Frequently Used Conceptual Frameworks and Design Principles for Extended Reality in Health Professions Education

Abstract

Health professions education (HPE) has witnessed a dramatic increase in the use of extended reality (XR), but there is limited evidence that conceptual frameworks are being effectively employed in the design and implementation of XR. This paper introduces commonly utilized conceptual frameworks that can support the integration of XR into the learning process and design principles that can be helpful for the development and evaluation of XR educational applications. Each framework and design principle is summarized briefly, followed by a description of its applicability to XR for HPE and an example of such application.

Introduction

In recent years, health professions education (HPE) has witnessed a dramatic increase in the use of extended reality (XR). This trend has been observed in all subdomains of this technology, including virtual reality (VR), augmented reality (AR), and mixed reality (MR) [1]. Many of these changes have been driven by the increased availability and affordability of XR hardware and software, as well as early reports of potential educational benefits stemming from the use of these technologies for the development of professional skills and competencies [2–4].

As with any new technology, the introduction of XR to HPE has been met with great excitement and high expectations of its potential benefits. But it has also been regarded with some skepticism due to the lack of clear evidence regarding its impact on educational outcomes and cost-effectiveness. Like all new training tools, its efficiency and effectiveness depend on careful implementation following sound theoretical principles [5], which have not been adequately addressed in the literature.

There is limited evidence of the role of conceptual frameworks in XR and how these theoretical constructs can be effectively used to implement this technology in HPE. This limitation is consistent with data gathered from higher education, where only 32% of technology developed follows some form of conceptual framework [6]. A systematic review conducted by Radianti et al. [7] identified a significant lack of reference to explicit learning theories in VR content or VR applications designed for higher education. As many as 68% of all papers included in their review omitted explicit references of any form of a conceptual framework to support the design or implementation of VR applications.

In this paper, we follow the definition of conceptual frameworks put forth by Bordage, which states that conceptual frameworks come from “theories with well-organized principles and propositions that have been confirmed by observations or experiments; models derived from theories, observations or sets of concepts; or evidence-based best practices derived from outcome and effectiveness studies” [8]. Conceptual frameworks do not operate in isolation; rather, a holistic approach to educational design may combine a number of frameworks that might emphasize different variables and outcomes while recognizing their inter-relatedness [8]. Each framework highlights or emphasizes different aspects of a problem or research question.

The purpose of this paper is to introduce a group of commonly used learning theories that provide the basis for conceptual frameworks that can support the integration of XR applications into the learning process. In addition, we highlight two design principles for XR user interfaces that can be helpful for the development and evaluation of XR for educational applications with a focus on learning. Design principles are defined as fundamental ideas about the development and evaluation of XR applications. Therefore, to apply these principles to specific XR projects, each application’s technological features and its functional context should be considered. The conceptual frameworks and design principles described in this paper are summarized in Table 1.

Table 1.

Examples of conceptual frameworks and design principles applicable to extended reality in health professions education

Framework	Brief description	Utilization — relevance to XR process (stage)	Example(s) in XR
Experiential learning cycle (Kolb)	Learning happens through a transforming experience via a 4-stage learning cycle: concrete experience, reflective observation, abstract conceptualization, and active experimentation. When students learn through hands-on experience and using analytical skills to reflect on their experience. These reflections lead to changes in the judgment, feelings, or skills of the student	Implementation Evaluation/assessment	Virtual patients Simulation Virtual task trainers
Four-step approach (Peyton)	The stepwise approach consists of the following four steps: (i) demonstration, (ii) deconstruction, (iii) comprehension, and (iv) performance. Peyton’s four-step approach is a good model for skills-lab teaching/training	Design Implementation Evaluation/assessment	Virtual task trainers Assessment of technical skills
Zone of proximal development (Vygotsky)	Refers to “the distance between the actual developmental level as determined by independent problem solving and the level of potential development … under [adequate] guidance….” Conceptually, it is the variable space between what a learner has mastered and what they are not yet able to do and is determined by what an individual can sufficiently perceive as doable when assisted	Design Implementation	Problem-solving simulations Adaptive learning task trainers
Mastery learning (Bloom, Carroll)	Learners gain mastery (as assessed relative to a minimum passing standard) through repeated opportunities to engage in deliberate practice of relevant, structured tasks that are specific to the learning objective	Design Implementation  Assessment Learner progress tracking	Task trainers Virtual patients
User-centered design	Iterative design process that emphasizes user perspective. Phases can include understanding the context of use, specifying user requirements, designing solutions, and then evaluating against those requirements	Design	All XR applications
Competency-based design	Approach to design that centers on achievement of competencies as educational outcomes. Design is tailored to meet objectives from cognitive, affective, and/or psychomotor domains	Design Implementation  Evaluation/assessment	Virtual task trainers Problem-solving simulations Assessment of technical skills

