Introduction

A disaster is an event in which demand exceeds immediately available resources. Disaster events overwhelm local response capacity, requiring a request for external assistance at the national or international level (Caldera & Wirasinghe, 2022). Thus, disasters must be considered not only in terms of their destructive impact but also in terms of the appropriate preparation of available resources in the community. Disaster preparedness is today widely accepted as no longer an option but an important issue (Yeo & Comfort, 2017). In particular, it is clear that demand for medical care will surge during a disaster situation that threatens many lives and that the timely availability of well-equipped and prepared healthcare workers is very important to disaster response (Yeo & Comfort, 2017).

Nurses are indispensable at disaster sites because they have the knowledge, skills, and capabilities necessary to actively contribute to disaster situations that enable them to function effectively at all stages of disaster management. Nurses may serve as first responders at disaster sites, direct healthcare providers, point-of-care coordinators, informants, educators, and counselors for mental health issues as well as perform triage (Winders et al., 2021). Disaster nursing is designed to provide nursing activities by systematically using professional knowledge and skills to reduce disaster-related risks to life and health (Huh & Kang, 2019). Moreover, nursing competency in disaster situations requires knowledge and skills specific to disasters, as it is necessary to provide nursing care in suboptimal environments affected by resource scarcities (Bouda et al., 2007; World Health Organization & International Council of Nurses [ICN], 2009).

However, most nurses and nursing students are not prepared properly for disaster situations (Labrague et al., 2018). In particular, nursing students lack knowledge about disasters and disaster nursing and do not fully understand the resources available in the community or the role of nurses in disasters (Hutchinson et al., 2011; Kaplan et al., 2012). Furthermore, even if nurses are willing to respond to disasters or major public health emergencies, their actual participation is determined by their self-perceived clinical abilities and personal safety concerns as well as the well-being of their family members (Ireland et al., 2006). Belief in being fully prepared for disaster situations increases the confidence of nurses in disaster response situations, and having previous disaster response experience and disaster-related education improves disaster response preparedness (Labrague et al., 2018). Conversely, lack of relevant experience creates stress and fear in nurses about their disaster response capabilities (Labrague et al., 2018).

Therefore, it is very important to prepare and educate nurses from the undergraduate level so they can prepare effectively for and respond quickly to disaster situations (Kamanyire et al., 2021).

International studies on disaster nursing education programs for nursing students have been published in greater numbers since the 9/11 terrorist attacks in the United States, the Hanawa earthquake in Japan, and the 2008 Sichuan earthquake in China. Even if the educational goal, education target, and education topic are selected, it is not easy to determine a feasible and cost-effective education method because of the intense, complex, and diverse characteristics of disasters (Noh et al., 2017; H. Y. Park & Kim, 2017). Many educators use simulations instead of real disaster experiences to improve the disaster nursing capabilities of their students (Hwang & Lee, 2021; Jose & Dufrene, 2014). Suggested it is desirable to combine theory and practice in disaster education. The main approach of previous studies (Hutchinson et al., 2011; Zinan et al., 2015) has been to first deliver theoretical content and then provide simulated learning experiences as training for mass casualty incidents (MCIs).

In addition to this, the format of disaster nursing education currently varies widely, from traditional lecture-style education to web education, tabletop training, virtual reality simulation (VRS), problem-focused learning, field study, and disaster simulation training (Jose & Dufrene, 2014). Disaster nursing and management education for nurses can lead to positive outcomes such as reduced mortality, improved healthcare services, and lower disaster-related costs (Kalanlar, 2018). A better way to help communities recover from disasters is to educate future nursing students about disaster preparedness and response (Grimes et al., 2020). Therefore, it seems to be an effective approach to apply educational programs that include simulations of disaster nursing scenarios for nursing undergraduate students to provide experiences that can lead to true learning and competency in disaster nursing and enable them to understand naturally the concept of theoretical knowledge gained from lectures presented in a simulation created to look like a real disaster, apply nursing activities, and promote a process of feedback and reflection.

This study was designed to develop a disaster nursing education program based on a simulation using standardized patients that allows nursing students to experience disasters to improve their preparedness for disasters and nursing competency. The effectiveness of the program was subsequently investigated and evaluated.

