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					 A Mobile Learning Environment to Support the Clinical Nursing Practicum

                              Chin-Yuan Lai, Cheng-Chih Wu, and Sheng-Mei Chen
                    National Taiwan Normal University and National Taichung Nursing College
                                      National Taiwan Normal University
                                      National Taichung Nursing College
                                       {yuan, chihwu}@ice.ntnu.edu.tw

             Abstract: This paper reports our implementation of a mobile learning environment to support
             nursing students’ clinical practicum. We investigated benefits and problems of using mobile
             learning environment in a clinical setting. Our findings show both instructor and students satisfied
             with this environment and achievement of students enhanced, yet technological issues relating to
             wireless connectivity and PDAs had impact on students’ usage of mobile devices in the clinical

     The “Clinical Nursing Practicum” course is an essential component of a nursing education program, aimed at
helping students link theory and practice at the final stage of their professional training. Still, Lee (1996) observed
students often experiencing difficulty during a clinical practicum. Students felt they received inadequate support
from teachers in the clinical area (Clifford, 1992). Clinical teaching of nursing students has traditionally required
one faculty member to supervise 8-10 students dispersed in different settings of a hospital. Geographic dispersal has
posed challenges to faculty and students in the realm of timely responses to student needs, clinical monitoring, and
student learning (Ndiwane, 2005) to which nurse educators seem indispensable (Landers, 2000).

      With swift advances of wireless network and mobile devices in recent years, those problems can be alleviated
by integrating emerging technology into the course. Handheld computers could serve as not only organizers but also
facilitators of efficient diagnostic reasoning in some clinical context (Rempher, Lasome & Lasome, 2003). Surgeons
used PDAs to simplify data entry and retrieval at the patient’s bedside (Fowler & etc., 2002). In family practice
residency, these handhelds’ functions included medication reference tools, electronic textbooks, and clinical
computational programs, as well as tracking of activities heretofore associated with desktop database applications
(Criswell & Prachman, 2002). Healthcare professionals used PDAs to find appropriate medications, check for drug
interaction, calculate doses, and consult clinical references (Tooey & Mayo, 2003). Nurses use handheld-computer-
based support system to elicit patients’ preferences for functional bedside performance (Ruland, 2002). While
widespread use of handheld technology has been noted in clinical practice, Huffstutler, Wyatt, and Wright (2002)
suggested that to equip nursing students with technological skills for their future work to remain competitive, these
advanced technologies must be integrated into nursing curricula to foster students’ proficiency in adapting to varied
and expanding complex information systems. Billings (2005) also urged nurse educators to harness the power of
mobile wireless technologies to create learner-centered teaching practices to facilitate students’ learning. This paper
reports our implementation of a mobile learning environment to support nursing college students’ clinical learning.
Effects and problems of using such an environment in clinical nursing were also investigated.
The mobile learning environment
     We collaborated with an experienced nursing teacher, who has taught the course for over 20 years, to develop
and field-test a constructed mobile learning environment. Requirement analysis was carried out by conducting a
preliminary questionnaire with the teacher, followed by several rounds of class observation and interviews.
Functionalities of the mobile learning environment which may facilitate the teacher’s conducting of the course were
identified. Handheld application tools and hardware used in the environment are described below.

Nursing record
     Purpose of this tool is to record observations on patients’ ABC (Appearance, Behavior, and Conversation),
routine tasks nursing students perform daily. Normally, students are unfamiliar with these records when taking care
of mental patients at the practicum stage. We thus provided students an easy record tool, which would give students
a respective prompt to lead them when recording these ABC items.

Nursing assessment
     Evaluation tools included Clinical Problem Assessment Scale for hospital patients, Scale for the Assessment of
Positive Symptoms (SAPS), and Scale for the Assessment of Negative Symptoms (SANS), each with questions on
diverse scales, programmed into handhelds to guide students to amass data when observing/diagnosing patients’
symptoms. Students learned assessment scales in school, yet found it inconvenient to bring paper-based materials to
a ward. Programmed scales in PDAs afforded students easy references and recording during observations.

