International Emergency Nursing 38 (2018) 3–9

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International Emergency Nursing

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Analysis of the effects of high-fidelity simulation on nursing students’ T

perceptions of their preparedness for disasters
⁎
Vesile Unvera, , Tulay Basakb, Sevinc Tastanc, Gulsah Kokb, Gulten Guvencb, Ayla Demirtasb,
Hatice Ayhanb, Gulsah Kösed, Emine Iyigunb, Nuran Tosunee
a
Acibadem Mehmet Ali Aydınlar University, School of Nursing, Istanbul, Turkey
b
University of Health Sciences, Gülhane School of Nursing, Ankara, Turkey
c
Eastern Mediterranean University, Health Science Faculty, Nursing Department, Via Mersin 10 Famagusta, North Cyprus, Turkey
d
Department of Nursing, Faculty of Health Science, Mugla Sıtkı Kocman University, Kotekli, Mugla, Turkey
e
Hasan Kalyoncu University, School of Nursing, Gaziantep, Turkey

A R T I C LE I N FO A B S T R A C T

Keywords: Introduction: As disasters may occur any time, health care staff and institutions should be prepared to manage
Disaster preparedness these events. The aim of study is to analyze the effects of high-fidelity simulation on the perceptions of senior
Nursing student nursing students regarding their preparedness for disasters.
High fidelity Methods: This study used a pretest-posttest design and was conducted as a quasi-experimental investigation.
Simulation
Results: Slightly less than the half of the students (42.5%) expressed that they were prepared to face a disaster.
There was a statistically significant difference in their scores on the Scale of Perception of Disaster Preparedness
among Nurses between the pre-intervention and postdisaster stage (p < 0.05).
Conclusion: Supporting simulation activities with drills positively affected nurses’ perceptions of disasters.

1. Introduction
Disasters damage people’s property and threaten individuals’ lives,
and they have increased in prevalence worldwide. “Natural disasters
and manmade disasters have very significant effects on individuals’
health and their physical, emotional and psychological well-being”
(p.65). To effectively manage the negative consequences of disasters,
appropriate management strategies should be developed and im-
plemented [1].
As disasters can occur any time, health care staff and institutions
should be ready to manage these events [2]. The World Health Orga-
nization (WHO) recommends that health care professionals in all
countries be trained in how to address disasters, regardless of the fre-
quency of these events in their country [1,3]. The fundamental en-
deavors of nursing practice are to provide care to the injured or ill, to
assist individuals and families in treating physical and emotional issues
and to work to improve the community’s health and well-being [4].
The word “disaster” refers to a sudden, overwhelming and unfore-
seen event. There is no single agreed-upon definition of a disaster, and
multiple definitions are found in the literature [5]. The definitions from
the International Strategy for Disaster Reduction (ISDR), the Interna-
tional Federation of Red Cross and Red Crescent Societies (IFRC) and
the World Health Organization are examples of how various organiza-
tions define disaster. Disasters are defined as a serious disruption of the
functioning of a community or society causing widespread human,
material, economic, or environmental losses that exceed the ability of
the affected community or society to cope using its own resources [6].
Nurses have significant responsibilities and play an important role in
disasters because they constitute the majority of health care personnel.
For instance, the International Council of Nurses (ICN) (2006, p. 13)
describes the value of nurses’ involvement in disasters as follows:
“Nurses, with their technical skills and knowledge of epidemiology,
physiology, pharmacology, cultural-familial structures, and psychoso-
cial issues, can assist in disaster preparedness programs, as well as
during disasters. Nurses, as team members, can play a strategic role
cooperating with health and social disciplines, government bodies,
community groups, and non-governmental agencies, including huma-
nitarian organizations” [7].
Therefore, during their undergraduate studies, nursing students
should receive training for their roles in disasters. Undergraduate pro-
grams should incorporate training methods that provide the core
competencies for nurses in relation to disaster preparedness.
Simulations and drills also play an important role in disaster pre-
paredness [8].

