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    Management in the Dental Office

    Stickiness – Skills Retention & Synthesis



    Ehab Heikal - BDS, FICD, MBA, DBA

    MSA University | Alexandria, Egypt | eheikal@me.com




    A persisting problem you have in your practice is that you train your staff and after a while, you find that they forget what they were taught. You wish you would glue the information in their minds.


    How do we get training to stick? It’s the million dollar question. Experts have long ago agreed that the interminable hours long dissertations and lectures are as ineffective as they are tedious. And with today’s training culture so focused on measurability, the question of skills retention and synthesis, or “stickiness”, is more relevant than ever.


    There are ten criteria to creating stickiness in training:

    Train using visual, auditory, kinesthetic* and tactile tools

    Make skills relevant and related

    Use low density classes

    Use short classes and short modules

    Repeat the message often

    Keep the message consistent

    Provide the learner with motivation

    Provide the learner with confidence

    Provide the learner with support

    Provide the learner with feedback


    What we know, and what we do

    Stickiness, as it relates to training, essentially involves two different elements – retention of the information being presented; and synthesizing the skills – putting them into practice in a live environment. They are two quite different concepts, and one does not necessarily follow the other. For example, I know that I am not supposed to talk over the phone while driving, but…! So I know that I should or shouldn’t do something, but I did something else.


    Training that actually translates into habitual behaviors in a live environment, therefore, must address both what people know and what people do. They are two separate and distinct outcomes, and need to be treated as such.



    “We remember what we understand; we understand only what we pay attention to; we pay attention to what we want.” - Edward Bolles


    A great number of studies have been conducted regarding how we process and store information, as well as on the effectiveness of different instructional approaches in facilitating the transfer of information into short- and long-term memory. What is clear are two things: The first is that individuals differ greatly in learning styles, and that retention is proportionate to the appropriateness of the instructional approach. The second is that, beyond learning styles, there are some common denominators (characteristics or average standard) to more effectively creating retention of concepts and knowledge.


    1. Learning Styles

    As has become common knowledge in the training industry, there are four fundamental learning styles: Visual, Auditory, Tactile** and Kinesthetic. Solid evidence exists that there is a direct causal relation to how well instruction matches a learners learning style, and how much information is retained.


    There is a great number of unsupported statistics flying around these days as to which learning styles are the most important. The truth is that, in order to maximize retention within a mixed group of learners, all four learning styles must be addressed.


    Just to clarify things, however, a 2002 survey of students by the Lewis Center for Educational Research in California gives us an indication as to the proportion of learners to learning styles:

    Learning Style # of Students Percentage
    Visual 167 29%
    Auditory 123 22%
    Auditory/Visual 76 13%
    Tacticle 57 10%
    Kinesthetic 54 10%
    Visual/ Tactile 35 6%
    Visual/Kinesthetic 23 4%
    Kinesthetic/ Auditory 14 3%
    Kinesthetic/Tactile 12 2%
    Auditory/Tactile 7 1%


     Learners Tactile
    (actively doing)
    30% of learners

    Remember what was done,
    not what was seen or talked about.

    Don't hear things well.
    Touch and movement are

    Not avid readers.
    Attack things physically (fight,
    hit, pound).

    Learn by imitation and

    Touches things to get a sense
    of them.

    Likes to talk about feelings.


    May have had or are having
    difficulty learning to read.

    Love games.

    May appear slow if
    information is not presented in their

    Likes to dress comfortably.

    May unconsciously touch
    people a lot.

    May be athletic, likes
    swimming, cooking, running, eating,
    sailing, dancing, working out,


    To ensure information and skills retention, therefore, the primary training methodology must involve both visual and auditory elements. This will reach 65% of learners. To address the remaining 35% of learners, both tactile and kinesthetic elements must also be included.


    A picture is worth a thousand words

    The importance of visual learning has been well documented. Park & Gabrieli established in 1995, pictures are inevitably remembered better than words on tasks of recall and recognition. This is important to remember in the design of a training program.


    More importantly to note is that, although 65% of learners are visual or auditory, tactile and kinesthetic approaches are required to create stickiness. In 1996, Ellis, Whitehill, & Irick established that getting hands-on experience was even better than pictures. In their study, they found that memory of pictures is significantly less than memory of interaction with operating and assembling an actual device.


    2. Common Denominators to Creating Stickiness

    a. Relevance and Relatedness

    The more relevant the subject matter is to the learner, the more likely it is to be retained. If the information is addressing a current need, recall is inevitably better. The tendency to retain information, in fact, is directly proportionate to the immediateness and perceived importance of the learner’s needs. For instance, most people will quickly memorize and retain the personal identification number for their bank card, but would not do as well memorizing the driving license number. The need for memorizing your PIN number is important, because writing it down is not a recommended option. It is also immediate – something you will likely need to have top of mind in the short term. Memorizing your car driving license is far less important – because it is easy to refer to just by getting it out to look at it, and it is not a number that you will be required to know all that often.


