The impact of clinical simulation on bridging the theory–practice gap in nursing education: a systematic review

Abstract

Background

Bridging the gap between theoretical instruction and practical competence remains a central challenge in nursing education. Nursing students often struggle to transfer classroom-acquired knowledge into real-world clinical environments, resulting in decreased confidence, impaired decision-making, and compromised patient care. Clinical simulation has emerged as a promising pedagogical tool to address this longstanding theory–practice gap by recreating realistic scenarios in a controlled setting.

Method

This systematic review synthesized studies published from 2010 to 2025 concerning the use of clinical simulation in nursing education. Five databases were searched using defined keywords to identify relevant studies. Eligible studies focused on simulation-based interventions aimed at enhancing nursing students’ clinical competence, decision-making, confidence, and knowledge transfer. Data extraction was independently performed by reviewers, and methodological quality was assessed using the Cochrane RoB 2, CASP, and Newcastle-Ottawa Scale (NOS) checklists. A thematic synthesis approach was employed to analyze both qualitative and quantitative findings.

Results

Of the fifteen included studies, twelve reported significant improvements in nursing students’ clinical decision-making, judgment, or self-confidence, involving over 1,100 participants. High-fidelity simulation and structured scenario-based interventions were particularly effective in enhancing core competencies such as cardiopulmonary resuscitation (CPR), infection control, and diagnostic reasoning. Thematic synthesis categorized findings into six domains: clinical decision-making, clinical judgment, learner self-confidence, empathy development, experiential learning, and learner satisfaction. Reported challenges included limited technological access, inconsistent debriefing, and insufficient faculty training. No adverse outcomes were noted, although potential publication bias and short follow-up durations were identified as limitations.

Conclusion

Simulation-based education can serve as an effective and scalable strategy to reduce the theory–practice gap in nursing education. Its success depends on sustained implementation, institutional support, and pedagogical integration. Future research should emphasize long-term effectiveness and explore context-specific barriers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-07790-8.

Introduction

Nursing education is one of the fundamental pillars in training professional healthcare personnel, aiming to empower students with competence in both theoretical knowledge and practical skills of clinical care [1]. However, a persistent challenge in this field is the significant gap between theoretical learning acquired in academic settings and the practical skills required in real-world clinical environments—a phenomenon widely recognized as the “theory–practice gap” [2, 3].

The roots of this gap are multifaceted: reduced opportunities for bedside training due to increasing student populations, limited patient interaction caused by ethical and safety concerns, and the absence of structured frameworks for translating knowledge into practice [4]. As a result, students often struggle to provide independent clinical care, make sound clinical decisions, and experience high levels of anxiety upon entering actual healthcare settings [5, 6].

In recent decades, clinical simulation has emerged as an innovative educational strategy that has garnered growing attention. This approach enables the recreation of clinical scenarios in controlled and interactive environments, allowing students to gain hands-on experience without compromising patient safety [7]. Simulation tools—ranging from basic manikins to advanced technologies such as virtual reality and AI-based systems—offer students the opportunity to practice complex or rare clinical situations that are not commonly encountered in real-life settings [8, 9].

Research has demonstrated that simulation-based education can lead to significant improvements in clinical decision-making, critical thinking, interprofessional communication, self-confidence, and anxiety reduction [10–12]. Nevertheless, the extent to which simulation effectively bridges the theory–practice gap remains a matter of debate. While some studies highlight its positive impact, others suggest that the benefits may be limited or short-lived [13, 14].

Moreover, most previous reviews have focused broadly on the advantages of simulation, with relatively few studies specifically examining its role in narrowing the theory–practice gap. This research gap has become more pronounced in the post-COVID-19 era, where access to clinical placements has become increasingly restricted [14, 15]. Recent surveys indicate that over 60% of newly graduated nursing students report feeling unprepared for real-world clinical tasks, citing limited bedside exposure and gaps in applying theoretical knowledge [16]. While several earlier reviews have examined the general benefits of simulation in nursing education [17], few have focused specifically on its role in bridging the theory–practice gap. Moreover, most were conducted prior to the COVID-19 pandemic and did not include recent innovations such as virtual simulation or studies from underrepresented regions [18, 19]. This review addresses these gaps by incorporating empirical studies from 2010 to 2025, analyzing both affective and cognitive outcomes, and highlighting context-specific implementation challenges.

