# Simulation-Based Mastery Learning with Deliberate Practice Improves Clinical Performance in Spinal Anesthesia

Authors: Ankeet D. Udani; Alex Macario; Kiruthiga Nandagopal; Maria A. Tanaka; Pedro P. Tanaka
Journal: Anesthesiology Research and Practice
 (2014)

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## Abstract

Introduction. Properly performing a subarachnoid block (SAB) is a competency expected of anesthesiology residents. We aimed to determine if adding simulation-based deliberate practice to a base curriculum improved performance of a SAB.Methods. 21 anesthesia residents were enrolled. After baseline assessment of SAB on a task-trainer, all residents participated in a base curriculum. Residents were then randomized so that half received additional deliberate practice including repetition and expert-guided, real-time feedback. All residents were then retested for technique. SABs on all residents’ next three patients were evaluated in the operating room (OR).Results. Before completing the base curriculum, the control group completed 81% of a 16-item performance checklist on the task-trainer and this increased to 91% after finishing the base curriculum (P<0.02). The intervention group also increased the percentage of checklist tasks properly completed from 73% to 98%, which was a greater increase than observed in the control group (P<0.03). The OR time required to perform SAB was not different between groups.Conclusions. The base curriculum significantly improved resident SAB performance. Deliberate practice training added a significant, independent, incremental benefit. The clinical impact of the deliberate practice intervention in the OR on patient care is unclear.


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## Body

## 1. Introduction

Research in expert performance identifies deliberate practice as the hallmark of superior performance. Deliberate practice training as described by Ericsson and colleagues entails (1) motivated learners, (2) well-defined learning objectives, (3) precise measurements of performance, (4) focused and repetitive practice, and (5) informative real-time feedback concerning performance [1]. Deliberate practice has been shown to be effective in increasing performance skills in various domains including music, sports, and games such as chess and typing [2, 3]. Recently, educators in science and medicine have been using principles of deliberate practice to design training modules in an attempt to improve student performance [4]. Simulation technologies in particular have been used in the deliberate practice of procedural skills at the graduate medical education level as there is opportunity for repeated practice and immediate feedback in controlled, safe, representative scenarios.Simulation-based instruction of procedural skills in medicine is becoming widespread. Simulation-based medical education has been shown to increase knowledge, provide opportunities for practice, and allow for assessment [4, 5]. Despite these benefits, the methodology used in simulation variesby instructor, institution, and available resources. Rigorous evaluation of educational techniques such as simulation requires standardized protocols, which, to date, are lacking [6]. Deliberate practice training in simulation-based instruction has been shown to be effective in promoting learning and retention in the performance of lumbar punctures and central line placement [7, 8]. However using deliberate practice to train residents to perform subarachnoid blocks, an expected competency [9], has not been studied, especially to determine whether it can actually change clinical performance on real patients. The most common method for learning this fundamental skill is through apprenticeship with a faculty anesthesiologist. Additional instructional methods include viewing online videos and tutorials, textbooks, workshops, lectures, and simulation-based training [10]. The efficacy of these various educational techniques to achieve competency in the technical performance of a subarachnoid block is unknown.More generally, the assessment of procedural skills in anesthesiology can be improved compared with other domains of learning and has fallen behind other fields [11]. Thus, the goals of our study were to (1) use a Delphi method to develop the recommended sequence of steps for placement of a subarachnoid block, (2) use this procedural checklist to create a base standardized curriculum consisting of written material and a teaching video, (3) determine whether this base curriculum compared with the base curriculum plus mastery learning through deliberate practice could improve the technical performance of a subarachnoid block on a task-trainer simulator, and (4) determine whether clinical performance of this procedure on patients having joint replacement surgery was improved by either curriculum or both curricula. The primary outcomes were percentage of checklist tasks performed correctly. We also measured the operating room time used to place a subarachnoid block in actual patients.


