Nurse Education Today 37 (2016) 59–65

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Nurse Education Today

journal homepage: www.elsevier.com/nedt

Effects of nursing process-based simulation for maternal child

emergency nursing care on knowledge, attitude, and skills in
clinical nurses☆,☆☆
Sunghee Kim, Gisoo Shin ⁎
Red Cross College of Nursing, Chung-Ang University, Seoul, South Korea

a r t i c l e i n f o s u m m a r y

Article history: Background: Since previous studies on simulation-based education have been focused on fundamental nursing
Accepted 14 November 2015 skills for nursing students in South Korea, there is little research available that focuses on clinical nurses
in simulation-based training. Further, there is a paucity of research literature related to the integration of the
Keywords: nursing process into simulation training particularly in the emergency nursing care of high-risk maternal and
Nursing process neonatal patients.
Patient simulation
Purposes: The purpose of this study was to identify the effects of nursing process-based simulation on knowledge,
Emergencies
Maternal-child nursing
attitudes, and skills for maternal and child emergency nursing care in clinical nurses in South Korea.
Participants: Data were collected from 49 nurses, 25 in the experimental group and 24 in the control group, from
August 13 to 14, 2013.
Methods: This study was an equivalent control group pre- and post-test experimental design to compare the
differences in knowledge, attitudes, and skills for maternal and child emergency nursing care between the
experimental group and the control group. The experimental group was trained by the nursing process-based
simulation training program, while the control group received traditional methods of training for maternal and
child emergency nursing care.
Results: The experimental group was more likely to improve knowledge, attitudes, and skills required for clinical
judgment about maternal and child emergency nursing care than the control group. Among five stages of nursing
process in simulation, the experimental group was more likely to improve clinical skills required for nursing
diagnosis and nursing evaluation than the control group.
Conclusion: These results will provide valuable information on developing nursing process-based simulation
training to improve clinical competency in nurses. Further research should be conducted to verify the effective-
ness of nursing process-based simulation with more diverse nurse groups on more diverse subjects in the future.
© 2015 Elsevier Ltd. All rights reserved.

Introduction
The advent of the Millennium Project and subsequent development
goals, specifically those that focus on reducing child mortality and
improving maternal health, have focused worldwide attention on safety
in maternity care (United Nations, 2013). Since these goals were set,
maternal mortality rates have declined globally by an estimated 47%
from 543,000 in 1990 to 287,000 in 2010 (WHO, 2014). Estimated
☆ Financial support: This work was supported by a research grant in 2013 from Laerdal
Medical Korea.
☆☆ Conflict of interest: Neither author has any actual or potential of interest including
any financial, personal, or other relationships with other people or organization that could
inappropriately influence or be perceived to influence this work.
⁎ Corresponding author at: Red Cross College of Nursing, Chung-Ang University, 84
Heukseok-ro, Dongjak-gu, Seoul 156-756, South Korea. Tel.: +82 2 820 5975; fax: +82
2 824 7961.
E-mail address: gisoo@cau.ac.kr (G. Shin).
child mortality has also dropped by 41% from 87 deaths per 1000 live
births in 1990 to 51 in 2011 (United Nations, 2013). Although high
mortality is largely seen in less developed countries, advanced countries
have also been challenged to improve the safety of maternal and
neonatal health care. It appears to be even more difficult to reduce
mortality rates when they are low than when they are high (WHO,
2014). A further decline in mortality rates needs a stronger focus on
access to obstetric emergency care with skilled nursing personnel
(United Nations, 2013).
South Korea's total fertility rate, the average number of children a
woman has in her lifetime, reached the population replacement level
of 2.1 children per woman in 1983. Ever since then, the total fertility
rate of Korea continuously dropped from 1.48 in 1998, and 1.22 in
2010, to 1.19 in 2013, which currently ranks 219th out of 224 countries
and has become one of the lowest fertility countries in the world.
Despite the low fertility rate in South Korea, the number of premature
and low birth-weight neonates with less than 1500 g at birth is growing