Therefore, this systematic review aims to examine and synthesize the evidence published between 2010 and 2025 to determine whether clinical simulation can serve as an effective approach to reducing the theory–practice gap in nursing education. The findings of this review can inform educational policymakers, curriculum designers, and clinical educators in adopting innovative strategies to enhance the quality of clinical learning.

Accordingly, this study seeks to address the following questions:

• How does simulation-based education contribute to bridging the theory–practice gap in undergraduate nursing education?

• What are the main thematic outcomes reported in the literature regarding students’ clinical competence, including clinical decision-making, confidence, practical skills, empathy, and the integration of theoretical knowledge?

• Which types and formats of simulation interventions (e.g., high-fidelity simulation, structured scenarios, gamification, virtual reality) have been found most effective in promoting clinical learning?

• What limitations, methodological challenges, or contextual barriers are reported in the current literature that may affect the interpretation or generalizability of simulation outcomes

Methodology

This study is a systematic review assessing the impact, challenges, and implementation strategies of clinical simulation in bridging the theory-practice gap in nursing education. It was designed and reported in adherence to the PRISMA 2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [20]. The review synthesizes literature published between 2010 and 2025 to capture developments in simulation-based education during a period of increasing integration into nursing curricula. Literature prior to this period was excluded due to limited methodological rigor and relevance.

The review targeted empirical studies involving nursing students and simulation-based interventions that reported measurable outcomes such as clinical competence, decision-making, confidence, or theory-to-practice transfer. Eligible study designs included experimental, quasi-experimental, mixed-methods studies, and systematic reviews with robust methodology.

This review was not pre-registered in PROSPERO or other public registries. While protocol registration plays a critical role in enhancing transparency and minimizing bias, it was not pursued due to the exploratory nature of the review and the iterative refinement of eligibility criteria and thematic categories during the early stages of screening.

Nonetheless, to enhance methodological transparency, we adhered closely to the PRISMA 2020 guidelines and provided detailed documentation of our eligibility criteria, data extraction methods, risk of bias assessment, and synthesis strategy.

Research question

Using the PICO framework, the research question was defined as follows:

• Population (P): Nursing students.

• Intervention (I): Simulation-based education.

• Comparison (C): Traditional or non-simulation-based education.

• Outcome (O): Reduction in the gap between theoretical and practical training.

Information sources

To identify pertinent studies, a systematic search of five principal electronic databases was conducted: PubMed, Scopus, Web of Science, Google Scholar, and Embase. These databases were selected for their comprehensive coverage of healthcare, medical education, and clinical sciences. Google Scholar was additionally included to identify potentially relevant grey literature and studies not indexed in major databases. A structured approach was applied during the Google Scholar search, in which only the first 100 results were screened based on predefined relevance and eligibility criteria. This inclusion was justified by Google Scholar’s broader indexing of conference papers, theses, and non-indexed peer-reviewed articles.

Search strategy

A tailored and reproducible search strategy was developed for each database using a combination of relevant keywords and Boolean operators. Filters were applied to restrict the results to English and Persian-language articles published between January 2010 and April 2025. However, for the purpose of quality appraisal and consistency in synthesis, only English-language studies were ultimately included in the final review. Detailed search strategies for each database are provided in the supplementary file1.

Eligibility criteria

Studies were included in this review if they met the following criteria:

Inclusion and exclusion criteria

Studies were included in this review if they met the following criteria:

1. Focus of the Study: Articles that directly examined clinical simulation as a method for educating nursing students, enhancing the transfer of theoretical knowledge into practice, or improving clinical skills. Additionally, studies in the broader field of professional medical education were considered if their findings were generalizable to nursing education—such as improvements in conceptual understanding, decision-making, self-confidence, satisfaction, empathy, patient-centeredness, or experiential learning.

