Online Simulation in Palliative Care Education for Early-Career Nurses in Japan: A Pre–Post Exploratory Evaluation of Perceived Outcomes and Feasibility

Abstract

Background:

Early-career nurses often encounter difficulties in symptom management and communication with patients and families in palliative care. Although simulation-based education improves clinical competence, most programs require in-person participation. Evidence regarding the feasibility and outcomes of fully online simulation with immediate feedback for palliative care training remains limited.

Objective:

To examine the perceived outcomes and feasibility of a fully online simulation-based palliative care education program for early-career nurses in Japan.

Design:

Exploratory pre–post, single-arm study.

Setting/Subjects:

The study was conducted in Japan and included 34 early-career nurses with 2–4 years of clinical experience who participated in a 90-minute online program delivered via Zoom.

Measurements:

The program comprised briefing, simulation, group work, and debriefing sessions focusing on total pain and communication. Outcomes were assessed at baseline, immediately post-intervention, and 1 month after using the Palliative Care Difficulties Scale, Nurses’ Difficulty with Cancer Care Scale, Palliative Care Self-reported Practices Scale, and measures of confidence and satisfaction. Open-ended responses were analyzed descriptively.

Results:

Scores improved significantly from baseline in Palliative Care Difficulties Scale scores for symptom alleviation (p = 0.024, d = 0.41) and communication (p = 0.002, d = 0.57). Confidence in recognizing total pain (p = 0.008, d = 0.63) and communication (p = 0.011, d = 0.66) increased from baseline. Researcher-rated practice levels improved in 9 of 14 items, and mean satisfaction was 5.2/6. Qualitative findings indicated that most participants applied their learning in clinical practice.

Conclusions:

These findings suggest that the program may contribute to improvements in perceived difficulties and confidence, supporting its potential feasibility as an educational model.

Introduction

As cancer continues to be a major cause of death globally, ¹ effective palliative care is increasingly needed to alleviate patient suffering and preserve quality of life. ² Palliative care is critical in comprehensive cancer management, addressing patient distress holistically across its physical, psychological, social, and spiritual domains. In addition, it is a core responsibility for all health care providers, ³ with nurses playing a crucial role in managing not only physical symptoms but also the psychological, social, and spiritual aspects of patient distress.

Despite its recognized importance, early-career nurses encounter substantial challenges in delivering high-quality palliative care. In Japan, nurses with 2–4 years of clinical experience commonly report difficulties in managing complex symptoms, addressing psychosocial needs, and communicating effectively with patients and families.^3,4 Pain management in Japan is addressed only as a component of symptom management during undergraduate education. ⁵ Conversely, postgraduate pain education primarily depends on institutional policies and individual clinical experience, resulting in inconsistent learning opportunities among nurses. International studies similarly show that early-career nurses frequently feel underprepared to respond to the multifaceted needs of patients receiving palliative care.^6,7 These challenges can contribute to stress and burnout among such early-career nurses. ⁸ Strategic education is needed to enhance their confidence in clinical skills and communication.

Simulation-based learning has been shown to enhance skill development and build confidence through structured experiential learning in a safe environment.^9–11 However; most of these programs are conducted face-to-face, creating physical barriers for nurses during their work shifts. Online education methods such as augmented reality and e-learning have been increasingly adopted as simulation approaches, offering advantages including flexible access and standardized learning experiences. ¹² Nevertheless, both methods are limited by their high development costs.^13,14 To date, the effectiveness of fully online simulation-based palliative care education using Zoom (Zoom Video Communications, Inc., San Jose, CA, USA), which requires no development costs, remains insufficiently reported.^15–18

While traditional palliative care education primarily relies on role-play, simulation-based learning promotes clinical reasoning in complex situations. Given the limited evidence supporting fully online implementation with immediate instructor feedback, this program was designed based on experiential learning and self-efficacy theories and adhered to the Healthcare Simulation Standards of Best Practice established by the International Nursing Association for Clinical Simulation and Learning (INACSL).^19–21

Hence, this study aimed to explore the feasibility and perceived outcomes of a fully online palliative care simulation program for early-career nurses with 2–4 years of experience. The program focuses on core competencies in total pain management and communication through interactive learning via Zoom. This study seeks to provide preliminary empirical evidence to inform the future development of accessible online palliative care training for early-career nurses. We hypothesized that participation in the online simulation program would be associated with reduced perceived difficulty and increased practice levels in palliative care among early-career nurses.

