematic analysis. Results: Four themes were developed. Entering a New Space framed simulation as a “third space” between classroom and ward, with heightened visibility and realism alongside culturally patterned restraint. Stress and Roles as Catalysts for Learning showed that pressure could sharpen focus yet narrow voice, especially when feedback felt abrupt or ill-timed. The Duality of Participation and Observation highlighted complementary learning routes: performers learned through accountable action under time constraints, while observers gained analytic perspective and re-read events in debriefing. Facilitation and Cultural Safety emphasised that calm guidance supported participation, whereas harsh correction often intensified silence linked to kreng-jai. Conclusion : SBL was experienced as more than technical practice; tone, timing, and role design mattered. Explicit observer objectives and structured debriefing may strengthen culturally safe participation and fair learning opportunities. simulation-based learning nursing students debriefing cultural safety Thailand Figures Figure 1 Introduction The transition from classroom learning to clinical practice remains a recurring challenge in nursing education (Alharbi, Nurfianti, Mullen, McClure, & Miller, 2024). In Thailand, undergraduate curricula integrate lectures, skills laboratory training, and hospital placements; nevertheless, second-year students have described early clinical practice as a period marked by lack of confidence and anxiety when caring for real patients (Arpanantikul & Pratoomwan, 2017). This theory–practice gap becomes particularly visible at the bedside: students may remember procedural steps, yet hesitate when they must prioritise, communicate, and act under authentic clinical pressure (van Graan, Williams, & Koen, 2016). Simulation-based learning (SBL) is widely used in nursing education to help narrow the theory–practice gap by offering a structured space where students can practise, make errors, and receive feedback without compromising patient safety (Alharbi et al., 2024; Diaz-Navarro et al., 2024). Evidence suggests that SBL can support students’ confidence, clinical judgement, and teamwork, although outcomes vary across programmes and settings (Bray & Østergaard, 2024; Cant & Cooper, 2017). For some students, simulation becomes a moment that feels real—a point at which they begin to see themselves acting in the nurse’s role rather than only learning about it (Skedsmo et al., 2023; Xuto et al., 2025). At the same time, SBL does not work in the same way for everyone. What students take from simulation is shaped by contextual conditions, including the learning climate and how facilitation and feedback are enacted across the pre-brief, scenario, and debriefing phases (Olaussen, Heggdal, & Tvedt, 2020). In this sense, recent international discussions increasingly frame simulation not simply as a technology, but as an educational approach that can either widen or reduce inequities in learning opportunities, depending on how it is designed and facilitated (Diaz-Navarro et al., 2024). In the Thai context, simulation can feel less like a classroom exercise and more like a rehearsal for the ward. Realistic equipment, time pressure, and close instructor observation may create a heightened sense of visibility, which students described as emotionally demanding (Bø, Madangi, Ralaitafika, Ersdal, & Tjoflåt, 2022; Bray & Østergaard, 2024). Within this setting, cultural expectations—particularly kreng-jai, reflecting deference and a reluctance to challenge authority—shape how students communicate with instructors (Areemit et al., 2021; Chung, 2021). During debriefing, students may speak less, ask fewer questions, or respond cautiously, not because they lack ideas, but because silence can function as a respectful and culturally appropriate response (Hyun Soo, Peter, & Saul Barry, 2013; Ulmer et al., 2018). These interactional cues matter because they shape the emotional climate of SBL and place facilitators in a pivotal position. As reflected in students’ accounts, a sharp or impatient tone could halt thinking mid-sentence, whereas a calm, invitational manner made it easier to speak, try, and learn (Areemit et al., 2021). Simulation frameworks often describe distinct phases; however, in practice pre-briefing, the scenario, and debriefing can be experienced as a more continuous pedagogical flow rather than neatly separated steps (Dieckmann, Gaba, & Rall, 2007; Jeffries, 2020; Rudolph, Simon, Dufresne, & Raemer, 2006). Within this fluid process, facilitator tone and the timing of feedback may shape psychological safety and students’ willingness to speak, particularly in contexts where hierarchy and face concerns influence classroom interaction (Areemit et al., 2021; Hyun Soo et al., 2013; Ulmer et al., 2018). Psychological safety, therefore, is not an automatic by-product of simulation technology; it requires deliberate facilitation and attention to the learning climate (Diaz-Navarro et al., 2024). In Thailand, published SBL studies tend to foreground learner satisfaction and self-confidence following simulation (Kuesakul, Nuampa, Pungbangkadee, Ramjan, & Ratinthorn, 2024; Xuto et al., 2025). These outcomes matter, yet they can miss the interactional texture of learning—hesitation, silence, careful wording, and the ways students read an instructor’s tone as part of the learning environment. Less is known about how these interactional processes, together with role design (performer/observer), shape learner voice and silence across the pre-brief–scenario–debrief flow in hierarchical learning cultures. Accordingly, this qualitative descriptive study explored Thai undergraduate nursing students’ formative experiences of SBL, focusing on how cultural norms and facilitator interactions shaped psychological safety and learning engagement, and offering a practice-oriented account to inform culturally responsive facilitation and observer role design. Research question How do Thai undergraduate nursing students experience SBL as a formative learning process, and how do cultural norms and facilitator interactions shape psychological safety and learning engagement across the simulation flow? Methodology Research Design A qualitative descriptive design was used to capture learner-centred, context-specific features of simulation-based learning (SBL) in this programme (Villamin, Lopez, Thapa, & Cleary, 2025). Qualitative description supported low-inference, practice-oriented reporting, while reflexive thematic analysis (TA) offered a flexible way to develop patterned meanings without imposing a priori coding structures. Sampling and the interview guide were shaped by this stance, and the analysis stayed close to students’ accounts rather than being driven by pre-set categories. The study formed the qualitative component of a broader mixed-methods project on SBL in an undergraduate nursing programme. In that wider work, surveys summarised outcomes such as satisfaction and perceived confidence; the interviews examined how students made sense of these outcomes in everyday learning terms and within their cultural context. The two strands were designed to be complementary rather than duplicative. In this paper, we report the qualitative findings to clarify how—and under what conditions—simulation shaped learners’ participation and sense of safety, rather than to estimate the magnitude of outcomes. Setting and SBL Implementation The study was conducted in an undergraduate nursing programme in Eastern Thailand and focused on SBL as implemented across the programme, embedded within clinical/practicum courses (e.g., adult, paediatric, maternal and child, and community nursing). Delivery was organised for large cohorts using a rotation-based format across multiple rooms and stations. Typically, one instructor oversaw several student groups, and multiple groups progressed through the simulation flow concurrently. Within each scenario, 4–6 students acted as lead performers while others took observer roles to support learning at scale. Roles were rotated across repeated runs to promote equitable exposure. Sessions generally followed a consistent structure: pre-brief (5–10 minutes), scenario run (10–15 minutes), and debrief (20–30 minutes). Debriefing commonly used the GAS model (Gather–Analyse–Summarise). Facilitators had completed institutional training in simulation-based teaching and had experience in both skills laboratory and ward settings. Scenarios were aligned with programme learning outcomes and delivered in ways designed to support engagement across the simulation flow. Participants and Recruitment Purposive sampling was used with a maximum-variation approach. Twenty-four third- and fourth-year undergraduate nursing students who had recently participated in SBL were recruited. Variation was sought across practicum areas, students’ most recent role in simulation (lead performer or observer), and the extent of prior SBL exposure. Recruitment materials were distributed through channels intended to minimise pressure, including campus noticeboards and QR-code posters in shared areas, as well as announcements on the course learning management system. Expressions of interest were directed to the research team rather than teaching staff. To reduce the risk of perceived coercion, course instructors were not involved in recruitment or interviewing and had no role in students’ assessment or grading for this study. Participation was voluntary, and no incentives or travel reimbursement were provided. Instruments A semi-structured interview guide was developed with reference to the SBL and experiential learning literature and organised around the typical phases of simulation: pre-briefing, scenario participation or observation, and debriefing. The guide explored students’ sense of preparedness, cognitive and emotional load, role allocation and the observer experience, perceptions of debriefing quality, authenticity and fidelity, transfer to clinical learning, and views on assessment-related implications. Content validity was reviewed by three experts in simulation pedagogy and nursing education, who assessed clarity, relevance, and coverage. Feedback was used to refine clarity, relevance, and coverage of the questions. The guide was then piloted with two students who were not included in the final analysis, resulting in minor wording adjustments (Polit & Beck, 2017). No incentives were offered in order to minimise undue influence on participation. The interview guide moved from brief context to the simulation experience itself. It began with short background questions (age, year of study, and current study or life context), then explored prior exposure to SBL and perceptions of the classroom learning climate. Participants were then asked about implementation details—such as their role (performer/observer), the number and length of scenarios, the adequacy of pre-briefing, and resources or fidelity—before reflecting on learning (e.g., clinical judgement and confidence) and areas for improvement. A brief satisfaction check was used only to open conversation and prompt richer accounts; it was not treated as quantitative data. Procedure Interview participants were drawn from the survey phase of the wider mixed-methods project. At the end of the questionnaire, students were offered the option to be contacted for a follow-up interview. Those who opted in accessed the study information page via a QR code/link shared through the course learning platform and campus notices. After reviewing the participant information sheet, they provided electronic consent (via a confirmation click) and left brief contact details to enable interview scheduling (on-campus or remote). One-to-one interviews were conducted in Thai, either face-to-face in a private room on campus or remotely (telephone/online), according to participant preference. Interviews were conducted by four members of the research team (TL, PP, CV, and NS) using the same semi-structured guide. Interviews typically lasted 45–60 minutes and were audio-recorded with permission. Recordings were transcribed verbatim. Quotations presented in this article were translated into English by a bilingual researcher and checked by a second bilingual co-author to support meaning equivalence across languages (Squires, 2009; Temple & Young, 2004; van Nes, Abma, Jonsson, & Deeg, 2010). Brief field notes on the setting and participants’ affect were also used to inform interpretation during analysis. Data Analysis Reflexive thematic analysis was used to interpret patterns of meaning across the interview dataset (Braun & Clarke, 2006). Transcripts were managed in QDA Miner to support systematic organisation of data extracts and analytic memos. Analysis began with close, repeated reading to develop familiarity with the breadth and nuance of participants’ accounts. Initial coding was undertaken as an interpretive, iterative process, with TL and PP generating codes to capture meaning across the dataset and to attend to different emphases in students’ descriptions of simulation, participation, and facilitation. Rather than treating codes as fixed or pursuing reliability metrics, the analytic focus was on reflexive engagement with the data: codes were revisited, merged, refined, or reworked as later interviews complicated earlier interpretations. Regular analytic meetings were used as critical dialogue to surface assumptions, challenge emerging interpretations, and recalibrate theme boundaries in relation to the original extracts. Themes were developed progressively through cycles of code clustering, theme drafting, and returning to the dataset to test coherence and distinctiveness, with key analytic decisions documented in brief memos to maintain transparency. Consistent with reflexive TA, credibility was supported through sustained interpretive dialogue and reflexive practice across the team rather than through inter-coder reliability calculations. Researcher reflexivity. The research team comprised nurse educators with experience designing and facilitating SBL, which provided an informed sensitivity to the simulation environment and the interactional cues students described. At the same time, this positioning carried a risk of leaning towards familiar narratives of simulation as inherently beneficial or of normalising facilitation practices as “standard”. Reflexivity was