http://dx.doi.org/10.1016/j.nedt.2015.11.016
0260-6917/© 2015 Elsevier Ltd. All rights reserved.
60 S. Kim, G. Shin / Nurse Education Today 37 (2016) 59–65
rather than declining, together with the increased number of high-risk
pregnancy in obstetric patients (Korean Ministry of Health and
Welfare, 2012). The decreased total fertility rate and the increased ma-
ternal and infant mortality rates have become a serious social and health
problem in South Korea.
Maternal and infant mortality rates are major indicators used to
measure a nation's health condition (Beck et al., 2010). According to
the Korean maternal mortality estimation, direct maternal mortality
ratio in 2012 in Korea, caused mainly by bradytocia, postpartum hemor-
rhage, hypertensive diseases such as pre-eclampsia and eclampsia, and
amniotic embolism, increased to 1.6 times more than previous years,
while the indirect maternal mortality ratio, caused by high-risk
pregnancy, increased by 6 times in 2012, which is mainly due to the
rapid increase in the number of high-risk pregnant women aged over
35 and associated complications of pregnancy. In addition, because of
the high-risk preterm birth from high-risk pregnant women, there is
the increased rate of perinatal death showing low Apgar scores
measured neonates' appearance, pulse, grimace, activity, and respira-
tion at 1 and 5 minutes after birth (Lee et al., 2012).
Emergencies can happen at all times, and they are characterized by
significant time pressure, high stakes decisions, and technical and
ethical challenges associated with caring for mother and child simulta-
neously (Daniels et al., 2010). Provision of safe care in these situations
requires the presence of skilled health personnel. In developing coun-
tries, this was only ensured in approximately 66% of births in 2011
(United Nations, 2013). Although professional attendance at birth is
practically guaranteed in high-income countries, inappropriate man-
agement of emergencies can lead to maternal and neonatal mortality
and serious morbidity (CEMACH, 2004). Therefore, appropriate and
prompt clinical nursing skills are the first and foremost requirement of
clinical nurses in dealing with emergency maternal and child patients.
Simulation-Based Training for Emergency Nursing Care
Since the importance of patients’ rights was introduced to the
medical field in order to guarantee fair and safe medical treatment as
well as prompt access to emergency care and medical specialists, nurs-
ing activities in a clinical setting has been remarkably restricted in South
Korea (Son, 2010). In order to solve such problems, simulation-based
educational training both for nursing students and newly appointed
nurses has been adopted in South Korea. Simulation training for nursing
education first began in the United States, expanding to most of Asian
countries, such as Japan, China, and South Korea (Central Intelligence
Agency, 2014). In South Korea, a number of nursing colleges began
offering simulation-focused emergency skill-focused educational
programs from the year 2000, together with the active investigation of
the effectiveness of these simulation-based educational programs.
Simulation-based training has been demonstrated as an effective educa-
tional tool, especially for nursing care for patients at high risk, because
simulation can be used as an effective training strategy to develop
appropriate abilities to deal with complicated and unpredictable emer-
gency situations (Burns et al., 2010). However, there has been little
research done to develop nursing process-based simulation programs,
nor to identify the effectiveness of such simulation (Dearmon et al.,
2013; Hicks et al., 2003).
The types of simulation-based education can be classified by the
types of fidelity, and more attention has been recently given to simula-
tion with human patient simulator (HPS). Human patient simulator
refers to a mannequin which is a model of the human body used as a
tool to facilitate the simulated learning. The human patient simulator
is fitted with computer software that allows the educator to replicate
normal and abnormal bodily responses to events and therapeutic inter-
ventions (Yang, 2008; Sanford, 2010). Some advantages of simulation-
based education using HPS for emergency maternal and child nursing
care are that simulation provides learners with a safe learning environ-
ment, yet provides a lifelike emergency experience with no actual harm
to the patient, and that the learners are permitted to spend time
practicing a wide variety of actual emergency measures over and over
again (Hunziker et al., 2010).
Nursing process is a goal-oriented framework of comprehensive
nursing care, involving five major steps of nursing assessment,
diagnosis, planning, implementation, and evaluation. Nursing process
provides the nurse with the direction in making clinical judgment
about individualized and comprehensive nursing care, not just as a
task-oriented approach that focuses only on the tasks that need to
achieve a certain performance standard, but rather a thought-oriented
approach that focuses more on a systematic progression of thinking
and reasoning process that can apply to solving and rectifying health
problems in patients. For this reason, there is a growing need for
developing simulation in which nursing process is integrated (Burns
et al., 2010).
Since previous studies on simulation-based education have been
mainly conducted with nursing students in South Korea (Yoo, 2013),
there is little or no research with clinical nurses in simulation-based
training, not to mention clinical nurses' emergency nursing care skills
for obstetric and neonatal patients at high risk. Problems may be
encountered, especially when dealing with emergency situations in
the intensive care unit for newborns and the delivery room if nurses
are not sufficiently trained in clinical experience and emergency care
unit. In this regard, the lack of practical skills and adaptability of many
nurses have been reported in the precedent study (Jho, 2010). Further-
more, there is a need to study knowledge, attitudes, and skills of clinical
nurses after simulation training that has scenario based on nursing
process (Cant and Cooper, 2010). Therefore, this study was conducted
to identify the effectiveness of a nursing process-based simulation
educational program for high-risk maternal and child nursing care,
tailored to develop emergency nursing competency in clinical nurses
in South Korea.
Methods
Study Question
The purpose of this study was to identify the effects of a nursing
