Recognising that a patient may be dying is an interpretive clinical accomplishment rather than a single-act diagnostic decision. Nursing students must integrate changing physiological, functional, communicative and relational cues while managing uncertainty and the emotional consequences of end-of-life care. Simulation is widely used to prepare students for such encounters, but improvement within a simulated setting cannot be assumed to transfer into clinical recognition of dying. To explain how, why, for whom and under what circumstances simulation may support nursing students’ recognition of dying and transfer of learning from simulated encounters to clinical practice. A realist review was undertaken using iterative programme-theory development, theory-driven searching, relevance–richness–rigour appraisal, context–mechanism–outcome reasoning and programme-theory refinement. Four bounded evidence-search routes identified 48 records. After removal of five duplicates, 43 records were screened, 29 reports underwent detailed eligibility assessment and 24 evidence reports were included in the realist synthesis. Simulation most plausibly supported recognition through five interacting processes: calibrated noticing of ambiguous cues; emotionally consequential psychological safety; explanatory reappraisal during debriefing; contextual and relational authenticity; and opportunities to retrieve and enact learning in clinical placements. Knowledge, confidence, reflective ability and simulated performance represented proximal outcomes rather than evidence of clinical transfer. Transfer was more likely when clinical placements supplied comparable patient trajectories, continuity of contact, supervisory support, access to contextual information and permission to voice uncertainty. Excessive emotional load, cue fixation, low contextual authenticity and restrictive clinical environments could interrupt the proposed pathways. Simulation can contribute to learning needed for recognition of dying, but its effects are contingent. The refined programme theory locates transfer in the interaction between simulation design, learner interpretation, debriefing, clinical opportunity and workplace conditions rather than in simulation exposure alone.
