Development and Effect of a Simulation-Based Disaster Nursing Education Program for Nursing Students Using Standardized Patients

ABSTRACT Background Disaster nursing deploys professional nursing knowledge and skills systematically to reduce disaster-related risks to life and health. Disaster nursing education requires providing simulations using standardized patients. Purpose The purpose of this study was to develop, based on the International Council of Nurses' Framework of Disaster Nursing Competencies, a simulation-based disaster nursing education program for nursing students that employed standardized patients. Methods A nonequivalent, control group, pretest-and-posttest design was used. Participants were senior nursing students from two universities, with 70 assigned to the experimental group, 35 assigned to the comparison group, and 35 assigned to the control group. Data were collected from January 25 to April 3, 2019. The simulation-based disaster nursing education program consisted of a 60-minute theoretical lecture on disaster management and two scenarios. The effectiveness of the simulation-based disaster nursing education program was measured using levels of disaster nursing competencies, disaster triage competency, disaster preparedness, critical thinking disposition, and confidence in disaster nursing. Results Significant differences were found between the experimental and comparison/control groups in terms of disaster nursing competencies (F = 20.06, p < .001), nursing triage (F = 17.35, p < .001), disaster preparedness (F = 60.37, p < .001), critical thinking disposition (F = 19.63, p < .001), and confidence in disaster nursing (F = 20.24, p < .001). Conclusions Simulation-based disaster nursing education programs using standardized patients can be useful in disaster nursing education. They can contribute to future changes in nursing education and practice by improving the disaster nursing capabilities and preparedness of students.


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)  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).

The Journal of Nursing Research
Yeon mi PARK and Won Ju HWANG 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.

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).

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).

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 .96as 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 The Journal of Nursing Research Yeon mi PARK and Won Ju HWANG 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 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 w 2 test, t test, and Fisher's exact test.Verification of 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.
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.

General Characteristics
The 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).

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

The Journal of Nursing Research
Yeon mi PARK and Won Ju HWANG 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).

Discussion
A simulation-based disaster nursing education program was developed in this study using standardized patients for nursing students, and the effectiveness of this program was analyzed.
The program was shown to improve performance in several key dimensions, including competency in disaster nursing, triage score, disaster preparedness, critical thinking, and confidence in disaster nursing, which are key to inducing intention to participate in disaster nursing.Various educational methods have been attempted in recent years to improve the effectiveness of disaster nursing education in Korea and other nations, with simulation found to be the highest level of learning method that requires both theoretical knowledge and clinical skills.This effect has been reported in many studies (Kaplan et al., 2012;Morrison & Catanzaro, 2010).Simulations are suitable to create chaotic disaster situations (Currie et al., 2018), provide learning experiences that are different from those provided in classroom settings (Carter & Gaskins, 2010), and improve disaster nursing through realistic experiences.Its utilization is high in that learning about it is naturally induced.
In this educational program, standardized patients were used to increase the fidelity of the simulation.Although the authors found no domestic literature on the use of standardized patients in studies of disaster nursing, the MCI trainings targeting nursing students and addressed in studies conducted outside Korea have mostly used standardized patients.For example, over 20 standardized patients were used in a tornado-related MCI scenario in which 132 nursing students and 25 radiology students participated (Zapko et al., 2015), 28 standardized patients were used in a bus crash scenario (Saber et al., 2017), and 32 standardized patients played the role of casualties in a building collapse simulation scenario (Currie et al., 2018).
Scenario 1 in this study differed significantly from the abovementioned MCI scenarios in terms of the situational flow and its associated concentrated space, script for communication with the detailed state of the disaster, and clinical cues.To erase the artificiality of the scenario, more effort was put into the natural acting of standardized patients.However, because these standardized patients are real individuals, they were more naturally limited than high-fidelity simulators in terms of physiological indicators such as blood sugar level, blood pressure, and pupillary reflex.
Disaster nursing education programs, including the program proposed in this study, focus mainly on the disaster response  & ICN, 2009) has noted nursing to be the most important role during the disaster response stage, during which the preservation of life and health of victims is prioritized.Nurses are the frontline healthcare providers in most disaster response efforts (Firouzkouhi et al., 2021;World Health Organization & ICN, 2009).
On the other hand, Langan et al. (2019) pointed to nurses as essential not only in the immediate response to disasters but also in disaster preparedness and long-term recovery to address the health-related consequences of disaster events (Langan et al., 2019).Although it seems appropriate to focus on achieving disaster preparedness and response steps in a short time span, the development of a more-expansive educational program is necessary that covers both the prevention and mitigation stages to recognize disaster-related risks in the community and take appropriate action as early as possible and the recovery and rehabilitation stages to help individuals and the community recover and rehabilitate.
The earthquake scenarios used in this study were constructed based on a relatively recent earthquake in Pohang City to give students experience on events that have actually occurred in their area (Yamamoto, 2013).In addition to earthquakes, there are various types of disasters such as storms, collapses, and floods.However, in nursing education, the focus should be on learning disaster management principles (Hutchinson et al., 2011;Kaplan et al., 2012;Morrison & Catanzaro, 2010).Therefore, in many previous studies and in this study, the learning method was designed to emphasize disaster management principles using a specific disaster situation as a prototype (Alfred et al., 2015;Currie et al., 2018;Saber et al., 2017).