process-based simulation training program for high-risk maternal and
child emergency nursing care between the experimental group and
the control group. The specific research question was as follows:
Is nursing process-based simulation training for clinical nurses
effective for improving nursing knowledge, attitudes, emergency
care skills such as assessing, diagnosing, planning, implementing, and
evaluating that are related to maternal and child care?
Design
This study was designed as an equivalent control group pre- and
post-test experimental study to compare the differences in knowledge,
attitudes, and skills in relation to maternal and child emergency nursing
care between the experimental and the control groups. The experimen-
tal group was trained by the nursing process-based simulation training
program, while the control group received training only with traditional
methods and procedures for maternal and child emergency nursing
care (Fig. 1).
Participants
Through mailing out official documents, participants for this study
were collected from the members of the Korean Hospital Nurses
Association and the Seoul Nurses Association of Korea in August 2013.
The minimum number of the study participants required for this
study was estimated at 45 nurses, using the calculation of sampling
formula with the version 3.1.2 of G* power program (Faul et al., 2007)
at the significance level of 0.05, effect size of 0.5, and test power(1-β)
 S. Kim, G. Shin / Nurse Education Today 37 (2016) 59–65
Maternal Condition
· Patient name: · Age: 29
· Gender: Female · Allergies: None
· Height/Weight: 160cm/64kg
· Primary care giver: Husband
· Medical history: None
· Primary medical diagnosis: 39 weeks pregnant with PROM
· Present illness: None
Pretest
*Neonatal Emergency Care
Exp.
(n=25) *Delivery Emergency Care
*Knowledge
Cont. *Attitude
(n=24)
*Skill
Fig. 1. Study design and flow.
of 0.8 with the number of groups of two. In this study, the total of 45
participants represented the sufficient number of the sample size
for detecting group differences. However, considering the possible
drop-out rate of 10%, the final number of the participants was 50 nurses.
The selection criteria of the study participants was set to exclude any
nurses who had had previous experience of working at obstetrics and
gynecology wards or neonate care units, under the assumption that
their previous experience might affect the study results. Fifty partici-
pants were randomly assigned either to the experimental group or the
control group. One nurse withdrew from the study, resulting in 25
participants in the experimental group and 24 in the control group.
Before conducting this study, approval was granted by the institutional
review board (IRB) of the university with which affiliated (1041078-
21306-HR-004402).
Study Instrument
In order to measure the effectiveness of the training program for
emergency nursing care for high-risk obstetric and neonatal patients,
an evaluation tool was developed based on knowledge, attitude, and
skill domains suggested by International Council of Nurses (2009). The
content validity of the tool was tested by two medical doctors and two
head nurses working at a neonate intensive care unit, two medical doc-
tors and two head nurses working at the delivery room, one nursing
professor teaching maternal and child nursing, one professor teaching
pediatric nursing, and one simulation expert. In addition, a pilot test
was conducted with 150 senior nursing students in order to test the
reliability of the tool, resulted in Cronbach alpha coefficients of the
subcategories of the tool ranged from .73 to .75.
Knowledge on High-Risk Maternal and Child Emergency Nursing Care
Knowledge on high-risk maternal and child emergency nursing care
was measured with a 25-item scale with yes and no questions that in-
cluded neonatal resuscitation for newly born infants who showed infant
respiratory distress syndrome (IRDS) as well as emergency nursing
care for fetal respiratory failure during the second stage of labor, both
of which were based on the guidelines provided by the American
Heart Association for neonates (2010) and the American Congress of
61
Neonatal Condition
· Patient name: · Age: GP: 31+2
· Gender: Female · Allergies: No known
· Height/Weight: 41cm/ 1.75kg
· Primary care giver: Mother
· Medical history: None
· Primary medical diagnosis: Prematurity
· Present illness: No breath sound and chest movement,
Treatment Post-test
*Neonatal Emergency Care
NP
*Delivery Emergency Care
*Knowledge
*Attitude
CP
*Skill
Obstetricians and Gynecologists (2014). In addition, after 6 clinical
cases were given to the participants, three cases for mothers and three
for neonates, their abilities to perform nursing assessment, diagnosis,
planning, implementation, and evaluation were scored on a 10-point
scale. The content validity of the 6-item clinical case tool was tested
by four medical specialists in OB/GYN and pediatricians, four nurses,
and two nursing professors. Cronbach alpha coefficient of this instru-
ment in this study was .80.
Attitudes
The questionnaire to measure attitude variables was developed by the
researchers in this study based on literature review and previous studies.
The attitude questionnaire had 5 items on a 10-point Likert-type scale, in-
cluding the level of satisfaction with the simulation program, improve-
ment in confidence in maternal and child emergency nursing, reduction
in job-related stress, future utilization of simulation in educational activi-
ties, and application of simulation to clinical judgment. The Cronbach
alpha coefficient of the attitude instrument in this study was .81.
Skills
Skills required for high-risk maternal and child emergency nursing
care were evaluated by a checklist that was developed based on the
nursing process-based simulation modules. The checklist included nurs-
ing assessment, diagnosis, planning, implementation, and evaluation for
the resuscitation procedure for neonatal respiratory failure as well as
emergency nursing care for fetal respiratory failure during the second
stage of labor, each of which was given two points for ‘doing a good
job,’ and one point for doing a poor job,’ which were then converted
into a perfect score of 10. Cronbach alpha coefficient of this instrument
in this study was .84.
Data Collection Procedure
Integration of Nursing Process into Simulation for Experimental Group
Simulation Scenario Development. As a result, the scenario for simulation
was developed, including IRDS and failure in dealing with labor progress.
62 S. Kim, G. Shin / Nurse Education Today 37 (2016) 59–65

