Enhancing ICU-OR Handoff Communication Through Simulation-Based Education in Nurse Anesthesiology Training

Abstract

Background:

Effective handoff communication during the transition of critically ill patients between the intensive care unit (ICU) and operating room is essential for patient safety, yet formal training in standardized handoff protocols remains limited in nurse anesthesiology education.

Methods:

This project evaluated a simulation-based learning intervention integrating a structured handoff communication tool to prepare nurse anesthesia students for high-risk care transitions. Sixteen second-year doctoral nurse anesthesia students participated in a high-fidelity simulation involving the transfer of a critically ill patient from the operating room to the ICU. The simulation incorporated prebriefing, a scenario using a standardized handoff tool, and structured debriefing. Student perceptions were assessed using the Simulation Effectiveness Tool-Modified (SET-M).

Results:

Fifteen students completed the evaluation, with 94% strongly agreeing they felt empowered to make clinical decisions and had opportunities to practice decision-making skills. High confidence was reported in prioritizing care (94%), communicating with healthcare teams (94%), and providing safety interventions (94%). Qualitative feedback revealed overwhelmingly positive perceptions, with students recommending earlier curriculum placement.

Conclusions:

Simulation-based handoff training effectively enhanced student confidence in communication, clinical decision-making, and team collaboration. This approach bridges the gap between didactic instruction and clinical application, preparing students for safe care transitions and interdisciplinary teamwork.

The transition of critically ill patients between the intensive care unit and the operating room (OR) represents a high-risk period requiring effective communication to ensure patient safety and continuity of care. These patients often present with multiple comorbidities, hemodynamic instability, and dependence on life-sustaining therapies, making comprehensive handoff communication between ICU providers and anesthesia teams essential to support safe care transitions and facilitate appropriate perioperative anesthetic management.

Standardized handoff communication tools have been shown to enhance consistency, minimize errors and omissions, and strengthen interdisciplinary teamwork.^1–7 Despite the documented benefits of structured communication protocols, formal training in handoff communication remains limited within the nurse anesthesiology curriculum. Simulation-based learning offers an effective strategy to bridge this gap by providing students with opportunities to practice communication skills in realistic, high-acuity scenarios while receiving constructive feedback.^8,9

Evidence-based intervention

Recognizing the need to integrate didactic instruction with clinical application, a doctoral nurse anesthesiology program at a regional university in the southeastern United States implemented a simulation-based curriculum enhancement. The educational intervention introduced an immersive experience in which Student Registered Nurse Anesthetists (SRNAs) and ICU advanced practice providers utilized a structured handoff tool to guide the transition of a critically ill patient from the ICU to the OR and back postoperatively. This approach aimed to reinforce the importance of standardized communication in critical care transitions while developing competency in both technical and nontechnical skills essential for safe patient care.

The structured handoff tool utilized in this simulation was adapted from the University of California, Los Angeles (UCLA) OR-to-ICU Bedside Handoff Checklist Tool, a comprehensive communication framework designed to standardize the transfer of critically ill patients between perioperative and critical care settings.¹⁰ This evidence-based tool organizes the handoff into 4 sequential phases: introduction, surgeon report, anesthesia report, and critical care team readback, with each phase addressing specific clinical domains essential for safe transitions of care. The checklist prompts providers to systematically communicate critical information including patient identifiers, neurologic and hemodynamic status, ventilator settings, current infusions with weight verification, procedural details, postoperative management parameters (including MAP/SBP targets and transfusion triggers), line/drain/tube placements, and anticipated clinical concerns. Importantly, the tool concludes with a structured readback component that requires the receiving team to summarize the immediate plan of care, prioritize clinical concerns, and confirm contact information and call triggers, thereby closing the communication loop and verifying shared understanding.¹⁰ By providing a standardized structure that addresses both clinical content and team communication processes, this type of handoff tool has been shown to reduce information omissions, minimize reliance on memory, and create a shared cognitive model among interdisciplinary team members during high-risk care transitions.^11–13 The integration of such a tool into simulation-based education allows students to practice and refine this systematic approach to handoff communication before encountering these critical scenarios in clinical practice.

