Innovative nursing training in prehospital trauma care: design and impact assessment using a dual-cabin ambulance simulator
- Open Access
- 11.02.2026
- Research
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Abstract
Introduction
Trauma is a leading cause of death worldwide, affecting millions of people annually. Most deaths occur in the early moments after an accident and before the patient reaches a medical facility, highlighting the importance of prehospital care in reducing the consequences of trauma [1, 2]. Ambulances, as the primary unit providing prehospital services, along with nurses and trained emergency medical technicians, play a crucial role in the initial management and transfer of trauma patients [3]. Teaching nursing students prehospital care skills, rapid decision-making, teamwork, and crisis management is particularly important in the management of trauma patients. Evidence suggests that the use of high-fidelity simulators, which provide a realistic environment, can improve the training of these capabilities and enhance the quality of education [4]. Despite the advantages of using medical simulators, many educational programs are still based on traditional training or training in static laboratory environments that are unable to provide stressful, unpredictable, and realistic conditions similar to the real ambulance environment. Therefore, there is a need to develop more realistic and advanced simulators [5]. The shortcomings and limitations of existing training cause students to feel anxious, helpless, and perform poorly when faced with real professional situations in the future [6]. Although simulation-based training is well established in medical education, including prehospital care, recent developments in virtual simulation—particularly immersive virtual reality (VR)—have introduced new opportunities for scalable, standardised, and safe skills practice. By offering realistic scenarios that can be repeated without risking patient safety, VR enables learners to practice deliberately, learn from errors, and improve clinical and non-clinical competencies. Evidence also suggests that VR simulation can be more cost-effective than traditional simulation-based education in certain contexts [7]. In recent years, the development of realistic simulators, with a focus on the back cabin of an ambulance, has garnered attention for prehospital care training purposes. For example, Halabi et al. designed an interactive simulator that allows learners to practice prehospital scenarios in a safe environment by adjusting the layout of the equipment inside the cabin [8].
Evidence shows that high-fidelity simulators, which can provide elements such as movement, sirens, and team interaction, play an effective role in enhancing the quality of training. The results of these studies have shown that scenarios that create a more realistic environment increase the sense of immersion and mental and practical involvement of learners and help improve learning [9, 10]. The study by Power et al. in Ireland is one of the advanced examples of ambulance simulation that provides a realistic environment for training learners by using physical and digital elements similar to a real ambulance [11]. The results of another study conducted by Mills et al. showed that virtual reality-based simulations can be equal to or even more effective than live simulations in some cases [12]. Other examples of immersive simulations, such as VROnSite and Megacity, are designed to provide a safe environment for team interaction, risk analysis, and emergency decision-making [13, 14]. Evidence suggests that the use of virtual reality in simulation systems can reduce costs and increase training effectiveness by providing appropriate psychological conditions, repeatability, and safety [15, 16].
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It is noteworthy that most of these simulators focus primarily on the rear cabin treatment area and do not address the ambulance driving aspect—including training on the ambulance route, dispatch decision-making, external environmental conditions, and siren sound—and do not cover factors such as coordination between the driver and the medical team and group decision-making in critical situations [8, 10, 11]. In addition to the technical aspects, the educational dimension of simulation is also of great importance. Several studies have shown that the use of ambulance simulators reduces perceived stress among novice nurses, increases self-efficacy, and improves the quality of clinical decision-making [17, 18]. Creating a safe environment for students who will encounter trauma patients in real-life situations is of particular importance. Therefore, scenario-based training and interactive practice in a simulated environment provide a unique opportunity to improve students’ skills and reduce clinical errors during practice [19]. Despite recent advances in simulation-based training, most existing systems focus solely on the replication of the treatment cabin and do not address critical aspects of prehospital care such as real-time coordination between the driver and medical team, decision-making under motion, management of unpredictable situations during patient transfer, and situational awareness. This educational gap highlights the need for simulators that can provide a more realistic experience of ambulance operations—including both the driver cabin and the treatment cabin simultaneously. Therefore, the present study was designed with three specific objectives: (1) the design and construction of a dual-cabin ambulance simulator (>2), the development and implementation of a scenario-based training program using this simulator, and (3) the evaluation of its educational effectiveness on students’ prehospital care performance.
