The value of the ‘7E’ instructional model in the teaching of nursing students in nursing clinical probation

Abstract

Objective

To investigate the value of 7E instructional model in the teaching of nursing students in nursing clinical probation.

Methods

One hundred and fifty-nine nursing undergraduates of the class of 2018 who were on probation in our hospital from November 2020 to June 2021 were selected as the control group by convenience sampling, and the traditional teaching model was adopted; an additional 171 nursing undergraduates of the class of 2019 who were on clinical probation in the same hospital from November 2021 to June 2022 were selected as the experimental group, and the 7E instructional model was adopted, including elicit, engagement, exploration, explain, elaborate, evaluate and extend.

Results

After the intervention, the experimental group was higher than the control group in theoretical knowledge scores (59.47 ± 4.51 VS 54.11 ± 8.46), practical skills scores (19.62 ± 1.36 VS 19.14 ± 1.24) and total course scores (90.13 ± 2.98 VS 84.67 ± 4.47); total scores of learning motivation (30.57 ± 5.24 VS 29.41 ± 4.77), learning cooperation ability (20.35 ± 4.41 VS 19.02 ± 4.25), information literacy (23.14 ± 4.36 VS 21.12 ± 3.95) and self-regulated learning ability (114.00 ± 19.72 VS 109.07 ± 18.61); total scores of viewpoint acquisition (43.58 ± 5.21 VS 42.16 ± 5.10), emotional care (33.41 ± 4.54 VS 32.09 ± 4.47), transposition thinking (13.04 ± 2.97 VS 11.56 ± 2.43) and empathy ability (89.03 ± 13.87 VS 85.81 ± 13.55); and total scores of positive attitudes toward communication skills (55.39 ± 7.03 VS 51.54 ± 6.54), with a statistically significant difference (P < 0.05).

Conclusion

The 7E instructional model contributes to improved course grades, self-regulated learning and empathy, and positive attitudes toward communication skills among nursing students in their nursing clinical probation.

Introduction

In the wake of the Healthy China initiative and the associated reforms of the medical model, society’s demands on nurses have been increasing accordingly. In addition to a solid theoretical foundation and strong operational skills, they are required to gain comprehensive competencies, such as verbal communication ability, humanistic care ability, empathy ability and critical thinking ability [1, 2]. Nursing undergraduates, as the future backbone of the nursing profession, are expected to benefit from a well-rounded education and continuously cultivate their skills. However, nursing students are often caught in a series of dilemmas, such as how to deal with the gradual decrease in practice opportunities and insufficient exercise of practical skills, while coping with the frequent occurrence of negative events, such as doctor–patient disputes and the increasing distrust of medical staff by patients [3]. Their difficulties have been alleviated by the introduction of clinical probation, which is a practical opportunity to lay a robust foundation for their future clinical internships [4]. In recent years, teaching staff have been showing increasing interest in ways to deliver efficient and high-quality clinical probation to nursing undergraduates. Clinical nursing probation is an important link in the process of nursing education. It is a bridge for students to transition from basic theory to clinical practice, and it is an important way to cultivate and improve nursing students’ logical thinking and clinical comprehensive application of the theory they have learned. It is a necessary process to realise the transformation from students to practice nurses. Nursing clinical probation includes observational learning, practical operation, case discussion and nursing ethics and psychology. The implementation of clinical probation of nurses is a systematic and comprehensive process. It aims to help students combine theoretical knowledge with clinical practice and improve their professional skills and professionalism through observation, practice, learning and assessment [5]. Nursing teaching is facing problems, such as students’ lack of independent learning motivation, lack of empathy and humanistic care literacy and poor understanding of the importance of communication skills [6]. Therefore, nursing educators need to discuss how to improve the quality of nursing students’ education. For example, the innovation, integrity and effectiveness of teaching need to be improved, and the preparation, implementation and evaluation of the training need to be further enriched [7].

