Handoffs, defined as the real-time transfer of care and responsibility from one healthcare provider to another, are crucial for ensuring continuous, high-quality care and patient safety (Kim et al., 2022; Lim & Pajarillo, 2015). This process relies heavily on effective communication, as inadequate handoff communication is a significant patient safety concern, often resulting in medical diagnosis delays, adverse events, and increased lengths of stay (Halm, 2013; The Joint Commission, 2023; Wolinska et al., 2022). These complications can lead to increased medical costs and dissatisfaction among patients and healthcare workers (Baker, 2010; Starmer et al., 2014).

Effective handoff is important in pediatric settings. Pediatric patient information often requires caregiver input, making handoffs particularly significant in pediatric departments (Patton et al., 2017). Coordinated communication and accountability between pediatric nurses optimize patient safety (Lee et al., 2020; Uhm et al., 2018). Children, particularly those in the pediatric intensive care unit (PICU), are often vulnerable (Breuer et al., 2015). The intricacies of pediatric care, including drug adjustments to accommodate growth and metabolism, underscore the critical importance of effective communication in ensuring optimal healthcare outcomes (Breuer et al., 2015, Nagpal et al.,2010).

According to a review of surgical malpractice claims, postoperative patients had the highest risk of complications or death due to a lack of information transfer during handoff (Mazzocco et al., 2009; Wolinska et al., 2022). The postoperative care of pediatric surgical patients demands meticulous attention to detail to manage various needs, such as wound monitoring, pain management, and medication dosing (Nagpal et al., 2010). As children can experience rapid health changes post-surgery, effective handoffs are essential to identify and address potential complications and enhance patient recovery (Mannix et al., 2017).

Especially, congenital heart disease (CHD) is the most common of all major pediatric congenital malformations. It leads to frequent hospitalizations and long hospital stays (Oster et al., 2013). In cases of congenital heart diseases, where post-operative complications can be subtle yet critical, the continuous involvement of families can bridge communication gaps, ensuring that changes in vital signs or behaviors aren't overlooked. Thus, effective handoff becomes paramount in the pediatric setting to relay information to young patients and to foster collaboration and understanding among healthcare providers, parents, and patients, ultimately contributing to patient-centered care (Wolinska et al., 2022). This handoff process should not disturb ongoing care, which can be a challenge (Hansson et al., 2020

Recognizing these challenges, recent studies report that structured patient handoff processes can improve communication and the standardized handoff process includes the situation, background, assessment, recommendation (SBAR) tool (Leonard et al., 2004) and the illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by receiver (I-PASS) tool to facilitate the exchange of patient information between core patient care team members (Patton et al., 2017; Starmer et al., 2014). Although SBAR has been used for handoffs during changes in shifts or patient location, it has limited applicability, particularly for complex patients who require broader information and context (Starmer et al., 2012). I-PASS is a comprehensive handoff program that trains clinicians to concisely exchange and synthesize relevant patient information. I-PASS helps health professionals develop a shared mental patient model so that every clinician involved in the patient's care is aligned with the overall treatment goals (Blazin et al., 2020). Starmer et al. (2012) described the five components of the I-PASS program's quality patient handoff: illness severity (I), patient summary (P), action list (A), situational awareness and contingency plans (S), and synthesis by the receiver (S). I-PASS program can reduce errors and be adapted across various pediatric handoff contexts (Starmer et al., 2012).

According to the Institute for Patient-and Family-Centered Care (IPFCC), “Family-centered care (FCC) is the planning, intervention, and evaluation of health care through a mutually beneficial partnership among health care providers, patients, and families. Family-centered bedside handoffs facilitate the exchange of pertinent information between providers and improve patient engagement” (Brannon, Ray, Lark and Kindratt, 2022, Mardis et al., 2016). This concept is a pivotal aspect of pediatric nursing (Brannon et al., 2022) that promotes effective communication and ensures that care aligns with the unique needs of the pediatric patient and their family. Effective communication and handoff responsibility are fundamental components of pediatric nursing education in family-centered care. Lim & Pajarillo, 2015 recommended the use of bedside handoff to accurately correct information and reduce errors through face-to-face interactions with patients and their families.

Moreover, recent research highlights that FCC-based standardized handoffs can reduce medical errors, improve patient outcomes, and enhance overall family and patient satisfaction (Breuer et al., 2015; Taylor, 2015). This approach humanizes the handoff process to ensure a more comprehensive and effective transfer of care. However, most studies related to handoffs in pediatric nursing involve limited pediatric populations in non-diverse settings, such as the transfer of pediatric heart surgery patients from the delivery room to the neonatal unit (Nagpal et al., 2010, Patton et al., 2017). There is a lack of comprehensive tools designed for the unique needs of pediatric care transitions. Addressing these issues requires a multifaceted approach for nursing professionals that considers the complexities of pediatric care, family involvement, and the diverse settings in which handoffs occur.