Materials and Methods

Design

This study adopted a single-group pre–post comparison design, as it preliminarily examined the feasibility and perceived outcomes of a fully online, simulation-based palliative care program integrating immediate instructor feedback, for which empirical evidence remains limited. Given this study design, blinding of participants and facilitators was not feasible. This study adhered to the reporting guidelines of the Transparent Reporting of Evaluations with Nonrandomized Designs. ²² Ethical approval was obtained from the Clinical Research Ethics Review Committee of the Mie University Hospital (approval no.: U2022-032).

Operational definition of terms

The educational program on palliative care addressed topics such as total pain management and communication skills, developed with reference to prior studies.^3,16,23,24

Setting and participants

This study enrolled nurses with 2–4 years of professional experience who were employed at hospitals, including designated cancer care centers, semidesignated facilities, and related institutions staffed with certified nurse specialists in cancer nursing, in the Tokai region. Nurse volunteers reviewed the study information, signed an informed consent form, and secured an online environment to join the program.

Development/Intervention

Built on previous studies that highlight total pain management and communication as core skills for years 2–4 nurses, ²⁴ the simulation-based online palliative care training program was developed with reference to the End-of-Life Nursing Education Consortium-Japan framework. The simulations were designed according to INACSL best practices. ²¹ The program was developed in 2023 in accordance with the INACSL Standards of Best Practice in effect at that time. Following the 2025 revision of the INACSL Standards, we confirmed that the program components remain consistent with the updated standards. Using simulated patients, this study conducted clinical scenarios in a low-fidelity simulation environment. These scenarios included briefing (introduction), simulation session, and debriefing (review). Participants received preparatory handouts describing the case scenario and essential concepts. The learning objectives were as follows: (1) to identify patients’ multidimensional suffering and (2) to communicate appropriately according to the patient’s condition. The case scenario involved an adult patient with advanced esophageal cancer presenting with pain due to spinal metastasis. In addition to physical suffering, the patient experienced psychological and spiritual distress, including culturally influenced concerns such as “not wanting to burden my family.” In addition, participants were instructed to complete an online connection test in advance. Before each session, Internet connectivity and audiovisual functionality were confirmed to ensure technical stability and minimize disruptions during the simulation. To enhance sustainability, the program was designed using existing institutional resources (e.g., a widely available videoconferencing platform and low-fidelity simulation methods), without requiring dedicated simulation equipment or proprietary software.

A team composed of three nurse researchers with over 5 years of experience in palliative care education, one cancer nursing specialist, and one certified palliative care nurse developed the program. Through a series of in-person and e-mail meetings, the team designed both the case scenarios and program content, ensuring realistic case settings and appropriate complexity for nurses in their second to fourth year of practice. Before the program began, eligible participants were recruited and confirmed through a pretest.

The simulation lasted 90 minutes and was conducted in groups of 3–4 participants, progressing through the following steps: (1) Briefing, (2) Simulation session, (3) Group work, (4) Debriefing, and (5) Summary (Table 1). During the briefing, psychological safety was emphasized, and participants were informed that mistakes were acceptable and would be used constructively to facilitate learning. Each group was facilitated by an experienced educator who had been involved in cancer nursing education for over 5 years and individuals who had completed simulation instructor training. All simulation activities were conducted using an online platform. Intervention fidelity was maintained using a standardized program manual and predefined procedures, with all sessions following the same structure. Participant adherence was monitored based on attendance and completion of all scheduled simulation components.

