Asia-pacific Journal of Multimedia Services Convergent with Art, Humanities, and Sociology Vol.9, No.4, April (2019), pp

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1 Asia-pacific Journal of Multimedia Services Convergent with Art, Humanities, and Sociology Vol.9, No.4, April (2019), pp 호흡기질환환자간호를위한시뮬레이션설계및평가 최윤하 채민정 요약 본연구의목적은만성폐쇄성폐질환 환자시뮬레이션시나리오를적용하여간호학생의문제해결과정과학습태도에미치는영향을확인하기위한단일군사전 사후설계연구이다 시나리오는전문가들로구성하여 에서제시고하고있는시나리오를기반으로우리나라임상상황에맞게구성하였다 이시나리오는 년 월자발적인참여의사를밝힌 학년간호학생을대상으로실시되었다 시나리오는문제인식 간호사정 중재 평가의 단계로구성하였으며실제임상상황과유사한환경을제공해주는 를활용하였다 환자시뮬레이션시나리오사용전에학생들의문제해결과정과학습태도정도를측정하였으며교육전보다후에점수가향상되었음을확인할수있었다 본연구결과를토대로간호학생들을위한시뮬레이션교육이확대되어야하며다양한시나리오개발이필요할것으로본다 핵심어 시뮬레이션 시나리오 문제해결과정 학습태도 간호학생 Abstract The purpose of this study is to investigate the effect of simulation scenario of patients with chronic obstructive pulmonary disease on the problem solving process and learning attitude of nursing students. Scenario development is composed of experts and constructed according to the clinical situation of Korea based on scenario presented in simulation in nursing education (Laerdal). This scenario was conducted for third year nursing students who voluntarily participated in July The contents of the scenario consisted of four stages of problem recognition, nursing assessment, intervention, and evaluation. SimMan3G was used to provide an environment similar to the actual clinical situation. We measured the students' learning attitudes and problem solving process before using COPD patient simulation scenario. As a result, it was confirmed that the attitude of problem solving process and learning attitude improved after the training. Based on the results of this study, simulation training for nursing students should be expanded and various Received (March 26, 2019), Review Result(April 5, 2019) Accepted(April 10, 2019), Published(April 30, 2019) ISSN: AJMAHS Copyright 2019 HSST 413

2 scenarios developed Keywords: simulation, scenario, problem solving process, learning attitude, nursing student 서론 빠르게변화하고있는보건의료환경은환자의권리강화, 안전관리의중요성증가로효과적인실무능력을갖춘전문직간호사로서의역량을요구하고있으며 [1] 학생들은다양한술기를경험하고싶지만직접간호보다는관찰이나모니터링위주의실습이이루어지고있어충분한수행능력을발휘하기가어려운실정이다 [2]. 현재간호교육은과학적지식체를바탕으로비판적인의사결정, 환자상황에따른간호사정, 안전하고효과적인간호중재를제공할수있도록임상실습교육에많은신경을쓰고있다 [3]. 임상실습은간호학생들이이론적지식이나개념수준에머물지않고배운지식을통합하여졸업후간호사로서핵심역량과문제해결능력을갖출수있도록이루어져야한다 [4]. 시뮬레이션기반임상실습교육은임상적환경을모의현실로적용한것으로가상의시나리오를통해환자시뮬레이터 (Human patient Simulator) 를활용하여학습자스스로문제를직접해결할수있도록실습환경을제공해주는것이다 [5]. 이는학습자의적극적인참여를촉진하며이론과실무의통합을포함하는과정 [6] 으로환자의안전을위협하지않고도임상술기의반복학습이이루어져임상수행능력을향상시킬수있다 [4]. 또한의사소통능력, 타부서간의협의, 비판적사고능력등의교육을포함해수행과정을점검할수있는디브리핑은효과적인자기성찰과구체적인학습의기회를제공할수있게해준다 [1][2]. 선행연구에서간호학생들에제공하는시뮬레이션교육이지식과임상수행능력 [7-10], 학습태도 [9], 자신감과자기효능감 [11][12], 문제해결능력 [8][12][13] 을향상시키는데효과적인것으로나타났다. 시뮬레이션실습사례로는호흡기계관련환자및심장질환환자간호 [1], 열성경련환아간호 [2], 호흡곤란증후군환아간호 [13], 만성폐쇄성폐질환, 뇌경색, 당뇨병, 허혈성심질환간호 [4], 분만간호 [14], 급성천식환자간호 [15] 등의시뮬레이션연구가수행되었다. 그러나시뮬레이션학습에서사용하는시나리오의대부분이외국에서개발되어우리나라상황과맞지않아우리나라실정에맞는다양한학습시나리오의개발 [16] 과실습교육의질향상을위해시뮬레이션실습사례개발과정및상호평가와공유가필요하다 [13]. 현재국내에서시행하고있는시뮬레이션실습이주로성인환자대상응급간호 호흡기계간호 교육으로이는학생들이실제환자상태를파악하고응급및위기상황에효율적으로대처할수있는역량을기르는데반복적으로학습할필요성이있음을시사하고있다 특히본연구의시뮬레이션실습교육주제인만성폐쇄성폐질환질환은많은나라에서주요사망원인중하나 로 에서는 년사망원인의 위가될것이라고보고한바있다 입원중사망률은약 이며중환자실에입원한환자의사망률은 에달하기때문 에호 414 Copyright 2019 HSST

