Making It Stick

Maintaining student attention with deliberate difficult practice leads to improved knowledge and performance skills.

By Kevin R. Glover, M.S., M.Ed., Vice President, Corporate Communications, Clinical Education and Sales Training, and Connie Murray, R.D., M.Ed., Director of Clinical Education and Sales Training at B. Braun Medical Inc.

Maintaining student attention, or “making it stick” in the classroom, is a challenge for every educator. In an increasingly competitive and commoditized market, making clinical skills “stick” is critical to the success of many medical device manufacturers as clinically competent field sales personnel are often the only key differentiator in the selling process. But maintaining student attention in the classroom is easier said than done when one considers the complexity of cognitive information processing.

A challenge across various training environments is that all students have limited cognitive capacity. Consider the fact that new information is attended to or discarded from a student’s sensory register within one second. In the event that the student selectively chooses to attend to instruction for one second, the content then moves to his or her working memory where the new information continues to be either attended to or discarded every 15 to 30 seconds to make room for new incoming information. If an instructor fails to consistently grab attention, neglects to make meaningful connections to the student’s prior knowledge and experience, or does not to make the student actively engage (work) during instruction, it is unlikely new knowledge or skills will be encoded into the student’s long-term memory. If what’s being taught does not move to or stick in the student’s long-term memory files, it will never be recalled or applied with customers in the field.

Our dilemma as educators is that beyond this limited cognitive capacity challenge of maintaining a student’s attention, each individual learner possesses unique predominant intelligences, learning styles, and personality types. Students enter the training classroom at different starting points in knowledge and experience, and each learns at a different pace.

So how can we as educators possibly keep training consistently interesting or make relevant connections to each individual in the classroom every 15 to 30 seconds to overcome these variables?

The only viable answer is effort—curricula built primarily around engaging students through a deliberate difficult practice methodology. At our company, medical device manufacturer B. Braun Medical Inc. (B. Braun), we believe that an effort-based curriculum—that makes students really work and forces them to selectively attend to instruction—ultimately makes new knowledge and skills stick in students’ long-term memory files.

Learning by Doing

To address the “making it stick” challenge, B. Braun created a two-day comprehensive advanced peripheral IV catheter procedure training curriculum to test this effort-based deliberate practice methodology. The program includes an IV catheter procedural knowledge and skills pre-assessment; a didactic anatomy and IV procedure review; deliberate, increasingly difficult practice with both computer-based, haptic virtual IV procedure simulators and prosthetic task-based simulators; and an IV catheter procedure knowledge and skills post-assessment. So far, our training classes have included 20 sales representatives who all have gone through initial training and have been selling our IV catheter product between six months and 10 years.

Course participants start with a pretest that measures IV procedural knowledge and also a performance skills pretest by conducting a peripheral IV insertion procedure on a prosthetic arm with controlled blood flow (see Figure 1 in the downloadable PDF below). The pressurized fluid system with this simulation tool allows for realistic blood flashback and the ability to simulate tourniquet application with pressure and release of pressure for tourniquet removal. A 30-step IV performance skills checklist is used to measure baseline performance skills beginning with the physician’s order verification and ending with the IV procedure documentation.

After the pre-tests, students receive a one-day didactic anatomy and IV procedural review course by an IV certification nurse. On day two, students practice peripheral IV catheter placement first-hand using the Laerdal Virtual IV (VIV) Haptic Trainer (Figure 2). Practicing IV insertions with the Laerdal VIV allows students to select the appropriate IV site (based on the patient case presented), prepare the site using the proper tools, and select the appropriate gauge catheter. Students then conduct the procedure with the simulated-catheter in a haptic device, which allows the students to feel the patient’s skin, veins, and venous puncture. Students view the procedure on the computer monitor, which displays visual results of the actions performed using the haptic device. For example, a flashback of blood is visible when the simulated needle successfully enters the patient’s vein. A case review, included in each simulated patient case, reports scoring of the participant’s procedural performance. In our course, sales representatives need to practice with the VIV until they achieve a score of 90 to 100 percent (passing with a successful stick and no critical errors). Practicing this procedure first-hand allows students (or sales trainees) the ability to really understand the needs of the audience they are selling to.

Assessing Knowledge

In preparation for the final knowledge and skills assessment, students are provided with the 30-step IV performance skills checklist and an Advanced Venipuncture Training Aid (VATA) (Figure 3) for review and practice. Course participants end the program with both a knowledge and simulation-skills  post-assessment. The Limbs & Things Advanced Venipuncture Arm (Figure 1) is attached to a live person, which provides the students with the sense (and stress) that they are performing the venipuncture procedure on a real patient. Each student receives a doctor’s order and plays the role of the clinician placing the IV including: entering the room, assessing the patient, choosing the appropriate IV site, selecting the correct IV supplies, conducting the venipuncture procedure, dressing and securing the IV, talking with the patient, disposing of waste supplies appropriately, exiting the room, and documenting the procedure in the patient’s chart. The class facilitator and one observer assess each student utilizing the 30-step IV performance skills checklist. No feedback is provided during the actual procedure. Each student receives feedback and a review after completing their performance assessment simulation.

The knowledge and skills performance gains between pre- and post-assessments are shown in Tables 1 and 2. Even though all 20 participants were previously trained and are experienced IV catheter sales representatives (seven nurses), their average knowledge gain was 20.6 percent and average skills performance gain was 24.45 percent.

This deliberate difficult practice methodology will keep on proving itself as B. Braun continues to measure the return on education with larger numbers of students. Ultimately, an effort-based curriculum like this example forces students to selectively attend to more instruction, which results in more instructional content stored in long-term memory for later recall and application. Importantly, this method of comprehensive training can be applied to other industries beyond medical device sales.

Kevin R. Glover is vice president, Corporate Communications, Clinical Education and Sales Training at B. Braun Medical Inc. He can be reached at Connie Murray is director of Clinical Education and Sales Training at B. Braun Medical Inc. She can be reached at

Lorri Freifeld is the editor/publisher of Training magazine. She writes on a number of topics, including talent management, training technology, and leadership development. She spearheads two awards programs: the Training APEX Awards and Emerging Training Leaders. A writer/editor for the last 30 years, she has held editing positions at a variety of publications and holds a Master’s degree in journalism from New York University.