Develop and Evaluate of an Infection Control Simulation Training in Nursing Students

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Chan, Natalie P.M. Lee, Janet Y.H. Wong This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8674602/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 10 You are reading this latest preprint version Abstract Aim/objective To develop and evaluate an infection-control cardiopulmonary resuscitation (CPR) simulation training program for undergraduate nursing students, assessing simulation acceptability, situational awareness improvement, and technical skills competency. Background Nursing students should manage clinical emergencies while rigorously adhering infection prevention and control (IPC) protocols. Although resuscitation and IPC are often taught separately, integrating them through simulation-based learning can better prepare students by combining technical skills, non-technical skills, and IPC skills within realistic, safe environments. Design Quantitative interventional study integrated into final-year Hong Kong nursing curriculum. Methods A total of 272 students participated in a high-fidelity resuscitation scenario in an isolation ward with scripted IPC errors. Simulation acceptability was assessed using the Simulation Design Scale (SDS) and Educational Practice Questionnaire (EPQ). Situational awareness was evaluated pre- and post-training using the Mission Awareness Rating Scale (MARS). Competency was assessed via a checklist based on hospital protocols and CPR guidelines. Results Participants reported high acceptability scores: SDS means of 4.14 (presence) and 4.04 (importance), and EPQ means of 4.24 and 4.11, respectively (5-point scales). Significant improvements in post-training MARS scores for both Content (2.58®2.29) and Workload (2.59®2.35) subscales (p<0.01). Higher SDS and EPQ scores correlated with greater improvements in situational awareness. Competency assessment revealed strengths in AED use and bag-valve-mask ventilation, but gaps in breathing assessment, noting arrest time, airway adjunct use, and correcting IPC errors. Conclusions Integrated infection-control CPR simulation is feasible, well accepted, enhances situational awareness, and highlights areas for competency improvement. These findings support experiential learning for complex, high-risk clinical environments. Background Contemporary nurse education increasingly emphasizes experiential and practice‑based learning to prepare students for the complexity, uncertainty, and time pressure of real clinical environments (Bordelon and Dudding, 2020; Koukourikos et al., 2021). Simulation has become a central strategy within this paradigm because it offers structured, authentic experiences in which students can integrate theoretical knowledge, psychomotor skills, and non‑technical competencies such as communication, teamwork, and situational awareness in a safe and supportive setting (Koukourikos et al., 2021; Wai et al., 2021). Through repeated, guided exposure to realistic scenarios and debriefing, experiential learning in simulation can foster clinical judgement, confidence, and readiness for practice without compromising patient safety (Wai et al., 2021; Bordelon and Dudding, 2020). At the same time, patient safety agendas worldwide highlight two persistent educational priorities: effective response to clinical emergencies and consistent adherence to infection prevention and control (IPC) practices. Cardiorespiratory arrest is a high‑stakes, low‑frequency event for undergraduate students, yet it demands rapid assessment, technically competent cardiopulmonary resuscitation (CPR), and coordinated team performance (Onan et al., 2017; Wai et al., 2021). In parallel, nursing students must learn to apply standard and transmission‑based precautions, use personal protective equipment correctly, and manage airways safely to minimize the risk of healthcare‑associated infections for both patients and staff (Darawad and Al-Hussami, 2013; Labrague et al., 2018; Van De Mortel et al., 2012; Kim and Park, 2021). Although these domains are often taught separately in curricula, nurses in practice must simultaneously manage resuscitation procedures and infection control requirements, particularly in isolation settings and during outbreaks (Foong et al., 2020; Sowan et al., 2022). Simulation‑based education provides an opportunity to bring these strands together within a single experiential learning activity. Integrating CPR with infection control procedures in high‑fidelity scenarios allows students to rehearse complex responses that combine technical skills, non‑technical skills, and IPC behaviors under realistic time pressure (Onan et al., 2017; Sowan et al., 2022). Such designs are also well suited to exploring cognitive aspects of performance, including situational awareness and mental workload, which are known to influence decision‑making and team effectiveness in deteriorating patient and emergency situations (Wai et al., 2021; Sowan et al., 2022). However, there is still limited quantitative evidence on how integrated resuscitation–infection‑control simulations affect undergraduate nursing students’ situational awareness, their perceptions of simulation design and educational practices, and their observable competence in infection‑sensitive CPR performance (Onan et al., 2017; Sowan et al., 2022). This study responds to these needs by developing and evaluating an infection‑control CPR simulation training program for undergraduate nursing students in Hong Kong. By linking perceptions of design, educational practices, situational awareness, and performance outcomes, this work seeks to inform the design of experiential learning strategies that better prepare nursing students for complex, high‑risk clinical situations. Objectives In the current literature, there is a notable lack of studies focusing on infection control CPR simulation training for nursing students. This study aims to address this gap by investigating the effectiveness of tailored infection control CPR training program for nursing students in Hong Kong. The objectives of the proposed study are as follows: To Develop an Infection Control Simulation Training Program : Design a tailored simulation training program integrating infection control protocols within CPR scenarios for nursing students. To Evaluate Acceptability and Usability of the Simulation Design : Assess the overall acceptability and usability of the simulation training from the perspective of both students and educators. To Evaluate Non-Technical Skills : Examine students' non-technical skills, such as situational awareness, during the training to understand their ability to respond effectively in real-life situations. To Evaluate Student Competency : Measure the competency of nursing students in applying infection control measures, and performing CPR effectively, assessing both knowledge and practical skills. This project is conducted in collaboration with the Hospital Authority, ensuring that the training aligns with current healthcare standards and practices and clinical practice requirements. Objective 1: Develop an Infection Control Simulation Training Program Study Design and Procedure This study employed an interventional design embedded within the curriculum for nursing students at Hong Kong Metropolitan University, School of Nursing and Health Sciences. Participants were recruited directly from the course NURS N412F Integrated Nursing (General Health Care), targeting final-year general nursing students. On the training date, participants received an information sheet detailing the study's purpose, procedures, and potential risks. Informed consent was obtained before commencing the training. A briefing session-oriented participants to the training environment and objectives, ensuring clear expectations. The training content was specifically designed for this study, with participants informed about the nature of the scenarios. Consent was obtained to ensure psychological safety, emphasizing that the activities are simulated and designed to avoid harm. Following the training, a debriefing session facilitated reflection on experiences and reflections and assessed psychological stress, ensuring participant well-being. This structured approach aims to establish a supportive and safe learning environment while effectively evaluating the impact of infection control CPR simulation training. Scenario in Simulation Training The scenario involves a 65-year-old male patient with a history of diabetes mellitus, hypertension, and acute coronary syndrome, who had undergone percutaneous coronary intervention. He was admitted during the afternoon shift with symptoms of fever, cough, and palpitations, following recent travel to China, his oxygen saturation (SpO2) was initially 92%, improving to 95% with supplemental oxygen at 4 liters via nasal cannula. The patient was admitted to an isolation ward. During the night shift, the cardiac monitor indicated ventricular tachycardia, prompting the participants to intervene. A confederate doctor intentionally performed improper practices, including incomplete personal protective equipment (PPE) use, failure to apply a two-hand technique during bag-valve mask ventilation, and neglecting to inflate the balloon of the endotracheal tube. Participants were tasked with identifying these errors, proposing corrected actions, and estimating the time required for each correction. The scenario aimed to heighten students’ awareness and enhance their responsiveness to critical infection control and emergency care situations. Learning Objectives for the Simulation Training Recognize Pulseless Ventricular Tachycardia : Identify the signs of pulseless ventricular tachycardia and apply the American Heart Association (AHA) algorithm for appropriate patient management. Administer Manual Ventilation and Compression Safely : Perform manual ventilation and chest compressions