# Transformative Applications in Education/Nerveblock Simulator
## An Evaluation: Upper Limb PNB Simulator

The Questions We Needed Answered…
* Will the Lippincott simulation program help our novice new hire sales representatives to know the most common surgical procedures in which patients and providers can benefit from peripheral nerve block (PNB) anesthesia/analgesia?
* Will this program enable these sales representatives to describe how nerve blocks are performed including how nerve stimulators are used to locate a specific nerve, how anesthetic is administered, and the difference between single shot and continuous PNB techniques?
* Will the program advance our learner’s understanding of the brachial plexus anatomy and help them to have credible conversations with anesthesiologists regarding at least three upper extremity surgical procedures?

### Introduction

We conducted a learning styles survey at B. Braun Medical in December, 2006 with 120 sales representatives and sales managers. Of this population of employees 85% had more than 5 years of experience with B. Braun Medical, 45% of the group was between 30–42 years old and 46% was older than 43 years old. Males represented 61% of the survey group and females represented 39%.
We received 96 learning styles survey responses (80%), which indicated that 89% of our targeted learners felt that live workshops were the most effective training format. However, the same survey indicated that 62% of our sales team felt videos to be an effective training medium and 52% felt the same about print. The cognitive channel preferences of our learners (Figure 1) were 41% kinesthetic, 41% visual/auditory, and 18% verbal/readers. At the time, we found it interesting that 62% of our sales representatives and sales managers felt training videos to be effective even though we had never produced training videos. This coupled with the fact that 41% of our representatives were inclined towards visual/auditory learning inspired us to begin developing videos and animations as a part of our training curriculum to support both print-based and live classroom activities.
Figure 1. Cognitive channel preferences of target audience (Neil Fleming VARK Model)
As can be seen in Figure 2, the B. Braun Medical field force exhibits a multimodal learning style with a slight dominance for a “learn by doing” preference (Kolb methodology), which is supported by the higher prevalence of a body kinesthetic (41%) cognitive channel preference (Fleming methodology). Collectively, these findings suggested that we develop a blended curricular approach with an emphasis on either live or virtual experiential training programs.
Figure 2. Dominant learning style of target audience (Kolb model). Multimodal is universal, and converging (do/think) is dominant.
We are currently in the process of planning a peripheral nerve block (PNB) training program. Given the diverse learning preferences of our sales team, in addition to the success we have had with the blended training programs that we have developed since December 2006, we plan to build the following learning components into our peripheral nerve block training program.
* Print-based self-study modules (supplemented with animations and videos) • A clinical PNB certification program (utilizing simulation tools) • Live classroom instruction (utilizing simulation tools) • Presentation skills training • Observation of best practice skills in simulated customer situations • Peer-to-peer tutoring in simulated customer environments • Sales management pull through, coaching and feedback
This review will be focused on how the Lippincott Upper Limb PNB Simulator Program might address the needs of our learners related to the PNB certification, live classroom instruction and peer-to-peer tutoring components of our planned curriculum.

