419 students were enrolled in years 3-5 and 387 chose to participate in the study.
302/387 (78%) responded, all of whom had a personal computer and 150/387(38%) already owned a handheld mobile device. The majority(68%) felt confident in their general IT skills and with the use of a mobile device. Initial perceptions of the advantages to using a PDA in medical education were the benefits of instant access and portability of the device. Disadvantages were thought to be loss or theft of the device, the development of dependency upon it and concerns that it might appear disrespectful.
Post study survey (see Table )
140 students responded (74/133 year 3 students, 66/123 year 4 students) with a response rate of 54.7% Year 5 students were not surveyed as they had already graduated but if included for "intention to treat" purposes, the response rate of the cohort as a whole was 140/387 (36%). Six responses were incomplete and 134 questionnaires were analysed. Of the 102 respondents that did use their PDA, 47% did so at least once a week, mostly within the clinical setting (48%) or at home (27%). In PDA users, the British National Formulary (89%) and Oxford Handbook of Clinical Medicine (87%) were the most popular resources. Feedback from patients and teachers was mixed but 45% students did not respond to this question. 32 respondents (24%) had not used their PDA, and in this group, the main reasons were cited as needing to carry another device (78%) and learning preferences (41%) and concerns around theft and loss (28%).
37% of all respondents had smartphones and 98% of all respondents wanted the initiative to continue either with the School providing DrCompanion resources with or without a PDA or smartphone
Results of post-study survey.
124/387 students enabled data logging by synchronising their devices (55 year 3, 41 year 4, 28 year 5 students). The students accessed the resources on their DrCompanion cards on average 68.5 times (median) over the monitored 10 month period (interquartile range 17.8 - 160.5). The most popular resources were the British National Formulary (BNF, a drug reference) and the Oxford Handbook of Clinical Medicine (OHCM) (Table ).
The themes that emerged from the data analysis of the focus groups and free text responses within the surveys allowed us to answer our research questions.
How students used the tool
The focus groups participants agreed with the survey results on the practical aspects of using the technology. They tended to use it mostly between patients or scheduled teaching activities, and less commonly during delivered teaching sessions. As was expected through the very nature of the mobile technology, using it 'on the go' was a recurrent statement, including locally and on elective (i.e. on clinical attachment abroad). For the most part they used to it to access quick references, with the most popular resources being the BNF and the OHCM, validating the questionnaire results, and shown by student quotes below:
• "I used it principally for making reference on the wards and I use the anatomy quite a lot when we are in theatres." (FG:C)
• "I tend to use the PDAs as a quick reference on the wards - for drugs and that sort of thing." (FG:C)
Some students continued to make use of the PDA at home even though similar resources could be accessed via a home computer. This highlighted the role of the mobile device as an additional tool rather than a replacement.
How student learning was enabled
Four ways in which learning was enabled emerged from the focus group analysis. These were
1. Timely access to key facts -learning in context
2. Consolidation of knowledge through repetition
3. A supplement rather than a replacement
4. Making use of wasted time
Timely access to facts - learning in context:
The focus group participants described using the PDA/DrCompanion to learn whilst actively engaged in clinical activities as well as in spare moments, allowing them to learn in context:
• "When you see the patient and can access the information at the same time." (FG:B)
• "I' d never use it if I was actively talking to a patient. But again as soon as that conversation has finished I'm happy even if they're still around." (FG:B)
Consolidation of knowledge through repetition:
Students found that instant access through the mobile technology allowed them to repeatedly look up information with ease, reinforcing their knowledge. They recognised that this was an important part of learning and appreciated the opportunity offered:
• "Reinforcing key points at point of need." (FG:A)
• "Initially, you may look at it three times and then after that you will become more confident." (FG:A)
A supplement rather than a replacement:
Those students who had integrated the PDA/DrCompanion into their learning strategies recognised that its role lay most successfully as a supplement rather than a replacement:
• "I think it's complementary rather than substitution." (FG:C)
• "It is actually nice that it's there, because you know - it is handy, it's just another tool that you can use." (FG:D)
Making use of wasted time:
Another benefit was the ability to make the most of empty time spaces as accessing information via the PDA in spare moments was seen as an opportunity to make constructive use of time. These were short segments of time between formal scheduled events, or for example between patients in clinic. The portability of the PDA enabled them to spend time they felt otherwise wasted, learning:
• "You're absolutely right - that's a real plus. 'Carpe diem' - making use of time. Very much. I agree definitely." (FG:B)
• "Actually, that's one of the reasons I have started to use it a lot more. There and then when there isn't anything to do you can make use of time." (FG:B)
Barriers that inhibited the learning opportunity
Careful analysis of the data showed that in addition to technological issues, there were more self-imposed and subtle barriers that had restricted the students. Many of them felt that using the PDA whilst in a clinical context interrupted the ongoing experience:
• "I tend to look for opportunities to use it when I'm not doing really anything else. Rather than using it and perhaps disrupting what else is going on." (FG:B)
• "Personally I prefer to kind of engage with the clinical situation then go away and read it as a separate thing." (FG:D)
There was also a widely expressed view that students had had negative experiences with patients and staff. Although this was hearsay for the most part rather than directly experienced, these negative perceptions left the students reluctant to openly use the technology on many occasions:
• "I think some people mentioned that if they were on the ward, some of the doctors thought they were using their phones." (FG:C)
• "I think some doctors have made comments about "What are you doing on that, are you texting someone, or playing games." (FG:D)
Students were concerned about having to carry another device, the possibility of theft, loss or damage and the electronic nature of the device.
Dislike of technology:
• "It's just that I've never been very techie." (FG:D)
• "But I just wonder if there is actually something which is more intuitive - with less extra effort - it might be more useful...." (FG:C)
• "One or two occasions when it would just freeze or stop, or just get frozen on loading, and that's probably how I started using it less and less." (FG:D)
Extra device to carry:
• "The only thing is, you don't have that many pockets - certainly I don't. So, I would have my wallet in one pocket, my phone in another - because you can't keep your phone at home - and I found it quite hard to carry it around with me all the time." (FG:C)
How barriers were overcome - necessity for change
The responses from the students showed that these barriers could be overcome, but needed both individual and institutional input to optimise the opportunity. Offering the opportunity to all, rather than just those who were already mobile technology-friendly, engaged students who would have missed out otherwise.
• "I was quite averse to it at first - I was one of the haters..." "What changed your mind?""I think it's actually finding I did use the PDA and it did come in handy several times. It just makes life a bit easier." (FG:C)
A change in attitude, behaviour and approach was required for the PDA to become an optimal tool, and a failure to change resulted in non-use or non-acceptance of the device. This was required both of the students and of the clinicians. If teachers were enthusiastic and advocated their use on ward rounds and in clinics then students were more likely to be encouraged to make it part of their routine. They had to find a way of working with the PDA to get the most out of it.
• "I know quite a few people who have just left them in their bedroom and have never touched them - it's off all the time." (FG:A)
• "It's things like that [teacher advocacy] which encourage you, maybe I will bring it with me tomorrow and take it on the ward round with me." (FG:B)
The same applied to their interactions with patients. As discussed above, the etiquette of using a PDA whilst with patients was of concern, and the students had to learn how to incorporate it into their consultations without harming their relationship with the patient:
• "I guess the patients need to be informed of what you are doing and not feel as if you are being distracted by something else whilst you are talking to them." (FG:A)
Focus group participants also felt that integration into a Smartphone platform would remove some of the barriers that they had encountered.
• "Now, I'm thinking maybe I will get an iPhone actually, because it might be really useful to have everything on a similar PDA-type idea but merged with a phone. I'm definitely quite keen." (FG:C)
We have developed a conceptual framework showing the contribution of current learning theories to mobile learning in the clinical setting and the impact of contextual factors, both positive and negative. Figure illustrates a model based on our findings and it is discussed further in the next section. A trigger (external or internal) leads to the recognition of an educational need, following which the mobile device enables learning to take place. Positive and negative factors can affect the cycle at any stage. Broken arrows show areas where further research is needed.
Illustration of a model for mobile learning in the clinical setting showing influence of positive and negative contextual factors.