⁎
Corresponding author.
E-mail addresses: vunver1@gmail.com (V. Unver), tulay.basak@sbu.edu.tr (T. Basak), gulsah.kok@sbu.edu.tr (G. Kok).

https://doi.org/10.1016/j.ienj.2018.03.002
Received 9 September 2017; Received in revised form 26 February 2018; Accepted 5 March 2018
1755-599X/ © 2018 Elsevier Ltd. All rights reserved.
V. Unver et al.
Simulation is a learning and teaching strategy that is commonly
employed in health-related education. High-fidelity simulation provides
nursing students the opportunity to practice, develop, and apply
knowledge and skills in a realistic clinical situation while remaining in
a safe environment [9]. The term “simulation” has been defined in
different ways. Simulation is a strategy that is designed to represent
procedures, decision-making procedures and critical thinking and helps
nursing students learn during the pre-service period through imitations
of real patient cases [10]. Gaba stated that “simulation is a technique,
not a technology, to replace or amplify real experiences with guided
experiences, often immersive in nature, that evoke or replicate sub-
stantial aspects of the real world in a fully interactive fashion” [11].
Simulation is known for its ability to standardize patient conditions
and to implement them consistently [10]. The use of simulation
training for disaster preparedness combines theoretical knowledge and
clinical skills and provides an invaluable experience for nursing stu-
dents [12]. In addition, simulation enables nursing students to improve
their clinical skills without risking patient safety [10]. Simulation is a
teaching method that reinforces learning and provides long-lasting
learning. In terms of disaster training, simulation is one of the most
accessible techniques and is also cost-effective [13]. In disaster simu-
lations, the participants learn how to manage the care services for in-
jured people, to triage patients, to research cases more effectively and
make corresponding decisions and to develop procedures [14]. These
skills are the reasons simulations are commonly used in disaster
training, and it is widely argued that simulations improve trainees’
knowledge, skills and performance [10].
Simulation-based education employs simulation techniques, which
can be lower, medium or high fidelity. Lower-fidelity simulation edu-
cation consists of the use of mannequins (as a part-task trainer) to
improve psychomotor skills. Simulation education with higher fidelity
involves the use of both mannequins and simulated patients. Simulated
patients are individuals who are trained to act as real patients to si-
mulate a set of symptoms or problems during the practice case or sce-
nario [15].
Research suggests that disaster training provided by nurse trainers
through simulations is desirable because it improves the skills of nur-
sing students [16]. Nurses are among the first health care professionals
to encounter and help terrified, injured or dead people after disasters.
In addition, nurses compose the majority of health care personnel and
have important roles during disasters. Furthermore, nurses help to
educate individuals about disasters and improve their disaster pre-
paredness [1]. Therefore, nursing students should receive disaster
preparedness education to help them increase people’s awareness of
how to manage disasters [2,17]. Through this education, nurses can
become competent in disaster preparedness and equipped with the
necessary information and attitudes towards disasters. In addition,
improving nurses’ disaster perceptions is an integral component of the
activity planning and measure development process. Nurses’ percep-
tions also contribute to the effective planning and implementation of
health care activities during disasters. Thus, including disaster pre-
paredness training in educational programs is critical. At the nursing
school where the study was conducted, disaster preparation courses
have been delivered for nearly ten years. The academic year when the
study was performed was the first time that the simulation-based course
was provided. The aim of this study was to analyze the effects of a
disaster nursing course including a high-fidelity simulation program on
senior nursing students’ perceptions of their disaster preparation.
2. Research questions
In parallel to the aims of the study described above, the study at-
tempted to answer the following research questions:
• What are the preparedness levels and perceptions of senior nursing
students regarding disasters?
4
International Emergency Nursing 38 (2018) 3–9
• What are the effects of the method used in this study on senior
nursing students’ preparedness levels and perceptions about dis-
asters?
• What is the students’ feedback regarding the training method used?
3. Methods
3.1. Study design
This study used a pre-test-post-test design and conducted a quasi-
experimental investigation. It was implemented within the framework
of the “nursing practices in extraordinary conditions” course, which is
provided to senior nursing students. The study was conducted at a
nursing school in Turkey between April 2015 and June 2015.
3.2. Participants
The participants in this study were senior nursing students (n = 87).
All the participants voluntarily participated in the study.
3.3. Data collection tools
The study data were collected through the use of three different
tools. The first tool was used to collect the sociodemographic char-
acteristics of the participants and their views on disaster preparedness.
The second data collection tool was the Scale of Perception of Disaster
Preparedness among Nurses (SPDPN), which was developed by Ozcan
and Erol [18]. The scale comprises twenty items and has three major
components: preparation stage (related items: 1 through 6), interven-
tion stage (related items: 7 through 15) and post-disaster stage (related
items: 16 through 20). The item responses were developed in ac-
cordance with a five-point Likert-type scale (1-completely disagree, 2-
disagree, 3-partly agree, 4-agree, 5-completely agree). Cronbach’s alpha
coefficient for the original scale was 0.90 [18]. In the current study,
Cronbach’s alpha was 0.94. The scale was employed in the study as both
a pre-test and a post-test measurement tool.
The third data collection tool was a survey questionnaire with
twelve items. It was developed by the authors to collect the students’
feedback regarding the disaster simulation used in the study.
3.4. Procedure
The study followed seven steps: “pre-course preparation”, “pre-
course evaluation”, “theoretical course”, “establishment of a mobile
emergency first aid hospital”, “simulation activities”, “demonstration”
and “post-course evaluation” (Fig. 1 Flow chart). Each step is described
below:
3.4.1. Pre-course preparation
Pre-course preparation involved meetings with the faculty members
assigned to the eight-week course. During the meetings, the following
activities were planned: identifying the learning goals, developing
scenarios, accessing the required materials for the scenarios, identifying
the roles covered in the scenarios, designing moulage activities, pre-
paring the types of event (road accident, fire, wreck, etc.) and preparing
the mobile emergency hospital. In addition, a series of meetings was
conducted to coordinate with the Republic of Turkey Prime Ministry
Disaster and Emergency Management Presidency (Turkish: Afet ve Acil
Durum Yönetimi Başkanlığı, AFAD) during the implementation of the
drill.
The simulated patient, patient relative and bystander roles were
voluntarily performed by the non-participating nursing students. Those
playing the role of patients in the simulation and moulage activities
were trained by the faculty members. The physical diagnoses of the
simulated patients were presented on cards placed on their neck. In the
area of the simulated incident, equipment such as real concrete piles,
V. Unver et al. International Emergency Nursing 38 (2018) 3–9