Method
This single-group quasi-experimental study, with a pre-test-post-test design, was conducted at Gerash University of Medical Sciences in 2024–2025. This study aimed to evaluate the effectiveness of training skills for dealing with trauma patients in a simulated ambulance environment. It should be noted that the single-group design limits the ability to attribute observed changes solely to the intervention, and potential confounders such as prior informal experience or learning outside the intervention may affect results.
Participants
The present study included all sixth-semester nursing students who met the inclusion criteria: (I) no prior experience with trauma patient simulations and (II) completion of the course “Nursing in Crisis and Unexpected Events.” All eligible students enrolled in 2024–2025 participated in the study through convenience sampling. Due to the limited number of eligible students, the study included the entire accessible population, a commonly applied approach in quasi-experimental studies with small populations. It should be acknowledged that using convenience sampling may introduce selection bias, which could limit the generalizability of the findings. Although the Krejcie and Morgan table was initially used as a numerical reference [20], formal power analysis was not feasible in this context, and this pragmatic approach aligns with similar studies in the literature [21, 22]. Considering a 20% probability of attrition, the sample size was increased to 60, and ultimately, 58 students completed the study.
Design and development of a simulated ambulance
The design and construction of a simulated ambulance in this study were carried out to create a realistic environment for training in prehospital care. In designing this simulator, special attention was paid to three essential principles in educational simulator design: fidelity, reality, and immersion, and efforts were made to enhance these elements through accurate replication of ambulance dimensions, standardized equipment layout, simulated environmental sounds, and controlled light and motion effects. To achieve these goals, all dimensions, facilities, sounds, lights, movement structure, specialized equipment, and the way students interact with the simulated environment were designed and implemented based on field observations, ergonomic principles, and objective ambulance standards.
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In the front cabin of the simulator, a driving simulation system was designed, including a large 42-inch display, steering wheel, brake, accelerator, and clutch pedals, and gear lever. Communication capabilities also included a wireless radio system to simulate contact with the emergency command center and voice communication between the technician and the driver through an internal hatch.
In the design of the ambulance’s rear treatment cabin, efforts were made to create a realistic physical environment that approximates the spatial configuration and operational conditions of an actual ambulance. The physical structure of the cabin was designed according to the actual dimensions of the ambulance and can withstand the weight of several students, an instructor, and a patient. The interior surfaces were made of shockproof, waterproof, and washable materials, and the equipment was placed precisely in accordance with clinical ambulance patterns. In this space, it is possible to implement a wide range of emergency scenarios. Specialized equipment—including an adjustable stretcher with an aluminum structure, an ECG monitor, a defibrillator, a portable mechanical ventilator, a suction device, a bag-valve-mask (BVM) resuscitator (with adult/pediatric masks and an oxygen reservoir), a medicine box, and a trauma jump bag (portable trauma kit) (e.g., tourniquets, pressure/hemostatic dressings, gauze/bandages, splints, and a cervical collar)—was placed in the ambulance simulator. Additional items included various splints, a syringe pump, a portable oxygen cylinder, a long spine board and short spine board, a stethoscope, an arm blood pressure monitor, airway management equipment (e.g., oropharyngeal and nasopharyngeal airways), resuscitation bags, essential emergency medications, a hemoglucometer, a bed, a folding chair with rails, and a storage area for consumables. Internal lighting, equipped with LED emergency lights that the technician can control, enables the management of lighting conditions during interventions such as intubation (Fig. 1).
Fig. 1
The ambulance simulator, consisting of two cabins: the driver cabin and the treatment cabin
Unlike other existing models that often only target the rear cabin space or trauma mannequins, this simulator attempts to integrate both clinical situation simulation and operational driving conditions simultaneously. By combining realistic equipment, confined space, sound effects, and movement simulation, the design aimed to promote an immersive learning experience. This feature enables students to encounter not only equipment and scenarios, but also space, sound, psychological stress, and inter-team interaction. Additionally, receiving immediate feedback and the ability to perform various missions based on emergency protocols and pre-hospital protocols are other unique advantages of this simulator over similar models. However, the novelty of combining driving and clinical scenarios may introduce variability in individual student stress responses, which could influence performance scores.