Conceptual Frameworks Applicable to Extended Reality Educational Activities in Health Professions Education

Experiential Learning

Experiential learning is defined as “the process whereby knowledge is created through the transformation of experience. Knowledge results from a combination of grasping and transforming experience” [9]. According to experiential learning theory, learners cycle through four different learning modes: concrete experience, reflective observation, abstract conceptualization, and active experimentation. Learners can enter the cycle at any point, and this process can happen quickly or over time [9]. Experiential learning asserts that knowledge acquisition is enhanced in environments where learners can explore, experience, and assimilate new information in the context of what they already know, using analytical skills to reflect on their experience. These reflections lead to changes in the learner’s judgment, feelings, or skills.

Application to XR

XR has the unique advantage of giving users the freedom to explore knowledge and environments through means not usually afforded to them by traditional methods. In the absence of a reference framework, many educational XR applications are designed with a specific learning outcome in mind but do not explicitly consider the learning process. XR-based educational activities are experiential learning opportunities because learners are immersed in a simulated environment which authentically mimics the actual setting where the knowledge and skills being learned will be put into practice. Learners make sense of observations as well as problem-solving and coordinated joint activities in the virtual world. Studies from different research fields (e.g., education, medicine) advocated the potential of VR as a technology that induces user interactivity [10]. VR provides a rich and engaging education context that supports experiential learning as users can experience learning by doing. This raises interest and motivation, effectively supporting knowledge retention and skills acquisition [10].

Example of Use

Virtual patients (VPs) are being increasingly used in XR-based educational activities to teach and practice clinical reasoning skills. The use of VPs alleviates the uncertainty of standardized patient cases and, significantly, facilitates a cognitive apprenticeship through experiential learning in a safe and permanently stable learning environment [9, 11]. While VPs are widely used in HPE [12], barriers to implementation of VPs include resource, cost [13], educator comfort with technology, and curricular integration.

Peyton’s Four-step Approach

The Peyton four-step approach is a widely accepted stepwise approach for skills-lab training in undergraduate and graduate health professions education and has been shown to be more effective than standard instruction [14]. It consists of the following four steps: (i) demonstration by the instructor of the whole procedure in real-time (“demonstration”); (ii) instructor repeats the demonstration while describing all procedural sub-steps (“deconstruction”); (iii) student talks the instructor through the procedure, and the instructor performs the procedure under the guidance of the student (“comprehension”); and (iv) student carries out the procedure on their own initiative (“performance”) [15]. The third step is considered an essential advancement in Peyton’s teaching approach and is especially beneficial for skill acquisition. The process of guiding the instructor through the procedure requires the student to remember and think about the first two steps in order to provide the instructor with the necessary direction [16]. This process can help students organize their thoughts and support student-centered learning [17]. Advancement to the point of comprehension where students themselves provide direction assists with the transfer of relevant information into the long-term memory. Peyton’s fourth step is also of educational importance as this is the stage in which the instructor provides feedback to the learner, a key component for effective skill acquisition in simulation-based medical education [18].

Application to XR

In Peyton’s four-step learning approach, the didactic portion of the curriculum concentrates on the first two steps, “Demonstration” and “Deconstruction” of a skill by the instructor [19]. Incorporating XR into these steps offers learners more practice opportunities, eventually making it easier to proceed to the next steps of “Comprehension” and “Performance.” In addition, real-time and rapid feedback in the form of interactivity and live mapping of performance can be significantly enhanced with XR-based educational activities, permitting learners to advance more rapidly to a level comparable to an experienced health professional and to gain the ability to perform independently [20].

Example of Use

Albrecht, Nikendei, and Praetorius assessed the face, content, and construct validity of a novel VR otoscopy simulator and its applicability to otologic training using the Peyton four-step approach when designing and implementing their experimental setup. The VR otoscopy simulator was equipped with a lifelike model ear and an otoscope handpiece for otologic training on the correct handling of the otoscope and correctly performed examination. The handpiece allowed the user to see, in real-time, a detailed 3-dimensional model of the outer and middle ear when looking through the otoscope. In addition, the simulator had a scale indicating the insertion depth of the otoscope, and virtual patients moaned when the otoscope was inserted too deeply. A second screen allowed the tutor to see the same image as the student. The results encourage the use of the otoscopy simulator as a complementary tool to traditional teaching methods in a curriculum for medical students [21].