3 Asia-pacific Journal of Multimedia Services Convergent with Art, Humanities, and Sociology Vol.9, No.4, April (2019) 흡곤란을사정하고필요한간호를제공하는하는것이중요하다. 이에본연구자는만성폐쇄성폐질환환자사례를기반으로시뮬레이션실습교육을통해간호 학생의문제해결과정과학습태도의효과를확인하고효율적인교육프로그램개발의기초자료를제 공하고자한다. 연구방법 연구설계 본연구는 G 시에소재한 3 학년간호학생을대상으로내과병동에서의만성폐쇄성폐질환환자시 뮬레이션기반학습시나리오를적용하여문제해결과정과학습태도의효과를확인하기위한단일집 단사전 - 사후설계연구이다. Treatment Simulation Learning of care for Chronic obstructive pulmonary disease patient in respiratory medicine ward pre-test Problem solving process Learning attitude 1week 2weeks 3weeks Orientation for the simulation practice learning pre-learning (presentation of ppt) Simulation evaluation and debriefing (Running time : 15 minutes, post-test Problem solving process Learning attitude Debriefing : 10 minutes,) [ 그림 1] 연구설계 [Figure 1] Research design of this study 연구대상 표본수선정을위해 G-power 3.1 을이용하여 one group paired t-test 를위한대상자수를효과 크기 (effect size) 0.5, 유의수준 (α)=0.05, 검정력 (1-β)= 0.85 로계산한결과대상자수가 38 명으로나 왔다. 본연구에서의대상자간호학생수는 40 명이었다. ISSN: AJMAHS Copyright 2019 HSST 415

4 연구도구 문제해결과정문제해결과정은 Lee, Park, choi[19] 가개발한측정도구로문제의명료화 (6문항), 해결방안모색 (6문항), 의사결정 (6문항), 해결책수행 (6문항), 평가및반영 (6문항) 등 5개영역의총 30문항으로이루어져있으며각문항들은 1점 ( 아주드물게 ) 에서 5점 ( 매우자주 ) 의 Likert 척도로측정하였다. 점수가높을수록문제해결과정능력이높은것을의미하며 Lee, Park, choi[19] 의연구에서는 Cronbach's α= 이었고, 본연구에서는 Cronbach's α=.84였다. 학습태도 학습태도는 Hwang[18] 의도구로총 16문항, Likert 4점척도로구성되어있으나본연구에서는 10문항을선택하여본연구에맞게수정 보완하여사용하였으며수업시간에대한본인의생각 (2문항 ), 수업태도 (5문항), 수업의필요성 (1문항), 앞으로의계획 (1문항) 등으로구성하였다. 각문항들은 4점척도로 전혀그렇지않다 1점, 대체로그렇지않다 2점, 대체로그렇다 3점, 매우그렇다 에 4점을주었으며, 점수가높을수록학습태도가좋음을의미한다. Hwang[18] 의연구에서신뢰도 Cronbach's α=.84였고, 본연구에서의신뢰도는 Cronbach's α=.86이었다. 연구진행절차 시뮬레이션교육 교수자준비및연구보조원훈련 2011년부터시뮬레이션을활용한효율적기본간호학실습교육, Nursing Simulation Operating Training 및 Simulators 활용활성화전략, S-PBL 교육, Simulation specialist Training Course을이수하였다. 연구보조원으로는임상경력 2년과시뮬레이션경험이있는석사과정중인 1인을훈련시켰다. 시뮬레이션설계 학습목표 만성폐쇄성페질환환자간호를위한학습목표는시뮬레이션교육프로그램을통해학습자가도 416 Copyright 2019 HSST

