Background: The continued use of high fidelity full sized human patient simulation manikins (HF-HPSMs) for developing decision making skills of nursing students has led to growing research focusing its value on student learning and decision making skills. Methods: In October 2012, a cross-sectional survey using the 24-item Nurse Decision-Making Instrument was used to explore the decision making process of 232 pre-registration nursing students (age 22.0 + 5.4; 83.2% female) in Singapore. Results: The independent samples t-tests demonstrated three significant predictive indicators. These indicators include: prior experience in high fidelity simulation based on pre-enrolled nursing course (t = 70.6, p = .001), actual hands-on practice (t = 69.66, p < .005) and active participation in debrief (t = 70.11, p < .005). A complete experience based on role-playing followed by active discussion in debrief was a significant contributor to the decision making process (t = 73.6667, p < .005). However, the regression model indicated active participation in debrief as a significant variable which explained its development (t = 12.633, p < .005). Conclusions: This study demonstrated the usefulness of active participation in simulation learning for an analytic- intuitive approach to decision making, however active participation in debrief was a more important influencing element than role-playing. In situations where resources are limited for students to experience hands-on role-playing, peer reviewing and feedback on others’ experiences could benefit students, just as much. However, further study is warranted to determine the development of HF-HPSMs as a pedagogic tool for enhancing the decision making process of nursing students.