## 2. Methods

### 2.1. Checklist Development

A checklist of the necessary procedural steps for block placement was adapted from previous neuraxial block checklists [12–14]. Then, a modified Delphi-approach was used to refine and ensure face and content validity. This method is designed to achieve consensus among experts assembled to serve as a panel [15, 16]. Each action was listed in order and given equal weight using a dichotomous scoring system (“satisfactory” or “unsatisfactory”). The initial checklist was designed by 1 author, pilot-tested on a group of 3 local faculties, and then reviewed by 5 board-certified anesthesiologists from four different hospitals to answer specific questions and give feedback. Suggestions for adding or deleting steps were encouraged, and the checklist was reviewed iteratively by the panel until consensus was achieved.Written teaching materials including the procedural checklist, FAQs, and technique description were produced and modified using the same Delphi-approach described above. A 15-minute video was also produced that provided step-by-step instructions corresponding to the procedural checklist.The performance assessment parts of the study were conducted in several phases (Figure1). The IRB determined this study to be exempt. Stanford anesthesiology PGY2 residents were recruited to participate in the study. Each resident completed a survey to collect demographic data; prior experience with spinal and epidural anesthetics and lumbar punctures, prior practice on a subarachnoid or epidural block task-trainer, and subjective comfort level in performing spinal anesthesia (5-point ordinal scale) were obtained via survey.Figure 1
Study flow chart following informed consent and enrollment.


### 2.2. Task-Trainer Performance Assessment

A baseline assessment of each participant performing a subarachnoid block was made on a task-trainer (Lumbar Puncture Simulator II, Kyoto Kagaku, Japan) before they were exposed to the base curriculum. The video-recorded performances at baseline were later scored by two authors (A. D. Udani and P. P. Tanaka), one of whom was blinded to which group the participant was in. The assessments used the 16-item checklist developed in the Delphi process. Each item was graded as either satisfactory or unsatisfactory by two trained faculty raters. After the control group residents finished the base curriculum, they received no further training and underwent immediate testing via a second skills assessment on the same task-trainer, on the same day. This was also videotaped and scored in the same fashion.It was assumed that before exposure to the base curriculum residents would properly complete 65% of the tasks properly in correct order and power calculation (n=9 for each group) indicated that an increase to 95% after the deliberate practice curriculum could be detected with alpha = 0.05 and beta = 0.6.


### 2.3. Clinical Performance Assessment

One to 5 days after completion of the base curriculum residents were videotaped performing subarachnoid blocks in the operating room on 3 consenting patients. These were the first three patient blocks placed by the resident participant since completing their educational module. The same two faculty raters using the same 16-item checklist scored their performance and recorded the time to achieve subarachnoid block. Time was measured using a stopwatch for three contiguous intervals: patient positioning (from patient in room to sitting position), setup (from sitting position to injection of local anesthetic wheal), and subarachnoid injection (from injection of local anesthetic wheal to completion of subarachnoid injection).Power analysis showed that a sample size of 9 patients in each group would provide sufficient power (alpha 0.05 and beta 0.6) to detect a 3-minute decrease in time from positioning to injection if the baseline time equaled 9 minutes (SD 4 mins) for these junior residents. The 9 minutes was based on prestudy data collected on 6 residents.Residents were also randomized via a random number generator such that, in addition to the base curriculum, half received simulation-based deliberate practice under the guidance of one faculty anesthesiologist (P. P. Tanaka).


### 2.4. The Mastery Learning with Deliberate Practice Model of SAB

Fundamental principles of deliberate practice training were followed, including (1) having motivated learners (residents volunteered to improve specific aspects of their performance), (2) giving well-defined learning objectives (goals were broken down into specific steps), (3) providing precise measurements of performance (steps corresponded to specific actions), (4) engaging in focused and repetitive practice (residents engaged in specific activities and steps performed unsatisfactorily were repeated until performed satisfactorily), and (5) giving informative real-time feedback concerning performance (residents received one-on-one faculty coaching).


