REVIEW ARTICLE
Learning and Teaching Motor Skills in Regional Anesthesia
A Different Perspective
Reuben J. Slater, BSc (Hon), BMed, FANZCA,* Damian J. Castanelli, MBBS, MClin Ed, FANZCA,†‡
and Michael J. Barrington, PhD, MBBS, FANZCA*§
Abstract: Existing literature on learning in regional anesthesia broadly
covers the rate of skill acquisition and the structure of educational
programs. A complementary body of literature spanning psychology to
medical education can be found describing skill acquisition in other fields.
Concepts described in this literature have direct application to the teaching
of regional anesthesia. This review introduces a selection of these complementary educational concepts, applying them to ultrasound-guided
regional anesthesia skills education.
Key educational concepts presented in this article can be divided into
3 sections, namely, how residents acquire manual skills, how tutors teach,
and type of feedback.
(Reg Anesth Pain Med 2014;39: 230–239)
A
regional anesthesia training program should produce confident anesthesiologists capable of safe, independent practice.
Tutors and residents alike are challenged by the complexity of
the skills that must be acquired with limited time and clinical
exposure. This review discusses motor skills learning, a subset
of the skills required for ultrasound-guided regional anesthesia
(UGRA). An overview of evidence for teaching UGRA has recently been published.1
Regional anesthesia educational literature describes curricula,2 the use of simulation, and supervised practice to teach regional anesthesia.3 Documenting the volume of practice before
residents are judged as competent is prevalent.4–7 How motor
skills are learned and taught attracts less attention, yet the education literature effectively describes these concepts. The development of expertise has been studied in many domains,8
providing a knowledge base for planning teaching. For example, students acquire motor skills at variable rates and pass
through distinct behavioral stages. Therefore, it is important to
implement individual teaching strategies, such as preparatory
teaching, task setting, assessment, and feedback. This review
aims to summarize relevant educational theory and apply it
to the teaching of UGRA.
Studies of Learning in Regional Anesthesia
Learning studies in neuraxial anesthesia have predominantly investigated procedural volumes required before residents
From the *Department of Anaesthesia and Pain Medicine, St Vincent’s
Hospital, Fitzroy; †Department of Anaesthesia and Perioperative Medicine,
Monash Medical Centre; ‡Department of Anaesthesia and Perioperative
Medicine, Monash University; and §Melbourne Medical School, Faculty
of Medicine, Dentistry and Health Sciences, University of Melbourne,
Melbourne, Victoria, Australia.
Accepted for publication February 6, 2014.
Address correspondence to: Reuben J. Slater, BSc (Hon), BMed, FANZCA,
Department of Anaesthesia and Pain Medicine, St Vincent’s Hospital,
Fitzroy, Victoria 3065, Australia (e‐mail: ben.slater2@svhm.org.au).
The authors declare no conflict of interest.
Copyright © 2014 by American Society of Regional Anesthesia and Pain
Medicine
ISSN: 1098-7339
DOI: 10.1097/AAP.0000000000000072
230
achieved competency. Studies by Kopacz et al,5 Konrad et al,9
and Kestin6 introduced learning curves and the use of cumulative
summation analysis to skills acquisition. These studies defined
competency differently, leading to variable results.
Rosenblatt and Fishkind10 documented that, after 15 attempts,
87.5% of residents were able to place an interscalene brachial
plexus block without intervention. A survey of senior anesthesia
residents’ experience with nerve blocks confirmed that their exposure was insufficient for confident practice.11 Studies demonstrate
that the experience required for a minimal level of competence
may exceed opportunities available for many residents.11
Ultrasound-guided regional anesthesia involves complex
motor skills and a broad knowledge base. Novices find key
skills, such as optimizing sonographic images and recognizing
sonographic anatomy, challenging. Despite this, Orebaugh et al12
demonstrated that residents performed UGRA more efficiently
than nerve stimulator-guided techniques with a success rate of
97% using UGRA. As residents became more experienced, procedural time decreased as their ability to efficiently identify neural
structures improved.
