1. Initial instructional model
The initial model was based on the framework of the six-step Clinical Reasoning Cycle [6]. In the first step, students are to consider the overall situation, meeting the HSP as health professionals. This includes the circumstances in which students understand and describe the HPS’s situation and list what they see, hear and feel. In the second step, students are to collect information, observing the HSP, and identify main cues from collected information. In the third step, students are to systematize the information and derive the HSP's problems and major issues based on it. They also need to infer causes and results of the problems based on identified information with relevant evidence. In the fourth step, students are to set goals for the expected outcomes, and suggest plans (i.e., treatment, test and care) for HSP, synthesizing identified information and contents. In the fifth step, students are to suggest the expected outcomes and describe the effect of whether the HSP's condition can be improved through suggested plans. Finally, students are to reflect on the whole process and summarize what has been learned newly through this process. They are also to think about what they could have done differently from what they learned in this process, completing the entire 6-step process.
2. Secondary instructional model
The initial model was revised via expert review. Through reflecting on its process and sharing their insights, major improvements were conducted as follows: intuitiveness to be increased by displaying the overall flow of the instruction in steps, guide of the teaching-learning process in detail, description of the facilitator role, and guide for HSP and learning resources each clip. The secondary model was as follows (Fig. 2).
3. Final instructional model development and validation
Five experts were asked to complete the validation tool regarding secondary model. The CVI for each item and the CVI in this study were 0.8 or higher following two expert validations. It indicates that the validity of the final model is acceptable [8].
4. Results of model usability test
The usability test was conducted to evaluate its applicability in a teaching-learning context [9].
Two educators designed and implemented a 3-hour course in adult health nursing and emergency medical practice, respectively, using the instructional model and anaphylactic shock HSP case. They started with a 20-minute orientation, including the course outlines that describe the learning objectives, process, methods, assessments, and students’ roles. Then, twenty five students formed a group of 5 persons in group (i.e., 5 groups in total) and educators provided students with guides to use HoloPatient and HoloLens.
For the next 130 minutes, students were engaged in HSP-based learning activities through interactive learning and active participation. The interactive approach was facilitated with HSP observation and assessment, group discussion, selected presentations, and non-judgmental feedback from educators as a facilitator. Before observing CLIP 1, educators explained the brief scenario about anaphylactic shock, facilitated students to discuss in groups, using guided Q1 and then participated in a whole discussion and selected presentations for 10 minutes. They assisted students in groups in observing and assessing CLIP 1 of the HSP experiencing anaphylactic shock for 15 minutes, and then facilitated them to discuss in groups, using guided Q2 and participated in a whole discussion and selected presentations for 15 minutes. Educators assisted students in groups in observing and assessing the CLIP 2 for 10 minutes and let them discuss in groups, using the guided Q 3, 4, and 5, and then participated in a whole discussion and selected presentations for 25 minutes. They assisted students in groups in observing and assessing the CLIP 3 for 20 minutes and let them discuss in groups and then participated in a whole discussion and selected presentations for 15 minutes.
At the end of course, students participated in a 30-minute debriefing following the 20-minute self-reflection.
Regarding participating educators’ perspectives on the instructional model, they generally reported satisfaction with the instructional model of HSP-based learning. They reported that the process of activities each clip facilitated active learning and deep learning (i.e., problem solving). They also mentioned that the final step of debriefing helped summarize the whole case of HSP:
The process of small group discussion, selected presentation, and discussion in whole was helpful to identify areas that were not identified or should be kept in mind. (Instructor A)
…, it was a good opportunity for students in groups to share their thinking about symptoms and signs of the HSP change according to the level of severity. It helped them get to know how colleagues solve problems and recognize other perspectives in the same situation. (Instructor B)
Educators made some recommendations for its improvement. They suggest that the writing method needs to be specified, depending on observing method of the HSP to facilitate active and deep learning:
It was necessary to distinguish the writing method according to observing method of HoloPatent. It was not easy for them to write directly what they observed, wearing the HoloLens. So HoloLens wearers need to tell what they observed from the HSP immediately, and colleagues can write down it. (Instructor A)
5. Final instructional model
The final model has six steps as follows (Fig. 3).
1 Step: Consider the situation
In order for students to understand the HSP's situation before meeting it as health professionals, educators present the HSP's situation briefly to students. Students think about what problems the HSP has and what to do.
Then, educators assist students in groups in meeting the CLIP 1 of the HSP directly or indirectly. The educator (or students) wears the HoloLens, providing students with an opportunity to meet the CLIP 1 of HoloPatient. Students write what they understand about the HSP’s situation and assess, seeing, hearing, and feeling individually or in group, as well as the test results and environmental conditions around the HSP. Depending on the severity of the HSP and the level of the student, students can observe one or several CLIPs in module step by step. In this process, educators need to monitor the learning environment (e.g., solving technical problems).
2 Step: Collect cues and information
Students conduct a small group discussion to collect information they observed from the HSP and identify information that can be a major clue to the HSP with prior knowledge. Educators present prepared questions and proceeds step-by-step, or two or three questions at a time according to a pre-planned time. Then, the educator selects two groups to present their discussion in whole. Thus, students can share and summarize the information and cues in whole. Educators also provide feedback on this and allocates time according to the operation guideline.
3 Step: Identify problems and issues with potential cause
Students are to systematize information collected through group discussion and identify major issues related to problems of the HSP. They elicit actual problems of the HSP and issues related to potential problems from the identified information. They present the relevant evidence, inferring the cause and result of the problem from the identified information, and diagnose the HSP's problem through logical reasoning.
Educators provide feedback, so that students can share the contents of small group discussion through discussion and presentation in whole. If necessary, students can meet the CLIP 2 of the HSP in advance.
4 Step: Action plan with rationale
Students set goals for expected changes, prognosis or outcomes in the HSP’s situation, plan and suggest necessary treatments, tests, and care to be performed, synthesizing all information and problems found previously. They also find changes in HSP’s severity and progress according to evidence and treatment. Educators conduct this process, guiding small group discussion and selected presentations in whole, and providing feedback.
5 Step: Expected outcomes
Students present expected outcomes from treatment or care they suggested, and predict the HSP's prognosis and results, predicting the HSP's outcomes, and evaluating the results.
Then, educators select two groups to present the discussion in whole, collect, and organize additional contents and give feedback on this.
6 Step: Reflection
Students reflect on the whole process and summarize what they have learned newly individually. Before debriefing, educators provide time for students to write and think about how to deal with a similar patient in future, and what can be done differently from what was learned this time.
During debriefing, students are to recall the learning process and reflect through discussion and presentation of new and additional learning, and educators provide feedback as needed. Debriefing tool prepared in advance should be used.
After completing the CLIP 1 of HSP-based learning in this way, students can meet CLIP 2 - CLIP N of the HSP through the above steps. A second or other CLIP of the HSP can be planned in advance and put into an appropriate stage for use. Educators do not need to go through all of the above 6 steps. Within the scope that can achieve learning goals, they can expand or reduce steps flexibly depending on the planned HSP-based learning hours in courses, the number of students and devices, internet conditions, etc.