Effect of community-based tabletop simulation on disaster nursing competency, preparedness, transfer motivation, and self-efficacy: a quasi-experimental study

Abstract

Background

Nurses play a critical role in community-based disaster response; however, gaps remain in disaster preparedness and in translating disaster-related competencies into clinical practice. Despite the widespread use of simulation-based education, evidence regarding the effectiveness of low-cost, scalable approaches, such as tabletop simulation, in undergraduate nursing education remains limited. This study aimed to evaluate the effectiveness of a community-based tabletop simulation program on disaster nursing competency, preparedness, transfer motivation, and learning self-efficacy.

Methods

A quasi-experimental study with a non-equivalent control group design was conducted among 93 undergraduate nursing students (experimental group, n = 43; control group, n = 50). The experimental group participated in a structured community-based tabletop simulation program in addition to standard instruction, whereas the control group received standard instruction only. The program focused on the 3T disaster response process—triage, treatment, and transport with emphasis on patient transport decision-making based on hospital capacity and available resources. The outcome variables were assessed at three time points (baseline, immediately post-intervention, and follow-up). Repeated measures analysis of variance was used to examine the group-by-time interaction effects.

Results

Significant group-by-time interaction effects were observed for all outcome variables. The experimental group demonstrated greater improvements than the control group in disaster nursing competency (F = 23.13, p < .001), disaster preparedness (F = 24.53, p < .001), transfer motivation (F = 4.83, p = .011), and learning self-efficacy (F = 5.14, p = .009). The improvements in the experimental group were sustained across the three measurement points, whereas changes in the control group were modest. These findings indicated that the tabletop simulation program contributed to enhanced disaster-related competencies and psychological readiness for practice.

Conclusions

Community-based tabletop simulation appears to be an effective and scalable educational strategy for strengthening disaster nursing competency, preparedness, and transfer motivation among undergraduate nursing students. Integrating structured tabletop exercises into nursing curricula may support workforce readiness in disaster-prone settings. Further multicenter studies with long-term follow-up are warranted to confirm these findings.

Trial registration

Not applicable.

Background

Recent disasters increasingly reflect the combined effects of natural hazards, social disruption, urban density, and climate change, placing substantial strain on community health systems [1]. Climate change is now widely recognized as a major public health threat that affects healthcare delivery, nursing practice, and population resilience and expands nurses’ responsibilities from emergency response to climate adaptation, risk communication, and support for community resilience [2]. This broader climate–health nexus has been increasingly emphasized in nursing research, which highlights the need to integrate environmental health, sustainability, and climate-responsive competencies into nursing education [3]. In Korea, major disasters such as large-scale wildfires, Middle East Respiratory Syndrome, coronavirus disease 2019 (COVID-19), and the Itaewon crowd crush have highlighted the need to strengthen field-based disaster response capacity and community resilience [4]. In particular, social disasters such as the Itaewon tragedy have underscored the importance of nursing across the full disaster cycle, including preparedness, response, and recovery [5]. Prior studies have also emphasized that disaster-related nursing competence extends beyond technical skills, encompassing a core capability that supports the recovery and sustainability of health systems across the preparedness–response–recovery continuum [6]. In disaster situations, nurses perform key roles such as initial assessment, triage, emergency care and resource coordination, infection control, psychological support, and multidisciplinary collaboration and communication. Therefore, disaster nursing competency should be conceptualized as an integrated performance capability that goes beyond knowledge acquisition to include clinical judgment and team-based decision-making under conditions of limited information, resources, and time. A quasi-experimental study in Korea found that an education program based on an international competency framework significantly improved disaster knowledge, triage, and disaster preparedness, supporting the value of competency-based education [4].

Nevertheless, disaster-related education in undergraduate nursing programs relies heavily on theory-centered lectures within the curriculum, and opportunities to repeatedly practice the decision-making, collaboration, and communication required in actual disaster settings are limited [7]. In particular, nursing students need opportunities to practice the triage, treatment, and transport (3T) disaster response process, with the transport component involving patient transport decision-making based on hospital capacity and available resources. Because disasters are infrequent and high-risk, providing sufficient repetitive experience in clinical settings is difficult; this has led to simulation-based education being proposed as an essential strategy in disaster nursing education [8].

Recent research in disaster nursing education suggests that simulation-based learning can improve not only disaster nursing competence but also learning self-efficacy and transfer motivation, while simulation-based education has been associated more broadly with improvement in nursing students’ knowledge, confidence, and satisfaction [9]. Structured disaster education has also been shown to strengthen both disaster management knowledge and disaster response self-efficacy among nursing students [10]. Accordingly, the outcomes of disaster education should be evaluated in terms of not only knowledge and skill acquisition but also learners’ psychological readiness and willingness to apply learning in practice [11]. This perspective is consistent with social cognitive theory, which conceptualizes learning as the reciprocal interaction of personal, behavioral, and environmental factors [12], and with the application of social learning principles in nurse education, where observation, modelling, feedback, and reinforcement facilitate the transfer of learning to practice [13].

Furthermore, repeated simulation has been reported to strengthen disaster response self-efficacy [8], and disaster response self-efficacy is positively associated with willingness to work in disaster settings while partially mediating the negative effect of disaster anxiety on such willingness [14]. This indicates that self-efficacy is not merely an immediate affective by-product of training but a practically significant psychological resource that supports action under uncertainty. For this reason, the evaluation of disaster nursing education should extend beyond knowledge and technical competence to include learning self-efficacy, transfer motivation, and the broader psychological readiness required for disaster response [14].

