Training of future vascular surgeons is challenged by the healthcare system's demands for improved patient safety and outcome, and an expectation that the staff meet the patient well prepared. Endovascular procedures are commonplace in vascular surgery1. They require superior technical skills and knowledge, and simulation-based education (SBE) is in high demand among vascular surgical trainees (VST), according to a recent European needs assessment2. Although several errors in health care may be attributed to teamwork and communication3, most studies have focussed on SBE aimed at the surgeon but studies focussing on SBE of the endovascular assistants (EVA) are sparse. The aim of this study was to assess the effects of providing EVAs with SBE in basic endovascular skills. We hypothesized that offering a SBE program to EVAs, similar to that offered to VSTs, improves teamwork in the operating room, and the EVAs' job satisfaction and pre-understanding of the procedure.

The study combined quantitative and qualitative outcomes. The SBE was aimed at EVAs. All SBE sessions were performed during work hours. A modified version of the SBE program 'PROficiency-based Stepwise Endovascular Curricular Training program' (PROSPECT) 4, aimed originally at VSTs, was created and used. This stepwise curriculum included e-learning and five simulation-based cases in endovascular treatment of peripheral arterial disease (PAD). A multiple-choice questionnaire (MCQ) test had to be passed to advance from one e-learning module to the next. Compared to the original PROSPECT program, EVAs did not need to reach the benchmark level of skill in simulation cases. All EVAs underwent four simulations on each of the five cases led by the same experienced researcher (JL). Quantitative data were assessed before (pre) and after (post) the SBE program with a standardised simulation case using a Global Rating Scale (GRS) (max score 55 points), Examiner's checklist (max score 85 points), validated simulator metrics for technical skills, and a validated MCQ for cognitive aptitude (20 questions). Qualitative data were collected through two independent semi-structured focus group interviews with half of the EVAs in each group. Interviews were conducted by an experienced interviewer (MS) who did not participate in the SBE sessions. All interviews were monitored by a trained assistant assuring completeness and uniformity. Interviews were audio-recorded, with participants' consent, and transcribed verbatim. The transcriptions were subject to inductive qualitative analysis4 by JL, RS and MS independently, and patterns were grouped in themes.

Eleven EVAs from a large vascular surgical centre completed the program. All EVAs were nurses with experience in peripheral endovascular (approximately 100 endovascular PAD procedures within the last 1-2 years). Technical skills (table 1), assessed with GRS, Examiner's checklist, Procedure, and Fluoroscopy time, improved significantly (P <.001). For cognitive aptitude (table 1), the MCQ scores increased significantly as well (P = .004). Statements from the qualitative interviews were grouped into six themes: "Job satisfaction", "Learning potential", "Culture", "Feedback", "Overwhelming" and "COVID-19" (figure 1). The responses from the EVAs were diverse but mainly positive. They expressed increased job satisfaction and improved preunderstanding of the procedures and flow in the angio-suite. However, they expressed ambiguity and incomprehension of the reason for the SBE and thought it originated from leadership's perception of EVAs' lack of skills. In addition, the e-learning material and pre- and post-tests were considered overwhelming and stressful. They felt they were forced to take the course at the cost of valuable time for patient care, as the SBE-session was given during work-hours.

Simulation-based education, originally aimed at VSTs, may improve EVAs' cognitive aptitude and technical skills in endovascular procedures. More importantly, this study showed that EVAs benefit substantially on a positive subjective level from learning skills and gaining knowledge otherwise pertained to the surgeon. Generally, the EVAs expressed improved flow and understanding of surgical decisions in the angio-suite, also supported by the MCQ scores. Future studies should investigate whether SBE for EVAs can improve performance in the angio-suite by reduction of errors, improved teamwork, reduction of stress, surgeon's performance, and patient-related outcomes.

1 Freischlag JA, Kibbe MR. The Evolution of Surgery: The Story of "Two Poems." JAMA 2014;312(17):1737-8. Doi: 10.1001/jama.2014.14448. 2 Nayahangan LJ, van Herzeele I, Konge L, Koncar I, Cieri E, Mansilha A, et al. Achieving Consensus to Define Curricular Content for Simulation Based Education in Vascular Surgery: A Europe Wide Needs Assessment Initiative. European Journal of Vascular and Endovascular Surgery 2019;58(2):284-91. Doi: 10.1016/j.ejvs.2019.03.022. 3 Maertens H, Aggarwal R, Moreels N, Vermassen F, van Herzeele I. A Proficiency Based Stepwise Endovascular Curricular Training (PROSPECT) Program Enhances Operative Performance in Real Life: A Randomised Controlled Trial. Eur J Vasc Endovasc Surg 2017;54(3):387-96. Doi: 10.1016/j.ejvs.2017.06.011. 4 Elo S, Kyngäs H. The qualitative content analysis process. Journal of Advanced Nursing 2008;62(1):107-15. Doi: https://doi.org/10.1111/j.1365-2648.2007.04569.x.