2. Study Design: Eligible studies included quantitative research such as experimental, quasi-experimental, cross-sectional studies, and systematic reviews.

3. Outcomes: Only articles that reported at least one of the following outcomes were selected: improved clinical competence, enhanced decision-making, increased self-confidence, effective transfer of theoretical knowledge to practice, or enhanced clinical readiness for real-world care settings. Additional affective and experiential outcomes such as satisfaction, empathy, and engagement in experiential learning were also considered.

4. Timeframe: Only studies published between 2010 and 2025 were included.

5. Language: Articles had to be published in English.

Studies were excluded from the review if they:

1. Focused solely on specialized professional training without addressing the transfer of concepts to undergraduate nursing education;

2. Lacked empirical data or a clear methodology (e.g., editorials, letters to the editor, opinion pieces—unless they contained structured empirical data);

3. Were published in languages other than English or Persian;

4. Did not report outcomes relevant to the theory–practice gap.

Data extraction and management

Data extraction was independently performed by two researchers using a standardized extraction form. The extracted data included the following information:

• Study characteristics: Author(s), year of publication, study design, sample size, and research setting.

• Simulation features: Type and format (e.g., structured, practice-based, or narrative), duration, frequency of implementation, and the educational content covered (such as cardiopulmonary resuscitation skills, critical care, etc.).

• Outcomes: Improvement in clinical skills, transfer of theoretical knowledge, decision-making, confidence, and student satisfaction.

• Reported implementation challenges: Including resource limitations, infrastructure constraints, and insufficient mentorship.

• Strategies for effective implementation: Such as structured feedback, realistic scenarios, and repeated practice.

• Methodological details: Tools used for outcome assessment (questionnaires, performance tests, interviews), and the type of statistical or descriptive analysis applied.

Initial citation records were organized using Google Sheets and subsequently managed with EndNote to remove duplicates and ensure accurate referencing.

The search strategy was developed by the first author and reviewed in collaboration with the second author, who had expertise in conducting literature reviews. Although no professional librarian was part of the team, the final strategy underwent internal peer review.

Discrepancies in study selection or data extraction were resolved through direct discussion between the two authors.

These procedures ensured methodological consistency, transparency, and accuracy throughout the entire review process.

Quality assessment

Given the methodological diversity of the included studies, we applied validated risk of bias assessment tools tailored to study design. For experimental and quasi-experimental studies, the Cochrane Risk of Bias 2 (RoB 2) tool was used. Systematic and umbrella reviews were assessed using the Newcastle-Ottawa Scale (NOS), and qualitative and mixed-methods studies were evaluated with the Critical Appraisal Skills Programme (CASP) checklist. All appraisals were conducted independently by reviewers using standardized criteria, with disagreements resolved by consensus. Studies were not excluded based on their risk of bias rating. However, risk assessments informed the narrative synthesis, and findings from studies judged to be at higher risk of bias were interpreted with caution. Further information is presented in Table S2 (Supplementary File).

Data synthesis

Due to heterogeneity in study designs, simulation types, and outcome measures, we employed a thematic synthesis approach to qualitatively analyze and interpret findings across studies. The thematic analysis followed the six-phase framework outlined by Braun and Clarke (2006) [21]: (1) familiarization with the data (2), generating initial codes (3), searching for themes (4), reviewing themes (5), defining and naming themes, and (6) producing the report. All included studies were independently reviewed and coded by both authors using an inductive, data-driven approach. Emerging themes were derived based on recurring patterns in outcomes and intervention characteristics. Any discrepancies were resolved collaboratively through discussion between the authors. This approach enabled the identification and integration of key concepts across diverse methodologies into coherent thematic categories.