Pre-course preparation

Pre-test
(n=87)

Theoretical course
(n=87) 1. Practice area:
falling from a
height (4 cases)

2. Practice area:
Establishment of being trapped in
mobile hospital the wreckage (4

3. Practice area:
being trapped in
the wreckage (4
20 simulation scenarios First aid on site
in the mobile first-aid (n=40) 4. Practice area:
hospital fire scenario (4
(n=87) cases)

5. Practice area:
road accident
First aid to victims at
(4 cases)
Drill hospital (n=40)
(n=87)

Tables
Disaster coordination
Post-test and feedback
team (n=7)
(n=87)
(n=87)

Fig. 1. Flow chart.

Photo 1. Students’ simulation experiences in mobile emergency hospital.

5
V. Unver et al.
shattered furniture, colored smoke bombs, glass fragments, and corpse
bags was distributed, and a fully equipped ambulance was used to
transfer the injured people. For casualties, a mobile morgue was es-
tablished.
3.4.2. Pre-course evaluation
Immediately prior to the theoretical courses, the participants were
informed about the goals and details of the program. A data collection
tool assessing the participants’ sociodemographic characteristics and
views about disasters as well as the SPDPN were administered.
3.4.3. Theoretical courses
The theoretical courses were jointly delivered by the Nuclear,
Biological, Chemical (NBC) unit, AFAD and the National
Medical Rescue Team. The following topics were discussed in the
courses: collaboration with different institutions during emergencies,
the team approach, triage and first aid practices at the disaster site and
at the hospital, transportation of injured people, use of the radio, pre-
paration of first aid bags, and introduction to the departments of the
mobile hospital.
3.4.4. Establishment of the emergency mobile hospital
Following the completion of theoretical courses, a mobile emer-
gency hospital was established in the school yard. The participants were
involved in this activity (see Photo 1). The hospital included an oper-
ating room, an intensive care unit and three initial intervention areas.
These areas were all fully equipped. Before the simulation activities, the
participants visited the hospital and were informed about how to use
the equipment.
3.4.5. Simulation activities
The ultimate goal of the simulation activities was to prepare the
participants to implement disaster-related interventions through sce-
narios before the drill. Simulation activities were carried out in the
mobile emergency hospital with simulated patients. In the simulation
activities, a total of twenty scenarios were employed. These scenarios
covered patients with multiple traumas, extreme fractures, object pe-
netration, traumatic pregnancies, hypovolemic shock due to bleeding,
head trauma, and myocardial infarction. For each scenario, four to five
participants performed the associated activity. The activities were
consistent with the pre-determined learning goals (Box 1). Before the
simulation activities, a briefing session was conducted. Following the
activities, a debriefing session was held. The simulation activity lasted
nearly one hour for each group.
3.4.6. Drill
A day after the simulation activities, a drill was conducted. The drill
included an earthquake scenario. There were five practice areas. The
first one addressed individuals who had fallen from a height due to
panic. The second and third areas covered being trapped in the
wreckage. The fourth area pertained to a fire, and the fifth involved a
road accident. Each area included four simulated patients. Forty par-
ticipants were assigned to the incident area. The other forty were as-
signed to the emergency hospital. Seven participants worked as the
disaster coordination team. Groups of two or three nursing students
intervened in the situation under the guidance of a faculty member.
A briefing session was held with the participants immediately prior
to the drill. They were informed about the groups that they belonged to
