Incorporating the Productive Failure Model into Simulation-Based Learning

Failure is any deviation from a desired goal. In general, failure is not viewed with a positive vibe. Productive failure refers to a learning design where learners generate and explore representations and solutions to complex and novel problems. Simulation on the other hand, is a technique to replicate or amplify real world experiences in a controlled, learning environment. In this paper, the author shares how the productive failure principle is incorporated into simulation-based learning, for use in novice learners before instructions are delivered. Besides this, where there are process failures in the healthcare system, these can be curated into learning activities using the productive failure model in a simulated activity, where participants can brainstorm in teams to come up with novel, unique, practical and customised solutions.

This synergistic new model offers yet another learning design, which has the potential to transform the way failure is viewed and perceived.

Introduction

In general, people are not comfortable with failure. One reason could be that having been brought up in societies where success is a key performance indicator (KPI) in almost all aspects of life; be it in schools, institutions of higher learning, businesses and industries, on the job training, public service and large organizations, it has become the norm and the accepted. Traditionally, failure is viewed negatively and is linked to many negative connotations such as lack of motivation, lower cognitive capability, less proactive drive and others. Of late, there has been a move towards being able to accept some degree of failure. This remains patchy across the various industries, likely due to unique characteristics, culture and practices within each one.

Failure is now being viewed as almost an essential step towards successful learning. In this context, John Dewey, an American educator and philosopher believes “failure is instructive”, as people can learn from the experience of failure just as they do from the experience of success. In healthcare today, issues of open disclosure, ‘non-blame culture’, open reporting, reporting of near misses and root cause analyses are standard practice across many departments and institutions. Reporting errors and failure is becoming more accepted and not linked to punitive measures being meted out. In fact, these are now used for sharing and learning during peer-reviewed sessions and departmental rounds. When failure occurs, there is the conduct of root cause analysis to see whether systems factors or human factors predominate. Corrective measures are then planned and implemented. This is now almost a standard approach to errors and failure; ie. when the errors or failure has occurred. However, what if there can be a different way of approaching failure and errors?

Failure and Medicine

Traditionally, failure is less accepted in Medicine. Failure is the deviation from a desired outcome, whether avoidable or unavoidable. Whilst there are opportunities and learnings in failures, when dealing with humans as well as ‘life and death’ situations, failure certainly has a negative connotation. Today, more and more healthcare leadership has begun advocating the compelling call for change, whereby staff is more comfortable with handling failure and errors. With this evolution and greater understanding on learning from failure, a different approach may now be more feasible. Whilst traditionally, failure was detected from errors which had taken place and sentinel events that had already affected patients, healthcare staff can now pay attention to smaller, day to day process failures, review them regularly and institute the change for improvement in a step-wise fashion. Whether these are systems-based factors or human factors linked, these small cumulative actions will be synergised to eventually have a bigger notable change. With the changed culture and greater psychological safety, the value of noting small failures will become obvious to staff and be viewed more positively in the medium to longer term. Moreover, these small errors can be the early warning signs, which, if managed in a timely manner, can avoid subsequent more serious failures and errors.

Productive Failure      

Productive failure (PF) refers to a learning design that entails conditions for learners to persist in generating and exploring representations and solutions for solving complex, novel problems or situations. The use of PF methodology is thought to activate deeper learning for eventual better understanding. In the PF approach, no prior instructions, tutorials or lecture on the topic/ theme is provided. These are delivered only after the learners have gone through the experience and come up with their proposed solutions.  In this approach the following are the proposed interdependent mechanisms: Activation and differentiation of prior knowledge in relation to the targeted concept

1. Attention to the critical features involved in the targeted concepts
2. Ability to explain and elaborate on these critical features, as well as
3. Organization and assembly of the critical features into the targeted concepts

PF is used to explain how failure is beneficial to learning: where learners are given a carefully curated and designed problem/ scenario to resolve prior to instructions pertaining to the topic, and concept. In trying to get the solution or attaining resolution of the problem, learners may face road-blocks, have to make u-turns, go through several iterations of their perceived concepts and so on. The experience of failure can challenge learners current thinking and motivate them to revisit and revise their thinking and understanding. They may also become more aware of their knowledge limitations.  The learners may encounter one or multiple failures, which they have to overcome. In the process of doing this, learners will have to:

• stretch their minds/ mindset
• circumvent their initial straightforward ideas
• see the “other side of the coin”
• Look at the bigger picture
• Understand the views of other team members which are different from their own
• Generate as many potential resolutions as possible, to eventually choose the best fit solution

The brainstorming process has been argued to be the beneficial learning process, which helps in the grasping of concepts and in understanding or assimilating the subsequent instructions to be delivered. In PF, learners are encouraged to practice ‘wide and deep’ brainstorming. In this way they are encouraged to cover the topic with some degree of depth and breadth. It is also interesting to note that some of the learners may tend to demonstrate ‘mirror thinking’. This is where mirror neurons define persons via the role models they observe and interact with. The learning occurs through the brain’s mirror system and it is also important for emotional connections with others and the passing of information through the generations. This takes place at the neo-cortex level, which is also known as the “observing brain” The roles being referred to here can be personal roles, situational roles and even aspirational roles. Thus, learners can emulate these roles they have observed (part of their past exposure and experience) and apply them in problem solving.

Simulation and Productive Failure

Simulation is a technique that can replace or amplify real world experiences with guided ones that evoke or replicate aspects of the real world practice in a fully controlled, interactive and immersive manner. Simulation allow learners to make errors without harming patients, ie. to enable learners to encounter failure without negative consequences to patients. It can be repetitive, deliberate and it represents experiential learning. In wanting to inculcate the learning through PF, the following was planned using simulation-based learning for medical students posted to the emergency department:

1. Designing a well curated scenario to target a concept the learners have not been taught before
2. Conducting the pre-briefing session (similar to that before any simulation activity, except that the concept and principles being tested are not included or explained in the briefing)
3. Conducting an in-lab simulation session using the scenario to assess how learners resolve and manage the scenario
4. Post-simulation activity debriefing, which include:
   1. Debriefing the simulation activity
   2. Instruction on the concept/ topic being tested and
   3. Illustration on how the new knowledge and skills learnt can be transferred to the real/ actual work environment
5. Repetition of the same simulation scenario (on a case-by-case basis) for learners to consolidate and reinforce what they have learnt

This model of study is useful for medical students who are just commencing clinical postings. They would have had sufficient exposure to basic sciences but not to concepts such as ATLS (Advanced Trauma Life Support) and Sepsis guidelines (Surviving Sepsis Guide and Early Goal Directed Therapy). Thus, the steps described above are suitable for this cohort of learners, in applying PF principles. The pre-briefing is essential as learners must be familiar with the use of simulation-based learning and the capabilities of the manikin and equipment in use. However, in testing PF, the concept of the topic of ATLS or Sepsis would not be covered and thus no instructions pertaining to this would be shared with the learners before the simulation activity. The lab simulation activity is conducted as in any other simulation scenario. The faculty observing must be familiar with the concept and principles of PF, besides just an understanding of simulation-based learning principles and debriefing. The learners will be working in their teams, to solve and manage the clinical scenario which has been curated. The faculty will be observing their brainstorming process and if there is a systematic approach they are undertaking. They may face roadblocks or failures which can be illustrated through the simulation capabilities such as changing the vital signs. In curation of the scenario, the faculty would have incorporated or embedded some fundamental activity, pertaining to the concepts to be taught, within the simulation scenario. Learners will be seen to utilise some form of trial and error approach in negotiating the scenario. They will also use self-directed learning using their prior experiences and past knowledge. Any failure will have consequences on the ‘patient’, but as this is a simulation activity, no actual patient would be harmed. When these learners make ‘mistakes’, the negative experience itself can be useful in solidifying conceptual understanding ultimately when the instructions and concepts are shared later. Therefore, the properly designed scenario using PF principles in mind can be a catalyst for learning.

Pertaining to the debriefing, this can be viewed from two parts:

1. General debriefing, which includes how the team worked together, their interaction and communications processes
2. Specific focused debriefing, touching on the concepts being embedded in the scenario eg. ATLS or sepsis management. Here, the principles and concepts will be shared for the first time with these learners. This is also where the faculty can share on the transference of knowledge and skills to the actual clinical environment.