While high-fidelity simulations are highly effective for training, they face practical limitations in terms of scaling up and sustaining community-based education owing to constraints related to equipment, personnel, space, and operational costs [15]. Prior reports have suggested that low-cost tabletop training using simple tools (e.g., card-based patient information) can be utilized for disaster triage and transport decision-making training and has been well received by participants [16]. Furthermore, tabletop training can strengthen the disaster resilience of organizations and communities by identifying system vulnerabilities and promoting improvements [17], and disaster simulation can serve as a community-participatory resilience-building strategy [18].

Previous studies have suggested that disaster nursing education can improve competence and preparedness [4]. However, research remains limited on whether a community-implementable tabletop-based program can comprehensively improve disaster nursing competence, disaster preparedness, transfer motivation that facilitates learning transfer, and learning self-efficacy [19, 20]. Furthermore, the effectiveness of disaster education may be over- or underestimated based on a single post-assessment; therefore, a design that examines changes over time is necessary. Virtual simulations have been shown to improve transfer motivation—the willingness to apply acquired knowledge and skills in real-world practice—and learning self-efficacy, or learners’ belief in their capability to successfully perform learning tasks [11]. Previous studies have also suggested that repeated simulation experiences can further enhance learning self-efficacy [4]. While previous studies have demonstrated the positive effects of simulation-based training on transfer motivation and learning self-efficacy, empirical validation of these effects in community-based tabletop simulation training for disaster nursing remains limited. Therefore, this study aimed to develop and implement a community-based disaster nursing tabletop simulation education program and examine its effect on disaster nursing competency, disaster preparedness, transfer motivation, and learning self-efficacy of nursing students through a non-equivalent control group pre–post quasi-experimental design.

Methods

Study design

A quasi-experimental study with a non-equivalent control group pre–post design was conducted. Data were collected at three time points: before the intervention (T1), immediately after the intervention (T2), and four weeks after the intervention (T3). The four-week follow-up interval was determined to assess short-term retention of educational outcomes while considering the academic schedule and feasibility of participant follow-up [21, 22]. Considering the difficulty of randomization in educational settings [23], participants from two geographically separated campuses of the same university were assigned to the experimental and control groups. This approach was used to minimize contamination of the training content between the groups. To reduce potential sources of external variability, the control group was selected from another campus of the same university rather than from a different institution. Both campuses operated under the same university-level academic policies and offered comparable nursing curricula based on the accreditation standards of the Korean Accreditation Board of Nursing Education, including disaster nursing content within the Community Health Nursing course.

Participants

The study participants were fourth-year nursing students attending two campuses of the same university, recruited using convenience sampling through both online and offline announcements. Participation was voluntary. Both groups completed the same traditional theory-based disaster nursing class offered in the regular curriculum. Students from one campus were assigned as the control group, while those from the other campus were assigned as the experimental group. The experimental group participated in a disaster tabletop exercise in addition to the existing theoretical training. Eligible students were those who had completed disaster nursing theory but had no prior experience with simulation training; those with prior simulation experience or those who did not provide consent were excluded. Ethical approval was obtained from the Institutional Review Board of the authors’ affiliated institution, and written informed consent was obtained from all participants. To ensure confidentiality while enabling repeated measures analysis, participants used self-generated identification codes. The participants were informed that participation did not affect academic evaluation.

The sample size was calculated using G*Power 3.1.9.7 (effect size = 0.25, significance level = 0.05, power = 0.80, 3 measurements). A minimum of 86 participants was required, and 104 participants were recruited after accounting for potential dropouts. Of the 104 participants initially recruited, 11 were excluded from the final analysis because of withdrawal for personal reasons or incomplete responses. Data from 93 participants were included in the final analysis (Fig. 1).

Fig. 1.

Flow diagram of participant recruitment, allocation, and analysis

Hypotheses

The study hypotheses are as follows:

• Hypothesis 1. There will be a significant group-by-time interaction effect on disaster nursing competence.

• Hypothesis 2. There will be a significant group-by-time interaction effect on disaster preparedness.

• Hypothesis 3. There will be a significant group-by-time interaction effect on transfer motivation.

• Hypothesis 4. There will be a significant group-by-time interaction effect on learning self-efficacy.

Development of a community-based disaster nursing tabletop simulation program

The community-based disaster nursing tabletop simulation program implemented in this study was designed to train nursing students in the core response competencies required to minimize mortality and morbidity and maintain the continuity of essential healthcare services in disaster situations. These training objectives align with United Nations’ Sustainable Development Goal (SDG) 3 (Good Health and Well-Being), which aims to reduce health losses and strengthen health security. The program was developed by the research team and implemented according to the Analysis–Design–Development–Implementation–Evaluation (ADDIE) model to ensure a systematic educational design.

Step 1. analysis

The literature review examined key design elements of simulation-based disaster education, as well as performance elements such as initial assessment, triage, first aid, patient transport coordination, and interprofessional communication, which are essential in community disaster nursing. Noting that simulation can help observe and evaluate the process by which learners transfer prior learning to decision-making in disaster situations [24], we expanded the analytical framework to include transfer-related variables rather than limiting the effectiveness of education to knowledge improvement alone.

We also conducted a survey and focus group interview with 10 fourth-year nursing students to assess their level of disaster nursing knowledge, experience with disaster education and simulation, and educational needs. The needs analysis revealed that existing disaster education tends to be theory-driven and lacks learning experiences that allow students to repeatedly practice team-based decision-making, resource allocation, and communication in a community context.

Step 2. design

Establishing learning objectives

Learning objectives were established to minimize health losses and maintain continuity of essential healthcare services in disaster situations. In addition, the objectives were designed to enable nursing students to communicate effectively with team members in disaster situations and carry out emergency medical response procedures from the time of the incident to the completion of casualty transport at the disaster site. These objectives were implemented in accordance with the on-site emergency medical response procedures outlined in the Disaster Emergency Medical Response Manual of the Ministry of Health and Welfare of South Korea [25].