and when the drill would start; additionally, they were told that a fa-
culty member would be available to assist them whenever it was
needed. The drill was then initiated. The following announcement was
issued: “An earthquake occurred in the province on 28 May 2015 at
09.00 am. The earthquake was very severe and lasted for 30 s. The data
from the Kandilli observatory indicate that the magnitude of the
earthquake was 7.1. You are part of the health care team tasked with
going to the areas. It is expected that some of you will help the victims
6
International Emergency Nursing 38 (2018) 3–9
in the area or at the hospital together with AFAD teams.”
The AFAD teams rescued the victims from the debris, and the par-
ticipants then intervened in the cases in accordance with the pre-de-
termined learning goals. Next, injured victims were transported either
to the mobile emergency hospital or to the morgue, depending on their
triage codes. At the hospital, the participants treated the injured victims
based on their triage code. The patients were then transported to the
appropriate unit, such as the morgue, operating room or intensive care
unit
Box 1. Learning goals.
Learning goals related to Learning goals related to the drill
simulation activities
• Determining the triage codes • Determining the triage codes
of victims of victims
• Performing necessary • Performing necessary
interventions at the hospital interventions in the field
consistent with the triage consistent with the triage code
code to accomplish team to accomplish team work
work • Working in coordination with
• Using time effectively AFAD
• To improve students' personal • Using time effectively
preparedness • To improve students' personal
preparedness
3.4.7. Post-course evaluation
Following the drill, the SPDPN was administered to the participants
again. The participants’ feedback on the disaster simulation activities
was obtained through the administration of a survey questionnaire.
3.5. Ethical considerations
The study was conducted after written ethical approval was ob-
tained from the ethical committee of the military education and re-
search hospital, and permission to apply was granted by the nursing
school.
3.6. Statistical analysis
The data collected were analyzed using Statistical Package for the
Social Sciences (SPSS, Inc., Chicago, IL, USA) software for Windows
version 17.0. Descriptive statistics were generated using the arithmetic
mean and standard deviation, minimum–maximum scores, interquartile
range, frequency, and percentage. The results obtained were compared
using the Wilcoxon signed rank test. A p value < 0.05 was considered
statistically significant.
4. Results
The participants in the study were all women. The average age of
the senior nursing students was 21.95 ± 0.26 years. Table 1 indicates
the views of the participants regarding the simulation practice in terms
of their preparedness for disasters.
Table 2 shows the participants’ mean pre- and post-test scores on the
SPDPN and its subdimensions (preparation stage, intervention stage
and post-disaster stage). As the table shows, there was a statistically
significant difference in their scores for the preparation stage, the in-
tervention stage and in the post-disaster stage (p < 0.05). For the some
items (item1, 2, and 3) in the preparation stage, no significant differ-
ence was found.
Graph 1 shows how ready the students are before and after the
training disaster. Before the training, slightly less than the half of the
students (42.5%) expressed that they were ready for disaster. After, the
V. Unver et al. International Emergency Nursing 38 (2018) 3–9

Table 1
Nursing students’ views regarding the preparation stage.

N %

Having prior experience with a disaster

Yes 11 12.6
No 76 87.4

Prepared for disaster with family members (go bag, etc.)

Yes 8 9.2
No 79 90.8

Conception of disaster Graph 1. Student perceptions of disaster preparedness.