Several studies examine how long-axis needle-imaging skills
are acquired. Using a turkey breast/olive model, Sites et al13 measured a significant improvement in resident performance during
6 trials when feedback was given after each trial. de Oliveira Filho
et al14 used a meat phantom and applied a discovery learning
model, believing it represented how most individuals learn.
Individuals varied in their rate of skill acquisition, with 30%
of participants attaining proficiency. A mathematical model suggested that to achieve a 95% success for long-axis needleimaging skills or placing the needle tip next to a target, 37 or
109 attempts would be required, respectively. Barrington et al15
used a cadaver training model of in-plane sciatic nerve blockade.
Resident performance was assessed evaluating long-axis needle
visualization and probe steadiness. Residents performed 30 simulated blocks with feedback after each attempt. Consistent with de
Oliveira Filho et al, residents varied significantly in their rate of
skill acquisition; however, their results suggested that competency
in needle placement would be achieved in 28 trials. These differing results with different teaching paradigms (discovery-learning vs
feedback) indicate the potential value that feedback can have on
acquiring skills. More broadly, this implies that teaching strategies
can optimize motor skill learning and tutors should consider incorporating these into training programs.
Equipment for UGRA is constantly changing; visualizing
needles has become easier as hardware, software, and the needles
themselves improve. With technological advances, some of the
previously mentioned studies may be obsolete. Teachers and residents must remain abreast of the latest advances and adjust
their skill sets appropriately. The studies mentioned in this section
have been summarized in Table 1.
How Are Motor Skills Learned?
Educational literature describes the development of motor skills across many domains; principles are generic rather
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Motor Skills in Regional Anesthesia
TABLE 1. A Summary of the Papers Mentioned in “Studies of Learning in Regional Anesthesia”
Author
Kopacz et al
Procedure(s)
5
Konrad et al9
Kestin6
Rosenblatt and
Fishkind10
Orebaugh et al12
Spinal, epidural,
intubation
Subjects
7 first-year residents
Methodology
Objective measures of
success used for a range
of procedures over
6 months of training
Measured success or failure
of a range of procedures
over a year
Spinal, epidural,
11 first-year residents
brachial plexus block,
intubation, arterial
line insertion
Obstetric epidural,
Junior residents in a
CUSUM analysis charting
spinal, central venous
department over a year
success or failure of
catheter and arterial
4 techniques
line Insertion
Interscalene block,
All first- and second-year
Reporting of experience during
nerve stimulator
residents in a department
an 8-mo period, utilising level
over 8 months
of supervision and success
Interscalene
222 consecutive blocks by Total block time, imaging time,
block, UGRA
practitioners with a range
and time for needle insertion
of experience
measured for each block
Outcome
45 and 60 attempts at spinal
and epidural anesthesia,
respectively, were required to
achieve a 90% success rate
Epidural anesthesia was
the most difficult
procedure to perform.
CUSUM is a useful technique
to monitor training of
practical procedures.
Number of blocks required to
reach proficiency was greater
than previously thought.
97.3% success rate. Time to
perform block and acquire
image decreased over 4 wk.
Time to insert needle
did not change
Residents can rapidly
improve performance
using a simulated task.
Failure to visualize needle
most common error.
37 to 109 attempts were
required to achieve
proficiency, significant
variation between subjects.
Sites et al13
Simulated UGRA
10 residents between first
and third year
Simulated tasks, videotaped
and assessed for speed
and accuracy
de Oliveira
Filho et al14
Simulated UGRA
(bovine phantom)
30 anesthesiologists or
residents who had
no experience
with ultrasound
Discovery learning paradigm.
25 consecutive trials of
needle insertion and then
needle insertion to a target.
Analysis using CUSUM
and Bush and Mosteller’s
learning model
Feedback offered after each
Significant variation in
trial. Procedures video-taped
proficiency, 28 simulated
and scored blind. CUSUM and
blocks to become proficient.