Process
The training program was conducted over five consecutive weekdays, totaling 15 h, in an ambulance simulator comprising two sections: the driver’s cabin and the rear treatment cabin, designed to replicate real emergency conditions. Emergency nursing instructors facilitated the training process through practical trauma scenarios, while students trained in small groups of four using real equipment, including a stretcher, splints, oxygen machine, suction device, and ventilator, in simulated conditions with role-playing. Each daily three-hour session followed a standardized sequence: 20 min of instructor demonstration, 90 min of hands-on practice in the treatment cabin, 20 min of integrated driving-and-clinical simulation, and 50 min of structured debriefing. The sequence of scenarios, time allocation, and demonstration-to-practice ratio were standardized across all groups to ensure consistency and reproducibility. Structured debriefing sessions used a consistent approach to facilitate reflection and consolidate learning, and a written facilitator guide documented scenario flow, instructions, and debriefing procedures.
The training scenarios included: (1) forehead fracture (2), jaw wound (3), clavicle fracture (4), penetrating abdominal wound with bowel protrusion (5), open humerus fracture (6), hand laceration (7), open thigh wound (8), hip fracture, and (9) tibia fracture. The educational intervention process is illustrated in Fig. 2.
Fig. 2
Steps of the educational intervention
Measurements
In this study, the effectiveness of the educational intervention, using the Kirkpatrick model approach, was examined at the first and second levels.
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First level (reaction)
To assess the participants’ satisfaction with the training provided in the ambulance simulator environment, a researcher-made questionnaire consisting of 22 questions was used. First, by systematically reviewing the scientific literature and reviewing previous educational satisfaction questionnaires, the initial items were identified. To refine the questionnaire items, a focus group was conducted with four faculty members and four students. The faculty members were considered “relevant” because they had direct academic/clinical experience in prehospital care simulation and/or teaching in emergency medicine/nursing and medical education, and they were involved in planning, delivering, or evaluating simulation-based training at our institution. The student participants were purposefully selected to ensure they could comment on item clarity and relevance; they were recruited from the target population and had previous exposure to simulation-based skills training. The student focus group participants did not take part in the main intervention/data collection, to avoid influencing the study outcomes. The items were examined for clarity, content adequacy, and complete coverage of conceptual dimensions, and after making the necessary corrections, the initial version of the questionnaire was prepared. Finally, this questionnaire was prepared in the form of 22 items with a five-point Likert scale (1 = very dissatisfied, 5 = very satisfied). Content validity was confirmed by eight experts in nursing, emergency medicine, and medical education, with CVR and CVI values exceeding 0.75, indicating acceptable content validity. The face validity of the questionnaire, in terms of item clarity and comprehensibility, was initially assessed through cognitive interviews with six nursing students, leading to revisions based on their feedback. Subsequently, both the face and content validity of the OSCE checklists were rigorously evaluated and confirmed by a panel of eight experts specializing in nursing, emergency medicine, and medical education. The internal reliability of the questionnaire was assessed using Cronbach’s alpha, which was 0.729, indicating moderate internal consistency; the questionnaire items are provided in S1 Appendix.
