Finding Success in Productive Failure

by Thao K. Huynh,  PGY2 Oncology Pharmacy Practice Resident, University of Maryland School of Pharmacy

Learning is an activity that requires our undivided attention. Learning a novel or unfamiliar concept often involves struggle, which is a necessary component to critical thinking. A teaching method that causes a greater amount of struggle will lead to more learning as exemplified by productive failure.

According to Manu Kapur, productive failure engages students in differentiating prior knowledge from features of the new concept.¹ In using productive failure as a teaching strategy, there are two phases. The first phase requires students to generate and explore, while the second phase encourages them (with the help of the teacher) to consolidate and assemble new knowledge. In the first phase, teachers must discern what students know about a novel concept that hasn’t yet been formally taught. During this phase, a complex problem is presented collaboratively amongst students. During the second phase, the novel concept must be consolidated and presented with direct instruction in a structured way.²

In order to test this method, Kapur conducted a classroom-based research experiment comparing direct instruction with productive failure. In an all-boys school in Singapore, seventy four ninth grade students were taught about the mathematical concept variance in two different ways. Students were tested prior to the intervention to evaluate their pre-existing knowledge and it was similar at baseline in both groups. In one classroom students were provided direct instruction (DI).  In the other classroom, students in the productive failure (PF) group were provided no instruction or guidance. The two classes differed in that the DI class of 35 students participated in four 55 minute periods of instruction where the teacher explained the concept of variance, modeled the application of the concept by working through problems with the class, and highlighted pitfalls and misconceptions. Students in this class were able to work through problems in triads followed by a discussion of the solutions by the teacher. DI students were assigned homework after each class to reinforce the topic. In contrast, the PF class was not provided direct instruction during the first two periods. Instead, students worked in triads to solve one of the problems on their own. In periods three and four, PF students were provided the same direct instruction but the teacher also compared and contrasted student solutions and explained the solution in a manner similar to the DI class.  The PF class were given and solved fewer problems than did students in the DI class.   Moreover, students in the PF class were not given homework. Following this period of instruction, both groups of students took the same exam.  All students performed similarly overall – however, students in the PF group outperformed students in the DI group on the conceptual insight and data analysis portions of the exam.¹

Although, it can be argued that students in the productive failure group outperformed the direct instruction group due to a greater amount of time devoted to to studying the concepts; their performance is likely related to the amount of time and energy put forth into delving critically into the topic.

Productive failure can be used in the pharmacy curriculum and clinical pharmacy practice to help enhance learning experiences.  Incorporating productive failure may work in a group setting such as Abilities or Practice Lab, case discussions, and problem-based learning courses.  Students in these small learning groups naturally (without direct instruction) have some prior knowledge on the topic.  Productive failure will facilitate development of their critical thinking skills.  Allowing student to struggle is critical to the process.  This sets the stage for the instructor to introduce new concepts to students. This environment, according to Collins, leads “metacognitive scaffolding, contrasting cases, peer-interaction scripts, mixed-ability groups, and perhaps representational scaffolding in the intervention phase will enhance student learning in the [direct] instruction phase.”³ Furthermore, a lack of struggle can lead to detrimental outcomes.  For example, in a study that observed nurses on a patient care unit, when problems arose, instead of analyzing the situation, they opted for quick (but less than optimal) solutions.⁴

I believe productive failure is most useful when there is sufficient time to explore different solutions to a complex problem. If time is critical, productive failure may be detrimental. In addition, for productive failure to have the greatest benefit, learners should have some baseline knowledge on the topic.  In other words, the new concepts must be related in someway to the students prior knowledge.  If the new concepts are too foreign, students might not be able see the connections between their prior knowledge and the new knowledge.  I’ve encountered a recent situation where productive failure would not have worked well. An oncologist wanted to use equine thymoglobulin for a critically ill patient with steroid refractory acute graft-versus-host disease post stem cell transplant.  The drug needed to be administered as soon as possible. Not being an expert in this topic and having never seen horse thymoglobulin used before, I needed to clarify this with my preceptor. I found a review article on the topic but my preceptor needed to provide guidance. In this situation, using productive failure as a strategy to learn a novel concept without any instruction would have caused further delay in patient care as well as the potential for patient harm. On the other hand, productive failure worked with two students I asked to lead a topic discussion. The topic was acute myeloid leukemia, which neither student had any previous knowledge. I began with few patient cases for the students to read and discuss with one another.  After the students had an opportunity to struggled through the patient cases, I provided a formal one-hour interactive presentation. I measured the success of how well the students applied the information to direct patient care situations.  I saw a dramatic increase in knowledge from both students and they were able to provide appropriate recommendations to the patient care team.