Table 1.

Content of the Online Simulation Palliative Care Education Program

Program (90 min)

1.Preclass materials

Content/learning objectives, case studies, data on the case’s disease, total pain, pain assessment items, and communication skills

2.Briefing (10 min)

Conducting a content/case study using prelearning materials, sharing learning objectives, and explaining the flow

3.Simulation session (75 min)

□First patient selection

1)Simulation implementation (4 min)/physical assessment of simulated patients 2)Group work (10 min)/discussion of simulation outcomes and areas for improvement 3)Debriefing (10 min)/supporting participants in understanding the following pain assessment items: pain intensity, pain characteristics, impact of pain on daily life, and response/side effects of current treatment

□Second patient selection

1)Simulation implementation (4 min)/physical assessment of simulated patients 2)Debriefing (5 min)/supporting participants in understanding the following according to holistic pain materials: “Physical assessment is necessary for assessing holistic pain.”

□Third patient selection

1)Simulation implementation (4 min)/communication with simulated patients 2)Group work (10 min)/discussion on what was achieved and areas for improvement during the simulation 3)Debriefing (10 min)/supporting participants in identifying the following elements based on communication materials: environment setting, active listening skills, silence, open questions, and Naming, Understanding, Respecting, Supporting, and Exploring (NURSE)

□Fourth patient selection

1)Simulation implementation (4 min)/communication with simulated patients 2)Debriefing (5 min)/supporting participants in understanding the following concepts based on NURSE communication materials: Naming, Understanding, Respecting, Supporting, and Exploring

4.Summary (5 min)

Content/Verifying whether the content learned and learning objectives were achieved

Measurements

The primary outcome was the change in Palliative Care Difficulties Scale (PCDS) ³ scores from baseline (preintervention) to one month after the intervention. Secondary outcomes included changes in Nurses’ Difficulty with Cancer Care (NDCC) ²⁵ and Palliative Care Self-reported Practices Scale (PCPS) ³ over the same period. Additional outcomes were confidence and researcher-rated practice level, post-intervention satisfaction, and participants’ 1-month reflections.

All instruments and evaluation procedures were the same as those used in a previous study ²³ and are thoroughly described therein. Briefly, the present study used standardized and validated Japanese versions of the PCDS, NDCC, and PCPS scales. In addition, a self-developed scale was used to measure confidence and satisfaction, based on a prior study. ²⁶ Furthermore, practice level was assessed using an Objective Structured Clinical Examination-based evaluation during online simulation, with evaluators rating performance according to predefined criteria. To provide supplementary contextual insights, qualitative comments were reviewed and summarized using a Berelson-based descriptive content analysis approach. ²⁷

Procedure

Participants were recruited through their respective institutions, which shared the study information and collected the signed consent forms from interested nurses.

Assessment timeline

Baseline (T0): Data were collected using the PCDS, NDCC, PCPS, practice level, and confidence scales immediately before the intervention.

Immediate post-intervention (T1): The same measures were administered, except for the PCPS, and participants additionally rated their satisfaction.

One-month follow-up (T2): Follow-up assessments included all measures except the researcher-evaluated practice level, and participants provided open-ended comments on how they applied their learning.

Participants received a small token of appreciation (approximately 1000 JPY) upon completion of the study.

Sample size

Prior studies did not provide a clear estimate of the effect size; hence, the present study’s calculation was based on Cohen’s guidelines. Through a two-tailed test with an assumed effect size of d = 0.4 (medium to large), an alpha level of 0.05, and a beta level of 0.20, the minimum required sample size was calculated to be 27. However, considering an anticipated dropout rate of 10%, the target sample size was finally set at 30.

