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The effect of simulation-based training on palliative care competence: A systematic review and meta-analysis
Carmen Ka Man Choi1, Lily Man Lee Chan2, Jojo Yan Yan Kwok3
1School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China; School of Nursing and Health Sciences, The Hong Kong Metropolitan University, Hong Kong SAR, China.
Background:
Palliative care and end-of-life care training are increasingly recognized as essential components of nursing education worldwide. Comprehensive training in general palliative care can prepare nurses for handling complex challenges. Simulation-based training offers an innovative approach to prepare nurses and nursing students for the demands of palliative and end-of-life care.
Objectives:
To examine the effect of simulation-based training in improving nursing students' and nurses' knowledge, attitudes, skills, and confidence in palliative care compared to conventional education or no intervention.
Data Sources:
Five databases, including PubMed, MEDLINE, EMBASE, CINAHL PLUS, and Cochrane CENTRAL, were searched from inception to May 8, 2025.
Methods:
Randomized controlled trials and quasi-experimental studies involving nurses and nursing students were included. The outcomes assessed were knowledge, attitudes, skills, and confidence related to palliative care. Two reviewers independently screened studies, extracted data, and assessed the risk of bias using the Cochrane Risk of Bias tools. A narrative synthesis was conducted, and meta-analysis was performed by using a random-effects model. Standardized mean differences with 95% confidence intervals were used as the effect measure under the inverse-variance method. Heterogeneity was assessed using I2 statistics and Cochran's Q test.
Result:
Eleven studies (3 randomized controlled trials and 8 quasi-experimental studies) involving 909 participants (588 nurses [64.7%] and 321 nursing students [35.3%]) were included, with 9 studies contributing to the meta-analysis. Simulation-based training showed statistically significant improvements in knowledge (SMD = 1.49; 95% CI: 1.12 to 1.86, Z = 7.91, p < 0.00001) and skill performance (SMD = 1.29; 95% CI: 0.79 to 1.78, Z = 5.08, p < 0.00001) for both nurses and nursing students. Subgroup analysis revealed that nursing students experienced significant gains in confidence (SMD = 1.39; 95% CI: 0.51 to 2.28, Z = 3.10, p = 0.002) compared to non-simulation settings. However, the effect of simulation-based training on improving nurses' and nursing students' attitudes remains inconclusive.
Conclusion And Implications:
Simulation-based training significantly enhances nursing students' confidence, as well as nurses' and nursing students' knowledge and skill performance in palliative and end-of-life care. However, its effect on attitudes remains uncertain, and high-quality randomized controlled trials are needed. Future research should focus on robust trials to assess the long-term effects, address cultural and psychological factors, accommodate the diverse needs of nurses and students, and incorporate patient outcome assessments.