effectively and safely. Implement Infection Control Measures : Apply effective infection control measures diligently during patient management to ensure safety for both patient and healthcare providers. Demonstrate Effective Communication and Teamwork : Exhibit clear communication and teamwork to facilitate optimal patient care during emergencies. The study was conducted over three days in early March 2024. Session began with a 30-minute pre-simulation workshop, including refresher on basic life support (BLS) and airway management. A 10-minute briefing on the scenario background and environment orientation followed, familiarizing participants with the manikin, emergency trolley, patient monitor, and electronic patient bed. The simulation lasted 20 minutes and was followed by a 30-minutes debriefing led by a qualified facilitator. A total of 239 final-year nursing students successfully completed all assessments. The facilitator-to-student ratio was maintained at 1:4 to ensure adequate support throughout the training. Objective 2: Evaluate Acceptability and Usability of the Simulation Design The second objective is to evaluate the acceptability and usability of the simulation design. Two validated instruments will be employed to achieve this: the Simulation Design Scale (SDS) and the Educational Practice Questionnaire (EPQ). The SDS (Jeffries, 2005) is a 20-item questionnaire (Appendix 1) that uses a 5-point Likert scale to assess participants' perceptions of the simulation's effectiveness, realism, and overall design quality. It evaluates five categories: Objective/information: clarity and presentation of learning objectives and relevant information Support: availability of resources and assistance during simulation Problem-solving: opportunities for critical thinking and decision making Feedback: quality and timeliness of feedback and guided reflection Fidelity: realism of the simulation environment and scenarios Each category directly corresponds to specific design features, providing a comprehensive assessment of students' experience and preferences for effective learning. The EPQ (Jeffries & Rizzolo, 2006) is a 16-item questionnaire (Appendix 2) designed to assesses the perceived importance and value of the simulation experience. This instrument focuses on: Active learning: hands-on practice and engagement Collaboration: opportunities for teamwork and communication Diverse ways of learning: accommodation of different learning styles High expectations: challenges that motivate students during simulation By combining the SDS and EPQ, this study will fain valuable insights into the strengths and areas for improvement within the simulation design and educational practices, ultimately informing enhancements to optimize learning outcomes. Objective 3: Evaluate Students' Non-Technical Skills This objective focuses on assessing nursing students’ non-technical skills, especially on situational awareness. Situational awareness is defined as the ability to perceive, comprehend, and anticipate events in complex, dynamic clinical situations (Hogan et al. 2006). It encompasses three levels: Perception: Recognizing elements in the environment Comprehension: understanding the significant of these elements Projection: Anticipating future status based on current information Situational awareness is crucial in nursing practice as it support effective teamwork and communication, ultimately improving clinical outcomes (Fore & Sculli, 2013; Gabr, 2019; Singh et al., 2006). Simulation provides a controlled environment where students can nurture theses skills through realistic clinical scenarios. Such training enhances their ability to assessment evolving situation, communicates effectively, and collaborate with team members, preparing them for real-world clinical challenges. To measure situational awareness among participants, this study employed the Mission Awareness Rating Scale (MARS) developed by Matthews and Beal (2002). MARS (Appendix 3) is a subjective self-assessment tool that measures situational awareness via two subscales: the Content Subscale and the Workload Subscale. Each subscale contains four questions reflecting the three levels of situational awareness: identification, comprehension, and prediction – rated on a four-point Likert scale. This straightforward and easily administered tool yields nuanced insights into nursing students’ situational awareness capabilities during simulation training. Objective 4: Evaluate Students’ Competency The fourth objective of the pilot study is to evaluate students’ competency, encompassing their clinical performance and skills during the training sessions. Competency was measured using a checklist (Appendix 4), adopted to from local hospital and reviewed by the research team. The checklist was aligned with established guidelines for learning objectives, such as the American Heart Association’s guidelines for CPR training. Competency assessments were conducted by qualified simulation facilitator, who rated each team’s performance according to the checklist criteria. To ensure consistency and inter-rater reliability, facilitators participated in a briefing session prior to assessment to calibrate evaluation standards. Particular emphasis was placed on critical tasks, including the timing of CPR interventions, as prompt responses are essential to improving patient survival outcomes. Results In early March 2023, a total of 272 undergraduate nursing students participated in the simulation training. The participants were divided into groups of four, resulting in a total of 81 groups. Sixty-six students (24.27%) reported having prior clinical experience in resuscitation. Of these, 30 students (11.03%) had served as observers, 21 students (7.72%) had acted as compressors, 9 students (3.31%) had provided rescue breaths to patients, and the remaining 6 students (2.21%) had taken on assisting roles prior to the simulation training. In addition to their clinical placements in the curriculum, 267 students (98.16%) worked as part-time student nurses in various specialties. The students’ demographic background is summarized in Table 1. Table 1. Participants’ Demographic Data N(%) Sex Female Male Not disclose 214 55 3 (78.68) (20.22) (1.10) Age Median: 22 (Min: 18; Max: 28) Part-time work as a Nursing Student (extra clinical exposure out of curriculum) Yes No 267 5 (98.16) (1.84) Specialty of Part-time Nursing Student Med Surg Rehab O&T AED Oncology O&G Community Neurosurgery Mixed Specialty Others 124 47 35 18 8 7 7 6 5 4 6 (45.59) (17.28) (12.87) (6.62) (2.94) (2.57) (2.57) (2.21) (1.84) (1.47) 2.21) Resuscitation Experience Yes No 66 207 (24.27) (75.83) Role of Previous Resuscitation Observer Compressor Rescue Breath Assistant 30 21 9 6 (11.03) (7.72) (3.31) (2.21) Evaluate Acceptability and Usability of the Simulation Design The assessment of the Simulation Design Scale (SDS) revealed valuable insights into participants’ perceptions various elements of the simulation design. Overall, participants express a generally positive view of both effectiveness and importance of the simulation design features. For the Objective and Information category, the mean score for the presence of this design element was 4.03 (SD=0.66), with its importance was rated slightly lower at 3.98 (SD=0.58). This suggests that while participants considered the learning objective clear, they perceived their importance as marginally less significant. The Support category attained a mean presence score of 4.10 (SD=0.63), compared to an importance score of 4.01 (SD=0.59), indicating strong recognition of the resources and assistance provided during simulation. The Problem-Solving element was rated highest in terms of design effectiveness, with a mean of 4.16 (SD=0.47) and received a significant importance rating of 4.03 (SD=0.47), underlining its critical role in facilitating critical thinking during the simulation. Feedback received particularly high scores for design effectiveness and importance, with means of 4.28 (SD=0.61) and 4.11 (SD=0.57) respectively, highlighting the participants' appreciation for timely and constructive feedback. The Fidelity category, which evaluates the realism of simulation environment and scenarios was also highly rated, with a mean effectiveness score of 4.19 (SD=0.62) and an importance rating of 4.10 (SD=0.58). Overall, the total mean score for the presence of simulation design elements was 4.14 (SD=0.55), with participants rating the overall importance of these elements at 4.04 (SD=0.54). These outcomes reflect a positive perception of the simulation design and its relevance to the learning experience (Table 2). Table2. Simulation Design Scale (SDS) Results Categories Assessing Simulation Design Element Mean (SD) Important Mean (SD) Objective and Information 4.03 (.66) 3.98 (.58) Support 4.10 (.63) 4.01 (.59) Problem Solving 4.16 (.47) 4.03 (.47) Feedback 4.28 (.61) 4.11 (.57) Fidelity 4.19 (.62) 4.10 (.58) Total 4.14 (.55) 4.04 (.54) Evaluate Acceptability and Usability of the Simulation Design The evaluation of the Educational Practice Questionnaire (EPQ) highlighted the perceived effectiveness and importance of key educational practices embedded in the simulation design. Participants rated the Active Learning component with a mean effectiveness score of 4.24 (SD=0.51) and an importance score of 4.10 (SD=0.50), indicating substantial appreciation for the active learning opportunities provided during simulations. The Collaboration category similarly received high ratings, with an effectiveness mean of 4.27 (SD=0.56) and an importance mean of 4.12 (SD=0.53), underscoring participants’ recognition of teamwork as a vital aspect of the learning experience. For the Diverse Ways of Learning category, participants reported an effectiveness score of 4.24 (SD=0.59) and rated its importance at 4.11 (SD=0.56), reflecting acknowledgment of the simulation’s ability to accommodate multiple learning styles. The High