therefore embedded within the analytic process. Throughout coding and theme development, TL and PP kept brief reflexive memos to note assumptions, moments of surprise, and points where early interpretations did not fit later interviews. These reflections were used in regular analytic dialogue to interrogate how the team’s professional roles and cultural insider status might shape what was noticed, what was taken for granted, and how silence, deference, and kreng-jai were interpreted. To further strengthen analytic discipline, a senior qualitative researcher who was not involved in students’ teaching reviewed emerging theme summaries and challenged the team to clarify boundaries, avoid over-reading, and retain alternative interpretations where the data were ambiguous. Ethical Considerations Ethics approval: HS046/2567(E3). Participation was voluntary with consent by action. Participants were reminded of the right to decline or withdraw at any time without repercussions; confidentiality and anonymity were ensured by de-identification and secure storage. Interviews were scheduled after formal course assessments; interview content had no bearing on grades. Trustworthiness Trustworthiness was supported through transparent documentation and sustained engagement with the dataset. All interviews were audio-recorded (with permission) and transcribed verbatim, and the analytic process was documented through dated memos that captured key decisions in coding and theme refinement. The team returned repeatedly to the original extracts to check coherence, distinctiveness, and interpretive fit, particularly for culturally sensitive accounts involving silence, hierarchy, and relational risk. Thick description of the setting, participants, and SBL implementation is provided to support readers’ judgements about transferability. Sampling was guided by information power, with recruitment ceasing when additional interviews no longer added substantively new insight to the developing thematic structure for the study purpose (Malterud, Siersma, & Guassora, 2016). Results Twenty-four students participated in the study. Most were female (17/24, 70.8%), and the mean age was 22 years (SD = 1.25; Table 1). Analysis focused on how students described entering, participating in, and making sense of simulation across the pre-brief, scenario, and debriefing flow, with particular attention to role positioning (performer/observer) and facilitation as experienced within Thai classroom culture. Learners’ experiential overview of SBL Students rarely described simulation as just another class. Instead, they spoke about SBL as a distinctive learning space with a ward-like feel and a heightened sense of visibility, shaped by equipment, time constraints, and being watched by peers and instructors. As one participant noted, “It was like caring for a real patient through role-play” (Case 8). When describing participation—particularly in debriefing—students often framed silence and reluctance to correct peers as socially and culturally appropriate rather than as disengagement: “When the teacher had already spoken, I didn’t add my view—I didn’t want to look impolite” (Case 7). Overall, students remembered simulation through its emotional and relational weight as much as its technical content, providing context for the themes presented below. Thematic analysis Reflexive thematic analysis developed four themes: (1) Entering a New Space, (2) Stress and Roles as Catalysts for Learning, (3) The Duality of Participation and Observation, and (4) Facilitation and Cultural Safety (Table 2). Entering a New Space described simulation as a “third space” between classroom and ward, shaped by realism, pressure, and culturally patterned silence. Stress and Roles as Catalysts for Learning captured how nervousness could sharpen focus yet also constrain voice, and how performer versus observer positioning shaped what students noticed and retained. The Duality of Participation and Observation elaborated how learning occurred through doing, watching, and revisiting the same event during debriefing. Facilitation and Cultural Safety described how facilitator tone and feedback timing were experienced as central to psychological safety, intertwined with cultural expectations such as kreng-jai. Together, these themes portray simulation as both skills practice and a relational pedagogy enacted within Thai classroom norms and power dynamics. Together, these themes suggest that simulation was experienced not only as skills practice but as a relational pedagogy enacted within Thai classroom culture and power dynamics (Table 2). Theme 1: Entering a New Space—Navigating from Classroom to Simulation For many Thai nursing students, the simulation room felt like a “third space”: no longer the familiarity of lectures, but not yet the ward. Their accounts clustered around three connected strands—pressure, realism, and silence—each shaping what it meant to enter this environment. Sub-theme 1.1: The weight of pressure Students described early simulation encounters as emotionally weighty, with stress exceeding what they typically felt in classroom learning. One student said, “Every subject felt stressful… when I entered the simulation, the pressure was already there” (Case 7). Intensity also shifted with role expectations. As the same participant noted, “When I was the performer, it was more stressful than when I was just observing” (Case 7). Across these accounts, the simulation room carried an evaluative tension—felt in the body and in the moment—that students read as part of learning to “become” a nurse. Sub-theme 1.2: Realism as rehearsal for practice Alongside pressure, students valued simulation for how close it felt to practice. Several described it as a space where they could test themselves under near-clinical conditions, make mistakes, and then recalibrate. One student explained, “It let me practice caring for patients on my own; it felt like I could really try and then see how to improve” (Case 8). Another added, “When I went in, it was as if I was already caring for a patient, not just studying in class” (Case 12). What mattered here was not realism as a technical property alone, but realism as a learning cue—helping classroom knowledge move from being remembered to being enacted. Sub-theme 1.3: Silence as a cultural stance Students also described cultural norms that shaped participation inside the simulation space. Hesitation to speak up—especially to correct peers—was reported repeatedly. One student shared, “Even when I saw a friend doing something wrong, I stayed quiet because I didn’t want them to feel embarrassed” (Case 13). Another reflected on restraint during group interactions: “I felt pressure and didn’t dare to speak up when the teacher was already talking” (Case 7). Importantly, these silences were framed as relational work: showing kreng-jai, protecting face, and maintaining harmony, even when doing so limited immediate feedback or peer correction. Overall, Theme 1 described simulation as a threshold—stressful yet formative, realistic yet socially bounded—where students practised skills while navigating respect, belonging, and emerging professional identity. Theme 2: Stress and Roles as Catalysts for Learning Students described simulation as emotionally intense. Stress and nervousness were part of the learning texture—sometimes supportive, sometimes disruptive. What students learned also depended on where they were positioned in the session: being the performer carried a different kind of pressure from watching as an observer. Sub-theme 2.1: Stress as a sharpened edge Many accounts centred on tension in the room. For some, that intensity appeared to heighten focus and speed up recall. One participant reflected, “I froze at the beginning, but the nervousness made me remember the steps faster” (Case 11). Another noted, “The pressure pushed me to think more quickly about what needed to come first” (Case 3). At other times, stress tipped into overload—particularly when correction was experienced as abrupt. As one student put it, “When the professor corrected me sharply during the scenario, I lost confidence and stopped talking” (Case 14). Across these descriptions, stress operated like a sharpened edge: it could support judgement and prioritisation, yet it could also narrow participation and voice. Sub-theme 2.2: Role-based contrasts Students drew a clear contrast between being inside the scenario and observing from outside it. Performers spoke about responsibility and the fear of missing details: “When I was the one doing it, I felt pressured and forgot small details” (Case 9). Observers, by comparison, described more cognitive space to scan the situation and rehearse responses mentally: “As an observer, I could see everything and think about how I would handle it, but I didn’t always speak up” (Case 18). These accounts described two learning routes: one through action under time pressure; the other through distance, noticing, and quiet comparison with one’s own intended practice. Sub-theme 2.3: Facilitation under pressure Students repeatedly linked their stress experience to how facilitation was enacted in the moment. When instructors allowed the scenario to unfold and offered structured feedback in the debrief afterwards, students described feeling supported and able to learn from mistakes: “When the teacher let us finish first and then explained step by step, I felt clearer about what I had done right and wrong” (Case 13). In contrast, mid-scenario interruptions could shift attention away from the patient and towards fear of error: “When the professor interrupted during the simulation, I lost focus on the patient and just worried about mistakes” (Case 14). Overall, Theme 2 described how stress and role positioning intersected with facilitation style to shape whether pressure functioned as productive challenge or as a constraint on participation and confidence. Theme 3: The Duality of Participation and Observation Students described learning in simulation through two positions: being “in the hot seat” and watching from the outside. These were not portrayed as equivalent experiences. Each position offered different learning affordances, and students often made sense of the session by moving between these perspectives—especially when they returned to the event during debriefing. Sub-theme 3.1: The “hot seat” of participation Being the lead performer was described as stressful, yet many students also framed it as the moment learning became real. Inside the scenario, they felt pressure to prioritise and act with accountability. As one student put it, “When I was inside, I felt pressured and nervous, but it made me think much faster about what to do first” (Case 11). Another linked this position to leadership and self-control: “Being in the hot seat made me realise how important it was to stay calm and lead the group” (Case 16). For these students, participation did not simply test knowledge; it demanded decisions, and acting under pressure made lessons harder to forget. Sub-theme 3.2: The “cool gaze” of observation Observers described a calmer experience, with more room to scan the situation and think through alternatives. One student explained, “As an observer, I could see what everyone was doing and think about how I would handle the situation” (Case 18). Another noted, “Watching others made me realise mistakes and compare them with how I might respond” (Case 9). Here, distance created perspective. Watching became a quiet form of rehearsal—an opportunity to notice patterns and anticipate responses that could be difficult to access when one is inside the action. Sub-theme 3.3: Making sense through debriefing Students repeatedly pointed to debriefing as the point where these two viewpoints came together. Several described that understanding shifted after hearing how performers and observers interpreted the same scene. One participant said, “Afterwards, hearing both sides helped me realise what I had missed when I was inside” (Case 22). Another reflected, “Group discussion made me think again about my own actions” (Case 23). In these accounts, debriefing was where experience was re-read: what felt chaotic in the moment could be reorganised into clearer priorities, rationales, and alternatives. Overall, Theme 3 described learning as movement across roles—doing, watching, and revisiting the event together. Theme 4: Facilitation and Cultural Safety Students rarely spoke about facilitation as background. The facilitator was “felt” in the room—through tone, timing, and the way feedback entered the scenario. What students noticed most was whether guidance opened space to try, or whether it closed space down and made silence feel safer. Sub-theme 4.1: Calm guidance versus harsh correction Participants contrasted supportive guidance with moments when correction felt sharp. One student recalled, “If I met a professor who got angry, I felt pressured and didn’t dare to try anything” (Case 11). Others described the opposite effect when teachers stayed calm and allowed them to continue even when they faltered. As a fourth-year student explained, “When the teacher just listened and let us finish first, I felt safe to continue” (Case 17). Across these accounts, the way feedback was delivered shaped whether students stayed engaged or withdrew. Sub-theme 4.2: Debriefing as a constructive space For many students, the debrief was where learning became tangible. They valued reviewing the scenario step by step, not only to check correctness but also to speak more openly about what they were thinking and feeling. One participant said, “When we reviewed it together, I could see what I did right and wrong, and I wasn’t afraid to admit mistakes” (Case 13). Others described how a calm debrief helped nervousness settle into confidence. In this way, debriefing was not merely a wrap-up; its atmosphere shaped whether mistakes were experienced as usable lessons or as personal failure. Sub-theme 4.3: Cultural safety intertwined with learning Facilitation also interacted with cultural expectations around speaking, respect, and protecting others from embarrassment. Silence in discussion was often described as relational rather than disengaged. One student admitted, “Even when I knew my friend had missed something, I didn’t correct them in front of others” (Case 13). For these learners, kreng-jai—the impulse to avoid