Mastery Learning

Mastery learning theory is based on the premise that “if the students are normally distributed with respect to aptitude, but the kind and quality of instruction and the amount of time available for learning are made appropriate to the characteristics and needs of each student, the majority of students may be expected to achieve mastery of the subject” [22]. Foundational work from Carroll [23, 24] and Bloom [22] has been further developed and applied to HPE by multiple scholars, including McGaghie et al. who call attention to the applicability of mastery learning to HPE settings, where cognitively advanced, motivated learners are expected to achieve mastery in not only foundational knowledge, but also clinical skills [25].

Mastery learning as a guiding principle of educational design is grounded in behavioral, constructivist, and social cognitive theoretical traditions [26]. Intrinsic to design using mastery learning as a framework is the need to establish a minimum passing standard (and, by extension, a means of assessing whether learners have met the standard) and to build in opportunities for learners to engage in continued practice or study until they meet that standard. Thus, mastery learning is closely tied to the concept of deliberate practice, during which a learner engages in specific, highly structured tasks designed to counter weaknesses and improve performance [27].

Application to XR

Integration of XR-based educational activities along mastery learning principles has the most intuitive connection to skills development training in health professions education. XR allows learners to repeatedly practice technical skills like sterile technique and emergency response skills at their own speed, overcoming the problems of lack of access and the resource constraints of clinical learning centers that have limits to how many students can practice at one time [28]. XR takes advantage of the ability to develop our relationship with the physical world, enabling psychomotor practice to take place repeatedly to improve dexterity. While initial investments for equipment and content development may be high, compared to traditional models of simulation (manikin, standardized patient), VR and AR have the advantage of much greater flexibility in terms of time, setting, and content [29]. VR also extends the opportunity for auto-generated analyses that yield a rich source of data for formative feedback and assessment of mastery, essential linchpins of mastery learning. As such, educational activities designed to use XR as a means of deliberate practice offer opportunities for learners to repeatedly practice in structured, high-yield, self-regulated modules without the resource-intensive demands of traditional simulation [29].

Example of Use

The mastery learning theory is often used for skill development. Some institutions are using Microsoft Dynamics 365 Guides and Hololens2 to develop a mixed reality application to train students by providing holographic instructions, 3D holographic images, and videos that are visually tethered to a task trainer. The holographic images allow students to visualize structures such as arteries, veins, and vertebra within the optic lens of the Hololens2. Procedures including lumbar puncture, central line, arterial line, thoracostomy, thoracentesis, paracentesis, and sterile urinary catheterization are standardized using evidence-based protocols. Visual cues are given to the students in a systematic order to teach steps of the procedures. Students can independently practice a variety of skills until competency is achieved. Faculty time has been shown to be decreased by more than 75%, and competency testing outcomes were equivalent to traditional training methods.

Zone of Proximal Development

The zone of proximal development (ZPD) is a theory of cognitive development first introduced by the psychologist Lev Vygotsky in 1978 to help describe age-related cognitive developmental stages in children. Since that time, ZPD has been applied to many different types of learners in a variety of educational settings. Vygotsky proposed that social interaction profoundly influences cognitive development. He defined ZPD as “the distance between the actual development level as determined by independent problem solving and the level of potential development as determined through problem-solving under adult guidance or in collaboration with more capable peers” [30]. Put another way, ZPD is the variable space or distance between what an individual has already mastered and what they are not yet able to do, which is determined by what the individual can sufficiently perceive as feasible when assisted [31].

With respect to HPE curricula, keeping learners in their own ZPD should enable them to navigate clinical tasks or solve problems that might be too difficult to accomplish when working independently but can be accomplished with the support of an instructor and/or peers. If activities are too easy, learners aren’t challenged enough and may become disengaged. Conversely, if the activity is too difficult, learners may become frustrated, and little to no learning may occur as a result. Typically, learners in the health professions are within their ZPD if guidance is provided to accompany them while being asked to execute a particular clinical task or solve a particular problem. However, more complex clinical skills and responsibilities may be too difficult for the learner to take on, leading to unwanted tension or “destructive friction” [32], and can be viewed as activities that are outside or at the edge of their personal ZPD [33].