Expectation component, which reflects the challenging elements of the simulation, was also rated positively with an effectiveness mean of 4.22 (SD=0.60) and an importance mean of 4.12 (SD=0.63), demonstrating that participants valued the program’s ability to push their learning boundaries. Overall, the total mean score for assessing the effectiveness of educational practices was 4.24 (SD=0.51), with the total importance mean was 4.11 (SD=0.51). These findings emphasize that the participants recognized and valued the educational features that enhanced their learning within the simulation environment (Table 3). Table 3. Educational Practice Questionnaire (EPQ) Results Categories Assessing Simulation Design Element Mean (SD) Important Mean (SD) Active Learning 4.24 (.51) 4.10 (.50) Collaboration 4.27 (.56) 4.12 (.53) Diverse Way of Learning 4.24 (.59) 4.11 (.56) High Expectation 4.22 (.60) 4.12 (.63) Total 4.24 (.51) 4.11 (.51) Evaluate Students' Non-Technical Skills The Mission Awareness Rating Scale (MARS) was used to assess participants’’ situational awareness before and after the simulation training. The assessment employed a one-sample T-test (2-tailed) to compare pre- and post-intervention scores. The results for the Content subscale revealed a pre-intervention mean score of 2.58 (95% CI: 2.53, 2.64) and a post-intervention mean score of 2.29 (95% CI: 2.22, 2.35). This decline indicates a reduction in participants’ subjective difficulty in understanding situational content after training. Similarly, for the Workload subscale, the pre-intervention mean was 2.59 (95% CI: 2.53, 2.65), while the post-intervention mean dropped to 2.35 (95% CI: 2.28, 2.41), which suggests a significant reduction in the perceived mental workload after the simulation. These statistically significant reductions in both subscales suggest that the simulation training effectively enhanced students’ situational awareness, enabling them to manage situational content more intuitively and with less cognitive effort during clinical simulations. (Table 4) Table 4. Pre and Post Simulation Mission Awareness Rating Scale (MARS) Results Pre – MARS Mean (95% CI) Post – MARS Mean (95% CI) P-value* Content 2.58 (2.53, 2.64) 2.29 (2.22, 2.35) <0.01 Workload 2.59 (2.53, 2.65) 2.35 (2.28, 2.41) <0.01 *Remarks: One-sample T-test (2-tailed) Correlation Analysis Between MARS, SDS, and EPQ Correlation analysis was conducted to investigate the relationships between participants' situational awareness, as measured by the Mission Awareness Rating Scale (MARS), perceptions of the simulation design using the Simulation Design Scale (SDS), and evaluations of educational practices via the Educational Practice Questionnaire (EPQ). The findings demonstrated significant negative correlations between post-intervention MARS scores and both SDS and EPQ totals. Specifically, the post-MARS score correlated negatively with the SDS Total Assessing Simulation Design Element (r = -0.26, p < 0.01) and SDS Total Importance (r = -0.33, p < 0.01), suggesting that better perceptions of simulation design are associated with reduced cognitive load after training. Similarly, the EPQ Total Assessing Simulation Design Element showed a negative correlation of -0.18 (p < 0.01) with post-MARS scores, while EPQ Total Importance had a stronger negative correlation of -0.32 (p < 0.01), indicating that higher valuation of educational practices corresponds to decreased mental effort during situational awareness. Additionally, the changes between pre- and post-MARS scores were significantly correlated with perceptions of simulation design: SDS Total Assessing Simulation Design Element (r = -0.16, p < 0.05) and SDS Total Importance (r = -0.21, p < 0.01) showed significant associations with MARS changes. For EPQ, the Total Assessing Simulation Design Element correlated with pre- and post-MARS at -0.13 (p < 0.05), and EPQ Total Importance correlated at -0.17 (p < 0.01). Collectively, these results indicate that higher effectiveness and importance ratings for both simulation design and educational practices are linked to lower mental workload related to situational awareness, highlighting that well-structured simulation education can optimize cognitive efficiency and improve training outcomes for nursing students. Evaluate Students’ Competency The checklist assessing critical actions during cardiopulmonary arrest simulations revealed varied performance across essential tasks (Table 5). Patient Assessment Majority of participants (76.54%) successfully checked for patient response, indicating awareness of this vital first step. However, only 41.98% checked for breathing, highlighting a significant area for improvement in respiratory assessment. Checking the carotid pulse was adhered to by 75.31%, and 80.25% called for help, demonstrating understanding of emergency procedures. Alarmingly, only 18.52% noted the time of cardiopulmonary arrest, suggesting gaps in temporal awareness important for resuscitation monitoring. Chest Compression Most participants positioned themselves correctly beside the patient's chest wall (90.12%), but only 66.67% initiated compressions without prompting. Correct compression site was identified by 88.89%, and the two-head technique was performed by 96.30%, showing good technical knowledge. Compression depth (58.02%) and rate (69.14%) were less consistently achieved, indicating needs for further training. Complete chest recoil was allowed by 80.25%, chest board placement by 71.60%, and the compression-to-ventilation ratio (30:2) was maintained by 87.65%. Automated External Defibrillation (AED) A strong majority (91.36%) effectively operated the AED, with proper pad placement by 85.19%. However, only 71.60% correctly pressed the “Analyze” button and ensured no contact with the patient, alongside similar percentages vocalizing “clear,” underlining the need for improved procedural and communication skills. The “Shock” button was pressed correctly by 96.30%, and CPR was resumed promptly without pulse check by 98.77%. Overall, AED voice prompt adherence was high (90.12%). Airway and Ventilation Most students maintained a proper patient positioning by removed the pillow appropriately (88.89%), but only 17.28% performed suctioning and 18.52% inserted an oropharyngeal airway (OPA), signaling major skill gaps. The bag-valve mask (BVM) was used correctly by all participants, with 82.72% applying a filter for infection prevention. Effective oxygen delivery (>15L reservoir flow) and two-handed seal without leakage were achieved by only 61.73%. Rescue breaths were administered properly by 81.48%, but only 30.86% checked for visible chest rise, crucial for confirming ventilation efficacy. Infection Control and Confederate Errors Appropriate personal protective equipment (PPE) was worn by 76.54%, but 33 instances of incomplete PPE were noted, with only 5 corrections made (15.15%). The failure to use two-handed seal during BVM ventilation occurred 33 times with only one correction (3.03%). In contrast, timely inflation of the endotracheal tube (ETT) balloon had a correction rate of 53.33%. These findings highlight critical areas for enhanced training in adherence to infection control protocols and ventilation techniques. Strength and Limitation This project was initially piloted within the Hospital Authority among registered nurses working in the infectious disease center. The scenario effectively integrated emergency resuscitation skills with comprehensive nursing care focusing on infection control. The robust methodology allowed for testing frontline nurses’ responses to interactions with confederate doctors, yielding encouraging results despite the small pilot sample size. Following the pilot, the project was disseminated corporately and selected for collaboration with a local university to train undergraduate nursing students. To meet undergraduate nursing competency requirements, the project was adapted to include more detailed checklist steps and group sizes of four students. However, managing large cohorts with multiple confederate doctors introduced administrative complexity. The dropout rate remained low, and participants showed appreciation for the training program, contributing extensive qualitative feedback via online evaluations. Nevertheless, many reported physical and mental exhaustion following the training, and the effectiveness of the online evaluation platform was questioned. Future qualitative research is recommended to explore participant experiences in depth and optimize feedback mechanisms. Analytically, simple T-tests were employed to assess pre- and post-test differences, revealing statistical significance in outcomes. The upcoming study will apply paired T-tests for more rigorous analysis. Conclusion This study pioneered an integrated cardiopulmonary resuscitation and infection control simulation training program for undergraduate nursing students in Hong Kong, embedding experiential learning principles within the curriculum. Participants demonstrated high acceptability of the simulation design and educational practices, alongside significant improvements in self-reported situational awareness, as evidenced by reduced perceived difficulty and mental workload on the Mission Awareness Rating Scale. Competency assessments identified strengths in core resuscitation actions such as AED use and team coordination, but also revealed persistent gaps in initial patient assessment, airway management, compression quality, and infection control error correction. These findings affirm the value of simulation as an experiential learning strategy that effectively links technical proficiency, non-technical skills, and infection prevention behaviors essential for safe clinical practice. The positive correlations between simulation design perceptions and cognitive outcomes further support refining such program to optimize student readiness for high-stakes, complex emergencies. Future research should incorporate paired statistical analyses, qualitative exploration of participant experiences, and longitudinal follow-up to evaluate sustained competency gains and curriculum integration. Declarations Ethics approval and consent to participate This study was approved by the Research Ethics Committee of Hong Kong Metropolitan University, School of Nursing and Health Sciences ( REC Reference No: HE-SF2024/03 ). All participants received written information about the study and provided informed consent prior to participation. Participation was voluntary, and students were assured that their decision to participate or withdraw would not affect their academic standing. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to institutional policies and participant confidentiality but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding ☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. ☒ The authors declare that they have no known financial interests/personal relationships which may be considered as potential competing interests. Authors’ contributions Tomas CHAN: Conceptualization; Methodology; Investigation; Formal analysis; Data curation; Writing – Original Draft; Visualization Natalie LEE: Project administration; Resources Janet WONG: Supervision; Funding acquisition; Review & Editing Corresponding Author Tomas CHAN Hiu Yeung, MPH, BNurs, RN Advanced Practice Nurse Central Nursing Department, Tung Wah Hospital, Hospital Authority, Hong Kong, China. Email: [email protected] / [email protected] Co-author Natalie LEE Po Man, DHSc (Nursing), MSc (Nursing), BSN, RN, FRSPH Assistant Professor Department of Nursing, Hong Kong Metropolitan University, Hong Kong, China. Email: [email protected] Supervisor Janet WONG Yuen Ha, PhD MNurs, BNurs, RN, APN, FHKCHSE, FCHSM, FAAN Dean and Professor School of Nursing and Health Sciences, Hong Kong Metropolitan University, Hong Kong, China. Email: [email protected] Acknowledgements The authors would like to thank the nursing students who participated in this study, the simulation facilitators, and the Hospital Authority colleagues who supported scenario development. The authors also acknowledge the administrative support and logistical arrangements provided by the School of Nursing and Health Sciences, Hong Kong Metropolitan University. References Bordelon CJ, Dudding K. Simulation: Building Skills and Improving Outcomes. Neonatal Netw. 2020;39(5):255–6. https://doi.org/10.1891/0730-0832.39.5.255 . Darawad MW, AI-Hussami M. Jordanian nursing students’ knowledge of, attitudes towards, and compliance with infection control precautions. 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Exploring the role of simulation to foster interprofessional teamwork among medical and nursing students: A mixed-method pilot investigation in Hong Kong. J Interprof Care. 2021;35(6):890–8. https://doi.org/10.1080/13561820.2020.1831451 . CINAHL Complete. Additional Declarations No competing interests reported. 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Chan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyElEQVRIiWNgGAWjYDACCQaGgx8MbBKg3AMGxGhhfCxRkEaaFmYDng+HSdDCP7vHTELC4HwefwPzsY9fGO4YE7bkzhkziQKD28USB9iSZ8swPDMjqMVAIgdky+3EhgM8xswSDIdtiNPCY3AucT4pWowNeAwOJG4AamH8wHCYsMMkbqQVPpYwSE7ceJgtmZnB4DBh7/PPSN5w8MMfu8R5x5sPM/6oOGzYQFAPAwc0JpiBiIeIiAQC9gdwJuMPonSMglEwCkbBSAMA8Vc8fJ3mX1wAAAAASUVORK5CYII=","orcid":"","institution":"Hospital Authority","correspondingAuthor":true,"prefix":"","firstName":"Tomas","middleName":"H.Y.","lastName":"Chan","suffix":""},{"id":588272234,"identity":"c586b724-9104-4733-8f7f-6c2f28b2b583","order_by":1,"name":"Natalie P.M. Lee","email":"","orcid":"","institution":"Hong Kong Metropolitan University","correspondingAuthor":false,"prefix":"","firstName":"Natalie","middleName":"P.M.","lastName":"Lee","suffix":""},{"id":588272235,"identity":"370ae45d-c9da-4efc-97a3-cb6b6092dd4a","order_by":2,"name":"Janet Y.H. Wong","email":"","orcid":"","institution":"Hong Kong Metropolitan University","correspondingAuthor":false,"prefix":"","firstName":"Janet","middleName":"Y.H.","lastName":"Wong","suffix":""}],"badges":[],"createdAt":"2026-01-23 03:38:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8674602/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8674602/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102353420,"identity":"1d9bb7f6-3e3a-4458-92f5-336e818944e7","added_by":"auto","created_at":"2026-02-10 19:52:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1220210,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8674602/v1/9d65df3d-b0ad-4eba-b659-938b5219b454.pdf"},{"id":102353419,"identity":"1eaaf3f8-5acb-477e-9c96-0dec381b6cab","added_by":"auto","created_at":"2026-02-10 19:52:54","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":42569,"visible":true,"origin":"","legend":"","description":"","filename":"Appendices.docx","url":"https://assets-eu.researchsquare.com/files/rs-8674602/v1/f9e13e6edb7accd7a87c344b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Develop and Evaluate of an Infection Control Simulation Training in Nursing Students","fulltext":[{"header":"Background","content":"\u003cp\u003eContemporary nurse education increasingly emphasizes experiential and practice‑based learning to prepare students for the complexity, uncertainty, and time pressure of real clinical environments (Bordelon and Dudding, 2020; Koukourikos et al., 2021). Simulation has become a central strategy within this paradigm because it offers structured, authentic experiences in which students can integrate theoretical knowledge, psychomotor skills, and non‑technical competencies such as communication, teamwork, and situational awareness in a safe and supportive setting (Koukourikos et al., 2021; Wai et al., 2021). Through repeated, guided exposure to realistic scenarios and debriefing, experiential learning in simulation can foster clinical judgement, confidence, and readiness for practice without compromising patient safety (Wai et al., 2021; Bordelon and Dudding, 2020).\u003c/p\u003e\n\u003cp\u003eAt the same time, patient safety agendas worldwide highlight two persistent educational priorities: effective response to clinical emergencies and consistent adherence to infection prevention and control (IPC) practices. Cardiorespiratory arrest is a high‑stakes, low‑frequency event for undergraduate students, yet it demands rapid assessment, technically competent cardiopulmonary resuscitation (CPR), and coordinated team performance (Onan et al., 2017; Wai et al., 2021). In parallel, nursing students must learn to apply standard and transmission‑based precautions, use personal protective equipment correctly, and manage airways safely to minimize the risk of healthcare‑associated infections for both patients and staff (Darawad and Al-Hussami, 2013; Labrague et al., 2018; Van De Mortel et al., 2012; Kim and Park, 2021). Although these domains are often taught separately in curricula, nurses in practice must simultaneously manage resuscitation procedures and infection control requirements, particularly in isolation settings and during outbreaks (Foong et al., 2020; Sowan et al., 2022).\u003c/p\u003e\n\u003cp\u003eSimulation‑based education provides an opportunity to bring these strands together within a single experiential learning activity. Integrating CPR with infection control procedures in high‑fidelity scenarios allows students to rehearse complex responses that combine technical skills, non‑technical skills, and IPC behaviors under realistic time pressure (Onan et al., 2017; Sowan et al., 2022). Such designs are also well suited to exploring cognitive aspects of performance, including situational awareness and mental workload, which are known to influence decision‑making and team effectiveness in deteriorating patient and emergency situations (Wai et al., 2021; Sowan et al., 2022). However, there is still limited quantitative evidence on how integrated resuscitation\u0026ndash;infection‑control simulations affect undergraduate nursing students\u0026rsquo; situational awareness, their perceptions of simulation design and educational practices, and their observable competence in infection‑sensitive CPR performance (Onan et al., 2017; Sowan et al., 2022).\u003c/p\u003e\n\u003cp\u003eThis study responds to these needs by developing and evaluating an infection‑control CPR simulation training program for undergraduate nursing students in Hong Kong. By linking perceptions of design, educational practices, situational awareness, and performance outcomes, this work seeks to inform the design of experiential learning strategies that better prepare nursing students for complex, high‑risk clinical situations.\u003c/p\u003e"},{"header":"Objectives","content":"\u003cp\u003eIn the current literature, there is a notable lack of studies focusing on infection control CPR simulation training for nursing students. This study aims to address this gap by investigating the effectiveness of tailored infection control CPR training program for nursing students in Hong Kong.\u003c/p\u003e\n\u003cp\u003eThe objectives of the proposed study are as follows:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003e\u003cstrong\u003eTo Develop an Infection Control Simulation Training Program\u003c/strong\u003e: Design a tailored simulation training program integrating infection control protocols within CPR scenarios for nursing students.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eTo Evaluate Acceptability and Usability of the Simulation Design\u003c/strong\u003e: Assess the overall acceptability and usability of the simulation training from the perspective of both students and educators.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eTo Evaluate Non-Technical Skills\u003c/strong\u003e: Examine students\u0026apos; non-technical skills, such as situational awareness, during the training to understand their ability to respond effectively in real-life situations.