causing discomfort—guided how they responded to both peers and teachers. Students’ accounts consistently linked psychological safety with cultural safety: when both were present, students felt more able to contribute; when either was threatened, withholding voice became the safer option. Overall, Theme 4 described facilitation as more than a teaching technique: calm feedback and respectful debriefing supported participation, whereas harsh correction reduced voice and confidence, with these effects intensified by cultural expectations around hierarchy and face. Discussion This study offers a culturally situated account of simulation-based learning (SBL) in Thai undergraduate nursing education. Students often described SBL as more than rehearsal. For many, it functioned as an early moment of professional entry—highly visible, emotionally charged, and shaped by familiar classroom norms. This reading sits alongside broader syntheses showing that SBL can support competence development, confidence, and preparedness across diverse curricular approaches (Alharbi et al., 2024; Cant & Cooper, 2017). What our participants emphasised, however, was how real the nurse role felt in simulation, sometimes earlier than comparable opportunities in practice. Where early clinical exposure is perceived as limited or delayed, simulation may operate as a liminal space in which theoretical knowledge is tested against the situated demands of patient care. This interpretation aligns with sociocultural perspectives that frame learning as participation within communities of practice (Lave & Wenger, 1991) To integrate the findings, Figure 1 presents a thematic map showing how Thai nursing students experienced simulation-based learning as a pedagogical flow. Students entered the simulation space with heightened pressure and a sense of realism (Theme 1), which shaped stress and role positioning during the scenario (Theme 2). Learning then unfolded through complementary performer and observer perspectives (Themes 3), with understanding consolidated in debriefing as shared reflection. Across the flow, facilitation and cultural safety (Theme 4) shaped how pressure, feedback, and silence were experienced at multiple points. The figure is intended as an analytic summary of patterned meanings rather than a causal model, highlighting how contextual conditions, learner roles, and facilitation intersected to influence meaning-making, safety, and readiness to engage. Across interviews, kreng-jai emerged as a salient mediator of participation. This resonates with Thai evidence showing how hierarchy, kreng-jai, and feedback norms influence what is said, to whom, and when (Areemit et al., 2021). It is also consistent with work describing “silent participation” as culturally intelligible rather than disengaged (Chung, 2021). Our findings extend this discussion by suggesting that facilitator tone and timing can either widen or narrow the space for student voice. When facilitation felt calm and non-punitive, deference sometimes shifted toward respectful engagement, allowing students to ask questions and acknowledge uncertainty without embarrassment. In contrast, harsh or abrupt correction could prompt withdrawal that appeared less about knowledge deficits and more about relational risk-management in the face of hierarchy (Areemit et al., 2021). These patterns were not identical for every participant, but they recurred often enough to shape how debriefing was experienced. They underline the practical importance of culturally responsive facilitation and debriefing, particularly given that much of the dominant debriefing discourse has been shaped in Western educational traditions and may require culture-sensitive adaptation in high power-distance Asian settings (Hyun Soo et al., 2013; Ulmer et al., 2018) The duality of learning through active participation versus observation also provided important insights. Students in-role described learning through performance under pressure; observers more often described a reflective stance, noticing patterns, errors, and alternative actions from a distance. This is consistent with social learning accounts of vicarious learning, in which learning can occur through observing others and the consequences of action (Bandura, 1978). Our findings add a practical condition: observational learning was described as more useful when it was intentionally structured (e.g., guided prompts or focused questions), rather than left as passive watching. This matters in settings where opportunities to perform are limited by time, group size, or available equipment. Under these conditions, the observer role may be better treated as an active learning position rather than a secondary one (Bø et al., 2022). Finally, the findings point to a tension between the visible infrastructure of simulation and the less visible pedagogical conditions that students described as shaping learning—facilitator practice, debriefing climate, and psychological safety. Rather than equating fidelity with equipment alone, our data support a broader understanding of simulation quality as a socially organised learning practice. This aligns with theoretical arguments that simulation is not only a technical set-up, but a form of social practice in which interactional conditions matter (Dieckmann et al., 2007). Read this way, simulation quality extends beyond physical realism to include psychological fidelity—that is, the extent to which learners experience the scenario as meaningful, believable, and emotionally safe (Burford et al., 2023). From this perspective, SBL is less a technological showcase and more a relational pedagogy, strengthened through facilitation that is both psychologically safe and culturally attuned. Policy and practice implications For many participants, simulation was not experienced as a peripheral exercise but as an early—and highly visible—entry point into patient care roles. Our document comparison suggests that accreditation requirements in the region place stronger emphasis on infrastructure (e.g., facilities, mannequins, equipment) than on minimum pedagogical conditions (e.g., facilitator preparation, structured debriefing, and learner psychological safety). Several practical implications follow. First, the observer role could be formalised. Participants described observation as cognitively useful; programmes could therefore treat observers as active learners by assigning explicit objectives and structured prompts. Second, debriefing warrants greater emphasis. In our document set, debriefing was less explicitly specified than infrastructural requirements; yet participants’ accounts suggest that culturally attuned debriefing can enable reflection without fear of embarrassment. Finally, participants framed fidelity not only as physical realism but also as fairness—whether opportunities were equitable across groups. Standards that address group size, time allocation, role rotation, and equipment readiness may therefore be as consequential as equipment investment for sustaining trust in simulation. Limitations and future directions This study has several limitations. First, the qualitative strand inevitably overlaps with constructs also measured quantitatively (e.g., confidence, satisfaction); however, the qualitative analysis examined how students made sense of these constructs and under what conditions they shifted, rather than estimating magnitude. Second, although stress inoculation and dual-process ideas informed our interpretive lens, the underlying mechanisms were not directly tested; cognitive load, physiological markers, and longer-term transfer were not assessed. Third, comparative discussion relied on available evidence from a small number of ASEAN settings, and the regional literature remains uneven across countries, limiting broader generalisation. Finally, the study was conducted in a single institution, which supported depth but constrained breadth. Future work could test specific pedagogical levers—such as structured debriefing and observer task design—across multiple sites and programme years. Reflexivity As nurse educators and cultural insiders, our positions likely shaped what we noticed and how we interpreted participants’ accounts. Reflexivity was addressed through regular interpretive dialogue across the analytic team, the use of analytic memos, and an audit trail documenting key coding and theme-development decisions. Rather than seeking consensus metrics, we used critical discussion to surface divergent readings and to examine how our assumptions may have shaped interpretation. Conclusion This study highlights a distinctive Thai perspective in which simulation was often experienced less as reinforcement and more as an early professional initiation. Students described simulation as a first opportunity to inhabit the nurse role within a bounded space where errors could be surfaced and discussed without patient harm. Across themes, participation was shaped not only by scenario demands but also by cultural norms around hierarchy and silence, and by facilitation practices—particularly tone, timing of feedback, and the climate created in debriefing. At a policy level, the document comparison suggests a persistent misalignment between infrastructure-focused accreditation requirements and the pedagogical conditions that students described as shaping learning. Addressing this misalignment—by strengthening expectations around facilitation, debriefing, observer role design, and equitable access to participation—may help align simulation provision with educational evidence and learner experience in context. Declarations Ethics approval and consent to participate Before conducting the study, ethics approval was granted from the University (reference number HS046/2567(E3)). Informed consent was obtained from all subjects involved in the study. All responses in the data collection process were collected and analysed anonymously. Consent for publication Participants provided consent for the use of anonymised quotations in publications. All identifying information has been removed. Availability of data and materials The interview transcripts are not publicly available due to confidentiality and the risk of participant identification. De-identified excerpts may be available from the corresponding author upon reasonable request and subject to ethics approval/conditions. Competing interests The authors declare that they have no competing interests. Funding This study was supported by a grant from the Faculty of Nursing, Burapha University (0166/2566). Authors’ contributions TL conceptualised and led the study, managed the project, supervised the research team, conducted the formal analysis, curated the data, and wrote the original draft. WKi contributed to study methodology and formal analysis. PP conducted qualitative investigation, managed data curation, performed transcription and coding, prepared visualisations, and contributed to writing—review and editing and validation. CV conducted qualitative investigation, provided resources, and contributed to data curation. NS conducted qualitative investigation and contributed to data curation. WKa contributed to conceptualisation, investigation, and data curation. PuP contributed to quantitative investigation and validation. PT contributed to writing—review and editing. All authors reviewed and approved the final manuscript. Acknowledgements We would like to thank the Faculty of Nursing, Burapha University, for supporting this research. Declaration of generative AI in scientific writing During the preparation of this work the author(s) used Grammarly and ChatGPT in order to assist in improving the language clarity of this manuscript. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the published article. Authors’ information Trakulwong Luecha: 0000-0002-2526-7751 Charunyakorn Viriya: - Nattaya Sangsai: - Patcharin Poonthawe: 0000-0003-1765-8071 Witchaporn Kidsamrong: 0009-0009-1711-0816 Warisa Kanbuala: 0009-0004-9341-2246 Puntaree Pikulnee: 0009-0001-5093-7745 Paweena Tivasiripong: 0009-0007-4675-988X References Alharbi, A., Nurfianti, A., Mullen, R. F., McClure, J. D., & Miller, W. H. (2024). The effectiveness of simulation-based learning (SBL) on students’ knowledge and skills in nursing programs: a systematic review. BMC Medical Education, 24 (1), 1099. doi:10.1186/s12909-024-06080-z Areemit, R. S., Cooper, C. M., Wirasorn, K., Paopongsawan, P., Panthongviriyakul, C., & Ramani, S. (2021). Hierarchy, “Kreng Jai” and Feedback: A Grounded Theory Study Exploring Perspectives of Clinical Faculty and Medical Students in Thailand. Teaching and Learning in Medicine, 33 (3), 235-244. doi:10.1080/10401334.2020.1813584 Arpanantikul, M., & Pratoomwan, A. (2017). Clinical Learning Experiences of Second-Year Thai Nursing Students: A Phenomenological Study. Pacific Rim international journal of nursing research, 21 , 121-134. Bandura, A. (1978). Self-efficacy: Toward a unifying theory of behavioral change. Advances in Behaviour Research and Therapy, 1 (4), 139-161. doi:10.1016/0146-6402(78)90002-4 Bø, B., Madangi, B. P., Ralaitafika, H., Ersdal, H. L., & Tjoflåt, I. (2022). Nursing students' experiences with simulation-based education as a pedagogic method in low-resource settings: A mixed-method study. J Clin Nurs, 31 (9-10), 1362-1376. doi:10.1111/jocn.15996 Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3 (2), 77-101. doi:10.1191/1478088706qp063oa Bray, L., & Østergaard, D. (2024). A qualitative study of the value of simulation-based training for nursing students in primary care. BMC Nursing, 23 (1), 308. doi:10.1186/s12912-024-01886-0 Burford, B., Grieg, P., Kelleher, M., Merriman, C., Platt, A., Richards, E., . . . Vance, G. (2023). Interprofessional simulation as an enhancement of psychological fidelity: A focus group study of medical and nursing students. Health Science Reports, 6 (5), e1237. doi:10.1002/hsr2.1237 Cant, R. P., & Cooper, S. J. (2017). Use of simulation-based learning in undergraduate nurse education: An umbrella systematic review. Nurse Education Today, 49 , 63-71. doi:10.1016/j.nedt.2016.11.015 Chung, J. H. J. (2021). We participate, silently”: Explicating Thai university students’ perceptions of their classroom participation and communication. Qualitative Research in Education, 10 (1), 62–87. doi:10.17583/qre.2021.7159 Diaz-Navarro, C., Armstrong, R., Charnetski, M., Freeman, K. J., Koh, S., Reedy, G., . . . Issenberg, B. (2024). Global