Development and validation of the psychological safety in nursing simulation (PSSANS) tool

Abstract

Background: Nursing students frequently experience psychological pressure during simulation-based education, and promoting psychological safety in these settings may improve learning effectiveness. Aim: This study aims to develop and validate the Psychological Safety in Nursing Simulation (PSSANS) tool for undergraduate nursing students. Design: This was a methodological study. Methods: An initial pool of 28 PSSANS items was developed through a literature review. Content validity was evaluated in two rounds by a five-expert panel, retaining items with a content validity index (CVI) of ≥0.80. Two items were added after the first round based on expert recommendations, and all 30 items met the CVI threshold in the second round. A pretest involving 20 nursing students was conducted to assess item clarity and completion time. Subsequently, data from 366 nursing students with prior simulation experience were used to examine validity and reliability using item analysis, exploratory factor analysis (EFA), confirmatory factor analysis (CFA), convergent validity, and internal consistency testing. Results: EFA revealed a 21-item, 4-factor structure accounting for 59.8% of the total variance, and CFA supported its construct validity. Convergent validity was demonstrated by a significant negative correlation with the Penn State Worry Questionnaire. The PSSANS showed acceptable internal consistency, with an overall Cronbach's α of 0.757 and subscale α values ranging from 0.622 to 0.889. Conclusions: The PSSANS is a valid and reliable tool for assessing psychological safety in nursing simulation settings and may help nursing educators foster psychologically safe learning environments and enhance educational outcomes. © 2026 Elsevier Ltd