Looking for ways to improve the way you teach?  Embracing the productive failure method will facilitate learning by encouraging learners to differentiate new concepts from prior knowledge and to be analytical in applying these new concepts.

References

1. Kapur M. Productive failure. Cognition and Instruction. 2008 Jul;26(3):379-424.
2. Kapur M, Toh PLL. Educational design research – Part B: Illustrative cases. Enschede, the Netherlands: T. Plomp, & N. Nieveen (Eds.); c2013. Chapter 17, Productive failure: From an experimental effect to a learning design; p. 341-355.
3. Collins A. What is the most effective way to teach problem solving? A commentary on productive failure as a method of teaching. Instr Sci 2012;40:731-735.
4. Edmondson AC. Learning from failure in health care: frequent opportunities, pervasive barriers. Qual Saf Health Care 2004;13(Suppl II):ii3-ii9.

Bullet-proof: Rethinking PowerPoint Presentations

by Sharon Martin, PharmD, PGY-1 Pharmacy Practice Resident, University of Maryland Medical Center

Learners of my generation have seen the transformation from a classroom full of students focused on the chalkboard/whiteboard to one full of laptop computers with all eyes on the instructor’s PowerPoint slideshow. As a recent graduate, I witnessed this transition and found slideshow lectures often “death by PowerPoint.” PowerPoint-based lectures were the norm in most of my pharmacy school courses.  Students expected every bit of information they needed to know to be written directly on the slides.  But many educators feel that learners lose the big picture when focusing on these small details.  PowerPoint presentations can be impersonal and discourage active student participation.¹ Thus, the effectiveness of this teaching method has been questioned by a number of educators.^1,2 Studies have shown that active learning improves student performance.²  Traditional lecturing (similar to many PowerPoint presentations of today) results in higher student failure rates, particularly in science, technology, engineering, and mathematic courses.²

One element of PowerPoint slide decks that has received particular attention is the use of bullet points. In his discussion on PowerPoint design, David Farkas outlines the major arguments against bullet points, but rejects the idea that bullet points are inherently detrimental to instruction.  Bullet points tend to over-simplify the ideas of the presenter.  The hierarchy in which the presenter organizes the bullet points potentially confuse the audience.  And slides with lots of bullet points encourage the audience to read the slides instead of listening to what the presenter has to say.³  Given that these potential problems, how could one use PowerPoint in a more constructive way and avoid bullet points? A recent presentation moved me to reflect on how revamping presentations can turn PowerPoint slideshows from a method for passive information transmission to an engaging and active method of instruction.

Get the picture? - Key principles

Dr. Penciner offers up an antidote to the “death by PowerPoint” approach to teaching. In his discussion of instructional design, he provides simple suggestions for developing more effective presentations. His approach is designed around three key principles: tell a story, keep it simple, and manage your flow.^4,5

Tell a story

Storytelling has long been an educational tool, but the art of storytelling has been lost today. Storytelling allows professionals to imagine real life scenarios and to better understand their role in practice.⁶ Modern instruction can employ new technology to enable “digital storytelling” where multimedia (video, music, etc.) is used to tell stories.^6,7 Penciner encourages educators to use PowerPoint to augment the narration of a story by using slides of images that represent the actions or subjects of the story.^4,5 In educating health professionals, storytelling using PowerPoint might consist of an image of a patient (fictional or with the patient’s permission!) with the presenter discussing the patient’s “story” or medical history with the class.

Keep it simple

The principle “keep it simple” will help make your presentations “bullet proof.” As Farkas points out, presentations have historically lent themselves to the bullet point format as presenters have a number of key points they hope to get across to the audience.³ Penciner suggests that these key points can be more effectively portrayed using images. Using images rather than words encourages the audience to focus on what the presenter is saying rather than reading the slides.  In turn this allows the audience to more effectively remember the message of the presentation.^4,5  In practice, how do you keep it simple? Re-format each slide with three (or more) bullet points and separate each “point” onto its own slide (for a total of 3 slides).  Find an image that represents that point.  Then cut the wording down to one to three words that clearly state the central message.