5 Asia-pacific Journal of Multimedia Services Convergent with Art, Humanities, and Sociology Vol.9, No.4, April (2019) 달해야하는것으로대상자의증상과징후확인, 간호문제확인, 간호중재및평가, 기록, 문제해결 과정에필요한의사소통능력과관련이있다. 구체적인학습목표는 [Table 1] 과같다. 표 만성폐쇄성폐질환환자간호를위한학습목표 시나리오 만성폐쇄성폐질환환자간호를위한시뮬레이션시나리오는 Simulation in Nursing Education (Laerdal) 에서제공하고있는 Chronic obstructive pulmonary disease-oxygen therapy case를토대로임상전문가, 성인간호학교수, 시뮬레이션담당교수와의합의를거쳐수정하였으며 [Table 2] 와같다. ISSN: AJMAHS Copyright 2019 HSST 417

6 표 시뮬레이션운영을위한시나리오 Monitor setting(instructor) Student intervention Patient manikin(action) Cue Role member providing cue: family member Problem recognition (3minutes) HR:92(rate/min) BP:130/80mmHg SpO 2 :88% Temp:37 RR:28(rate/min) Wash hand Introduce self Identify patient History taking related to chief complaint - Prior medical history - Recent medical history It s hard to get a sputum out and cough a lot My husband smoked 2 packs a day for 30years during the last year he has had two exacerbation Recently he has complained of increasing fatigue with activity and inability to sleep well at night Weigh dropped Focused assessment (4minutes) HR:96(rate/min) BP:140/80mmHg SpO 2 :88% Temp:37 RR:30(rate/min) Wheezing(+) on both sides ABGA: PH PaCO PaO Barrel chest Alert Cyanosis Check vital signs Check lung sound Check ABGA results &SpO 2 level Check chest changes Check skin color and condition Identify consciousness and cognitive functions Why are you coughing badly? 418 Copyright 2019 HSST

7 Asia-pacific Journal of Multimedia Services Convergent with Art, Humanities, and Sociology Vol.9, No.4, April (2019) Monitor setting(instructor) Student intervention Patient manikin(action) Cue Intervention (5minutes) Low flow oxygen trend - RR < to 24(rate/min) - BP > to 140/90mmHg - SpO2 > to 93% Hight flow oxygen trend - SpO 2 > to 98% - RR < to 10(rate/min) Breath sound with wheezes bilaterally Flower s position Apply low oxygen (connect nasal cannula and a flowmeter) Ausculate breath sounds Notify Dr. of patient condition (O2 amount turning control equipment of O2 flowmeter by Dr s prescription) Albuterol nebulizer application by Dr s prescription Solu-Medrol 125mg/vial IV (after 1 to 4 divided doses they were intravenously injected for 30 minutes) Patient education: pursed lips breathing Psychological support Continues to cough Role member providing cue: family member If student provides hightflow oxygen, family member will be quick to point out that it is not helping and that he is getting worse! Problem resolution (3minutes) HR < to 90(rate/min) BP < to 130/90mmHg SpO 2 > to 95% RR < to 20(rate/min) Check patient condition (Vital sign & SpO 2 level) Check ABGA results Report to the patient physician Continuous breath monitoring I think it s little better than before ISSN: AJMAHS Copyright 2019 HSST 419