    As with relevance, relatedness is also desired, because words as well as pictures are read or understood faster when preceded by a related context. For instance, it is easier to identify the word “butter” when it comes after “bread” than when it comes after “doctor” This impacts the sequential requirements of training design, as well as the need to have conducted a thorough participant analysis.


    b. Low Density

    Although much is said about the “less is more” theory, it is rarely practiced in training. There is a great deal to indicate that low density training – training which focuses on fewer learning objectives – is far more effective than training that “covers a lot of ground.”


    Thus no more than 50% of material presented should be new, and that the rest of class time should be devoted to material or activities designed to reinforce the material in learners’ minds.


    This principle is supported by the fact of importance of simplicity in establishing retention. People who learn and master a skill (A) and then immediately learn and master a second skill (B), performed poorly when skill A was performed 5 hours later. People who learned a skill (A), waited five hours, learned a second skill (B), and then waited five hours were able to perform both skills successfully.


    c. Short Modules, Short Classes

    It has been shown many times that the average adult attention span in a learning environment is about 15 minutes, and that modules within a class should not exceed that time limit. As with the low density principle, studies have also shown that retention of key learning points does not increase from a full-day to a half-day program – and can actually decrease depending on the density of the program.


    d. Repetition

    Repetition is a key component to moving information from short-term memory to long term memory.


    The Fading Effect

    H.F. Spitzer, in his prominent 1939 study on memory retention, demonstrated how memory fades. He showed how, when information was taught, but unsupported, recall diminished over time:


    Time from First Learning

    % of Material Remembered

    % of Material Forgotten

    After 1 day



    After 7 days



    After 14 days



    After 21 days



    After 28 days



    After 63 days







    His research highlighted two clear points: First, that regular reinforcement of information is critical to combat fading. The second is that, even unsupported, a residual portion of information will remain in memory over time. This supports the theory that the impact of training over time is in fact cumulative.


    Memory increases gradually with successive repetitions. And if repetition is important, the spacing of repetition is also important.



    For a learner to apply the skills in a live environment there are several elements that must be in place. As previously mentioned, simply having a skill does not necessarily translate into using a skill. For example, imagine you sent your assistant to a magicians school (For the sake of the example, just assume there is such a school). She has no real interest in becoming a magician, but you informed her that going to the class was mandatory. Chances are, she is not going to automatically start doing her magical tricks in the office, even though she now has the information and knowledge to do so if she wished.


    For a skill to become a practice – applied on a consistent basis, there are four key elements that need to be in place:



    The more compelling the motivation, the reason for doing it, the more likely the skill will be applied. Tell the assistant-turned-magician that she’ll get an extra $5 a week to do her magical tricks in the office; she would still likely turn it down. However, tell her that if she doesn’t do it, she will be fired, she may consider it.


    Motivation can be internal (eg. pride, integrity, loyalty etc.) or external. External motivators can include financial incentives, positive reinforcement, contests, etc. The most effective external motivator is establishing non-negotiable performance standards, and framing those standards with positive and negative consequences. The standards have to be set and consistently maintained by a superior. The new behavior becomes expected, and nothing less is acceptable or tolerated.



    Because the skill is new, people often lack the confidence to make change. The more confident we are in the veracity of the skills, as well as in our abilities to execute them, the more comfortable we will be trying them. The magician will be more likely to try a routine if she is confident that it will be accepted and that she will do it well.



    People will be more likely to continue trying to develop more skills in a live environment when they are being consistently assisted and encouraged. This requires coaching, and the attention of direct supervisors. The magician will be more likely to try if she is being encouraged, and if she knows that there is someone there to provide guidance.



    People are more likely to continue an action when they see positive results to the action. This requires coaching, and continuous feedback. Once the magician has had success, and received thunderous applause, she might be convinced to do it again.


    Stickiness – the permanent transfer of new concepts, and shaping of new behaviors – is created by ensuring that these ten criteria are met. And it only takes one of the criteria to be missing to have a significant negative impact on the stickiness of a training program.


    The difficulty in attaining stickiness is that the people typically in charge of the training rarely, if ever, have control over all of the criteria. A well designed and executed four handed dentistry training program, for example, can be marginalized by the absence of enforced performance standards.


    Maximizing training stickiness requires a clear, consistent and committed focus to singular training goals. It means planning training with overlapping skills – ie. your Dealing with standardization training program should also reinforce the skills of the Quality campaign introduced six months earlier. It requires diligence and follow-through at application level. Like an automobile engine, each moving part must work both independently and interdependently toward a common goal.





    * Kinesthetic learning is a teaching and learning style in which learning takes place by the student actually carrying out a physical activity, rather than listening to a lecture or merely watching a demonstration. Kinesthetic learning is when someone learns things from doing it or being part of doing it.

    **Tactile learners are those who learn through experiencing/doing things. For this reason, tactile learners may become bored more quickly than other students while listening to a class lecture.

       Tactile learners like to experience the world and act out events. To remember a phone number, tactile learners may remember the pattern of their fingers as the press the numbers.