Bush and Mosteller’s learning
model used for analysis.
15 residents who had
Barrington et al15 Simulated UGRA
(cadaver, sciatic Nn)
performed < 5
UGRA procedures
CUSUM indicates cumulative sum control chart analysis; UGRA, ultrasound guided regional anesthesia.
than specific and provide insight into teaching motor skills
in UGRA.
The Power Law of Learning
Performance improves with practice and is described by a
robust relationship16 valid across domains including sport, chess,
and music.8 Initial practice leads to a rapid development. As practice continues, the improvement demonstrated for a quantum of
practice decreases so learning curves display a logarithmic shape,
explaining “The power law of learning.” Improving performance can be demonstrated after thousands of hours of practice.
Crossman17 documented individual improvement in cigar rolling
after 10 years of practice and 100,000,000 cigars. Learning curves
have been published for a wide range of anesthesia procedures,
including arterial line insertion, intubation, brachial plexus, and
neuraxial blockade.5,9
Behavioral Stages of Motor Learning
Ultrasound-guided regional anesthesia skills are associated
with clinical decisions, patient care, and working in a team.
Cognitive load theory describes how information can overload
our cognitive capacity. The theoretical cognitive space that is
© 2014 American Society of Regional Anesthesia and Pain Medicine
used to attend to sensory information and solve problems is labeled attentional capacity.51
Schema18 are organized patterns of thought or behavior
used to minimize cognitive load. When examining motor skills,
they can be considered “motor programs.” Motor skills learning
can be conceptualized as the creation of schema. Schema theory
states that prepackaged sequences of actions are stored in procedural memory and the desired outcome is represented and
stored in recognition memory. When the schema is executed, the
result is compared with the desired outcome; learning occurs
through adjustment of both recall and recognition memory.
Dreyfuss,19 Rassmussen,20 Fitts and Posner,21 and Anderson16
have described learner behaviors as they acquire new motor skills.
Learners typically pass through stages that are not discrete but
characterize approximate points in the “qualitative evolution of
a skill.”16 These models are summarized in Table 2. In this review,
the work of Fitts and Posner21 later adapted by Anderson,16 is
emphasized because this model has behavioral correlates in
both learning anesthesia and cognitive neuroscience (Table 3).
The Early (or Cognitive) Stage
Residents need a concept of a new motor skill. This concept
may be based on didactic instruction, observation, or previous
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Regional Anesthesia and Pain Medicine • Volume 39, Number 3, May-June 2014
Slater et al
TABLE 2. Four Models Describing Stages of Motor Skill Acquisition
Author and References
Stages
Summary
Adams L. (describing Noel Burch,
1970 Gordon Training International19)
1.
2.
3.
4.
1.
2.
3.
4.
5.
1.
2.
3.
Widely quoted in management courses and
education courses. Does not appear in the
peer-reviewed literature with regularity.
Dreyfuss,48 1980
Rasmussen (for more detail, refer to
review by Long52 or Rasmussen’s
original description.29)
Fitts and Posner21/Anderson16
Unconsciously unskilled
Consciously unskilled
Consciously skilled
Unconsciously skilled
Novice
Competence
Proficiency
Expertise
Mastery
Skill based
Rule based
Knowledge based
1. Early (cognitive)
2. Intermediate (associative)
3. Final (autonomous)
experience. In the cognitive stage, attempts at the skill are
problem-solving exercises creating movements that match their
concept of the skill. Problem solving may fully occupy their
In Dreyfuss’ model, a novice rigidly
follows rules. As he progresses through
the stages, he starts to use rules in
context. Finally, new rules are intuitively
developed and enacted.
Devised to describe situations in which
rapid decisions have to be made. First,
skills are attained; then as knowledge
is increased, the learner gains the ability
to use these skills appropriately. Finally,
the learner develops a required solution
from broad-based knowledge.