Statistical analysis

The unit of analysis was the individual participant. Data were collected between January 2023 and August 2023. Nurses with ≥20% missing data were excluded from the analyses. Participant characteristics were summarized as numbers and percentages, with descriptive statistics calculated for all measures. Statistical data were analyzed using EZR (Jichi Medical University, Tochigi, Japan), a graphical interface for R (The R Foundation for Statistical Computing, Vienna, Austria). ²⁸ Friedman test was used for comparing variables across three time points (pre, post, and 1-month follow-up). Pairwise comparisons between post-intervention and follow-up were examined using the Wilcoxon signed-rank test. For evaluating categorical changes in practice levels, McNemar’s test was applied. The threshold for statistical significance was set at p < 0.05. Effect sizes were estimated with Cohen’s d using G*Power version 3.1.9.7. ²⁹ The satisfaction survey results are presented as means and standard deviations (SDs).

Results

Summary of participant recruitment and participant attributes

Initially, 43 nurses expressed interest in participating in this study. Two participants had previously attended palliative-care-related activities; however, as these experiences were limited in scope and differed from the objectives of the present program, they were not considered to substantially overlap. This point is acknowledged as a potential source of heterogeneity. One individual was excluded for failing to meet the eligibility criteria, and 42 nurses were subsequently informed of their eligibility. However, two missed baseline measurements because of absences, and one withdrew because of poor Internet connectivity. During the 1-month follow-up period, five participants were lost to follow-up. Ultimately, 34 participants completed the study (Fig. 1). No adverse events related to participation in the online simulation program were reported during the study period.

FIG. 1.

Flowchart of participant recruitment.

Eight facilities participated. Over half of the participants had graduated from nursing universities, and only two (5.9%) had received palliative care training beforehand. Table 2 shows the participant characteristics and baseline data.

Table 2.

Summary of Participant Attributes

	N = 34
	Mean (SD)
Age (years)	25.3 (4.4)
	n (%)
Educational status
Associate’s degree (3 years)	14 (41.2)
College degree	20 (58.8)
Experience in palliative care training
None	32 (94.1)
Clinical experience (years)
2	11 (32.4)
3	12 (35.3)
4	11 (32.4)
Number of patients with cancer cared (per year)
0	4 (11.8)
1–9	13 (38.2)
10–49	15 (44.1)
50–99	2 (5.9)
>100	0 (0)

For “Number of cancer patients treated (per year),” responses were obtained from the five options shown in the table.

SD, standard deviation.

Comparison of PCDS, NDCC, PCPS, and confidence before and after the intervention

Table 3 presents the mean and SD values of PCDS, NDCC, PCPS, and confidence scores at baseline (T0), immediately after the intervention (T1), and during the 1-month follow-up period (T2). For the primary outcome (PCDS), the perceived difficulty in alleviating symptoms (p = 0.024, d = 0.414) and communicating with the patient and family (p = 0.002, d = 0.571) significantly improved between T0 and T2. Conversely, NDCC and PCPS exhibited no substantial disparities between T0 and T2. For the two learning objectives, participants’ level of confidence in noticing total pain (p = 0.008, d = 0.625) and in communicating with patients (p = 0.011, d = 0.658) significantly increased.

Table 3.

Comparison of Outcome Measures at Baseline, Immediately After, and 1 Month After the Educational Intervention