In order to develop a scenario for the simulation activity that is consistent
with and can be applied to a clinical situation, primary assessment of
needs for emergency nursing care for high-risk obstetric and neonatal
patients was conducted with 10 head nurses, 10 charge nurses, and 10
nurses in charge of in-service training at 10 women's and children's
hospitals located in Seoul and Gyeong-gi Province of South Korea, using
a structured questionnaire. The questionnaire included items on clinical
cases, which had actually occurred in clinical settings, specified by
medical diagnosis, occurrence frequency, level of importance, and level
of difficulty in maternal and child emergency nursing care.
Composition and Validity Testing of Scenario. A simulation educational
program with HPS was developed based on NANDA-NOC-NIC linkage
(Johnson et al., 2001). Two modules of high-risk maternal and child
emergency nursing care were developed, including lecture notes and
guidelines for learners, followed by confirming the content validity of
the modules by two medical doctors in OB/GYN and a neonate intensive
care unit, two medical directors at women's and children's hospitals,
and one professor in simulation education.
Intervention for Experimental Group. Nursing process-based simulation
training was implemented with 25 participants in the experimental
group for 2 days from August 13 to 15, 2013. After an orientation pro-
gram was given to participants in the experimental group, a pre-test
on knowledge about and attitudes toward emergency nursing care for
high-risk obstetric and neonatal patients was conducted, followed by
an evaluation of nursing skills. After that, a 1-day simulation training
with a scenario in which nursing process was integrated was given to
the experimental group. A post-test to measure the effectiveness of
simulation training was conducted 4 weeks after simulation.
Results
Subjects' Demographic Characteristics
The number of study subjects was 49 nurses, 25 in the experimental
group and 24 in the control group. There were no differences in subjects'
age, types of employed hospitals, nursing departments at which they
were working, and nursing position between the experimental and
the control groups, while there were differences in subscales for motiva-
tion for participating in simulation training and the expected outcomes
of simulation between the two groups (Table 1).
Both the experimental and the control groups had only female
nurses with the average age of 29.9 in the experimental group and
33.1 in the control group. Types of medical institutions nurses in
both groups were mainly university medical centers (98% of the
subjects in the experimental group, and 100% of those in the control
group), and the most common nursing position was staff nurses (84%
of nurses in the experimental group and 70.8% of those in the control
group).
The most frequent reason for participating in this training program
was to improve clinical skills in both groups (80% of the experimental
group and 70.8% of the control group), followed by strengthening
their competence in the experimental group (36.0% of the subjects)
and hoping the participants in the control group would transfer their
duty post to a maternal and child ward (66.7% of the subjects), which in-
dicated the difference between the two groups (χ2 = 4.61, P = .046).
The highest expectation of the simulation program was the improve-
ment in clinical skills and competence through the program in both
groups (88.0% of the participants in the experimental group and 83.3%
of the control group).