Reflective journal
     In order to help instructor learn the progress of students and their thoughts and feelings during a practicum, in
the interest of timely and appropriate feedback, we designed a tool for students to write their daily journal. Many
items of mood (fear, anger, horror, anxiety, sorrow, sadness, glee, anticipation, love) were outlined to allow students
to choose those reflecting their perspectives and emotions when doing patient care. The reflective dialogue tool
helps the teacher understand students’ learning and helps students know themselves better.

Discussion forum
     To promote students’ interaction with peers, instructor and nursing staff, a forum was set up to allow all
participants to have dialogues with others. Each week the instructor would initiate a nursing topic for discussion and
students could either respond to the discussion topic or initiate topics/questions of interest. The instructor would
moderate a forum by proffering comments or asking students to classify their thoughts further. Nursing staff in the
hospital also joined the discussion and shared their precious practical experiences with students.

Concept mapping
      To help students understand patients’ problems, make diagnoses, outline nursing plan, and conduct nursing
assessments, we offered students a PDA concept mapping tool, PicoMap. The tool was developed by labs of Highly
Interactive Computing in Education (Hi-CE) of the University of Michigan (http://hice.org/pocketpc). It enables
users not only to create and edit concept maps, but also to exchange such maps via infrared beam of PDA. The tool
is helpful for our cooperative learning activities. Students can share viewpoints while organizing their ideas.
Audio recording
     Communication between students and patients is the first step toward taking good care of patients. To help
students analyze their communication with patients, we used an audio recorder (Resco.net, http://www.resco.net) for
Pocket PC to tape their dialogues. Students could easily and quickly sound record what they wished on the spot.

      Figure 1 shows our mobile learning environment. The instructor notebook computer and students PDA were
fitted with wireless cards. They could access the teaching server and Internet by way of access points, which then
connected to the hospital LAN and ADSL line. Teaching server served as a network and resource server to allow
participants access to teaching material and Internet resources: course bulletin, course resources, discussion forum,
nursing vocabulary database, personal files reservoir, nursing record, nursing assessment instruments, interview
record, reflective journals, et al.

         Instructor’s notebook

                                                                              ADSL          Internet



                                   Access Point

                                                                                          Teaching server
           Student’s PDA

                                    Figure 1. The mobile learning environment

Scenarios of using the mobile learning environment
     Below we describe typical scenarios of students’ daily activities to delve into how a mobile learning
environment can support learning. These were edited from various resources, including student journals, field
observations, and post-experiment interview with students.

Morning briefing
     “After arriving in the hospital, the instructor brought us together to join in the daily briefing. I used PDA to
audio-record reports from nursing staff and our discussions, and sometimes I wrote down the terms which I didn’t
understand,” said one student in her journal.

Time with a patient
     In her journal, she elaborated: “After finishing morning care and regular nursing, we began to talk to our
patient; I did the talk first, and my partner helped me audio-tape the conversation (allowed by the nursing leader).
Ten minutes later it was my partner’s turn to talk to the patient and my turn to record. After talking to the patient, we
came back to the nursing station and accessed the network via PDAs to write our nursing records. In the afternoon,
we usually accompanied our patient to participate team therapeutics activities, including viewing a video,
occupational therapy, etc. At this time we filled out the nursing assessment tool in the PDA to assess the patients’

Meeting with the instructor
     Our field observations read: “In early afternoon, all students came to the meeting room to discuss with the
instructor. Students first used PADs to beam their concept maps to the instructor. The instructor thereupon discussed
students’ problems individually. While it was not her turn to discuss with the instructor, a student exchanged
information downloaded from the Internet with fellow students. With everybody actively engaged in discussion, one
student’s PDA accidentally beeped to reminding her the battery was low. To avoid losing data, she instantly shut it
down and used the backup PDA offered by the instructor. After the discussion, the instructor let students download
materials from her notebook to their PDAs, asking them to read the materials and further revise their concept maps.”