METHODS

A simulation‑based educational intervention was conducted as a component of an advanced anesthesia principles course in a nurse anesthesia Doctor of Nursing Practice program. The simulation design included 3 structured components that aligned with best practices for simulation‑based education. These were prebriefing, immersive simulation, and debriefing.¹⁴ The scenario followed a 28‑year‑old male patient status post gunshot wound who underwent an exploratory laparotomy in the ICU and required return to the OR for re‑exploration and washout. Detailed clinical data, including ventilator settings, hemodynamic parameters, laboratory results, and medications, were embedded in the scenario to support clinical realism and decision‑making demands. Participants used a structured communication tool adapted from the UCLA OR-to-ICU Bedside Handoff Checklist Tool.

Participants and setting

The simulation was conducted in a university‑based simulation center equipped with a high‑fidelity manikin capable of reproducing respiratory mechanics, hemodynamic variability, and physiological responses consistent with the patient case. Sixteen SRNAs were assigned to rotating simulation groups, and each simulation rotation included designated roles for providers in the OR, ICU, and postoperative transition to ensure engagement in interprofessional communication and team‑based care processes. Nurse anesthesia faculty served in the roles of simulation facilitators and OR staff, the SRNAs simulated the role of the anesthesia professional, and an acute care nurse practitioner simulated the role of the ICU provider.

Simulation procedure

Prebriefing

All participating SRNAs were required to complete an asynchronous prebriefing session prior to the simulation experience. This session aimed to establish psychological safety, review learning objectives, and outline expectations. Prebriefing content emphasized structured handoff communication, considerations for OR-to-ICU transitions in care, and integration of these elements in providing safe care. Consistent with best practices for nursing simulation, prebriefing was designed to enhance learner confidence and readiness for engagement in the scenario.¹⁴

Scenario execution

The simulation involved the transition of the mechanically ventilated, hemodynamically unstable trauma patient from the OR to the ICU setting. Students were required to perform handoff communication to an ICU provider using a structured communication tool developed for this activity. The handoff included the interpretation of rapidly changing hemodynamics, complex ventilator management, and sepsis‑related complications. The scenario incorporated real‑time communication of vital signs, ventilator pressures, laboratory values such as elevated lactate (4.5 mmol/L), and positive blood cultures indicating Gram‑negative sepsis to prompt evidence-based clinical decision making in the ICU. SRNAs participated in interdisciplinary communication, including reporting to ICU staff, surgical teams, and anesthesia colleagues, reflecting objectives related to leadership and interprofessional collaboration.

Debriefing

Immediately following the simulation, faculty facilitators conducted a structured 30‑minute debriefing designed to meet the Healthcare Simulation Standards of Best Practice set by International Nursing Association for Clinical Simulation and Learning.¹⁴ Debriefing emphasized reflective practice, emotional processing, recognition of performance gaps, and reinforcement of effective clinical judgment. Faculty encouraged participants to analyze the impact of handoff communication errors, evaluate team performance, and consider system‑level improvements in transfer‑of‑care protocols.

Instruments and data collection

The Simulation Effectiveness Tool-Modified (SET-M),¹⁵ a validated 19‑item instrument measuring learners’ perceptions of simulation effectiveness in prebriefing, scenario performance, and debriefing domains, was used for data collection. Items were rated using a 3‑point Likert scale (1 = do not agree, 2 = somewhat agree, and 3 = strongly agree). Domains assessed included perceived increases in confidence, understanding of pathophysiology, ability to prioritize care, communication skills, and clinical judgment enhancement. Participants completed the SET-M immediately after the simulation to capture real‑time perceptions of the simulated use of a structured communication tool for transfer of care between the OR and the ICU. Although participants were asked to complete the entire survey, only 7 items were included in the analysis of the project. These were chosen due to their relevancy and applicability to evaluate the goals of the project. These items were as follows:

I felt empowered to make clinical decisions

I had the opportunity to practice my clinical decision-making skills

I am more confident in my ability to prioritize care and interventions

I am more confident in communicating with the patient

I am more confident in my ability to report information to the healthcare team

I am more confident in providing interventions that foster patient safety

In addition to these 6 items, one open-ended question was included in the analysis. SRNAs were asked “What else would you like to say about today’s simulated clinical experience?”

Data analysis

Descriptive statistics were used to summarize demographic variables and SET‑M item responses. Responses were aggregated by subscale (prebriefing, scenario, and debriefing). Higher scores represented greater perceived effectiveness of the simulation. Qualitative comments collected in the open‑ended section of the SET‑M were reviewed for common themes related to learning experiences, perceived challenges, and suggestions for improvement.