Second level (learning)
The Objective Structured Clinical Examination (OSCE) was used to assess clinical skills. Students participated in a pre-test before starting the program and were re-evaluated with the same test with similar scenarios after one week of training. This evaluation aimed to observe the changes in the clinical skills of the students before and after the educational intervention. To implement the Objective Structured Clinical Examination (OSCE), consisting of nine structured skill stations, nine trauma-related clinical scenarios previously developed and validated by Najafi et al. [23] were utilized. Participant performance at each station was assessed using a skill evaluation checklist developed by the National Registry of Emergency Medical Technician Skills and validated in previous studies [23, 24]. The face and content validity of the OSCE checklists were reviewed and confirmed by a panel of eight experts in nursing, emergency medicine, and medical education. While formal construct validity (e.g., discrimination between novice and expert) was not directly assessed in this study, the checklists are standardized tools widely used in trauma skill assessment [21‐24]. The internal consistency reliability of the checklist, calculated using the Kuder–Richardson coefficient, was 0.82, indicating satisfactory reliability for research purposes. The checklist measured nine essential competencies in trauma management, including trauma patient assessment (43 points), airway insertion and suctioning (14 points), bleeding control and shock care (7 points), lower-limb traction splinting (14 points), supine spinal immobilization (14 points), seated spinal immobilization (12 points), long-bone stabilization (10 points), joint stabilization (9 points), and manual ventilation and intubation (26 points). Each item was scored dichotomously (0 = no skill or incorrect performance, 1 = correct performance). Although students completed each station in 7 min, raters were allowed an additional 2–3 min if needed to ensure accurate scoring of all items, maintaining feasibility and minimizing cognitive overload. The total attainable score ranged from 0 to 149, with higher scores reflecting greater clinical competence. The OSCE was conducted in a rotating-station format, allowing each participant to sequentially complete all nine stations. Each station was independently evaluated by two trained raters, consisting of nurse practitioners and emergency medical technicians with a minimum of three years of clinical experience. Prior to the examination, students attended a brief orientation session that introduced the OSCE procedures, timing, and scoring methods. The scores assigned by both raters were recorded separately, and the mean score for each skill was used for data analysis. The inter-rater reliability was assessed using the intraclass correlation coefficient (ICC), which was found to be 0.96.
Statistical analysis
Descriptive statistics, including mean and standard deviation, were used to summarize the data from the satisfaction questionnaire. The distribution of OSCE checklist data in the pre- and post-tests was assessed for normality using the Shapiro-Wilk test, which indicated non-normal distribution for all checklists (all p < 0.05). Consequently, the non-parametric Wilcoxon Signed-Rank Test was used to compare pre- and post-intervention OSCE data. Effect sizes were also calculated to quantify the magnitude of improvement, and the corresponding values are reported in Table 2. All statistical analyses were performed using SPSS V.21 software, and a p-value of less than 0.05 was considered statistically significant.
Results
Fifty-eight nursing students from two consecutive admissions who were studying in the sixth semester participated. The average age of the students was 21.38 ± 0.58. Of these, 40 (69%) were female and 18 (31%) were male. All students had previously completed the course “Nursing in Crisis and Unexpected Events,” and none had experience in training in an ambulance simulation environment.
Table 1 shows the results of students’ satisfaction scores with the ambulance simulator-based educational intervention. The mean scores of all items were above 4, indicating a high level of students’ satisfaction with the simulated environment, scenarios, quality of education, and effectiveness of the ambulance simulator-based educational intervention.
Table 1
Mean and standard deviation of students’ satisfaction scores with the ambulance simulator-based training
No | Items | Median | IQR (25th–75th)* | Mean | SD |
|---|---|---|---|---|---|
1 | Realism of the ambulance simulator and training conditions | 5 | 4–5 | 4.72 | 0.45 |
2 | Realism of trauma patient scenarios | 4 | 3–5 | 4.14 | 0.80 |
