Development of a virtual simulation-based nurse education program to provide psychological support for patients affected by infectious disease disasters

다국어 초록 (Multilingual Abstract)

Over the past decades, there have been outbreaks of a variety of infectious diseases, including SARS, H1N1 influenza, Ebola, and MERS. Now, COVID-19 has spread around the world, infecting millions and causing a great number of deaths, and continues to threaten most countries. Disasters caused by novel infectious diseases with high fatality rates and the possibility of a mass epidemic may result in various psychological problems as well as physical threats to life or health. Psychological problems in patients who have been confirmed positive and quarantined may include worry or anxiety about the diagnosis or the treatment itself, and fear for death and may lead to a sense of isolation, anger, social stigma, and guilt. In such circumstances, the need for nurses to provide those patients with psychological support as well as physical assistance becomes even more important. Unfortunately, education related to dealing with infectious disease disasters tends to focus on infection management or physical care, while education in psychological support has been more limited due to social distancing to reduce the risk of infection. Hence, virtual simulation has recently been emerging as a new educational strategy given that realistic situations of disaster can be replicated, and in-person training can be alternated with virtual training when social distancing is required in clinical settings.
This study used system development methodology to develop a virtual simulation-based nurse education program educating them on how to provide psychological support for patients suffering from infectious disease disasters according to the ADDIE process of instructional design, based on situated learning theory and the INACSL Standards for simulation design. A pre-post, randomized controlled trial was conducted to evaluate its effectiveness.
In this study, literature reviews of both domestic and international guidelines and manuals on psychological support in infectious disease disasters have been performed. Additionally, nurses’ experiences in caring for patients with infectious diseases have also been explored by conducting qualitative interviews among nine nurses who have cared for patients with infectious diseases in an isolation ward. These literature reviews and interviews in determining the nurses’ demands of the education provided, namely its purpose, contents, the virtual simulation scenarios depicted, the simulation video, the system interface, and screens. Their input has been integrated into the design. A video recording of a simulated scenario, a nurse providing psychological support for a COVID-19 patient in an isolation ward according to the PFA core modules, was completed. Based on this, a virtual simulation-based education program consisting of preparatory learning, pretest, prebriefing, virtual simulation, and debriefing was developed, using the e-learning development software: Articulate Storyline.
To evaluate the effectiveness of the program developed, 93 nurses who had not worked in an isolation ward were chosen. Of these 93, forty-five were assigned to the experimental group using the virtual-simulation-based education program for psychological support, while the remaining forty-eight were assigned to the control group, which was provided with text-based educational materials on psychological support. To assess the effectiveness of the program, they were asked to complete self-reported questionnaires about the level of disaster mental health competence, problem solving process, self-leadership, learning self-efficacy, and motivation to transfer. Analysis of the data collected was undertaken using SPSS Statistics 23.0 and was comprised of a paired t-test, an independent t-test, and ANCOVA. The statistical results from data analysis show the experimental group’s posttest scores in all variables significant increases from the pretest scores: disaster mental health competence (t=-10.605, p<.001), problem solving process (t=-9.564, p<.001), self-leadership (t=-6.381, p<.001), learning self-efficacy (t=-5.607, p=<.001), and motivation to transfer (t=-4.528, p=<.001). In contrast, the control group’s increases between pretest and posttest scores of learning self-efficacy and motivation to transfer were not found to be statistically significant. In addition, the differences in the experimental group’s pretest and posttest scores of in all variables: disaster mental health competence (F=5.149, p=.026), problem solving process (t=3.024, p=.003), self-leadership (t=2.063, p=.042), learning self-efficacy (t=3.450, p=.001), and motivation to transfer (t=2.095, p=.039) were found to be more statistically significant than the control group. To evaluate the level of satisfaction with the education program developed in this study, the experimental group’s responses to debriefing questions were analyzed using Graneheim and Lundman (2004)’s content analysis. Based on the analysis results, sub-categories including ‘immersed in a realistic simulation,’ ‘having empathy to patients,’ ‘having experience as an isolation ward nurse,’ ‘reflecting on previous nursing care,’ ‘recognizing importance of psychological support,’ ‘gaining confidence,’ and ‘transferring simulation experience to clinical practice,’ and the categories of ‘getting into the situation of infectious disease disasters,’ ‘learning from reflection,’ and ‘professional growth’ were all derived.
The virtual simulation-based nurse education program for psychological support for patients with infectious disease disasters developed in this study has been found to augment the level of disaster mental health competence, problem solving process, self-leadership, learning self-efficacy, and motivation to transfer while providing nurses with positive experiences by letting them immerse themselves in a realistic simulated situation of being in an isolation ward, the experience of which allows them to learn from self-reflection. It is accordingly expected that virtual simulations, loaded with various scenarios dealing with many kinds of infectious diseases and many types of patients, will be developed for nurses to use as effective education strategies related to providing psychological support and thus improve the quality of nursing care for patients with infectious diseases.