Application to XR

XR-based educational activities designed using multi-user platforms align very well with ZPD theory. A multi-user XR environment allows multiple users to share a virtual space (VR) or virtual space projected onto their common working environment (AR). In this type of virtual setting, learners with different levels of foundational knowledge and sets of skills are able to gather together in a familiar setting to discuss, create, or perform various types of cooperative activities while also maintaining the freedom to move and act independently without interfering with the actions of others. Additionally, models and objects can be observed and shared among all users, meaning all learners are able to observe the behaviors of others as they engage in problem-solving or executing tasks. In this way, multi-user VR and AR educational activities offer learners the opportunity to explore their personal ZPD but enable them to potentially expand it.

Example of Use

Riddle et al. [34] described a pilot study in which learners worked both independently and in teams in an immersive environment using wearable VR technology and layered images that allowed users to manipulate a neuron in a virtual setting. GLASS^© technology wearables created an immersive educational experience focused on the individual user, which was applied to activities that emphasized foundational histological and anatomical concepts. With respect to ZPD, this novel approach allowed learners to work on these activities both individually and in simultaneous, real-time groups [34]. The authors noted the potential benefits to educational and clinical applications this type of wearable, interactive, user-centric, augmented reality could provide. Overall, this work highlights how the use of XR technology has the potential to support cooperative work, as well as interdisciplinary collaboration when applied to HPE. The benefits of these unique experiences address one of the core tenets of ZPD, which is enabling learners to challenge themselves individually, or with assistance from or cooperation with other users and/or guided instruction.

Design Principles Applicable to Extended Reality Educational Activities in Health Professions Education

User-centered Design

User-centered design (UCD) is an iterative design process that can be applied to the design of XR applications. This process typically has several steps or phases that are followed throughout the process from conception to implementation. Each step of the process emphasizes the involvement of the user in the process. This can be done through a variety of methods. Early work by Donald Norman has influenced this process, particularly as it relates to human–computer interface [35]. Principles underlying this process include ensuring designers understand how the end-user will be able to interact with the system. Phases in user-centered design can include understanding the context of use, specifying user requirements, designing solutions, and then evaluating against those requirements. As this is an iterative process, the design is not linear in nature but rather evaluates the design throughout by continually comparing it to the user’s context and requirements [36].

There are variations of the UCD process, and the principles can also be incorporated into other design processes. The evaluation process generally includes usability testing with actual end-users. A standardized tool that can be used to support this process is the System Usability Scale [37]. This ten-item scale can be used to evaluate software, hardware, websites, and XR experiences. The NASA Task Load Index is another tool that can be used to measure the workload in human–machine interface systems [38]. The use of these scales and other mechanisms to provide feedback to designers from end-users are critical to ensuring the product that is developed or adopted for use will not frustrate users due to a poor design interface that detracts from the learning process.

Application to XR

When applying UCD principles to the development of XR applications, there are specific areas that should be addressed. Understanding the goals and tasks involved in the experience is important. This should build from the learning outcomes that drive the learning experience. Determining the level of immersion required is essential to help determine the best type of XR experience to create or select. Do users need to be fully immersed in their environment as they would in virtual reality, or will they need to interact with objects in the real world in combination with the digital one? The use of augmented and mixed reality may be more appropriate to the blending of real and digital. In XR environments, the user may be embodied as an avatar and will interact in ways that are different than in the real world [39]. The same principles to assist in the development of XR environments can also be used to evaluate existing programs.

Specific UCD principles that are important to consider in XR should include what options of interaction should be used. This can be referred to as game mechanics and should provide the learner with the basics to work through the program [40]. Options such as using teleportation to move around in the environment may be more suitable for the experience than actual walking or using a joystick to move. Drop-down menus or hot spots to interact within the scenarios are other options to consider [41]. Other principles can include organizing content to keep items together and accessible to the user in the XR environment. Keep the environment simple to avoid too many distractions, use cues in the environment to help the user know where to focus, and provide feedback to give users a sense of progression [42]. Impact on the user such as cybersickness and psychological safety are also considerations that can be influenced by the XR design as well as the process power of the devices used [43].

Example of Use

An example of how UCD principles were used in XR application development is found in the work by Chang et al. [41] in the design considerations of their Resuscitation Training simulation. They used principles from game mechanics to determine navigation in the XR experience as well as how a user would interact with digital objects. Aebersold et al. [43] developed a VR experience, Under the Skin, to help healthcare professionals learn about the risks of administering vesicant chemotherapeutic agents [44]. One of the learning goals was to expose the learners to what happens at a cellular level when a vesicant extravasation occurs and leaks into the patient’s tissue. The original idea was to have the user grasp a magnifying tool to view the cellular level. User feedback obtained during the usability testing phase indicated that this caused difficulty and frustration, which prevented users from meeting the learning goal. The use of a clickable button to view the cellular level was found to be a more usable option and decreased the frustration without impacting the learning goals.