Manage your flow

In order to manage the flow of your presentation and use simple slides as described, there are two additional documents you should have available. The first is a set of presenter’s notes which outline the information you want to discuss with each slide. This document serves two purposes: 1) to keep you on track during your presentation (although ideally you should have practiced enough to not need these notes in the middle of presenting) and 2) to reference if asked to present the same material in the future.⁴  The second document is a handout to be shared with the audience.  This is a general outline of the material you will discuss during the lecture, provides space for note taking, and may include additional words to support your audience.  This document should be used by students to study the material at a later point.⁴

Armed with these principles, let’s change those bullet points into images.  Let’s use PowerPoint as it was intended – a tool for effective presentations and audience engagement.

References

1. Reynolds G. Presentation Zen: How to design & deliver presentations like a pro. (accessed June 06, 2014).
2. Freeman S, Eddy SL, McDonough M, et al. Active learning increases student performance in science, engineering, and mathematics. Proc Nat Acad Sci 2014 Early Edition (doi: 10/1073/pnas)
3. Farkas D. A heuristic for reasoning about PowerPoint deck design. (accessed June 06, 2014).
4. Penciner R. Does Powerpoint enhance learning? CEJM 2013;15(2):109-112.
5. Penciner R. Nine words you need to know for a more effective presentation. (accessed June 06, 2014)
6. Matthews J. Voices from the heart: the use of digital story telling in education. Community Pract 2014;87(1):28-30.
7. Bernard R. What is digital storytelling? Educational Uses of Digital Storytelling.  University of Houston, College of Education. (accessed June 08, 2014)

Soft Skills Are Important Too

by Chelsea McSwain, Pharm.D., PGY1 Pharmacy Practice Resident, Holy Cross Hospital

Soft skills vs. hard skills…what is the difference?  Soft skills are those personal qualities and interpersonal abilities that are needed to relate to other people and work in groups.¹ In contrast, “hard skills” are those skills that are essential to job function and can more easily be quantified.  For pharmacists hard skills include filling and checking the accuracy of prescriptions, calculating doses, and recalling information about drug therapy.  The pharmacist’s soft skills would include communicating effectively, critical thinking, problem solving, teamwork, time management, conflict management, cultural awareness, responsibility, leadership, and work ethic (to name but a few!).  These skills, although often under-appreciated, are essential to a successful career in pharmacy.  Unfortunately, these important skills are frequently overlooked and have been historically de-emphasized in pharmacy curricula.

A recent editorial by Dr. Cynthia Boyle in the American Journal of Pharmaceutical Education (AJPE) titled “Leadership is Not a Soft Skill” discusses the importance of emphasizing leadership in pharmacy education.² She argues that leadership development is a lifelong process – the time and dedication required to master self-efficacy, self-assessment, reflection, entrepreneurship, and advocacy does not happen overnight.  The importance of leadership, rooted in the social and administrative sciences, has diminished in recent years and was placed on the “back burner” relative to the other two core areas of pharmacy education – clinical and pharmaceutical sciences.  Boyle argues that there needs to be more emphasis on the affective domain as we design and develop pharmacy curricula and courses.³

The Center for the Advancement of Pharmacy Education (CAPE) released its revised educational outcomes in 2013.  The new CAPE outcomes document addresses feedback that called for the “inclusion of an affective domain that would address personal and professional skills, attitudes, and attributes required for the delivery of patient-centered care.”⁵ The educational outcomes are centered around four domains, including 1) foundational knowledge, 2) essentials for pharmacy practice and patient-centered care, 3) effective approaches to pharmacy practice and care, and 4) the ability to develop personally and professionally. The document cites self-awareness, leadership, innovation, entrepreneurship, and professionalism as key outcomes in this fourth domain.⁵ These outcomes have been included in the 2016 American Council for Pharmacy Education (ACPE) Draft Accreditation Standards, and if accepted, it will be a requirement for all pharmacy schools and pharmacy educators to ensure that graduates of Doctor of Pharmacy curricula have achieved them.⁶ At the American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting 2013, the proposed revised PGY1 Pharmacy Residency Accreditation Standards were discussed at a town hall session.  In the draft standards, a new competency domain was articulated: Professionalism, Leadership, and Practice Management.⁷ As a participant in the town meeting, I noted that many speakers advocated for increased emphasis on these competencies.  It makes sense that all three major bodies in pharmacy education have proposed changes. 