The resulting themes encompassed areas such as enhanced theory-to-practice transfer, improved clinical judgment and decision-making, increased learner self-confidence and satisfaction, development of empathy, and the role of simulation fidelity in learning outcomes. Challenges such as limited debriefing practices, inconsistent simulation design, and lack of faculty preparation were also synthesized. The results were presented narratively, emphasizing both the transformative potential and implementation barriers of simulation-based learning in bridging the theory–practice gap in nursing education.

Limitations

Despite efforts to adhere to methodological standards, this systematic review has several limitations that should be considered when interpreting the findings:

1. Heterogeneity in study design: Considerable variation in study types, sample sizes, assessment tools, and simulation interventions prevented the use of quantitative meta-analysis. As a result, the findings were synthesized qualitatively.

2. Variable quality of evidence: Some included studies exhibited moderate to high risk of bias, which may weaken the robustness of their findings. Although these studies were retained in the review, their results were interpreted with caution.

3. Geographic and technological constraints: In certain regions, limited access to advanced simulation technologies and educational infrastructure may reduce the generalizability of findings to low-resource educational settings.

4. Educational context of some studies: A number of included studies were conducted in broader professional education contexts rather than nursing-specific settings. These studies were retained due to their transferable insights—such as improvements in conceptual understanding, instructional interaction, and content design—but this inclusion is acknowledged as a methodological limitation, reflecting the scarcity of dedicated research on clinical simulation in nursing.

5. Lack of protocol registration: The review was not pre-registered on platforms such as PROSPERO. While protocol registration enhances transparency, the exploratory nature of the study and the evolving inclusion criteria led to the decision not to pre-register. This is acknowledged as a limitation; however, all review stages were reported in full compliance with PRISMA guidelines.

6. A small number of included studies were systematic reviews. These were selectively incorporated to strengthen the thematic synthesis—specifically for underrepresented domains such as empathy and experiential learning. Their inclusion did not introduce data duplication, as the synthesis remained qualitative and conceptual, aligned with the scope of a conventional systematic review.

Results

A total of 15 studies were ultimately included in the review after a comprehensive screening and eligibility assessment. Initially, a broad literature search across major academic databases yielded a substantial number of records focusing on the use of clinical simulation in nursing education. The study selection process is detailed in the PRISMA flow diagram (Fig. 1), which outlines the number of records identified, screened, excluded, and finally included, along with justifications for exclusion at each stage. Further details regarding the characteristics of the included studies are summarized in Table 1. The evidence reviewed highlights the potential of clinical simulation to significantly narrow the theory–practice gap, with reported improvements in students ‘clinical judgment, decision-making, self-confidence, empathy, experiential engagement, and satisfaction in real-life scenarios. The reviewed literature provides key insights into the Impact of Simulation, Challenges to Learning Effectiveness, Effective Strategies for Simulation Implementation and Critical Analysis of Findings:

Fig. 1.

Prisma floe diagram

Table 1.