Natural disasters, such as earthquakes, floods, etc.
Terrorist attacks with biological and chemical agents
Accidents at electricity or nuclear power plants
Disease outbreaks, such as bird flu
All
Priorities during disasters
Evacuating as many victims as possible
Following the instructions of the department head
Following the disaster management protocol of the hospital
training almost all of the students (89.7) stated that they were ready for
disaster.
Table 3 shows that the nursing students’ scores on the SPDPN and its
subscales were higher after the high-fidelity simulation practice than
before. The difference between the two scores was statistically sig-
nificant (p < 0.05).
Table 4 presents the participants’ views regarding the disaster si-
mulation activities. Overall, 74.7% of the participants reported that
they recognized the significance of education and collaboration. Fur-
thermore, 70.1% of the participants were pleased with this program,
and 60.9% of them said that they had a chance to improve their
knowledge base during the session following the simulation activities.
5. Discussion
Nurses’ preparedness for disasters is crucial to the ability and
84 96.6
79 90.8
77 88.5 capacity to respond to a disaster and to deliver an effective disaster
70 80.5 response. In this study, the disaster-related perceptions of the partici-
80 92.0
pants were analyzed in accordance with the “disaster management
continuum” method. The disaster management continuum is commonly
24 27.6
accepted as a method for addressing all aspects related to a disaster.
3 3.4
60 69.0 Numerous models have been used to provide a disaster management
continuum. The approach adopted in this study is consistent with
Veenema’s Disaster Nursing Timeline model. In this model, the phases
of disasters are classified into three components: Pre-incident, which
includes prevention/mitigation and preparedness; incident (response);
and post-incident, which involves recovery reconstruction/rehabilita-
tion [19].
Educational programs at many nursing schools include courses
about disaster management. However, to make this learning more
permanent, these courses should be delivered using appropriate
methods. Disaster drills or simulations provide health care personnel
with the opportunity to practice and assess their preparedness for real-
life surges in patient volume [20]. In this study, the participants’ post-
test scores on the SPDPN were greater than their pre-test scores. This
increase was most strongly evident for the intervention stage (See
Tables 2 and 3). In a study by Ozcan and Erol, the SPDPN scores of the
participants who took disaster training and those who did not were
significantly different [18]. Many studies claim that nursing students
who participate in disaster simulations or drills learn to prioritize

Table 2
Participants’ pre- and post-test scores on the SPDPN.

Disaster preparedness scale Pre-test Post-test z p

Mean SD Mean SD

Preparation stage 1. To feel ready for disasters, I should regularly participate in in-service training activities 4.39 0.88 4.47 0.66 −0.651 0.515
2. I should reinforce my knowledge of disasters through regular drills to feel ready for them 4.33 0.81 4.48 0.59 −1.623 0.104
3. I should know from which units I can get help in the case of a disaster (disaster intervention, search and 4.45 0.87 4.59 0.52 −1.110 0.267
rescue, logistic support, communications, etc.)
4. I must challenge my knowledge of disaster preparation, and I should learn what I do not know about it 4.40 0.90 4.61 0.51 −2.137 0.033
5. It is important for me to know the communication system used in disasters 4.48 0.88 4.71 0.45 −2.494 0.013
6. I should know what to do in the prioritized order in case of disasters 4.40 0.95 4.72 0.45 −3.025 0.002

Intervention 7. I think that my educational background (undergraduate courses, in-service training activities, etc.) is 3.08 0.97 4.10 0.68 −6.720 < 0.001
sufficient for my preparedness for disasters
8. I can carry out the procedures of implementing an emergency plan and evacuation of a disaster site 3.04 0.89 4.18 0.66 −6.810 < 0.001
9. I can triage disaster victims on site 3.38 0.86 4.44 0.56 −6.884 < 0.001
10. I can provide first aid to disaster victims 3.27 0.91 4.44 0.56 −7.202 < 0.001
11. I can care for people who are subject to terrorist attacks 2.90 0.99 4.00 0.68 −6.825 < 0.001
12. I can care for people who are subject to biological or chemical attacks 2.97 0.99 3.87 0.80 −5.588 < 0.001
13. In the case of an epidemic disease, I can prevent contamination 3.07 0.96 3.86 0.81 −5.812 < 0.001
14. In disasters, I trust myself to provide first aid to patients without physician guidance 3.08 0.96 4.30 0.59 −7.178 < 0.001
15. When saving victims, I can work as any component of the health care team 3.49 0.98 4.38 0.55 −6079 < 0.001

Post-disaster period 16. I am aware of my roles and responsibilities during the post-disaster period 3.56 0.98 4.48 0.55 −6.649 < 0.001
17. Following a disaster, I can provide psychological support to disaster victims 3.80 0.82 4.36 0.59 −5.266 < 0.001
18. I can recognize the symptoms of acute stress disorder and post-traumatic stress syndrome among 3.81 0.87 4.21 0.64 −3.938 < 0.001
disaster victims
19. I can train people with post-disaster trauma to become self-sufficient until they are transferred to the 3.44 0.98 4.26 0.63 -6.301 < 0.001
hospital
20. During the post-disaster period, I can fulfill my duties concerning the provision of healthy food, drink, 3.64 0.99 4.34 0.57 -6.002 < 0.001
and accommodations for victims

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V. Unver et al. International Emergency Nursing 38 (2018) 3–9

Table 3
Comparison of the nursing students’ scores on the SPDPN and its subscales before and after the training.