### Simulator Program Overview

The stated purpose of the Upper Limb Peripheral Nerve Block Simulator Program is to provide a tool to enhance a student/practitioner’s skill in PNB anesthesia. The training DVD is divided into three distinct (and/or interrelated) sections:
1. The “Upper Limb Blocks” section contains 3-D animations, audio narration, written procedures and over 600 references, which reviews all of the essential information related to anatomy, procedural indications, complications and technique needed to learn how to perform an upper extremity PNB.
2. The “Anatomy” section provides learners with a brief description and 3-D animations of the anatomy of the upper extremity as well as the anatomical specifics inherent in each block procedure.
3. The “Simulator” section allows learners to perform each of the peripheral nerve blocks of the upper limbs on a 3-D reconstitution of a real human body based on the Visual Human Project (a mission established in 1989 by the National Institute of Health to build a comprehensive digital library representing the complete, normal adult male and female anatomy.
The tutorial gives a very broad overview of the program, but gives no instructions regarding where to start or recommendations related to the best sequence of instruction. I started in the “Upper Limb Blocks” section of the program (Figure 3), which proved to be the best course of action, and found that the other two sections were linked to this primary training section and supported both the fundamental knowledge (Anatomy) and the practice component (Simulator). After selecting “Upper Limb Blocks,” I next needed to select the PNB type to begin instruction (Figure 4). The eleven block procedure selections include: axillary and interscalene brachial plexus blocks, supraclavicular and infraclavicular blocks, mid-humeral block, and median nerve, radial nerve and ulnar nerve blocks for both the elbow and the wrist.
Figure 3. Home screen
Figure 4. PNB selection screen
I selected the interscalene nerve block training segment, which will be described for the balance of this review. When the interscalene block training portion of the program opened (Figure 5) the training automatically started with an audio narration of a 3-D animation (bottom left navigation button). This narrated animation can be paused, fast forwarded or rewound, or skipped forward or back in larger, logical instructional chunks. The little house icon will take the user back to the upper limb block procedure selector screen (Figure 4). The “Video” button takes the learner to a real-world audio narrated procedure. The “Library” button combines select 3-D, 360 degree animation stills, which can be manually rotated, with accompanying text-based slides that also review the procedure. Imbedded within these slides are hot links to more specific information related to the interscalene nerve block procedure in addition to reference material specifically aligned with the text on the slide. The “Anatomy” button allows the user to focus specifically on studying the block-specific still graphics. The “Index” button allows learners to rapidly search for specifically needed content via a list of the logical instructional chucks for either the “Animation” or “Library” components of the program (e.g., indications, complications, etc.). The “Animation,” “Anatomy,” “Library,” “Video,” and “Simulation” components of the program are briefly described below.
Figure 5. PNB Interscalene brachial plexus block home screen
Animation: The narrated voice over animation begins by describing the clinical indications for an interscalene brachial plexus block, which include providing analgesia and/or anesthesia for surgeries on the shoulder and arm. Next, a variety of procedural contraindications are shared including phrenic paralysis and chronic respiratory disease. The patient’s proper position is explained. The key anatomical landmarks necessary for locating the interscalene groove, which resides between the anterior scalene muscle and middle scalene muscle, is discussed. Locating and marking the stimulating needle puncture site is explained as well as the step by step technique for advancing the needle to the correct bundle of nerves (Figure 6) to elicit an adequate (Figure 7) versus an inadequate (Figure 8) motor response, all while avoiding anatomical areas that could harm the patient like the juglar vein.
Figure 6. Advancing the stimulating needle to the appropriate nerve bundle
Figure 7. Adequate motor response
Figure 8. Inadequate motor response
Anatomy: Learners who need more detailed instruction can select the “Anatomy” button any time that the narrated voice over animation is running to review the applicable anatomy in greater depth. As can be seen in Figures 9-12, users can manipulate the brachial plexus anatomy by adjusting the viewing angle, magnifying the view, and selecting a variety of anatomical layers; nerves, vasculature, and two different layers of muscle.
Figure 9. Brachial plexus nerves
Figure 10. Brachial plexus vasculature
Figure 11. Brachial plexus inner muscle and lung
Figure 12. Brachial plexus with outer muscle
Library: Learners who need more detailed or slower instruction can select the “Library” button any time that the narrated voice over animation is running to view a text-based narrative, which is accompanied by a text specific, labeled, anatomical still graphic in addition to a 3-D graphic that can be rotated by the learner to explore different anatomical perspectives. Text on some of the pages is hot linked to additional levels of pertinent content if deeper levels of understanding are desired or required. For example, the word “references” is a hot link within the text shown in Figure 13. If clicked by the user, a detailed list of references, related to “technique,” in this example would, be available to the learner. The user is able to then select any of these listed references for the specific reference detail (Figure 14).
Figure 13. Narrative text with 3-D manipulative graphic
Figure 14. Linked reference list
Video: Learners who want to see the real-world interscalene block procedure can select the “Video” button any time that the narrated voice over animation is running. This portion of the training program aligns a video of the procedure with voice over narration and accompanying anatomical graphics from the “Animation” and “Anatomy” sections so that the didactic content is contextually connected to practical application (Figure 15).
Figure 15. Video of interscalene nerve block procedure
Simulation: Learners can practice what they have learned within the “Animation,” “Anatomy,” “Video” and Library components of the program by “doing” the interscalene block procedure on a virtual patient. The digital male patient can be positioned by the learner for the best procedural approach (Figure 16). He can be moved up and down or left and right. He can be rotated 360 degrees vertically or horizontally. It’s possible to zoom in and out of the procedural site and the patient’s skin can be made transparent to better visualize nerves, muscles and vasculature (Figure 17), or more transparent to visualize just the nerves and arteries. The learner can locate the interscalene groove by moving the cursor over the patient’s skin to identify the key anatomical landmarks. The needle puncture site can then be marked by using line and curve drawing tools, after which the stimulating needle (size) can be selected and inserted (Figure 18). The needle is advanced with the mouse when the “Technique” button is selected. Conducting the virtual procedure is extraordinarily challenging. Learners will need to constantly toggle between “Technique” and the “See” transparency feature to adjust the needle placement to achieve adequate motor response, which can be visualized by watching the patient’s muscle movement – or lack there of – on the animation on the right (Figure 19 and 20). The goal of the exercise is to get the stimulating needle as close to the appropriate nerve bundle as possible, while reducing the milli-amperage intensity of the needle, while getting adequate muscle response, without injuring the virtual patient.
Figure 16. Positioning the virtual patient
Figure 17. Visualizing the anatomical structures in the virtual patient
Figure 18. Identifying the anatomical landmarks and marking the needle puncture site
Figure 19. Conducting the virtual nerve block procedure
Figure 20. Visualizing the anatomical structures during the virtual procedure

