2020 has been a tough year for global health. As movement between countries has increased and technology has advanced, international cooperation and interdependence have become more important than ever. To manage global health issues such as infectious diseases and disasters and unfair intervention by pharmaceutical companies, we need to be equipped with global health capacities [1]. Coronavirus disease (COVID-19) currently presents the most serious problem for global health, and subsequently global nursing capacity. It threatens not only population health and socio-economic well-being, but also the core concerns of society, including humanitarian issues and human rights. Therefore, we need to develop a curriculum for an outbreak of infectious diseases, which is pandemic, one of social disasters that the world is going through, so that nursing students are equipped with global health competencies to face today’s global health issues.

A disaster is an incident that causes widespread human, physical, economic, or environmental disruption and loss, and the resultant stress exceeds the resources of an individual or community and severely harms livelihoods or property [2, 3]. Because disasters destroy fundamental local organizations and basic functions, they cannot be easily overcome without external aid. The World Health Organization (WHO) divides disaster management into four stages: prevention, preparation, response, and recovery [4]. Education and training programs to mitigate and prepare for disasters are the most cost-effective methods of disaster management, and are also effective at improving population resilience and speedy recovery after a disaster [5].

Disasters can be classified as natural or social disasters. The COVID-19 pandemic we are currently experiencing is an example of a social disaster [6]. Although medical technology and public health and hygiene have improved, novel infectious diseases capable of causing pandemics have been emerging at a faster rate since the twentieth century. Notable examples include the emergence of the Severe Acute Respiratory Syndrome (SARS) in 2002, the Middle East Respiratory Syndrome (MERS) in 2015, Zika virus, and lastly the Novel Coronavirus, or SARS-Cov2, in 2019. As such, we need to prepare for facing the threat of other infectious diseases disaster in the future [7].

Although awareness of disasters is growing among medical personnel, educational programs to help them prepare for disasters are still limited. One study reported that most clinical nurses believe that they lack experience and education in disasters and disaster nursing, and rate their own disaster preparedness as low [3]. This lack of experience can cause stress and fear regarding disaster management. Believing that one is thoroughly prepared for a disaster can enhance confidence in coping with it. Therefore, prudent systematic education and training are required starting from the undergraduate level to prepare healthcare providers for disasters.

Some studies highlighting the importance of such programs have been conducted after the outbreak of COVID-19. Hamele et al. [8] suggested the 4S pandemic plan—“stuff”, “space”, “staff”, and “systems”—which emphasized the importance of “just in time” regular training in preparation for a pandemic. This raises the question, “How thoroughly were we prepared for the COVID-19 outbreak?” This question applies to the preparedness of all individuals, but particularly those working in healthcare, especially caregiving personnel such as nurses. The preparedness of frontline healthcare workers to respond to epidemic outbreaks is vital. Especially frontline nurses who take a major part in responding to outbreaks, require the awareness and ability to handle an epidemic outbreak from infection control skills to ensuring the safety of population [9]. When asked about the most difficult aspects of coping with COVID-19, nurses stated extended working hours, psychological and physical stress, insufficient education, and lack of personal protective equipment (PPE) [7]. In a cross-sectional study in China, suitable provision and wearing of PPE, improved education for pandemic management, increased staffing, and social and psychological support, were proposed as needs of front-line nurses [10]. Education on wearing PPE especially increased the rate of PPE-wearing by nurses and decreased the rate of COVID-19 infection among medical personnel [11]. In short, the COVID-19 outbreak and emergence of novel infectious diseases over the last several years have taught us the importance of developing a prepared response to infectious disease disasters. However, existing disaster nursing education has mostly focused on mass casualty incidents and natural disasters [12]. There have been some international studies investigating pandemic response training programs for nursing students. However, there has been almost no simulation research modeling the existing response to novel infectious diseases, among undergraduates in South Korea.

Existing methods of disaster training and education include classical lecture-based teaching, case studies, debates, expert talks, as well as table-top methods and virtual reality simulation [13]. Of these, simulation improves trainees’ judgment, adaptability, and coping ability in the field, as well as their knowledge, confidence, practical ability, and skills [14, 15, 16, 17]. The urgent and unpredictable circumstances at a disaster site demand rapid decision-making and problem-solving. Because it is difficult to experience real disasters for preparatory training, simulations—based on structured scenarios—allow trainees to experience them indirectly instead. To organize a systematic simulation program, a theoretical framework is necessary. From 1999 to 2015, the most frequently used simulation framework was National League for Nurses (NLN)/Jeffries simulation [18]. In NLN/Jeffries simulation framework, the simulation design includes detailed learning objectives, learner role assignments, systematic strategies for re-debriefing or debriefing, and simulation flow. Also, Jeffries simulation model is based on constructive learning theory, which is a useful theoretical framework for safe and effective simulation-based clinical nursing education [19]. Jeffries simulation model, which comprises five components, teacher, student, educational practice, design characteristics, and evaluation, is used to create positive educational effects through simulation education. Specifically, previous research reported that simulation learning positively influenced students’ critical thinking and self-confidence [13, 19, 20] as well as their disaster response competence. Thus, this model was found to provide an effective theoretical framework for managing and evaluating nursing simulations.