consensus statement on simulation-based practice in healthcare. Advances in Simulation, 9 (1), 19. doi:10.1186/s41077-024-00288-1 Dieckmann, P., Gaba, D., & Rall, M. (2007). Deepening the theoretical foundations of patient simulation as social practice. Simul Healthc, 2 (3), 183-193. doi:10.1097/SIH.0b013e3180f637f5 Hyun Soo, C., Peter, D., & Saul Barry, I. (2013). It is time to consider cultural differences in debriefing. Simulation in Healthcare, 8 (3), 166-170. doi:10.1097/SIH.0b013e318291d9ef Jeffries, P. (2020). Simulation in Nursing Education: From Conceptualization to Evaluation (3rd ed.). Washington: Wolters Kluwer Health. Kuesakul, K., Nuampa, S., Pungbangkadee, R., Ramjan, L., & Ratinthorn, A. (2024). Evaluation of antenatal simulation-based learning on satisfaction and self-confidence levels among Thai undergraduate nursing students during the COVID-19 pandemic: a mixed-method study. BMC Nursing, 23 (1), 161. doi:10.1186/s12912-024-01824-0 Lave, J., & Wenger, E. (1991). Situated learning: Legitimate peripheral participation [Cambridge University Press doi:10.1017/CBO9780511815355]. Retrieved Malterud, K., Siersma, V. D., & Guassora, A. D. (2016). Sample Size in Qualitative Interview Studies: Guided by Information Power. Qual Health Res, 26 (13), 1753-1760. doi:10.1177/1049732315617444 Olaussen, C., Heggdal, K., & Tvedt, C. R. (2020). Elements in scenario-based simulation associated with nursing students' self-confidence and satisfaction: A cross-sectional study. Nursing Open, 7 (1), 170-179. doi:10.1002/nop2.375 Polit, D. F., & Beck, C. T. (2017). Nursing research: Generating and assessing evidence for nursing practice (10th ed.). Philadelphia: Wolters Kluwer Health. Rudolph, J. W., Simon, R., Dufresne, R. L., & Raemer, D. B. (2006). There's No Such Thing as “Nonjudgmental” Debriefing: A Theory and Method for Debriefing with Good Judgment. Simulation in Healthcare, 1 (1). doi:10.1097/01266021-200600110-00006 Skedsmo, K., Bingen, H. M., Hofsø, K., Steindal, S. A., Hagelin, C. L., Hilderson, D., . . . Olaussen, C. (2023). Postgraduate nursing students’ experiences with simulation-based learning in palliative care education: A qualitative study. Nurse Education in Practice, 73 , 103832. doi:10.1016/j.nepr.2023.103832 Squires, A. (2009). Methodological challenges in cross-language qualitative research: A research review. International Journal of Nursing Studies, 46 (2), 277-287. doi:10.1016/j.ijnurstu.2008.08.006 Temple, B., & Young, A. (2004). Qualitative Research and Translation Dilemmas. Qualitative Research, 4 (2), 161-178. doi:10.1177/1468794104044430 Ulmer, F. F., Sharara-Chami, R., Lakissian, Z., Stocker, M., Scott, E., & Dieckmann, P. (2018). Cultural prototypes and differences in simulation debriefing. Simulation in Healthcare, 13 (4), 239-246. doi:10.1097/SIH.0000000000000320 van Graan, A. C., Williams, M. J. S., & Koen, M. P. (2016). Professional nurses' understanding of clinical judgement: A contextual inquiry. Health SA Gesondheid, 21 , 280-293. doi:10.1016/j.hsag.2016.04.001 van Nes, F., Abma, T., Jonsson, H., & Deeg, D. (2010). Language differences in qualitative research: is meaning lost in translation? European Journal of Ageing, 7 (4), 313-316. doi:10.1007/s10433-010-0168-y Villamin, P., Lopez, V., Thapa, D. K., & Cleary, M. (2025). A Worked Example of Qualitative Descriptive Design: A Step-by-Step Guide for Novice and Early Career Researchers. Journal of Advanced Nursing, 81 (8), 5181-5195. doi:10.1111/jan.16481 Xuto, P., Prasitwattanaseree, P., Chaiboonruang, T., Khiaokham, L., Nimarangkul, K., Bressington, D., & Miyata, C. (2025). Developing clinical leadership through high-fidelity obstetric simulation: A multimethods study in Thai nursing students. Clinical Simulation in Nursing, 102 , 101720. doi:10.1016/j.ecns.2025.101720 Tables Table 1. Participant characteristics (N = 24) Characteristic n % M ± SD Min–Max Gender Male 7 29.2 Female 17 70.8 Year of study 3rd year 13 54.2 4th year 11 45.8 Age (years) 22.0 ± 1.25 20–24 Table 2. Themes, Sub-themes, Illustrative Meaning, and Example Quotations. Theme Sub-theme Illustrative Meaning Example Quotations (EN, Case No.) Theme 1: Entering a New Space—Navigating from Classroom to Simulation Sub-theme 1.1: The weight of pressure Students described early simulation encounters as emotionally weighty, with stress heightened on entering the room and intensifying when taking the performer role rather than observing. “Every subject felt stressful… when I entered the simulation, the pressure was already there” (Case 7) “When I was the performer, it was more stressful than when I was just observing” (Case 7) Sub-theme 1.2: Realism as rehearsal for practice Students valued simulation as rehearsal for practice, allowing them to attempt patient care independently, make mistakes safely, and recalibrate before clinical placements. “It let me practice caring for patients on my own; it felt like I could really try and then see how to improve” (Case 8) “When I went in, it was as if I was already caring for a patient, not just studying in class” (Case 12) Sub-theme 1.3: Silence as a cultural stance Hesitation to speak—particularly to correct peers—was framed as respectful restraint shaped by kreng-jai, protecting face and maintaining harmony rather than disengagement. “Even when I saw a friend doing something wrong, I stayed quiet because I didn’t want them to feel embarrassed” (Case 13) “I felt pressure and didn’t dare to speak up when the teacher was already talking” (Case 7) Theme 2: Stress and Roles as Catalysts for Learning Sub-theme 2.1: Stress as a sharpened edge Stress operated as a sharpened edge: it could heighten focus and prioritisation, yet could also tip into overload and reduce voice, particularly when in-scenario correction was experienced as abrupt. “I froze at the beginning, but the nervousness made me remember the steps faster” (Case 11) “The pressure pushed me to think more quickly about what needed to come first” (Case 3) “When the professor corrected me sharply during the scenario, I lost confidence and stopped talking” (Case 14) Sub-theme 2.2: Role-based contrasts Performers experienced responsibility and time pressure that could narrow attention, whereas observers reported more cognitive space to scan the situation, compare responses, and rehearse alternatives. “When I was the one doing it, I felt pressured and forgot small details” (Case 9) “As an observer, I could see everything and think about how I would handle it, but I didn’t always speak up” (Case 18) Sub-theme 2.3: Facilitation under pressure Facilitation shaped how pressure was experienced: allowing the scenario to unfold and reserving step-by-step feedback for debrief supported learning from mistakes, while mid-scenario interruptions shifted attention towards fear of error. “When the teacher let us finish first and then explained step by step, I felt clearer about what I had done right and wrong” (Case 13) “When the professor interrupted during the simulation, I lost focus on the patient and just worried about mistakes” (Case 14) Theme 3: The Duality of Participation and Observation Sub-theme 3.1: The “hot seat” of participation Participation in the “hot seat” made learning feel real; acting under pressure demanded decisions, prioritisation, and leadership, making lessons memorable. “When I was inside, I felt pressured and nervous, but it made me think much faster about what to do first” (Case 11) “Being in the hot seat made me realise how important it was to stay calm and lead the group” (Case 16) Sub-theme 3.2: The “cool gaze” of observation Observation offered a calmer, analytic vantage point, enabling students to see the whole scene, notice errors, and mentally rehearse how they would respond. “As an observer, I could see what everyone was doing and think about how I would handle the situation” (Case 18) “Watching others made me realise mistakes and compare them with how I might respond” (Case 9) Sub-theme 3.3: Making sense through debriefing Debriefing was where performer and observer perspectives were integrated; shared discussion helped students re-read the event, clarify rationales, and identify what they had missed. “Afterwards, hearing both sides helped me realise what I had missed when I was inside” (Case 22) “Group discussion made me think again about my own actions” (Case 23) Theme 4: Facilitation and Cultural Safety Sub-theme 4.1: Calm guidance versus harsh correction Students contrasted calm, invitational guidance with harsh correction; facilitator tone influenced whether they continued to engage or withdrew. “If I met a professor who got angry, I felt pressured and didn’t dare to try anything” (Case 11) “When the teacher just listened and let us finish first, I felt safe to continue” (Case 17) Sub-theme 4.2: Debriefing as a constructive space Students described debriefing as the point where learning became tangible; reviewing the scenario step by step enabled open reflection, normalised mistakes, and helped nervousness settle into confidence. “When we reviewed it together, I could see what I did right and wrong, and I wasn’t afraid to admit mistakes” (Case 13) Sub-theme 4.3: Cultural safety intertwined with learning Psychological safety was intertwined with cultural safety: kreng-jai and face concerns shaped whether students corrected peers or spoke up, making respectful facilitation central to participation. “Even when I knew my friend had missed something, I didn’t correct them in front of others” (Case 13) Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8654727","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"advancing-simulation-practice","associatedPublications":[],"authors":[{"id":587353706,"identity":"01030cfc-e239-4d53-8a2a-7c34b7cc4da9","order_by":0,"name":"Trakulwong Luecha","email":"","orcid":"","institution":"Faculty of Nursing, Burapha University","correspondingAuthor":false,"prefix":"","firstName":"Trakulwong","middleName":"","lastName":"Luecha","suffix":""},{"id":587353707,"identity":"7318e9b9-2cf1-41e1-ba32-502bd2c96c0c","order_by":1,"name":"Charunyakorn Viriya","email":"","orcid":"","institution":"Faculty of Nursing, 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version.\u003c/p\u003e","description":"","filename":"Figure1AthematicmapofThainursingstudentsexperiencesofsimulationbasedlearning1.png","url":"https://assets-eu.researchsquare.com/files/rs-8654727/v1/19c89bc2813d95ae1e710bb7.png"},{"id":103192442,"identity":"2fecbfe2-2659-4b02-b7ac-d716c2d05aae","added_by":"auto","created_at":"2026-02-23 02:24:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":926097,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8654727/v1/27dce497-4603-4fac-ad86-39115458855a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Thai nursing students’ formative experiences of simulation-based learning: Implications for facilitation and debriefing","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe transition from classroom learning to clinical practice remains a recurring challenge in nursing education (Alharbi, Nurfianti, Mullen, McClure, \u0026amp; Miller, 2024). In Thailand, undergraduate curricula integrate lectures, skills laboratory training, and hospital placements; nevertheless, second-year students have described early clinical practice as a period marked by lack of confidence and anxiety when caring for real patients (Arpanantikul \u0026amp; Pratoomwan, 2017). This theory\u0026ndash;practice gap becomes particularly visible at the bedside: students may remember procedural steps, yet hesitate when they must prioritise, communicate, and act under authentic clinical pressure (van Graan, Williams, \u0026amp; Koen, 2016).\u003c/p\u003e\n\u003cp\u003eSimulation-based learning (SBL) is widely used in nursing education to help narrow the theory\u0026ndash;practice gap by offering a structured space where students can practise, make errors, and receive feedback without compromising patient safety (Alharbi et al., 2024; Diaz-Navarro et al., 2024). Evidence suggests that SBL can support students\u0026rsquo; confidence, clinical judgement, and teamwork, although outcomes vary across programmes and settings (Bray \u0026amp; \u0026Oslash;stergaard, 2024; Cant \u0026amp; Cooper, 2017). For some students, simulation becomes a moment that feels real\u0026mdash;a point at which they begin to see themselves acting in the nurse\u0026rsquo;s role rather than only learning about it (Skedsmo et al., 2023; Xuto et al., 2025). At the same time, SBL does not work in the same way for everyone. What students take from simulation is shaped by contextual conditions, including the learning climate and how facilitation and feedback are enacted across the pre-brief, scenario, and debriefing phases (Olaussen, Heggdal, \u0026amp; Tvedt, 2020). In this sense, recent international discussions increasingly frame simulation not simply as a technology, but as an educational approach that can either widen or reduce inequities in learning opportunities, depending on how it is designed and facilitated (Diaz-Navarro et al., 2024).\u003c/p\u003e\n\u003cp\u003eIn the Thai context, simulation can feel less like a classroom exercise and more like a rehearsal for the ward. Realistic equipment, time pressure, and close instructor observation may create a heightened sense of visibility, which students described as emotionally demanding\u0026nbsp;(B\u0026oslash;, Madangi, Ralaitafika, Ersdal, \u0026amp; Tjofl\u0026aring;t, 2022; Bray \u0026amp; \u0026Oslash;stergaard, 2024). Within this setting, cultural expectations\u0026mdash;particularly kreng-jai, reflecting deference and a reluctance to challenge authority\u0026mdash;shape how students communicate with instructors (Areemit et al., 2021; Chung, 2021). During debriefing, students may speak less, ask fewer questions, or respond cautiously, not because they lack ideas, but because silence can function as a respectful and culturally appropriate response (Hyun Soo, Peter, \u0026amp; Saul Barry, 2013; Ulmer et al., 2018). These interactional cues matter because they shape the emotional climate of SBL and place facilitators in a pivotal position. As reflected in students\u0026rsquo; accounts, a sharp or impatient tone could halt thinking mid-sentence, whereas a calm, invitational manner made it easier to speak, try, and learn (Areemit et al., 2021).