The 7E instructional model is based on the theory of constructivism and was initially proposed in 2003 by Arthur Einsenkraft [8], a former president of the American Teachers Association. He based it on the 5E instructional model [9] developed by the American Biological Science Curriculum and added the two new stages of ‘elicit’ and ‘extend’ [10]. The seven stages of this model are as follows: elicit, engage, explore, explain, elaborate, evaluate and extend; together, these are known as the ‘7e’ model, formed from the initial letters of the stages [11]. The model is systematic, cyclical, extensive and practical, which enables the introduction of diverse teaching methods at each stage and integrates their respective advantages. It encourages students to conduct inquiry-based learning through investigation, experiment and discussion and extends knowledge to multidisciplinary fields, which not only facilitates the construction and exercise of theoretical knowledge and practical ability but also cultivates students’ comprehensive competencies. The 7E instructional model is of great significance and research value in leading the reform and development of clinical probation teaching and cultivating application-oriented nursing undergraduates. Domestically, explorations of the 7E instructional model are ongoing and have been remarkably productive in an array of specialised fields. A randomised controlled trial by Nekouei [12] found that compared with conventional teaching methods, the 7E learning cycle model was more effective in improving nursing students’ critical thinking, prevention knowledge and self-efficacy of diabetic foot ulcers. However, there are still few studies on the application of this model in the field of nursing teaching, and the effect of the 7E teaching model needs further verification. Therefore, in this study, we apply the 7E instructional model to the clinical probation teaching of nursing undergraduates in surgical nursing, aiming to serve as a reference for the reform of teaching in this field.

Subjects and methods

Subjects

The mutual control experiment design was adopted for this research. One hundred seventy-one nursing undergraduates of the class of 2019 who were on clinical probation in our hospital between November 2021 and June 2022 were selected as the experimental group; an additional 159 nursing undergraduates of the class of 2018 who were on probation in the same hospital between November 2020 and June 2021 were selected as the control group. The inclusion criteria were as follows: (1) four-year nursing undergraduates who had passed the national unified enrolment examination; (2) junior nursing undergraduates in the probation stage; and (3) nursing undergraduates who gave informed consent and voluntarily participated in this study. The exclusion criteria were as follows: (1) nursing undergraduates who were absent from the probation ≥ 3 times due to sick leave or personal leave according to the probation class schedule; and (2) nursing undergraduates who withdrew from the study for personal reasons. This study strictly followed ethical principles, clarified the research purpose and implementation plan to teachers and students before implementation, allowed students to independently decide whether to participate and required them to sign an informed consent form. This study was completed in the course of nursing teaching. All nursing students received intervention and did not involve the recruitment and withdrawal of participants. This study was approved by the ethics approval committee of the hospital.

Study methods

Control group: the traditional teaching model was adopted, in which the content of each chapter was taught according to the syllabus. The teaching process included the following: (1) 1 week before the lecture, the instructor released the pre-study content and classic clinical cases through the online platform, and the students independently looked up the information to obtain a basic understanding of the disease; (2) in the classroom, the instructor briefly explained the case using multimedia tools, such as presentation slides, pictures and videos, and issued a question; the students then discussed the question in groups (five groups, according to the number of students, with five or six students per group). Nursing procedures were used to complete the differential diagnosis of the patient, health assessment and the development of implementation goals, treatment plans and measures. After the discussion, a representative of each group was selected to present the results of the discussion, during which other groups could make comments and ask questions based on the results, and finally, the instructor added corrections to the discussion and summarised the guidance; (3) The teacher led the students to carry out nursing examination, including patient assessment, medical history collection, nursing skills and precautions. After the lecture, the instructor summarized the contents of the examination into nursing cases and wrote a reflective diary based on any deficiencies.

Experimental group: The 7E teaching mode was adopted to teach the syllabus in an orderly manner. The teaching syllabus requirements of the control group and the experimental group were consistent. The teaching process included the following steps: 2 weeks before the class, literature and movies related to narrative nursing were recommended through the online platform, and excellent parallel medical records were uploaded; 1 week before the class, the clinical cases, specific questions, specific requirements and reference books were released, and one or two literature review or guideline references were recommended, supplemented by questions, spot checks and other methods of encouraging students to complete the pre-study task. After the class, students reflected on what they had learned in this course and completed the post-course reflection questions provided by the instructor; during this time, students could consult online at any time if there were omissions, deficiencies or difficulties in their knowledge base.