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eTo Evaluate Student Competency\u003c/strong\u003e: Measure the competency of nursing students in applying infection control measures, and performing CPR effectively, assessing both knowledge and practical skills.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThis project is conducted in collaboration with the Hospital Authority, ensuring that the training aligns with current healthcare standards and practices and clinical practice requirements.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective 1: Develop an Infection Control Simulation Training Program\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design and Procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study employed an interventional design embedded within the curriculum for nursing students at Hong Kong Metropolitan University, School of Nursing and Health Sciences. Participants were recruited directly from the course\u0026nbsp;NURS N412F Integrated Nursing (General Health Care), targeting final-year general nursing students.\u003c/p\u003e\n\u003cp\u003eOn the training date, participants received an information sheet detailing the study\u0026apos;s purpose, procedures, and potential risks. Informed consent was obtained before commencing the training. A briefing session-oriented participants to the training environment and objectives, ensuring clear expectations.\u003c/p\u003e\n\u003cp\u003eThe training content was specifically designed for this study, with participants informed about the nature of the scenarios. Consent was obtained to ensure psychological safety, emphasizing that the activities are simulated and designed to avoid harm. Following the training, a debriefing session facilitated reflection on experiences and reflections and assessed psychological stress, ensuring participant well-being. This structured approach aims to establish a supportive and safe learning environment while effectively evaluating the impact of infection control CPR simulation training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eScenario in Simulation Training\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe scenario involves a 65-year-old male patient with a history of diabetes mellitus, hypertension, and acute coronary syndrome, who had undergone percutaneous coronary intervention. He was admitted during the afternoon shift with symptoms of fever, cough, and palpitations, following recent travel to China, his oxygen saturation (SpO2) was initially 92%, improving to 95% with supplemental oxygen at 4 liters via nasal cannula. The patient was admitted to an isolation ward.\u003c/p\u003e\n\u003cp\u003eDuring the night shift, the cardiac monitor indicated ventricular tachycardia, prompting the participants to intervene. A confederate doctor intentionally performed improper practices, including incomplete personal protective equipment (PPE) use, failure to apply a two-hand technique during bag-valve mask ventilation, and neglecting to inflate the balloon of the endotracheal tube. Participants were tasked with identifying these errors, proposing corrected actions, and estimating the time required for each correction. The scenario aimed to heighten students\u0026rsquo; awareness and enhance their responsiveness to critical infection control and emergency care situations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLearning Objectives for the Simulation Training\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003e\u003cstrong\u003eRecognize Pulseless Ventricular Tachycardia\u003c/strong\u003e: Identify the signs of pulseless ventricular tachycardia and apply the American Heart Association (AHA) algorithm for appropriate patient management.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAdminister Manual Ventilation and Compression Safely\u003c/strong\u003e: Perform manual ventilation and chest compressions effectively and safely.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eImplement Infection Control Measures\u003c/strong\u003e: Apply effective infection control measures diligently during patient management to ensure safety for both patient and healthcare providers.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eDemonstrate Effective Communication and Teamwork\u003c/strong\u003e: Exhibit clear communication and teamwork to facilitate optimal patient care during emergencies.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe study was conducted over three days in early March 2024. Session began with a 30-minute pre-simulation workshop, including refresher on basic life support (BLS) and airway management. A 10-minute briefing on the scenario background and environment orientation followed, familiarizing participants with the manikin, emergency trolley, patient monitor, and electronic patient bed. The simulation lasted 20 minutes and was followed by a 30-minutes debriefing led by a qualified facilitator. A total of 239 final-year nursing students successfully completed all assessments. The facilitator-to-student ratio was maintained at 1:4 to ensure adequate support throughout the training.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective 2: Evaluate Acceptability and Usability of the Simulation Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe second objective is to evaluate the acceptability and usability of the simulation design. Two validated instruments will be employed to achieve this: the Simulation Design Scale (SDS) and the Educational Practice Questionnaire (EPQ).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe SDS (Jeffries, 2005) is a 20-item questionnaire (Appendix 1) that uses a 5-point Likert scale to assess participants\u0026apos; perceptions of the simulation\u0026apos;s effectiveness, realism, and overall design quality. It evaluates five categories:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eObjective/information: clarity and presentation of learning objectives and relevant information\u003c/li\u003e\n \u003cli\u003eSupport: availability of resources and assistance during simulation\u003c/li\u003e\n \u003cli\u003eProblem-solving: opportunities for critical thinking and decision making\u003c/li\u003e\n \u003cli\u003eFeedback: quality and timeliness of feedback and guided reflection\u003c/li\u003e\n \u003cli\u003eFidelity: realism of the simulation environment and scenarios\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eEach category directly corresponds to specific design features, providing a comprehensive assessment of students\u0026apos; experience and preferences for effective learning.\u003c/p\u003e\n\u003cp\u003eThe EPQ (Jeffries \u0026amp; Rizzolo, 2006) is a 16-item questionnaire (Appendix 2) designed to assesses the perceived importance and value of the simulation experience. This instrument focuses on:\u003c/p\u003e\n\u003cp\u003eActive learning: hands-on practice and engagement\u003c/p\u003e\n\u003cp\u003eCollaboration: opportunities for teamwork and communication\u003c/p\u003e\n\u003cp\u003eDiverse ways of learning: accommodation of different learning styles\u003c/p\u003e\n\u003cp\u003eHigh expectations: challenges that motivate students during simulation\u003c/p\u003e\n\u003cp\u003eBy combining the SDS and EPQ, this study will fain valuable insights into the strengths and areas for improvement within the simulation design and educational practices, ultimately informing enhancements to optimize learning outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective 3: Evaluate Students\u0026apos; Non-Technical Skills\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis objective focuses on assessing nursing students\u0026rsquo; non-technical skills, especially on situational awareness. Situational awareness is defined as the ability to perceive, comprehend, and anticipate events in complex, dynamic clinical situations (Hogan et al. 2006). It encompasses three levels:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003ePerception: Recognizing elements in the environment\u003c/li\u003e\n \u003cli\u003eComprehension: understanding the significant of these elements\u003c/li\u003e\n \u003cli\u003eProjection: Anticipating future status based on current information\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eSituational awareness is crucial in nursing practice as it support effective teamwork and communication, ultimately improving clinical outcomes (Fore \u0026amp; Sculli, 2013; Gabr, 2019; Singh et al., 2006). Simulation provides a controlled environment where students can nurture theses skills through realistic clinical scenarios. Such training enhances their ability to assessment evolving situation, communicates effectively, and collaborate with team members, preparing them for real-world clinical challenges. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo measure situational awareness among participants, this study employed the Mission Awareness Rating Scale (MARS) developed by Matthews and Beal (2002). MARS (Appendix 3) is a subjective self-assessment tool that measures situational awareness via two subscales: the Content Subscale and the Workload Subscale. Each subscale contains four questions reflecting the three levels of situational awareness: identification, comprehension, and prediction \u0026ndash; rated on a four-point Likert scale. This straightforward and easily administered tool yields nuanced insights into nursing students\u0026rsquo; situational awareness capabilities during simulation training.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective 4: Evaluate Students\u0026rsquo; Competency\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe fourth objective of the pilot study is to evaluate students\u0026rsquo; competency, encompassing their clinical performance and skills during the training sessions. Competency was measured using a checklist (Appendix 4), adopted to from local hospital and reviewed by the research team. \u0026nbsp;The checklist was aligned with established guidelines for learning objectives, such as the American Heart Association\u0026rsquo;s guidelines for CPR training.