\u003c/p\u003e\n\u003cp\u003eSimulation frameworks often describe distinct phases; however, in practice pre-briefing, the scenario, and debriefing can be experienced as a more continuous pedagogical flow rather than neatly separated steps (Dieckmann, Gaba, \u0026amp; Rall, 2007; Jeffries, 2020; Rudolph, Simon, Dufresne, \u0026amp; Raemer, 2006). Within this fluid process, facilitator tone and the timing of feedback may shape psychological safety and students\u0026rsquo; willingness to speak, particularly in contexts where hierarchy and face concerns influence classroom interaction (Areemit et al., 2021; Hyun Soo et al., 2013; Ulmer et al., 2018).\u0026nbsp;Psychological safety, therefore, is not an automatic by-product of simulation technology; it requires deliberate facilitation and attention to the learning climate\u0026nbsp;(Diaz-Navarro et al., 2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn Thailand, published SBL studies tend to foreground learner satisfaction and self-confidence following simulation (Kuesakul, Nuampa, Pungbangkadee, Ramjan, \u0026amp; Ratinthorn, 2024; Xuto et al., 2025). These outcomes matter, yet they can miss the interactional texture of learning\u0026mdash;hesitation, silence, careful wording, and the ways students read an instructor\u0026rsquo;s tone as part of the learning environment. Less is known about how these interactional processes, together with role design (performer/observer), shape learner voice and silence across the pre-brief\u0026ndash;scenario\u0026ndash;debrief flow in hierarchical learning cultures. Accordingly, this qualitative descriptive study explored Thai undergraduate nursing students\u0026rsquo; formative experiences of SBL, focusing on how cultural norms and facilitator interactions shaped psychological safety and learning engagement, and offering a practice-oriented account to inform culturally responsive facilitation and observer role design.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch question\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHow do Thai undergraduate nursing students experience SBL as a formative learning process, and how do cultural norms and facilitator interactions shape psychological safety and learning engagement across the simulation flow?\u003c/p\u003e"},{"header":"Methodology","content":"\u003ch2\u003eResearch Design\u003c/h2\u003e\n\u003cp\u003eA qualitative descriptive design was used to capture learner-centred, context-specific features of simulation-based learning (SBL) in this programme (Villamin, Lopez, Thapa, \u0026amp; Cleary, 2025). Qualitative description supported low-inference, practice-oriented reporting, while reflexive thematic analysis (TA) offered a flexible way to develop patterned meanings without imposing a priori coding structures. Sampling and the interview guide were shaped by this stance, and the analysis stayed close to students\u0026rsquo; accounts rather than being driven by pre-set categories.\u003c/p\u003e\n\u003cp\u003eThe study formed the qualitative component of a broader mixed-methods project on SBL in an undergraduate nursing programme. In that wider work, surveys summarised outcomes such as satisfaction and perceived confidence; the interviews examined how students made sense of these outcomes in everyday learning terms and within their cultural context. The two strands were designed to be complementary rather than duplicative. In this paper, we report the qualitative findings to clarify how\u0026mdash;and under what conditions\u0026mdash;simulation shaped learners\u0026rsquo; participation and sense of safety, rather than to estimate the magnitude of outcomes.\u003c/p\u003e\n\u003ch2\u003eSetting and SBL Implementation\u003c/h2\u003e\n\u003cp\u003eThe study was conducted in an undergraduate nursing programme in Eastern Thailand and focused on SBL as implemented across the programme, embedded within clinical/practicum courses (e.g., adult, paediatric, maternal and child, and community nursing). Delivery was organised for large cohorts using a rotation-based format across multiple rooms and stations. Typically, one instructor oversaw several student groups, and multiple groups progressed through the simulation flow concurrently.\u003c/p\u003e\n\u003cp\u003eWithin each scenario, 4\u0026ndash;6 students acted as lead performers while others took observer roles to support learning at scale. Roles were rotated across repeated runs to promote equitable exposure. Sessions generally followed a consistent structure: pre-brief (5\u0026ndash;10 minutes), scenario run (10\u0026ndash;15 minutes), and debrief (20\u0026ndash;30 minutes). Debriefing commonly used the GAS model (Gather\u0026ndash;Analyse\u0026ndash;Summarise). Facilitators had completed institutional training in simulation-based teaching and had experience in both skills laboratory and ward settings. Scenarios were aligned with programme learning outcomes and delivered in ways designed to support engagement across the simulation flow.\u003c/p\u003e\n\u003ch2\u003eParticipants and Recruitment\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003ePurposive sampling was used with a maximum-variation approach. Twenty-four third- and fourth-year undergraduate nursing students who had recently participated in SBL were recruited. Variation was sought across practicum areas, students\u0026rsquo; most recent role in simulation (lead performer or observer), and the extent of prior SBL exposure.\u003c/p\u003e\n\u003cp\u003eRecruitment materials were distributed through channels intended to minimise pressure, including campus noticeboards and QR-code posters in shared areas, as well as announcements on the course learning management system. Expressions of interest were directed to the research team rather than teaching staff. To reduce the risk of perceived coercion, course instructors were not involved in recruitment or interviewing and had no role in students\u0026rsquo; assessment or grading for this study. Participation was voluntary, and no incentives or travel reimbursement were provided.\u003c/p\u003e\n\u003ch2\u003eInstruments\u003c/h2\u003e\n\u003cp\u003eA semi-structured interview guide was developed with reference to the SBL and experiential learning literature and organised around the typical phases of simulation: pre-briefing, scenario participation or observation, and debriefing. The guide explored students\u0026rsquo; sense of preparedness, cognitive and emotional load, role allocation and the observer experience, perceptions of debriefing quality, authenticity and fidelity, transfer to clinical learning, and views on assessment-related implications.\u003c/p\u003e\n\u003cp\u003eContent validity was reviewed by three experts in simulation pedagogy and nursing education, who assessed clarity, relevance, and coverage. Feedback was used to refine clarity, relevance, and coverage of the questions.\u0026nbsp;The guide was then piloted with two students who were not included in the final analysis, resulting in minor wording adjustments (Polit \u0026amp; Beck, 2017). No incentives were offered in order to minimise undue influence on participation.\u003c/p\u003e\n\u003cp\u003eThe interview guide moved from brief context to the simulation experience itself. It began with short background questions (age, year of study, and current study or life context), then explored prior exposure to SBL and perceptions of the classroom learning climate. Participants were then asked about implementation details\u0026mdash;such as their role (performer/observer), the number and length of scenarios, the adequacy of pre-briefing, and resources or fidelity\u0026mdash;before reflecting on learning (e.g., clinical judgement and confidence) and areas for improvement. A brief satisfaction check was used only to open conversation and prompt richer accounts; it was not treated as quantitative data.\u003c/p\u003e\n\u003ch2\u003eProcedure\u003c/h2\u003e\n\u003cp\u003eInterview participants were drawn from the survey phase of the wider mixed-methods project. At the end of the questionnaire, students were offered the option to be contacted for a follow-up interview. Those who opted in accessed the study information page via a QR code/link shared through the course learning platform and campus notices. After reviewing the participant information sheet, they provided electronic consent (via a confirmation click) and left brief contact details to enable interview scheduling (on-campus or remote).\u003c/p\u003e\n\u003cp\u003eOne-to-one interviews were conducted in Thai, either face-to-face in a private room on campus or remotely (telephone/online), according to participant preference. Interviews were conducted by four members of the research team (TL, PP, CV, and NS) using the same semi-structured guide. Interviews typically lasted 45\u0026ndash;60 minutes and were audio-recorded with permission. Recordings were transcribed verbatim. Quotations presented in this article were translated into English by a bilingual researcher and checked by a second bilingual co-author to support meaning equivalence across languages\u0026nbsp;(Squires, 2009; Temple \u0026amp; Young, 2004; van Nes, Abma, Jonsson, \u0026amp; Deeg, 2010).\u0026nbsp;Brief field notes on the setting and participants\u0026rsquo; affect were also used to inform interpretation during analysis.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData Analysis\u003c/h2\u003e\n\u003cp\u003eReflexive thematic analysis was used to interpret patterns of meaning across the interview dataset\u0026nbsp;(Braun \u0026amp; Clarke, 2006). Transcripts were managed in QDA Miner to support systematic organisation of data extracts and analytic memos. Analysis began with close, repeated reading to develop familiarity with the breadth and nuance of participants\u0026rsquo; accounts. Initial coding was undertaken as an interpretive, iterative process, with TL and PP generating codes to capture meaning across the dataset and to attend to different emphases in students\u0026rsquo; descriptions of simulation, participation, and facilitation. Rather than treating codes as fixed or pursuing reliability metrics, the analytic focus was on reflexive engagement with the data: codes were revisited, merged, refined, or reworked as later interviews complicated earlier interpretations. Regular analytic meetings were used as critical dialogue to surface assumptions, challenge emerging interpretations, and recalibrate theme boundaries in relation to the original extracts. Themes were developed progressively through cycles of code clustering, theme drafting, and returning to the dataset to test coherence and distinctiveness, with key analytic decisions documented in brief memos to maintain transparency. Consistent with reflexive TA, credibility was supported through sustained interpretive dialogue and reflexive practice across the team rather than through inter-coder reliability calculations.\u003c/p\u003e\n\u003ch2\u003eResearcher reflexivity.\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe research team comprised nurse educators with experience designing and facilitating SBL, which provided an informed sensitivity to the simulation environment and the interactional cues students described. At the same time, this positioning carried a risk of leaning towards familiar narratives of simulation as inherently beneficial or of normalising facilitation practices as \u0026ldquo;standard\u0026rdquo;. Reflexivity was therefore embedded within the analytic process. Throughout coding and theme development, TL and PP kept brief reflexive memos to note assumptions, moments of surprise, and points where early interpretations did not fit later interviews. These reflections were used in regular analytic dialogue to interrogate how the team\u0026rsquo;s professional roles and cultural insider status might shape what was noticed, what was taken for granted, and how silence, deference, and kreng-jai were interpreted. To further strengthen analytic discipline, a senior qualitative researcher who was not involved in students\u0026rsquo; teaching reviewed emerging theme summaries and challenged the team to clarify boundaries, avoid over-reading, and retain alternative interpretations where the data were ambiguous.\u003c/p\u003e\n\u003ch2\u003eEthical Considerations\u003c/h2\u003e\n\u003cp\u003eEthics approval: HS046/2567(E3). Participation was voluntary with consent by action. Participants were reminded of the right to decline or withdraw at any time without repercussions; confidentiality and anonymity were ensured by de-identification and secure storage. Interviews were scheduled after formal course assessments; interview content had no bearing on grades.\u003c/p\u003e\n\u003ch2\u003eTrustworthiness\u003c/h2\u003e\n\u003cp\u003eTrustworthiness was supported through transparent documentation and sustained engagement with the dataset. All interviews were audio-recorded (with permission) and transcribed verbatim, and the analytic process was documented through dated memos that captured key decisions in coding and theme refinement. The team returned repeatedly to the original extracts to check coherence, distinctiveness, and interpretive fit, particularly for culturally sensitive accounts involving silence, hierarchy, and relational risk. Thick description of the setting, participants, and SBL implementation is provided to support readers\u0026rsquo; judgements about transferability. Sampling was guided by information power, with recruitment ceasing when additional interviews no longer added substantively new insight to the developing thematic structure for the study purpose (Malterud, Siersma, \u0026amp; Guassora, 2016).\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTwenty-four students participated in the study. Most were female (17/24, 70.8%), and the mean age was 22 years (SD = 1.25; Table 1). Analysis focused on how students described entering, participating in, and making sense of simulation across the pre-brief, scenario, and debriefing flow, with particular attention to role positioning (performer/observer) and facilitation as experienced within Thai classroom culture.