Role-reversal simulation training to enhance performance and reduce stress of endovascular scrub nurses in the operating room

Introduction
To perform safe endovascular aortic repair (EVAR) procedures, an entire team of anesthesiologists, nurse anesthetists, scrub nurses, surgeons, and assistants is needed.
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Simulation-based education (SBE) in endovascular aortic repair is increasingly being implemented in the training of vascular surgical trainees (VST) to enhance competencies and improve patient safety.
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Role-reversal training, e.g., training the scrub nurse in the surgeon's tasks, has been hypothesized to improve collaboration and patient care.
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Despite this, SBE in surgical procedural steps is seldom offered to scrub nurses, as most SBE for nurses focuses on team training, nontechnical skills,
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or nurse-specific tasks.
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Authorities, educational bodies, and hospitals are increasingly seeking proof of the “return of investment” of SBE, just as learners undergoing training need assurance that SBE truly enhances their surgical skills. Measuring the effect of SBE during real procedures is called transfer, and improved patient outcomes due to SBE have notoriously been difficult to measure.
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Transfer can be challenging, as supervisor takeover reduces measurable effects, and differences in complexity between patients hinder patient outcomes comparisons.
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Other surrogate measures of transferability do, however, exist. One such measure is stress level, and it is well described that lower stress levels can improve surgical performance.
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In light of the global shortage of nurses, reducing stress in the operating room would be a relevant goal of SBE to improve staff recruitment and retention.
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Perceived stress can be assessed with the Cognitive Appraisal ratio (CA) and a short version of the State-Trait Anxiety Inventory – State (STAI-S).
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As a measure of autonomic nervous system activation, heart rate variability (HRV) can be monitored continuously with an electrocardiogram (ECG) as an objective surrogate marker of physical stress. It has been shown that higher HRV levels correspond to lower stress levels among surgeons.
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A recent proof-of-concept study showed how HRV of scrub nurses can be monitored during EVAR procedures with wireless ECG patches.
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However, in that study, the complexity and lengths of the observed procedures were not corrected. In addition, the perceived stress level was not investigated, and the SBE course was a preliminary version of the program used in the present study.
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Another measure of transfer is the analysis of periprocedural errors as a descriptor of the overall team performance. Errors can be captured and categorized with the Imperial College Error Capture tool (ICECAP), explicitly developed for endovascular and vascular procedures. Each error can be classified into one of 6 categories: Equipment, Communication, Procedure-independent pressures, Technical, Safety, and Patient.
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This study aimed to assess if skills learned through role-reversal training by scrub nurses following an EVAR-simulation training program designed for VST reduce perceived and measured stress levels and errors occurring during EVAR procedures in the hybrid suite.

Methods
Study design
Prospective cohort study.

Participants
Scrub nurses and endovascular assistants with no experience in EVAR, defined as having never scrubbed in and assisted independently for an EVAR procedure, were invited to participate in the study from January 1st 2022 to February 28th 2023. Participants were included from 2 vascular surgical departments in Denmark: the Copenhagen University Hospital-Rigshospitalet and Aarhus University Hospital. Both are tertiary academic centers and perform EVAR procedures regularly. All participants completed a demographic questionnaire focusing on their experience level before inclusion in the study.

Simulation-based education
Participants completed a standardized SBE program in infrarenal EVAR, initially developed for VST and described in detail in a recent publication.
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In summary, the EVAR SBE program consists of an E-learning program and standardized hands-on sessions in procedural steps and sizing. Participants completed the program in pairs, with one instructor per 2 participants.

Five E-learning modules covered topics on anatomy, disease, tools, procedural steps, follow-up, complications, radiation safety, and planning and sizing. In addition, the E-learning contained 3 multiple-choice tests.

The hands-on training was performed on the ANGIO Mentor Flex II Simbionix simulator (Simbionix, Surgical Science Sweden AB, Gothenburg, Sweden). It consisted of 5 modules with content of increasing complexity: Procedural steps (2 modules), tortuous vessels, endoleaks, and ruptured aneurysm. In addition, participants received one hands-on module on planning and sizing in the 3Mensio software 10.3 (Pie Medical Imaging BV, Maastricht, The Netherlands).

The nurse program differed from the surgeons’ in 2 ways. First, the nurses received the E-learning as small lectures, allowing them to ask questions, and the multiple-choice tests were used to initiate interactive discussions and were not required to pass. Second, the nurses’ performances were not rated, and during all cases, they received continuous formative feedback from the instructor. Hence, they were not required to be able to finish the case independently. These modifications were decided to ease course implementation based on previous experience providing SBE to scrub nurses. The program was completed over 3 days with 7 hours of daily training.