8 학생준비 오리엔테이션시뮬레이션학습에서자기주도적으로스스로동기화할수있는책임감을갖고상황재현을위해각자구체적인역할들을충분히수행할수있도록 4명의소집단으로편성하도록하였다. 시뮬레이션교육을효율적으로운영하기위해팀별로각각시뮬레이터의다양한기능을경험하도록했으며총 120분소요되었다. 사전학습교수-학습활동을통해서시뮬레이션에대한높은기대를가질수있도록조별로학습목표와사전학습문제를제시하여학생들로하여금능동적으로참여하고간호문제를해결할수있도록하였다. 총 120분소요되었다. 문제해결을위한시뮬레이션운영및디브리핑 본연구자는호흡기질환환자간호시뮬레이션교육프로그램을운영하기전본연구에참여하지않은학생들 15명을대상으로리허설을시행하였으며, 역할수행, 의사소통과정등의피드백을참고로학생들이각각의역할배정, 팀원간의사소통, 호흡기질환환자의간호중재를계획할수있도록지도하였다. 고충실도 (Hight fidelity) 마네킨 (SimMan3G) 을작동하여사정및중재에필요한활력징후모니터링, 심음및호흡음청진, 심전도와산소포화도모니터링을실습하도록하였다. 시뮬레이션팀구성원은총 10팀으로각팀당 4명씩책임간호사, 사정간호사, 투약간호사, 의사 1인으로역할은팀내에서자율적으로결정하도록했다. 시뮬레이션시작전에모든수행과정들은디브리핑에사용하기위해녹화될것임을공지하고, 제한시간은 15분으로 150분소요되었다. 디브리핑 (debriefing) 은시뮬레이션과정이녹화된동영상을이용하여진행하였으며, GAS(Gather-Analysis-Summarize) 의모델을사용하여평가하였다 [20]. 수집 (Gather) 단계는시뮬레이션활동후학습자의반응을알아보는것으로간호수행에대한생각과느낌을, 분석 (Analysis) 단계는수행에대한분석과정으로어떤간호중재를시행하였는지, 당황스러웠거나부족했던부분은무엇이었는지에관한내용이었다. 요약 (Summarize) 단계는시뮬레이션교육을통해학습한내용을검토하는과정이었다. 디브리핑은팀전원이참여할수있도록진행하였으며시뮬레이션과정동안수행한내용에대해질문하고피드백하였으며팀당 10분으로 100분소요되었다. 420 Copyright 2019 HSST

9 Asia-pacific Journal of Multimedia Services Convergent with Art, Humanities, and Sociology Vol.9, No.4, April (2019) 자료수집및분석방법 본연구의자료수집기간은 2017년 7월 1일부터 30일까지였으며, 작성된설문지는연구참여동의서와함께본연구자가수거하였다. 수집된자료는 SPSS/WIN 22.0 program 을이용하여분석하였다. 대상자의일반적인특성은기술통계를사용하여분석하였고, 시뮬레이션학습전 후학습태도, 와문제해결과정의차이를비교하기위해 Paired-test 를실시하였으며, 문제해결과정과학습태도간의상관관계는 Pearson Correlation으로분석하였다. 연구결과 3.1 대상자의일반적특성 연구대상은간호학과 3 학년재학생 40 명으로남자 9 명 (22.0%), 여자 31 명 (78.0%) 이었다. 전공만 족도는매우만족이 32 명 (80%) 으로나타났다. 표 대상자의일반적특성 교육후문제해결과정과학습태도의비교 호흡기질환환자의시뮬레이션교육이학습태도에미치는점수는 4점만점에교육전 3.20점에서교육후 3.52점으로평균평점이 0.32점이높아졌으며통계적으로유의한차이를보였다 (t=3.03, p=0.12). 문제해결과정은 5점만점에 3.39점에서 4.65점으로 1.26점이높아졌으며통계적으로유의한차이 (t=2.96, p=0.03) 를보였으며 5가지하위영역모두유의한결과를나타냈다. ISSN: AJMAHS Copyright 2019 HSST 421