Effectiveness of the Simulation-Based Disaster Nursing Education Program
In this study, the experimental group, which received the simulation-based disaster nursing education program, showed a statistically significant improvement over both the comparison and control groups in disaster nursing competency.This result is consistent with that of a study that reported improvements in nursing student knowledge and skills after participation in an educational program based on the ICN disaster nursing competencies (Huh & Kang, 2019;Levoy et al., 2018;Zinan et al., 2015).
Whereas both preparedness and response competencies improved in both the experimental group and the control group, the prominent increase in response competencies in the experimental group may be attributable to the affective and descriptive objectives of the program (e.g., triage and basic first aid, application of psychological emergency intervention, ensuring safety, performing disaster nursing, and nursing for vulnerable groups), accounting for more than the cognitive objectives, as the simulation focused on the immediate postdisaster response stage.
Triage score in the experimental group was statistically significantly different from the control group.This result is in line with a study reporting a triage accuracy of 81.2% after the application of a simulation education to an explosive accident scenario in a school (Hutchinson et al., 2011), a study reporting an increase in triage accuracy in disaster situations after applying the SALT triage system and case-oriented practical training (Celik et al., 2019), and a study reporting increased triage scores after simulation-based training (Farra et al., 2013).
Disaster situations must often be addressed immediately using limited resources.Thus, triage must be performed quickly and accurately, and continuous education and training are essential, as they affect patient survival rates directly.Triage skills, which rely heavily on prior experience, although likely difficult for nursing students, can be learned and mastered through repeated exposure to simulated situations.In Alim et al. (2015), triage skills increased after a simulation intervention.On the basis of situational learning theory, that study reported a significant correlation between triage and team collaboration.Further studies may be required in the future, and if positive correlations are identified, it will also be meaningful to develop interventions to increase collaboration among teams involved in disasters (Alim et al., 2015).
In this study, the improvement in disaster preparedness was more significant in the experimental group than the comparison and control groups.In Huh and Kang (2019), in which the original scale for disaster preparedness was developed, a disaster nursing education program was developed and applied as a case-based small group learning method.The result showed that the disaster preparedness score increased by 45.70 points in the experimental group and 10.16 points in the control group in the pre-post comparison, with a significant difference between the two groups that is in line with the results of this study.However, because the items of the disaster preparedness scale are limited to those required to evaluate knowledge required in the response stage without overlap with items of the disaster nursing competency scale, caution is advised in interpreting results and comparative analyses.
In this study, the knowledge (i.e., disaster preparedness) score was significantly higher in the experimental group than the control group.This finding is consistent with those of previous studies.Brannan et al. (2008) reported academic achievement in the experimental (simulation learning) group as significantly better than in the control (theoretical learning) group, Hur and Park (2012) reported the knowledge score in the experimental group receiving video lecture and simulation education as significantly higher than that in the control group receiving the video lecture only, a study reported the knowledge score in the experimental group receiving nursing simulation training for patients with cardiac arrest to be significantly higher than that in the control group receiving a traditional lecture, and Brannan et al. reported the knowledge score in the simulation experimental group to be significantly higher than that in the theoretical lecture control group.This study, in combination with prior works, supports simulation education as more The Journal of Nursing Research Yeon mi PARK and Won Ju HWANG effective in increasing knowledge than traditional education methods.In this study, disaster risk factors in the local community, including understanding of the disaster management process and disaster emergency healthcare support system, were identified, and the scenarios were composed to facilitate transmission of the lecture content (e.g., how to establish a disaster preparedness plan for oneself and one's family, the role of a nurse in a disaster, resources necessary for the health needs of the victim, and the psychological impact of a disaster).
In this study, improvement in critical thinking was significantly greater in the experimental group than in the comparison and control groups.Although comparative analysis is difficult because of the lack of prior studies confirming the effects of simulation-based education disaster nursing programs on critical thinking in nursing students, the results are consistent with those of previous studies reporting an improvement in critical thinking in nursing students after simulation education (Cant & Cooper, 2017;Hwang & Kim, 2020;Kim & Ha, 2020).Critical thinking is the personal tendency/habit to value and use the thought of making self-regulating judgments for problem solving and decision making in personal/professional work settings (Yoon, 2008).Critical thinking in nursing students may be improved in disaster simulation scenarios by repeatedly thinking about the intervention to be prioritized and the assessments required for the intervention.
In this study, improvement in confidence in disaster nursing improved more significantly in the experimental group than in the comparison and control groups, which is in line with the results of previous studies (Currie et al., 2018;Kaplan et al., 2012;Saber et al., 2017).Hung et al. (2020) reported their experimental group showed higher performance confidence after participation in a simulation-based educational program for emergency management that used a low-fidelity simulator compared with their control group, which received lecture-style education only (Hung et al., 2020).In addition, Levoy et al. (2018) developed and applied a disaster nursing education program that integrated the ICN disaster nursing competency framework, homeland security campaigns, and assessment program guidelines that successfully improved confidence in disaster nursing.Confidence in that study was evaluated as confidence in cardiopulmonary resuscitation, confidence in using a defibrillator, and confidence in the preparation and implementation of endotracheal intubation.Furthermore, Levoy et al. subdivided perceived confidence into the three categories of nursing confidence in a disaster situation, confidence as a member of a disaster response team, and confidence in triage performance in a disaster situation.
In this study, considering the various tasks each individual was required to confidently perform, it seemed valid to evaluate "confidence in disaster nursing" by considering confidence in triage, confidence in first aid treatment, and confidence in emergency psychological interventions with a focus on the items necessary to meet the learning objectives for each scenario.Nursing educators should actively utilize simulation-based educational programs to help learners fully understand disaster situations by preparing various disaster situation scenarios.Thus, developing and applying a step-by-step and continuous education program to cultivate are necessary to improve not only knowledge but also disaster nursing competency and confidence, including preparedness for disaster nursing.
Analyzing the evaluation and learning satisfaction results for the simulation education program conducted on the experimental group showed the program to provide a realistic and useful learning experience with high learning satisfaction, which is in line with the results of previous studies (Alfred et al., 2015;Currie et al., 2018;Saber et al., 2017).Furthermore, the experiences of both the experimental group and the standardized patients who participated in the simulation were special to all participants in that they were a specific topic of disaster, as in previous studies such as an infectious disease disaster (Alfred et al., 2015;Hwang & Lee, 2021;Saber et al., 2017).This further highlights the importance of and need for education related to disasters and disaster nursing.
This study was affected by several important limitations.First, we used a small convenience sample drawn from senior nursing students in a limited number of regions in South Korea.Second, although using standardized patients is a useful and effective simulator that allows learners to experience disasters in simulated disaster situations, physiological indicators such as blood sugar and blood pressure levels, pulse, pupillary response, and apnea cannot be realistically simulated.Because of the importance of these physiological indicators in actual disaster situations, additional research is needed to consider how to properly implement these scenarios without compromising fidelity.Third, objectively evaluating the acquisition of competency is difficult because most of the disaster nursing competencies measured in this study were a direct effect of the educational program and were reported using self-report surveys.Future studies should adopt an expanded program structure that may be reevaluated through the provision of repeated practice opportunities.

