Anaesthesia residents required 16 to 20 supervised attempts to feel competent in performing specific peripheral nerve blocks, highlighting the need for structured training.
Absolute Event Rate: 0% vs 0%
Regional anaesthesia provision across the UK remains highly variable, with significant differences in service delivery and the availability of meaningful training opportunities 1. The publication of various guidelines has positioned regional anaesthesia as a central element of peri-operative management 2-5. Although a curriculum revision led by Regional Anaesthesia UK (RA-UK) has established regional anaesthesia as a core component of anaesthetic training 6, surveys continue to highlight a persistent lack of confidence among residents and consultants 1, 7. Turbitt et al. have described how the ‘Plan A’ block concept, designed to promote regional anaesthesia skills more widely, has been implemented in clinical practice 8. They identify three challenges to the wider uptake of regional anaesthesia: resource limitations; lack of confidence; and variable access to structured training. In this editorial, we consider more broadly how to overcome the second and third of these challenges within a governance framework of clinical effectiveness and patient safety. We perceive the concept of clinical governance in the NHS as structures and processes focused on adherence with procedure, and risk and reputation management. The mechanics of clinical governance such as guidelines, checklists, redundancies and standard operating procedures support safe and effective practice but are often focused on risk reduction. However, governance can move beyond concerns with authority and accountability to encourage, empower and challenge organisations and those who work within them to reach their full potential. Such attempts at standardisation imply a rather simplified, linear view of the complex and sometimes messy world of healthcare work. Although standardisation practices offer reassurance to those responsible for publicly maintaining standards of care 9, on an individual level they can also act to remove agency from the expert. The two interdependent components of governance, the development of expertise and the reduction of risk, must both be acknowledged, and this is true of regional anaesthesia practice. Traditionally, anaesthetists have excelled at recognising, measuring and managing risk. However, we need to address not only safety but also the promotion of clinical capability in regional anaesthesia. There are different degrees of capability. Achieving true mastery of a skill is said to require at least 10 years of deliberate practice 10. However, to enable a safe and effective regional anaesthesia service across every department in the UK, widespread mastery is not needed; competence is enough. In the context of regional anaesthesia, competence may be defined as the ability to perform a peripheral nerve block safely and effectively, characterised by a low failure and complication rate that is in line with nationally agreed standards. A minority of anaesthetists will progress naturally to more advanced practice and their contributions to innovation and research remain important. But if we want to maximise benefit across the system, our priority must be to increase the proportion of clinicians within each department who can perform routine blocks. This has been framed around the ability to perform ‘Plan A’ blocks safely and effectively 11. How then might we develop this broad group of anaesthetists to become competent at regional anaesthesia? A logical educational approach is to require theoretical understanding before ‘hands-on’ practice, as this seems to promote better skill transfer and retention in neuraxial anaesthesia 12. Clinicians who understand the rationale, anatomy and potential complications of a technique are better prepared to execute it safely, a concept described previously as conceptual coherence 13. This approach can be translated to peripheral nerve blocks. Theoretical knowledge in regional anaesthesia can be acquired from a wide array of resources such as articles; textbooks; and online video demonstrations 14. Only once this is learned should the learner progress to developing the motor components of the skill (needle handling and ultrasound image acquisition). Initially, these are best practised in environments where no patient is exposed to risk, using models; phantoms; cadavers; and simulators. Learners may already be familiar with the basis of scanning and safe needle advancement using these for vascular access. Well-designed simulation courses include key components such as expert instructor presence and multifaceted instruction on technical and non-technical skills relating to regional anaesthesia 15. The next step is supervised performance on patients. Survey data from the UK in 2023 suggested that anaesthesia residents required around 20 supervised attempts before they felt competent in performing a specific peripheral nerve block 1. An international Delphi exercise conducted by the European Society of Regional Anaesthesia proposed a similar range of between 16 and 20 supervised attempts 16. Unsurprisingly, the precise number will vary with block complexity, individual aptitude and the quality of supervision. Taken together, these elements form a broad hierarchy of regional anaesthesia training quality: theoretical knowledge; guided discussion; simulation on basic models progressing onto anatomically correct phantoms and cadavers; and, finally, supervised performance on patients. When clinical opportunities are limited, the other components can facilitate the maintenance of skills. A structured and combined approach that draws on all tiers of this hierarchy offers the most sustainable pathway for developing expertise across a department 17. This applies not only to those learning for the first time, but also to the retention and maintenance of skills, for instance in ‘just in time’ training 12. Organisational structures also have a major influence on how expertise develops. Departments with a designated lead for regional anaesthesia tend to offer better training opportunities 1, and the presence of block rooms has been associated with improved efficiency 18 and facilitates greater case exposure. An under-reported benefit of block rooms is that they also give colleagues outside formal training pathways a central, accessible hub in which to maintain or enhance their skills. They also create capacity for follow-up of blocks performed the previous day by utilisation of time in between blocks, enabling earlier identification and management of complications. We have developed a conceptual model illustrating how a procedural skill such as regional anaesthesia is developed and maintained (Fig. 1). The ‘peaks’ in the learning curves correspond to discrete learning events, followed by ‘troughs’ that reflect the natural decay of proficiency during periods of reduced practice. In the early stages of learning, skill decay is high, attributable to limited development of procedural muscle memory. With sustained practice, individuals may progress to a plateau of competence characterised by low failure and complication rates. A subset of individuals may achieve further performance breakthroughs subsequently, enabling