SPDPN and subdimensions Pre-training period Post-training period Z* P

Median (IR) Min-Max Median (IR) Min-Max

SPDPN 3.70 (0.65) 1.00–4.95 4.30(0.70) 3.60–5.00 -7.572 0.001

Preparation stage 4.50 (1.00) 1.00–5.00 4.83(0.83) 3.67–5.00 -2.370 0.018
Intervention stage 3.11 (0.89) 1.00–4.89 4.11(0.78) 3.00–5.00 -7.654 0.001
Post-disaster stage 3.80 (0.80) 1.00–5.00 4.20 (1.00) 3.40–5.00 -6.921 0.001

*
IR, interquartile range, Wilcoxon signed rank test.

patients care during disasters to do what is most appropriate for the
patient and the community [21,22]. Gardner et al. (2016) argued that
simulation-based training programs have a positive impact on skill
acquisition, performance, and patient outcomes. Simulation-based
training also offers unique opportunities to address high-risk and
complex events in challenging environments in which the operating
team must be prepared to act quickly and effectively [23]. A study by
Chan et al. (2010) developed a disaster course using the framework of
the International Council of Nurses Disaster Nursing Competencies. In
that study, self-ratings on disaster nursing competencies increased from
2.09 pre-training to 3.71 post-training [24]. Therefore, courses on
disaster management are essential to improving nursing students’
awareness of the topic.
Disaster preparedness can be achieved in two basic ways: personal
preparedness and professional preparedness [8]. Personal preparedness
refers to being aware of the topics, including family disaster and
emergency case plans, go bags, emergency communication cards, cor-
rect ways of acting in emergency cases and evacuation. In this study,
slightly more than half of the participants were partially ready to
manage disasters (56%, see Table 1). Additionally, 90.8% of the par-
ticipants (79 nursing students) reported that they did not have a go bag.
Similarly, Schmidt et al. (2011) found that 79.3% of students (915) did
not have a go bag [25]. Their finding is consistent with the present
results.
There are various opinions regarding the professional preparedness
of nurses during disasters [8]. During a disaster, nurses are expected to
be able to fulfill the role of a medical practitioner in some ways. This
role can be described as beyond the normal scope of nursing practice in
terms of their knowledge and abilities [26]. Nevertheless, it is essential
for nurses to be trained in disaster medicine in order to be assigned to
medical tasks during an emergency response. Triaging patients is an
assigned medical task that figures prominently in the literature. To
provide opportunities for professional preparedness at the school where
this study was conducted, the disaster management course was based
on Turkey’s regulations and nurses’ responsibilities. During the simu-
lation activities and drill, the participants were trained in accordance
with these roles. Specifically, the following skills were emphasized
during the simulation activities implemented before the drill: triage,
interventions for victims with multiple traumas on site, interventions
for injured patients at the hospital, team work and time management.
During the drills, the participants had the opportunity to triage patients
on site and at the hospital and to provide first aid. Duarte and Haynes
(2006) argued that education related to disasters should be multi-
disciplinary in nature [27]. In the current study, this criterion was met
through the inclusion of the AFAD teams as government disaster
management teams. Their involvement appeared to contribute to the
participants’ professional preparedness.
In the study, nearly all the participants expressed positive views
regarding the disaster simulation activities and drill (See Table 4).
Kaplan et al. (2012) also conducted an emergency preparedness disaster
simulation (EPDS) for nursing students. After the simulation, approxi-
mately 95% of the students indicated that they “agreed or strongly
agreed” that the simulation increased their knowledge and confidence
in managing emergency preparedness events and in working in teams
[28]. One of the best ways to prepare for a disaster is to participate in
mock disaster drills or tabletop exercises. It is very important for nur-
sing schools to incorporate these drills into their courses to increase
students’ disaster preparedness. Nursing faculty should work with local
emergency coordinators and participate in area drills [29]. In this
study, a local emergency planner, AFAD, was a partner in the simula-
tion activities and drill. This collaboration appeared to have positive
effects on the participants’ opinions about the simulation activities and
drill.
5.1. Limitation
The participants in this study were senior nursing students. In the
theoretical courses, information about chemical, biological, radi-
ological and nuclear injuries was provided, but these issues were not
covered in the simulation activities. In the future, scenarios with these
types of injuries should be included to raise participants’ awareness of
how to manage those situations.