The model described by Fitts and Posner
and later Anderson is described in detail
in Table 3 and also in the text of
this review.
attentional capacity, a limited cognitive space. In the early behavioral stage, residents seem indecisive and error prone with a complete focus on the task and lack of situational awareness.16
TABLE 3. Description of a Resident Performing Brachial Plexus Block and Corresponding Behavioral and
Neuropsychological Correlates of the Motor Skill Stages Described by Fitts and Posner and Later by Anderson
Stage
Early (cognitive)
Intermediate
(associative)
Final (autonomous)
232
Behaviors50
Description
In this stage, a resident attempting an axillary brachial
plexus block struggles to set up the environment, his
biomechanics are poor, and he checks and rechecks
landmarks. All movements lack conviction. The resident
does not know whether to look at patient or ultrasound
screen. Despite this indecision he is completely focused
on the task at hand and unaware of what is occurring in the
procedure room. He does not interact with the care team
or patient. When attempting long-axis needle placement,
the needle is poorly visualized, the resident makes seemingly
random movements and often the needle and probe are
moved simultaneously to improve the view.
In this stage, there is more structure to the resident’s
performance. The resident is more likely to position
herself correctly and optimize the ultrasound image.
The resident’s movements are more concise and seem
planned. When performing long-axis needle placement,
she may hold the probe steady with relatively good
control and interact with the patient and other members
of the care team while performing the block. If the task
becomes challenging or the environment becomes more
stressful, the resident reverts to a problem-solving mode,
and her behavior reflects the cognitive stage.
The resident now performs the block with ease. Movements
are precise, efficient, and inspire confidence. The resident
can comfort the patient and interact with the care team
while performing the block. He is not disrupted by
unexpected events, and if the block becomes complex, he
has developed strategies to deal with problems encountered.
Neuroimaging16
• Inaccurate
• Inconsistent
• Inefficient
• Slow, halting
• Timid
• Rigid
• Many errors
• Lateral prefrontal area
(general planning)
• More relaxed
• More consistent
• More efficient
• More adaptable
• More confident
• Fewer errors
• Supplemental motor area
(guidance of action)
• Posterior parietal cortex
(motor planning)
• Hippocampus
(retrieval of memory)
• Automatic
• Consistent
• Accurate
• Adaptable
• Fluid
• Recognizes errors
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Regional Anesthesia and Pain Medicine • Volume 39, Number 3, May-June 2014
Residents in this stage may have an internal monologue, reminding themselves of the required sequence of events or mistakes they have previously made.22
During the cognitive stage, motor behaviors that lead to
success are reinforced and those that lead to failure are extinguished. Eventually, a solution to the motor problem is generated in the form of a schema. The neurologic correlate of this
stage is neural activity concentrated in the prefrontal and parietal regions. As motor skills improve, this activity decreases,
whereas activity in the supplemental motor area and hippocampus
increases.16,23
The Intermediate (or Associative) Stage
The resident in the associative stage has developed a schema,
which has 2 consequences. First, the resident’s movements become more fluid and definite; they seem relaxed and make fewer
mistakes. Second, their use of attentional capacity has decreased
so that they can effectively interact with their environment, which
allows their situational awareness and nontechnical skills to improve. At this stage, a resident might be confronted with more
challenging cases and opportunities for independent practice.9
These scenarios place pressure on the resident’s nascent motor
plan, and they may revert to a problem-solving approach exhibiting cognitive stage behaviors.
The Final (or Autonomous) Stage
The resident in this stage has automatic, accurate, fluid, and
consistent movements. Residents easily recognize mistakes, adapt
to unexpected situations, and make errors infrequently; little
cognitive input is required to perform the task, leaving attentional
capacity available to concentrate on other issues. In anesthesia,
this may be reflected by a superior ability to communicate with
and monitor the patient and interact with other members of the
care team.
