Background: Elevated anxiety can negatively affect academic performance, health, and team functioning in healthcare education. Simulation-based learning in nursing, while educationally valuable, may provoke anxiety that influences learning outcomes and student well-being.

Methods: A cohort study using retrospective and prospective data examined self-reported anxiety and physiological anxiety indicators, including heart rate variability (HRV) and mean arterial pressure, during prebriefing, simulation, and debriefing phases. Post-simulation participant reflections were also collected, and thematic analysis was conducted to identify patterns in perceived anxiety and coping strategies.

Results: Anxiety and physiological stress responses fluctuated across simulation phases. Pre-simulation mean arterial pressure significantly predicted intra-simulation HRV, indicating baseline physiological state influences anxiety responses. Qualitative themes highlighted common stressors, coping strategies, and the role of debriefing and simulation fidelity in shaping anxiety experiences.

Conclusion: Effective prebriefing, structured debriefing, and anxiety-regulation strategies may support adaptive stress responses in simulation-based nursing education. Integrating both quantitative and qualitative insights can inform simulation design to enhance learning outcomes and promote student well-being.