Introduction

Regional anaesthesia (RA) has increased in popularity, particularly since the introduction of ultrasound-guided techniques. In expert hands, current RA techniques have the advantages of increased success, shorter onset time, reduced complications, reduced dose requirements and cost-effectiveness, over traditional techniques.1–3 Clinical expertise is in turn a reflection on the effectiveness of RA education and training. The skill sets required for successful and safe RA are complex and diverse, especially with the widespread uptake of ultrasound-guided regional anaesthesia (UGRA). They include anatomy, physiology, pharmacology, sonoanatomy, identification and optimisation of sonography images, and needle visualisation dexterity skills,4–8 as well as professional attributes of communication, teamwork, decision making and situational awareness.9 10

These technical skills have previously been published by the 2010 American Society of Regional Anesthesia (ASRA) and the European Society of Regional Anaesthesia and Pain Therapy joint committees.11 Furthermore, anaesthesia training programmes are being restructured from a time-based to competency-based models. An example in North America is the 2014 RA competency milestones published by the American Board of Anesthesiology/Accreditation Council for Graduate Medical Education.12

Achieving these educational goals is a formidable challenge for our subspecialty. To assist in delivering this curriculum, the ASRA established an Education Special Interest Group (SIG) in April 2017. This study was initiated through the SIG research collaboration, composed of a multidisciplinary and multinational cooperation between clinicians, medical educators and psychologists.

This study has two objectives. The first objective is to help engagement of stakeholders (researchers, educationalists, clinicians and research grant reviewers) by providing a list of the current diversity of topics in RA education. Given the breadth of possible research activities, a second objective was to prioritise topics by order of research need. This prioritisation was performed by obtaining expert regional anaesthetists’ opinions on which topics are most relevant for RA education.

This study used a Delphi method, in which rounds of questionnaires are sent to participants. Advantages include anonymity, minimising bias from strong personalities, equal weighting of all opinions and not geographically restricted as electronic questionnaires are used. Similar prioritisation studies using this electronic Delphi method have been undertaken by other craft groups, including respiratory medicine, maternal/perinatal medicine and clinical anaesthesia.13–15 Our purpose in conducting this study is to prioritise scholarly attention and funding towards improving the evidence base for initiatives in RA education.

Methods

This prospective study used questionnaires to rank, in order of prioritisation, research topics relevant to RA education and training. Structured electronic Delphi questionnaires were sent via email to blinded participants. The study was performed between September 2017 and January 2018.

Rounds 2 and 3 prioritisation

Topics with median scores between 3 and 6 in round 1 were reranked in round 2, along with the additional topics suggested by participants in round 1. To emphasise prioritisation of topics, instructions to participants were changed. Each topic was to be given a single score within a range of scores anchored with explicit text descriptions: 1–3 for ‘lowest research priority’, 4–7 for ‘interesting but intermediate in research priority’ and 8–10 for ‘essential research priority’. Participants were asked to select the appropriate priority category, to choose a score within that category and to rank topics in relative importance to each other. Topics which scored a median of ≤3 were excluded.

Round 3 was the final questionnaire and prioritised the topics identified as higher ranked in round 1, that is, a median score of ≥6 by more than 60% of the participants. This round used the same instructions and Likert scale as in round 2. Figure 1 illustrates this Delphi methodology.

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Figure 1

Flow diagram of study and summary of results at each Delphi round.

In all rounds, participants did not interact nor were they aware of the identities of other participants. A table summary of the previous round, with the median, IQR and absolute percentage of participants who scored ≥6 for all research topics, was provided to all participants. However, no individual scores or comments were identified in these summaries. Only study investigator AC had access to individual scores. Participants were given 3 weeks to score each round. Reminder emails were sent 1 week prior and 3 days after this deadline.

All scores were entered into a Microsoft Excel spreadsheet (V.2016, Microsoft, Redmond, Washington). Descriptive statistics were performed and reported as median scores with 25th–75th IQR and as the proportion of all participants who scored 6 or higher for each topic.

Results

Fifty-two email invitations were sent. Thirty-eight participants (73%) accepted the invitation. Thirty-seven returned scores for round 1 (97% response). All 38 participants returned scores for rounds 2 and 3 (100% response). The 38 participants included 29 authors (76%) of RA education journal articles and RA textbook contributions, 20 training programme directors (53%), and 12 were also members of national or international anaesthesia education programmes (32%).

In round 1, participants ranked the 74 initially generated topics. Fifty topics reached the threshold of higher priority scores and were included in round 3. In round 2, 24 intermediate ranked topics were scored, along with 8 new topics suggested by participants. Based on predefined criteria, no topic was excluded in either round 1 or round 2. A total of 82 topics were thus ranked in order of research priority in round 3. These results are summarised in figure 1.

Topics were categorised into seven themes: research on structure and design of an RA training curriculum; the effectiveness of equipment and in vitro models in training RA skill sets; assessment of RA knowledge and skills; knowledge translation from practice and lectures to RA performance in a clinical setting; research methodology and protocol design of RA education studies; research on development, retention and proficiency of RA motor skills; and the role of simulation in RA education.

There were 13 topics ranked as ‘essential research priority’ by participants, defined as a median score of 8 or higher in round 3. These topics are listed in table 1. There were four topics each on simulation and curriculum, three topics on knowledge translation, and one topic each on methodology and assessment.