Expert Performance
Ericsson has written extensively about expert performance,
how expertise is defined and how individuals achieve it. Expertise is characterized by superior and reproducible performance
across many domains. Experts in chess win more often and
expert musicians play more complex pieces making fewer
mistakes. Expert medical practitioners consistently perform
at a higher level than their peers.8 However, success alone
may not be the best metric to define expertise. For example,
the high success rate reported by Orebaugh et al24 potentially
reflects how closely residents were supervised rather than their
learning or expertise. In surgical studies, time and error metrics distinguish novices from experts but more complex metrics
are required to distinguish between advanced beginners and
experts.25 Advanced metrics include measures of kinematics,
such as the imperial hospital surgical assessment tool,26 or
the ability to multitask while performing a skill. Smith et al27
suggest expertise goes beyond technical proficiency and is
determined by maximizing patient comfort, anticipating problems, communicating well, and recognizing the limits of
safe practice. These attributes are consistent with the autonomous stage and directing attentional capacity to nontechnical
skills.28
Application of Educational Expertise to
Teaching UGRA Skills
At the end of anesthesia training, residents should be not
only capable of high procedural success rates under supervision
© 2014 American Society of Regional Anesthesia and Pain Medicine
Motor Skills in Regional Anesthesia
but also proficient, safe, and confident in independent practice,
capable of self-assessment, and managing their ongoing professional development. To do this, we need to do more than provide
experience. How can we teach procedures more effectively? Specific teaching strategies based on what we know of how motor
skills develop may improve learning.
Preparatory Teaching
A learner performing a motor skill for the first time must
have a concept of the desired outcome; their goal is to craft a
series of movements into a schema to fit this outcome. This
concept can be informed by didactic teaching, reading references, watching videos, or observing clinical practice. Surgical residents have successfully learned knot tying using a
computer-aided video package.29 Learning by observing may
be an underused resource in medical skills education.30 Observing senior colleagues in everyday practice may have a powerful
influence on residents’ practice.31 Even when an anesthesiologist is not actively teaching, observant residents may be learning
by example, so that, as “exemplars of performance,” what we do
may be more important than what we teach.31
Task Deconstruction
Experts perform procedures automatically; hence, a motor
task may be “easier done than said.”32 In contrast, novices require discrete steps and explicit direction. Cognitive task analysis tools break down complex skills into individual processes
and decisions to facilitate teaching.33 In anesthesia, task analysis tools have been used to examine the individual tasks involved
in procedures including axillary brachial plexus blockade34 and
central line insertion.35,36
Simulated Practice
Individual tasks and processes can be practiced in a laboratory environment. Practicing individual components of motor
skills is known as part-task training37 or fractionization.46
Adding steps of a motor program together sequentially until
eventually the whole task is performed is described as segmentation.38 Tasks and processes may be sequential or occur in parallel. Motor skills occurring in parallel are not suitable for
fractionation. Integral to long-axis needle visualization is the
specific interaction between the ultrasound transducer and needle
which cannot be replicated unless the components are practiced
together.38
Temporal separation of simulated training sessions is important. A resident undertaking a task 10 times in 1 session (massed
practice) may not learn as much compared with attending
5 sessions with 2 trials each (blocked practice). The benefit of
blocked practice is related to the requirement for the “motor problem” to be partially resolved.39 However, enhanced learning in the
massed practice setting can be achieved by teaching a number of
skills in a random order, thus disrupting the resident’s flow and
challenging them on each task.40,41
A “pre-trained novice”49 can be created by maximizing
procedural learning in simulated environments, with the learner
developing some automaticity and spare attentional capacity before their clinical practice commences.
Supervised Practice
A teacher should choose the appropriate level of performance for a resident, by assessing the prior knowledge and level
of proficiency.21 Options for varying the difficulty of skill
233
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Slater et al
FIGURE 1. Learning and teaching concepts presented in this article, related to the learning stages described by Fitts and Posner.21
performance include practicing only part of the procedure, varying the support provided, or allowing the resident to perform
only straightforward cases.