Background

Experiential learning theory provides the basis for simulation education. By providing an experience of clinical practice in a safe learning environment for learners through scenarios and by promoting discussion and feedback between learners and instructors and a process of reflective reflection, simulation education approximates authentic learning via experiential learning, as experiences lead to qualitative and quantitative growth within the learner through a reflective process (Jeffries, 2005).

Simulations may be used in various forms by nursing educators. In disaster nursing education, mock training using MCI scenarios is the main focus (Currie et al., 2018; Kaplan et al., 2012; Saber et al., 2017). Other studies have applied highly innovative teaching methods. For example, Farra et al. (2013) incorporated VRS developed through Second Life, which allows users to experience online virtual reality interacting with three-dimensional environments based on situational learning theory, into disaster nursing education. It was developed and used by researchers based on the International Nursing Coalition for Mass Casualty Education's disaster nursing capabilities. The control group received only web-based education, whereas the experimental group received VRS in addition to web-based education. Both groups were repeatedly measured 2 months later to test effectiveness. Farra et al. also applied VRS to teach decontamination technology in disaster situations and reported that nursing and medical schools directly developed VRS for disaster management and simple treatment and rapid transport severity classification, indicating the learning effects of mutual disaster education.

Tabletop methods are another educational method used in disaster education in public health schools and with hospital nurses (Nyamathi et al., 2007). However, the focus has been on disaster management and coordination rather than on the clinical roles of doctors and nurses. In addition, tabletop training was applied primarily before the application of simulations in disaster nursing education programs (Jennings-Sanders et al., 2005; Levoy et al., 2018). Notably, a hepatitis A outbreak scenario has only been used in tabletop training (Colleran-Santos & Toronto, 2014).

Cooperative disaster simulation education has also been applied in disaster nursing education (Zapko et al., 2015) with nursing students and radiology students working together. In addition, there has been a simulation study that integrated and applied leadership principles of nurses in case of disaster as well as disaster response techniques during disaster nursing education. In addition, there was a study in which simulation training was conducted by configuring two scenarios to prepare for an epidemic emergency (Morrison & Catanzaro, 2010).

However, studies that increase the reproducibility of disaster situations caused by earthquakes and use standardized patients composed of professional actors have been rare. Therefore, the conceptual framework of this study was to develop a simulation-based educational program using standardized patients and to verify the effectiveness of this program based on the simulation model (National League for Nursing/Jeffries Simulation Framework) by Jeffries (2005; Figure 1).

Figure 1.:

Conceptual Framework of the Study Based on the Jeffries Simulation Model

Instructors help learners in the disaster nursing learning process based on their clinical career providing nursing care to patients during disaster situations, educational experience in simulation education, and experience in completing the disaster nursing curriculum. In addition, after simulation practice, the experience of learning is shared with learners through debriefing. Learners are undergraduate students in nursing departments who faithfully play their role as active learning activity and team members to improve basic knowledge, attitudes, and skills in disaster nursing education.

For educational activities, feedback from instructors after disaster-related learning and simulation practice, interaction between students and faculty through practice and debriefing, team cooperation in simulations, and appropriate operating hours and simulation education for learning are provided. The simulation education program through the interaction of the above three components sets specific learning goals to achieve disaster nursing competencies in the disaster preparation and response stages and utilizes a practice environment that reproduces the disaster situation and uses standardized patients. In addition, by conducting complex simulation interventions designed to include subject assessment and cues to solve problems during simulation practice, learning outcomes such as disaster nursing capabilities, disaster severity classification, disaster readiness, critical thinking tendencies, confidence in disaster nursing, and intention to participate in disasters can be achieved.

Methods Design

This quasi-experimental study used a nonequivalent, control group, pretest–posttest design to investigate the effect of a simulation-based disaster nursing education program using standardized patients conducted for nursing students in their fourth year of college to assess their competency in disaster nursing, triage score, disaster preparedness, critical thinking, and confidence in disaster nursing (Table 1).

Table 1. - Study Design: Nonequivalent Pretest-and-Posttest Design Group Pretest Intervention Posttest Experimental (n = 70) O1 X1 O2 Comparison (n = 35) O1 X2 O2 Control (n = 35) O1 – O2

Note. O1, O2 = disaster preparedness, disaster preparation competencies, critical thinking disposition, triage, confidence in disaster nursing; X1 = simulation-based disaster nursing education program using standardized patients; X2 = traditional lecture-based method.

