Initial clinical simulation exposure among nursing students: A mixed-methods psychophysiological and qualitative observational study

Background Simulation-based learning enhances nursing education but may provoke anxiety that affects learning and well-being. Methods A cohort study examined self-reported anxiety, mean arterial pressure (MAP), heart rate variability (HRV), and post-simulation reflections during nursing students' first high-fidelity simulation. Results Self-reported anxiety did not correlate with HRV; however, physiological and qualitative findings suggested anticipatory stress before simulation. Pre-simulation MAP predicted intra-simulation HRV. Conclusion Anticipatory stress may begin before simulation, highlighting the pre-simulation period as a critical opportunity for interventions that promote learner readiness, psychological safety, and effective simulation-based learning.