\u003c/p\u003e\n\u003cp\u003eCompetency assessments were conducted by qualified simulation facilitator, who rated each team\u0026rsquo;s performance according to the checklist criteria. To ensure consistency and inter-rater reliability, facilitators participated in a briefing session prior to assessment to calibrate evaluation standards. Particular emphasis was placed on critical tasks, including the timing of CPR interventions, as prompt responses are essential to improving patient survival outcomes.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn early March 2023, a total of 272 undergraduate nursing students participated in the simulation training. The participants were divided into groups of four, resulting in a total of 81 groups. Sixty-six students (24.27%) reported having prior clinical experience in resuscitation. Of these, 30 students (11.03%) had served as observers, 21 students (7.72%) had acted as compressors, 9 students (3.31%) had provided rescue breaths to patients, and the remaining 6 students (2.21%) had taken on assisting roles prior to the simulation training. In addition to their clinical placements in the curriculum, 267 students (98.16%) worked as part-time student nurses in various specialties. The students’ demographic background is summarized in Table 1.\u003c/p\u003e\n\u003cp\u003eTable 1. Participants’ Demographic Data\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eN(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eNot disclose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e214\u003c/p\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(78.68)\u003c/p\u003e\n \u003cp\u003e(20.22)\u003c/p\u003e\n \u003cp\u003e(1.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003eMedian: 22\u003c/p\u003e\n \u003cp\u003e(Min: 18; Max: 28)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePart-time work as a Nursing Student\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(extra clinical exposure out of curriculum)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e267\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(98.16)\u003c/p\u003e\n \u003cp\u003e(1.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSpecialty of Part-time Nursing Student\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMed\u003c/p\u003e\n \u003cp\u003eSurg\u003c/p\u003e\n \u003cp\u003eRehab\u003c/p\u003e\n \u003cp\u003eO\u0026amp;T\u003c/p\u003e\n \u003cp\u003eAED\u003c/p\u003e\n \u003cp\u003eOncology\u003c/p\u003e\n \u003cp\u003eO\u0026amp;G\u003c/p\u003e\n \u003cp\u003eCommunity\u003c/p\u003e\n \u003cp\u003eNeurosurgery\u003c/p\u003e\n \u003cp\u003eMixed Specialty\u003c/p\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e124\u003c/p\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(45.59)\u003c/p\u003e\n \u003cp\u003e(17.28)\u003c/p\u003e\n \u003cp\u003e(12.87)\u003c/p\u003e\n \u003cp\u003e(6.62)\u003c/p\u003e\n \u003cp\u003e(2.94)\u003c/p\u003e\n \u003cp\u003e(2.57)\u003c/p\u003e\n \u003cp\u003e(2.57)\u003c/p\u003e\n \u003cp\u003e(2.21)\u003c/p\u003e\n \u003cp\u003e(1.84)\u003c/p\u003e\n \u003cp\u003e(1.47)\u003c/p\u003e\n \u003cp\u003e2.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eResuscitation Experience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003cp\u003e207\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(24.27)\u003c/p\u003e\n \u003cp\u003e(75.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRole of Previous Resuscitation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eObserver\u003c/p\u003e\n \u003cp\u003eCompressor\u003c/p\u003e\n \u003cp\u003eRescue Breath\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAssistant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(11.03)\u003c/p\u003e\n \u003cp\u003e(7.72)\u003c/p\u003e\n \u003cp\u003e(3.31)\u003c/p\u003e\n \u003cp\u003e(2.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eEvaluate Acceptability and Usability of the Simulation Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe assessment of the Simulation Design Scale (SDS) revealed valuable insights into participants’ perceptions various elements of the simulation design. Overall, participants express a generally positive view of both effectiveness and importance of the simulation design features.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the \u003cstrong\u003eObjective and Information\u003c/strong\u003e category, the mean score for the presence of this design element was 4.03 (SD=0.66), with its importance was rated slightly lower at 3.98 (SD=0.58). This suggests that while participants considered the learning objective clear, they perceived their importance as marginally less significant.\u003c/p\u003e\n\u003cp\u003eThe \u003cstrong\u003eSupport\u0026nbsp;\u003c/strong\u003ecategory attained a mean presence score of 4.10 (SD=0.63), compared to an importance score of 4.01 (SD=0.59), indicating strong recognition of the resources and assistance provided during simulation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe \u003cstrong\u003eProblem-Solving\u003c/strong\u003e element was rated highest in terms of design effectiveness, with a mean of 4.16 (SD=0.47) and received a significant importance rating of 4.03 (SD=0.47), underlining its critical role in facilitating critical thinking during the simulation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFeedback\u003c/strong\u003e received particularly high scores for design effectiveness and importance, with means of 4.28 (SD=0.61) and 4.11 (SD=0.57) respectively, highlighting the participants' appreciation for timely and constructive feedback.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe \u003cstrong\u003eFidelity\u0026nbsp;\u003c/strong\u003ecategory, which evaluates the realism of simulation environment and scenarios was also highly rated, with a mean effectiveness score of 4.19 (SD=0.62) and an importance rating of 4.10 (SD=0.58).\u003c/p\u003e\n\u003cp\u003eOverall, the total mean score for the presence of simulation design elements was 4.14 (SD=0.55), with participants rating the overall importance of these elements at 4.04 (SD=0.54). These outcomes reflect a positive perception of the simulation design and its relevance to the learning experience (Table 2).\u003c/p\u003e\n\u003cp\u003eTable2. \u003cstrong\u003eSimulation Design Scale (SDS) Results\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCategories\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAssessing Simulation Design Element\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eImportant\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eObjective and Information\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.03 (.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.98 (.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSupport\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.10 (.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.01 (.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eProblem Solving\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.16 (.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.03 (.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFeedback\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.28 (.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.11 (.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFidelity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.19 (.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.10 (.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.14 (.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.04 (.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eEvaluate Acceptability and Usability of the Simulation Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe evaluation of the Educational Practice Questionnaire (EPQ) highlighted the perceived effectiveness and importance of key educational practices embedded in the simulation design. Participants rated the \u003cstrong\u003eActive Learning\u003c/strong\u003e component with a mean effectiveness score of 4.24 (SD=0.51) and an importance score of 4.10 (SD=0.50), indicating substantial appreciation for the active learning opportunities provided during simulations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe \u003cstrong\u003eCollaboration\u003c/strong\u003e category similarly received high ratings, with an effectiveness mean of 4.27 (SD=0.56) and an importance mean of 4.12 (SD=0.53), underscoring participants’ recognition of teamwork as a vital aspect of the learning experience. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the \u003cstrong\u003eDiverse Ways of Learning\u003c/strong\u003e category, participants reported an effectiveness score of 4.24 (SD=0.59) and rated its importance at 4.11 (SD=0.56), reflecting acknowledgment of the simulation’s ability to accommodate multiple learning styles.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe \u003cstrong\u003eHigh Expectation\u003c/strong\u003e component, which reflects the challenging elements of the simulation, was also rated positively with an effectiveness mean of 4.22 (SD=0.60) and an importance mean of 4.12 (SD=0.63), demonstrating that participants valued the program’s ability to push their learning boundaries.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOverall, the total mean score for assessing the effectiveness of educational practices was 4.24 (SD=0.51), with the total importance mean was 4.11 (SD=0.51). These findings emphasize that the participants recognized and valued the educational features that enhanced their learning within the simulation environment (Table 3).\u003c/p\u003e\n\u003cp\u003eTable 3.\u0026nbsp;\u003cstrong\u003eEducational Practice Questionnaire (EPQ) Results\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCategories\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAssessing Simulation Design Element\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eImportant\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eActive Learning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.24 (.