Training organization

The training consisted of a lecture and pre-briefing (100 min), task training (20 min), team learning (10 min), simulation (20 min), debriefing (40 min), and evaluation and closing (10 min). The pre-learning materials included the Korean disaster management system, stages of emergency medical response in disasters, roles and functions of public health centers and on-site emergency medical centers, triage criteria, and the 3T procedure. These materials were designed to help learners transition from “knowledge” to “performance” in a hypothetical scenario [24].

Step 3. development

Scenario development

The scenario was developed to simulate a community mass casualty event involving the collapse of an old apartment building during remodeling. A Code Orange alert was triggered by the Central Emergency Medical Dispatch Center, involving the following:

• Establishment and operation of on-site emergency medical centers.

• Severity triage based on the Simple Triage and Rapid Treatment (START) system.

• Provision of emergency care and priority decision-making under limited resources.

• Patient transport decision-making based on hospital capacity and available resources.

• Response to unexpected situations in disaster settings (e.g., injuries to medical personnel, traffic jams, unauthorized entry of reporters into secondary control lines during coverage).

Content validation and preliminary research

The first-aid and scenario content were validated by consensus among four experts in disaster nursing, comprising two members of the research team and two external experts: a professor of adult nursing, a professor of emergency medicine, a nurse with more than 10 years of intensive care unit experience, and a nurse with more than 10 years of emergency department experience. The content validity was assessed following Lynn’s procedure [26] and met the criteria of an item-level content validity index (I-CVI) of 0.80 or higher and a scale-level content validity index (S-CVI) of 0.90 or higher.

Moreover, a preliminary survey was conducted with seven nursing students to confirm the feasibility and clarity of the program. The unexpected elements of the scenarios were improved based on participant feedback.

Step 4. Implementation

The program was conducted over five weeks, from August 18 to September 19, 2025, with groups of 8–9 students. The students were assigned roles within the public health rapid response team and the Disaster Medical Assistance Team (DMAT). They were divided into triage, first aid, and transportation teams.

To enhance realism, sirens were sounded, cordons were established, and a tent was setup to represent the on-site emergency medical station. Students were required to apply the 3T procedure to 20 casualties within 20 min, with the accuracy of role performance and effectiveness of team communication as key performance criteria. To ensure intervention fidelity, all tabletop simulation sessions were conducted by the principal investigator using a standardized protocol. All participant groups received identical scenarios, educational content, session duration, evaluation criteria, and the same performance checklist to ensure consistent implementation across groups. This design was consistent with evidence that scenario-based simulation training enhances learner self-efficacy and performance [27].

Step 5. Evaluation

The program’s educational outcomes were evaluated by focusing on changes in disaster nursing competencies, disaster preparedness, transfer motivation, and learning self-efficacy.

Outcome measures

The research instrument comprised 10 questions on general characteristics and 50 questions on disaster nursing competency, disaster preparedness, transfer motivation, and learning self-efficacy. These questions were designed to assess the program’s effectiveness and were modified and supplemented according to the program’s learning objectives.

Disaster nursing competency and disaster preparedness, which represent the direct goals and core outcomes of disaster nursing education, were designated as the primary outcome because they are central to evaluating the effectiveness and potential applicability of the program [4, 28]. Transfer motivation and learning self-efficacy, which are extended indicators describing the psychological conditions for transferring and sustaining competency improvement in actual practice, were classified as secondary outcomes [11, 24] to clarify the research hypotheses, ensure adequate statistical power, control multiple comparisons, and prioritize interpretation. These classifications helped enhance the reliability and applicability of the conclusions [29].

An expert panel of five nursing professors with experience in conducting simulation-based training was formed to evaluate the revised instrument for content validity through two rounds of review (I-CVI ≥ 0.98; S-CVI ≥ 0.90). The original response scales of the validated instruments were retained for all outcome measures.

Disaster nursing competency

In this study, disaster nursing competency was defined as a performance ability that integrates knowledge, skills, and clinical judgment required of nursing students during the preparation and response phases of a disaster. Prior discussions grounded in the International Council of Nurses (ICN) disaster nursing competency framework [30] and reports of ICN core competency areas (preparation, communication, assessment, intervention, and safety) observed in actual disaster responses [31] served as the theoretical basis for this definition. Disaster nursing competency was measured using a 26-item tool developed by Park [32] based on the ICN, which was modified and supplemented to fit the learning objectives of this study’s tabletop simulation.

Through a second content validity review by an expert panel, nine items with an I-CVI of less than 0.80 in the first evaluation were deleted or separated into integrated semantic items; item wording was clarified, and two items were added based on the learning objectives. The revised 20 items were subjected to a second content validity test, and all items had an I-CVI of 0.80 or higher, with an average I-CVI of 0.98. A 5-point Likert scale was used, ranging from 1 = “not at all true” to 5 = “very true,” with a total score ranging from 20 to 100. Higher scores indicated higher disaster nursing competency. The internal consistency reliability (Cronbach’s α) was 0.95 at the time of tool development. In this study, it was 0.95, 0.97, and 0.97 for the first, second, and third surveys, respectively.

Disaster preparedness

Disaster preparedness was defined as the state of readiness to carry out an actual response to a possible disaster, with plans, resources, training, and role recognition. Based on Park’s tool [32], the items were reorganized to align with the educational objectives of this study. Of the original 14 items, five were deleted and one was added, resulting in 10 items.