Doing homework
      When interviewed, one student related: “On the bus heading home, I didn’t use PDA again, owing to lack of
battery time. After I arrived home, the first thing I did was to charge my PDA, then synchronize it with my PC. Then
I started doing my homework, including writing reflective journals, reviewing my conversations with the patient,
joining the forum discussions. Finally, I surfed the Internet to search related materials for supporting my judgments
on patient’ problems and revised my concept maps.”

     We used the environment to support a three-week nursing clinical practicum session. During the practicum
session, we amassed various data for analysis: e.g., field observations, students’ reflective journals, questionnaires
and interview data to understand the instructor, students, and the nursing staff’s perceptions of using PDA in nursing
practicum. A triangulation method was applied to conclude our findings from these various data.

Advantages of using the environment
     Analysis of results demonstrated that all participants had positive feedback on the use of the mobile learning
environment in nursing practicum. For students, PDA was a top-flight cognitive partner in clinical learning. Students
reflected, in the questionnaire, that the most two benefits of their using PDA were saving time and helping them
remember detailed information. Because PDAs allowed timely recording of information or ideas when they came to
mind, they needed less time to manage information after their daily practicum, compared to what they did before.
Also, with reference materials accessible via PDA, it required less effort to recall the details during their practice in
the hospital. It is thus evident that PDAs became cognitive tools for students in nursing practice where resources
were limited. In addition, the instructor described her students seemingly thirsty for learning and more enthusiastic
than those of the former practicum session she had taught. Our field observations also manifested that students
expressed themselves as active learners in this mobile learning environment.

     For the instructor, PDAs alleviated difficulties in supervising many students at one time, meaning she had more
time to discuss deeply with students to help them understand the nursing practice. In the interview, the instructor
indicated that she no longer had to shadow students for trivial things, such as reminding them to bring materials or
hand in assignments, since students engaged in active learning. Also, PDA usage promoted interaction between
instructor and students, who indicated that they could get immediate feedback from the instructor by transmitting
homework via the web. They likewise could use PDAs to show questions to the instructor, who would quickly
understand their problems and guide them to find the answers. The instructor said the biggest change was that she
could quickly understand students’ problems and afford them proper guidance. She further cited the joy of sharing
information with students: PDAs enhanced her relationship with them, what with students’ genius for using
emergent technology, while students found her ineptness in this aspect. Students therefore taught the instructor how
to utilize this technology while they scored notable achievements.

       In conducting this experiment, we encountered some problems: access of network, use of PDA, and integration
of mobile technology with teaching. Chief problems of network access were that it was limited in certain areas and a
little slow. There were only two Access Points set up in hospital due to its outdated network facility, one at wards
where students practiced and the other at the meeting room where the instructor discussed problems with students,
who could not access the Internet except at these two sites. Students found it not convenient for them when they had
timely information to be accessed via networks at other sites. Slowness resulted from outdated network facilities in
the hospital, with uploading speed 128Kb and downloading speed 768Kb. Accessing the database was even slower.

     When using PDAs, students reflected obstacles like small screen, initial unfamiliarity with operating PDAs,
lack of PDA-based webpages, disorder of webpage content, and crash of PDAs. They also indicated problems in
finding a spare socket in the hospital to recharge their PDA. With a battery running low, the screen displayed a
prompt: Better shut down your PDA to avoid losing your information! Students would be forced to shut down their
PDAs, even during discussion with the instructor. As for integrating mobile technology into nursing courses, two
major problems arose. First, the instructor was at a loss to deal with technical difficulties students faced in the
hospital. A technician had to follow participants to offer immediate help in dealing with accidents. Second, it took
time and effort to communicate with the instructor regarding design of PDA application tools for nursing practice.

Concluding remarks
      Results show students and instructor satisfied with using a mobile learning environment in clinical practicum.
Hospital nursing staff also supported using PDAs to aid students’ learning in nursing practice and even looked
forward to using PDAs in their work. Both students and instructor approved use of PDAs, hoping for more chances
to use PDAs in subsequent practicum sessions. It is suggested that more software and learning activities are needed
for the best use of PDA in nursing practicum.

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