Ethical considerations

Participation in the simulation was a required component of the course curriculum; however, completion of the SET‑M was voluntary. All data were collected anonymously, and no identifying information was linked to responses. Institutional review board exemption was obtained in accordance with educational research guidelines.

RESULTS

Following completion of the scenario, SRNAs (N = 15) reported high levels of agreement across all measures of confidence and perceived learning. The 6 items chosen for analysis are shown in Figure 1.

Figure 1.

SRNA perceived confidence postsimulation.

Nearly all participants (88%, N = 14) strongly agreed that after the simulated use of the structured communication handoff tool, they felt empowered to make clinical decisions during the experience, with 2 participants not choosing an answer for this item. Regarding perceived opportunities to practice clinical decision making, most SRNAs (94%, N = 15) strongly agreed that the scenario allowed them to do so, while one SRNA reported they did not agree.

Confidence in providing interventions to improve patient safety and confidence in communicating with the team were strongly positive, with 94% (N = 15) indicating strong agreement and the remaining SRNA (N = 1) selecting somewhat agree. Students expressed high confidence in their ability to prioritize care and interventions, with 94% (N = 14) strongly agreeing with only one student expressing disagreement.

Students showed more variability in confidence in patient communication. The majority (63%, N = 10) strongly agreed that the use of the structured communication tool improved their communication with patients, while 31% (N = 5) somewhat agreed, and one SRNA reported that they did not agree.

Most students (56%, N = 9) provided comments to the open-ended question (Table 1). SRNAs generally liked the experience and felt it contributed meaningfully to their clinical preparation. Several (N = 5) felt the simulation value would increase if positioned before or at the beginning of clinical experiences, rather than where it was placed at the time of this project. Overall, the results indicate a consistently positive student perception of the scenario’s impact on confidence, communication skills, decision-making ability, and empowerment in clinical practice.

Table 1.

Open-Ended Comments From SET-M

Theme	Description	Representative Quotes
Overall positive experience	Learners found the simulation enjoyable and valuable for reinforcing skills.	“I enjoyed this sim! Very fun and was beneficial…” “Helpful sim lab… valuable lesson!” “This simulation was very helpful…”
Recommendation to offer simulation earlier	The most common theme. Students believe the simulation would be more impactful if scheduled before or early in clinicals.	“Would be beneficial earlier on during clinicals.” “Do earlier on, maybe 1–2 semesters earlier…” “Maybe earlier in the program?” “Helpful… but helpful prior to starting clinical.”

DISCUSSION

The development and implementation of this simulation experience focused on handoff communication between ICU and OR/anesthesia providers, addressing a critical educational and clinical need in nurse anesthesiology training. By integrating a standardized communication tool into the simulation, this approach reinforced evidence-based practice and helped prepare students to deliver safe, coordinated care during complex transitions.

Interpretation of findings

The results of this educational intervention demonstrate consistently high levels of perceived learning and confidence among participating SRNAs across multiple domains of clinical competence. The near-universal strong agreement regarding empowerment to make clinical decisions (88%) and opportunities to practice clinical decision-making (94%) suggests that the simulation successfully created an authentic learning environment in which students felt ownership and autonomy in their clinical reasoning. This is particularly interesting given that the scenario involved a hemodynamically unstable trauma patient with sepsis-related complications, requiring rapid interpretation of evolving clinical data, including elevated lactate levels and positive blood cultures. The ability to engage confidently in clinical decision-making within such a complex case reflects the simulation’s effectiveness in bridging the gap between theoretical knowledge and practical application.

Student confidence in providing patient safety interventions and communicating with the healthcare team showed similarly robust results (94% strong agreement for both domains), suggesting that the integration of the structured handoff tool within the simulation experience effectively supported the development of interprofessional communication skills. This finding is especially relevant given that the scenario required students to engage in multidirectional communication with ICU staff, surgical teams, and anesthesia colleagues while managing complex ventilator settings and hemodynamic parameters. The high confidence levels suggest that the UCLA handoff checklist provided sufficient scaffolding to guide comprehensive information exchange in high-acuity situations.