Secondary content validity testing was conducted on the revised 10 items, and all items had an I-CVI of 0.80 or higher, with an average I-CVI of 1.00. The measure used a 5-point Likert scale (1 = “not at all” to 5 = “very much”), with a total score ranging from 10 to 50. Higher scores indicated higher levels of disaster preparedness. Cronbach’s α was 0.88 in Park’s study [32] and 0.89 in this study, with values of 0.93, 0.94, and 0.94 for the first, second, and third surveys, respectively.

Transfer motivation

Transfer motivation was defined as an individual’s willingness to apply knowledge and skills acquired through education and training to the actual performance context. In this study, transfer motivation was measured using the scale developed by Park and Kweon [33]. The final scale comprised 10 items and was constructed by deleting one redundant item, adding one item, and clarifying the wording for some items following expert content validity review. The I-CVI of the 10-item scale ranged from 0.8 to 1.0.

A 7-point Likert scale was used, ranging from 1 = “not at all” to 7 = “very much,” with a total score ranging from 10 to 70. Higher scores indicated a higher transfer motivation. Cronbach’s α was 0.94 in the study by Park and Kweon [33]. In this study, it was 0.95, 0.96, and 0.97 for the first, second, and third surveys, respectively.

Learning self-efficacy

Learning self-efficacy was defined as a learner’s belief in their ability to successfully perform specific learning tasks. This study used the scale developed by Park and Kweon [33]. The wording of several items was clarified during expert content validation. After the first review, a second content validity test was conducted on the revised 10 items, with I-CVI values ranging from 0.8 to 1.0.

A 7-point Likert scale was used, ranging from 1 = “not at all” to 7 = “very much,” with a total score ranging from 10 to 70. Higher scores indicated higher self-efficacy. Cronbach’s α was 0.95 in the study by Park and Kweon [33]. In this study, it was 0.95, 0.95, and 0.96 for the first, second, and third surveys, respectively.

Data analysis

The collected data were analyzed using IBM SPSS Statistics 26.0 (IBM Corp., Armonk, NY, USA). The general characteristics of the participants were presented as frequencies, percentages, means, and standard deviations.

Baseline homogeneity between the groups was analyzed by conducting an independent samples t-test and an χ² test. To evaluate the effectiveness of the intervention, between-group differences in disaster nursing competence, transfer motivation, disaster preparedness, and learning self-efficacy for the experimental and control groups immediately post-intervention and four weeks after the intervention were analyzed using the independent t-test. The main effect of time and the group-by-time interaction effect were analyzed using repeated measures analysis of variance (ANOVA). The sphericity assumption was checked by conducting Mauchly’s test, and if this assumption was violated, the Greenhouse–Geisser correction was applied. Post hoc evaluations were performed using the Bonferroni test. Between-group comparisons at each time point were conducted using independent-samples t-tests to support interpretation of the group × time interaction effects. Because these between-group comparisons were pre-specified and conducted for interpretive purposes rather than exploratory purpose, no additional multiplicity correction was applied. All statistical tests were two-tailed, with a significance level of p < .05.

Results

Participant characteristics

A total of 93 participants were included in the final analysis, comprising 43 in the experimental group and 50 in the control group. The mean age of the participants was 23.69 ± 3.10 years, with 68 (73.1%) female students. No significant differences (p > .05) were observed between the two groups in the general characteristics compared in this study, including academic achievement, major satisfaction, clinical practice satisfaction, disaster experience, disaster nursing education experience, residential area safety, and intention to participate in disaster response (Table 1).

Table 1.

Baseline characteristics of participants by group (N = 93)

Characteristics	Category	Total (N = 93)	Cont. (n = 50)	Exp. (n = 43)	χ² or t	p
		n (%) or M ± SD	n (%) or M ± SD	n (%) or M ± SD
Age		23.69 ± 3.10	24.04 ± 3.60	23.28 ± 2.38	1.18	0.240
Sex	Female	68 (73.1)	35 (70.0)	33 (76.7)	0.54	0.465
	Male	25 (26.9)	15 (30.0)	10 (23.3)
Academic Grade	< 3.5	26 (28.0)	14 (28.0)	12 (27.9)	0.24	0.888
	3.5 ~ 3.9	41 (44.1)	23 (46.0)	18 (41.9)
	≥ 4.0	26 (28.0)	13 (26.0)	13 (30.2)
Major Satisfaction	Dissatisfied	1 (1.1)	0 (0)	1 (2.3)	2.55*	0.246
	Moderate	19 (20.4)	8 (16.0)	11 (25.6)
	Satisfied	73 (78.5)	42 (84.0)	31 (72.1)
Clinical Practice Satisfaction	Dissatisfied	5 (5.4)	1 (2.0)	4 (9.3)	4.90*	0.090
	Moderate	26 (28.0)	11 (22.0)	15 (34.9)
	Satisfied	62 (66.7)	38 (76.0)	24 (55.8)
Disaster Experience	No	71 (76.3)	39 (54.9)	32 (45.1)	0.16	0.685
	Yes	22 (23.7)	11 (50.0)	11 (50.0)
Disaster Nursing Education Experience	No	85 (93.4)	44 (91.7)	41 (95.3)	0.50*	0.680
	Yes	6 (6.6)	4 (8.3)	2 (4.7)
Residential Area Safety	Vulnerable	7 (7.6)	4 (8.2)	3 (7.0)	0.56*	0.836
	Moderate	22 (23.9)	13 (26.5)	9 (20.9)
	Safe	63 (68.5)	32 (65.3)	31 (72.1)
Intention to Participate in Disaster Response		4.40 ± 0.63	4.40 ± 0.64	4.40 ± 0.62	0.10	0.923

Note. Cont. = control group; Exp. = experimental group; * = Fisher’s exact test

Baseline homogeneity

No significant differences were observed between the groups in the pre-test scores for the primary dependent variables: disaster nursing competency, disaster preparedness, transfer motivation, and learning self-efficacy. The disaster nursing competency scores were 72.50 ± 13.62 for the control group and 69.60 ± 12.57 for the experimental group (t = 1.06, p = .292). Transfer motivation (t = 0.53, p = .596) and learning self-efficacy (t = 1.11, p = .272) were also not statistically significant (Table 2).