	T0	T1	T2		pb/Cohen’s d
Outcome measure	Mean (SD)	Mean (SD)	Mean (SD)	p a	T0–T1	T0–T2	T1–T2
Primary endpoint
PCDS
Alleviating symptoms	3.59 (1.01)	3.22 (1.03)	3.22 (0.73)	0.005**	0.092/0.366	0.024*/0.414	>0.999/0.000
Communicating with the patient and family	3.78 (0.95)	3.36 (0.92)	3.27 (0.82)	0.001**	0.057/0.452	0.002**/0.571	>0.999/0.101
Secondary endpoint
NDCC
Communication	55.74 (15.71)	55.26 (11.71)	51.56 (10.73)	0.118	>0.999/0.033	0.088/0.300	0.459/0.329
Confidence
Noticing total pain	2.50 (0.83)	3.24 (0.61)	3.03 (0.80)	0.000**	0.000**/0.993	0.008**/0.625	0.729/0.286
Communicating with patients	2.32 (0.91)	2.88 (0.77)	2.88 (0.77)	0.001**	0.023**/0.658	0.011**/0.658	>0.999/0.000
PCPS
Pain	3.61 (1.20)	—	4.06 (0.50)			0.135/0.431
Communication	3.47 (1.17)	—	3.87 (0.64)			0.115/0.397

n = 34. Effect size (Cohen’s d): medium (≥0.5), large (≥0.8). PCDS: 5-point Likert scale (1 = never, 2 = sometimes, 3 = occasionally, 4 = often, 5 = very much). NDCC: 6-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = somewhat disagree, 4 = somewhat agree, 5 = agree, 6 = strongly agree). PCPS: 5-point Likert scale (1 = not at all, 2 = rarely, 3 = sometimes, 4 = mostly, 5 = always). T0, preintervention; T1, post-intervention; T2, 1-month post-intervention.

Statistical tests: ^aFriedman test, ^bWilcoxon signed-rank test with Bonferroni adjustment.

*p < 0.05, **p < 0.01 indicate statistical significance.

NDCC, Nurses’ Difficulty with Cancer Care; PCDS, Palliative Care Difficulties Scale; PCPS, Palliative Care Self-reported Practices Scale.

Comparison of the nursing practice level evaluated by researchers before and after the intervention

Table 4 presents the percentage of practice in evaluating researchers at T0 and T1. In the Pain assessment, items such as “Checking for daily activities interfered with pain” (p = 0.000), “Identifying drowsiness, constipation, and nausea as side effects of medical opioids” (p = 0.039), “Checking patient’s status when the pain appeared” (p = 0.000), and “Correcting patient’s misconceptions about opioids (addiction, gradual loss of effect, strong side effects, etc.) appropriately” (p = 0.000) exhibited a significant change. In the Communication, a significant difference was noted in the items “Repeating what the patient says in his or her own words” (p = 0.000) and “Enduring short silent periods (5–10 seconds)” (p = 0.010). In the NURSE communication, the “Understanding” (p = 0.024), “Recognizing” (p = 0.006), and “Supporting” (p = 0.003) items demonstrated a significant difference.

Table 4.

Comparison of the Nursing Practice Level Evaluated by Researchers Before and After the Intervention

			T1
Practice item			Unable (%)	Able (%)	p a
Pain Assessment
Checking patient’s pain intensity using pain scales such as NRS, Face Scale, and VAS	T0	Unable	10 (29.4)	9 (26.5)	0.149
		Able	3 (8.8)	12 (35.3)
Checking for daily activities interfered with pain		Unable	14 (41.2)	16 (47.1)	0.001**
		Able	0 (0)	4 (11.8)
Identifying drowsiness, constipation, and nausea as side effects of medical opioids		Unable	11 (32.4)	12 (35.3)	0.039 *
		Able	3 (8.8)	8 (23.5)
Checking patient’s status when the pain appeared		Unable	13 (38.2)	16 (47.1)	0.001**
		Able	0 (0)	5 (14.7)
Correcting patient’s misconceptions about opioids (addiction, gradual loss of effect, strong side effects, etc.) appropriately		Unable	9 (26.4)	20 (58.8)	0.001**
		Able	3 (8.8)	2 (5.9)
Communication
Setting up a quiet and private place	T0	Unable	33 (97.1)	0 (0)	1
		Able	0 (0)	1 (2.9)
Using open-ended queries		Unable	1 (2.9)	6 (17.6)	0.505
		Able	3 (8.8)	24 (70.6)
Repeating what the patient says in his or her own words		Unable	10 (29.4)	17 (0.5)	0.001**
		Able	1 (2.9)	6 (17.6)
Enduring short silent episodes (5–10 seconds)		Unable	12 (35.3)	13 (38.2)	0.010 *
		Able	2 (5.9)	7 (20.6)
NURSE communication
Naming	T0	Unable	22 (64.7)	3 (8.8)	0.724
		Able	5 (14.7)	4 (11.8)
Understanding		Unable	4 (11.8)	13 (38.2)	0.024**
		Able	3 (8.8)	14 (41.2)
Recognizing		Unable	16 (47.1)	14 (41.2)	0.006**
		Able	2 (5.9)	2 (5.9)
Supporting		Unable	15 (44.1)	13 (38.2)	0.003**
		Able	1 (2.9)	5 (14.7)
Exploring		Unable	0 (0)	2 (5.9)	1
		Able	0 (0)	32 (94.1)