## Simulator Program Evaluation

As we dig into whether the Lippincott Upper Limb PNB Simulator software might address the needs of our learners related to the PNB certification, live classroom instruction and peer-to-peer tutoring components of our planned curriculum, it might be helpful to share a brief overview of the collective research, of which I am an advocate, regarding cognitive information processing, multiple intelligences and deliberate practice.
The first step of the cognitive information processing sequence is sensory input, which includes the cumulative internal and external, or environmental stimulus, experienced by a person at any given moment in time. All of this stimuli hits a sensory register, which has limited capacity. It can only accept and hold a limited amount of sensory input. The sensory input is stored for about a half a second at which point it is either processed, because we pay attention to the stimuli, or the sensory input is lost to accommodate new stimuli. Attention is the only way that sensory inputs reach conscious thought. Due to limited capacity our sales representatives selectively choose to attend to certain incoming information while simultaneously choosing to ignore other information. Selective attention is a process of allocating resources to manage limited capacity.
Sensory input that is attended to is selected for further processing and moves to the temporary (or working) memory. At this stage, files on the hard drive or concepts and information stored in the long term memory are accessed for use in making sense of the incoming information. The storage duration of sensory input in working memory is longer than the sensory register, but still a very brief 15 to 30 seconds. Working memory, like the sensory register, has limited capacity. Information is stored in working memory in small chunks of data. These chunks of data will be lost, or pushed out, every 15–30 seconds to make room for new data unless the existing data is rehearsed (practiced) or encoded into long term memory for later recall. Rehearsal is the simple act of consciously looping or repeating the sensory input for recall later, like repeating a phone number until one has the chance to write it down. Encoding, on the other hand, happens when new information in the temporary memory matches or is aligned in some way to a sales representative’s existing concepts or anchoring ideas – their past experiences and prior learning. If a sale rep’s existing long term cognitive files are connected in some way to the information in short term memory these new ideas will be relevant to the rep and provide entry points for the new information to be permentantly filed, or encoded for later recall and application as represented by the green arrows in Figure 20 (Driscoll, 2005. Linn, Davis & Eylon, 2004).
Many researchers believe that the brain is modular and retains long-term memories in multiple systems. For example one theory is that the brain is split between two memory systems; verbal and non-verbal. The verbal memory module contains verbal and auditory memory files. The non-verbal memory module contains visual memory files, tactile memory files, and olfactory memory files. Others, like I, believe in an even more granular memory filing system that separates incoming information into distinnct verbal liguistic, logical mathmatical, visual spatial, musical, body kinesthetic, intrapersonal and interpersonal files (Gardner, 2004). I believe that the size of these distinct long term memory files is impacted to a large degree by an individual’s learning style. What this means, to those of us who wish to teach others, is that our curricular content and methodology should seek to capture a sales rep’s attention utilizing a variety of techniques in an effort to make connections to these multiple long term files. The more long term memory files we open the better chance we have of our representatives encoding our training content into a variety of these files for later recall and application.
Finally, According to Ericsson (1993, 1995), the most important identifiable factor separating elite performance from average performance is the amount of deliberate practice undertaken over a long period of time, with an appropriate level of difficulty, while receiving informative feedback, and having opportunities for repetition and correction of errors, to attain excellence. Hard work, or effort, compels attention and facilitates the movement of instruction from short term memory to long term memory.
Our blended teaching methodology at B. Braun Medical is informed by this research. The Lippincott Upper Limb PNB Simulator software program is transformative and aligned with our curricular approach for the following reasons:
1. The program stimulates and arouses student curiosity and interest. Instruction that offers novel, complex, or incongruous patterns in the learning environment will stimulate student interest and capture their attention. Capturing and maintaining student attention through arousal can open the pathway between temporary memory and long term memory. According to Driscoll (2005) maintaining student attention on a perceptual arousal level can be achieved by varying instructional approaches and intermittently changing the tone and tempo of instruction. The Lippincott PNB Simulator design methodology seeks to achieve a robust level of curiosity by creating real-world student-relevant problems in each learning component of the program, which can only be resolved by knowledge seeking behavior.
2. It is an active learning program, which will allow our sales representatives to learn by “doing” in the simulator component of the program. Ultimately conducting a successful peripheral nerve block procedure requires a significant level of deliberate, difficult practice, while consistently failing and receiving meaningful feedback, which will help encode relevant knowledge for latter recall. This active component of the program supports our targeted learners who have a slight dominance for a “learn by doing” preference and a higher prevalence of a body kinesthetic cognitive channel preference. In addition, the simulator aspect of the program supports 89% of our learners who state a preference for experiential learning activities. The literature suggests that the effort that our sales representatives will invest in this program will enhance their attention, encode new knowledge into long term memory and drive meaningful learning (Driscoll, 2005. Linn, Davis & Eylon, 2004. Ericsson, Krampe & Tesche-Rmer, 1993. Jonassen, 1999).,, ,
3.The program leverages the multiple intelligences and multimodal learning styles of our targeted audience. Sales representatives will optimize retention (or knowledge integration) since different kinds of peripheral nerve block representations of the same material will encode the new knowledge to multiple long term memory files. For example, a verbal/linguistic, visual/spatial and intrapersonal preference learner who reads a description of the interscalene nerve block technique, can rotate a 3-D anatomical image of correct needle placement and can slowly “own” the content through personal reflection, will be more able to recall and apply this information later than the same student who only sees a video of the procedure (Linn, Davis & Eylon, 2004. Gardner, 2004). ,
4. The constructivist design of the program supports opportunities for learners to identify and then fill knowledge gaps. Jonassen suggests that student “puzzlement is the catalyst for meaning making.” This training program helps make a blind, unseen procedure “visible” in a variety of ways for a variety of learners with a diverse range of prior experiences. When a knowledge gap is identified by a student they explore their “puzzlement” in a variety of ways as they construct new knowledge (Linn, Davis & Eylon, 2004. Jonassen, 1999).,
5. The most successful sales representative understand their customer’s business and help them solve problems. Our non-clinical sales representatives need to have a competent understanding of the common surgical procedures that can benefit from PNBs and a good fundamental understanding of how PNBs are performed in order to have credible and productive conversations with their clinical customers. In this regard the literature suggests that the Upper Limb PNB Simulator Program is an authentic, high-fidelity, simulated learning task that is transferable to a real world selling situation. The instruction is also both intrinsically and extrinsically goal directed in that sales representatives will be intentionally immersed in their learning in order to be successful (Jonassen, 1999).
As a stand alone program designed for self study, the Lippincott Upper Limb Nerve Block Simulator Program doesn’t have a collaborative component. Many researchers suggest that students are naturally interpersonal learners who need to socially negotiate the knowledge construction process (Jonassen, 1999). I don’t think that this is always the case and in fact believe that forced collaborative learning could significantly inhibit introverted students, or intrapersonal learners, who have strong introspective and self-reflective capabilities. These kinds of students need more time to reflect, incorporate the ideas of others, and compose their contributions carefully, rather than forming imperfect (and unacceptable) arguments. That being said, we do design interpersonal collaborative components to our curricular design, but usually allow intrapersonal learners adequate preparation time for these kinds of sessions. The Lippincott Upper Limb Nerve Block Simulator Program is so deep and so complex that we could utilize it in a variety of ways for both independent and collaborative study. For example, students could be assigned one of the eleven upper limb peripheral nerve blocks for in depth self study, but also be required to teach their peers about the specific block during live classroom sessions. This approach would leverage the program to facilitate student collaboration allowing for debate in the classroom. Hearing a variety of other perspectives is often a synergistic process that yields greater understandings.
Figure 21. Cognitive Information Processing / Multiple Intelligences Model