Data Collection and Participants

Data were collected from students from January 25 to April 3, 2019. The participants were nursing students in their fourth year who were conveniently sampled from two universities in South Korea. The selection criteria included students who had completed more than two semesters of basic nursing practice, understood the purpose of this study, and agreed to voluntarily participate. All of the participants gathered at a designated place at each school and filled out a consent form and a structured questionnaire. The participants were divided into three groups (experimental group, comparison group, and control group) by each school using a random number table. Then, the research assistant informed the participants of the schedule and procedure of the study.

The minimum number of study subjects required was calculated using the G*Power 3.1 program. With a significance level (α) of .05, a power of 0.80, and an effect size (f) of 0.33, the minimum number of samples required to compare the means of the three groups was 93. Thirty-five participants were included in each group to account for a potential dropout rate of about 10%. Five participants submitted insufficient information for the analysis and were excluded, leaving data from 140 participants available for the final analysis, with 70 in the experimental group and 35 each in the comparison and control groups.

Intervention Preparation of standardized patients before the simulation

To improve the consistency and completeness of the program, two preliminary training sessions were conducted for standardized patients before practice. Professional actors with extensive prior experience acting as standardized patients in various simulations were recruited as standardized patients in this study. They were educated on the purpose and application of the simulation training as well as the simulation procedure. The role and precautions for the standardized patients were explained; that is, they were asked to respond consistently and the same to the learners without providing any additional information. The simulation program using standardized patients was improved by doing simulation training before conducting the educational program.

Setting up the program: scenario contents

In the experimental group, the training program was conducted in groups of two to three people, and after the intervention was completed, a posttest survey was conducted. A simulation-based disaster nursing education program using standardized patients consisted of a 60-minute lecture-style theoretical class focusing on disaster preparedness and nursing in the disaster response stage followed by two scenarios and a 40-minute debriefing, which took 4 hours and 20 minutes (one session). The comparison group was provided with the same 60-minute theoretical lecture as the experimental group, after which a posttest survey and a learning satisfaction assessment were conducted. A posttest survey was conducted 2 days after the pretest for the untreated control group. The scenario consisted of a disaster site with multiple casualties and a situation in an evacuation center for victims needing healthcare (Table 2).

Table 2. - Scenario Contents of Simulation Program Session Aims of Practice Contents of Scenario First Immediate response to disaster scene with mass casualties 1. Performing triage to multiple casualties
2. Dealing with the vulnerable group at a disaster scene
3. Providing psychological care in a disaster situation
Case 1: One hour after the earthquake, the house of Mrs. Kim is in a state of  chaos. It is dark in the house because of a blackout. The walls are cracked, and the furniture is toppled over. Mrs. Kim is trying to call the paramedics and her son on her cell phone under the living room table, but there is no connection. Her husband, with impaired mobility because of stroke, who was calling out for the name of his grandson sometime ago, has not spoken for a while. Her eldest daughter is lying unconscious holding her dead 2-year-old son, and her second daughter has a bruise on her back and is coughing and crying in fear. Her Vietnamese daughter-in-law, who is 7 months pregnant, has suffered a severe laceration in her right thigh. At the request of the National Emergency Management Agency, Nurse Na who is a local public health center nurse and the leader of the Disaster Medical Assistance Team arrives at the earthquake site along with her team members. At 8:30 p.m., with confirmation from the fire department that the risk of secondary collapse of this building is low, Nurse Na enters the house of Mrs. Kim. Nurse Na assesses the disaster scene without delay as much as possible and performs the role of a community nurse as an early responder. Second Chronic disease management during disasters 1. Nursing care for hypoglycemia
2. Checking socioeconomical support system around victims
3. Encouraging self-care of chronic disease in a disaster situation
4. Providing psychological care in the postdisaster stage
Case 2: On the third day after the earthquake, Nurse Na arrives at the  elementary school in Buk-gu, Pohang, where about 500 victims are gathered. Nurse Na stops by a designated medical area on one side of the relief center to check the patient management registration book and sets out to meet the high-risk patients. In a shelter for 500 victims, Mrs. Kim is crying while lying crouched in a blanket in a relief tent. She is restless, covered in cold sweat, and her hands are shaking lightly. There is unopened bread, milk, and an insulin syringe placed over her head. Considering the situational characteristics of the disaster evacuation site, a nursing assessment and appropriate nursing intervention should be performed.
Instruments Demographic characteristics

Age, gender, previous disaster nursing education experience, previous disaster drill experience, actual disaster experience, grades, satisfaction with nursing major, and satisfaction with practice were the demographic variables surveyed in this study.