The class was conducted under the framework of the 7E instructional model, which operates as follows: (1) elicit: students are introduced to an understanding of specialised diseases, special treatment and nursing care and are provided with real clinical cases and related pictures, videos, documents and other materials to demonstrate relevant nursing experience and fully stimulate their interest in learning; (2) engage: students will have formed a preliminary impression of the content of the case through pre-course study; based on this, the instructor leads the students to review the specific circumstances of the case and emphasises the clinical manifestations of the patient, diagnostic points, auxiliary tests and other key points, thereby immersing students in the clinical situation and encouraging them to participate in the exploration activities; (3) explore: the literature-oriented case-based learning/reference-induced self-education (CBL–RISE) teaching method is used to organise students to discuss the case. In this process, students discuss specific issues in the case based on their reading, understanding and analysis of the textbook and literature, while the instructor answers questions, corrects problems promptly and accurately grasps and captures the main points of knowledge; (4) explain: after each group shows and reports the results of the discussion, the students in the group compare the results with those of other groups or the conclusions provided by the instructor and the textbook; they can raise questions about different points of view, state their views and learn from each other. The instructor should guide, supplement and correct the students in the process of discussion and finally explain to the students how to form scientific concepts; (5) elaborate: students design their own simulation based on the case scenarios and their knowledge and compile a simulation script by collecting, organising and analysing information and literature beforehand and then presenting it in class. The detailed implementation process is divided into three stages: preparation, implementation planning and evaluation. The preparation stage includes students’ scene preparation, material preparation and role preparation; in the implementation planning phase, the instructor randomly selects a group to present the simulation and guides the students with passive prompts during the simulation process; the evaluation stage involves learning from each other and evaluating each other in a peer-assisted way, pointing out each other’s shortcomings, cultivating teamwork awareness and ability and thus enlivening the classroom atmosphere; (6) evaluate: at the end of each apprenticeship course, the instructor evaluates the overall performance of the students and assesses their mastery of theoretical knowledge (a total of 100 points), accounting for 60% of the total score, and operational skills (a total of 100 points), accounting for 40% of the total score, and the students’ overall grades are calculated; (7) extend: this section is divided into six sessions in accordance with the three stages of preliminary work preparation, writing of parallel medical records and sharing of parallel medical records. Details of the stages are as follows: [i] preliminary work preparation: students form initial impressions after reading and watching narrative nursing literature, film and television works, sample parallel medical records and are organised to watch a summary of narrative nursing, classic cases of narrative nursing and videos of narrative nursing practice in three sessions; [ii] writing of parallel medical records: the instructor introduces the concept of parallel medical records, the current situation, writing skills, precautions, classic bridges and the differences and connections between parallel medical records and ordinary medical records and displays and explains the sample parallel medical records to strengthen the cognitive structure of the students and standardise the writing format; At the end of the lecture, the instructor leads the students through practical nursing exercises, including basic information collection, medical history collection and nursing evaluation. The instructor also applies the concept of narrative nursing to communicate with the patients and guide them, in a positive and humanistic way, to understand the patient’s journey of the disease and to appreciate the patient’s inner feelings. Students are required to complete the parallel medical records after the class in two sessions; [iii] sharing of parallel medical records: sharing parallel medical records with the help of a problem-based learning (PBL) approach, including students’ reading, group discussion and instructor’s summary, or by inviting nursing students in the internship stage to share their own clinical experience and feelings to carry out peer education and deepen students’ understanding of narrative nursing and medical humanities.

The control group and the experimental group were taught twice a week for ≥ 120 min each time, and a total of 24 lessons were taught.

Effectiveness evaluation

Course assessment

Students in the experimental group and the control group were assessed in the same way before and at the end of the probationary course.

(1) Theoretical knowledge assessment: This included single-choice questions, multiple-choice questions, short-answer questions and case studies (total score of 100 points), accounting for 70% of the total grade; the question bank was compiled by the faculty team, and the assessment was conducted in a closed-book exam format.

(2) Practical skills assessment: up to 30 points were awarded for clinical thinking, 50 points for operational skills and 20 points for humanistic care, accounting for 30% of the total score; representative cases were selected by clinical nursing instructors according to the content of the probation, such as the emergency care of a duodenal ulcer combined with upper gastrointestinal haemorrhage and shock, to implement a comprehensive assessment of students.

Evaluation of self-regulated learning ability

The evaluation tool for self-learning ability developed by Zhang Xi Yan et al. [13] was adopted to evaluate the self-regulated learning ability of nursing undergraduates; the tool involves the four dimensions of learning motivation, self-management ability, learning cooperation ability and information quality, with a total of 30 entries. A 5-point Likert scale was used, with higher scores indicating more independent learning, and Cronbach’s α coefficient was 0.822. Five nursing education specialists who were consulted were generally satisfied with the test questions.