According to Vygotsky, tasks can be conceptualized as
within a resident’s independent capability, beyond their capability, or within their zone of proximal development (ZPD), where
TABLE 4. A Summary of Concepts Derived From Education Literature With Relevance to Teaching in Regional Anesthesia
Description
Power law of learning
17
Deliberate practice8
Attentional capacity50
Application
Performance improves with practice. Initially
performance improves rapidly, however,
with ongoing practice, performance
improvements decrease. Practice continues
to have small benefits even in very
experienced practitioners.
Teacher assesses performance, identifies
problems, and targets practice to
eliminate problems.
A cognitive space with limited capacity
used to focus on a specific aspect of
the environment.
Stages of motor
skill learning 21
Three behavioral stages, which can be
identified as a resident acquires a motor skill.
Expertise8
Performing at a level that is consistently
superior to your peer group.
Systematic Training and
Assessment of Technical
Skills (STATS framework)32
A systematic training and assessment tool for
motor skills comprising (1) knowledge based
learning, (2) task deconstruction, (3) training
in laboratory environment, (4) transfer of
skills to the clinical environment, and
(5) obtaining privileges for independent practice.
Resident’s performance will improve
rapidly with practice. After ongoing
practice, the rate of improvement in
performance is less; however, quality
practice will always lead to some
performance improvement.
Practice does not necessarily lead to
performance improvement, high-quality
practice is required.
Residents attempting a skill for the first
time will focus their attention on the skill.
As attentional capacity is limited, he will
have a limited ability to focus on other
areas of the clinical environment.
The behaviors exhibited by a resident can be
used to assess her level of motor skill learning.
Training can then be set appropriately.
Performing at the highest level. Practitioners
who are experts are likely to have had
thousands of hours of experience and
have engaged in deliberate practice.
A way of structuring a training program
for aspects of a curriculum that require
motor skills. Can be used granting
privileges for independent practice.
Continued next page
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Motor Skills in Regional Anesthesia
TABLE 4. (Continued)
Description
33,36
Cognitive Task Analysis
A method of breaking down a motor skill that
has become automated into sections that can
be taught effectively.
Self-directed learning45
Residents who can independently set appropriate
academic goals and design strategies to achieve
their academic goals.
Learning and performance51
Performance of a motor skill is a measure of
immediate aptitude. If a learning session
leads to a sustained improvement in
performance when the skill is tested after a
delay, learning has occurred.
A person performing a motor skill while being
observed by a resident. Can be live or via
digital media.
Exemplar of performance45
Zone of Proximal
Development (ZPD)42
Scaffolding42
Challenge point43
Fractionation38
Segmentation38
Massed practice39
When a resident performs a task that is difficult
enough that they require help from a tutor,
it is described as being in the ZPD. Tasks
performed in the ZPD promote learning.
A term used to describe the support given to a
resident, when they are performing a task
in the ZPD.
There is an optimal level of difficulty for any
motor task given to an individual resident.
Tasks that are too easy or too difficult do
not promote learning.
Practicing discrete components of a motor skill.
Adding discrete components of a motor skill
together after they have been practiced separately.
Practicing a motor skill repetitively at a
single session.
Blocked practice39
Practicing a motor skill at several
discrete sessions.
Pretrained novice49
A resident who has practiced a skill in a
nonclinical environment. When they transfer
the skill to the clinical environment they have
more attentional capacity.
Feedback45
Feedback can be internal, a resident critiquing
their own performance or external, a tutor
providing information about a resident’s
performance.
Briefing can be used before a learning interaction
to assess a resident’s knowledge and define
appropriate goals and limits. Debriefing or
delivering feedback can then refer directly
to the goals set.
Brief/debrief46,47
Application
For an exemplar of performance, a skill may
be “easier done than said.” Cognitive task
analysis provides a method to break down
motor skills into steps so steps can be
taught individually.
Self-directed learners tend to perform better
academically. They tend to be internally
motivated to learn and practice. This is in
comparison to externally motivated residents,
who are driven by desire to please or to
pass examinations.
