Simulation Anxiety and its Effect on Clinical Judgment for Undergraduate Nursing Students

Published:September 28, 2022DOI:


      • Simulation anxiety has been assumed to be problematic.
      • Suggested anxiety-reducing interventions in the literature have mixed effectiveness.
      • In this study, anxiety did not significantly predict clinical judgment scores.
      • Faculty should help students function through anxiety rather than eliminating it.



      High anxiety during simulation has been well documented with calls to reduce students’ anxiety. Simulation anxiety is often assumed to be harmful to students and a variety of anxiety-reducing interventions have been suggested. The purpose of this study was to explore the effect of different types of anxiety on the clinical judgment of undergraduate nursing students in simulation.


      This research used a one-group repeated measures quantitative design using the conceptual framework of Tanner's (2006) model of clinical judgment.


      Anxiety did not have a significant impact on clinical judgment, both overall and within each of the four phases of Tanner's (2006) model.


      The findings imply a changed focus to reframe anxiety and how we think about its effects. Understanding that not all anxiety is debilitating but some is facilitative challenges the assumption that faculty need to attempt to lower students’ anxiety in simulation. Rather than seeking to lower anxiety for all students, nursing educators should help students function despite anxiety, in order to prepare them for real world nursing practice.


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        • Adamson K.A.
        • Gubrud P.
        • Sideras S.
        • Lasater K.
        Assessing the reliability, validity, and use of the lasater clinical judgment rubric: three approaches.
        Journal of Nursing Education. 2012; 51: 66-73
        • Adamson K.A.
        • Kardong-Edgren S.
        A method and resources for assessing the reliability of simulation evaluation instruments.
        Nursing Education Perspectives. 2012; 33: 334-339
        • Al-Ghareeb A.
        • Cooper S.
        • Mckenna L.
        Anxiety and clinical performance in simulated setting in undergraduate health professional's education: An integrative review.
        Clinical Simulation in Nursing. 2017; 13: 478-491
        • Alpert R.
        • Haber R.N.
        Anxiety in academic achievement situations.
        The Journal of Abnormal and Social Psychology. 1960; 61: 207-215
        • American College Health Association (ACHA)
        American College Health Association-National College Health Assessment II: Reference Group Executive Summary Spring 2018.
        American College Health Association, Silver Spring, MD2018
        • Burbach B.
        • Struwe L.
        • Young L.
        • Cohen M.
        Correlates of student performance during low stakes simulation.
        Journal of Professional Nursing. 2019; 35: 44-50
        • Chmil J.V.
        • Turk M.
        • Adamson K.
        • Larew C.
        Effects of an experiential learning simulation design on clinical nursing judgment development.
        Nurse Educator. 2015; 40: 228-232
        • Fogg N.
        • Kubin L.
        • Wilson C.E.
        • Trinka M.
        Using virtual simulation to develop clinical judgment in undergraduate nursing students.
        Clinical Simulation in Nursing. 2020; 48: 55-58
        • Haerling K.
        Cost-utility analysis of virtual and mannequin-based simulation.
        Simulation in Healthcare. 2018; 13: 33-40
        • Hahs-Vaughn D.L.
        • Lomax R.G.
        An introduction to statistical concepts.
        4th ed. Routledge, Abingdon2020 (ISBN: 978-1138650558)
        • Hayden J.K.
        • Smiley R.
        • Alexander M.
        • Edgren S.
        • Jeffries P.
        The NCSBN National Simulation Study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education.
        Journal of Nursing Regulation. 2014; 5: S3-S40
        • Holland B.
        • Gosselin K.
        • Mulcahy A.
        The effect of autogenic training on self-efficacy, anxiety, and performance on nursing student simulation.
        Nursing Education Perspectives. 2017; 38: 87-89
        • Ignacio J.
        • Dolmans D.
        • Scherpbier A.
        • Rethans J.
        • Lopez V.
        • Liaw S.
        Development, implementation, and evaluation of a mental rehearsal strategy to improve clinical performance and reduce stress: A mixed methods study.
        Nursing Education Today. 2016; 37: 27-32
        • Ignacio J.
        • Scherpbier A.
        • Dolmans D.
        • Rethans J.
        • Liaw S.
        Mental rehearsal strategy for stress management and performance in simulations.
        Clinical Simulation in Nursing. 2017; 13: 295-302
      1. Jeffries P.R. The NLN Jeffries Simulation Theory. Wolters Kluwer, Philadelphia, PA2016
        • Klenke-Borgmann L.
        • Cantrell M.
        • Mariani B.
        Nurse Educators’ guide to clinical judgment: A review of the conceptualization, measurement, and development.