Evaluation of empathy ability

The Jefferson Scale of Empathy – Health Professionals [14] was used, including the three dimensions of viewpoint selection, emotional care and transposition thinking, with a total of 20 entries. A 7-point Likert scale was used, with higher scores indicating stronger empathy, the Cronbach’s α coefficient of the scale was 0.739 and the test–retest reliability was 0.843.

Attitudes toward communication skills

The Chinese version of the Communication Skills Attitude Scale, revised by Ren Peishu et al. [15], was adopted for medical students, including the two factors of positive and negative attitudes, with a total of 26 entries. A 5-point Likert scale was used, with higher positive attitude scores and lower negative attitude scores indicating more positive attitudes toward communication skills; two metric factors were extracted for the factor analysis, with a cumulative contribution of 32.92%.

Statistical analysis

All data in this study were analysed statistically using SPSS 26.0 software(IBM, Armonk, NY, USA). Students’ achievements, self-regulated learning, empathy and communication skills scores were expressed as mean ± standard deviation, and two independent samples t-tests were employed for inter-group comparisons, with a test level set at α = 0.05.

Results

General data

As shown in Table 1, the participants were full-time nursing undergraduates in their junior year. In the experimental group, there were 171 students, including 27 men (15.79%) and 144 women (84.21%), aged 20.37 ± 1.08 years; in the control group, there were 159 students, including 23 men (14.47%) and 136 women (85.53%), aged 20.68 ± 1.10 years.

Table 1.

General data

Group	Item	Value
Experimental group (n = 171)	Male/female (n (%))	27(15.79)/144(84.21)
	Age (years old)	20.37 ± 1.08
Control group (n = 159)	Male/female (n (%))	23(14.47)/136(85.53)
	Age (years old)	20.68 ± 1.10

Comparison of course grades between the two groups

Table 2 shows that there is no statistically significant difference (p > 0.05) between the theoretical knowledge scores, practical skills scores and total scores of the two groups of students before the intervention. After the intervention, the experimental group had higher theoretical knowledge scores (59.47 ± 4.51 vs. 54.11 ± 8.46), practical skills scores (19.62 ± 1.36 vs. 19.14 ± 1.24) and total scores (90.13 ± 2.98 vs. 84.67 ± 4.47) than the control group, with a statistically significant difference (p < 0.01).

Table 2.

Comparison of course grades between the two groups

Item	Experimental group (n = 171)	Control group (n = 159)	t	P
Theoretical knowledge	59.47 ± 4.51	54.11 ± 8.46	7.251	<0.001
Practical skills	19.62 ± 1.36	19.14 ± 1.24	3.342	0.001
Total course score	90.13 ± 2.98	84.67 ± 4.47	13.139	<0.001

Comparison of self-regulated learning ability between the two groups

Table 3 shows no statistically significant difference between the two groups in terms of self-regulated learning ability before the intervention (p > 0.05). After the intervention, the experimental group had greater learning motivation (30.57 ± 5.24 vs. 29.41 ± 4.77), learning cooperation ability (20.35 ± 4.41 vs. 19.02 ± 4.25), information literacy (23.14 ± 4.36 vs. 21.12 ± 3.95) and total scores (114.00 ± 19.72 vs. 109.07 ± 18.61) than the control group, with a statistically significant difference (p < 0.05).

Table 3.

Comparison of self-regulated learning ability between the two groups

Stage	Item	Experimental group (n = 171)	Control group (n = 159)	t	P
Pre-instruction	Learning motivation	28.67 ± 4.24	28.94 ± 4.51	0.561	0.575
	Independent learning ability	37.81 ± 5.92	37.43 ± 5.54	0.601	0.548
	Learning cooperation ability	17.05 ± 3.28	17.21 ± 3.31	0.441	0.660
	Information literacy	20.89 ± 3.47	21.01 ± 3.52	0.312	0.755
	Total score	104.42 ± 14.95	104.59 ± 15.03	0.103	0.918
Post-instruction	Learning motivation	30.57 ± 5.24***	29.41 ± 4.77	2.098	0.037
	Independent learning ability	39.94 ± 7.22**	39.52 ± 6.94	0.538	0.591
	Learning cooperation ability	20.35 ± 4.41***	19.02 ± 4.25	2.786	0.006
	Information literacy	23.14 ± 4.36***	21.12 ± 3.95	4.400	<0.001
	Total score	114.00 ± 19.72***	109.07 ± 18.61	2.332	0.020