3 | Level of educational challenge provided during the training process | 4 | 4–5 | 4.21 | 0.67 |
4 | Creating a better understanding of the patient’s condition and how to care for a trauma patient | 4 | 4–4 | 4.07 | 0.41 |
5 | Effectiveness in improving the skill of caring for a real trauma patient | 5 | 4–5 | 4.65 | 0.48 |
6 | Availability of necessary equipment and resources | 4 | 4–5 | 4.10 | 0.91 |
7 | Effectiveness of the educational method in promoting knowledge and skills | 4 | 4–5 | 4.09 | 0.68 |
8 | Effectiveness of instructor guidance during skill training | 5 | 5–5 | 4.79 | 0.41 |
9 | Level of interaction and participation in the training process | 4 | 4-4.25 | 4.03 | 0.67 |
10 | Quality of feedback provided by the instructor | 4 | 4–4 | 4.07 | 0.41 |
11 | Quality of feedback from the trauma environment and model | 4 | 4–4 | 4.02 | 0.35 |
12 | :A variety of educational methods to promote the learning of skills | 4 | 4–5 | 4.10 | 0.64 |
13 | Usefulness and effectiveness of the educational method used in learning | 4 | 4–5 | 4.14 | 0.63 |
14 | Enjoyability of the training process | 4 | 4–4 | 4.05 | 0.54 |
15 | Motivation for the training provided | 4 | 4–5 | 4.07 | 0.69 |
16 | Coverage of the content necessary for mastering clinical skills | 4 | 4–5 | 4.21 | 0.52 |
17 | Feeling of mastery of the content provided | 4 | 4–5 | 4.27 | 0.59 |
18 | Increase in self-confidence for caring for a trauma patient | 4 | 4–5 | 4.05 | 0.69 |
19 | Preparation for genuine encounters with a trauma patient | 4 | 4-4.25 | 4.10 | 0.61 |
20 | Preparation for future professional roles | 5 | 4–5 | 4.62 | 0.49 |
21 | Overall usefulness of training with this method | 5 | 4–5 | 4.65 | 0.48 |
22 | Willingness to recommend this educational method to other classmates | 4 | 4–5 | 4.03 | 0.70 |
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Table 2 shows the results of comparing clinical skills scores before and after ambulance simulator-based training. The mean scores of overall clinical skills, as well as nine standard skills for dealing with trauma patients, improved significantly after training with the ambulance simulator compared to before training (p < 0.001). Effect size calculations indicated that all nine OSCE skill domains demonstrated large or very large effect sizes, confirming substantial improvement following the intervention.
Table 2
Comparison of clinical skills scores before and after ambulance simulator-based training
Trauma Patient Care Skill | pretest | posttest | Z value* | p-value | Effect Size (r) | ||
|---|---|---|---|---|---|---|---|
Mean | SD | Mean | SD | ||||
Trauma patient assessment (0–43) | 19.78 | 4.71 | 25.97 | 2.25 | -6.05 | 0.000 | 0.794 |
Airway insertion and suctioning (0–14) | 6.84 | 1.42 | 8.52 | 1.40 | -4.73 | 0.000 | 0.621 |
Bleeding control and shock care (0–7) | 3.22 | 1.15 | 4.64 | 0.93 | -5.25 | 0.000 | 0.689 |
Lower-limb traction splinting (0–14) | 6.36 | 1.28 | 8.76 | 1.20 | -6.07 | 0.000 | 0.797 |
Supine spinal immobilization (0–14) | 6.59 | 1.36 | 8.91 | 1.03 | -5.99 | 0.000 | 0.787 |
Seated spinal immobilization (0–12) | 5.69 | 1.51 | 7.84 | 1.24 | -5.74 | 0.000 | 0.754 |
Long-bone stabilization (0–10) | 5.09 | 0.88 | 6.24 | 1.00 | -4.10 | 0.000 | 0.657 |
Joint stabilization (0–9) | 4.34 | 1.13 | 5.91 | 1.03 | -5.30 | 0.000 | 0.696 |
Manual ventilation and intubation (0–26) | 14.09 | 2.51 | 18.59 | 1.65 | -6.34 | 0.000 | 0.832 |
Discussion
The results of this study indicate that the design and implementation of a dual-cabin ambulance simulator can provide a promising training platform for training nursing students in the management of trauma patients, although the single-group pretest/posttest design poses limitations in the strength of inference. Therefore, it cannot be claimed that the improvements were solely due to the simulation and its two-part structure, and the results should be considered as preliminary findings that need to be confirmed in controlled studies. The two-part structure of the simulator includes a driver’s cabin and a treatment cabin and is designed to approximate the prehospital reality and provide an interactive experience for learners. The use of real equipment and structured scenarios also helps to increase realism. The confined space of the treatment room, simulated environmental sounds, team interaction, and exposure to emergency situations likely provided an immersive learning experience, which was also observed in the students’ self-reported satisfaction outcomes. Previous studies have shown that structured, realistic scenarios can enhance learners’ cognitive, affective, and practical engagement and facilitate effective skill learning [9, 10]. Ricciardi and De Paolis have also reported that high-fidelity simulations are more effective in teaching decision-making and response skills [15].