### 2.5. Statistical Analysis

Proportions of participants’ gender and exposure to spinal simulator prior to the study were compared using the Fisher exact test. Number of neuraxial blocks prior to the study and perceptions of comfort performing spinal anesthesia were compared among the 2 groups using the nonparametric Mann-WhitneyU test (http://www.socscistatistics.com/). The Cohen kappa coefficient was used to assess interrater reliability. To assess the impact of the added deliberate practice training, baseline and posttest checklist scores were compared using analysis of covariance to determine if the scores were more improved for the intervention group than for the control group.


## 2.1. Checklist Development

A checklist of the necessary procedural steps for block placement was adapted from previous neuraxial block checklists [12–14]. Then, a modified Delphi-approach was used to refine and ensure face and content validity. This method is designed to achieve consensus among experts assembled to serve as a panel [15, 16]. Each action was listed in order and given equal weight using a dichotomous scoring system (“satisfactory” or “unsatisfactory”). The initial checklist was designed by 1 author, pilot-tested on a group of 3 local faculties, and then reviewed by 5 board-certified anesthesiologists from four different hospitals to answer specific questions and give feedback. Suggestions for adding or deleting steps were encouraged, and the checklist was reviewed iteratively by the panel until consensus was achieved.Written teaching materials including the procedural checklist, FAQs, and technique description were produced and modified using the same Delphi-approach described above. A 15-minute video was also produced that provided step-by-step instructions corresponding to the procedural checklist.The performance assessment parts of the study were conducted in several phases (Figure1). The IRB determined this study to be exempt. Stanford anesthesiology PGY2 residents were recruited to participate in the study. Each resident completed a survey to collect demographic data; prior experience with spinal and epidural anesthetics and lumbar punctures, prior practice on a subarachnoid or epidural block task-trainer, and subjective comfort level in performing spinal anesthesia (5-point ordinal scale) were obtained via survey.Figure 1
Study flow chart following informed consent and enrollment.


## 2.2. Task-Trainer Performance Assessment

A baseline assessment of each participant performing a subarachnoid block was made on a task-trainer (Lumbar Puncture Simulator II, Kyoto Kagaku, Japan) before they were exposed to the base curriculum. The video-recorded performances at baseline were later scored by two authors (A. D. Udani and P. P. Tanaka), one of whom was blinded to which group the participant was in. The assessments used the 16-item checklist developed in the Delphi process. Each item was graded as either satisfactory or unsatisfactory by two trained faculty raters. After the control group residents finished the base curriculum, they received no further training and underwent immediate testing via a second skills assessment on the same task-trainer, on the same day. This was also videotaped and scored in the same fashion.It was assumed that before exposure to the base curriculum residents would properly complete 65% of the tasks properly in correct order and power calculation (n=9 for each group) indicated that an increase to 95% after the deliberate practice curriculum could be detected with alpha = 0.05 and beta = 0.6.


## 2.3. Clinical Performance Assessment

One to 5 days after completion of the base curriculum residents were videotaped performing subarachnoid blocks in the operating room on 3 consenting patients. These were the first three patient blocks placed by the resident participant since completing their educational module. The same two faculty raters using the same 16-item checklist scored their performance and recorded the time to achieve subarachnoid block. Time was measured using a stopwatch for three contiguous intervals: patient positioning (from patient in room to sitting position), setup (from sitting position to injection of local anesthetic wheal), and subarachnoid injection (from injection of local anesthetic wheal to completion of subarachnoid injection).Power analysis showed that a sample size of 9 patients in each group would provide sufficient power (alpha 0.05 and beta 0.6) to detect a 3-minute decrease in time from positioning to injection if the baseline time equaled 9 minutes (SD 4 mins) for these junior residents. The 9 minutes was based on prestudy data collected on 6 residents.Residents were also randomized via a random number generator such that, in addition to the base curriculum, half received simulation-based deliberate practice under the guidance of one faculty anesthesiologist (P. P. Tanaka).


