Self-confidence and anxiety in clinical decision-making among nursing students during high-fidelity simulation training: a longitudinal study

BACKGROUND: Clinical decision-making is a core nursing competency that develops progressively through education and practice. However, nursing students frequently report reduced self-confidence and increased anxiety when required to make clinical decisions. High-fidelity simulation (HFS) provides a safe, realistic environment to practice clinical decision-making and may influence these psychological determinants. Longitudinal studies on how repeated exposure to HFS affects anxiety and self-confidence across an entire nursing curriculum remain limited. METHODS: A four-year longitudinal study examined changes in nursing students' self-confidence and anxiety in clinical decision-making during repeated annual exposure to HFS within a single cohort. A total of 143 students completed pre- and post-intervention questionnaires using the Nursing Anxiety and Self-Confidence with Clinical Decision-Making-High-Fidelity Simulation scale (NASC-CDM-HFS). Linear mixed-effects models with random intercepts for participants examined year-by-year changes in self-confidence and anxiety, adjusted for age and prior healthcare experience. The anxiety models were further adjusted for baseline self-confidence levels. RESULTS: Pre-intervention self-confidence increased naturally across the program, whereas pre-intervention anxiety declined, indicating growing familiarity with clinical practice. After participating in HFS, significant improvements were observed during the first year. Self-confidence increased (b = 6.64, 95% CI [4.17, 9.11]) and anxiety decreased (b = -2.90, 95% CI [-5.27, -0.68]). In subsequent years (Y2-Y4), HFS produced no additional statistically significant effects. CONCLUSION: High-fidelity simulation enhancess self-confidence and reduces anxiety during clinical decision-making among novice nursing students. However, significant effects were only found during the first training year. This suggests that the psychological impact of HFS is strongest when students are exposed to simulationtraining for a first time. To repeat these psychological benefits throughout the curriculum, simulation activities should be progressively adapted in complexity, integrated more frequently, and aligned with students' advancing clinical competencies.