Table 2.

Comparison of baseline outcome variables between the groups (N = 93)

Variable	Total (N = 93) M ± SD	Cont. (n = 50) M ± SD	Exp. (n = 43) M ± SD	t	p
Disaster nursing competency	71.16 ± 13.16	72.50 ± 13.62	69.60 ± 12.57	1.06	0.292
Disaster preparedness	36.85 ± 6.13	37.48 ± 6.08	36.12 ± 6.17	1.07	0.287
Transfer motivation	58.01 ± 8.36	58.44 ± 8.05	57.51 ± 8.78	0.53	0.596
Learning self-efficacy	60.40 ± 6.98	61.14 ± 6.64	59.53 ± 7.35	1.11	0.272

Notes. Cont. = control group; Exp. = experimental group

Effects on disaster nursing competency

The pre-intervention mean scores for disaster nursing competency were 72.50 ± 13.62 for the control group and 69.60 ± 12.57 for the experimental group. Immediately after the program, the scores were 76.54 ± 12.42 for the control group and 88.81 ± 8.74 for the experimental group, showing a statistically significant difference between the two groups (t = − 5.43, p < .001). Four weeks later, the scores were 81.40 ± 12.95 for the control group and 89.35 ± 9.30 for the experimental group, with the experimental group maintaining significantly higher scores (t = − 3.35, p = .001) (Table 3). Therefore, Hypothesis 1 was supported.

Table 3.

Changes in disaster nursing competency, disaster preparedness, transfer motivation, and learning self-efficacy across three time points (N = 93)

Variable	Group	T1a	T2b	T3c		F	p
		M ± SD	M ± SD	M ± SD
Disaster nursing competency	Cont. (n = 50)	72.50 ± 13.62	76.54 ± 12.42	81.40 ± 12.95	Group	7.73	0.007
	Exp. (n = 43)	69.60 ± 12.57	88.81 ± 8.74	89.35 ± 9.30	Time	87.76	< 0.001 a < b < c
	t (p)	1.06 (0.292)	-5.43 (< 0.001)	-3.35 (0.001)	Group*Time	23.13	< 0.001
Disaster preparedness	Cont. (n = 50)	37.48 ± 6.08	38.46 ± 5.83	40.70 ± 6.06	Group	11.21	0.001
	Exp. (n = 43)	36.12 ± 6.17	45.07 ± 3.98	44.81 ± 4.34	Time	60.13	< 0.001 a < b, c
	t (p)	1.07 (0.287)	-6.28 (< 0.001)	-3.71 (< 0.001)	Group*Time	24.53	< 0.001
Transfer motivation	Cont. (n = 50)	58.44 ± 8.05	60.28 ± 7.02	61.12 ± 8.95	Group	0.96	0.329
	Exp. (n = 43)	57.51 ± 8.78	64.05 ± 7.56	62.47 ± 7.56	Time	18.83	< 0.001 a < b, c
	t (p)	0.53 (0.596)	-2.49 (0.015)	-0.78 (0.440)	Group*Time	4.83	0.011
Learning self-efficacy	Cont. (n = 50)	61.14 ± 6.64	61.56 ± 5.79	62.38 ± 7.51	Group	0.52	0.472
	Exp. (n = 43)	59.53 ± 7.35	64.35 ± 7.33	63.74 ± 6.47	Time	9.74	< 0.001 a < b, c
	t (p)	1.11 (0.272)	-2.05 (0.043)	-0.93 (0.355)	Group*Time	5.14	0.009

Note. Cont. = control group; Exp. = experimental group; a = pre-test, b = immediate post-test, and c = 4-week follow-up. Bonferroni-adjusted post hoc test

Repeated measures ANOVA revealed a significant main effect of group (F = 7.73, p = .007, partial η² = 0.08, 95% CI: 0.01–0.20) and a significant interaction effect between group and time point (F = 23.13, p < .001, partial η² = 0.20, 95% CI: 0.10–0.30). The mean disaster nursing competency score in the experimental group increased from 69.60 at pre-test to 88.81 at immediate post-test and 89.35 at the 4-week follow-up. The corresponding mean scores in the control group were 72.50, 76.54, and 81.40, respectively. Bonferroni post hoc analysis revealed significant differences at all time points: pre-test–post-test, pre-test–4 weeks post-test, and post-test–4 weeks post-test (Table 3; Fig. 2).

Fig. 2.

Trajectories of outcome variables across time in the experimental and control groups

Effects on disaster nursing preparedness

The mean pre-intervention scores were 37.48 ± 6.08 for the control group and 36.12 ± 6.17 for the experimental group. Immediately after the intervention, a significant difference was observed between the two groups (t = − 6.28, p < .001): 38.46 ± 5.83 for the control group and 45.07 ± 3.98 for the experimental group. After four weeks, the scores remained significantly higher in the experimental group (40.70 ± 6.06 in the control group and 44.81 ± 4.34 in the experimental group, t = − 3.71, p < .001) (Table 3). Therefore, Hypothesis 2 was supported.