Competency in disaster nursing

In this study, the ICN framework of disaster nursing competencies was used as the basis for evaluating the competency of nursing students in disaster nursing. As the simulation-based disaster nursing education program was focused on disaster preparedness and response stages, the contents of Domains 3–9 of the ICN disaster nursing competency framework were set as the basic categories. Among the 92 competencies in the domains, 39 items related to the disaster nursing competency of nursing students were selected as preliminary items, as suggested in a previous study (Colleran-Santos & Toronto, 2014).

Primary validity was evaluated by an expert group consisting of one professor of community nursing, one professor of adult nursing, and one professor of child nursing, resulting in an average content validity index (CVI) of .93 and a Cronbach's alpha for disaster nursing competency scale reliability of .95. The final disaster nursing competency scale comprised 26 items covering disaster-nursing-related knowledge, skills, and judgment expected of nursing students. The scale was scored using a 5-point scale.

Disaster preparedness

Disaster preparedness was measured by modifying and supplementing 26 items by Huh and Kang (2019). The disaster nursing education program was applied with the developer's approval using a case-based small group learning method to meet the purposes of this study. At the time of development, the original scale included all areas of disaster (disaster prevention and mitigation, disaster preparedness, disaster response, and disaster recovery and rehabilitation). For this study, the scale was modified and supplemented to reflect our focus on the disaster preparedness and response stages only. The revised scale is scored on a 5-point Likert scale, consisting of 14 final items after validation by three experts. The measured CVI was .95 and the Cronbach's alpha was .88 in this study.

Triage score

To evaluate the triage score in the event of a disaster, the triage scenario used in the national disaster life support curriculum as well as a scale consisting of five items developed by the authors with reference to the triage scenario (J. Y. Park & Choi, 2012) were used. Using a binary scale, a correct answer was given 1 point and an incorrect answer was given 0 points. The total score ranged from 0 to 5 points, with higher scores indicating a higher triage score. The CVI was .96 as a result of a scale validity evaluation by an expert group of three nursing professors.

Critical thinking

Critical thinking was measured using the critical thinking scale developed by Yoon (2008) for nursing students, with higher scores indicating a higher level of critical thinking. Critical thinking disposition includes 27 items in seven areas: intellectual passion/curiosity (five items), prudence (four items), confidence (four items), systemicity (three items), intellectual fairness (four items), healthy skepticism (four items), and objectivity (three items). Questions 1 and 25 are inverse questions. Each item is scored on a 5-point Likert scale. The Cronbach's alpha value was .84 as measured in the study by Yoon and .87 as measured in this study.

Confidence in disaster nursing

Self-confidence in disaster nursing was measured using a single item framed using the simulation practice standard (2017) of the Korea Institute of Nursing Education and Evaluation. The score ranges from 0 (not very confident) to 10 (very confident), with higher scores associated with higher confidence in disaster nursing.

Ethical Considerations

In this study, data were collected with the approval (KHSIRB-17096) of the institutional review board of Kyung Hee University for ethical consideration of the participants, and the measures and scales were used with the approval of their respective developers. Before the start of the research, students who wished to participate in the study were informed of the purpose and procedures of the study, method of data collection, confidentiality and anonymity policies, and data storage and disposal protocols and that the submitted questionnaire information would be used for research purposes only.

Data Analysis

The data analysis for this study was performed using the IBM SPSS Statistics 23.0 (IBM Inc., Armonk, NY, USA) program. The general characteristics of the participants and the values of each variable were calculated as frequency, percentage, mean, and standard deviation. Verification of homogeneity according to the general characteristics of subjects was conducted using the χ2 test, t test, and Fisher's exact test. Verification of homogeneity according to the dependent variable of the three groups was carried out using analysis of variance. The differences by dependent variable were analyzed using one-way analysis of variance, and significant variables were analyzed using the Scheffe post hoc test. The reliability of the scale was calculated and expressed in terms of Cronbach's alpha coefficient.