The recent COVID-19 pandemic ushered in an era of online learning, highlighting the need for innovative nursing education modalities (Moon, 2023). Alternative nursing practice education programs were developed to replace nursing students' clinical practice during the pandemic (De Gagne et al., 2022). The shift from traditional classroom learning to online learning indicates a need for new nursing education modalities. The metaverse is emerging as a way to overcome the difficulties associated with videoconferencing tools and implement smoother interactions with fewer spatiotemporal constraints (Kim & Kim, 2023). According to previous research (Yang & Kang, 2022), a metaverse platform allows users to virtually engage in social interactions, emotional exchanges, and communication. Miller and Jensen (2014) emphasized that nursing education using the metaverse allows students to effectively practice in a safe learning environment. The metaverse platform uses avatars to enhance interactivity and immersion and maintain anonymity at the space (Han & Noh, 2021; Kim & Kim, 2023).

In addition, simulations are increasingly accepted and implemented in healthcare education because they focus on a student's experience in solving problems, performing skills, and making decisions (Yang & Kang, 2022). Simulation training using avatars on a metaverse platform with real pediatric clinical scenarios allows nursing students to practice caring for critically ill children with congenital heart conditions in a safe and controlled environment (Kang & Moon, 2023; Oster et al., 2013).

Among the metaverse platforms, ZEPETO, developed by Naver Zepeto in South Korea in 2018, stands out Zepeto, 2023. It can be accessed through a mobile phone or personal computer. Users adopt avatars to engage in games with voice and text chat functionalities (Moon, 2023). This platform facilitates communication among nurses, patients, and nursing students in a clinical trial-like space, promoting immersion in real clinical situations. ZEPETO enables real-time group or one-on-one communication, allowing users to convey information verbally, through text, or using avatar gestures (Oh, 2022). ZEPETO provides interactive experiences and offers learner-centered education, enhancing learning effectiveness, motivation, and immersion more than traditional online platforms (Kim et al., 2022).

ZEPETO could have several potential disadvantages, including variations in user familiarity and understanding of the platform, occasional technical issues, and the need for a stable internet connection (Kim, 2023). In metaverse-based simulations, learning quality can be influenced by the access environment. That is, obstacles such as the internet and Wi-Fi might inhibit participants' abilities to use a metaverse platform (Kim, 2023). Despite these limitations, ZEPETO is a valuable metaverse-based nursing education tool. Its interactive features and real-time communication capabilities contribute to a dynamic learning environment, allowing users to engage in immersive scenarios and simulations (Kang & Moon, 2023).

In rare situations involving high-risk patients, such as those with congenital heart disease, ZEPETO provides a valuable opportunity for learners to practice and repeatedly learn handoff skills in a safe virtual clinical environment (Dean et al., 2020; Moon, 2023). Overall, it promotes patient safety and alleviates insufficient opportunities for clinical practice. Therefore, virtual reality technology is widely used in nursing education (De Gagne et al., 2023).

This study aims to enhance students' handoff-related competency, providing them with valuable skills for effective communication and care delivery in the pediatric healthcare setting. Nursing and medical metaverse platforms are still in their early stages, with the learning effectiveness and efficacy of these platforms yet to be fully validated (Liaw et al., 2018; Yang & Kang, 2022). Our study adds valuable insights to the ongoing exploration of metaverse-based handoff programs in the pediatric healthcare domain.

Our study aimed to examine the impact of a metaverse-based handoff simulation program on handoff competency, handoff efficacy, learning realism, and learning satisfaction compared to a control group. It assessed if the program could maximize effective communication between nurses based on a communication-based metaverse pediatric intensive care unit based on ZEPETO. This study could be used to develop an integrated, family-centered pediatric nursing education program that increases students' handoff-related competency.

This study explored the following specific hypotheses:

•

Hypothesis 1. The experimental group will demonstrate a greater increase in the mean handoff competency score than the control group.

•

Hypothesis 2. The experimental group will demonstrate a greater increase in the mean handoff self-efficacy score than the control group.

•

Hypothesis 3. The experimental group will demonstrate a greater increase in the mean learning realism score than the control group.

•

Hypothesis 4. The experimental group will demonstrate a greater increase in the mean learning satisfaction score than the control group.