Therefore, this study aimed to design a simulation training program for novel infectious disease disasters based on the simulation model of Jeffries, and to investigate the effects of this training on nursing students.

This study aimed to develop and test the effectiveness of a novel infectious disease disaster simulation module to train nursing students to better prepare for such occurrences in the future. In Jeffries simulation model, they suggest to evaluate knowledge, skill performance, learner satisfaction, critical thinking and self-confidence as outcomes [17]. To this end, we analyzed the effects of the simulation model on nursing students’ critical thinking disposition, disaster preparedness, triage, disaster nursing competencies, confidence in disaster nursing, willingness to participate in the disaster response, and knowledge about COVID-19.

Disaster preparedness showed significant improvements after pre-training and after simulation training in this study. This supports the results of several prior studies that reported increased confidence and disaster preparedness among nurses following disaster preparation training. In one study that implemented a disaster preparation simulation for 90 nursing college students, 95% of participants reported an improvement in their ability to cope with a disaster [12]. In another study of nursing college students in Indonesia, improved disaster preparedness, triage, and initial disaster response competency were reported after a disaster simulation program [29].

Competency in disaster nursing also showed a significant increase at each time point (F = 44.09, p < .001). According to a previous study, disaster nursing competency is positively affected by actual disaster experience. Satoh et al. [30] reported that nursing students with experience of a disaster nursing program showed significantly better disaster nursing competency, disaster nursing knowledge, understanding of their role in the disaster response, and teamwork, compared to those without this experience, at the site of the Fukamoto earthquake in Japan in 2016.

Confidence in disaster nursing improved significantly after the program, especially after pre-training. The improvement after simulation training compared to after pre-training was not statistically significant, but there was a trend-level improvement. This is consistent with a study by Jung et al. [3], in which confidence in disaster nursing improved after nurses participated in a disaster nursing convergence program. Cant and Cooper [31] reviewed 12 studies on simulation-based learning in nursing, and found that it improved learners’ confidence, critical thinking ability, and knowledge in six of these studies, which corroborates our findings.

In the present study, the ratio of participants who reported willingness to participate in the disaster response increased significantly, from 46 persons (59.0%) before pre-training, to 56 persons (71.8%) after pre-training, and 69 persons (88.5%) after simulation training. This is in agreement with previous studies, including one study by Jeffries [17] in which students participated in a disaster simulation based on a simulation model; in a subsequent in-depth interview, the students reported a desire to participate in disaster rescue activities [32]. Another previous study had found that experience with disaster preparation training or disaster education not only significantly improved willingness to participate in disaster response, but also fostered the will of healthcare workers to protect civilians from the hazardous circumstances of a disaster [33].

Even among clinical nurses, willingness to participate in disaster response has been reported to increase with experience. This is consistent with previous results showing that increased experience of disasters or disaster training is associated with increased confidence and willingness to participate in disaster response [34]. One study also reported that trained medical personnel experience less fear about exposure to hazards in disaster situations [35]. These results demonstrate that disaster nursing simulation improves competency in disaster nursing and disaster preparedness, leading to improvements in confidence in disaster nursing and willingness to participate in the disaster response [12, 29, 36]. Therefore, high-fidelity simulation-based programs for nursing students can help nurses who can lead the field response to disasters—a frontline role that demands diverse competencies.

On the other hand, even after the intervention, this study did not show any significant changes in the participants’ critical thinking ability, which matches findings from some earlier studies. In a study by Chae and Choi [37], no differences in critical thinking disposition were observed even after administering a simulation program, which the authors attributed to lack of implementation time studies using multi-mode simulation [38], high-fidelity simulation [39], and simulation convergence programs [3] which have likewise reported no significant effects on critical thinking.

Contrastingly, other studies have reported that simulation programs have had positive effects on critical thinking [16, 40, 41, 42]. In particular, Al Gharibi and Arulappan [43] reported that students who experienced three simulation sessions showed better critical thinking disposition than students who experienced only one simulation session. As explained by Brown and Chronister [44]—whose study reported no significant change in critical thinking after only 30 minutes of high-fidelity simulation—critical thinking is determined by an individual’s learning habits, motivation, basic knowledge, logical ability, and social characteristics. It is a unique trait of individuals that is not easily changed [45]. These observations support the claims of Chae and Choi [37] and Al Gharibi and Arulappan [43] that a curriculum of simulation with sufficient duration is required to significantly improve critical thinking. Thus, when interpreting the results of the present study, it is important to consider that only a single three-hour session of the intervention was administered.