Clinical Procedure-Based Training for Control Group

Development of Traditional Methods and Content Validity. In order to

Table 1
maintain the homogeneity of traditional methods of training for mater- General characteristics of experimental group and control group.
nal and child emergency nursing care between the two groups, a list of
EP CP t/x2 p
clinical skills for the control groups was derived from the same list of
(n = 25) (n = 24)
skills included in the scenario for simulation for the experimental
group. After that, an evaluative checklist for clinical skills for the control Mean age years (mean ± SD) 29.92 ± 8.15 33.08 ± 10.25 1.192 .456
Clinical experiences (year) 5.39 ± 7.33 9.72 ± 10.30 1.688 .078
group was developed with items that were organized into a series of (mean ± SD)
nursing assessment, diagnosis, planning, implementation, and evalua-
tion. The content validity of the checklist was confirmed by two medical Type of facility (n (%))
University hospital 23 (92.0) 24 (100) 2.00 .490
directors of women's and children's hospitals and two nursing faculty General hospital 2 (8.0) 0
members specialized in maternal and child nursing, followed by
revising the contents accordingly. Type of department (n (%))
Internal medicine/surgery ward 14 (56.0) 8 (33.3)
Intensive care unit 7 (28.0) 11 (45.8) 3.51 .320
Intervention for Control Group. The intervention of the control group Operation room 2 (8.0) 4 (16.7)
outpatient-clinic 2 (8.0) 1 (4.2)
started from August 16 to 17, 2013. After an orientation program was
given to participants in the control group, a pre-test on knowledge Position (n (%))
and attitudes toward emergency nursing care for high-risk obstetric Nurse 21 (84.0) 17 (70.8) 4.55 .103
Staff nurse 4 (16.0) 3 (12.5)
and neonatal patients was conducted, followed by an evaluation
Charge nurse 0 (0.0) 4 (16.7)
of nursing skills. After that, a 1-day training focused on traditional
methods and procedure with the checklist was implemented. A post- Participation motivation (n (%))⁎
Interest of simulation education 4 (16.0) 9 (37.5) 2.90 .114
test to measure the effectiveness of training was conducted 4 weeks
Skills improvement in performing 20 (80.0) 17 (70.8) 0.56 .520
later. Need to transfer to maternity 9 (36.0) 16 (66.7) 4.61 .046
Confidence improvement 10 (40.0) 9 (37.5) 0.03 1.000

Data Analysis Method Expected effect (n (%))⁎

Confidence 18 (32.0) 13 (54.2) 1.68 .244
Decision making ability 3 (12.0) 10 (41.7) 5.53 .025
Data collected were analyzed using SPSS WIN 18.0 program as
Clinical performance ability 22 (88.0) 20 (83.3) 0.22 .702
follows: First, subjects' demographic characteristics were analyzed Problem solving ability 17 (68.0) 17 (70.8) 0.05 1.000
with percentage, while homogeneity between the two groups was Communication skill 1 (4.0) 3 (12.5) 1.18 .349
analyzed with chi-square test, Fisher's exact test, and t-test. In addition, EP = Experimental group: Nursing process scenario-based simulator training.
the differences between the experimental and the control groups and CP = Control group: Traditional methods of training.
between the pre- and the post-tests were analyzed by using t-test. ⁎ Multiple responses.
 S. Kim, G. Shin / Nurse Education Today 37 (2016) 59–65 63

Comparison of High-Risk Maternal and Child Emergency Nursing Care emergency nursing care, and nursing diagnosis (t = 1.45, P = .162) for
Before and After Training maternal emergency nursing care between the pre- and the post-tests.

Table 2 showed the before-and-after comparison of simulation
training for high-risk maternal and child emergency nursing care on
knowledge, attitudes, and skills between the experimental group and
the control group.
The average pre-test score on the neonatal emergency nursing care
area in the experimental group was estimated at 6.49 ± 1.19, while
the average post-test score was 8.43 ± 1.10, which showed a statistical
difference between the pre- and the post-tests (t = 13.61, P b .001). In
addition, the average pre-test score on maternal emergency nursing
care in the experimental group was estimated at 5.81 ± 1.11, while
the average post-test score was 8.41 ± 1.11, which also showed the
statistical difference between the pre- and the post-tests (t = 22.21,
P b .001).
The average pre-test score on neonatal emergency nursing care area
in the control group was estimated at 6.28 ± 1.51, while the average
post-test score was 7.33 ± 1.34, which showed a statistical difference
between the pre- and the post-tests (t = 10.10, P = .001). In addition,
the average pre-test score on maternal emergency nursing care in the
control group was estimated at 5.82 ± 1.27, while the average post-
test score was 6.86 ± 1.32, which also showed the statistical difference
between the pre- and the post-tests (t = 10.86, P = .001). However, in
the control group, there was no statistical difference in nursing diagno-
sis (t = 2.42, P = .280) and evaluation (t = 0.77, P = .449) for neonatal
Comparison Between Experimental Group and Control Group
There was no difference in the pre-test on knowledge, attitudes, and
skills for high-risk maternal and child emergency nursing care between
the experimental group and the control group, which showed the
homogeneity of the two groups prior to training (Table 3). However,
after simulation training was implemented, the experimental group
receiving simulation was more likely to score high on the average
total scores on knowledge, attitudes, and skills for emergency nursing
care than the control group receiving traditional methods of training
(t = 7.19, P b .001).
Discussion
The purpose of this study was to develop a simulation training
program based on a scenario with sequential order of nursing process,
tailored for clinical nurses in South Korea in order to develop
clinical competency for high-risk maternal and child patients in an
emergency clinical situation, followed by testing the educational
effectiveness of the simulation program. The summary of the research
results follows.
Nurses both in the experimental group and the control group
appeared to improve significantly on knowledge and attitudes after