n = 34. This evaluation was conducted in two stages (Unable and Able).

Statistical tests: ^aMcNemar test was applied.

^*p < 0.05, ^**p < 0.01 indicate statistical significance.

Satisfaction with the educational program

Table 5 presents the satisfaction levels. The mean score for the 10 items was 5.2 points. In particular, items such as “The training’s level of difficulty was appropriate,” “The duration of the training was reasonable, neither too long nor too short,” “No problems with the environment emerged,” and “I was able to discuss with my peers and analyze what was good and what was lacking,” obtained 4.97, 4.76, 5.03, and 5.21 (SD = 0.87, 1.07, 1.00, and 0.69) points, respectively.

Table 5.

Satisfaction with the Educational Program

Item	Mean (SD)
Today’s training was satisfactory	5.24 (0.070)
The training content was appropriate for my needs	5.26 (0.71)
The learning objectives were clear	5.32 (0.77)
The training’s level of difficulty was appropriate	4.97 (0.87)
No problems with the environment emerged	5.03 (1.00)
The duration of the training was reasonable, neither too long nor too short	4.76 (1.07)
The instructor’s involvement was supportive of learning	5.35 (0.92)
The level of tension was appropriate	5.15 (0.78)
The handouts provided in advance aided in learning	5.35 (0.69)
I was able to discuss with my peers and analyze what was good and what was lacking	5.21 (0.69)

n = 34. 1 = strongly disagree, 2 = disagree, 3 = somewhat disagree, 4 = somewhat agree, 5 = agree, 6 = strongly agree.

Participant feedback at 1 month after the intervention

Table 6 summarizes participants’ open-ended comments collected 1 month after the intervention. These comments were reviewed and descriptively categorized to provide supplementary contextual feedback. In total, 78 brief comments were analyzed and summarized. The most frequently reported category was “Putting into practice what was learned in the training” (48 comments), “Reviewing and learning the training” (13 comments), “Not yet applying what was learned in the training” (9 comments), and “Future goals” (8 comments).

Table 6.

