From Caterpillar to Butterfly: What Pinterest Taught Me about Failure, Learning Needs and Effecting Change in CE/CPD: Part 2

By Annette Schwind, MS, CHCP, and Audrie Tornow, CHCP, Paradigm Medical Communications, LLC 

The previous article in this series reviewed the role of failure as a learning tool, and explored case vignettes as an experiential learning methodology that can be used in CME/CPD activities to offer HCPs opportunities to try and fail without negative consequences to patients. In this second article, we will explore hands-on learning. 

Hands-on Learning

Another way of providing experiential learning is hands-on instruction. Recently, Paradigm implemented a series of nine regional workshops that demonstrated the power of hands-on education to foster “aha” moments through failure to motivate learning, and how establishing risk-free environments to practice application of knowledge and skills can lead to behavior change. 

The workshops were focused on educating neurologists and physiatrists in the use of botulinum toxin A (BoNT-A) injections to treat upper limb spasticity (ULS). First, an expert faculty member delivered a brief lecture reviewing characteristics of ULS, basic anatomy, BoNT pharmacology and injection guidance techniques. Learners then proceed to the first hands-on exercise: the anatomy lab. 

In the anatomy lab, learners divided into groups of five or six, and gathered around one of several cadavers. One side of the cadaver had been previously prosected and the other side was intact. Each learner was provided with a syringe filled with a different color of dye simulating BoNT-A and assigned a muscle or muscle group often involved in ULS. The learners were asked to inject into the intact side of the cadaver where they would inject BoNT-A to treat spasticity in their assigned muscles. Once all learners in a group had injected, the supervising faculty member uncovered the prosected side of the cadaver and led the participants through an in-depth review of the actual muscle anatomy, while another faculty member dissected the side of the cadaver where the learners had just injected. Learners then returned to the newly exposed side of the cadaver to examine the results of their injections. The colored dye made it easy to see the placement of the learners’ injections and compare with where the injections should have been placed to achieve optimal treatment results. 

Figure 1. The Anatomy Lab

the anatomy lab.png

The faculty estimated that learners, on average, incorrectly placed the injections 58% of the time. This was in stark contrast to the knowledge and competence displayed by learners on written pre-test items dealing with anatomy. Seeing that their colored dye showed up in places it shouldn’t have been gave many of the learners pause as they reflected on what they thought they knew compared to the evidence in front of them. Clearly, knowledge and competence on paper did not translate into similar knowledge and competence in practice. The cognitive dissonance created by their failures in the anatomy lab exercise prepared and motivated participants to learn how to improve their performance of BoNT injections for ULS. 

Figure 2. Anatomy Lab Results

anatomy lab results.png

Following the anatomy lab, learners viewed a video of the expert faculty administering BoNT injections to a patient with ULS using ultrasound guidance, a technique that improves accuracy of injection placement. Learners also viewed a patient interview where she discussed her condition, past and current treatment, and the impact the injection therapy has had on her quality of life. These videos demonstrated the fundamentals of a technique that would help bridge the practice gap so vividly displayed by the anatomy lab and put a human face on the importance of optimal injection placement. 

Next, participants entered the ultrasound lab for another hands-on exercise. Here, learners broke into teams of two for hands-on practice with ultrasound machines. One learner would perform an ultrasound on his/her partner’s arm and then the partners would switch, giving the other learner the chance to try. The faculty members moved among the pairs, observing learner skills in two specific areas: properly reading the ultrasound display and localizing target muscles. Faculty provided feedback and instruction to the participants as they circulated among the pairs. 

Figure 3. The Ultrasound Lab

ultrasound lab.png

As they observed the learners, faculty rated them on their first attempts and last attempts using a 4-point scale where 1=Poor, 2=Fair, 3=Good, 4=Excellent. Faculty gave learners average ratings of 1.7 and 1.6, respectively on the two tasks on their first attempts (see figure 4). These ratings would seem to contradict the findings of the pre-tests, where learners showed considerable familiarity with the use of ultrasound and identifying structures on ultrasound displays. Again, as with the anatomy lab, the hands-on exercise confronted learners with failure, revealing performance in practice did not match performance on paper. 

But failure wasn’t the end — it was only a step in the learning process. Following practice and feedback, faculty gave learners average ratings of 3.1 on both items. These objective observation results represent an improvement of 82% in learner skill in reading ultrasound displays and a 94% improvement in skill regarding localizing target muscles for injection. 

Figure 4. Ultrasound Lab Results

ultrasound lab results.png

Learners were also asked to rate themselves. Initial average self-ratings were slightly lower than initial faculty ratings, which may reflect lack of confidence along with lack of experience. However, learner average self-ratings after instruction, feedback and practice were identical to the faculty ratings. It appears that their failures did not discourage learners from using the faculty feedback to improving their skills. 

How did these workshops impact the clinical practice of the participants? Commitment to change responses showed that HCPs recognized the value of using guided injection methods and now intended to use them in their practices. They also were ready to incorporate BoNT-A into their treatment plans for patients who have ULS, demonstrating a shift in their treatment approach. Finally, learners took away a better understanding of anatomy, which they intended to use to improve their evaluation of ULS in their patients. When asked about potential barriers to implementing these changes, learners cited the need for more practice and access to equipment. 

Two months following their participation, respondents to Paradigm’s follow-up survey indicated they had indeed made a practice change. The most frequently implemented change was also the top intended change noted immediately after the regional meetings: using guided injection techniques. Although the response rate to the follow-up survey was too low to draw definitive conclusions, these results suggest that the initiative prompted positive changes in practice behavior among participants. It is probable that the barriers identified by the learners kept more from responding to the two-month follow-up survey.

The ULS workshops are one example of how hands-on exercises can be used in CME/CPD interventions to create situations for HCPs where initial or even repeated failure is a tool for acquiring and refining knowledge and competence, leading to improved performance. Including personalized expert guidance and feedback is crucial to the educational design of such activities. 

Failure can be uncomfortable, even painful, and it has profound consequences for HCPs and patients in healthcare practice. It can also be a powerful educational tool, as long as learners are in an environment where they can fail safely. Persistence is key. Emerging from its chrysalis, a butterfly must struggle to break free. The struggle strengthens the butterfly and prepares it for life, much like struggling with failure can prepare each of us for greater things.


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