## 2.4. The Mastery Learning with Deliberate Practice Model of SAB

Fundamental principles of deliberate practice training were followed, including (1) having motivated learners (residents volunteered to improve specific aspects of their performance), (2) giving well-defined learning objectives (goals were broken down into specific steps), (3) providing precise measurements of performance (steps corresponded to specific actions), (4) engaging in focused and repetitive practice (residents engaged in specific activities and steps performed unsatisfactorily were repeated until performed satisfactorily), and (5) giving informative real-time feedback concerning performance (residents received one-on-one faculty coaching).


## 2.5. Statistical Analysis

Proportions of participants’ gender and exposure to spinal simulator prior to the study were compared using the Fisher exact test. Number of neuraxial blocks prior to the study and perceptions of comfort performing spinal anesthesia were compared among the 2 groups using the nonparametric Mann-WhitneyU test (http://www.socscistatistics.com/). The Cohen kappa coefficient was used to assess interrater reliability. To assess the impact of the added deliberate practice training, baseline and posttest checklist scores were compared using analysis of covariance to determine if the scores were more improved for the intervention group than for the control group.


## 3. Results

The modified Delphi method resulted in a 16-item checklist of required procedural tasks (Table1). We used this procedural checklist to create a base curriculum of teaching materials (Appendices A and B) and a 15-minute video (available at http://www.youtube.com/watch?v=eblMcptvcAo&feature=youtu.be).Table 1
Procedural checklist for subarachnoid block.
Task
Satisfactory
Unsatisfactory
(1) Performs a “time-out” and places monitors on patient (pulse oximetry and NIBP).
—
—
(2) Verifies that spinal kit tray, nonsterile and sterile gloves (correct size), and cleansing solution are present.
—
—
(3) Palpates the superior aspects of the iliac crests and identifies the intersection at the L4 spinous process with nonsterile gloves on. Marks position at the L3/L4 or L4/L5 interspace.
—
—
(4) Cleans the overlying skin with chlorhexidine.
—
—
(5) Opens the spinal tray before placing sterile gloves on.
—
—
(6) Puts on sterile gloves with proper technique.
—
—
(7) Applies sterile drapes.
—
—
(8) Draws up lidocaine in the 3cc syringe and bupivacaine in the 5cc syringe. Administers local anesthesia in a wheal at the previously marked site.
—
—
(9) Injects more anesthetic in the correct location and angle.
—
—
(10) Inserts the introducer needle in the middle of the interspace with a slight cephalad angulation of 10 to 15 degrees. The bevel of the spinal needle should be in the sagittal plane.
—
—
(11) Advances spinal needle through anatomic structures until the subarachnoid space is reached. May experience a popping sensation as the ligamentum flavum is crossed.
—
—
(12) Withdraws the stylet each time a pop is felt to assess for CSF flow.
—
—
(13) Confirms CSF flow by aspiration before and after injecting anesthetic.
—
—
(14) Removes the spinal and introducer needle together once completed.
—
—
(15) Applies pressure with the provided 2 × 2 gauze and assesses good hemostasis.
—
—
(16) Removes the drape, lays the patient, and observes vitals.Disposes of all sharps and biohazard material appropriately.
—
