Intensive & Critical Care Nursing xxx (2018) xxx–xxx

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Intensive & Critical Care Nursing

journal homepage: www.elsevier.com/iccn

Research article

Standardised simulation-based emergency and intensive care nursing

curriculum to improve nursing students’ performance during simulated
resuscitation: A quasi-experimental study
Jie Chen a,b, Jian Yang c, Fen Hu c, Si-Hong Yu a, Bing-Xiang Yang a, Qian Liu a, Xiao-Ping Zhu c,⇑
a
Wuhan University School of Health Sciences, No. 115 Donghu Road, Wuchang District, Wuhan 430071, China
b
University of Connecticut School of Nursing, 231 Glenbrook Road, Storrs, CT 06269-2026, USA
c
Nursing Department, Zhongnan Hospital of Wuhan University, No. 169 Donghu Road, Wuchang District, Wuhan 430071, China

a r t i c l e i n f o a b s t r a c t

Article history: Background: Simulation-based curriculum has been demonstrated as crucial to nursing education in the
Accepted 6 February 2018 development of students’ critical thinking and complex clinical skills during a resuscitation simulation.
Available online xxxx Few studies have comprehensively examined the effectiveness of a standardised simulation-based
emergency and intensive care nursing curriculum on the performance of students in a resuscitation
Keywords: simulation.
Resuscitation Objective: To evaluate the impact of a standardised simulation-based emergency and intensive care
Simulation training
nursing curriculum on nursing students’ response time in a resuscitation simulation.
Curriculum
Baccalaureate nursing education
Design: Two-group, non-randomised quasi-experimental design.
Setting: A simulation centre in a Chinese University School of Nursing.
Participants: Third-year nursing students (N = 39) in the Emergency and Intensive Care course were
divided into a control group (CG, n = 20) and an experimental group (EG, n = 19).
Methods: The experimental group participated in a standardised high-technology, simulation-based
emergency and intensive care nursing curriculum. The standardised simulation-based curriculum for
third-year nursing students consists of three modules: disaster response, emergency care, and
intensive care, which include clinical priorities (e.g. triage), basic resuscitation skills, airway/breathing
management, circulation management and team work with eighteen lecture hours, six skill-practice
hours and twelve simulation hours. The control group took part in the traditional curriculum. This
course included the same three modules with thirty-four lecture hours and two skill-practice hours
(trauma).
Results: Perceived benefits included decreased median (interquartile ranges, IQR) seconds to start
compressions [CG 32 (25–75) vs. EG 20 (18–38); p < 0.001] and defibrillation [CG 204 (174–240)
vs. EG 167 (162–174); p < 0.001] at the end of the course, compared with compressions [CG 41
(32–49) vs. EG 42 (33–46); p > 0.05] and defibrillation [CG 222 (194–254) vs. EG 221 (214–248);
p > 0.05] at the beginning of the course.
Conclusion: A simulation-based emergency and intensive care nursing curriculum was created and
well received by third-year nursing students and associated with decreased response time in a resus-
citation simulation.
Ó 2018 Elsevier Ltd. All rights reserved.

⇑ Corresponding author at: Nursing Department, Zhongnan Hospital of Wuhan

University, Wuhan, Hubei, China.
E-mail address: zxp-1028@163.com (X.-P. Zhu).