Table of characteristics of included studies

No.	Title of the Study	First Author	Publication Year	Journal	Study Design	Sample Size and Setting	Themes	Key Outcomes
1	Effect of high-fidelity simulation on self-satisfaction and self-confidence among nursing students	Toqan, D.	2023	SAGE Open Nursing	Experimental/Quantitative	150 nursing students in Jordan	Confidence, Satisfaction, Simulation Impact	Simulation boosts students’ perceived readiness
2	Investigating the clinical decision-making of nursing students using high‐fidelity simulation, observation and think aloud	Abdulmohdi, N.	2023	Nursing Open	Mixed Methods	Nursing students (n = not specified precisely here, but likely ~ 30–50) in UK academic setting	Reasoning process, Decision pathway, Simulation environment	Insight into how students approach complex decision-making under simulation pressure
3	Effect of a simulation game on nursing students’ reflective thinking skills	Açıl, A.	2024	BMC Nursing	Mixed Methods	62 nursing students in Turkey	Reflection, Critical analysis, Active learning	Simulation games can enhance reflective thinking and active participation
4	Effects of simulation in improving the self-confidence of student nurses in clinical practice: a systematic review	Chernikova et al.	2020	BMC Nursing	Systematic Review	Multiple studies, international	Simulation for confidence building; Clinical preparedness	Increased self-confidence and readiness for real clinical settings
5	Use of simulation-based learning in undergraduate nurse education: An umbrella systematic review	Cant & Cooper	2021	Nurse Education Today	Umbrella Systematic Review	58 reviews, global	Simulation-based learning in undergraduate nursing; Structural improvements	Simulation improves learning but requires standardization and structured design
6	Simulation in Clinical Nursing Education	PMC Authors	2022	BMC Nursing	Literature Review	Various studies, USA	Clinical simulation; Theory-to-practice transfer	Effective for teaching clinical skills and bridging theoretical and practical knowledge
7	Effect of simulation role on clinical decision-making accuracy	Chow KM	2023	Nurse Education in Practice	Mixed Methods	Emergency nursing students, Hong Kong	Role-based simulation; Accuracy in decision-making	Different roles in simulation improve accuracy in clinical decision-making
8	Effectiveness of simulation-based interventions on empathy enhancement among nursing students: a systematic literature review and meta-analysis	Cho, M-K	2024	BMC Nursing	Systematic Review & Meta-analysis	Meta-analysis: Included 14 studies; mixed settings (global)	Empathy, Simulation effectiveness, Educational intervention	Simulation is effective in enhancing empathy, especially when interactive and experiential
9	Nursing Students’ Experiences of Empathy in a Virtual Reality Simulation Game	Mattsson, K	20,024	Computers, Informatics, Nursing	Descriptive Qualitative Study	19 nursing students from Finland	Empathy, Immersion, Emotional reflection, Perspective-taking	VR simulation can evoke authentic emotional responses and promote empathetic awareness
10	Analysis of high-fidelity simulation effects and their connection with educational practices in early nursing education	Wojcieszek	2025	BMC Nursing	Quantitative (Cross-sectional comparative study)	N = 100 nursing students, Poland	Confidence development, early clinical preparedness, student satisfaction, alignment with curriculum	Statistically significant improvement in student-reported confidence and satisfaction; early introduction of simulation linked to stronger academic engagement
11	Evaluating the Impact of Simulation-Based Training on Nursing Student Clinical Decision-Making Skills	Hanumanthayya	2025	Not officially published – ResearchGate preprint	Quasi-experimental	Not explicitly stated; nursing students in clinical training phase	Decision-making, critical thinking, confidence	Significant improvement in cognitive and affective domains
12	Effect of a simulation game on nursing students’ reflective thinking skills: a mixed methods study	Açıl	2024	BMC Nursing	Mixed methods	23 senior nursing students in Turkey	Reflective thinking, motivation, decision-making, self-confidence
13	Effects of a complex case study and high-fidelity simulation on mechanical ventilation…	Salameh	2021	Nurse Educator	Quasi-experimental	98 undergrad nursing students – Jordan	Clinical judgment, knowledge acquisition, fidelity	Significant post-intervention improvement
14	Nursing students’ clinical judgment skills in simulation and clinical placement…	Høegh-Larsen	BMC Nursing	BMC Nursing	Comparative quantitative	202 nursing students – Norway	Clinical judgment, self-assessment accuracy	Feedback is key; students lack accurate self-assessment
15	Simulation in Clinical Nursing Education	Koukourikos	2021	The Open Nursing Journal	Literature Review (Narrative)	Review of 15 + studies from Medline, CINAHL, Scopus — international settings	Theory–practice transfer; clinical judgment; confidence; experiential learning; fidelity; satisfaction	Recommendation to integrate simulation widely with instructional design to support transition to clinical competence

Impact of simulation on bridging the theory–practice gap

High-fidelity manikins and interactive scenario-based simulations significantly enhanced learners’ clinical judgment, including skills such as cardiopulmonary resuscitation (CPR), infection control, and real-time decision-making [22].