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLearners\u0026rsquo; experiential overview of SBL\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudents rarely described simulation as just another class. Instead, they spoke about SBL as a distinctive learning space with a ward-like feel and a heightened sense of visibility, shaped by equipment, time constraints, and being watched by peers and instructors. As one participant noted, \u003cem\u003e\u0026ldquo;It was like caring for a real patient through role-play\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Case 8). When describing participation\u0026mdash;particularly in debriefing\u0026mdash;students often framed silence and reluctance to correct peers as socially and culturally appropriate rather than as disengagement: \u003cem\u003e\u0026ldquo;When the teacher had already spoken, I didn\u0026rsquo;t add my view\u0026mdash;I didn\u0026rsquo;t want to look impolite\u0026rdquo;\u003c/em\u003e (Case 7). Overall, students remembered simulation through its emotional and relational weight as much as its technical content, providing context for the themes presented below.\u003c/p\u003e\n\u003ch2\u003eThematic analysis\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eReflexive thematic analysis developed four themes: (1) Entering a New Space, (2) Stress and Roles as Catalysts for Learning, (3) The Duality of Participation and Observation, and (4) Facilitation and Cultural Safety (Table 2). Entering a New Space described simulation as a \u0026ldquo;third space\u0026rdquo; between classroom and ward, shaped by realism, pressure, and culturally patterned silence. Stress and Roles as Catalysts for Learning captured how nervousness could sharpen focus yet also constrain voice, and how performer versus observer positioning shaped what students noticed and retained. The Duality of Participation and Observation elaborated how learning occurred through doing, watching, and revisiting the same event during debriefing. Facilitation and Cultural Safety described how facilitator tone and feedback timing were experienced as central to psychological safety, intertwined with cultural expectations such as kreng-jai. Together, these themes portray simulation as both skills practice and a relational pedagogy enacted within Thai classroom norms and power dynamics.\u003c/p\u003e\n\u003cp\u003eTogether, these themes suggest that simulation was experienced not only as skills practice but as a relational pedagogy enacted within Thai classroom culture and power dynamics (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eTheme 1: Entering a New Space\u0026mdash;Navigating from Classroom to Simulation\u003c/h2\u003e\n\u003cp\u003eFor many Thai nursing students, the simulation room felt like a \u0026ldquo;third space\u0026rdquo;: no longer the familiarity of lectures, but not yet the ward. Their accounts clustered around three connected strands\u0026mdash;pressure, realism, and silence\u0026mdash;each shaping what it meant to enter this environment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSub-theme 1.1: The weight of pressure\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStudents described early simulation encounters as emotionally weighty, with stress exceeding what they typically felt in classroom learning. One student said, \u003cem\u003e\u0026ldquo;Every subject felt stressful\u0026hellip; when I entered the simulation, the pressure was already there\u0026rdquo;\u003c/em\u003e (Case 7). Intensity also shifted with role expectations. As the same participant noted, \u003cem\u003e\u0026ldquo;When I was the performer, it was more stressful than when I was just observing\u0026rdquo;\u003c/em\u003e (Case 7). Across these accounts, the simulation room carried an evaluative tension\u0026mdash;felt in the body and in the moment\u0026mdash;that students read as part of learning to \u0026ldquo;become\u0026rdquo; a nurse.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSub-theme 1.2: Realism as rehearsal for practice\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAlongside pressure, students valued simulation for how close it felt to practice. Several described it as a space where they could test themselves under near-clinical conditions, make mistakes, and then recalibrate. One student explained, \u003cem\u003e\u0026ldquo;It let me practice caring for patients on my own; it felt like I could really try and then see how to improve\u0026rdquo;\u003c/em\u003e (Case 8). Another added, \u003cem\u003e\u0026ldquo;When I went in, it was as if I was already caring for a patient, not just studying in class\u0026rdquo;\u003c/em\u003e (Case 12). What mattered here was not realism as a technical property alone, but realism as a learning cue\u0026mdash;helping classroom knowledge move from being remembered to being enacted.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSub-theme 1.3: Silence as a cultural stance\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStudents also described cultural norms that shaped participation inside the simulation space. Hesitation to speak up\u0026mdash;especially to correct peers\u0026mdash;was reported repeatedly. One student shared, \u003cem\u003e\u0026ldquo;Even when I saw a friend doing something wrong, I stayed quiet because I didn\u0026rsquo;t want them to feel embarrassed\u0026rdquo;\u003c/em\u003e (Case 13). Another reflected on restraint during group interactions: \u003cem\u003e\u0026ldquo;I felt pressure and didn\u0026rsquo;t dare to speak up when the teacher was already talking\u0026rdquo;\u003c/em\u003e (Case 7). Importantly, these silences were framed as relational work: showing kreng-jai, protecting face, and maintaining harmony, even when doing so limited immediate feedback or peer correction.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOverall, Theme 1 described simulation as a threshold\u0026mdash;stressful yet formative, realistic yet socially bounded\u0026mdash;where students practised skills while navigating respect, belonging, and emerging professional identity.\u003c/p\u003e\n\u003ch2\u003eTheme 2: Stress and Roles as Catalysts for Learning\u003c/h2\u003e\n\u003cp\u003eStudents described simulation as emotionally intense. Stress and nervousness were part of the learning texture\u0026mdash;sometimes supportive, sometimes disruptive. What students learned also depended on where they were positioned in the session: being the performer carried a different kind of pressure from watching as an observer.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSub-theme 2.1: Stress as a sharpened edge\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMany accounts centred on tension in the room. For some, that intensity appeared to heighten focus and speed up recall. One participant reflected, \u003cem\u003e\u0026ldquo;I froze at the beginning, but the nervousness made me remember the steps faster\u0026rdquo;\u003c/em\u003e (Case 11). Another noted, \u003cem\u003e\u0026ldquo;The pressure pushed me to think more quickly about what needed to come first\u0026rdquo;\u003c/em\u003e (Case 3). At other times, stress tipped into overload\u0026mdash;particularly when correction was experienced as abrupt. As one student put it, \u003cem\u003e\u0026ldquo;When the professor corrected me sharply during the scenario, I lost confidence and stopped talking\u0026rdquo;\u003c/em\u003e (Case 14). Across these descriptions, stress operated like a sharpened edge: it could support judgement and prioritisation, yet it could also narrow participation and voice.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSub-theme 2.2: Role-based contrasts\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStudents drew a clear contrast between being inside the scenario and observing from outside it. Performers spoke about responsibility and the fear of missing details: \u003cem\u003e\u0026ldquo;When I was the one doing it, I felt pressured and forgot small details\u0026rdquo;\u003c/em\u003e (Case 9). Observers, by comparison, described more cognitive space to scan the situation and rehearse responses mentally: \u003cem\u003e\u0026ldquo;As an observer, I could see everything and think about how I would handle it, but I didn\u0026rsquo;t always speak up\u0026rdquo;\u003c/em\u003e (Case 18). These accounts described two learning routes: one through action under time pressure; the other through distance, noticing, and quiet comparison with one\u0026rsquo;s own intended practice.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSub-theme 2.3: Facilitation under pressure\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStudents repeatedly linked their stress experience to how facilitation was enacted in the moment. When instructors allowed the scenario to unfold and offered structured feedback in the debrief afterwards, students described feeling supported and able to learn from mistakes: \u003cem\u003e\u0026ldquo;When the teacher let us finish first and then explained step by step, I felt clearer about what I had done right and wrong\u0026rdquo;\u003c/em\u003e (Case 13). In contrast, mid-scenario interruptions could shift attention away from the patient and towards fear of error: \u003cem\u003e\u0026ldquo;When the professor interrupted during the simulation, I lost focus on the patient and just worried about mistakes\u0026rdquo;\u003c/em\u003e (Case 14).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOverall, Theme 2 described how stress and role positioning intersected with facilitation style to shape whether pressure functioned as productive challenge or as a constraint on participation and confidence.\u003c/p\u003e\n\u003ch2\u003eTheme 3: The Duality of Participation and Observation\u003c/h2\u003e\n\u003cp\u003eStudents described learning in simulation through two positions: being \u0026ldquo;in the hot seat\u0026rdquo; and watching from the outside. These were not portrayed as equivalent experiences. Each position offered different learning affordances, and students often made sense of the session by moving between these perspectives\u0026mdash;especially when they returned to the event during debriefing.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSub-theme 3.1: The \u0026ldquo;hot seat\u0026rdquo; of participation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBeing the lead performer was described as stressful, yet many students also framed it as the moment learning became real. Inside the scenario, they felt pressure to prioritise and act with accountability. As one student put it, \u003cem\u003e\u0026ldquo;When I was inside, I felt pressured and nervous, but it made me think much faster about what to do first\u0026rdquo;\u003c/em\u003e (Case 11). Another linked this position to leadership and self-control: \u003cem\u003e\u0026ldquo;Being in the hot seat made me realise how important it was to stay calm and lead the group\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Case 16). For these students, participation did not simply test knowledge; it demanded decisions, and acting under pressure made lessons harder to forget.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSub-theme 3.2: The \u0026ldquo;cool gaze\u0026rdquo; of observation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eObservers described a calmer experience, with more room to scan the situation and think through alternatives. One student explained, \u003cem\u003e\u0026ldquo;As an observer, I could see what everyone was doing and think about how I would handle the situation\u0026rdquo;\u003c/em\u003e (Case 18). Another noted, \u003cem\u003e\u0026ldquo;Watching others made me realise mistakes and compare them with how I might respond\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Case 9). Here, distance created perspective. Watching became a quiet form of rehearsal\u0026mdash;an opportunity to notice patterns and anticipate responses that could be difficult to access when one is inside the action.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSub-theme 3.3: Making sense through debriefing\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStudents repeatedly pointed to debriefing as the point where these two viewpoints came together. Several described that understanding shifted after hearing how performers and observers interpreted the same scene. One participant said, \u003cem\u003e\u0026ldquo;Afterwards, hearing both sides helped me realise what I had missed when I was inside\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Case 22). Another reflected, \u003cem\u003e\u0026ldquo;Group discussion made me think again about my own actions\u0026rdquo;\u003c/em\u003e (Case 23). In these accounts, debriefing was where experience was re-read: what felt chaotic in the moment could be reorganised into clearer priorities, rationales, and alternatives.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOverall, Theme 3 described learning as movement across roles\u0026mdash;doing, watching, and revisiting the event together.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eTheme 4: Facilitation and Cultural Safety\u003c/h2\u003e\n\u003cp\u003eStudents rarely spoke about facilitation as background. The facilitator was \u0026ldquo;felt\u0026rdquo; in the room\u0026mdash;through tone, timing, and the way feedback entered the scenario. What students noticed most was whether guidance opened space to try, or whether it closed space down and made silence feel safer.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSub-theme 4.1: Calm guidance versus harsh correction\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants contrasted supportive guidance with moments when correction felt sharp. One student recalled, \u003cem\u003e\u0026ldquo;If I met a professor who got angry, I felt pressured and didn\u0026rsquo;t dare to try anything\u0026rdquo;\u003c/em\u003e (Case 11). Others described the opposite effect when teachers stayed calm and allowed them to continue even when they faltered. As a fourth-year student explained, \u003cem\u003e\u0026ldquo;When the teacher just listened and let us finish first, I felt safe to continue\u0026rdquo;\u003c/em\u003e (Case 17). Across these accounts, the way feedback was delivered shaped whether students stayed engaged or withdrew.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSub-theme 4.2: Debriefing as a constructive space\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor many students, the debrief was where learning became tangible. They valued reviewing the scenario step by step, not only to check correctness but also to speak more openly about what they were thinking and feeling. One participant said, \u003cem\u003e\u0026ldquo;When we reviewed it together, I could see what I did right and wrong, and I wasn\u0026rsquo;t afraid to admit mistakes\u0026rdquo;\u003c/em\u003e (Case 13). Others described how a calm debrief helped nervousness settle into confidence. In this way, debriefing was not merely a wrap-up; its atmosphere shaped whether mistakes were experienced as usable lessons or as personal failure.