Improvement in a measurable aspect of a resident’s
performance during a teaching session does not
necessarily reflect learning. For learning to occur
the improvement must persist or be transferrable
to other skills.
As a qualified anesthesiologist, whenever you
perform a manual skill you are acting as a role
model to residents who may be watching.
What you do is profoundly more important
than what you teach.
The difficulty of a task should be modulated to
be appropriately challenging for the resident.
The type of support given to a resident can vary
from guidance through stages of a task, to
control of clinical environment.
Another way of describing the concept of ZPD,
tasks administered to residents need to be
appropriately challenging to promote resident.
A component of a motor task is practiced in
isolation. For example, ultrasound scanning to
identify neural structures is practiced in
a laboratory.
Components of a motor skill that have been
practiced separately are linked together.
Repetitively practicing the same motor skill
at a single setting may improve performance,
but not lead to learning.
Practicing motor skills in discrete blocks requires
the motor skill to be resolved at each setting.
This may improve learning.
Residents who have progressed beyond the first
stage of motor skills acquisition in simulated
practice, will have more attentional capacity
to apply to other aspects of the clinical
environment and nontechnical skills.
Learning cannot occur without feedback.
Feedback should be balanced and limited.
Before setting a task, have a discussion that
assesses a resident’s knowledge and level of
performance. Set a task of the appropriate
difficulty. Discuss responsibility for different
aspects of the clinical environment and limits
at which you will take over the task. This
discussion then forms a framework for
feedback at end of procedure.
Continued next page
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Slater et al
TABLE 4. (Continued)
Description
Dialogue of feedback
45
Application
Feedback in the form of a discussion may improve
the learning experience, by elucidating the
resident’s internal feedback processes before
giving external feedback.
Concurrent feedback45
Feedback delivered during the performance
of a skill.
Summary feedback45
Feedback performed at the end of a motor skill.
they can complete the task only with support.42 Performing tasks
in the ZPD allows development of skills. Guadagnoli and Lee43
describe a challenge point framework, suggesting that there is
an optimal difficulty that will promote learning. Bjork and Bjork44
describe the concept of “desirable difficulty,” suggesting that a
degree of challenge will enhance learning. A task allocated to a
resident should be complex enough that they can learn, without
being so complex that it is impossible to achieve.
In clinical settings, a tutor can assume control of the procedure and environment so as to allow the resident to concentrate
on a specific skill. This has been described as “scaffolding.”44
During regional anesthesia, environmental control includes attending to patient comfort, monitoring sedation and physiological parameters, or interacting with members of the care team.
As residents become more experienced, they take on more of
these responsibilities moving toward independent practice. This
process of environmental control should be disclosed to the resident, so they are aware of the process and not lulled into a false
sense of security.
Systematic Training and Assessment of
Technical Skills Framework
A framework for the systematic training and assessment of
technical skills (STATS) has been developed by Aggarwal et al.32
This provides a template for curriculum development in procedural teaching. The training program in regional anesthesia at
the Mayo Clinic described by Smith et al2 demonstrates how the
STATS framework can be applied to teaching UGRA.
Initiating feedback by asking an open question,
“How do you think you performed?” Gives
the tutor a concept of the resident’s internal
model of the skill and their internal feedback
processes. May encourage feedback about
the teaching session.
May be useful for novices performing
procedures with multiple steps, allowing
the novice to concentrate on a motor skill
without having to concentrate on the overall
sequence. In more experienced residents
concurrent feedback may inhibit learning.
Feedback provided at the end of a procedure.
Feedback
Feedback is an important tool that allows a resident to
close the gap between their current and desired performance
during all stages of skill acquisition. A model describing the
interaction of the resident and task, developed by Nicol and
MacFarlane-Dick,45 provides an opportunity for a deeper understanding of feedback. The model has been modified herein
(Fig. 1) to apply to motor skills learning.