Learners consistently demonstrated a stronger ability to apply theoretical principles in clinical environments. A large-scale meta-analysis further confirmed the significant improvement in diagnostic reasoning and critical thinking as a result of simulation-based instruction [23].

Additionally, multiple studies reported a perceptible narrowing of the theory–practice gap following structured simulation programs [24, 25].

Barriers to effective and sustainable simulation-based learning

Despite short-term improvements, several barriers compromised the long-term impact of simulation-based learning. These included insufficient debriefing, lack of repeated exposure, and inadequate faculty development. Some studies warned that student self-confidence and clinical readiness tend to decline over time without sustained reinforcement [7] [26]. Institutional and curriculum-related constraints were also noted as limiting factors to simulation effectiveness.

Effective design and implementation strategies for simulation integration

Evidence highlighted several implementation strategies that significantly enhanced experiential learning and student satisfaction. These included timely facilitator-led debriefing, realistic scenario fidelity, feedback immediacy, and advanced technologies such as virtual simulation [27]. Studies also emphasized the importance of administrative support, scheduling flexibility, and resource allocation to successfully embed simulation into nursing curricula [28].

Critical analysis of findings

Although none of the included studies reported adverse effects of simulation, methodological limitations were consistently noted. These included the use of self-reported outcomes such as confidence, limited long-term follow-up, and context-specific constraints that reduced generalizability. The predominance of positive findings also raises concerns about publication bias, necessitating further research with diverse methodologies and longer-term evaluation.

Discussion

This systematic review provides a synthesized analysis of the effectiveness, challenges, and implementation of clinical simulation in undergraduate nursing education. Drawing on 15 studies, the findings offer insights into how simulation-based interventions help bridge the gap between theoretical instruction and clinical practice while identifying the conditions that influence their success.

Satisfaction

Learner satisfaction emerged as a common outcome across several studies, often reported alongside self-confidence. One study used the “Satisfaction and Self-confidence in Learning” Scale to assess perceptions after high-fidelity simulation among 150 nursing students, revealing statistically significant improvements in both domains [29]. Another study reported high satisfaction following structured simulation experiences in Jordan, emphasizing the role of scenario fidelity and debriefing structure(16). Factors influencing satisfaction included the realism of scenarios, instructor facilitation, and the quality of post-simulation debriefing. While high satisfaction is encouraging, its correlation with actual clinical competence remains unclear. This review underscores the need to distinguish emotional impressions from objective performance, a distinction largely overlooked in current literature. Future studies should combine affective metrics with clinical performance indicators to better evaluate learning outcomes.

Decision-making

Simulation-based training significantly enhanced clinical decision-making, particularly when delivered through high-fidelity learning environments. One mixed-methods study with 23 nursing students used high-fidelity simulation paired with think-aloud protocols and the Health Science Reasoning Test, demonstrating significant gains in deductive and analytical decision-making processes [30]. Another quasi-experimental study reported improved clinical reasoning and decision-making performance post-simulation training as measured by structured observation and self-reported measures [31]. These findings are supported by meta-analytic evidence from Chernikova et al., who concluded that simulation-based learning substantially improves decision-making and problem-solving skills in higher education, especially when paired with active learning strategies and structured debriefing [17]. Since decision-making is a fundamental skill for safe clinical practice, these findings underscore the role of simulation in addressing the theory–practice gap. Yet, few studies compare effects across nursing specialties, highlighting the need for domain-specific simulation research.

Experiential learning

Experiential learning theory, particularly Kolb’s model, underpins many simulation programs in nursing education. One included review proposed a reflective learning framework to help bridge the theory–practice divide through structured cycles of experience, observation, and analysis [25]. However, most reviewed studies did not explicitly adopt experiential frameworks or measure learning depth. In one quasi-experimental study outside this review, guided reflection was shown to significantly enhance knowledge retention and critical thinking in nursing simulations [32]. These findings highlight the importance of integrating structured reflection into simulation designs to ensure deeper learning. This review contributes by linking experiential principles directly to simulation efficacy, an area often underdeveloped in prior literature. Future work should focus on standardizing instruments to assess experiential depth and knowledge transfer.

