An emerging nursing education trend is to utilize simulated learning experiences as a means to optimize competency and decision making skills. The purpose of this study was to examine differences in students' perception of clinical decision making and clinical decision making-related self-confidence and anxiety based on the sequence (order) in which they participated in a block of simulated versus hospital-based learning experiences. A quasi-experimental crossover design was used. Between and within group differences were found relative to self-confidence with the decision making process. When comparing groups, at baseline the simulation followed by hospital group had significantly higher self-confidence scores, however, at 14-weeks both groups were not significantly different. Significant within group differences were found in the simulation followed by hospital group only, demonstrating a significant decrease in clinical decision making related anxiety across the semester. Finally, there were no significant difference in; perceived clinical decision making within or between the groups at the two measurement points. Preliminary findings suggest that simulated learning experiences can be offered with alternating sequences without impacting the process, anxiety or confidence with clinical decision making. This study provides beginning evidence to guide curriculum development and allow flexibility based on student needs and available resources.

Complex simulations can facilitate students' synthesis of knowledge. Simulations of cognitively impaired elders provide nursing students the opportunity to use critical thinking and clinical decision-making skills in complex patient care situations. The authors report their experiences in designing, implementing, and evaluating a simulation on cognitive problems in elders using actors. This simulation required third-year baccalaureate nursing students to differentiate delirium from dementia, identify symptoms of heart failure, and address a family member's concerns.

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