Strengthening Patient-Safety in ERAS Pathways: An Evidence-Informed Framework for Simulation-Based Nursing Practice Development in Acute Surgical Care.

Background: Enhanced Recovery After Surgery (ERAS) pathways depend on nursing-led safety behaviours such as early mobilisation, opioid-sparing analgesia, device minimisation, and reliable discharge teaching to prevent immobility-related, opioid-related, and device-related harms. However, pre-licensure medical-surgical preparation inconsistently embeds these competencies, leaving ERAS delivery and patient-safety vulnerable to variation. Objective: To develop an evidence-informed, practice-development framework that translates ERAS principles into measurable nursing competencies and management priorities explicitly linked to patient-safety, quality improvement, and harm reduction in acute surgical care. Methods: This practice-development framework paper used a narrative literature review of ERAS guidelines, AACN Essentials, and published simulation reports (MEDLINE, CINAHL, Embase, Scopus, ERIC) to identify recurring competencies and scenario features. These were inductively organised and mapped to patient-safety priorities to derive a four-domain framework. Findings: Identified simulations emphasised early mobilisation and multimodal analgesia; nutrition, fluid stewardship, device minimisation, and ERAS-focused patient education were less represented. High-fidelity and virtual formats improved knowledge and confidence but rarely reported patient-level outcomes. These gaps informed a four-domain framework: (1) ERAS clinical pillars and priority nursing competencies; (2) scenario and modality design (including a worked POD-1 colorectal case); (3) assessment and feedback strategies anchored by the Lasater Clinical Judgement Rubric; and (4) implementation tools for nurse managers and ERAS leads to integrate simulation into orientation and quality dashboards. The framework conceptually links competencies to safety-relevant endpoints including opioid-related adverse events, immobility-related complications, device-related harms, and discharge-education reliability. Conclusions: ERAS-aligned simulation may offer a feasible, scalable patient-safety and practice-development strategy for aligning pre-licensure preparation with nursing-management priorities for harm reduction. The framework provides a conceptual model that warrants empirical evaluation. It maps ERAS pillars to nursing competencies, operationalises these through a reusable colorectal scenario, and links simulation-derived competencies to unit-level recovery and safety agendas.