Table 2
Analysis for pre-training and post-training difference.

Pre-training Post-training t p
(mean ± SD) (mean ± SD)

EP group (n = 25)
Neonatal emergency care Knowledge Knowledge of emergency care 6.45 ± 1.0 8.65 ± 0.50 12.29 b.001
Nursing process for emergency care 4.40 ± 0.90 9.07 ± 0.61 8.08 b.001
Attitude Confidence of emergency care 6.60 ± 1.16 8.48 ± 1.12 7.05 b.001
Skill Application of emergency care skill 6.89 ± 0.91 8.24 ± 1.02 8.73 b.001
Assessment 7.50 ± 1.53 8.69 ± 1.79 7.79 b.001
Diagnosis 5.33 ± 2.16 7.59 ± 2.26 5.42 b.001
Planning and implementation 7.42 ± 1.01 8.39 ± 1.14 7.07 b.001
Evaluation 7.33 ± 0.87 8.30 ± 1.04 6.68 b.001
Total 6.49 ± 1.19 8.43 ± 1.19 13.61 b.001
Delivery Knowledge Knowledge of emergency care 6.06 ± 0.86 8.32 ± 0.38 16.28 b.001
Emergency care Nursing process for emergency care 2.67 ± 0.87 9.73 ± 0.28 12.73 b.001
Attitude Confidence of emergency care 5.60 ± 1.19 8.88 ± 0.73 13.57 b.001
Skill Application of emergency care skill 6.43 ± 0.81 8.07 ± 1.13 12.14 b.001
Assessment 6.80 ± 1.01 8.94 ± 1.19 12.27 b.001
Diagnosis 4.52 ± 1.64 6.39 ± 2.13 5.61 b.001
Planning and implementation 6.98 ± 1.49 8.17 ± 1.87 5.81 b.001
Evaluation 7.43 ± 1.0 8.77 ± 1.19 7.24 b.001
Total 5.81 ± 1.11 8.41 ± 1.11 22.21 b.001
Total 6.15 ± 1.15 8.42 ± 1.15 26.55 b.001

CP group (n = 24)
Neonatal emergency care Knowledge Knowledge of emergency care 6.20 ± 1.02 8.04 ± 0.52 11.34 b.001
Nursing process for emergency care 5.8 ± 1.13± 8.3 ± 0.72 3.89 .001
Attitude Confidence of emergency care 5.96 ± 2.69 7.71 ± 1.83 5.29 b.001
Skill Application of emergency care skill 6.45 ± 1.06 6.91 ± 1.11 4.80 b.001
Assessment 7.32 ± 1.47 7.63 ± 1.63 3.56 .002
Diagnosis 4.28 ± 1.82 4.55 ± 2.12 1.27 .280
Planning and implementation 6.77 ± 1.62 6.99 ± 1.60 2.42 .024
Evaluation 7.42 ± 1.30 7.48 ± 1.19 0.77 .449
Total 6.28 ± 1.51 7.33 ± 1.34 10.10 .001
Delivery emergency care Knowledge Knowledge of emergency care 6.10 ± 0.78 7.83 ± 0.64 10.32 b.001
Nursing process for emergency care 4.2 ± 1.01 7.1 ± 0.95 7.21 b.001
Attitude Confidence of emergency care 5.54 ± 1.91 6.71 ± 1.55 3.29 .003
Skill Application of emergency care skill 6.14 ± 0.89 6.64 ± 1.04 6.69 b.001
Assessment 6.90 ± 1.14 7.26 ± 1.37 2.82 .010
Diagnosis 4.30 ± 1.55 4.58 ± 1.65 1.45 .162
Planning and implementation 6.43 ± 1.24 6.95 ± 1.44 5.58 .002
Evaluation 6.93 ± 1.64 7.78 ± 1.95 6.63 b.001
Total 5.82 ± 1.27 6.86 ± 1.32 10.86 .001
Total 6.05 ± 1.39 7.09 ± 1.33 14.86 .001
64 S. Kim, G. Shin / Nurse Education Today 37 (2016) 59–65

Table 3
Analysis between the experimental and the control groups.