Participant Feedback 1 Month After the Intervention

Category	Subcategory	Number		Participant’s comments (participant no.)
Putting into practice what was learned in the training	Putting pain management into practice	48	20	I made a point of asking patients in-depth questions about their pain and attempting to integrate their responses into their care. (123) After assessing and evaluating the pain, I became more aware of what was needed for relief. (135)
	Practicing communication with awareness of its importance		18	When a patient expressed, “I think I’d be better off dead,” I listened more calmly than before to their thoughts and hopes for the future. (115) When a patient said, “I want to die,” I was initially unsure how to respond. However, by applying what I had learned, I was able to listen calmly and patiently as they explained why they felt that way. (131)
	Encountering difficulties in practice		3	When massage and decompression did not relieve the pain, I tried using my own knowledge and coping methods, but when nothing seemed to work, I found myself at a loss. (109)
	Experiencing joy after implementation		2	I was delighted to hear patient’s wife say, “Thank you. May I come talk to you again?” (120)
	Practicing communication with family members		2	I facilitated a conversation with the patient’s wife and applied the NURSE approach, which helped me hear her thoughts. (112)
	Practicing sharing between health care professionals		2	Pain scales could be recorded in medical charts and shared among nurses. (104)
	Focusing on total pain		1	We organized a birthday party for a patient with terminal lung cancer, took photos with their spouse, and displayed them in their room. (112)
Reviewing and learning the training	Reviewing and learning communication	13	10	This training allows to reevaluate communication with patients. (127)
	Reviewing and learning pain management		3	Through this training, I was able to reflect on how I could have handled things better for a terminally ill patient who had previously been hospitalized for pain control. (125)
Not yet applying what was learned in the training	Lacking opportunity to put into practice what was learned in the training	9	7	After the training, I had no opportunity to interact with patients needing palliative care, so I never had a chance to put what I learned into practice. (144)
	Having an opportunity to apply what was learned in training existed, but was not implemented		2	I was unable to thoroughly discuss the patient’s willingness to undergo surgery or their prognosis because of the short timeframe and urgent nature of the admission. (106)
Future goals	Future goals	8	8	I aim to apply what I have learned in my future practice. (121)

Discussion

This exploratory study suggests that the fully online simulation-based palliative care education program was associated with reductions in early-career nurses’ perceived difficulties in alleviating symptoms and communicating with patients and families, as well as increases in their confidence in clinical practice. Participants’ high satisfaction level and qualitative feedback further support the perceived usefulness of the program.

Importantly, participants’ PCDS scores in both symptom management and communication improved after the intervention. Previous research has reported that these areas pose challenges for new nurses. ³ These findings suggest that simulation-based education may help reduce perceived difficulty in symptom management and communication with patients and families. Alleviating symptoms strongly improves patients’ quality of life, ³⁰ and communication is fundamental to palliative care. ³¹ Therefore, incorporating simulation methods into training programs that address both symptom management and communication may be beneficial for nurses, even when conducted online. Although no Minimal Clinically Important Difference has been validated, the observed small to moderate effect sizes suggest meaningful educational benefits of the program.

Moreover, no significant difference was observed in NDCC, possibly reflecting the program’s insufficient effectiveness because of its limited time (90 minutes) to include enough content to address all items related to perceived difficulty items. In a previous study, participants who attended 3–4 sessions tended to report lower perceived difficulty than those who attended only 1–2 sessions of a 90-minute lecture. ¹⁵ Therefore, implementing multiple sessions of programs with different content may further contribute to reductions in perceived difficulty.

In this study, the levels of confidence in recognizing the holistic suffering of patients with cancer and in communicating with such patients increased significantly both immediately after the intervention and during the 1-month follow-up period. Education and support programs have been shown to strengthen nurses’ confidence in their palliative care skills and knowledge.^32,33 Similar trends were observed in the present online program. Through a structured experiential learning process, including briefing, simulation, and reflective debriefing, nurses may have gained mastery experiences and opportunities for reflective practice, thereby enhancing their confidence and reducing perceived difficulty. In a 1-month follow-up survey, participants also reported changes in their coping abilities. Therefore, this program may have contributed to perceived personal growth and skill development.

Participants’ overall satisfaction was high in this study, indicating a favorable response. Among the satisfaction items, participants generally perceived the training content and level of difficulty as appropriate for their needs. These findings suggest that the program was well aligned with nurses in their second to fourth year of clinical experience and offered content at an appropriate difficulty level. In addition, no major technical problems were reported during the implementation of the online simulation. Potential network slowdowns can be a drawback of web-based simulations,^13,14 but no such problems were encountered in this online simulation. While high satisfaction scores and the absence of major technical difficulties suggest that the program was feasible, these findings should be interpreted cautiously. In this study, feasibility primarily reflects short-term acceptability and successful technical implementation within a self-selected sample and does not necessarily indicate scalability to broader or more diverse populations or to different health care systems.