Conclusions and Suggestions
The results of this study confirm simulation-based disaster nursing education programs using standardized patients based on ICN disaster nursing competencies to be an effective education approach to improving disaster nursing competency in nursing students.The disaster nursing education program developed in this study can be used as basic data for the development of future disaster nursing curriculum and is expected to contribute to improving and expanding the role of disaster nurses by improving the disaster nursing capacity of nursing students.
The results of this study support the following recommendations for future work.First, additional studies are needed to confirm the effectiveness found in this study of the disaster nursing simulation-based educational program using standardized patients.Second, because this study targeted senior nursing students in two universities only, repeated studies should be conducted on nursing students across a wider range of years and schools to confirm the observed effects.Third, follow-up research into the long-term sustainability of the observed improvements in disaster nursing competency is necessary.Fourth, an optimally effective simulation education program for undergraduate nursing students will necessarily be an integrated and expanded program that teaches disaster nursing in stages using various methods before the final simulation component.Finally, because of the current lack of a standardized measure of disaster nursing competency for Korean nursing students, clearly elucidating the effects of disaster nursing education programs is difficult.Therefore, a valid and effective tool for measuring this competency in Korean nursing students should be developed.

Figure 1
Figure 1 Conceptual Framework of the Study Based on the Jeffries Simulation Model 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.

Table 2
Scenario Contents of Simulation Program 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-inlaw, who is 7 months pregnant, has suffered a severe laceration in her right thigh.At the request of the National Emergency Management

Table 3
Homogenic Test of General Characteristics Among Groups (N = 140) Note.Exp.= experimental group; Comp.= comparison group; Cont.= control group.a Fisher's exact test was performed.

Table 4
Yamamoto (2013)he Program Application for Simulation Practice (N = 140) preparedness stages.Yamamoto (2013)attributed this to the need for healthcare workers to prioritize clinical responses.Furthermore, the ICN (World Health Organization Note. p Value was calculated using one-way analysis of variance; post hoc was performed with Scheffe's test.Exp.=experimental group; Comp.= comparison group; Cont.= control group.*p< .001.and