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Introduction Educational opportunities for nurses working within endoscopy services have historically been limited, with training primarily focused on technical skills for endoscopists. However, nurses play a pivotal role in patient care throughout the endoscopy pathway, from admission to discharge. The complexity of endoscopic procedures and the increasing acuity of patients heighten the risk of complications such as perforation, bleeding, and sedation-related adverse events. These scenarios require nurses to possess both technical and non-technical skills to manage deterioration effectively.The Endoscopy Life Threatening Events Recognition and Treatment (ELERT) course was developed to address this gap. Delivered through the North West Endoscopy Academy (NWEA), ELERT aims to equip nurses with the knowledge and confidence to respond to acute complications in the endoscopy setting. This paper outlines the development, implementation, and evaluation of the ELERT course using simulation-based training and iterative improvement cycles.Methods DesignThe ELERT course was designed using the Plan-Do-Study-Act (PDSA) methodology, enabling iterative refinement based on feedback. Simulation was chosen as the primary educational strategy, underpinned by experiential learning principles to bridge theory and practice. Scenarios incorporated both technical and non-technical elements, including clinical assessment, teamwork, communication, and escalation.ParticipantsAcross three cycles, 60 nurses from endoscopy units in the North West region attended ELERT. Faculty comprised experienced endoscopists, nurse educators, and practice educators. Delegate numbers were adjusted between cycles to optimise learning and faculty engagement.Intervention Each course began with an introductory session on risks and complications associated with endoscopy. Delegates then rotated through simulated scenarios tailored to endoscopy-specific emergencies, such as:Post-polypectomy perforationPost-ERCP pancreatitisGastrointestinal bleedingRespiratory arrest/oversedationSevere hypoglycaemiaBronchoscopy complications (introduced in Cycle 3)Scenarios were delivered in teams to reduce anxiety and foster collaboration. Debriefing followed each scenario, initially using guided questioning and later structured tools such as SHARP and Diamond debriefing methods to enhance reflection and learning.Evaluation Feedback was collected via Likert-scale ratings and qualitative comments. Metrics included perceived learning effectiveness and willingness to recommend the course. Faculty observations informed adjustments between cycles, including scenario design, delegate numbers, and debriefing techniques.Results Cycle 1The first cycle included 32 delegates and five faculty members. Scenarios combined paper-based exercises and hands-on simulation. Feedback was largely positive, with delegates appreciating the practical approach and emphasis on teamwork. Comments highlighted increased confidence and recognition of deterioration. However, constructive feedback suggested reducing paper-based elements and improving equipment availability. Faculty noted challenges in managing large groups and maintaining engagement during repetitive sessions.Cycle 2Adjustments included reducing delegate numbers to 16, increasing faculty, and replacing paper-based exercises with more immersive simulation using porcine models. A communication exercise was introduced to maintain motivation. Feedback indicated improved engagement and confidence in managing complications. Delegates valued the opportunity to lead teams and challenge hierarchy, though faculty identified inconsistencies in debriefing quality, underscoring the need for facilitator training.Cycle 3Further refinements included structured rotations through six scenarios, mini-debriefs after each, and the introduction of Bronchoscopy simulation. Icebreaker activities were added to create a supportive learning environment. SHARP and Diamond debriefing tools enhanced faculty confidence and improved reflective discussions. Themes emerging across cycles included challenges in leadership, communication, and cultural barriers to escalation. Delegates reported feeling more comfortable with technical skills and appreciated the relevance of the ABCDE approach tailored to endoscopy.Outcomes Learning effectiveness: Most delegates rated their experience highly (Cycle 1: 22/27 rated ‘5’; Cycle 2: 17/19 rated ‘5’; Cycle 3: 11/14 rated ‘5’).Recommendation: Nearly all participants indicated they would recommend the course (Cycle 1: 27 yes; Cycle 2: 19 yes; Cycle 3: 12 yes, 1 no, 1 maybe).Insights Positive feedback emphasised the value of hands-on simulation, team-based learning, and investment in nursing education.Direct quotes from delegates:‘Very informative day. Really enjoyed the hands-on approach.’[Delegate]‘Helped me to recognise deterioration, lead a team and challenge hierarchy.’[Delegate]Constructive feedback focused on equipment availability, scenario variety, and tailoring content for different roles.Conclusions The ELERT course demonstrates that simulation-based training is an effective strategy for enhancing nurses’ ability to manage life-threatening events in endoscopy. By integrating technical and non-technical skills, ELERT addresses a critical gap in workforce development and promotes a culture of safety and collaboration. Iterative refinement through PDSA cycles ensured responsiveness to delegate and faculty feedback, resulting in improved scenario design, facilitation, and learner experience.Delegates valued the course as distinct from traditional skills-based training, appreciating its relevance and the investment in their professional development. Challenges remain in faculty training for debriefing and scaling delivery to meet demand. Future directions include leveraging virtual reality technology to expand access and incorporating structured faculty development programs to standardise facilitation quality.