Repeated measures ANOVA revealed significant main effects of group (F = 11.21, p = .001, Partial η² = 0.11, 95% CI: 0.02–0.24) and a significant group × time interaction (F = 24.53, p < .001, Partial η² = 0.21, 95% CI: 0.11–0.31). The mean disaster preparedness score in the experimental group increased from 36.12 at pre-test to 45.07 at immediate post-test and 44.81 at the 4-week follow-up, whereas the control group increased from 37.48 to 38.46 and 40.70, respectively. Bonferroni post hoc analyses revealed significant changes from pre- to post-intervention and from pre-intervention to four weeks post-intervention (Table 3; Fig. 2).

Effects on transfer motivation

The mean transfer motivation scores in the control group were 58.44 ± 8.05 at pre-test, 60.28 ± 7.02 at immediate post-test, and 61.12 ± 8.95 at the 4-week follow-up. The corresponding mean scores in the experimental group were 57.51 ± 8.78, 64.05 ± 7.56, and 62.47 ± 7.56, respectively. The between-group difference was significant at immediate post-test (t = − 2.49, p = .015), but not at the 4-week follow-up (t = − 0.78, p = .440) (Table 3). Therefore, Hypothesis 3 was partially supported.

Repeated measures ANOVA showed that the main effect of group was not significant (F = 0.96, p = .329, partial η² = 0.01, 95% CI: 0-0.09), whereas the main effect of time (F = 18.83, p < .001, partial η² = 0.17, 95% CI: 0.07–0.27) and the group × time interaction (F = 4.83, p = .011, partial η² = 0.05, 95% CI: 0.01–0.12) were significant. The mean transfer motivation score in the experimental group increased from 57.51 at pre-test to 64.05 at immediate post-test and then slightly decreased to 62.47 at the 4-week follow-up. The corresponding mean scores in the control group were 58.44, 60.28, and 61.12, respectively. Bonferroni post hoc analyses revealed significant changes between the pre- and post-tests and between the pre-test and four weeks post-test (Table 3; Fig. 2).

Effects on learning self-efficacy

The pre-intervention mean scores for learning self-efficacy were 61.14 ± 6.64 for the control group and 59.53 ± 7.35 for the experimental group. Immediately after the intervention, the scores were 61.56 ± 5.79 for the control group and 64.35 ± 7.33 for the experimental group, indicating a significant difference (t = − 2.05, p = .043). However, after four weeks, the scores were 62.38 ± 7.51 for the control group and 63.74 ± 6.47 for the experimental group, suggesting no significant difference between the two groups (t = − 0.93, p = .355) (Table 3). Therefore, Hypothesis 4 was partially supported.

The results of the repeated measures ANOVA suggested that the main effect of group was not significant (F = 0.52, p = .472, Partial η² = 0.01, 95% CI: 0-0.07), but the effect of time (F = 9.74, p < .001, partial η² = 0.10, 95% CI: 0.02–0.18) and the group × time interaction effect (F = 5.14, p = .009, partial η² = 0.05, 95% CI: 0.01–0.13) were significant. The mean learning self-efficacy score in the experimental group increased from 59.53 at pre-test to 64.35 at immediate post-test and then slightly decreased to 63.74 at the 4-week follow-up, whereas the control group increased from 61.14 to 61.56 and 62.38, respectively. Bonferroni post hoc analyses revealed significant changes between the pre- and post-tests and between the pre-test and 4-week follow-up (Table 3; Fig. 2).

Discussion

This study implemented a quasi-experimental design with repeated measures to examine the effects of a community-based disaster nursing tabletop simulation program on nursing students’ disaster nursing competencies, disaster preparedness, transfer motivation, and learning self-efficacy. The results showed significant improvements in the experimental group overall, with a tendency for these gains to be maintained after the intervention.

Disaster nursing competence improvement: the transition from “understanding” to “performance”

Disaster nursing competence demonstrated a large group-by-time interaction effect (partial η² = 0.20), indicating that the intervention produced a substantial improvement over time compared with the control group. These results likely reflect the fact that the tabletop simulation provided a learning environment that required the integrated application of triage, prioritization, decision-making under resource constraints, and coordination of roles and communication within a team, rather than the mere reproduction of knowledge. Previous findings, which indicated unfolding tabletop simulations as a strategy for sustainably and interactively training nursing students in core disaster response skills—such as communication, prioritization, teamwork, and delegation—support the results of this study [17].

Even in medical institutions such as hospitals, the frequency of full-scale disaster drills is often limited due to time and financial constraints. Therefore, prior discussions indicating that tabletop exercises can enhance frontline decision-makers’ (e.g., charge nurses’) understanding of response procedures and leadership further support the practical significance of this study [34].

Improving disaster preparedness: simultaneous enhancement of confidence, role clarity, and the concretization of action plans

Disaster preparedness showed an interaction effect between group and time point (F = 24.53, p < .001). Disaster preparedness is not merely a measure of knowledge but a complex concept encompassing confidence, role clarity, psychological readiness, and the concretization of action plans [35]. In this study, the improvement in preparedness among the experimental group suggested that team-based discussions and decision-making processes helped form a cognitive framework regarding “what I can do, with whom, and in what order.” The tabletop simulation results—which demonstrated participants’ ability to identify gaps in their plans, alongside improvements in knowledge and confidence following the training—demonstrated that tabletop simulations can not only help assess individual-level confidence but also evaluate system-level preparedness [17].

Disaster education programs targeting nursing students in Korea have also shown significant improvements in disaster nursing competencies (knowledge, triage, and preparedness) [4], and a systematic review indicating that disaster preparedness is linked to disaster experience and training further supports the need for education [36]. This suggests that the present findings go beyond one-time satisfaction and reaffirm the role of education and training as a key determinant of disaster preparedness.