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.10 (.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCollaboration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.27 (.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.12 (.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDiverse Way of Learning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.24 (.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.11 (.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHigh Expectation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.22 (.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.12 (.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.24 (.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.11 (.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eEvaluate Students' Non-Technical Skills\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Mission Awareness Rating Scale (MARS) was used to assess participants’’ situational awareness before and after the simulation training. The assessment employed a one-sample T-test (2-tailed) to compare pre- and post-intervention scores.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe results for the \u003cstrong\u003eContent\u003c/strong\u003e subscale revealed a pre-intervention mean score of 2.58 (95% CI: 2.53, 2.64) and a post-intervention mean score of 2.29 (95% CI: 2.22, 2.35). This decline indicates a reduction in participants’ subjective difficulty in understanding situational content after training.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSimilarly, for the \u003cstrong\u003eWorkload\u003c/strong\u003e subscale, the pre-intervention mean was 2.59 (95% CI: 2.53, 2.65), while the post-intervention mean dropped to 2.35 (95% CI: 2.28, 2.41), which suggests a significant reduction in the perceived mental workload after the simulation.\u003c/p\u003e\n\u003cp\u003eThese statistically significant reductions in both subscales suggest that the simulation training effectively enhanced students’ situational awareness, enabling them to manage situational content more intuitively and with less cognitive effort during clinical simulations. (Table 4)\u003c/p\u003e\n\u003cp\u003eTable 4. Pre and Post Simulation \u003cstrong\u003eMission Awareness Rating Scale (MARS) Results\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePre – MARS Mean (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePost – MARS Mean (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eP-value*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eContent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e2.58 (2.53, 2.64)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e2.29 (2.22, 2.35)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWorkload\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.59 (2.53, 2.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.35 (2.28, 2.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Remarks: One-sample T-test (2-tailed)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorrelation Analysis Between MARS, SDS, and EPQ\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrelation analysis was conducted to investigate the relationships between participants' situational awareness, as measured by the Mission Awareness Rating Scale (MARS), perceptions of the simulation design using the Simulation Design Scale (SDS), and evaluations of educational practices via the Educational Practice Questionnaire (EPQ).\u003c/p\u003e\n\u003cp\u003eThe findings demonstrated significant negative correlations between post-intervention MARS scores and both SDS and EPQ totals. Specifically, the post-MARS score correlated negatively with the SDS Total Assessing Simulation Design Element (r = -0.26, p \u0026lt; 0.01) and SDS Total Importance (r = -0.33, p \u0026lt; 0.01), suggesting that better perceptions of simulation design are associated with reduced cognitive load after training. Similarly, the EPQ Total Assessing Simulation Design Element showed a negative correlation of -0.18 (p \u0026lt; 0.01) with post-MARS scores, while EPQ Total Importance had a stronger negative correlation of -0.32 (p \u0026lt; 0.01), indicating that higher valuation of educational practices corresponds to decreased mental effort during situational awareness.\u003c/p\u003e\n\u003cp\u003eAdditionally, the changes between pre- and post-MARS scores were significantly correlated with perceptions of simulation design: SDS Total Assessing Simulation Design Element (r = -0.16, p \u0026lt; 0.05) and SDS Total Importance (r = -0.21, p \u0026lt; 0.01) showed significant associations with MARS changes. For EPQ, the Total Assessing Simulation Design Element correlated with pre- and post-MARS at -0.13 (p \u0026lt; 0.05), and EPQ Total Importance correlated at -0.17 (p \u0026lt; 0.01).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCollectively, these results indicate that higher effectiveness and importance ratings for both simulation design and educational practices are linked to lower mental workload related to situational awareness, highlighting that well-structured simulation education can optimize cognitive efficiency and improve training outcomes for nursing students.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvaluate Students’ Competency\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe checklist assessing critical actions during cardiopulmonary arrest simulations revealed varied performance across essential tasks (Table 5).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMajority of participants (76.54%) successfully checked for patient response, indicating awareness of this vital first step. However, only 41.98% checked for breathing, highlighting a significant area for improvement in respiratory assessment. Checking the carotid pulse was adhered to by 75.31%, and 80.25% called for help, demonstrating understanding of emergency procedures. Alarmingly, only 18.52% noted the time of cardiopulmonary arrest, suggesting gaps in temporal awareness important for resuscitation monitoring.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChest Compression\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost participants positioned themselves correctly beside the patient's chest wall (90.12%), but only 66.67% initiated compressions without prompting. Correct compression site was identified by 88.89%, and the two-head technique was performed by 96.30%, showing good technical knowledge. Compression depth (58.02%) and rate (69.14%) were less consistently achieved, indicating needs for further training. Complete chest recoil was allowed by 80.25%, chest board placement by 71.60%, and the compression-to-ventilation ratio (30:2) was maintained by 87.65%.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAutomated External Defibrillation (AED)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA strong majority (91.36%) effectively operated the AED, with proper pad placement by 85.19%. However, only 71.60% correctly pressed the “Analyze” button and ensured no contact with the patient, alongside similar percentages vocalizing “clear,” underlining the need for improved procedural and communication skills. The “Shock” button was pressed correctly by 96.30%, and CPR was resumed promptly without pulse check by 98.77%. Overall, AED voice prompt adherence was high (90.12%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAirway and Ventilation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost students maintained a proper patient positioning by removed the pillow appropriately (88.89%), but only 17.28% performed suctioning and 18.52% inserted an oropharyngeal airway (OPA), signaling major skill gaps. The bag-valve mask (BVM) was used correctly by all participants, with 82.72% applying a filter for infection prevention. Effective oxygen delivery (\u0026gt;15L reservoir flow) and two-handed seal without leakage were achieved by only 61.73%. Rescue breaths were administered properly by 81.48%, but only 30.86% checked for visible chest rise, crucial for confirming ventilation efficacy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInfection Control and Confederate Errors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAppropriate personal protective equipment (PPE) was worn by 76.54%, but 33 instances of incomplete PPE were noted, with only 5 corrections made (15.15%). The failure to use two-handed seal during BVM ventilation occurred 33 times with only one correction (3.03%). In contrast, timely inflation of the endotracheal tube (ETT) balloon had a correction rate of 53.33%. These findings highlight critical areas for enhanced training in adherence to infection control protocols and ventilation techniques.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrength and Limitation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;This project was initially piloted within the Hospital Authority among registered nurses working in the infectious disease center. The scenario effectively integrated emergency resuscitation skills with comprehensive nursing care focusing on infection control. The robust methodology allowed for testing frontline nurses’ responses to interactions with confederate doctors, yielding encouraging results despite the small pilot sample size. Following the pilot, the project was disseminated corporately and selected for collaboration with a local university to train undergraduate nursing students.