There are 2 distinct feedback pathways available when a
resident undertakes a motor skill (Fig. 1). First, the resident
compares their performance to a mental concept of how the
skill should be performed (internal feedback). Second, an external source provides information on the resident’s performance
(external feedback). Before a resident performs a supervised
skill, there should be a discussion about goals to establish
agreed expectations. These goals define control of the clinical
environment, set limits on skill performance and, importantly,
frame postprocedure feedback. This concept mirrors the “briefing/
debriefing” model that is used extensively in the military, emergency services, and aviation.46,47
Feedback may most simply be initiated by asking the resident how they viewed their performance. This allows the tutor
not only to assess the resident’s attempt at the skill but also
the resident’s desired level of performance.45 External feedback
can be used to correct both what was observed during the procedure and also the resident’s internal model. Targeted feedback
is critical as the capacity to accept and use feedback is limited.
Feedback does more than correct technical points. Poor
performance may point to a lack of motivation if the resident
FIGURE 2. Illustrating the concept of internal and external feedback loops, modified from Nicol and Macfarlane-Dick.45
236
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Regional Anesthesia and Pain Medicine • Volume 39, Number 3, May-June 2014
Motor Skills in Regional Anesthesia
FIGURE 3. This framework draws on the concepts in the review to describe an “ideal” learning scenario. The framework could be
used in preclinical environments to create the pretrained novice, or in clinical environments.
does not appreciate the value of the skill or of performing it
as the tutor requires. Feedback can be used to discuss why the
skill is valuable or how the outcome may be improved if it is
performed in a given way. A knowledge deficit may be identified in the discussion and the tutor might be able to assist the
resident with advice about learning resources. During feedback,
a tutor will ideally have made 2 or 3 points that may include
constructive criticism, identification of weaknesses, problem
solving, and positive reinforcement of the resident’s technique.
The dialogue may conclude with feedback of how effective
the teaching session has been for the resident. The timing of
feedback is important; it should be given as close as possible
to the end of skill performance (summary feedback). There is
a risk if feedback is delivered constantly throughout performance (concurrent feedback) that the resident will depend on
this feedback with inhibition of learning. Concurrent feedback may be required with new skills or to prevent harm
to patients.
Summary
This review highlights the importance of teaching in the
acquisition of motor skills, a subset of the total skill base required
to practice UGRA. To do this, we have reviewed the literature
from the psychology and education domains. Table 4 provides
a summary of concepts and Figure 2 relates the concepts to
the stages of learning motor skills. Applying lessons from other
academic domains allows anesthesiologists to pass on their
© 2014 American Society of Regional Anesthesia and Pain Medicine
knowledge more effectively, with the goal of producing confident,
safe, and knowledgeable residents, capable of independent practice.
Residents should prepare themselves before attempting
new motor skills, and this should include creating a mental concept of how the skill is performed. Observing senior colleagues
is important and even when teachers are not actively teaching they
act as role models. Pretrained novices can be created through
preclinical training or simulations with clinical benefits. Within
the clinical environment, teachers can modulate task difficulty to
optimize learning. Structuring learning encounters with briefing
and debriefing can be used to establish agreed goals and frame
a feedback dialogue restricted to 2 to 3 balanced points.
Incorporating teaching strategies, which have been developed to maximize learning of motor skills, into regional anesthesia training programs provides the opportunity to improve
the quality and efficiency of learning opportunities. The UGRA
training program at the Mayo Clinic2 provides an excellent
framework for a UGRA teaching program. To conclude this review, we present an ideal framework for a single teaching session in Figure 3. This session could be in a simulator as part
of the training of a pretrained novice or supervised practice in
a clinical environment.
ACKNOWLEDGMENT
The authors thank Assistant Professor Lisa Warren (Department of Anesthesia, Critical Care and Pain Medicine at
Massachusetts General Hospital), who made insightful comments on several drafts of this review.
237
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Regional Anesthesia and Pain Medicine • Volume 39, Number 3, May-June 2014
Slater et al
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