        Nursing Education Perspectives. 2020; 41: 215-221
        • Koo T.K.
        • Li M.Y.
        A guideline of selecting and reporting intraclass correlation coefficients for reliability research.
        Journal of Chiropractic Medicine. 2016; 15: 155-163
        • Lasater K.
        Clinical judgment development: Using simulation to create an assessment rubric.
        Journal of Nursing Education. 2007; 46: 496-503
        • Lasater K.
        Clinical judgment: The last frontier for evaluation.
        Nurse Education in Practice. 2011; 11: 86-92
        • Lawrence K.
        • Messias D.K.H.
        • Cason M.L.
        The influence of simulation experiences on new nurses' clinical judgment.
        Clinical Simulation in Nursing. 2018; 25: 22-27
        • Lee K.C.
        The Lasater clinical judgment rubric: Implications for evaluating teaching effectiveness.
        Journal of Nursing Education. 2021; 60: 67-73
        • Li Y.Y.
        • Au M.L.
        • Tong L.K.
        • Ng W.I.
        • Wang S.C.
        High-fidelity simulation in undergraduate nursing education: A meta-analysis.
        Nurse Education Today. 2022; 111105291
        • Liyanage S.
        • Saqib K.
        • Khan A.F.
        • Thobani T.R.
        • Tang W.C.
        • Chiarot C.B.
        • Butt Z.A.
        Prevalence of anxiety in university students during the COVID-19 pandemic: A systematic review.
        International Journal of Environmental Research and Public Health. 2021; 19: 62
        • Lopez V.
        • Yobas P.
        • Chow Y.L.
        • Shorey S.
        Does building resilience in undergraduate nursing students happen through clinical placements? A qualitative study.
        Nurse Education Today. 2018; 67: 1-5
        • Mills B.
        • Carter O.
        • Rudd C.
        • Claxton L.
        • O'Brien R.
        An experimental investigation into the extent social evaluation anxiety impairs performance in simulation-based learning environments amongst final-year undergraduate nursing students.
        Nursing Education Today. 2016; 45: 9-15
        • Ormrod J.
        Human Learning.
        8th ed. Pearson, Upper Saddle River, NJ2020
        • Reed J.M.
        • Ferdig R.E.
        Gaming and anxiety in the nursing simulation lab: A pilot study of an escape room.
        Journal of Professional Nursing. 2021; 37: 298-305
        • Rogers B.A.
        • Franklin A.E.
        Cognitive load experienced by nurses in simulation-based learning experiences: An integrative review.
        Nurse Education Today. 2021; 99104815
      2. Sarason I.G. Pierce G.R. Sarason B.R. Cognitive interference: Theories, methods, and findings. Lawrence Erlbaum Associates, Inc, Mahwah, NJ1996
        • Saviola F.
        • Pappaianni E.
        • Monti A.
        • Grecucci A.
        • Jovicich J.
        • De Pisapia N.
        Trait and state anxiety are mapped differently in the human brain.
        Scientific Reports. 2020; 10: 11112
        • Shaffer F.A.
        • Curtin L.
        What can employers do to increase nurse retention?.
        American Nurse Journal. 2020; 15 (Accessed May 16, 2022): 57-59
        • Shinnick M.A.
        • Cabrera-Mino C.
        Predictors of nursing clinical judgment in simulation.
        Nursing Education Perspectives. 2021; 42: 107-109
        • Spielberger C.D.
        • Gorsuch R.L.
        • Lushene R.E.
        Manual for the State-Trait Anxiety Inventory.
        Consulting Psychologists Press, Polo Alto, CA1970
        • Sun H.
        • Wang S.
        • Wang W.
        • Han G.
        • Liu Z.
        • Wu Q.
        • Pang X.
        Correlation between emotional intelligence and negative emotions of front-line nurses during the COVID-19 epidemic: A cross-sectional study.
        Journal of Clinical Nursing. 2021; 30: 385-396
        • Tanner C.
        Thinking like a nurse: A research-based model of clinical judgment.
        Journal of Nursing Education. 2006; 45: 204-211
        • Turner K.
        • McCarthy V.
        Stress and anxiety among nursing students: A review of intervention strategies in literature between 2009 and 2015.
        Nursing Education in Practice. 2017; 22: 22-29
        • Victor-Chmil J.
        • Larew C.
        Psychometric properties of the Lasater clinical judgment rubric.
        International Journal of Nursing Education Scholarship. 2013; 10: 30
        • Wedgeworth M.
        Anxiety and education: An examination of anxiety across a nursing program.
        Journal of Nursing Education and Practice. 2016; 6: 23-32
        • Zheng R.
        • Zhou Y.
        • Fu Y.
        • Xiang Q.
        • Cheng F.
        • Chen H.
        • Li J.
        Prevalence and associated factors of depression and anxiety among nurses during the outbreak of COVID-19 in China: A cross-sectional study.
        International Journal of Nursing Studies. 2021; 114103809
        • Zsido A.N.
        • Teleki S.A.
        • Csokasi K.
        • Rozsa S.
        • Bandi S.A.
        Development of the short version of the spielberger state—trait anxiety inventory.
        Psychiatry Research. 2020; 291113223