## Summary

The appropriate role of computer applications in education should not be focused on replacing the teacher/expert classroom facilitator, but by providing the student with mind-extension cognitive tools that enhance the totality of instruction (Jonassen, Carr & Ping-Yueh, 1998). Active, constructive, authentic and intentional software applications like the Lippincott Upper Limb PNB Simulation Program is the type of mind-extension tool that Jonassen describes, which can act as a catalyst to promote deeper understanding. Wenglinsky (2005) also urges us to not isolate technological learning solutions, but to integrate technology (where it adds cognitive value) as a “piece of the puzzle in how teachers teach and how students learn.”
If thoughtfully integrated within the clinical certification, live classroom instruction and peer-to-peer tutoring components of our planned blended PNB curriculum, the Lippincott Upper Limb PNB Simulation Program will help our novice new hire sales representatives:
* Know the most common surgical procedures in which patients and providers can benefit from peripheral nerve block (PNB) anesthesia/analgesia.
* Enable them to describe how nerve blocks are performed including how nerve stimulators are used to locate a specific nerve, how anesthetic is administered, and the difference between single shot and continuous PNB techniques.
* Advance their understanding of the brachial plexus anatomy and ultimately help them to have credible conversations with anesthesiologists regarding upper extremity surgical procedures.

## References

* ^ Alain Delbos, James C. Eisenach, Natalie Albert, Patrick Narchi, Francois Singelyn, and Simon Levesque (2005) Upper Limb Peripheral Nerve Block simulator program DVD, Version 2.0, Lippincott Williams and Wilkins, Available: http://www.lww.com/ $179.00
* ^ http://www.vark-learn.com/english/index.asp Neil Fleming, VARK: A Guide to Learning Styles
* ^ Kolb, David A. (1983) Experiential Learning: Experience as the Source of Learning and Development
* ^ http://www.nlm.nih.gov/research/visible/visible_human.html United States National Library of Medicine, National Institute of Health, Visual Human Project
* ^ Driscoll. M.P. (2005) Psychology of learning for instruction (Third edition): Pearson Education, Inc.
* ^ Linn, M.C., Davis, E.A., & Eylons, B-S. (2004). The scaffolded knowledge integration framework for instruction. In M.C. Linn, E.A. Davis, & P. Bell (Eds.), Internet environments for science education (pp. 47–72). Mahwah, NJ: Lawrence Erlbaum Associates.
* ^ Gardner, Howard (2004) Frames of Mind: The Theory of Multiple Intelligences (Tenth edition). Basic Books, Perseus Books Group
* ^ Ericsson, K.A., Krampe, R.Th., Tesch-Romer, C. (1993) The role of deliberate practice in the acquisition of expert performance. Psychology Review. Volume 100, Number 3, 363-406
* ^ Ericsson, K.A., Kintsch (1995) Long-Term Working Memory. Psychology Review. Volume 102, No. 2, 211-245
* ^ Jonassen, David (1999) Meaningful learning with technology (Third edition). Pearson, Merrill Prentice Hall
* ^ Jonassen, D.H., Carr, C., Pin Yueh, H. (1998) Computers as mindtools for engaging learners in critical thinking. Techtrends. (43)2: pp. 24–32
* ^ Wenglinsky, Harold (2005). Using technology wisely: the keys to success in schools. Teachers College Press, Columbia University. New York, NY