NP (n = 25) CP (n = 24) t p
(mean ± SD) (mean ± SD)

Pre-training
Neonatal emergency care Knowledge Knowledge of emergency care 6.45 ± 1.0 6.20 ± 1.02 0.86 .395
Nursing process for emergency care 4.40 ± 0.90 5.8 ± 1.13 ± -1.49 .143
Attitude Confidence of emergency care 6.60 ± 1.16 5.96 ± 2.69 1.09 .281
Skill Application of emergency care skill 6.89 ± 0.91 6.45 ± 1.06 1.538 .131
Assessment 7.50 ± 1.53 7.32 ± 1.47 0.29 .772
Diagnosis 5.33 ± 2.16 4.28 ± 1.82 1.84 .072
Planning & Implementation 7.42 ± 1.01 6.77 ± 1.62 1.70 .096
Evaluation 7.33 ± 0.87 7.42 ± 1.30 -0.28 .780
Total 6.49 ± 1.19 6.28 ± 1.51 1.58 .121
Delivery emergency care Knowledge Knowledge of emergency care 6.06 ± 0.86 6.10 ± 0.78 -0.19 .851
Nursing process for emergency care 2.67 ± 0.87 4.2 ± 1.01 4.02 .162
Attitude Confidence of emergency care 5.60 ± 1.19 5.54 ± 1.91 0.13 .058
Skill Application of emergency care skill 6.43 ± 0.81 6.14 ± 0.89 1.125 .231
Assessment 6.80 ± 1.01 6.90 ± 1.14 -0.35 .762
Diagnosis 4.52 ± 1.64 4.30 ± 1.55 0.47 .641
Planning and implementation 6.98 ± 1.49 6.43 ± 1.24 1.41 .165
Evaluation 7.43 ± 1.0 6.93 ± 1.64 1.31 .198
total 5.81 ± 1.11 5.82 ± 1.27 1.31 .194
Total 6.15 ± 1.15 6.05 ± 1.39 1.84 .072

Post-training
Neonatal emergency care Knowledge Knowledge of emergency care 8.65 ± 0.50 8.04 ± 0.52 4.15 b.001
Nursing process for emergency care 9.07 ± 0.61 8.3 ± 0.72 1.15 .256
Attitude Confidence of emergency care 8.48 ± 1.12 7.71 ± 1.83 1.79 .080
Skill Application of emergency care skill 8.24 ± 1.02 6.91 ± 1.11 4.37 b.001
Assessment 8.69 ± 1.79 7.63 ± 1.63 2.16 .036
Diagnosis 7.59 ± 2.26 4.55 ± 2.12 3.26 b.001
Planning and implementation 8.39 ± 1.14 6.99 ± 1.60 3.54 .001
Evaluation 8.30 ± 1.04 7.48 ± 1.19 2.60 .014
Total 8.43 ± 1.19 7.33 ± 1.34 4.91 b.001
Delivery emergency care Knowledge Knowledge of emergency care 8.32 ± 0.38 7.83 ± 0.64 3.27 .002
Nursing process for emergency care 9.73 ± 0.28 7.1 ± 0.95 4.02 b.001
Attitude Confidence of emergency care 8.88 ± 0.73 6.71 ± 1.55 6.34 b.001
Skill Application of emergency care skill 8.07 ± 1.13 6.64 ± 1.04 4.61 b.001
Assessment 8.94 ± 1.19 7.26 ± 1.37 4.57 b.001
Diagnosis 6.39 ± 2.13 4.58 ± 1.65 3.33 .002
Planning and implementation 8.17 ± 1.87 6.95 ± 1.44 2.55 .014
Evaluation 8.77 ± 1.19 7.78 ± 1.95 2.17 .036
Total 8.41 ± 1.11 6.86 ± 1.32 6.69 b.001
Total 8.42 ± 1.15 7.09 ± 1.33 7.19 b.001