—All 21 residents invited to be in the study consented. The control group had more experience as anesthesia residents, self-reported experience with epidural blocks and simulation training, and higher self-rated comfort performing the spinal anesthesia procedure (Table2). Scoring of the videos of the residents performing the subarachnoid blocks demonstrated very good agreement (kappa = 0.938 SE = 0.044, 95% confidence interval: 0.852 to 1.0) between examiners.Table 2
Characteristics of residents enrolled in study (mean (SD, median, and range)).
Intervention group (deliberate practice)
Control group
Pvalue
N
11
10
Months of anesthesia residency completed
5.2 (3.8, 5, 0.25–10)
8.5 (2, 10, 5–12)
0.05
Age (yrs)
28.5 (1.4, 28, 26–31)
30.8 (3.8, 30, 26–37)
0.22
Gender (% F)
45%
20%
0.36
Self-reported number of spinals done before study
6.1 (5, 4, 0–15)
20.0 (16, 14, 3–50)
0.02
Self-reported number of epidurals done before study
9.8 (13, 2, 0–40)
34.5 (16, 30, 15–60)
0.002
Self-reported number of lumbar punctures done before study
5.2 (3, 5, 2–12)
6.5 (5, 7, 0–15)
0.69
Have you practiced on spinal simulator before study (% yes)
55%
0%
0.01
How comfortable are you performing spinal anesthesia(1 = not comfortable, 5 = very comfortable)
2.8 (0.9, 3, 1–4)
3.7 (0.82, 4, 2–5)
0.04Before completing the base curriculum, the control group properly completed 81% (SD = 7%, median 81%, and range 69–94%) of the 16 checklist tasks on the task-trainer simulator and this significantly increased to 91% (SD = 7%, median 94%, and range 81–100%) after finishing the base curriculum (P<0.02).The intervention group (the base curriculum plus deliberate practice) also significantly increased the percentage of checklist tasks properly completed on the task-trainer from 73% (SD = 15%, median 75%, and range 31–88%) to 98% (SD = 4%, median 100%, and range 88–100%), which was a significantly greater increase than observed in the control group (P<0.03).We were unable to study a full set of 3 patients having subarachnoid block placed per resident due to resident unavailability. In an average of 3.22 (SD 1.2, median 3, and range 2–5 days) days after finishing the curriculum, the control group (n=10 residents) successfully performed spinals on 20 of 21 patients (66% female, mean age 66 SD 12, mean BMI 28 SD 4.45, and range 19–34), with 1 of the spinals ultimately done by the attending (supervising) physician after the resident had prolonged difficulty. The intervention group (n=11) successfully performed spinals on 21 of 28 patients (50% female, mean age 61 yrs SD9, BMI 27 SD 4.9, and range 19–42), as 7 were placed by the attending after the resident had prolonged difficulty.The control group properly performed 84% (SD = 7%, median 88%, and range 69–94%) of checklist tasks versus 81% (SD = 14%, median 81%, and range 50–100%) of the intervention group (P = NS).The control group on average spent 296 seconds (SD = 104, median 283, and range 113–464) from patient in room to sitting position and 252 seconds (SD = 118, median 260, and range 46–474) from sitting position to injection of local anesthetic wheel while the intervention group (the base curriculum plus deliberate practice) on average spent 253 seconds (SD = 91, median 226, and range 125–517) from patient in room to sitting position and 338 seconds (SD = 91, median 338, and range 158–521) from sitting to injection (in each case,P = NS).Excluding the cases where the attending finished the spinal, time from injection of local anesthetic wheel to finish of subarachnoid injection was also not different for the two groups. This time equaled 253 seconds (SD = 156, median 201, and range 88–627) for the control group and 232 seconds (SD = 158, median 142, and range 86–527) for the intervention group (P = NS).