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSub-theme 4.3: Cultural safety intertwined with learning\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFacilitation also interacted with cultural expectations around speaking, respect, and protecting others from embarrassment. Silence in discussion was often described as relational rather than disengaged. One student admitted, \u003cem\u003e\u0026ldquo;Even when I knew my friend had missed something, I didn\u0026rsquo;t correct them in front of others\u0026rdquo;\u003c/em\u003e (Case 13). For these learners, kreng-jai\u0026mdash;the impulse to avoid causing discomfort\u0026mdash;guided how they responded to both peers and teachers. Students\u0026rsquo; accounts consistently linked psychological safety with cultural safety: when both were present, students felt more able to contribute; when either was threatened, withholding voice became the safer option.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOverall, Theme 4 described facilitation as more than a teaching technique: calm feedback and respectful debriefing supported participation, whereas harsh correction reduced voice and confidence, with these effects intensified by cultural expectations around hierarchy and face.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study offers a culturally situated account of simulation-based learning (SBL) in Thai undergraduate nursing education. Students often described SBL as more than rehearsal. For many, it functioned as an early moment of professional entry\u0026mdash;highly visible, emotionally charged, and shaped by familiar classroom norms. This reading sits alongside broader syntheses showing that SBL can support competence development, confidence, and preparedness across diverse curricular approaches (Alharbi et al., 2024; Cant \u0026amp; Cooper, 2017). What our participants emphasised, however, was how real the nurse role felt in simulation, sometimes earlier than comparable opportunities in practice. Where early clinical exposure is perceived as limited or delayed, simulation may operate as a liminal space in which theoretical knowledge is tested against the situated demands of patient care. This interpretation aligns with sociocultural perspectives that frame learning as participation within communities of practice (Lave \u0026amp; Wenger, 1991)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo integrate the findings, Figure 1 presents a thematic map showing how Thai nursing students experienced simulation-based learning as a pedagogical flow. Students entered the simulation space with heightened pressure and a sense of realism (Theme 1), which shaped stress and role positioning during the scenario (Theme 2). Learning then unfolded through complementary performer and observer perspectives (Themes 3), with understanding consolidated in debriefing as shared reflection. Across the flow, facilitation and cultural safety (Theme 4) shaped how pressure, feedback, and silence were experienced at multiple points. The figure is intended as an analytic summary of patterned meanings rather than a causal model, highlighting how contextual conditions, learner roles, and facilitation intersected to influence meaning-making, safety, and readiness to engage.\u003c/p\u003e\n\u003cp\u003eAcross interviews, kreng-jai emerged as a salient mediator of participation. This resonates with Thai evidence showing how hierarchy, kreng-jai, and feedback norms influence what is said, to whom, and when (Areemit et al., 2021). It is also consistent with work describing \u0026ldquo;silent participation\u0026rdquo; as culturally intelligible rather than disengaged (Chung, 2021). Our findings extend this discussion by suggesting that facilitator tone and timing can either widen or narrow the space for student voice. When facilitation felt calm and non-punitive, deference sometimes shifted toward respectful engagement, allowing students to ask questions and acknowledge uncertainty without embarrassment. In contrast, harsh or abrupt correction could prompt withdrawal that appeared less about knowledge deficits and more about relational risk-management in the face of hierarchy (Areemit et al., 2021). These patterns were not identical for every participant, but they recurred often enough to shape how debriefing was experienced. They underline the practical importance of culturally responsive facilitation and debriefing, particularly given that much of the dominant debriefing discourse has been shaped in Western educational traditions and may require culture-sensitive adaptation in high power-distance Asian settings (Hyun Soo et al., 2013; Ulmer et al., 2018)\u003c/p\u003e\n\u003cp\u003eThe duality of learning through active participation versus observation also provided important insights. Students in-role described learning through performance under pressure; observers more often described a reflective stance, noticing patterns, errors, and alternative actions from a distance. This is consistent with social learning accounts of vicarious learning, in which learning can occur through observing others and the consequences of action (Bandura, 1978). Our findings add a practical condition: observational learning was described as more useful when it was intentionally structured (e.g., guided prompts or focused questions), rather than left as passive watching. This matters in settings where opportunities to perform are limited by time, group size, or available equipment. Under these conditions, the observer role may be better treated as an active learning position rather than a secondary one (B\u0026oslash; et al., 2022).\u003c/p\u003e\n\u003cp\u003eFinally, the findings point to a tension between the visible infrastructure of simulation and the less visible pedagogical conditions that students described as shaping learning\u0026mdash;facilitator practice, debriefing climate, and psychological safety. Rather than equating fidelity with equipment alone, our data support a broader understanding of simulation quality as a socially organised learning practice. This aligns with theoretical arguments that simulation is not only a technical set-up, but a form of social practice in which interactional conditions matter (Dieckmann et al., 2007). Read this way, simulation quality extends beyond physical realism to include psychological fidelity\u0026mdash;that is, the extent to which learners experience the scenario as meaningful, believable, and emotionally safe (Burford et al., 2023). From this perspective, SBL is less a technological showcase and more a relational pedagogy, strengthened through facilitation that is both psychologically safe and culturally attuned.\u003c/p\u003e\n\u003ch2\u003ePolicy and practice implications\u003c/h2\u003e\n\u003cp\u003eFor many participants, simulation was not experienced as a peripheral exercise but as an early\u0026mdash;and highly visible\u0026mdash;entry point into patient care roles. Our document comparison suggests that accreditation requirements in the region place stronger emphasis on infrastructure (e.g., facilities, mannequins, equipment) than on minimum pedagogical conditions (e.g., facilitator preparation, structured debriefing, and learner psychological safety).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSeveral practical implications follow. First, the observer role could be formalised. Participants described observation as cognitively useful; programmes could therefore treat observers as active learners by assigning explicit objectives and structured prompts. Second, debriefing warrants greater emphasis. In our document set, debriefing was less explicitly specified than infrastructural requirements; yet participants\u0026rsquo; accounts suggest that culturally attuned debriefing can enable reflection without fear of embarrassment. Finally, participants framed fidelity not only as physical realism but also as fairness\u0026mdash;whether opportunities were equitable across groups. Standards that address group size, time allocation, role rotation, and equipment readiness may therefore be as consequential as equipment investment for sustaining trust in simulation.\u003c/p\u003e\n\u003ch2\u003eLimitations and future directions\u003c/h2\u003e\n\u003cp\u003eThis study has several limitations. First, the qualitative strand inevitably overlaps with constructs also measured quantitatively (e.g., confidence, satisfaction); however, the qualitative analysis examined how students made sense of these constructs and under what conditions they shifted, rather than estimating magnitude. Second, although stress inoculation and dual-process ideas informed our interpretive lens, the underlying mechanisms were not directly tested; cognitive load, physiological markers, and longer-term transfer were not assessed. Third, comparative discussion relied on available evidence from a small number of ASEAN settings, and the regional literature remains uneven across countries, limiting broader generalisation. Finally, the study was conducted in a single institution, which supported depth but constrained breadth. Future work could test specific pedagogical levers\u0026mdash;such as structured debriefing and observer task design\u0026mdash;across multiple sites and programme years.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eReflexivity\u003c/h2\u003e\n\u003cp\u003eAs nurse educators and cultural insiders, our positions likely shaped what we noticed and how we interpreted participants\u0026rsquo; accounts. Reflexivity was addressed through regular interpretive dialogue across the analytic team, the use of analytic memos, and an audit trail documenting key coding and theme-development decisions. Rather than seeking consensus metrics, we used critical discussion to surface divergent readings and to examine how our assumptions may have shaped interpretation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights a distinctive Thai perspective in which simulation was often experienced less as reinforcement and more as an early professional initiation. Students described simulation as a first opportunity to inhabit the nurse role within a bounded space where errors could be surfaced and discussed without patient harm. Across themes, participation was shaped not only by scenario demands but also by cultural norms around hierarchy and silence, and by facilitation practices\u0026mdash;particularly tone, timing of feedback, and the climate created in debriefing.\u003c/p\u003e \u003cp\u003eAt a policy level, the document comparison suggests a persistent misalignment between infrastructure-focused accreditation requirements and the pedagogical conditions that students described as shaping learning. Addressing this misalignment\u0026mdash;by strengthening expectations around facilitation, debriefing, observer role design, and equitable access to participation\u0026mdash;may help align simulation provision with educational evidence and learner experience in context.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eBefore conducting the study, ethics approval was granted from the University (reference number HS046/2567(E3)). Informed consent was obtained from all subjects involved in the study. All responses in the data collection process were collected and analysed anonymously.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eParticipants provided consent for the use of anonymised quotations in publications. All identifying information has been removed.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe interview transcripts are not publicly available due to confidentiality and the risk of participant identification. De-identified excerpts may be available from the corresponding author upon reasonable request and subject to ethics approval/conditions.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study was supported by a grant from the Faculty of Nursing, Burapha University (0166/2566).\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; contributions\u003c/h2\u003e\n\u003cp\u003eTL conceptualised and led the study, managed the project, supervised the research team, conducted the formal analysis, curated the data, and wrote the original draft. WKi contributed to study methodology and formal analysis. PP conducted qualitative investigation, managed data curation, performed transcription and coding, prepared visualisations, and contributed to writing\u0026mdash;review and editing and validation. CV conducted qualitative investigation, provided resources, and contributed to data curation. NS conducted qualitative investigation and contributed to data curation. WKa contributed to conceptualisation, investigation, and data curation. PuP contributed to quantitative investigation and validation. PT contributed to writing\u0026mdash;review and editing. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWe would like to thank the Faculty of Nursing, Burapha University, for supporting this research.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eDeclaration of generative AI in scientific writing\u003c/h2\u003e\n\u003cp\u003eDuring the preparation of this work the author(s) used Grammarly and ChatGPT in order to assist in improving the language clarity of this manuscript. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the published article.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; information\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eTrakulwong Luecha: \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;0000-0002-2526-7751\u003c/p\u003e\n\u003cp\u003eCharunyakorn Viriya:\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;-\u003c/p\u003e\n\u003cp\u003eNattaya Sangsai:\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;-\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatcharin Poonthawe: \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;0000-0003-1765-8071\u003c/p\u003e\n\u003cp\u003eWitchaporn Kidsamrong: \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;0009-0009-1711-0816\u003c/p\u003e\n\u003cp\u003eWarisa Kanbuala: \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;0009-0004-9341-2246\u003c/p\u003e\n\u003cp\u003ePuntaree Pikulnee:\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;0009-0001-5093-7745\u003c/p\u003e\n\u003cp\u003ePaweena Tivasiripong: \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 0009-0007-4675-988X\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAlharbi, A., Nurfianti, A., Mullen, R. 