Empathy

Empathy emerged as a meaningful affective outcome in several simulation-based nursing education programs. A recent meta-analysis involving 28 studies demonstrated that such interventions produced a small but statistically significant improvement in empathy among nursing students, with stronger effects observed in studies using quasi-experimental designs and larger sample sizes [33]. Complementary qualitative evidence from a Finnish study showed that students engaged in immersive virtual reality simulations reported greater emotional connection and compassion toward virtual patients [34]. However, not all interventions led to measurable gains—factors such as low scenario realism or insufficient time for debriefing appeared to limit empathy development. Given that empathy is essential for delivering holistic care, enhancing this skill through thoughtfully designed simulations can play a key role in narrowing the theory–practice gap. Future research should explore how timing, cultural alignment, and structured reflection influence empathic learning outcomes.

Clinical judgment

closely linked to decision-making accuracy—was significantly enhanced when simulations incorporated high fidelity, structured feedback, and complex, context-rich scenarios. In a randomized controlled trial from Jordan, 98 nursing students demonstrated marked improvement in clinical judgment scores following high-fidelity simulation, as measured by the Clinical Judgment Rubric [35]. Similarly, a qualitative study involving senior nursing students reported that simulations with realistic scenarios and guided debriefing enhanced students’ ability to recognize patient cues, reduce diagnostic bias, and articulate clinical reasoning pathways [30]A comparative study from BMC Nursing further revealed that students tended to overestimate their clinical judgment abilities when compared with evaluator-assessed scores using the Lasater Clinical Judgment Rubric, highlighting the importance of structured feedback in aligning self-perception with actual competence [36]. These findings underscore the role of instructional design—particularly scenario fidelity and post-simulation reflection—in facilitating the transfer of theoretical knowledge into sound clinical reasoning. This review contributes a nuanced understanding of how different feedback and assessment models influence judgment development. Further research is needed to evaluate longitudinal retention and compare instructional designs across clinical domains.

Self-confidence

Self-confidence consistently emerges as a central outcome in simulation-based nursing education. Studies have shown that repeated exposure to high-fidelity simulation improves learners’ confidence, particularly when sessions are well-structured and closely resemble real clinical situations [29, 37]. These findings suggest that both the realism and frequency of simulation play important roles in reinforcing student self-assurance. In contrast, single-session interventions often result in only temporary or modest improvements, indicating a possible dose–response effect. Recent large-scale findings also indicate that student satisfaction and self-confidence are strongly linked to the quality and diversity of educational practices within simulation design [38]. Similarly, Koukourikos et al. emphasized that simulation promotes the development of self-confidence and clinical decision-making by offering a safe and realistic environment for repeated practice [39]. Enhancing self-confidence is crucial for bridging the theory–practice gap, as it empowers students to act decisively and apply theoretical knowledge in real patient care. This review highlights the role of simulation dosage and instructional design in shaping confidence development—dimensions that have received limited attention in prior reviews. Future research should explore whether these confidence gains translate into lasting clinical competence and improved patient outcomes.

While the included studies employed various simulation formats—including high-fidelity mannequins, virtual reality environments, structured role-play, and digital simulation games—certain patterns of effectiveness emerged. High-fidelity simulations were particularly associated with enhanced clinical judgment and decision-making accuracy [17, 29, 30]. Virtual reality and game-based simulations appeared more effective in fostering empathy and reflective thinking, especially among early-year students [33, 34]. These findings suggest that the alignment between simulation type and intended learning outcome is crucial. Future studies should continue to explore which simulation modalities best target specific domains of clinical competence.

.Taken together, these findings suggest that simulation—when thoughtfully designed and integrated into broader curricula—can be a transformative element in nursing education. However, to realize its full potential, educators and institutions must address structural barriers, ensure faculty readiness, and adopt evidence-informed strategies that align simulation activities with learning objectives. Simulation should be viewed not as a standalone intervention but as a longitudinal, embedded component of clinical education that complements real-world experience.