After all the above steps, individual groups of learners may wish to go through the scenario once more, with the newly acquired instructions and knowledge they have received. This is extremely acceptable in view that simulation-based learning does encourage deliberate practice, where learners can go through the simulation again and again until they reach a certain comfort level. The subsequent attempts will not fulfil the definition of PF.

Productive failure and Process failure

The principle of PF can be expanded beyond just for learners’ education. Process failure in healthcare delivery is also about learning from failure and errors. How this happens is:

1. When there is any error/ failure, besides corrective action, it is highlighted to the supervisor who will lead or direct a Root Cause Analysis (RCA) to understand the issues involved such as the contribution of systems factors versus human factors.
2. Staff are encouraged to learn from the sharing and not blame
3. Having open and non-judgmental communications on the failure
4. Having the ability to question why staff do things in a certain way and not in a different way and if the latter is better/ safer, then it should be implemented and the change adopted

After reviewing all these errors and failure, one very good way to share with other staff and colleagues is by incorporating the scenario into a learning activity such as a simulation scenario. These scenarios can then be used to educate and practised over and over again in immersive format to help staff remember the steps and also understand why the change in action is needed.

There continues to be ongoing discussion and debate as to whether teaching a new concept should begin with ‘instructions first’ or independent ‘problem-solving first’.

When learners receive instructions first, they will tend to make less error in the simulation activity and as they already have the knowledge of the concept, they basically just have to apply these to the scenario given to them for management. They will thus be involved in less brain-storming and less decision making from scratch. This means the learners will have less floundering and can be more targeted and sharp in the approach. Therefore, less time will be needed. From the more positive perspective, as they would already have grasped the basic concepts during instructions, then the time for the simulation activity can be used to focus on deepening certain aspects of the concepts or to reiterate the more critical elements of the case management. On the other hand, when learners are subjected to problem solving first before any formal instructions, more time will be needed for them to discuss, brain storm and tap on their prior knowledge for sense-making. Unguided problem solving may lack structure and systematicity and this can be time consuming. The process of brain-storming will provide opportunities to discover and decipher on their own and helps to set some foundation for their future learning process. Learners going through this will usually go through an exploratory phase, leading to hopefully activation of the relevant prior knowledge which they can use to solve the scenario. They will also then understand their knowledge gaps, which will eventually lead them to search for deeper understanding through questioning, when the instructions are finally delivered. Some learner teams may not experience failure, but still, the journey and process they have to go through is invaluable as a form of learning. Failure here is also rather subjective as it may be in relation to some set goals or objectives. In some cases, faculty design the scenario for some degree of failure to be experienced in the initial, early clinical exposure phases so as to reduce the failure in the longer term or later clinical years. This must be curated appropriately.  Moreover, when planning the simulation focus may be on learning outcomes of the conceptual knowledge and its transfer. However, if one part of the problem solving simulation activity, is to make learners become aware of what they do not know or come up with other observations which may not be linked to the concept in question or learn which procedures do not work well, then these should also be the measurable outcomes. An example of this would be when the concept to be learnt is sepsis. Learners may in their brainstorming and problem-solving process, realise the top 3 commonest sites of infection in acute presentations, or when to decide on setting up a central venous catheter (CVC) and intra-arterial line in the management of a patient with septicaemia.

Discussion

Today, simulation has wide applications in healthcare; from healthcare education and training, to procedural and process learning and even logistical planning and operations. Incorporating the PF design into simulation-based activities present another option. This can be applied in many contexts:

1. In the introduction and learning of new concepts for novice learners such as medical students, nurses or junior residents. The spectrum of this is very broad and as long as faculty can design these appropriately and customise the learning goals, learning and inculcating habits through failure can become a positive experience, with longer term effect on an individual’s learning journey as they continue to strengthen their clinical reasoning and situational awareness capabilities.
2. In looking for unique and novel solutions to manage day to day failures and errors (which have been observed and encountered). Here is where the teams involved can seek to find new methodologies, new pathways and processes flow as well as new ways of doing things, using the PF design.

The PF design and methodology is suited for healthcare as the industry/ discipline involves:

1. Ongoing lifelong learning
2. Extremely dynamic processes and work flow as well as
3. Rapid changes, transformation and development

Conclusion

PF can present new models of learning opportunities in healthcare. When combined with simulation, the synergistic model offers yet another learning design, which has the potential to transform the way failure is viewed and perceived