Psychological Safety Orientation Before Simulation-Based Assessment and Clinical Performance in Intern Nurses: A Randomized Controlled Trial

Background: Although the use of simulation-based assessment (SBA) to assess nursing competency is growing, the high stakes associated with these tests might cause anxiety that affects performance. A vital aspect of learning environments is psychological safety, which is described as the conviction that one can take interpersonal risks without worrying about unfavorable outcomes. Aims: This study aimed to investigate whether providing intern nurses with a structured psychological safety orientation before simulation-based assessment enhances their clinical performance. Methods: At King Fahad Medical City, Saudi Arabia's Center for Research, Education, and Simulation Enhanced Training (CRESENT), a randomized controlled experiment was carried out. A total of 140 intern nurses were divided into two groups at random: the control group (n = 70) received a conventional prebriefing, while the intervention group (n = 70) received a 10-minute structured psychological safety orientation before SBA. Aseptic wound care, feeding tube management, medication administration, peripheral IV device management, and hand hygiene/PPE use were the five categories in which clinical performance was evaluated. An 11-item questionnaire was used to measure psychological safety before and after the assessment. Results: Peripheral IV device management pass rates were substantially higher in the intervention group than in the control group (98.6% vs. 88.6%, p=0.016, OR=8.90, 95% CI: 1.09-72.6). Although the intervention group showed improvements in aseptic wound care (94.3% vs. 87.1%) and medication administration (94.3% vs. 90.0%), these differences were not statistically significant. Between the pre- and post-assessment, the intervention group demonstrated significant decreases in perceived evaluative pressure (p=0.014) and loss of focus (p=0.011). Conclusions: A brief structured psychological safety orientation before simulation-based assessment improves intern nurses' perceptions of psychological safety and enhances their performance on anxiety-sensitive clinical skills. Integrating psychological safety principles into pre-assessment procedures represents a practical, low-cost strategy to optimize learner experience and objective performance outcomes in nursing education.