10 표 교육전 후학습태도와문제해결과정의비교 문제해결과정 학습태도간의상관관계 시뮬레이션교육후간호학생들의학습태도와문제해결과정간의상관관계는통계적으로유의 한정적인상관관계를보였다 (r=0.747, p<.016). 결과적으로학습태도가높을수록문제해결과정이 높은것으로나타났다. 표 학습태도 문제해결과정간의상관관계 논의 본연구는간호교육에서실습교육을위해활용하고있는시뮬레이터를가지고호흡기질환환자간호를적용하였을때간호학생들의문제해결과정과학습태도에대한효과를확인하고시뮬레이션실습교육에기초자료를제공하고자실시하였다. 본연구결과문제해결과정점수는시뮬레이션을적용하기전보다후에유의하게증가한것으로나타났다 (t=2.98, p=.003). 문제해결과정은 5개의하위영역으로분류되며문제의명료화, 해결방안모색, 의사결정, 해결책수행, 평가및반영영역에서모두교육전보다후에유의하게증가했으며특히의사결정이가장높게나타났다. 이러한결과는 2학년간호학생을대상으로브리핑, 시뮬레이션, 디브리핑 [1], 1학년간호학생을대상으로시뮬레이션, 문제중심학습 [21], 2학년간호학생을대상 422 Copyright 2019 HSST

11 Asia-pacific Journal of Multimedia Services Convergent with Art, Humanities, and Sociology Vol.9, No.4, April (2019) 으로시나리오관련핵심질문, 시뮬레이션실습 [22], 3 학년간호학생을대상으로브리핑, 시뮬레이 션, 디브리핑 [23] 을적용한연구결과와도일치한다. 문제해결과정은주어진상황을파악하여지식 과기술을통합적으로적용한후반복적인훈련을통해길러지는데 [2] 토론식사전학습을포함한 시뮬레이션실습교육은주어진시나리오상황에맞춰간호문제를모색하고문제해결을위한의사 결정과정에긍정적인영향을미친다 [15]. 또한디브리핑경험은개인의사고와감정을전환시키고 실수를확인하며자기성찰, 적극적인참여를격려하는과정으로시뮬레이션수업의질을향상시킨 다 [24][25]. 본연구에서는문제해결접근을위해시나리오상황에맞는학습목표를설정하고학생준 비과정에서는사전학습을통해문제를발견하고해결하는데필요한간호중재를생각하도록시간 을제공하였으며디브리핑과정에서는피드백을통해자기성찰이이루어져문제를해결하는과정 에긍정적인영향을미쳤을것으로사료된다. 하지만시뮬레이션실습교육이문제해결과정에유의한영향을미치지못한연구도있었는데본 연구도구와일치하지는않지만신규간호사를대상으로이론강의, 팀학습, 수기교육, 팀시뮬레이션, 디브리핑 [8], 4 학년간호학생을대상으로사전지식확인, 팀학습, 팀시뮬레이션디브리핑 [26] 을적용 한연구결과와는차이가있었다. 이는실험기간의차이로 12 주 [13], 10 주 [26], 9 주 [21], 6 주 [22], 1 주 [8] 등시뮬레이션교육적용시간이다양했으며결과도다르게나타났다. 시뮬레이션교육시시나 리오에대한상황을파악하기위해서활용하는문제중심학습법의경우학습자의참여의식을높이 며동기를부여하며재현된임상환경인실습에서문제해결능력을발휘하는데도움을준다 [21]. 게 다가소그룹토의는학습자들이학습과제를공유하고문제해결방식을단계적으로진행하도록한다 [26]. 본연구는 3 주에걸쳐진행하였으며 1 주 120 분, 2 주 120 분, 3 주 250 분으로첫째주오리엔테 이션에서는시뮬레이션교육에관한전반적인소개및경험을둘째주사전학습에서는소그룹팀 구성을기반으로학습목표를확인하고서로의견을공유하며다양한각도에서문제해결을위한방 안을모색하도록기회를제공하였으며셋째주시뮬레이션운영및디브리핑에서는간호과정에기 반을두고문제인식, 사정, 중재, 문제해결이이루어지도록한후녹화된영상을보면서상황을분 석하고재정리하는디브리핑시간을가졌다. 이처럼본연구결과와상이한이유로실험기간의차 이 [8][23] 외에도시간, 방법등다른요인이있을것으로판단되며추후시뮬레이션교육시문제해 결능력을높이는데필요한학습방법들을적용후효과를확인할필요가있겠다. 본연구결과학습태도점수는시뮬레이션을적용하기전보다후에유의하게증가한것으로나 타났다 (t=3.03, p=.012). 이러한연구결과는간호학생을대상으로사전학습, 시뮬레이션, 디브리핑 [27], 토론, 강의, 실습 [28] 에서교육을받기전보다후에학습태도가유의하게향상되어본연구결 과를뒷받침해주고있다. 시뮬레이션교육이상호학습적인효과를가져다주며학생들의적극적인 참여의식이학습태도에긍정적인영향을미친다 [26] 고보고한연구결과와도일치한다. 이는즉각적 인피드백은학습자의학습태도에긍정적인영향을주며 [3], 시뮬레이션실습시자기주도적학습 에대한인식이긍정적일수록그룹간의사소통, 적극적인태도에영향을미친다 [21] 고보고한연 구결과와비교했을때본연구의경우사전학습과정에서자기주도적으로문제를해결하도록했던 ISSN: AJMAHS Copyright 2019 HSST 423

