Abstract
Background The growing integration of artificial intelligence (AI) in healthcare necessitates that nurse leaders develop advanced competencies in decision-making, communication, and data-informed clinical judgment. Traditional simulation-based education, while effective, often relies on fixed scenarios with limited adaptability and minimal real-time decision support. AI-enhanced simulation offers a potential solution by creating responsive, adaptive learning environments that support leadership development. Methods This randomized controlled, parallel-group, pretest-posttest trial included 130 final-year nursing students who were randomly allocated to an intervention group (n = 65), receiving AI-adaptive simulation integrated with an AI-based workforce decision-support system, or a control group (n = 65). Twenty-one clinical preceptors served as trained and blinded outcome assessors and were not included in the randomized sample. Leadership performance was assessed using the Creighton Simulation Evaluation Instrument (C-SEI). Secondary outcomes included team performance, general self-efficacy, and AI acceptance. Results At Week 10, the intervention group demonstrated greater improvement in leadership performance than the control group (between-group difference in change = 5.20, 95% CI 4.18-6.22, p < 0.001), with a large standardized effect (Cohen's d = 1.78). Greater improvements were also observed in team performance (between-group difference in change = 0.63, 95% CI 0.44-0.82, p < 0.001, d = 1.24) and general self-efficacy (between-group difference in change = 5.30, 95% CI 3.82-6.78, p < 0.001, d = 1.37). Intervention-group students reported favorable AI acceptance, including perceived usefulness and ease of use. Conclusions AI-adaptive simulation integrated with an AI-based workforce decision-support system was associated with improved leadership performance, team performance, and self-efficacy among final-year nursing students under controlled simulation conditions. Further research is needed to determine whether these effects are sustained and transfer to clinical practice.