https://doi.org/10.1016/j.iccn.2018.02.003
0964-3397/Ó 2018 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Chen, J., et al. Standardised simulation-based emergency and intensive care nursing curriculum to improve nursing stu-
dents’ performance during simulated resuscitation: A quasi-experimental study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.
iccn.2018.02.003
2 J. Chen et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
Implications for Clinical Practice
 The impact of a standardised high-technology simulation-
based emergency and intensive care nursing curriculum
on third-year nursing students’ nursing management
and teamwork during simulated resuscitation scenarios
included decreased median seconds to start compres-
sions and defibrillation at the end of the course.
 The simulation-based emergency and intensive care nurs-
ing curriculum provided a safe learning environment to
nursing student and allowed repeated practice, the
debriefing process facilitated closing the simulated resus-
citation performance gaps.
 New graduate nurses may also benefit from this course
since the curriculum may also improve their ability to deli-
ver chest compressions and defibrillation in intensive care
unit, thus increase their confidence and boost protection
of patients’ safety.
Introduction
Nursing students lack actual resuscitation experience, but are
required to learn resuscitation skills during their education. Once
they graduate and assume clinical positions, they are expected to
participate in cardiopulmonary resuscitation (CPR) for cardiac
arrests (Cook et al., 2012; Sullivan et al., 2015). It is suggested
that the nursing curriculum should incorporate elements of resus-
citation at an early stage of students’ education, in order to build
confidence and provide preparation for this important skill in
clinical practice (Abe et al., 2013; De Buck et al., 2015; Ramm
et al., 2015).
Standardised simulation-based education interventions using
high fidelity simulations have been recognised as facilitating active
learning in a reproducible and safe environment, and can improve
health professionals’ resuscitation knowledge, skills, and team-
work (Cheng et al., 2015; Khanduja et al., 2015; Mundell et al.,
2013). Simulation is increasingly crucial in nursing education in
order to develop the critical thinking and complex clinical skills
required within the health care arena (Ballangrud et al., 2014;
Hebbar et al., 2015; Gerolemou et al., 2014. Simulation activities
improve acquisition of CPR skills in nursing students and clinical
nurses (Bukiran et al., 2014; Hernández-Padilla et al., 2015; Cook
et al., 2012).
Previous studies on the use of embedded simulation in med-
ical education curriculums, have demonstrated improvement in
participants’ self-assessment as well as performance of medical
management and teamwork skills in simulated resuscitation sce-
narios (Fang et al., 2014; Stone et al., 2014). Few studies have
been completed on the incorporation of simulation into an
emergency and intensive care curriculum in nursing education,
including both nursing management and teamwork. Additionally,
no study combining simulation into an emergency and intensive
care nursing curriculum with the goal of decreasing nursing
students simulated resuscitation response time had been
reported.
The purpose of the current study was to develop a standardised
high-technology simulation-based emergency and intensive care
nursing curriculum and to evaluate the impact of this curriculum
on third-year nursing students’ response time and teamwork dur-
ing simulated resuscitation scenarios.
Please cite this article in press as: Chen, J., et al. Standardised simulation-based emergency and intensive care nursing curriculum to improve nursing stu-
dents’ performance during simulated resuscitation: A quasi-experimental study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.
iccn.2018.02.003
Methods
Study design
A non-randomised, quasi-experimental study design was used
following the creation of a standardised high-technology,
simulation-based emergency and intensive care nursing curricu-
lum from September 2014 through May 2015. This study was
approved by the ethics committee of Wuhan University HOPE
School of Nursing in Wuhan, China (NO. 20140011).
Study participants
A group of third-year nursing students enrolled in the course of
emergency and intensive care was recruited in the study using
convenience sampling. To avoid contamination of intervention
effects between groups, participants were placed into groups based
on the semesters in which they took the emergency and intensive
care nursing course. Those who participated in the course from