Transfer motivation increased immediately after the intervention and declined slightly at follow-up, although it remained above baseline, with a significant group-by-time interaction. From the perspective of social cognitive theory, this pattern suggests that tabletop simulation strengthened not only learners’ beliefs in their capability to perform disaster-related tasks but also their willingness to apply what they had learned in practice [12]. Engaging in scenario-based decision-making, team discussion, and role negotiation may have provided mastery experiences, while observing peers’ reasoning and receiving facilitator-led debriefing may have contributed to vicarious experience and verbal persuasion [13, 37]. This interpretation is consistent with a previous finding that disaster-based tabletop exercises can facilitate the transfer of prior learning to realistic decision-making [24] and with evidence from a randomized controlled trial in an infectious disease disaster context showing significant improvements in both transfer motivation and learning self-efficacy [11].

However, the modest decline at follow-up suggests that transfer motivation is not sustained by intrapersonal factors alone. In social cognitive theory, behavior maintenance depends on reciprocal interactions among personal beliefs, behavioral opportunities, and environmental supports [12]. Thus, the immediate post-intervention increase may reflect heightened agency and perceived applicability, whereas longer-term maintenance appears to require opportunities for enactment, reinforcement, and structured feedback. This interpretation also aligns with qualitative evidence indicating that the organization and curricular integration of simulation-based training shape students’ transfer experiences [38]. Accordingly, future institutional curricula could incorporate periodic booster sessions, such as refresher micro-modules or follow-up tabletop simulation activities, to reinforce learning over time. In addition, transfer-supportive instructional strategies, including field-linked application tasks, repeated debriefing, and reflection-based feedback, may help sustain learners’ transfer motivation and facilitate the continued application of acquired knowledge and skills beyond the initial training period [39]. Learning self-efficacy also showed a significant group-by-time interaction, suggesting that the intervention strengthened an important psychological foundation for disaster response. According to social cognitive theory, self-efficacy is a central personal resource that influences whether individuals initiate, sustain, and persist in action under demanding conditions [12]. In the present study, tabletop simulation appears to have activated several major sources of self-efficacy. Team-based problem-solving and prioritization may have generated mastery experiences; peer interaction and observation may have offered vicarious learning; and facilitator coaching and debriefing may have functioned as social persuasion [13]. Evidence that even observers can improve self-efficacy in simulation settings further supports the possibility that the gains observed in this study were produced not only through direct task participation but also through the collective and dialogic structure of the learning environment [37].

This interpretation is important because disaster response self-efficacy has practical implications beyond the classroom. Previous research has shown that disaster response self-efficacy is associated with the willingness to work in actual disaster settings and mediates the pathway through which disaster anxiety reduces the willingness to respond [14]. Accordingly, the improvement in learning self-efficacy observed in this study may represent more than transient confidence or educational satisfaction; it may reflect the strengthening of a psychological resource that supports engagement and persistence under uncertainty. In addition, prior evidence that repeated simulation-based disaster nursing education significantly improves disaster response self-efficacy [8] provides a plausible explanation for the slight decline observed at follow-up. Although a single intervention may produce an initial efficacy gain, long-term maintenance is more likely when learners are exposed repeatedly to progressively challenging tasks and systematic performance feedback [12]. Future programs should therefore consider booster sessions and staged scenario progression as strategies to reinforce and sustain self-efficacy over time.

Practical implications: educational and policy implications

This study suggests that a community-based disaster nursing tabletop simulation can improve nursing students’ disaster response capacity, preparedness, willingness to practice, and learning self-efficacy. These findings have practical significance from an SDG 3 perspective because they support educational efforts to reduce disaster-related health losses and strengthen health-system response capacity. They also reinforce the foundations of climate-responsive nursing competence for increasingly frequent and complex community emergencies. Climate change is now recognized as a major public health threat that requires nurses to develop not only technical emergency response skills but also climate–health literacy, resilience, collaborative decision-making, and sustainability-oriented practice [40]. Evidence that nursing students’ climate change awareness and climate anxiety are significantly associated with sustainability attitudes further supports the view that disaster nursing education should help convert climate-related concern into practical professional competence and sustainable action [40]. In parallel, community-based education has been shown to strengthen professional skills, communication, self-confidence, critical thinking, and teamwork among nursing students [18]. This finding suggests that disaster nursing education may be especially effective when situated within local community contexts where preparedness and response are actually enacted [41].

Tabletop simulation has particular practical value because it is relatively low-burden, repeatable, and feasible in settings where high-fidelity simulation is difficult to implement [42]. It is especially suited to structured reasoning, prioritization, role clarification, and team-based decision-making in complex community disaster scenarios. However, tabletop simulation should not be interpreted as the only effective modality. A recent randomized controlled trial by Aslan and Erkayıran likewise found that peer education, role-play simulation, and a virtual escape room all improved therapeutic interaction skills, although each modality demonstrated different pedagogical strengths in interaction, immersion, and learner engagement [43]. This interpretation is consistent with the wider simulation literature. Virtual reality-based simulation has shown significant positive effects on nursing competence and offers immersive and repeatable learning opportunities [44], while virtual disaster simulation can enhance learning self-efficacy and transfer motivation [7]. Likewise, high-fidelity simulation, computer-based simulation, and combined approaches appear broadly comparable in improving knowledge, critical thinking, collaboration, and learning interest, although short-term skill gains may differ across formats, indicating that modality selection should be aligned with intended learning outcomes [45]. Game-based approaches such as escape rooms may also improve motivation, problem-solving, teamwork, and engagement [46, 47]. Accordingly, the key educational question is not which modality is universally superior but which combination is most appropriate for the target competencies. A blended simulation curriculum may therefore be preferable, with tabletop simulation used for collaborative planning and judgment; role-play or full-scale/high-fidelity simulation for communication and affective engagement; and virtual or game-based modalities for accessibility, repetition, and scalability [44, 45].