Notably, students demonstrated more variability in their confidence regarding patient communication, with only 63% strongly agreeing that the experience improved this skill, while 31% somewhat agreed. This finding likely reflects the nature of the scenario itself: the patient was mechanically ventilated, hemodynamically unstable, and presumably sedated or unconscious during the ICU-to-OR transition, which limited opportunities for direct patient interaction. This variability underscores an important educational consideration, where this simulation excelled in developing provider-to-provider communication and technical clinical skills, future iterations might benefit from incorporating scenarios that provide opportunities for patient-centered communication, such as preoperative assessments or postoperative family updates.

Timing and curriculum placement

Perhaps the most actionable finding emerged from the qualitative data, in which 5 of the 9 students who provided comments specifically recommended offering the simulation earlier in the curriculum, ideally before or at the beginning of clinical rotations. This feedback carries significant implications for curriculum design and suggests that students recognize the potential for this experience to serve as a foundational skill-building exercise. Given that the participants were second-year students who had already accumulated substantial clinical experience, their perspective that earlier exposure would have been beneficial suggests that handoff communication skills are best developed proactively rather than retrospectively. Early integration of structured handoff training could provide students with a mental framework and communication template to apply immediately in their initial clinical encounters, potentially reducing anxiety, improving performance, and accelerating clinical competence development.

Educational and clinical value

This curriculum enhancement provides significant value in advancing both nurse anesthesia education and patient care in the critical care setting. Training students to use a validated handoff communication tool supports accurate and complete information exchange, directly reducing the risk of preventable harm during transitions between the ICU and OR. By embedding this training within a simulation-based immersive learning experience, students applied didactic knowledge in a high-stakes, clinically relevant context that included interpreting rapidly changing hemodynamics, managing complex ventilator requirements, and communicating sepsis-related complications with appropriate urgency and clarity. This approach enhanced their clinical readiness and strengthened their ability to prioritize, communicate, and make clinical decisions under pressure.

Beyond technical skills, simulation experiences develop essential nontechnical competencies such as situational awareness, teamwork, effective communication skills, and patient advocacy, all of which are foundational to safe anesthesia practice. The high-fidelity nature of the simulation, featuring a manikin capable of reproducing realistic respiratory mechanics, hemodynamic variability, and physiological responses, allowed students to experience the cognitive and emotional demands of managing a critically ill patient while simultaneously executing structured handoff communication. The immediate debriefing session following the scenario provided crucial opportunities for reflective practice, emotional processing, recognition of performance gaps, and reinforcement of effective clinical judgment, and follows the Healthcare Simulation Standards of Best Practice.¹⁴

Alignment with professional standards

This project aligns with the core goals of doctoral-level nurse anesthesiology education by reinforcing evidence-based practice, interprofessional communication, and quality improvement, highlighting the nurse anesthetists’ role in driving safe and effective healthcare delivery. The integration of handoff communication simulation within nurse anesthesia curriculum aligns with the American Association of Colleges of Nursing competency-based education initiatives, which are essential for doctoral-level learners who are expected to transition into roles that require advanced communication and leadership skills.^16,17 The American Association of Colleges of Nursing Doctor of Nursing Practice Essentials Sub-Competencies addressed in this simulation experience are identified in Table 2. Additionally, integrating simulation experiences into the curriculum supports reflective practice and lifelong learning by encouraging students to engage in intentional practice, receive feedback, and develop habits of critical reflection that contribute to continuous professional growth.^18,19

Table 2.

Mapping of Simulation-Based ICU-to-OR Handoff Communication Project to AACN 2021 DNP Essentials Sub-Competencies

Sub-Competency	Application in Project
1.2f: Synthesize knowledge from nursing and other disciplines to inform education, practice, and research	The simulation integrates knowledge from critical care, anesthesia, and communication science to inform interprofessional education and practice.
1.3d: Integrate foundational and advanced specialty knowledge into clinical reasoning	Participants apply advanced clinical reasoning during high-acuity patient transitions in a simulated environment.
4.2c: Use data to evaluate outcomes of care processes and improve practice	Simulation debriefs and evaluations are used to assess communication effectiveness and identify areas for improvement.
6.1b: Engage with other health professionals to optimize care	CRNAs and ACNPs collaborate in simulation scenarios to ensure safe and effective patient handoffs.
6.2a: Demonstrate effective communication across professions and with patients and families	The structured handoff tool supports clear, consistent communication between ICU and OR teams.
8.1a: Demonstrate clinical judgment founded on evidence-based practice	Participants use evidence-based handoff protocols to guide clinical decision-making during transitions.
8.2c: Demonstrate leadership in interprofessional teams	The simulation fosters leadership skills by requiring participants to coordinate and lead handoff communications.
10.2a: Engage in self-reflection to improve practice	Postsimulation debriefs encourage reflective practice and continuous professional development.