management of anatomically or physiologically complex cases, often facilitated by advanced training such as postgraduate diplomas; specialist interest area modules; or fellowships. Although experts continue to exhibit performance fluctuations, these are attenuated compared with novices, reflecting greater consistency and a sustained high level of procedural competence. The current UK governance landscape remains weighted towards risk reduction. Systems that improve expertise, such as block rooms, simulation training and structured continuing professional development in regional anaesthesia, remain secondary rather than prioritised components of anaesthetic practice and training. This perceived optional status undermines efforts to standardise quality and perpetuates variability in practice. Risk reduction is at the heart of everyday anaesthetic practice. Every decision we make requires balancing potential benefit against the possibility of harm, and regional anaesthesia is no exception. Risk can be further classified into individual risk and organisational risk. Individual risk involves the anaesthetist's own perception and approach to risk reduction, whereas organisational risk focuses on the system processes. Individual perception of risk is shaped by the immediate clinical context as well as the anaesthetist's own risk appetite. This is highly personal and influenced by many factors such as personality; previous experience; and current level of expertise 19. A risk appetite that is too conservative may inadvertently deny patients access to surgery they need, and an appetite that is too liberal increases the likelihood of complications that may compromise quality of life and render the benefit of surgery negligible. The challenge is achieving a balance that is neither unnecessarily restrictive nor irresponsibly permissive. As well as factors mentioned previously, risk appetite also varies with innate cognitive biases. After a national patient safety alert is published or after experiencing the complication in one of our own patients, our risk assessment becomes more cautious and our appetite for risk diminished. Conversely, if an anaesthetist manages a complication successfully, they may attribute this to their own skill when, in reality, the outcome was shaped by less visible, favourable underlying factors. The anaesthetist may then feel a greater sense of safety and/or capability than before and become too willing to take on a similar risk in the future. This overestimate of their own ability can lead to a high level of risk appetite, and the practitioner is then straying into a state of mind which is termed the ‘illusion of self-control’ 20. Becoming aware of how such cognitive biases work is an important part of reducing risk. Organisational risk reduction is central to clinical governance. To address organisational risk, a practical four-step strategy can be applied across a wide range of regional anaesthesia challenges. First, identify the risk clearly. Second, distinguish between modifiable and non-modifiable risk factors through analysis. Third, develop interventions targeting the modifiable elements. Finally, if a complication arises despite these efforts, early recognition and standardised management are essential to limit morbidity. This framework, which is already used for planning a high-risk anaesthetic, can be translated for application at a system level. Concrete examples illustrate how these principles function in practice. The ‘prep–stop–block’ process provides a structured pause that helps teams verify critical safety steps before needle insertion 21. The development of this process stemmed from a wrong-sided block which clearly defined the risk. The Healthcare Safety Investigation Branch analysed the risk factors contributing to wrong-sided blocks and developed a targeted intervention in the form of a deliberate pause before performing a peripheral nerve block. Similarly, the NRFit connector system (ISO 80369-6:2025) is now the standard for the delivery of regional blocks to reduce wrong-route injections, showing how equipment standardisation can serve as a powerful risk reduction tool 22. Although these measures do not eliminate risk entirely, they make errors less likely and improve the margin of safety when systems and humans interact. Other areas of high risk have been identified such as local anaesthetic systemic toxicity; neuraxial infection/haematoma; wrong drug administration; and nerve damage. Work has been done to improve risk in these areas through the development of guidelines and protocols but, despite these efforts, they remain an area for further improvement and research. The focus of the 8th National Audit Project on the complications of regional anaesthesia will prove extremely valuable in this effort 23. From the perspective of resident doctors, gaining meaningful experience in regional anaesthesia throughout training depends on the presence of opportunities. While a proportion of opportunities will be influenced by organisational factors such as speciality mix of the hospital and number of regional anaesthesia providers, resident doctors can influence their chances by being prepared for learning. Understanding the relevant anatomy and describing safe needling practice principles contribute positively to a supervisor's confidence in handing over control of the probe and needle. A recurring concern is the number of resident doctors who progress through to the final years of training without feeling competent in the core ‘Plan A’ blocks 1. This is not only an issue for the individual but also reflects cultural and organisational challenges. Balancing surgical list management and educational benefit can leave resident doctors starved of regional anaesthesia opportunities, particularly with the current pressures on operating theatre activity. This may be reflected in regional anaesthesia represented as a disproportionately popular specialist interest area, due to resident doctors feeling they must compensate for lack of practice 1. Improving the culture around regional anaesthesia will not only provide improved access for patients but will also reduce the burden on resident doctors to find opportunities to develop and practise their skills. Peer-led teaching offers an additional and often underutilised option. Evidence suggests that training delivered by peers can be just as effective as instruction from senior clinicians 12. This creates a valuable opportunity within the training structure: senior residents can supervise more junior residents, creating a cycle in which everyone reinforces their skills. The supervising resident doctor deepens their understanding by teaching and the supervisee gains exposure. Such an approach not only expands training capacity but also fosters a culture of shared learning and collective responsibility. Both of these will contribute to the development of capability and the reduction of risk in regional anaesthesia and should help overcome the challenges posed by Turbitt et al. 8. AS is an Associate Editor of Anaesthesia.
Jamal et al. (Wed,) reported a other. Anaesthesia residents required 16 to 20 supervised attempts to feel competent in performing specific peripheral nerve blocks, highlighting the need for structured training.