Table 4
Student feedback about the disaster simulation program.

Partly agree Agree Fully agree

n % n % n %

1. I could combine my theoretical and practical knowledge 2 2.3 51 58.6 34 39.1

2. It improved my critical thinking skills – – 48 55.2 39 44.8
3. It improved my decision-making skills – – 50 57.5 37 42.5
4. It allowed me to make a connection with real-life facts 1 1.1 40 46.0 46 52.9
5. It allowed me to recognize my learning needs – – 39 44.8 48 55.2
6. It improved my self-esteem before I received a clinical assignment – – 43 49.4 44 50.6
7. During the simulation practice, I felt I was acting like a nurse 3 3.4 36 41.4 48 55.2
8. It increased my motivation – – 39 44.8 48 55.2
9. I understood the significance of communication and collaboration within the team. 2 2.3 23 26.4 62 71.3
10. I had the chance to improve my knowledge in the session following the simulation activity 1 1.1 33 37.9 53 60.9
11. I am pleased with this training – – 26 29.9 61 70.1
12. I suggest using this educational model in other training activities – – 22 25.3 65 74.7

8
V. Unver et al.
6. Conclusion
Nurses play a critical role in the disaster management process.
Therefore, disaster-related nursing courses and preparation of nursing
faculty members to teach this topic are urgently needed to adequately
prepare nursing students for possible disaster situations in the future
[30]. To ensure that nurses are efficient in caring for disaster victims,
nursing students should be trained in disasters and should be prepared
for their future roles in such events. Supplementing the simulation ac-
tivities with drills positively contributed to the participants’ perceptions
regarding their disaster preparedness. In future studies, the long-term
effects of the simulation activities on disaster preparedness should be
examined. In addition, similar studies should be conducted to increase
in-service nurses’ awareness of disaster management.
Author’s contribution to the paper
All of the authors have contributed to the study on conception and
design, drafting the article, revising it critically for important in-
tellectual content, and final approval of the version to be published. All
authors are in agreement with the content of the manuscript.
Funding
None.
Conflict of interest
No conflict of interest has been declared by the authors.
Acknowledgements
We would like to thank the nursing students who acted as the si-
mulated patients, patients’ relatives and bystanders; the Republic of
Turkey Prime Ministry Disaster and Emergency Management
Presidency and National Medical Rescue Team members; and Elif
Gezginci, Neslihan Ilkaz, Ozgü Bakcek, Gamze Acavut, and Damla
Bayrak’a for their invaluable contributions.
References
[1] Al Thobaity AA, Plummer V, Williams B. What are the most common domains of the
core competencies of disaster nursing? A scoping review. Int Emerg Nurs
2017;31:64–71.
[2] Jose MM, Dufrene C. Educational competencies and technologies for disaster pre-
paredness in undergraduate nursing education: an integrative review. Nurse Nurse
Educ Today 2014;34:543–51.
[3] World Health Organization Emergency and disaster risk management for health;
2013, Retrieved from < http://www.who.int/hac/techguidance/ preparedness/
en/ > [accessed: January 2017].
[4] Achora S, Kamanyire JK. Disaster preparedness: need for inclusion in undergraduate
nursing education. Sultan Sultan Qaboos University Medical Journal
2016;16:e15–9.
[5] ICN. Framework of Disaster Nursing Competencies. Retrieved from < http://www.
apednn.org/doc/resourcespublications/ICN%20Framework%20of%20Disaster
International Emergency Nursing 38 (2018) 3–9
%20Nursing%20Competencies%20ICN%202009.pdf > ; 2009 [Accessed: January
2017].
[6] ISDR. Terminology: Basic terms of disaster risk reduction; 2009, Retrieved
from < http://www.unisdr.org/files/7817_UNISDRTerminologyEnglish.
pdf > [accessed 26.12.16].
[7] ICN. Nurses and disaster preparedness. Geneva: International Council of Nurses;