With revised standards on the horizon with a renewed emphasis on “soft skills”, educators should be aware of the impact that this may have on instructional design and curriculum development.  Boyle notes that with the addition of these new expectations, we will be exposing a “hidden curriculum” – skills for which students have not been held directly accountable will now become major components of the formal curriculum. Students will need to develop their knowledge and skill through need guided learning opportunities and teachers will need to develop learning materials.  This poses significant challenges — how does one teach soft skills like leadership, professionalism, and advocacy? Perhaps it is not the act of teaching such skills that is the challenge, but a lack of effective evaluation and assessment tools that pose a problem.  Sorenson et al. piloted an elective course at the University of Minnesota that taught leadership skills to students.⁸ They utilized an end-of-course evaluation and focus groups to evaluate instructional design and student reactions to the learning experiences.  This may be the key to “evaluating” pharmacy leadership.  While it is difficult to objectively assess another person’s leadership skills, encouraging students to self-assess and reflect on the core components of leadership may well prove to be a key element of leadership education.  

With the evolution of new standards and a focus on the affective domain, graduates will (hopefully) possess not only the knowledge and clinical skills needed to care for patients but also the soft skills to lead and advocate for change. 

References

1. Schulz B. The importance of soft skills: education beyond academic knowledge. NAWA Journal of Language and Communication 2008;146-154. 
2. Boyle CR, Robinson ET.  Leadership is Not a Soft Skill. Am J Pharm Educ. 2013;77(10):Article 209. 
3. Clark DR. Bloom’s Taxonomy of Learning Domains. Accessed February 17, 2014.
4. Bradley-Baker LR, Murphy NL. Leadership Development of Student Pharmacists. Am J Pharm Educ. 2013;77(10):Article 219
5. Medina MS, Plaza CM, Stowe CD, et al. Center for the Advancement of Pharmacy Education (CAPE) Educational Outcomes 2013. Am J Pharm Educ. 2013;77(8):Article 162. 
6. Accreditation Standards and Key Elements for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree [draft]. American Council for Pharmacy Education. 2016; in progress. 
7. Annotated PGY1 Pharmacy Residency Accreditation Standards Revision Drafts, For Comment and Feedback. American Society of Health System Pharmacists. Dec 2013. Accessed May 10, 2014.
8. Sorenson TD, Traynor AP, Janke KK. Instructional Design and Assessment: A Pharmacy Course on Leadership and Leading Change. Am J Pharm Educ. 2009;73(2):Article 23. 

Accreditation – Should All Pharmacy Programs Be Alike?

by Caitlin Frese, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Bayview Medical Center

The Accreditation Council for Pharmacy Education (ACPE) is the national agency responsible for accrediting professional pharmacy degree programs since 1932.¹  According to ACPE’s 2013 annual report, there were 109 fully accredited programs, 16 schools in candidate status, and 4 with pre-candidate status.²  Accreditation in healthcare is commonplace – schools/colleges, continuing education providers, and residency training programs are all accredited. Why is accreditation important?  And should all programs be the same?

Accreditation is intended to ensure that high standards are met – not only in terms of the instructional design of the learning program but also its execution. For colleges/schools that offer the Doctor of Pharmacy degree, standards relate to the curriculum, experiential education program, strategic plan, faculty qualifications, and organizational support.  Although accreditation is intended to ensure that every school/college meets and maintains high standards, there is wide variability in skills and competencies obtained by students.  For example, schools of pharmacy located on a academic health sciences campus provide the opportunity for interdisciplinary interactions earlier in their curricula.  Programs located in states with progressive pharmacy practice acts may offer students a greater breadth of practice experiences relative to other programs that are limited by legal constraints.  Differences in curricular design, assessment strategies, experiential education opportunities, and interprofessional interaction often sets one accredited school apart from another.

National pharmaceutical organizations have advocated for revisions in the ACPE accreditation standards to ensure that future graduates are ready for practice and can meet employer expectations.  At a 2012 conference, stakeholders provided recommendations including:

• Greater emphasis on developing skills for literature evaluation and data interpretation.
• Identifying and cultivating behavioral attributes needed by pharmacists in practice including interprofessional collaboration, clinical reasoning, and motivation.
• Ensuring assessment data is utilized for program improvement.
• Using standard assessment questions at the conclusion of advanced practice experiences such as “Would you hire this student?” and “Are the student’s skills at a level ready to enter practice?”³

Many of the recommendations focus on ensuring the pharmacy program adequately trains student pharmacists to enter the workforce as healthcare providers capable of providing direct-patient care.