Note **: indicates a statistically significant difference between post-instruction and pre-instruction, P < 0.01; ***: indicates a statistically significant difference between post-instruction and pre-instruction, P < 0.01

Comparison of empathy ability between the two groups

Table 4 shows no statistically significant difference between the two groups in terms of empathy ability (p > 0.05). The total score of empathy ability and the scores of all dimensions of the experimental group were improved compared with those before the intervention (p < 0.001). After the intervention, the experimental group had greater viewpoint acquisition (43.58 ± 5.21 vs. 42.16 ± 5.10), emotional care (33.41 ± 4.54 vs. 32.09 ± 4.47), transposition thinking (13.04 ± 2.97 vs. 11.56 ± 2.43) and total scores (89.03 ± 13.87 vs. 85.81 ± 13.55) than the control group, with a statistically significant difference (p < 0.05).

Table 4.

Comparison of empathy ability between the two groups

Stage	Item	Experimental group (n = 171)	Control group (n = 159)	t	P
Pre-instruction	Viewpoint acquisition	40.36 ± 4.99	40.64 ± 5.01	0.508	0.612
	Emotional care	30.87 ± 4.18	31.12 ± 4.28	0.537	0.592
	Transposition thinking	10.92 ± 2.05	10.72 ± 1.97	0.902	0.368
	Total score	82.15 ± 9.95	82.48 ± 10.21	0.297	0.766
Post-instruction	Viewpoint acquisition	43.58 ± 5.21***	42.16 ± 5.10	2.499	0.013
	Emotional care	33.41 ± 4.54***	32.09 ± 4.47	2.659	0.008
	Transposition thinking	13.04 ± 2.97***	11.56 ± 2.43	4.933	<0.001
	Total score	89.03 ± 13.87***	85.81 ± 13.55	2.131	0.034

Note ***: indicates a statistically significant difference between post-instruction and pre-instruction, P < 0.01

Comparison of attitudes toward communication skills between the two groups

Table 5 shows no statistically significant difference between the two groups in terms of attitudes toward communication skills (p > 0.05). The positive attitude score of the experimental group increased (55.39 ± 7.03 vs. 53.17 ± 6.97), whereas the negative attitude score decreased (37.15 ± 5.98 vs. 39.82 ± 6.12) compared with that before the intervention, with a statistically significant difference (p < 0.01). After the intervention, the experimental group had greater total scores of positive attitudes toward communication skills (55.39 ± 7.03 vs. 51.54 ± 6.54) than the control group, with a statistically significant difference (p < 0.001), whereas there was no statistically significant difference between the negative attitude scores of the two groups (p > 0.05).

Table 5.

Comparison of attitudes toward communication skills between the two groups

Stage	Item	Experimental group (n = 171)	Control group (n = 159)	t	P
Pre-instruction	Positive attitude	53.17 ± 6.97	52.78 ± 6.72	0.517	0.606
	Negative attitude	39.82 ± 6.12	40.27 ± 6.35	0.655	0.513
Post-instruction	Positive attitude	55.39 ± 7.03**	51.54 ± 6.54	5.140	<0.001
	Negative attitude	37.15 ± 5.98***	37.33 ± 6.12	0.270	0.787

Note **: indicates a statistically significant difference between post-instruction and pre-instruction, P < 0.01; ***: indicates a statistically significant difference between post-instruction and pre-instruction, P < 0.01

Discussion

Clinical probation is a vital way for nursing undergraduates to consolidate theoretical skills and master operational skills, and it is also an essential part of cultivating comprehensive nursing abilities, such as theory-to-practice, communication and coordination and health education [16]. The present study found that the nursing undergraduates in the experimental group had higher theoretical and operational assessment scores and total scores than those in the control group (p < 0.01), which was consistent with the findings of Cai et al. [17], indicating that the 7E instructional model was more effective than traditional teaching in terms of the improvement of theoretical and practical assessment scores. The 7E instructional model, as a major variant of constructive teaching, systematically synthesizes and flexibly applies a variety of teaching methods to create a logical and procedural teaching paradigm for the unstructured classroom; this enables knowledge to be presented in a structured and progressive form, which is in line with the cognitive structure and cognitive ability of students. The extension of clinical practice is conducive to the exercise of practical skills such as communication, collaboration and humanistic care, thus promoting the dual enhancement of students’ theoretical knowledge and practical level.