국문 초록 (Abstract)

최근 수십년동안 사스. 신종플루, 에볼라, 메르스 등 다양한 감염병 재난이 발생했고, 특히 COVID-19는 전 세계적으로 확산되어 수많은 확진자와 사망자가 발생하면서 현재까지도 각 나라에 큰 위협이 되고 있다. 치명률이 높거나 집단발생의 우려가 큰 신종 감염병 재난으로 인한 피해는 생명이나 건강에 대한 신체적 위협 뿐 아니라 다양한 심리적 문제를 발생시키고 확진자와 격리자는 진단이나 치료 자체에 대한 걱정, 불안, 죽음에 대한 공포와 함께 격리로 인한 고립감이나 분노, 주변 사람에 대한 낙인과 죄책감까지 다양한 문제로 고통받고 있다. 따라서 간호사는 감염병 환자들에게 신체적, 정신적인 도움을 주어야 하는데 감염병 재난 관련 교육은 감염관리나 신체적 치료에 집중되어 있고, 사회적 거리두기로 인해 감염병 재난 심리교육은 더욱 제한되어 있다. 따라서 현실감 높은 감염병재난 상황을 재현할 수 있고, 임상현장에서의 대면교육의 제약을 보완할 수 있는 가상 시뮬레이션이 새로운 교육 전략으로 떠오르고 있다.
본 연구는 상황학습이론과 INACSL 시뮬레이션 설계 표준을 기반으로 ADDIE 교육시스템 개발과정에 따라 가상 시뮬레이션을 활용하여 감염병재난 환자 대상 심리지원을 위해 간호사 교육 프로그램을 개발하고 그 효과를 평가하기 위한 시스템 개발연구와 무작위 대조군 전후 실험연구로 시행되었다.
국내외 감염병 심리지원 가이드라인과 매뉴얼에 대해 문헌고찰을 시행하였고, 간호사들의 교육 요구도를 파악하기 위해 격리병동의 감염병환자를 돌본 경험이 있는 병원 간호사 9명을 대상으로 일대일 면담을 실시하여 감염병 환자 간호 경험을 탐구하였으며, 그 결과를 바탕으로 교육프로그램의 목적과 내용, 시뮬레이션 시나리오, 시뮬레이션 동영상, 시스템 인터페이스와 사용자 화면을 설계하였다. 표준화 환자를 활용하여 격리병동 간호사가 COVID-19 환자에게 PFA 핵심 모듈에 따라 심리지원을 제공하는 시나리오로 시뮬레이션 동영상을 촬영한 후 Articulate Storyline 이러닝 개발 소프트웨어를 이용하여 선행학습, 사전테스트, 프리브리핑, 가상시뮬레이션, 디브리핑으로 구성된 가상시뮬레이션 기반 교육프로그램으로 개발하였다.
개발 된 프로그램의 효과를 평가하기 위해 격리병동 근무 경험이 없는 병원 간호사 93명 중, 실험군 45명은 가상시뮬레이션 기반 심리지원 교육프로그램을 일주일동안 사용하게 하였고, 대조군 48명은 텍스트기반 심리지원 강의자료를 제공하여 일주일동안 사용하게 하였다. 참가자들의 교육효과는 재난정신건강역량, 문제해결과정, 셀프리더십, 학습자기효능감, 전이동기에 대한 자기보고식 설문지를 사용하여 측정하였다. 수집된 자료를 SPSS 23.0 통계프로그램을 활용하여 paired t-test, independence t-test, ANCOVA로 분석한 결과, 실험군에서는 재난정신건강역량 (t=-10.605, p<.001), 문제해결과정 (t=-9.564, p<.001), 셀프리더십 (t=-6.381, p<.001), 학습자기효능감 (t=-5.607, p=<.001), 전이동기 (t=-4.528, p=<.001) 에서 사전에 비해 사후 점수가 통계적으로 유의하게 증가하였다. 대조군에서는 학습자기효능감과 전이동이에서는 변화가 유의하지 않았다. 또한, 실험군의 사전 사후 점수 변화는 대조군의 점수 변화보다 재난정신건강역량 (F=5.149, p=.026), 문제해결과정 (t=3.024, p=.003), 셀프리더십 (t=2.063, p=.042), 학습자기효능감 (t=3.450, p=.001), 전이동기 (t=2.095, p=.039)에서 통계적으로 유의하게 증가하였다.
개발된 교육 프로그램의 만족도 평가를 위해 실험군 사용자의 디브리핑 답변을 Graneheim and Lundman (2004)의 내용분석방법으로 분석한 결과 ‘사실적 시뮬레이션에 몰입함’, ‘환자에게 공감하게 됨’, ‘격리병동 간호사로서의 경험을 함’, ‘이전의 자신의 간호돌봄에 대해 반성함’, ‘심리지원의 중요성을 인식함’, ‘자신감을 얻음’, ‘시뮬레이션 경험을 임상실무에 적용함’의 하위주제와 ‘감염병 재난 상황으로 들어감’, ‘성찰을 통한 학습’, ‘전문적 성장’ 의 메인주제가 도출되었다.
본 연구에서 개발된 가상시뮬레이션 기반 감염병재난 환자 심리지원을 위한 간호사 교육 프로그램은 재난정신건강역량, 문제해결과정, 셀프리더십, 학습자기효능감, 전이동기를 증진시켰고, 실제 같은 감염병동 상황에 몰입하면서 성찰을 통한 학습을 통해 긍정적 경험을 한 것으로 확인되었다. 앞으로 다양한 감염병 종류와 환자군을 대상으로 한 가상시뮬레이션 시나리오를 개발하여 감염병재난 심리지원 교육에 효율적인 보조자료로 사용하여 간호사의 감염병환자 간호의 질을 향상시킬 수 있기를 기대한다.

목차 (Table of Contents)

• I. Introduction 1
• 1. Background of the Study 1
• 2. Purpose of the Study 6
• 3. Definitions of Key Terms 7
• II. Literature Review 10
• 1. Psychological Support for Infectious Disease Disasters 10
• 2. Virtual Simulation 16
• III. Theoretical Background 22
• IV. Methods 33
• 1. Design 33
• 2. Participants 34
• 3. Instruments 37
• 4. Study Procedures 40
• 5. Data Collection 48
• 6. Ethical Considerations 50
• 7. Data Analysis 51
• V. Results 53
• 1. Development of a Virtual Simulation-based Education Program 53
• 2. Effectiveness of a Virtual Simulation-based Education Program 91
• VI. Discussion 104
• VII. Conclusion 122
• References 124
• Appendix 143
• 국문초록 162