A scalable simulation program for end-of-life care education in undergraduate nursing students: changes in OSCE-assessed clinical competence, knowledge, and confidence—a quasi-experimental one-group pretest-posttest study

Nursing students often have limited opportunities to provide end-of-life care during clinical placements. This study aimed to examine changes in objective clinical competence, knowledge, and confidence among undergraduate nursing students following participation in a scalable end-of-life care simulation program incorporating observational learning and structured debriefing. This quasi-experimental one-group pretest–posttest study was conducted at a single national university nursing program in Japan. Third-year students were recruited on a voluntary basis, and 27 of approximately 80 eligible students participated. The 80-min simulation program was adapted from a previously evaluated small-group scenario and redesigned for scalable delivery, in which approximately 25–30 students participated in a single session through direct care roles, structured observation, small-group discussion, and sequential debriefing. Objective clinical competence was evaluated using an objective structured clinical examination (OSCE) at baseline (T0) and 2 weeks later (T2). Knowledge and confidence were assessed at T0, immediately after the program (T1), and T2. Twenty-seven students enrolled in the study, and 25 completed all evaluations. The primary outcome, OSCE-assessed clinical competence, increased for physical assessment skills (3.08 ± 1.50 vs. 5.96 ± 1.17; mean difference 2.88, 95% CI 1.95–3.81; p < 0.001, Cohen’s dz = 1.285) and for psychological care skills (3.40 ± 2.80 vs. 7.80 ± 3.92; mean difference 4.40, 95% CI 2.57–6.23; p < 0.001, Cohen’s dz = 0.990). Among the secondary outcomes, knowledge scores increased from 7.00 ± 2.29 at T0 to 8.16 ± 1.57 at T1 and 8.20 ± 1.47 at T2 (Friedman p = 0.001, Kendall’s W = 0.262). Confidence in physical and psychological care also changed over time. Participation in this scalable simulation program was associated with short-term improvements in OSCE-assessed clinical competence, knowledge, and self-reported confidence. This format may offer a feasible approach to undergraduate end-of-life care education where direct clinical exposure is limited. Larger controlled studies are needed to confirm these findings. This study was registered in the UMIN Clinical Trials Registry (UMIN000056219) on 20 November 2024. Retrospectively registered.