Competency-based Design

Competency-based design (CBD) supports the goals of competency-based learning, an approach that is increasingly prevalent in HPE. In 2006, the International Competency-Based Medical Education collaborators outlined four key features of a competency-based approach: a focus on outcomes, an emphasis on abilities, a de-emphasis of time-based training, and the promotion of learner-centeredness [45]. In CBD, student readiness is assessed by clear performance outcomes that directly relate to and measure student competence [46].

In HPE, the outcomes (competencies) expected of program graduates extend beyond knowledge acquisition; thus, CBD would dictate that educational activities should also be targeted to all three of what are commonly referred to as the “three domains of learning”: cognitive, affective, and psychomotor. Incorporation of one or more domains of learning takes place through careful consideration and development of appropriate educational objectives which align with both the domain and the simplicity or complexity of the behavior. The cognitive domain is considered that which refers to knowledge, including factual, conceptual, procedural, and metacognitive knowledge [47]. Learning objectives targeting the cognitive domain commonly follow Bloom’s taxonomy [47, 48]. The affective domain addresses feelings and emotions, as well as attitudes, morals, ethics, and personal-social development. Krathwohl’s taxonomy for the affective domain includes receiving, responding, valuing, organization, and characterization [49]. The psychomotor domain refers to physical movement, performance of which comprises the objective. Harrow’s taxonomy for the psychomotor domain describes reflex movements, fundamental movements, perceptual abilities, physical abilities, skilled movements, and non-discursive communication [50].

Application to XR

Educational activities developed using CBD principles are well suited for healthcare programs that are preparing students to become practitioners. CBD is learner-centered and used to prepare students for graduation by creating XR applications to aid in the development of skills and check competency of students’ ability to perform assessments [51]. Research suggests that CBD leads to improvement in patient care, improved development, and retention of procedural skills, and is viewed as a valid way to assess students [52].

While many models of content delivery can support objectives in the cognitive domain, XR may have distinct advantages over some traditional educational models when it comes to targeting the affective and psychomotor domains. Some educators are evaluating whether XR can enable nurses to understand patients’ experiences in ways that could transform them into more empathic providers [53]. XR-based simulations of mental disorders may improve understanding of the effects of psychopathology and thus raise awareness for the learner [54]. However, there remains a gap in evidence to support this theory that XR learning exercises can help nurses be more empathetic. In the psychomotor realm, the concept of embodied learning, which posits that the body’s actions give rise to meaning and that adding movement to a learning signal should strengthen memory traces [55], has great scope for incorporation into XR-based educational activities.

Example of Use

Aebersold et al. [43] developed 360 videos to train nurses how to empathize and effectively care for patients who are Veterans or hard of hearing [56, 57]. The cognitive and affective domains of the CBD principles helped to guide the 360 video development. For the Veteran population, nurses were educated on military culture, establishing relationships, building rapport, and reintegration after deployment. Each video is recorded using a 360-degree camera capturing the view in all directions thus providing for an immersive learner experience if it is in a head mounted display. Learners can watch the video from several different perspectives and explore what is happening in the scenario. 360-degree video is generally accepted by students and has shown improvement in knowledge and communication skills.

Conclusion

The adoption of XR into HPE continues at an accelerated pace, with many institutions developing new applications or adapting existing ones to their training programs. But a careful approach is required to ensure that the introduction of this group of immersive learning technologies follows evidence-based educational principles.

This paper describes some commonly utilized conceptual frameworks and design principles and provides concrete examples of their use in health professions education. Design principles are necessary to guide the development of new XR applications to ensure they are effective and fit-for-purpose and minimize potential negative effects on users. The curricular implementation of new and existing XR applications must be guided by sound and proven conceptual frameworks to ensure their effectiveness as educational tools.

We hope this monograph can serve as a reference for educators embarking on designing or implementing XR-based educational activities, particularly in HPE fields and curricula. We look forward to seeing future research in this field that helps elucidate the impact of XR on educational outcomes and further the development of best practices in designing and implementing applications.

Declarations

Ethical Approval

Not applicable.

Informed Consent

Not applicable.

Conflict of Interest

The authors declare no competing interests.