In the class, both groups participated in general discussion, case discussion and skills practice. For the experimental group, thequestions raised by the learners were discussed and answered by the teacher if necessary. For the control group, the teacher firstprovided explanations of the learning sheet questions that most learners had failed to correctly answer, and then checked if they hadany further questions. Then, two nursing cases, “assessment of the heart and blood vessels” and “assessment of the abdomen,” werepresented to both groups for discussion. The learners were divided into groups, practiced history taking, interviewed the simulatedpatients, and discussed possible differential diagnosis based on the collected physical assessment. During the process of drill andFig. 4. The annotation tool provided by the learning system.H.-C. Lin, et al. Computers & Education 139 (2019) 207–221212discussion, there were three coaches assisting and guiding. Next, the teachers randomly chose learners and simulated patients toconduct nursing skills practice while other learners evaluated them using the nursing skills checklist. Lastly, learners discussed andprovided just-in-time feedback according to the learners' and teachers' checklist. The course lasted for 3 h. Fig. 9 illustrates thelearning situation of teaching on site.After the activities, the learners were administered the nursing skills test, as shown in Fig. 10. The examination lasted for 15 min,during which individual learners' skills proficiency level was evaluated. The learners were also asked to take the knowledge test andto complete the questionnaires of self-efficacy, cognitive load, and critical thinking tendency