12 부분이학습자의흥미와동기를부여했고자신감향상으로이어지면서실습에대한적극적인태도가학습태도를높이는데도움을주었을것으로판단된다. 본연구결과문제해결과정과학습태도간에양의상관관계를보였는데이는시뮬레이션교육과정에서문제해결에필요한지식, 기술, 태도의통합과정이비판적인사고뿐만아니라문제해결능력을함양시키며 [28] 시뮬레이션교육이토론식학습과병행될때간호학생의문제해결능력을향상시켜대상자의안위와건강문제해결에기여 [7] 한다고보고한결과를바탕으로학습태도가문제해결과정에영향을미치는요인임을확인하였다. 추후시뮬레이션교육의활성화를위해간호지식, 술기능력, 자기주도적학습역량, 비판적사고능력등다양한변수들을통해교육의효과를측정할필요가있겠다. 결론및제언 본연구결과 40명의간호학과학생들을대상으로시뮬레이션학습시나리오를적용해본결과시뮬레이션기반교육을통해간호중재에필요한지식습득, 대상자의건강문제를해결하는데필요한의사소통능력, 팀워크등학습태도와문제해결과정능력을향상시키는데효과적인교육방법임을확인할수있었다. 그러나교육과정운영상일개간호학생을대상으로단일군만으로하여연구의결과를해석하는데제한이있으므로추후체계적인연구설계를바탕으로비판적사고능력, 자기주도적학습, 자신감, 임상수행능력, 학업성취도등의효과를증진시킬수있는연구도필요하리라생각된다. References [1] H. K. Oh, Y. I. Han, Effects of nursing simulation-based education on problem solving process and self-efficacy of nursing college students. The Korean Journal of Health Service Management. (2012), Vol.6, No.4, pp [2] S. H. Kim, H. A. Nam, M. O. Kim, Critical thinking disposition, problem solving process, and simulation-based assessment of clinical competence of nursing students in pediatric nursing. Korean Academy of Child Health Nursing. (2014), Vol.20, No.4, pp [3] P. R. Jeffries, Designing, implementing, and evaluation simulation used as teaching strategies in nursing. Nursing Education Perspective. (2005), Vol.26, No.2, pp [4] J. M. Kim, Y. S. Choi, Effect of practice education using the simulator, critical thinking, problem solving ability and nursing process confidence of nursing students. (2015), Journal of Digital Convergence, Vol.13, No.20, pp [5] K. Lasater, Hight-fidelity simulation and development of clinical judgement: Student's experience. Journal of Nursing Education. (2007), Vol.46, No.6, pp Copyright 2019 HSST