Reviewing future employer expectations highlights gaps in the current ACPE standards.  Some expectations relate to managerial and business aspects of pharmacy (e.g. delegating tasks, measure/report performance, pharmaceutical supply chains); others place emphasis on health care delivery systems.⁴  Some employers expressed expectations that students should be competent in everyday activities such as documenting in electronic records, respecting patient confidentiality, managing drug waste, and administering common dosage forms.⁴   

After reflecting on my education and listening to the experiences of other recent graduates from different schools of pharmacy, many (but not all) of these expectations are already included in the curriculum.  However, the depth to which they are taught (if they are taught at all) varies greatly.  This likely explains the variability in competencies seen among graduating students today.

ACPE has released a draft version of the 2016 accreditation standards for comment.  These draft standards incorporate many of the recommendations from the stakeholders conference.⁵ These new standards would force schools/colleges of pharmacy to critically review their current curriculum and find opportunities for enhancement. Terminology within the proposed standards better delineates which items are necessary (i.e. “must” statements listed in the standard document) versus items recommended to enhance the quality of the program (i.e. “should” and “could” statements listed in the guidance document).⁵ Twenty-six standards are organized into three major themes: Educational Outcomes, Structure and Process to Promote Achievement of Education Outcomes, and Assessment.⁵ This change in organization of the standards document mirrors the change pharmacy. As health care delivery changes, the pharmacist’s role has shifted from the traditional dispensing/drug distribution functions to a focus on patient care functions, health outcomes, and cost-effective use of drugs.  This shift is evident within the proposed draft of Educational Outcomes as there is greater emphasis on patient care functions and practicing in interprofessional healthcare teams.⁵

One key change between the current and proposed standards is the separation of standards and guidance statements.^5,6 This separation is where pharmacy schools/colleges can customize their program and truly shine.  ACPE acknowledges that pharmacy programs differ and the guidance document is intended to elevate a program from meeting the bare minimum to producing outstanding graduates with unique skills that are highly sought by employers.

For faculty (or those seeking faculty positions), knowledge of the proposed standards and guidance documents should inform course development. The new standards allow for flexibility in terms of innovative course design and delivery methods.⁶  This could include adopting the “flipped classroom” method when redesigning a course or creating a new interdisciplinary elective.  The guidance document includes examples of co-curricular experiences that can be built into courses including student participation in activities such as Legislative Day, brown bag and medication review events, and serving as an institutional ambassador.⁶  It is unlikely that a school/college of pharmacy will be able to successfully implement and master all recommendations included in the guidance document.  Being selective about what can be optimally incorporated into the pharmacy program will maximize student learning and help set the school/college apart.

Ultimately the guidance document encourages schools to strive for excellence.  Accreditation ensures that students gain foundational knowledge and attain a reasonably similar level of competency to perform core professional functions regardless of what school/college they attend.  However, not all schools / colleges are alike.  Utilizing the guidance recommendations and capitalizing on local or state resources will help good programs become great programs.

References

1. Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree (Guidelines Version 2.0, Adopted: January 23, 2011, Effective: February 14, 2011). Accessed March 14, 2014.
2. Vlasses PH, Wadelin JW, Boyer JG, et al. Annual Report of the Accreditation Council for Pharmacy Education. Am J Pharm Educ 2013; 77(4):Article 83.
3. Zellmer WA, Beardsley RS, Vlasses PH. Recommendations for the Next Generation of Accreditation Standards for Doctor of Pharmacy Education. Am J Pharm Educ 2013; 77(3):Article 45.
4. Vlasses PH, Patel N, Rouse MJ, et al. Employer Expectations of New Pharmacy Graduates: Implications for the Pharmacy Degree Accreditation Standards. Am J Pharm Educ 2013; 77(3):Article 47.
5. Accreditation Council for Pharmacy Education. Accreditation standards and key elements for the professional program in pharmacy leading to the doctor of pharmacy degree (Draft Standards 2016, Released: February 3, 2014).  Accessed March 14, 2014
6. Accreditation Council for Pharmacy Education. Guidance for the accreditation standards and key elements for the professional program in pharmacy leading to the doctor of pharmacy degree (Draft guidance for standards 2016, Released: February 3, 2014).  Accessed March 14, 2014.