September to December 2014 were assigned to the control group
(CG) and those who enrolled in the course from March to May
2015 were designated into the experimental group (EG). The EG
participated in a standardised high-technology, simulation-based
emergency and intensive care nursing curriculum, whereas the
CG participated in the traditional curriculum.
Intervention: the curriculum
From September through December 2014, the CG participated
in the routine curriculum. This traditional curriculum included
three modules: disaster response, emergency care and intensive
care. This included thirty-four lecture hours and two skill-
practice hours (trauma) which were offered by Researcher A (JC).
From March through May 2015, the EG participated in a
simulation-based curriculum. The standardised simulation-based
emergency and intensive care nursing curriculum for third-year
nursing students consisted of three modules: disaster response,
emergency care, and intensive care, incorporating clinical priorities
(e.g. triage), basic resuscitation skills, airway/breathing manage-
ment, circulation management and team work. This was derived
from the Advanced Life Support (ALS), National League for Nursing
(NLN), triage and teamwork literature (Cheng et al., 2015; Mundell
et al., 2013). These modules included eighteen lecture hours, six
skill-practice hours and twelve simulation hours, with two simula-
tion sessions in each of the three modules. These six simulation
sessions consist of earth quake and fire scenarios in disaster
response, trauma and cardiac arrest scenarios in emergency care,
sepsis shock and cardiac arrest scenarios in intensive care.
To shortening lecture hours, the students were asked to review
the content after class time. Besides trauma care, the circulation,
airway and breathing (CAB) were covered in the six skill-practice
hours as well as in the simulation sessions. During the
intervention, each of the six sessions was conducted twice, for a
total of twelve simulation scenarios. Each simulation session was
60 minutes in length and repeated twice, consisting of an
introduction (review of scenario and learning objectives), the
resuscitation simulation and a debriefing.
Debriefing with Good Judgment (Rudolph et al., 2008), a theory-
based method aiming at closing performance gaps in medical edu-
cation was adopted to direct debriefing in this study. The process of
debriefing in this model are to: 1) note the performance gaps
related to learning objectives, 2) provide feedback depicting the
gaps, 3) explore the basis of performance gaps, 4) help close the
gaps through discussion. All the students could share their experi-
ences in the scenarios during the debriefing. The students may be
 J. Chen et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
asked questions such as ‘‘How did you feel about that?”, ‘‘Can you
explain then what will have to be done?”, ‘‘Can you tell me what
was valuable for you to learn in that experience?”, ‘‘Would you please
tell me what could be done to make this situation better?”, ‘‘How did
you feel about the interaction with each other?”, ‘‘What would do to
assist your partner during the simulation?”. In addition to capture
the objectives of this curriculum, the debriefing also focused on
the nursing management and teamwork objectives (Gundrosen
et al., 2014). This curriculum was delivered by Researcher A (JC).
The curriculum was created based on the Essentials of Baccalau-
reate Education for Professional Nursing Practice from the Ameri-
can Association of Colleges of Nursing (AACN, 2008). A panel of
five experts in disaster response, emergency care, intensive care,
nursing management and undergraduate nursing education
reviewed the content and feasibility of the curriculum. The experts
all agreed with the content of the curriculum. Based on the facili-
ties in the school, they recognised the feasibility of this curriculum.
Measures
Demographics
Participants’ demographic information included gender, age,
and place of residence.
Students simulated resuscitation performance
The outcome measures included the difference in nursing stu-
dents’ performance between pre- and post-intervention in the EG
and the difference in performance between the CG and the EG. This
included measuring the time elapsed from the call for assistance to
initiation of chest compressions and successful defibrillation for
each student. All the students have passed the test of chest com-
pressions in the second-year course of Fundamentals of Nursing,
therefore the technique of chest compressions was not the key
point of this study.
Thirty-nine third-year nursing students were recruited to form
19 resuscitation teams, 10 in the CG with two students in each