Table 2 includes the next 24 topics scored as a 7, which is equivalent to the highest cohort of intermediate priority topics. Table 3 includes the 14 lowest ranked topics. The online supplementary tables recategorise all 82 topics into the seven themes of curriculum (online supplementary table S1), equipment (online supplementary table S2), assessment (online supplementary table S3), knowledge translation (online supplementary table S4), methodology (online supplementary table S5), motor skills (online supplementary table S6) and simulation (online supplementary table S7).

For all tables, topics are arranged in order of highest to lowest overall median score, and then by order of proportion of participants who scored at least 6 in round 3.

Discussion

This study summarised the large and diverse body of research activities in RA education. These research activities were rewritten as 82 research topics and scored by a panel of expert participants, who ranked these topics in order of importance. Thirteen topics were found to be of essential priority, and resolving these specific questions would advance our current understanding of RA education.

Four of these topics were on the role of simulation. Further evidence is required to inform appropriate learning objectives and competency milestones during simulation training. In turn, deliberate practice is the educational technique that describes repetitive practice using these predefined learning outcomes, with structured feedback by expert faculty.17 While evidence for deliberate practice exists in RA ultrasound-guided needle guidance studies,18 19 the effectiveness of deliberate practice in RA simulation training was identified as a priority research area. Determining whether simulation training ultimately influences patient outcomes, such as improved safety, faster performance and higher efficacy, versus traditional clinical exposure, was also regarded as priority. Indeed, a recent systematic review of randomised controlled trials found only one study looked at patient outcomes after simulation training in RA.6

There were four curriculum topics ranked as essential. A description of a redesigned RA curriculum,20 based on a framework for systematic training and assessment of technical skills,21 has been previously published. Our study found, however, that further work is required to help define the characteristics of an ideal RA curriculum, including what are the core RA skill sets. Evaluation of success of the curriculum was also deemed to be a priority. Many institutions have dedicated RA ‘block rooms’, but measuring effectiveness of this initiative remains elusive. A recent article, published after this study commenced, found that surrogate measures of analgesia, pain scores and opioid consumption were reduced after introduction of a block room.22

Questions remained about the ability of physicians to maintain RA knowledge and motor skills. This was identified as translation of skill sets between different RA procedures, and whether anaesthetists (trainees or consultants) can retain new information learnt at workshops and simulation into clinical practice.

The two remaining essential priority topics were on assessment of the RA procedural skill. This involved defining the minimum competency for each RA task, and to reach consensus on which assessment tools should be used to evaluate competency. A systematic review has recently summarised the available assessment tools for RA procedures.23

The strengths of this prioritisation exercise include using a prospective, structured, electronic Delphi technique. Expert regional anaesthetists participated in categorising research topics over three iterative rounds of scoring, with an excellent response rate. The panel was international, with a large proportion contributing to the subspecialty as original journal authors and directors of RA training. The de-identified nature of scoring reduces bias from strong personalities influencing the consensus outcomes. Lastly, we predefined a priori thresholds for defining consensus, an important feature of robust Delphi studies.24

We thus believe that the essential priority topics identified in this study are clinically relevant to anaesthetists involved in RA education. For researchers, our results provide guidance on research activities that deliver the highest clinical and educational impact. Conversely, we do not imply that research in lower ranked topics is discouraged. As examples, topics in the top 30 are still rated highly by >70% of participants and include questions on standardising outcome measures in RA studies, as well as characterising and remediating quality compromising behaviours by novices.

There are several limitations to our study. Participants in this study are active and passionate RA educators and anaesthetists. Nonetheless, the sample size of 38 experts will not be representative of the entire RA research community, nor did we include anaesthesia trainees or public representatives who may harbour different weightings for the research priorities due to their unique perspectives. Even within this small panel, there were divergent opinions on the ranking of each topic, evidenced by relatively wide IQRs. Surveying RA programme directors in all RA societies worldwide may not necessarily provide a narrower result: the relative value each participant places on a specific topic will be influenced by their personal experiences and learning environments, and is a possible explanation of the differences in scoring. This subjective bias is minimised, but not fully removed, by imposing a minimum of two rounds of scoring for each topic and by aggregating scores from all participants.

Each study in the round 1 topic generation phase was treated independently when creating the EPICOT statements. This resulted in research topics with similar wording, and potentially could have been condensed. However, a strength of EPICOT is that the generated statements preserve context.16 For example, the question ‘standardizing outcome measures in RA education’ was ranked differently if related to assessment tools (rank 10), versus patient clinical outcomes (rank 14) and in a simulation context (rank 21). This allows researchers to help refine specific research activity.

The online supplementary tables reformat all 82 topics based on themes of curriculum, equipment, assessment, knowledge translation, methodology, motor skills and simulation. We caution that these themes are subjective and were categorised post hoc, as presented in the online supplementary tables. During the prioritisation phase, participants ranked topics without these thematic labels, and the tables were created only during manuscript preparation. Several topics could be classified under multiple themes. Our results have been presented using thematic organisation, as this may help researchers appreciate important directions and similarities within each theme. A group concept mapping exercise would be a more structured approach to elicit expert opinion on how different but related research topics could be classified.

In conclusion, we present the results of a Delphi study designed to summarise and then rank RA education topics in order of research priority. Experts in RA education, identified through a collaborative process within the ASRA Education SIG, were invited to participate. The 13 essential topics are diverse in nature, encompassing the role of simulation training, curriculum design, assessment of skills and retention of skills, in RA. The complete list of 82 topics should be considered by researchers when deciding how best to concentrate their efforts in the advancement of education in our subspecialty.