The OSCE results in this study indicated improved student performance on critical skills, consistent with the findings of Nazari et al. [21].
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However, due to the lack of a control group, these improvements cannot be definitively attributed to the simulation, and other factors such as repeated exposure, natural progression of learning, or the Hawthorne effect may have played a role. Therefore, these results should be interpreted as preliminary and promising findings and not as definitive evidence of effectiveness.
In addition to improving student performance, satisfaction scores indicated positive student acceptance. However, self-reported satisfaction may be influenced by social bias and may not necessarily reflect actual learning. The quality of scenario design and implementation, group interactions, effectiveness of instructor guidance, and relevance of content to future professional needs were all rated highly by most participants. In a study by Power et al., it was found that the use of ambulance simulators reduced anxiety, improved performance, and increased student motivation —a finding consistent with the positive perceptions of participants in the present study [11].
The driver’s cab portion of the simulator provides a realistic environment for practicing decision-making during a dispatch and creates dynamic and changing conditions during the maneuver. These features may provide more comprehensive and realistic training, unlike many standard simulators that are confined to a treatment cabin; however, this result should be interpreted with caution. Exposure to a realistic environment in terms of time and space can enhance immediate decision-making skills and performance in stressful situations [25]. Training with this simulator was also associated with increased students’ confidence in dealing with trauma patients, which is consistent with the results of a meta-analysis by Oliveira Silva et al. [26].
The Kirkpatrick model was used as an assessment framework, but only levels 1 (reaction) and 2 (learning) were examined. For a more comprehensive assessment, future studies should examine levels 3 (behavior) and 4 (outcomes) through long-term follow-up and observation in a real-world setting.
In this study, students’ skills were assessed only at pre- and post-tests and no control group was included, which limits the generalizability of the results. It seems that simulation should be integrated into curricula and replicated. Despite the lack of a control group, trauma simulation was associated with short-term skill improvement, similar to the findings of Park et al. in a pretest/posttest study without a control group [27]. Future research is needed to examine short- and long-term effects on patients and clinical behavior change, and the discrepancy in results may be related to different follow-up times in different studies. This study also had other limitations. Assessments were conducted only in the short term, and long-term outcomes such as skill retention and clinical behavior change in a real-world setting were not examined. Another limitation is the lack of validated instruments to directly assess key components of simulation such as fidelity, realism, and immersion. Although an attempt was made to simulate an environment with similar physical design, realistic equipment, and structured scenarios, a full analysis of the role of these features in educational outcomes is not possible without rigorous quantitative and qualitative assessments. Therefore, future studies should examine the relationship between the quality of simulation environment design and educational effectiveness using standardized and psychometric instruments, and evaluate the effects of ambulance simulators more comprehensively with controlled designs, larger samples, and long-term follow-up.
Conclusion
The use of a two-cabin ambulance simulator as an interactive educational tool demonstrates a potential positive impact on improving clinical performance and learner satisfaction. Features such as realistic design, use of real equipment, and implementation of practical and real-world scenarios likely contributed to creating an immersive learning experience. Although these findings are promising, further research with controlled designs is needed to confirm the effectiveness of such simulators. Integrating these simulators into nursing and emergency medical training programs is suggested as a potential strategy to bridge the gap between theoretical and clinical education, but this recommendation needs to be further investigated in future studies to assess its impact on student readiness for real-world situations.
Acknowledgements
Researchers are also thankful to all students who have participated in this study.
Declarations
Ethical approval
Ethical approval was obtained from the Ethics Committee of the Gerash University of Medical Sciences with code IR.GERUMS.1402.005. This study was not a clinical trial; therefore, a clinical trial number is not applicable. All stages of the study were conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants before entering the study. The findings were used confidentially and anonymously for discussion and publication.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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