## 4. Discussion

The base curriculum we developed for teaching subarachnoid blocks significantly increased correct performance of the technical aspects of the block in the control group. Importantly, the addition of deliberate practice led to a significantly higher increase in performance in the intervention group. As the depth and breadth of anesthesiology grow and as house staff time and resources are limited, it is important to determine which teaching methods yield the greatest learning [17]. In the current study, we used a rigorous procedure (the Delphi method) to establish a base curriculum and also examined the additional benefits of 1 : 1 mentoring according to predetermined guidelines of deliberate practice.Although overall benefits persisted several days later on actual patients, no differences in time required to place the blocks or checklist scores were observed between groups. This can be attributed to differences in learning climate between the simulated and operating room environments. Learning climate is defined as the tone or atmosphere of the teaching setting. Some key components of the learning climate may have impacted performance of residents. The operating room may be a challenging educational environment. There is noise from surgical instruments being set up, production pressure from the surgical team, and inherent patient characteristics may complicate subarachnoid block placement. An influential factor may be specific teaching behaviors by attending anesthesia faculty. For example, the time required for the subarachnoid injection was the most difficult of the three periods measured because attendings decided based on their own judgment when to intervene. Instead of encouraging residents to take a different approach to perform the SAB, we observed that the attendings would take over the procedure after a short period of time. The study protocol set no criteria a priori on how the attending should assist the resident and if and when the attending could intervene. The differences in learning climate between the simulated and operating room environments hindered consistency most ideal for resident education and research.The current study yielded several informative products and results. First, we used a rigorous, iterative methodology to establish a standard base curriculum. This curriculum is currently available to all residents to access via the Internet at any time. Second, we developed a training module using the base curriculum that significantly improved block placement performance. Third, we implemented a deliberate practice training component, which yielded additional performance benefits. Although we were unable to detect a difference in clinical performance between groups trained with the base curriculum and those with the additional deliberate practice, the gaps identified via the current study are being used to design future structured training. For example, we will emphasize the importance of the safety time-out and washing hands before wearing sterile gloves. Residency programs can also use our checklist evaluation to identify deficiencies in trainees and those who require extra instruction. Furthermore, our observations regarding potential confounding variables when transferring to clinical settings can inform future training initiatives.Simulation-based medical education translational studies attempt to demonstrate that results achieved in the educational laboratory (T1) transfer to improved downstream patient care practices (T2) and improved patient and public health (T3) [18]. Designing and implementing a T2 study comes with inherent difficulties. In fact a recent literature review of hundreds of simulation studies found that only 10% included follow-up data from the clinical environment [19]. It is therefore perhaps not surprising that although we obtained a positive T1 result (improved performance in a simulated subarachnoid block for both groups, particularly the deliberate practice group), this did not translate into a positive T2 result.This study has several limitations. First, the study enrolled a relatively small group of residents, 21 (although this figure represented 88% of the 24 residents in the PGY2 class). This highlights the challenge of single institution graduate medical education studies as there is usually too few available house staff to enroll to get larger sample sizes. Also, the residents enrolled in the study were at varying points in training and on average were approximately half way through PGY2 year. This variation led to differences in resident neuraxial block placement and simulator experience prior to study enrollment. It is likely that the impact of the teaching residents received on performance improvement is greatest for beginner residents in their first months of residency. The difference between the control and intervention group’s training prior to enrollment may also explain the difference in baseline SAB skills, 81% versus 73%, respectively. The impact of starting at a lower baseline score may overstate the overall change described from deliberate practice in the intervention group. However, the control group’s prior experience with the spinal simulator may also have influenced the higher baseline performance score. Finally, attending physicians are more likely to take over procedures from junior residents, those with little training experience. This may have resulted in 7 incomplete blocks in the intervention group versus 1 in the control group. Multi-institution studies may be a way to enroll subjects more quickly and increase sample size, although it may be even more difficult to control for prior experience and skills. Another limitation is that posttesting occurred immediately after training potentially enhancing recall.


## 5. Conclusions

The current study represents an advance in simulation-based education, particularly in anesthesia, due to the development and implementation of a base curriculum and the formalized methodology of deliberate practice training. Moreover, this study is one of few investigations examining transfer to clinical settings. Our results and observations have identified specific considerations and areas for improvement in subsequent training modules. For example, this study focused on the technical skill required to place a subarachnoid block but there is more to this in actual practice, including the decision of whether a block is indicated and obtaining consent and postoperative follow-up. The best way to teach all of those elements together deserves further study. More generally, this study provides an attempt at rigorous methodology for designing, implementing, and evaluating simulation-based learning interventions in medicine.



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