the word anxiety with several letters erased out
UNLV Nursing grad student Wendy Matthew

Wendy Matthew, MSN, RN, CHSE, UNLV Nursing graduate student in the PhD in Nursing Education program

Mar. 3, 2022

By Joseph Gaccione (UNLV School of Nursing Associate Director of Communications)

Panic attacks. Fainting. Simulation is designed to inspire confidence in nursing students, as they practice their skills in a safe and supportive clinical-like environment. But as UNLV Nursing graduate student Wendy Matthew has seen, many new nurses are struggling to get through their simulation activities due to overwhelming feelings of anxiety.

Matthew identifies these group of nursing students as part of generation Z, born between 1997 and 2012. She argues this generation of nursing students, despite ample resources at their fingertips to ease their training, are finding themselves more and more stressed, impacting their education and relationships with peers and instructors.

Through her research, Matthew hopes to increase awareness on how generation Z nursing students handle their emotions during simulation and what faculty can do to help them overcome their stresses and insecurities. 


When Matthew is not in class, she works as a professor at California State University, Stanislaus; she also doubles as the Simulation Program Director for their nursing school. This is where she sees first-hand what her students are experiencing more and more.  “I noticed a change in our students in the sense that it almost seems like when they have an uncomfortable emotion - anxiety or feeling pressured - they're unable to kind of move through it,” she says. “If there's a simulation that makes them uncomfortable, they just stand there. Maybe they don't engage with the patient, [they] might just look out the window.”

Matthew decided to base her Ph.D. in Nursing Education dissertation on the generation Z experience in simulation, looking specifically at emotional processing. She started exploring where this anxiety was coming from, if it was a generational habit or something more pedagogical. Her research initially was limited because there wasn’t much already published about generation Z students in simulation.  So, she had to start with a fresh slate with specific goals in mind: do students emote in simulation and if so, how is it managed?


Matthew collected data over a six-month period in 2021, noting responses from her student participants. As she investigated, Matthew saw a range of emotions, both positive and negative, and explored the mental and physical manifestations of those feelings, particularly the ones related to stress. She says, “They feel like they freeze up. Physiologically, they say they're sweaty. Their heart's racing, [and] their brain is foggy.” She also says some students would feign competency in a skills assessment if they were with a partner, just so they didn’t look bad. “When I heard the students say that, I [thought] we can find a way to make them comfortable to say, ‘I don't know how to do this,’ Matthew recalled. “They could pick up the phone and say, ‘We're in simulation. I know I have resources. I'm calling the charge nurse to show me how to do this dressing change’ or whatever [task], making them feel comfortable instead of having them fake it.” She adds one of the ways she connects with her students, particularly the ones feeling nervous, is through her own personal experiences. “I had anxiety doing procedures on my patients because I didn't want to hurt them,” Matthew says. “Of course, I would have never killed them by putting an IV in, but I felt like I could have, and I just put all that pressure and anxiety on myself. I always told the students, ‘I get the anxiety that you're feeling. Let's figure out how we can try to fix this.’”

Matthew found a range of factors that contribute to the students’ simulation anxiety, from lack of preparation time to short attention span to a perceived disconnect between them and their cohort.  She found one of the key roots of the students’ anxiety came from self-image. “They did not want to look like they were incompetent,” she says. “They did not want to look like they shouldn't be a nurse. They wanted to be as equal or better than the other students in the classroom. I think a lot of it was image and making sure that their faculty saw them as knowledgeable, as well as their classmates.”

She adds social media technology has compounded the pursuit of an acceptable outward presentation. “They’ve always been able to portray the image they want to portray. They've always been able to take 10 selfies and pick the best one. They've always been able to pick the best parts of their vacation and post it online [for] this beautiful, perfect image. That hurts them in simulation, because you can't practice the exact scenario beforehand, you can't have a do-over, you can't have a perfect image. When they have that much control over how they appear in life and then strip it away in simulation, I think they might experience anxiety more than we do because of that technology.” In fairness, Matthew understands some of her students use social media to actually help them process their feelings. “They [say], ‘I really messed up in simulation today,' and then they go on TikTok or YouTube, and there's another nurse saying, ‘Guys, you're never going to believe what happened to me in simulation today.' [This nurse] experienced the same exact thing as [the student] experienced, like [they are ]not in this alone. They feel they have a community out there than when I was in nursing school. I didn't have someone on TikTok telling me how they messed up the nursing school, so I felt alone in it. So, I think it could hurt and help.”

There are pressures students put on themselves, and there are also environmental pressures, coming from established expectations. The combination of the two can exacerbate student apprehension in this quest for the ideal image.   “The bar is so high these students probably have never experienced any type of failure in their entire lives," Matthew explains. "They have always been the smartest, always been the best performing, and then you put them in a situation where they're going to fail. Failures are expected because they don't know everything, and then they just don't know how to handle that failure at all.”


On January 28th, Matthew successfully defended her Ph.D. dissertation in front of her graduate committee. Based on her research, Matthew concluded more positive emotions in health care simulation education can be achieved with thorough pre-briefings (a belief augmented by another recently published study on standards of best practice) and prep work; allowing students to take moments to self-regulate (deep breaths, collect themselves); ensuring helpful resources are available; addressing possible judgement; and constructive debriefings that focus on solutions, not just what went wrong. Matthew’s dissertation completed just one particular portion of her research.  She feels knowledgeable enough to create interventions for students for future research as well as look further into areas of social media, psychological safety, and feelings of being set up to fail.

Acknowledging a student’s sensitivity is important, but is there a risk of holding a student’s hand too much in becoming a nurse? Matthew disagrees, says it’s important to have empathy in recognizing stress when it’s there, because it not only affects their performance, but the care they give to a patient. “When I came into this, I was concerned about this generation because they have so much anxiety, even for things that to me, seems unprovoked," Matthew admits. "[But] even though I can't relate to it, it doesn't mean it's not real for them. [Students] are going to be in situations that are scary. They are going to be in situations where the patient just codes right in front of them. You can't just stand there and say, ‘I have anxiety.’ You have to do something. What I realized is if we give them the right tools, they do really well. Adjust the way we do things so we can help them be successful.” Matthew adds she gained more appreciation for her students after performing her research.

The other main point Matthew wants students and faculty to remember is they should be working together to pinpoint the ideas of anxiety and remove them. “I think the main thing is we're a team. The minute you take away, ‘They’re judging me’, the students do so much better," she says. "Yes, I'm faculty and yes, you're a student, but we're still a team. You're here to learn and I'm here to help that. You're not going to be perfect; it’s okay. If we make mistakes, we're going to talk about it, And I think starting off on that foot is helpful creating that team mindset.”

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