13 Asia-pacific Journal of Multimedia Services Convergent with Art, Humanities, and Sociology Vol.9, No.4, April (2019) [6] A. J. Bland, A. Topping, B. Wood, A concept analysis of simulation as a learning strategy in the education of undergraduate nursing students. Nurse Education Today (2011), Vol.31, No.7, pp [7] M. S. Lee, S. W. Han, Effect of Simulation based Practice on Clinical Performance and Problem Solving Process for Nursing Students. Journal of Korean Academy Society Nursing Education. (2011), Vol.17, No.2, pp [8] Y. H. Kim, K. S. Jang, Effect of a Simulation based Education Cardio-pulmonary Emergency Care Knowledge, Clinical Performance Ability and Problem Solving Process in New Nurses. Journal of Korean Society of Nursing Science. (2011), Vol.41, No.2, pp [9] H. R. Kim, E. Y. Choi, H. Y. Kang, S. M. Kim, The Relationship among Learning Satisfaction, Learning Attitude, Self-efficacy and the Nursing Students Academic Achievement after Simulation-based Education on Emergency Nursing Care. Journal of Korean Academy Society Nursing Education. (2011), Vol.17, No.1, pp [10] H. S. Byun, K. H. Kwon, B. D. Suh, Effect of a simulation-based education for advanced cardiovascular life support on knowledge, self-efficacy, clinical performance ability and problem solving process in nursing students. Joural of the Korea Entertainment Industry Association. (2014), Vol.8, No.4, pp [11] T. A. Hoadley, Learning advanced cardiac life support: a comparision study of the effects of lowand high fidelity simulation. Nursing Education Perspectives. (2009), Vol.30, No.2, pp [12] S. O. Kim, S. Y. Park, Effects of High- Fidelity Simulation-Based Training of Nursing Students according to their Learning Styles. Journal of Korea Contents Associations (2013), Vol.25, No.11, pp [13] H. K. Hur, S. M. Park, Y. H. Shin, Y. M. Lim, G. Y. Kim, K. K. Kim, H. O. Choi, J. H. Choi, Development and Applicability Evaluation of an Emergent Care Management Simulation Practicum for Nursing Students. Journal of Korean Academy Society Nursing Education. (2013), Vol.19, No.2, pp [13] M. N. Lee, H. S. Kim, H. C. Jung, Y. H. Kim, K. a Kang, Development and evaluation of a scenario for simulation learning of care for children with respiratory distress syndrome in neonatal intensive care units. Child Health Nurs Res. (2013), Vol.19, No.1, pp [14] Y. A. Song, Effect of simulation-based practice by applying problem based learning on problem solving process, self-confidence in clinical performance and nursing competence. Korean J Women Health Nurs. (2014), Vol.20, No.4, pp [15] M. J. chae, Effect of simulation-based education by applying problem based learning on learning attitude, problem solving process, clinical performance ability of nursing students. (2016), Vol.16, No.4, pp [16] L. S. Ko, H. S. Kim, I. S. Kim, S. S. Kim, E. G Oh, E. J. Kim, J. H. Lee, S. W. Kang, Development of a scenario and evaluation for simulation learning of care for patients with asthma in emergency units. Journal of the Korean Academy of Fundamentals of Nursing. (2010), Vol.17, No.3, pp [17] Y. M. Kim, Y. J. Kim, J. J. Kim, J. Y. Seo, M. E. Ahn, E. K. Eo, T. H. Lee, Y. S. Lee, S. G. Jung, S. P. Jung, T. O. Jung, S. H. Cheon, Emergency medicine, Koonja Publishers, Seoul (2011) [18] S. Y. Hwang, Effects of problem-based learning on the knowledge achievement, critical thinking ability, attitude and motivation toward learning of nursing students. Unpublished doctors thesis. Chonnam National University, Gwangju,, Korea (2003). ISSN: AJMAHS Copyright 2019 HSST 425

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1.. Volume 12, Number 1, 6~16, Factors influencing consultation time and waiting time of ambulatory patients in a tertiary teaching hospital Jee-In Hwang College of Nursing Science, Kyung Hee University :