The fully online simulation-based palliative care education program in this study was associated with changes in the difficulty scale, confidence, and practice level. Likewise, a previous study evaluating a role-play-based palliative care education program showed significant improvements in these scales. ²³ This finding is consistent with that of face-to-face education comparing simulation and role-play among nursing students. ³⁴ The results of the present study indicate that even in online education targeting nurses with 2–4 years of clinical experience, role-play and simulation may yield comparable educational outcomes, despite being different educational methods.

This study has several limitations. First, 8 of the 42 participants dropped out. The main reasons for dropout were factors specific to online learning, such as poor Internet connectivity and unreachability. To reduce dropouts, future studies should implement measures that provide technical support and send regular reminders.^35,36 Attrition may have introduced bias; however, because baseline data were available for only a small number of participants who were lost to follow-up, meaningful comparative analyses were not feasible. Second, the single-group pre–post study design prevents the establishment of causality and limits the generalizability of the results. Participants were also recruited voluntarily, potentially introducing selection bias. In addition, during the 1-month interval between the intervention and follow-up assessment, potential confounding factors, such as self-directed learning and ongoing clinical experience, may have influenced the observed changes. Furthermore, as this study was conducted in a single country (Japan), the findings may not be generalizable to other settings, given differences in cultural, educational, and health care systems. Third, some of the measurement tools used in this study, particularly those assessing confidence and practice levels rated by researchers, lacked established psychometric validation. Moreover, the number of patients cared for over the past year was based on self-reported categorical estimates and may have been subject to recall bias. Outcome assessments were not blinded, and several measures relied on self-report; therefore, expectancy effects and social desirability bias may have contributed to the observed improvements. The absence of formal inter-rater reliability testing also increases the possibility of evaluator bias in researcher-rated practice assessments. Furthermore, this study did not evaluate whether the observed changes in perceived difficulty and confidence were associated with improved patient and family outcomes. Future studies should incorporate validated measurement tools and patient- and family-centered outcomes within a randomized controlled trial design.

Conclusion

The fully online simulation-based education program was associated with reductions in the level of difficulty reported by nurses with limited experience in managing symptoms and communicating with patients and families. It was also associated with increased confidence in palliative care practice. Furthermore, participant satisfaction was high, and many participants reported applying their learning in practice, suggesting that this educational approach may support practical learning even within a short timeframe.

Authors’ Contributions

The authors helped prepare, draft, and edit the article. A.I., T.T., and M.T. conceived the idea of this research, followed by discussions with J.K., who contributed to finalizing the research idea. All three designed the content of the intervention program and developed the implementation procedures and evaluation measures. A.I., T.T., M.T., M.S., and Y.T. collected the data and implemented the intervention. A.I. conducted the statistical analyses. Thus, all the authors contributed to the preparation and editing of the article and approved the final version.

Abbreviations

ELNEC-J

End-of-Life Nursing Education Consortium-Japan

INACSL

International Nursing Association for Clinical Simulation and Learning

MCID

Minimal Clinically Important Difference

NDCC

Nurses’ Difficulty with Cancer Care

PCDS

Palliative Care Difficulties Scale

PCPS

Palliative Care Self-reported Practices Scale

Consent to Participate

Written informed consent was obtained from all participants prior to participation in the study.

Consent to Publication

Written informed consent for participation and publication of anonymized data was obtained from all participants.

Data Availability Statement

All data relevant to the study are included in the article.

Cite this article as: Inumaru A, Tamaki T, Tsujikawa M, Skaguchi M, Takeda Y, Kako J (2026) Online simulation in palliative care education for early-career nurses in Japan: A pre–post exploratory evaluation of perceived outcomes and feasibility, Palliative Medicine Reports 7:1, 345–355, DOI: 10.1177/26892820261441692.