Future research should prioritize longitudinal designs to assess the durability of simulation-driven improvements in competence and decision-making. Comparative studies evaluating the efficacy of emerging modalities such as virtual reality or hybrid simulations would further inform best practices. Additionally, investigation into how simulation fosters empathy, interprofessional collaboration, and ethical reasoning can expand its value beyond technical skill acquisition. With intentional implementation and ongoing evaluation, simulation holds promise not only to bridge the theory–practice divide but to reshape the future of nursing education.

Educational and practical implications

The findings suggest that for simulation to be truly effective, it must be integrated as part of a comprehensive educational framework. Curriculum designers are encouraged to integrate simulation as a complementary tool, not as a substitute for clinical training. Educators must receive proper training in debriefing techniques and effective feedback delivery, while policymakers consider investing in the necessary technological infrastructure and resources to support simulation-based learning in nursing education.

Conclusion

The findings of this systematic review suggest that the gap between theoretical instruction and clinical practice continues to be a significant barrier to the development of competent, confident, and practice-ready nurses. This gap driven by insufficient integration between academic curricula and the realities of clinical practice often contributes to student anxiety, reduced self-confidence, and clinical errors [22, 23].

Simulation-based education has emerged as an evidence-supported approach to bridge this disconnect. As demonstrated in studies by Görücü et al. and Zhao et al., simulation enhances technical skill acquisition and facilitates the effective application of theoretical concepts in safe, controlled learning environments [22, 23]. It enables experiential learning without endangering patient safety and promotes a shift from passive learning to active clinical engagement [40].

However, the long-term effectiveness of simulation depends on its structured implementation incorporating scenario realism, guided debriefing, regular repetition, and active instructor involvement [7, 26]. When these components are aligned with course objectives, simulation may serve as an effective pedagogical bridge between theory and clinical reality.

Nevertheless, the predominance of studies reporting positive outcomes raises concerns about publication bias. As noted in reviews by Cant & Cooper and Arteaga et al., few studies have reported neutral or adverse findings, which limits the objectivity of the current evidence base [41]. Future research should seek to present a more balanced picture, including potential limitations and contextual barriers to simulation-based learning.

Final recommendation

To sustainably reduce the theory–practice gap in nursing education, it is essential that:

• Simulation is integrated not merely as a teaching tool, but as a strategic, curriculum-embedded approach for transferring knowledge into clinical performance.

• Clinical instructors are adequately trained in the design and effective delivery of simulation-based learning.

• Future research adopts rigorous methodologies—including randomized, longitudinal, and multi-faceted designs—to evaluate the real-world effectiveness of simulation in preparing practice-ready nurses.

Ultimately, simulation can truly bridge the divide between education and clinical practice only when it is institutionalized not as a mere technique, but as a culture of experiential learning, rooted in the realities of modern healthcare and committed to practice-based competence.

Abbreviations

PRISMA

Preferred reporting items for systematic reviews and meta-analyses

NOS

The newcastle-ottawa scale

CASP

Critical appraisal skills programme

Authors’ contributions

Author ContributionsBoth authors contributed to the conception and design of the study. M.D. was responsible for formulating the research question, developing the methodology, and conducting the database searches. Study selection and data extraction were performed jointly by M.D. and H.K. Any disagreements were resolved through discussion between the two authors. M.D. prepared the initial draft of the manuscript. H.K., as the corresponding author, reviewed and revised the draft and ensured its alignment with the study objectives. Both authors read and approved the final manuscript.

Funding

The researchers provided all the resources needed to conduct this study, without any external funding. The research project received no financial support or grants from any funding agency or organization.

Data availability

All data analyzed in this study were extracted from previously published studies, which are cited in the manuscript. No new datasets were generated. Therefore, data sharing is not applicable.

Declarations

Ethics approval and consent to participate

Duo to study design Not applicable.

Consent for publication

N/A.

Competing interests

The authors declare no competing interests.