\u003c/p\u003e\n\u003cp\u003eTo meet undergraduate nursing competency requirements, the project was adapted to include more detailed checklist steps and group sizes of four students. However, managing large cohorts with multiple confederate doctors introduced administrative complexity. The dropout rate remained low, and participants showed appreciation for the training program, contributing extensive qualitative feedback via online evaluations. Nevertheless, many reported physical and mental exhaustion following the training, and the effectiveness of the online evaluation platform was questioned. Future qualitative research is recommended to explore participant experiences in depth and optimize feedback mechanisms.\u003c/p\u003e\n\u003cp\u003eAnalytically, simple T-tests were employed to assess pre- and post-test differences, revealing statistical significance in outcomes. The upcoming study will apply paired T-tests for more rigorous analysis.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study pioneered an integrated cardiopulmonary resuscitation and infection control simulation training program for undergraduate nursing students in Hong Kong, embedding experiential learning principles within the curriculum. Participants demonstrated high acceptability of the simulation design and educational practices, alongside significant improvements in self-reported situational awareness, as evidenced by reduced perceived difficulty and mental workload on the Mission Awareness Rating Scale. Competency assessments identified strengths in core resuscitation actions such as AED use and team coordination, but also revealed persistent gaps in initial patient assessment, airway management, compression quality, and infection control error correction.\u003c/p\u003e\n\u003cp\u003eThese findings affirm the value of simulation as an experiential learning strategy that effectively links technical proficiency, non-technical skills, and infection prevention behaviors essential for safe clinical practice. The positive correlations between simulation design perceptions and cognitive outcomes further support refining such program to optimize student readiness for high-stakes, complex emergencies. Future research should incorporate paired statistical analyses, qualitative exploration of participant experiences, and longitudinal follow-up to evaluate sustained competency gains and curriculum integration.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Research Ethics Committee of Hong Kong Metropolitan University, School of Nursing and Health Sciences (\u003cstrong\u003eREC Reference No: HE-SF2024/03\u003c/strong\u003e). All participants received written information about the study and provided informed consent prior to participation. Participation was voluntary, and students were assured that their decision to participate or withdraw would not affect their academic standing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to institutional policies and participant confidentiality but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e☒\u0026nbsp;The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003cbr\u003e\u0026nbsp;\u0026nbsp;\u003cbr\u003e\u0026nbsp;☒\u0026nbsp;The authors declare that they have no known financial interests/personal relationships which may be considered as potential competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTomas CHAN:\u0026nbsp;\u003c/strong\u003eConceptualization; Methodology; Investigation; Formal analysis; Data curation; Writing \u0026ndash; Original Draft; Visualization\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNatalie LEE:\u0026nbsp;\u003c/strong\u003eProject administration; Resources\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJanet WONG:\u0026nbsp;\u003c/strong\u003eSupervision; Funding acquisition;\u0026nbsp;Review \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding Author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTomas CHAN Hiu Yeung, \u003cem\u003eMPH, BNurs, RN\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdvanced Practice Nurse\u003c/p\u003e\n\u003cp\u003eCentral Nursing Department, Tung Wah Hospital, Hospital Authority, Hong Kong, China.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEmail: [email protected] / [email protected]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCo-author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNatalie LEE Po Man, DHSc (Nursing), MSc (Nursing), BSN, RN, FRSPH\u003c/p\u003e\n\u003cp\u003eAssistant Professor\u003c/p\u003e\n\u003cp\u003eDepartment of Nursing, Hong Kong Metropolitan University, Hong Kong, China.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEmail: [email protected]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupervisor\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJanet WONG Yuen Ha, PhD MNurs, BNurs, RN, APN, FHKCHSE, FCHSM, FAAN\u003c/p\u003e\n\u003cp\u003eDean and Professor\u003c/p\u003e\n\u003cp\u003eSchool of Nursing and Health Sciences, Hong Kong Metropolitan University, Hong Kong, China.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEmail: [email protected]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the nursing students who participated in this study, the simulation facilitators, and the Hospital Authority colleagues who supported scenario development. The authors also acknowledge the administrative support and logistical arrangements provided by the School of Nursing and Health Sciences, Hong Kong Metropolitan University.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBordelon CJ, Dudding K. Simulation: Building Skills and Improving Outcomes. Neonatal Netw. 2020;39(5):255\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1891/0730-0832.39.5.255\u003c/span\u003e\u003cspan address=\"10.1891/0730-0832.39.5.255\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDarawad MW, AI-Hussami M. Jordanian nursing students\u0026rsquo; knowledge of, attitudes towards, and compliance with infection control precautions. 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Exploring the role of simulation to foster interprofessional teamwork among medical and nursing students: A mixed-method pilot investigation in Hong Kong. J Interprof Care. 2021;35(6):890\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/13561820.2020.1831451\u003c/span\u003e\u003cspan address=\"10.1080/13561820.2020.1831451\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. CINAHL Complete.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8674602/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8674602/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eAim/objective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo develop and evaluate an infection-control cardiopulmonary resuscitation (CPR) simulation training program for undergraduate nursing students, assessing simulation acceptability, situational awareness improvement, and technical skills competency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNursing students should manage clinical emergencies while rigorously adhering infection prevention and control (IPC) protocols. Although resuscitation and IPC are often taught separately, integrating them through simulation-based learning can better prepare students by combining technical skills, non-technical skills, and IPC skills within realistic, safe environments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative interventional study integrated into final-year Hong Kong nursing curriculum.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 272 students participated in a high-fidelity resuscitation scenario in an isolation ward with scripted IPC errors. Simulation acceptability was assessed using the Simulation Design Scale (SDS) and Educational Practice Questionnaire (EPQ). Situational awareness was evaluated pre- and post-training using the Mission Awareness Rating Scale (MARS). Competency was assessed via a checklist based on hospital protocols and CPR guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants reported high acceptability scores: SDS means of 4.14 (presence) and 4.04 (importance), and EPQ means of 4.24 and 4.11, respectively (5-point scales). Significant improvements in post-training MARS scores for both Content (2.58®2.29) and Workload (2.59®2.35) subscales (p\u0026lt;0.01). Higher SDS and EPQ scores correlated with greater improvements in situational awareness. Competency assessment revealed strengths in AED use and bag-valve-mask ventilation, but gaps in breathing assessment, noting arrest time, airway adjunct use, and correcting IPC errors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIntegrated infection-control CPR simulation is feasible, well accepted, enhances situational awareness, and highlights areas for competency improvement. These findings support experiential learning for complex, high-risk clinical environments.\u003c/p\u003e","manuscriptTitle":"Develop and Evaluate of an Infection Control Simulation Training in Nursing Students","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-10 19:52:38","doi":"10.21203/rs.3.rs-8674602/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-04T07:35:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-02T04:36:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-21T13:39:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"83864378669560129249209276600157254813","date":"2026-02-20T20:54:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"194736033619131182390941658146864591424","date":"2026-02-12T10:26:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-05T10:32:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-28T09:44:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-26T12:20:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-26T12:16:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-01-23T03:28:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e67b39ae-b3bd-4f7a-bbc6-53d93ced245e","owner":[],"postedDate":"February 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-03-04T07:40:42+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-10 19:52:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8674602","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8674602","identity":"rs-8674602","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}