Therefore, the findings of the present study support the value of tabletop simulation in disaster nursing education; however, these effects should not be overgeneralized. Simulation-based education is generally beneficial, but it does not always produce immediate or consistent gains. For example, a recent systematic review of simulation-based education reported improvements in knowledge, skills, and self-efficacy across multiple studies, but affective outcomes were mixed and the limited follow-up data warranted cautious interpretation regarding retention [48]. Likewise, a meta-analysis of immersive virtual reality in nursing students found significant improvements in knowledge and self-efficacy, whereas psychomotor skill performance was not significantly enhanced, and satisfaction and confidence were inconsistent; some benefits also diminished at follow-up [49]. These findings suggest that the effects of simulation may vary depending on the educational modality, intervention intensity, opportunities for repeated practice, the quality of feedback and debriefing, and the length of follow-up [48, 49]. Accordingly, tabletop simulation should be understood as a useful and scalable educational strategy for improving disaster nursing competence and preparedness, but not as a universally superior standalone intervention; rather, it may be most effective when combined with other simulation modalities and reinforcement strategies that support transfer over time.

Limitations and future research

This study has several limitations that should be considered when interpreting the findings.

First, because a non-equivalent control design with non-randomized assignment was used, selection bias cannot be excluded and causal inference remains limited. Although both campuses operate under the standardized accreditation requirements of the Korean Accreditation Board of Nursing Education, the possibility that unmeasured institutional or campus-level differences influenced the study outcomes cannot be completely ruled out. Therefore, residual selection bias should be considered when interpreting the intervention effects and generalizing the findings beyond the study groups.

Second, the study was conducted in a single course at one institution, which restricts the generalizability of the findings to other curricular, institutional, and sociocultural contexts. In addition, although relevant baseline characteristics were homogeneous between the groups, unmeasured factors such as prior healthcare-related experience may have influenced the outcomes. Future studies should examine these variables as potential confounders or moderators.

Third, the experimental group received the tabletop simulation in addition to standard classroom instruction, whereas the control group received only standard classroom instruction. Therefore, some of the observed between-group differences may have resulted from the additional educational exposure, increased time spent engaging with disaster-related content, or the attention and novelty associated with the active, hands-on simulation, rather than by the specific mechanism of tabletop simulation alone. Future studies should consider using an active control condition with comparable instructional time to better isolate the unique effects of tabletop simulation.

Fourth, the outcomes were assessed using self-reported, scale-based measures, which reflect perceived rather than objectively demonstrated competence. Therefore, the findings may be subject to social desirability and response biases and may not fully reflect participants’ actual performance.

Fifth, the validated instruments were modified to align with the learning objectives of the intervention. Although content validity was established through expert review, modification of the instruments may have influenced their original psychometric properties.

Finally, the relatively short follow-up period does not permit adequate evaluation of whether the observed gains are maintained over time or transferred into actual disaster response behaviors. These limitations are important because prior studies on disaster nursing education have similarly reported beneficial short-term effects while emphasizing the need for more rigorous designs, repeated training, and longer-term assessment of sustained competence and practical application [10, 14, 50]. Therefore, the present findings should be interpreted as preliminary rather than definitive evidence of effectiveness. Future research should include multicenter studies and randomized designs where feasible, incorporate checklist-based behavioral observation and objective performance indicators, and examine the long-term effects of booster sessions and repeated training on self-efficacy and skill retention. It should also compare the educational benefits and cost-effectiveness of tabletop simulation with other modalities such as full-scale simulation and virtual reality [11, 51, 52].

Conclusions

The findings of this study suggest that tabletop simulation contributes not only to the acquisition of disaster-related knowledge and response skills but also to learners’ learning self-efficacy and willingness to apply what they have learned in real-world disaster situations. These results provide empirical support for integrating tabletop simulation into disaster nursing curricula, highlighting its value as an educational strategy that extends beyond cognitive outcomes to affective and behavioral readiness.

However, increased willingness to apply learning should not be interpreted as inherently sustained over time. Sustaining transfer motivation may require intentional structural support within the program design, including repeated practice, structured debriefing, timely feedback, and explicit alignment of simulation experiences with real-world clinical or community disaster response contexts. In this regard, the significance of this study extends beyond immediate educational effects to informing the design of disaster nursing programs that foster durable learning transfer. Further research is needed to confirm and extend these findings to diverse settings and over longer follow-up periods.

Abbreviations

3T

Triage, Treatment, and Transport

ADDIE

Analysis, Design, Development, Implementation, Evaluation

ANOVA

Analysis of Variance

COVID-19

Coronavirus disease 2019

DMAT

Disaster Medical Assistance Team

ICN

International Council of Nurses

I-CVI

Item-level content validity index

IRB

Institutional Review Board

S-CVI

Scale-level content validity index

SDG

Sustainable Development Goal

START

Simple Triage and Rapid Treatment

Author contributions

MC and MK contributed equally as co-first authors. MC and MK conceptualized and designed the study, drafted the manuscript, and provided critical revisions. HC supervised the study, conducted data collection and analysis, and approved the final manuscript. All authors read and approved the final manuscript.

Funding

This study was supported by Eulji University in 2025 (EJRG-25-06). The funder had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to institutional and ethical restrictions.

Declarations

Ethical approval and consent to participate

This study was approved by the Institutional Review Board (IRB) of Eulji University (IRB No. EU25-017). All procedures involving human participants were conducted in accordance with the ethical standards of the IRB and the Declaration of Helsinki. Written informed consent was obtained from all participants prior to participation in the study. A small token of appreciation was provided to participants for their participation.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.