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Cultural prototypes and differences in simulation debriefing. \u003cem\u003eSimulation in Healthcare, 13\u003c/em\u003e(4), 239-246. doi:10.1097/SIH.0000000000000320\u003c/li\u003e\n\u003cli\u003evan Graan, A. C., Williams, M. J. S., \u0026amp; Koen, M. P. (2016). Professional nurses\u0026apos; understanding of clinical judgement: A contextual inquiry. \u003cem\u003eHealth SA Gesondheid, 21\u003c/em\u003e, 280-293. doi:10.1016/j.hsag.2016.04.001\u003c/li\u003e\n\u003cli\u003evan Nes, F., Abma, T., Jonsson, H., \u0026amp; Deeg, D. (2010). Language differences in qualitative research: is meaning lost in translation? \u003cem\u003eEuropean Journal of Ageing, 7\u003c/em\u003e(4), 313-316. doi:10.1007/s10433-010-0168-y\u003c/li\u003e\n\u003cli\u003eVillamin, P., Lopez, V., Thapa, D. K., \u0026amp; Cleary, M. (2025). A Worked Example of Qualitative Descriptive Design: A Step-by-Step Guide for Novice and Early Career Researchers. \u003cem\u003eJournal of Advanced Nursing, 81\u003c/em\u003e(8), 5181-5195. doi:10.1111/jan.16481\u003c/li\u003e\n\u003cli\u003eXuto, P., Prasitwattanaseree, P., Chaiboonruang, T., Khiaokham, L., Nimarangkul, K., Bressington, D., \u0026amp; Miyata, C. (2025). Developing clinical leadership through high-fidelity obstetric simulation: A multimethods study in Thai nursing students. \u003cem\u003eClinical Simulation in Nursing, 102\u003c/em\u003e, 101720. doi:10.1016/j.ecns.2025.101720\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Participant characteristics (N = 24)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cem\u003eM\u003c/em\u003e \u0026plusmn; \u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eMin\u0026ndash;Max\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e29.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e70.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003eYear of study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 3rd year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e54.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 4th year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e45.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e22.0 \u0026plusmn; 1.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e20\u0026ndash;24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 2. Themes, Sub-themes, Illustrative Meaning, and Example Quotations.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eTheme\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eSub-theme\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eIllustrative Meaning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eExample Quotations\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(EN, Case No.)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eTheme 1: Entering a New Space\u0026mdash;Navigating from Classroom to Simulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eSub-theme 1.1: The weight of pressure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eStudents described early simulation encounters as emotionally weighty, with stress heightened on entering the room and intensifying when taking the performer role rather than observing.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u0026ldquo;Every subject felt stressful\u0026hellip; when I entered the simulation, the pressure was already there\u0026rdquo; (Case 7)\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;When I was the performer, it was more stressful than when I was just observing\u0026rdquo; (Case 7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eSub-theme 1.2: Realism as rehearsal for practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eStudents valued simulation as rehearsal for practice, allowing them to attempt patient care independently, make mistakes safely, and recalibrate before clinical placements.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u0026ldquo;It let me practice caring for patients on my own; it felt like I could really try and then see how to improve\u0026rdquo; (Case 8)\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;When I went in, it was as if I was already caring for a patient, not just studying in class\u0026rdquo; (Case 12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eSub-theme 1.3: Silence as a cultural stance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eHesitation to speak\u0026mdash;particularly to correct peers\u0026mdash;was framed as respectful restraint shaped by kreng-jai, protecting face and maintaining harmony rather than disengagement.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u0026ldquo;Even when I saw a friend doing something wrong, I stayed quiet because I didn\u0026rsquo;t want them to feel embarrassed\u0026rdquo; (Case 13)\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;I felt pressure and didn\u0026rsquo;t dare to speak up when the teacher was already talking\u0026rdquo; (Case 7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eTheme 2: Stress and Roles as Catalysts for Learning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eSub-theme 2.1: Stress as a sharpened edge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eStress operated as a sharpened edge: it could heighten focus and prioritisation, yet could also tip into overload and reduce voice, particularly when in-scenario correction was experienced as abrupt.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u0026ldquo;I froze at the beginning, but the nervousness made me remember the steps faster\u0026rdquo; (Case 11)\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;The pressure pushed me to think more quickly about what needed to come first\u0026rdquo; (Case 3)\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;When the professor corrected me sharply during the scenario, I lost confidence and stopped talking\u0026rdquo; (Case 14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eSub-theme 2.2: Role-based contrasts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003ePerformers experienced responsibility and time pressure that could narrow attention, whereas observers reported more cognitive space to scan the situation, compare responses, and rehearse alternatives.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u0026ldquo;When I was the one doing it, I felt pressured and forgot small details\u0026rdquo; (Case 9)\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;As an observer, I could see everything and think about how I would handle it, but I didn\u0026rsquo;t always speak up\u0026rdquo; (Case 18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eSub-theme 2.3: Facilitation under pressure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eFacilitation shaped how pressure was experienced: allowing the scenario to unfold and reserving step-by-step feedback for debrief supported learning from mistakes, while mid-scenario interruptions shifted attention towards fear of error.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u0026ldquo;When the teacher let us finish first and then explained step by step, I felt clearer about what I had done right and wrong\u0026rdquo; (Case 13)\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;When the professor interrupted during the simulation, I lost focus on the patient and just worried about mistakes\u0026rdquo; (Case 14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eTheme 3: The Duality of Participation and Observation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eSub-theme 3.1: The \u0026ldquo;hot seat\u0026rdquo; of participation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eParticipation in the \u0026ldquo;hot seat\u0026rdquo; made learning feel real; acting under pressure demanded decisions, prioritisation, and leadership, making lessons memorable.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u0026ldquo;When I was inside, I felt pressured and nervous, but it made me think much faster about what to do first\u0026rdquo; (Case 11)\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;Being in the hot seat made me realise how important it was to stay calm and lead the group\u0026rdquo; (Case 16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eSub-theme 3.2: The \u0026ldquo;cool gaze\u0026rdquo; of observation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eObservation offered a calmer, analytic vantage point, enabling students to see the whole scene, notice errors, and mentally rehearse how they would respond.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u0026ldquo;As an observer, I could see what everyone was doing and think about how I would handle the situation\u0026rdquo; (Case 18)\u003cbr\u003e\u0026nbsp;\u0026ldquo;Watching others made me realise mistakes and compare them with how I might respond\u0026rdquo; (Case 9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eSub-theme 3.3: Making sense through debriefing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eDebriefing was where performer and observer perspectives were integrated; shared discussion helped students re-read the event, clarify rationales, and identify what they had missed.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u0026ldquo;Afterwards, hearing both sides helped me realise what I had missed when I was inside\u0026rdquo; (Case 22)\u003cbr\u003e\u0026nbsp;\u0026ldquo;Group discussion made me think again about my own actions\u0026rdquo; (Case 23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eTheme 4: Facilitation and Cultural Safety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eSub-theme 4.1: Calm guidance versus harsh correction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eStudents contrasted calm, invitational guidance with harsh correction; facilitator tone influenced whether they continued to engage or withdrew.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u0026ldquo;If I met a professor who got angry, I felt pressured and didn\u0026rsquo;t dare to try anything\u0026rdquo; (Case 11)\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;When the teacher just listened and let us finish first, I felt safe to continue\u0026rdquo; (Case 17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eSub-theme 4.2: Debriefing as a constructive space\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eStudents described debriefing as the point where learning became tangible; reviewing the scenario step by step enabled open reflection, normalised mistakes, and helped nervousness settle into confidence.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u0026ldquo;When we reviewed it together, I could see what I did right and wrong, and I wasn\u0026rsquo;t afraid to admit mistakes\u0026rdquo; (Case 13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eSub-theme 4.3: Cultural safety intertwined with learning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003ePsychological safety was intertwined with cultural safety: kreng-jai and face concerns shaped whether students corrected peers or spoke up, making respectful facilitation central to participation.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u0026ldquo;Even when I knew my friend had missed something, I didn\u0026rsquo;t correct them in front of others\u0026rdquo; (Case 13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"simulation-based learning, nursing students, debriefing, cultural safety, Thailand","lastPublishedDoi":"10.21203/rs.3.rs-8654727/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8654727/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e\u003cem\u003e \u003c/em\u003eThis study examined how stress, role positioning, and facilitator feedback timing/tone interact to shape participation and culturally safe learning in simulation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003cem\u003e \u003c/em\u003eA qualitative descriptive study was conducted as the qualitative strand of a broader mixed-methods project in an undergraduate nursing programme in Eastern Thailand. Between August and October 2024, 24 third- and fourth-year students participated in in-depth, semi-structured interviews in Thai (face to face or via Zoom). Interviews lasted 45–60 minutes, were transcribed verbatim, and analysed using reflexive thematic analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003cem\u003e \u003c/em\u003eFour themes were developed. Entering a New Space framed simulation as a “third space” between classroom and ward, with heightened visibility and realism alongside culturally patterned restraint. Stress and Roles as Catalysts for Learning showed that pressure could sharpen focus yet narrow voice, especially when feedback felt abrupt or ill-timed. The Duality of Participation and Observation highlighted complementary learning routes: performers learned through accountable action under time constraints, while observers gained analytic perspective and re-read events in debriefing. Facilitation and Cultural Safety emphasised that calm guidance supported participation, whereas harsh correction often intensified silence linked to kreng-jai.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003cem\u003e: \u003c/em\u003eSBL was experienced as more than technical practice; tone, timing, and role design mattered. Explicit observer objectives and structured debriefing may strengthen culturally safe participation and fair learning opportunities.\u003c/p\u003e","manuscriptTitle":"Thai nursing students’ formative experiences of simulation-based learning: Implications for facilitation and debriefing","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-10 12:54:55","doi":"10.21203/rs.3.rs-8654727/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c5fd51f9-da4f-40df-97df-df773308e6a0","owner":[],"postedDate":"February 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T02:23:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-10 12:54:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8654727","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8654727","identity":"rs-8654727","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}