team and nine in the EG with three in one team and two in each
of the other eight teams. Each team performed one simulated
resuscitation selected randomly from the three modules at the
beginning of the course. All teams completed three by the end of
the course. All students had simulated resuscitation experience
in the second-year courses of Fundamentals of Nursing, Nursing
Planning and Implementation. The simulations used a standard
set-up, which included Laerdal Sim-Man 3G (Laerdal Corporation,
Stockholm, Sweden).
The simulations were video recorded using software embedded
in the monitoring system in the simulation lab, which allowed for
accurate assessment of timing and sequencing of actions. Data
abstraction from the video recording was performed indepen-
dently by two raters, the first author and a qualified simulation
expert. Raters were allowed to watch the video recording as many
times as necessary to ensure accurate assessments. A combined
review was then compiled using both raters’ assessments. If there
were differences between the two raters’ reviews, a third qualified
simulation expert was involved and the average of the three raters’
reviews was used.
Students’ perspective of the curriculum
The participants in both group completed an online survey
about the teaching quality of the course, which is also a routine
evaluation of course outcomes, using a 100-point questionnaire
(0 = very poor, 100 = perfect). There are four domains in the ques-
Please cite this article in press as: Chen, J., et al. Standardised simulation-based emergency and intensive care nursing curriculum to improve nursing stu-
dents’ performance during simulated resuscitation: A quasi-experimental study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.
iccn.2018.02.003
3
tionnaire with two ten point items in the teaching attitude domain,
two ten-point items and one twenty-point item in the teaching
content domain, one ten-point item and one twenty-point item
in the teaching method domain and one ten-point item in the
teaching effect domain.
Data analysis
The data were analysed using Statistical Package for Social Sci-
entists (SPSS) for Windows, version 20.0. Demographics, pre-and
post-curriculum performance, and outcome measures were
reported using descriptive analysis. Categorical demographic char-
acteristics were compared with Fishers’ Exact test. The time
elapsed during the simulation scenarios in the pre- and post- inter-
vention of both groups was reported as medians and IQR, and anal-
ysis was completed by the Mann-Whitney U test. The difference in
students’ perspectives between the CG and EG were compared
using unpaired t-tests. Statistical significance was set with an
experiment-wise error rate of 0.05.
Study sample
The required sample size of the study was determined based on
the assumption made for the improvement of nursing students’
performance in simulated resuscitation scenarios. The determina-
tion of the sample size was based on assumed standardised mean
differences of seconds to starting compressions of 1.0 (Sullivan
et al., 2015)), the power and type 1 error probability set at 0.80
and 0.05, respectively. The required number of students per group
was 17 testing the improvement and the difference, which were
performed using G⁄Power 3.1.
Results
Participant sociodemographic
Thirty-nine third-year nursing students were enrolled in the
two-group, non-randomised quasi-experimental study. Partici-
pants in the EG and CG were ages 19–22 years (SD = 20.45) and
19–21 years (SD = 20.26), respectively (see Table 1).
Seconds to starting compression and defibrillation
There was no significant difference in resuscitation perfor-
mance between the EG and CG at the beginning of the course.
There was a significant decrease in the median ± IQR in seconds
elapsed between the call for assistance and initiation of chest com-
pressions in the EG; there was no significant decrease in the CG
(Fig. 1).
A similar decrease occurred in seconds elapsed from call for
help to successful defibrillation (Fig. 2). Fifteen percent of partici-
pants were able to successfully defibrillate at the start of the course
[15.79% (3/19) in the EG vs. 15.00% (3/20) in the CG, p > 0.05],
while all participants in the EG successfully defibrillated within
180 s. Participants in the CG [40.00% (8/20)] were able to success-
fully defibrillate upon completion of the resuscitation scenarios.
Students’ perspective of the curriculum
Table 2 describes the participants’ evaluation of the curriculum.
Students in the EG felt that the teaching quality and outcomes of
the domains were met more effectively than participants in the CG.
4 J. Chen et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx

Table 1
Participants’ sociodemographic by group (N = 39).

Variable EG CG t/Z p
n = 19 n = 20
Age (mean (SD)) 20.26 (0.653) 20.45 (0.686) 0.589 0.448
Gender
Female 16 13 1.892 0.170
Male 3 7
Place of residence
Urban 12 12 0.043 0.819
Rural 7 8

41 (31 - 49) s on a standardised simulation-based curriculum for paediatric med-

CG (n=20)
ical residents, which consisted of nine modules, incorporating
pre-curriculum
42 (33 - 46) s basic skills, airway/breathing, circulation and team management
EG (n=19) and specific topics such as anaphylaxis, and demonstrated to be
effective to improve participants’ simulated resuscitation perfor-
32 (25 - 75) s
CG(n=20) mance (Miyasaka et al., 2015; Stone et al., 2014).
post-curriculum
In this study, a group of 12 simulation scenarios were delivered
20 (18 - 38) s
EG (n=19)
during 12 weeks of instruction. Results revealed improved resusci-
tation performance in the simulation scenarios. At the end of the
curriculum, all participants in the EG demonstrated consistent, sig-
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75

Times (second, s)
nificant improvement in performance from the beginning of the
Fig. 1. Median (IQR) time to starting compressions at the beginning and the end of
course. Notably, there were no significant differences between
the curriculum: CG = control group; EG = experimental group. the performance of students in the CG at the beginning and the
end of the course. The course contents of the CG and EG are the
same, while the delivered styles are different. Both the course con-
222 (194 - 254) s
tents include three modules: disaster response, emergency care,
CG (n=20) and intensive care. These modules in CG were delivered only by
pre-curriculum lecture besides two skill-practice hours (trauma). However, the
221 (214 - 248) s
EG (n=19)
three modules in EG were embedded in simulation. Besides trauma
care, the ‘‘CAB” circulation, airway, and breathing were covered in
204 (174 - 240) s the six skill-practice hours as well as the simulation sessions. The
CG(n=20)
post-curriculum increased exposure to simulated scenarios and repeated exercises
167 (162 - 174) s could explain the improvement in resuscitation performance
EG (n=19)
(Liaw et al., 2015; Stone et al., 2014). The use of a simulation-
based nursing education curriculum allows for the translation of
0

0
15

17

20

22

25

27

30

nursing students’ knowledge into improved performance on a sim-

Times (second, s)
Fig. 2. Median (IQR) time to successful defibrillation at the beginning and the end
of the curriculum: CG = control group; EG = experimental group.
Discussion
This study evaluated the impact of a simulation-based emer-
gency and intensive care nursing curriculum focusing on emer-
gency care and critical care, incorporating clinical priorities (e.g.
triage), basic resuscitation skills, airway/breathing management,
circulation management and team work. The curriculum format
is consistent with the best practice model for education in resusci-
tation with reduced course duration and distributed practice over
time (Mailloux, 2011; Stone et al., 2014). The curriculum devel-
oped for this study was in line with previous studies which focused
ulated patient. The emergency and intensive care nursing curricu-
lum in this study provides opportunities for deliberate practice
with high-technology simulation to facilitate learning, such as
the debriefing about the performance, and repeated practice sce-
narios with clinical variations. This revealed that the curriculum
is pivotal in improving nursing students’ abilities to translate their
knowledge to performance in simulated emergency and critical
care settings.
In addition to exercises in the 12 simulation scenarios, the par-
ticipants in the EG formed teams to initiate compressions and to
prepare to defibrillate during the simulation-based curriculum.
This study underscored the importance of the necessity of team-
work to successfully minimise interruptions when providing chest
compressions and defibrillation, and to enhance the effectiveness
of chest compressions. This highlights the importance of teamwork
in clinical situations (Cheng et al., 2012; Crozier et al., 2015).

Table 2
Comparison of the participants’ course evaluation between the two groups (N = 39).

EG (n = 19) CG (n = 20) t p
M(SD) [95%CI] M(SD) [95%CI]
Teaching attitude 20.00 (0.00) [20.000, 20.000 ] 17.85 (1.631) [17.105, 18.500] 35.544 <0.001
Teaching content 39.47 (0.772) [39.125, 39.800] 34.20 (2.931) [32.955, 35.533] 11.741 0.002
Teaching method 29.63 (0.684) [29.333, 29.905] 25.30 (2.736) [24.000, 26.500] 20.529 <0.001
Teaching effect 9.84 (0.375) [9.650, 10.000] 8.75 (1.019) [8.294, 9.167] 40.992 <0.001
Teaching quality 98.95 (0.911) [98.571, 99.363] 86.10 (6.545) [83.126, 89.000] 14.794 <0.0001