In terms of triage, most studies on disaster response and preparation training had earlier reported that disaster nursing simulation programs have a significant effect on triage scores. However, because triage requires the ability to make rapid judgments in a short time, it is closely related to clinical experience and therefore can be difficult to improve in subjects lacking clinical experience. For example, when one week of pediatric disaster simulation training was given to residents, triage accuracy improved significantly [46]. However, when Kim and Lee [36] applied disaster simulation training for undergraduate students, the triage accuracy was 26%, which can be considered similar to the present study. Moreover, previous studies on triage in simulation training focused on multiple casualty incidents, earthquakes, or biochemical terror scenarios, there have been no studies focusing only on disaster pandemics. As such, the lack of effect on triage scores in this study are thought to be due to the program being limited to the specific disaster of a novel infectious disease and pandemic. Finally, the questionnaire on knowledge about COVID-19 was intended to spark participants’ interests and spread awareness of COVID-19, which was newly emerging when we began the development of this program in early 2020, but no significant difference in students’ knowledge before and after simulation training has been found. Nevertheless, if a more structured questionnaire were developed based on the knowledge about COVID-19 that has been accumulated in the last year, it could be used as an introduction to transfer the appropriate knowledge and capture students’ attention.

Although this is a valuable study, it still has some limitations. First, because this program was administered to a single group of nursing students, there may be difficulties in generalizing the program to more participants in the future. The study used a one-group pretest and posttest design and quasi experimental study. The participants were recruited from a university, which making it difficult to completely eliminate selection bias. It is also difficult to eliminate the maturation effect due to pre-training. As it is difficult to rule out effects of history, maturation, and statistical regression, nonequivalent control group can be added to improve the research design. Also, by adding serial time series design, we can confirm if the testing effects have affected on the results. Unfortunately, the ongoing COVID-19 pandemic made it difficult to recruit a more diverse sample and control group due to the constantly changing conditions for practicum training in nursing. Thus, further studies are required to develop with control group design. Second, wearing PPE was not included in the module for following reasons. Wearing PPE was already included as a part of regular courses for students not only for participants but all. We thought it was not strongly needed to include wearing PPE in the module due to time limitations. The scenario was based on a real-live situation which can happen at the very front line in the pandemic era. In most disaster situations, responders can’t be fully equipped as needed before they seize the scene. Finally, the novel infectious disease simulation module for disaster nursing used in this study consisted of pre-training, followed by a single simulation session lasting around three hours. Previous studies on simulation interventions have involved at least three to four sessions and have been up to six to eight weeks long or as long as one semester [43]. As mentioned above, critical thinking didn’t show a significant improvement. Several studies reported that simulation programs didn’t significantly affect on critical thinking skills [3, 37, 38, 39, 44]. To make a meaningful change of critical thinking, it requires a long period of time and education [47]. Based on all, we suggest to develop an authentic simulation module with enough periods of sessions. We need to develop sufficient disaster competencies and coping abilities among nurses to deal with disasters that could occur at any time in the future. We need education that accounts for the unique nature of infectious disease disasters, in which medical services plays an even more urgent role compared to other types of disaster.

The COVID-19 pandemic has made clear the urgent need for an information technology environment in the event of persistent infectious disease outbreaks. If these types of simulation scenarios were developed and provided in virtual reality, we expect that it would be an even more effective educational tool, given the nature of infectious disease disasters [48]. On the other hand, in-depth interviews revealed that these simulations induced strong interest and engagement in learning for students. In addition, future research on developing disaster nursing simulation education is needed.

This study showed that a simulation training program for the emerging pandemic crisis (COVID-19) positive affected nursing students’ disaster preparedness, disaster nursing competency, and confidence in disaster nursing. In a disaster, which is an urgent, critical situation demanding complex competencies, nurses are the ideal group to lead on the frontline with diverse competencies, confidence, and willingness to participate in disaster response. Simulation programs can help nursing students to improve their disaster competencies to prevent issues in providing healthcare in low-resources settings, combating the global burden of disease, considering the health implications of migration and displacement, and advocating for human rights. Based on our findings, we make the following suggestions. Future studies should develop a high-fidelity program and administer it to a larger group of nursing students and medical personnel to extend the study implication. As such, we hope that this study will help nursing students and medical personnel deal with infectious disease disasters that they face in community nursing practice in the future.