Results General Characteristics

The participants in this study included 140 nursing students, with 70 in the experimental group, 35 in the comparison group, and 35 in the control group. Sixty-six (94.3%) in the experimental group, 33 (94.3%) in the comparison group, and 32 (91.4%) in the control group had never received disaster nursing education in their nursing curriculum. Sixty-four in the experimental group (91.4%), 30 in the comparison group (85.7%), and 33 in the control group (94.3%) had never participated in disaster training or simulation-based disaster education, suggesting that most of the participants had never experienced disaster nursing education or other simulation-based training in their nursing curriculum. The analysis of homogeneity before the implementation of the simulation disaster education program found no significant difference among the groups, indicating that the three groups were homogeneous (Table 3).

Table 3. - Homogenic Test of General Characteristics Among Groups (N = 140) Characteristic Exp. (n = 70) Comp. (n = 35) Cont. (n = 35) χ2 or F p n % n % n % Age (years; M and SD) 22.26 1.38 22.91 1.92 22.83 1.56 2.69 .071 Gender 0.65 .724 a  Female 58 82.9 31 88.6 29 82.9  Male 12 17.1 4 11.4 6 17.1 Prior education in disaster nursing experience 0.36 .837 a  Yes 4 5.7 2 5.7 3 8.6  No 66 94.3 33 94.3 32 91.4 Prior disaster drill experience 1.61 .447 a  Yes 6 8.6 5 14.3 2 5.7  No 64 91.4 30 85.7 33 94.3 Prior disaster experience 0.31 .856  Yes 19 27.1 11 31.4 11 31.4  No 51 72.9 24 68.6 24 68.6 Grade 6.53 .367  > 4.0 7 10.0 4 11.4 4 11.4  3.6–4.0 33 47.2 14 40.0 10 28.6  3.0–3.5 22 31.4 15 42.9 19 54.3  < 3.0 8 11.4 2 5.7 2 5.7 Satisfaction with nursing major 2.07 .724 a  Very satisfied 33 47.1 17 48.6 12 34.3  Satisfied 34 48.6 17 48.6 21 60.0  Unsatisfied 3 4.3 1 2.8 2 5.7 Satisfaction with practice 5.58 .232 a  Very satisfied 32 45.7 17 48.6 11 31.4  Satisfied 34 48.6 16 45.7 18 51.4  Unsatisfied 4 5.7 2 5.7 6 17.2

Note. Exp. = experimental group; Comp. = comparison group; Cont. = control group.

a Fisher's exact test was performed.

Effect of the Disaster Nursing Simulation Using Standardized Patients

In the experimental group, competency in disaster nursing (F = 62.12, p < .001) and disaster preparedness (F = 60.37, p < .001) scores were significantly improved over the comparison and control groups. A post hoc test used to examine between-group differences showed the scores for both variables to be highest in the experimental group, followed by the comparison group and then the control group. Triage (F = 17.35, p < .001) and critical thinking (F = 1.63, p < .001) scores were also significantly higher in the experimental group than the comparison and control groups. In addition, a significant difference was observed among the three groups in terms of confidence in disaster nursing (F = 20.24, p < .001). On the basis of the post hoc test results, the experimental and comparison groups earned significantly higher confidence scores than the control group (Table 4).

Table 4. - Evaluation of the Program Application for Simulation Practice (N = 140) Outcome/Group Pretest Posttest O2–O1 F or χ2/Post Hoc p Mean SD Mean SD Mean SD Competency in disaster nursing 62.12 < .001*  ① Exp. (n = 70) 73.90 15.04 106.81 10.86 32.91 13.72 ① > ② > ③  ② Comp. (n = 35) 77.63 13.90 95.43 15.91 17.80 20.55  ③ Cont. (n = 35) 77.20 11.43 78.97 9.89 1.77 7.85 Disaster preparedness 60.37 < .001*  ① Exp. (n = 70) 35.41 8.03 57.83 5.72 22.41 8.77 ① > ② > ③  ② Comp. (n = 35) 37.54 7.46 49.91 12.42 12.37 13.67  ③ Cont. (n = 35) 35.89 7.09 39.31 7.00 3.43 8.44 Triage score 17.35 < .001*  ① Exp. (n = 70) 2.93 0.93 3.96 1.03 1.83 1.29 ① > ②, ① > ③  ② Comp. (n = 35) 2.66 1.21 2.94 1.28 0.29 1.18  ③ Cont. (n = 35) 2.43 1.14 2.66 1.35 0.23 1.35 Critical thinking 19.63 < .001*  ① Exp. (n = 70) 98.90 10.42 103.16 9.93 4.26 7.81