Please cite this article in press as: Chen, J., et al. Standardised simulation-based emergency and intensive care nursing curriculum to improve nursing stu-
dents’ performance during simulated resuscitation: A quasi-experimental study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.
iccn.2018.02.003
 J. Chen et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
Participants in the simulation-based emergency and intensive
care nursing curriculum believed that the objectives of the course
were met effectively. The simulation-based curriculum combined
simulation with lectures, reinforcing the application of knowledge
to practice (Kennedy et al., 2014; Stone et al., 2014). During the
debriefing, participants could share their experiences in the sce-
narios, and those who observed the scenarios through the video
recording system may also present their opinions. Students took
turns participating in the scenarios, observing other students dur-
ing a simulation and from this, could identify changes in their per-
formance, and the need to improve group communication. As a
result, students improved their knowledge and skills of emergency
and critical care following the debriefing, which is in line with the
aim of debriefing since the debriefing adopted from theory-based
model, debriefing with good judgment (Rudolph et al., 2008),
was intended to facilitate closing performance gaps. The data are
consistent with the students’ simulated resuscitation performance
improvement in the simulation-based curriculum. New graduated
nurses may also benefit from this course since the curriculum may
also improve their ability to deliver chest compressions and defib-
rillation in intensive care unit.
There is a lack of opportunities for nursing students to practice
requisite skills such as chest compression and defibrillation in clin-
ical settings, but these skills are essential for all nurses. Simulation
becomes an alternative learning experience for future practice. The
result of this study also confirmed that simulation experiences are
complementary to direct care opportunities and reinforce clinical
learning (AACN, 2008). Nursing students benefit from a
simulation-based curriculum since nurses in practice settings
may be asked to maintain their skills through the use of simula-
tion, specifically to maintain proficiency in CPR (Sullivan et al.,
2015).
Limitations
Selection bias may be present in this study. Those who partici-
pated in the simulation-based curriculum felt it was useful, and
may have been more likely to select the course. This study was
conducted in one institution, using six scenarios, with one faculty
facilitator. This study only focused on the evaluation of the circula-
tion management. Airway management as a crucial component of
the resuscitation is not included in simulated resuscitation perfor-
mance evaluation. Further study is needed to assess the entire
resuscitation process, to identify the replication of the
simulation-based curriculum and clarify the impact of the curricu-
lum on students’ nursing management and teamwork perfor-
mance. Student performance was evaluated in simulation
scenarios, not in clinical practice settings, therefore improved per-
formance in a resuscitation simulation does not necessarily trans-
late to improved skills in performing chest compression,
defibrillation and airway management or to improved patient
outcomes.
Conclusions
The simulation-based emergency and intensive care nursing
curriculum, including disaster response, emergency care and criti-
cal care, incorporating clinical priorities (e.g. triage), basic resusci-
tation skills, airway/breathing management, circulation
management and team work with distributed practice over time,
was well received by third-year nursing students and associated
with increased resuscitation performance: a) decreased time
elapsed from call for assistance to initiation of chest compressions
and b) successful defibrillation in less than 180 seconds in a simu-
lation setting. The result of this study may encourage incorporation
Please cite this article in press as: Chen, J., et al. Standardised simulation-based emergency and intensive care nursing curriculum to improve nursing stu-
dents’ performance during simulated resuscitation: A quasi-experimental study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.
iccn.2018.02.003
5
of simulation into nursing curriculum which could decrease the
response time in emergency situations.
Funding
This study was supported by the teaching research project,
Wuhan University School of Medicine, NO. 2015048 and NO.
2016019. The funding source had no role in the design and comple-
tion of the study; or in the preparation, or approval of this
manuscript.
Competing interests
The authors declare that they have no conflict of interests.
Ethical statement
This study was approved by the ethics committee of Wuhan
University HOPE School of Nursing in Wuhan, China (NO.
20140011).
Acknowledgements
We thank The Medical Virtual Simulation Experiment Teaching
Centre at Wuhan University School of Health Sciences which
helped with technical aspects of this study. We would like to thank
the students who participated in the study. We also wish to thank
Visiting Professor Doctor Sharon R. Redding and Doctor Carma
Erickson-Hurt, Project HOPE, for their professional review of this
manuscript.
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