Self-regulated learning ability refers to the ability to seek and utilise objective resources actively to acquire and master the necessary knowledge and skills effectively based on a certain learning motivation and attitude [18]. As a core competency necessary for nursing students, it depends on the characteristics of the nursing speciality, which facilitates the guarantee for future continuous learning, updating knowledge reserve and skills and adapting to the development needs of health services [19]. As shown in this study, the total score and three dimensions of self-regulated learning ability of nursing students in the experimental group were higher than those of the control group, except for the dimension of self-management ability (p < 0.05); after the intervention, the total score and dimensions of self-regulated learning ability of the experimental group improved compared with those of the pre-intervention period (p < 0.01), which was consistent with the results of the study by Adesoji et al. [20]. These indicate the obvious effectiveness of 7E instructional model (7E instructional model) in the improvement of students’ self-regulated learning ability. Always adhering to the tenet of “student-centered”, the 7E instructional model realizes the cultivation of students’ sense of independent inquiry and self-regulated learning ability through the integrated effect of each link.

Empathy ability refers to the process of learning and practising to consider problems and experiencing the feelings and emotions of others from their perspectives and then producing similar emotional experiences and behavioural responses [21]. Empathy ability extends social intelligence to the emotional domain. Nursing undergraduates with good empathy can help promote clinical communication ability, strengthen the understanding and trust between nurses and patients, improve the nurse–patient relationship, avoid emotional exhaustion and improve the quality of clinical care [22]. In our study, we showed that the total score and three dimensions of empathy ability in the experimental group were higher than those in the control group (p < 0.05); the total score and dimensions of empathy ability in the experimental group after the intervention were significantly higher than those before the intervention (p < 0.001), indicating the significant effect of the 7E instructional model on the cultivation of students’ empathy ability. The 7E instructional model breaks through the disadvantages of traditional teaching, i.e., teaching demonstration by instructors and passive imitation by nursing undergraduates, while neglecting their concern for patients’ feelings and lack of communication with patients on an emotional level. It ensures that students have a more in-depth understanding and thinking about the concept of “patient-centeredness”.

Efficient doctor–patient communication is the key to determining patient satisfaction, adherence and recovery [23]. Nowadays, communication skills training is included in many institutions as a required course component; the accumulation of knowledge and skills alone still cannot meet al.l clinical needs. ‘Attitude’ reflects the way an individual treats people and things, which has an emotional aspect and can have a direct impact on behaviour. Positive psychology believes that favourable emotional experiences are conducive to strengthening human thinking and behaviour [24, 25]. Therefore, a good attitude toward communication skills can affect the learning state and effect. According to our study, the total positive attitude score of communication skills of nursing undergraduates in the experimental group was higher than that of the control group (p < 0.001), although the difference in the negative attitude scores was not significant (p > 0.05); the total positive attitude score for communication skills in the experimental group increased and the total negative attitude score decreased after the interventions (all p < 0.01), indicating that the 7E instructional model has a certain effect on improving positive attitudes towards communication skills and negative attitudes of nursing students. The 7E instructional model can only be fully implemented through active communication with the patient, which allows students to realize the importance of communication in building a harmonious relationship with the patient and the key role of the attitude towards communication skills.

Nonetheless, there are some limitations to this study: this study was conducted only for clinical probation teaching. It is recommended that the 7E instructional model be utilized in future research for probation teaching sessions. Finally, this study compared the effects of traditional nursing teaching mode and 7E teaching mode. The gender ratio, personality characteristics and performance basis of participants may affect the results of the study. To mitigate this risk, we conducted a balanced comparison of the above variables before data processing and found that the two groups were comparable, which helped to control the influence of other factors on the research results.

Conclusion

The 7E instructional model contributes to improved course grades, self-regulated learning and empathy and encourages a positive attitude toward communication skills among nursing students in their nursing clinical probation.

Author contributions

CLP and DYT conceived of the study, and ZS and SXX participated in its design and data analysis and statistics. All authors helped to draft the manuscript, read and approved the final manuscript.

Funding

Shanxi Province General Teaching Reform and Innovation Project Fund（J20230455） .

Data availability

All data generated or analysed during this study are included in this article. Further enquiries can be directed to the corresponding author.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the Declaration of Helsinki and approved by the ethics committee of Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences. We obtained signed informed consent from the participants in this study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.