2006.
[8] Grochtdreis T, De Jong N, Harenberg N, Görres S, Schröder-Bäck P. Nurses’ roles,
knowledge and experience in national disaster preparedness and emergency re-
sponse: a literature review (Review article). SEEJPH 2017; 7:10.4119/UNIBI/
SEEJPH-2016-133; 2016.
[9] Aqel AA, Ahmad MM. High-fidelity simulation effects on CPR knowledge, skills,
acquisition, and retention in nursing students. Worldviews Evid Based Nurs
2014;11:394–400.
[10] McKenna KD, Carhart E, Bercher D, Spain A, Todaro J. Simulation use in paramedic
education research (super): a descriptive study. Prehosp Emerg Care
2015;19:432–40.
[11] Gaba DM. The future vision of simulation in health care. Qual Saf Health Care
2004(Suppl. 1):i2–10.
[12] Cant RP, Cooper SJ. The benefits of debriefing as formative feedback in nurse
education. Aust J Adv Nurs 2011;29:37–47.
[13] Farra S, Miller E, Timm N, Schafer J. Improved training for disasters using 3-D
virtual reality simulation. West J Nurs Res 2012;35:655–71.
[14] Franc- Law JM, Ingrassia PL, Ragazzoni L, Corte FD. The effectiveness of training
with an emergency department simulator on medical student performance in a si-
mulated disaster. CJEM 2010;12:27–32.
[15] Meakim C, Boese T, Decker S, Franklin AE, Gloe D, Lioce L, et al. Standards of best
practice: simulation standard I: terminology. Clin Simul Nurs 2013;9:3–11.
[16] Smith S, Farra S, Dempsey A, Arms D. Preparing nursing students for leadership
using a disaster-related simulation. Nurse Educ 2015;40:212–6.
[17] Veenema TG, Griffin A, Gable AR, MacIntyre L, Simons N, Couig MP, et al. Nurses as
leaders in disaster preparedness and response-a call to action. J Nurs Scholarship
2016;2016(48):187–200.
[18] Ozcan F, Erol S. Disaster preparedness and perceptions af nurses (Master thesis)
Istanbul, Turkey: Marmara University, Institute of Health Science; 2013.
[19] Veenema T. Essentials of disaster planning. In: Veenema T, editor. Disaster nursing
and emergency preparedness for chemical, biological, and radiological terrorism
and other hazards. New York: Springer Publishing Company; 2007. p. 3–23.
[20] Wallace D, Gillett B, Wright B, Stetz J, Arquilla B. Randomized controlled trial of
high fidelity patient simulators compared to actor patients in a pandemic influenza
drill scenario. Resuscitation 2010;81:872–6.
[21] Hensarling J, Connor D, Chilton J, Fountain R, Deal B, Klotz L, et al. Part II: col-
laborative learning in community health nursing for emergency preparedness.
Nurse Educ. Pract. 2015;15:82–9.
[22] Pang SM, Chan SS, Cheng Y. Pilot training program for developing disaster nursing
competencies among undergraduate students in China. Nurs Health Sci
2009;11:367–73.
[23] Gardner AK, DeMoya MA, Tinkoff GH, Brown KM, Garcia GD, Miller GT, et al. Using
simulation for disaster preparedness. Surgery 2016;160:565–70.
[24] Chan SS, Chan WS, Cheng Y, Fung OW, Lai TK, Leung AW, et al. Development and
evaluation of an undergraduate training course for developing International
Council of Nurses disaster nursing competencies in China. J Nurs Scholarship
2010;42:405–13.
[25] Schmidt CK, Davis JM, Sanders JL, Chapman LA, Cisco MC, Hady AR. Exploring
nursing students' level of preparedness for disaster response. Nurs Educ Perspect
2011;32:380–3.
[26] Yin H, He H, Arbon P, Zhu J, Tan J, Zhang L. Optimal qualifications, staffing and
scope of practice for first responder nurses in disaster. J Clin Nurs 2012;21:264–71.
[27] Duarte V, Haynes LC. Disaster preparedness: ''As Common As CPR''. Clin Simul Nurs
2006;2. e5-3e57.
[28] Kaplan BG, Connor A, Ferranti EP, Holmes L, Spencer L. Use of an emergency
preparedness disaster simulation with undergraduate nursing students. Public
Health Nurs 2012;29:44–51.
[29] Jennings-Sanders A, Frisch N, Wing S. Nursing students’ perceptions about disaster
nursing. Disaster Manage Response 2005;3:80–5.
[30] Stangeland PA. Disaster nursing: a retrospective review. Crit Care Nurs Clin North
Am 2010;22:421–36.