simulation had been implemented, which is consistent with other stud-
ies that showed the positive educational outcomes of simulation-based
programs (Grenvik et al., 2004; Jeffries, 2005). Simulation can improve
learning outcomes by providing learners with educational opportuni-
ties in a situation similar to a real clinical setting without having any
risk elements. Learners can try to solve nursing problems repeatedly
without harming the care recipient. Simulation can also serve as an ef-
fective learning tool, especially for new nursing employees, because
they can improve nursing competency required for quality nursing
care through experiential learning by direct participation, iterative
learning by repetition, and application of nursing theories into practice
(Alinier et al., 2004). For that reason, simulation-based educational
programs have been developed in the United States during the 1990s
and widely expanded to many other countries. Simulation-based educa-
tion itself has been evaluated as a valuable and effective learning tool
(Felton et al, 2013), especially for inexperienced new nurses or those
who want to transfer to other nursing units. In addition, simulation
can serve as an effective training tool for those who are dealing with
patients in emergency situations which cause a great deal of stress
and anxiety in nurses. Therefore, nursing process-based simulation for
dealing with the diversity of emergency cases will reduce the job-
related stress and improve professional confidence and competency
(Anderson and Warren, 2011). After simulation, the participants of
this study, who had never had previous experience of dealing with
emergency maternal and child patients, showed the increase in knowl-
edge and attitudes, which demonstrated simulation-based training as
an effective learning tool to improve knowledge which becomes the
fundamental element of clinical competency as well as attitudes
which positively act as improving confidence for work.
Nurses in the experimental group were more likely to score higher
on clinical nursing skills than those in the control group. In general,
simulation training has proceeded with scenarios that reenact the real
clinical scenes through an orientation process, implementation of
nursing intervention, and debriefing section (Jeffries, 2005). Recently,
the importance of integrating nursing process into the scenarios for
simulation-based nursing education has been recommended (LaFond
and Vincent, 2013). Back in 1973, the American Nurses Association pos-
tulated nursing process as the standard guideline in defining nursing
profession to establish the boundary and autonomy for professional
nursing practice. Nursing process consists of five stages of nursing as-
sessment, nursing diagnosis, nursing plan, nursing implementation,
and nursing evaluation. Among those stages, nursing diagnosis plays a
critical role in determining nursing plan and nursing implementation
and validating scientific knowledge for autonomous nursing practice
and the body of knowledge in nursing (Kozier and Erb, 2008).
Nevertheless, in reality, many clinical nurses in South Korea have
difficulty in applying nursing process to clinical patients, and the lack
of competence was found to be the single most important factor of
having difficulty in applying nursing process to patient nursing care
(Hong and Kim, 2011). Another study reported that both nursing
students and nurses appeared to take a lengthy time to make a nursing
diagnosis (Lee et al., 2013), which was mainly due to the lack of critical
 S. Kim, G. Shin / Nurse Education Today 37 (2016) 59–65
thinking and decision making abilities for clinical judgments. On the
other hand, nurses’ ability to make nursing diagnosis was improved
through an effective training program that was developed to apply
nursing process to various clinical patients (Buckley and Gordon,
2011). Therefore, there is a need to develop simulation training pro-
grams that focus on nursing diagnosis, among other stages in nursing
process.
Nurses who had received nursing process-based simulation were
more likely to score higher on evaluation for clinical nursing skills
than those in the control group. While nursing assessment includes a
procedure of gathering information and data before nursing diagnosis
is made, nursing evaluation is a process of assessing the outcomes of
nursing intervention at the end of the process, which determines
whether or not the intervention was effectively implemented against
the outcomes of patient condition (Cant and Cooper, 2010; Buckley
and Gordon, 2011). Nursing evaluation plays an important role in
measuring efficacy of nursing intervention, becomes objective criteria
for quality assurance of nursing care, and provides the practical
guidelines for individualized patient care (Burns et al., 2010).
This study has some limitations to generalize the study results since
this study had focused only a limited area of nursing services with the
limited number of nurses in South Korea. Nonetheless, this study dem-
onstrated replicable effects of simulation training in the nursing profes-
sion. In addition, the value of this study would be a new attempt to
integrate nursing process into simulation training. Further research
should be focused on the development of better scenarios applying
standard procedures of nursing process, tailored for more diverse
groups of nurses with more diverse subjects, in order to verify the valid-
ity and reliability of the program.
Conclusions
This study was conducted to identify the effectiveness of a
simulation-based training program for nurses who were prepared to
develop clinical competency in dealing with maternal and child
emergency nursing care in South Korea. In this study, five stages of
standard nursing process was integrated into the scenario, and the
simulation training program developed for this study demonstrated
the improvement in knowledge, attitudes, and skills in clinical nurses.
Nursing process-based simulation training for clinical nurses
showed improvement in nursing knowledge, attitudes, and skills
which are assessing, diagnosing, planning, implementing, and evaluat-
ing that are related to maternal and child emergency care. These results
will provide valuable information on developing simulation training
programs to improve clinical competency in nurses in the future.
Acknowledgments
We would like to thank clinical nurses who participated in this
study.
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