Abbreviations: AACN, American Association of Colleges of Nursing; DNP, Doctor of Nursing Practice.

The use of the SET-M instrument provided valuable data regarding student perceptions of simulation effectiveness across the prebriefing, scenario execution, and debriefing phases. While this project analyzed 6 specific items most relevant to handoff communication competencies, the instrument’s validated nature lends credibility to the findings and provides a foundation for ongoing curriculum evaluation and quality improvement.

Limitations

Several limitations should be acknowledged. First, the sample size was relatively small (N = 15), limiting the broader applicability of the findings. Second, the project relied exclusively on self-reported perceptions of confidence and learning rather than objective performance measures, which may not fully capture actual competence development. Future studies would benefit from incorporating direct observation tools or competency assessments to evaluate handoff communication quality objectively. Third, all participants were from a single nurse anesthesia program at one institution, which may limit generalizability to other educational contexts. Finally, the voluntary nature of the SET-M completion may have introduced response bias, as students who found the experience particularly positive or negative may have been more motivated to respond.

Implications for practice and future directions

The findings from this project suggest several important implications for nurse anesthesia education. Programs should consider integrating structured handoff communication training earlier in the curriculum, potentially within the first year of study, to establish foundational communication patterns before clinical rotations. Simulation scenarios should be designed to incorporate multiple opportunities for handoff communication across different clinical contexts (preoperative, intraoperative, postoperative, emergency situations) to build versatility and confidence. Additionally, programs might explore longitudinal assessment strategies that track students’ handoff communication competence development over time and across varied clinical settings.

Future research should investigate the transfer of simulation-based handoff skills to actual clinical practice through direct observation in real ICU-to-OR-to-ICU transitions. Studies examining the optimal timing, frequency, and spacing of handoff communication simulations would inform evidence-based curriculum design. Additionally, exploring interprofessional simulation experiences that include student nurses, medical students, surgical residents, and ICU fellows could enhance authenticity and prepare students for the collaborative nature of actual clinical handoffs.

CONCLUSION

This simulation-based educational intervention successfully integrated structured handoff communication training into a doctoral nurse anesthesiology curriculum, demonstrating high levels of student engagement, confidence development, and perceived learning effectiveness. The implementation of the UCLA OR-to-ICU Bedside Handoff Checklist within an immersive, high-fidelity simulation provided second-year SRNAs with an opportunity to practice critical communication skills while managing a complex, hemodynamically unstable patient requiring transition between critical care environments. Student feedback consistently reflected strong agreement regarding empowerment in clinical decision-making, confidence in team communication, and ability to prioritize patient safety interventions, validating the educational value of this approach.

The qualitative findings, particularly the recommendation to offer this experience earlier in the curriculum, provide important direction for future program development and underscore students’ recognition of handoff communication as a foundational competency rather than an advanced skill. By positioning structured handoff training at the beginning of clinical education, programs can establish evidence-based communication patterns that students can immediately apply and refine throughout their clinical rotations, potentially enhancing both learning efficiency and patient safety outcomes.

Integrating structured handoff training through immersive simulation experiences ensures that nurse anesthesiology students are not only clinically skilled but also prepared to lead safe, efficient, and high-quality transitions of care in complex perioperative and critical care environments.¹¹ As healthcare systems increasingly prioritize standardized communication protocols to reduce preventable harm during care transitions, nurse anesthesia education must continue to evolve by embedding these competencies early and reinforcing them throughout professional development. This project demonstrates a practical, evidence-based model for achieving this educational goal while advancing the profession’s commitment to patient safety, interprofessional collaboration, and excellence in anesthesia practice. Future work should focus on evaluating the longitudinal impact of simulation-based handoff training on clinical performance and exploring optimal curriculum integration strategies that maximize skill transfer to real-world practice settings.