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 Healthc Inform Res > Volume 24(2); 2018 > Article
Lee, Min, Oh, and Shim: Mobile Technology in Undergraduate Nursing Education: A Systematic Review

### Objectives

This study aimed to identify and systematically review the literature on the use of mobile technology in nursing education. The research findings could evidence the effectiveness of mobile technology in undergraduate nursing students' learning outcomes.

### Methods

Computerized searches were conducted using the Ovid-MEDLINE, Ovid-EMBASE, Cochrane Library, and CINAHL databases for relevant primary studies and limited to those between 2000 and February 2018. Only randomized controlled trials (RCTs) and quasi-experimental studies published in either English or Korean were included and critically appraised using Joanna Briggs Institute tools.

### Results

Seven RCTs and 7 quasi-experimental studies were identified. The mobile device and intervention applied varied throughout all the studies. Studies published earlier in the 2000s found that immediate access to clinical and pharmacological referencing information through the mobile device increased students' efficacy in clinical practice. Later studies, which were mostly conducted in Korea, reported that smartphone-based applications could promote nursing students' learning motivation and satisfaction but not their clinical skills and knowledge.

### Conclusions

We still seem to be in the beginning stage of implementing mobile technology in nursing education due to the limited implication of mobile technology and inconsistent research conclusions. In the future, rigorous primary empirical studies are needed to suggest the effective use of mobile devices in nursing education.

### I. Introduction

In the 21st century, technology is evolving more rapidly than ever. The younger generations, including undergraduate nursing students, live daily lives equipped with highly advanced mobile technology, challenging nursing educators to incorporate mobile technology in education to improve the learning outcomes of students [1,2]. Though no clear definition of mobile technology is confirmed in nursing education, the purpose of mobile technology is often described in nursing education as “handheld platforms that incorporate hardware, software, and communication [2].”
The personal digital assistants (PDAs) introduced in the early 1990s were initially used to store and manage personal information; however, they have further evolved into smart devices such as smartphones and tablet PCs, the latest version of mobile technology. These devices have multiuse features including audio and video recording and web portal support systems [3].
Due to their ubiquity, mobile devices have been proposed to enhance the outcomes of student clinical learning during clinical rotation and improve student-faculty interactions [4,5]. Nursing students practice in various clinical environments, including acute hospital settings and community health centers, where close individual supervision by the clinical instructors is not always available [5]. Additionally, nursing students tend to use knowledge and skills learned in the classroom when providing bedside care to patients. Current healthcare emphasizes evidence-based practice to ensure quality care, and mobile devices including PDAs and smartphones can be considered suitable for immediate access to up-to-date medical information [6,7]. The use of PDA resources supported clinical reasoning among undergraduate students by facilitating problem solving with reliable information [7]. Mobile-based applications further enable more active learning by actively constructing knowledge using a wide range of webbased clinical applications. Thus far, various mobile devices with applications have increasingly been used in classroom activities and clinical practicum including e-portfolio in many countries [2,5]. Although numerous studies found positive attitudes toward and satisfaction with the use of mobile devices among nursing students [6,7,8] and barriers to using mobile devices including protecting the confidential information of patients, infection control issues, technical difficulties, short battery life, the cost of mobile devices, and negative perceptions of hospital staff and patients [2,3].
The advantages of mobile technology in nursing education have been examined in research using a survey study design and qualitative research methods [4,8,9]. Recently published review studies only summarized the studies without critical study appraisals or described the benefits and barriers to use the mobile technology in nursing education [2,3]. This makes it difficult to determine the effectiveness of mobile device use and confirm their educational effects on nursing education. Thus, a systematic review is needed to review and critically appraise the literature on the implementation of mobile technology in undergraduate nursing education. The findings of this review will contribute to the advancement of nursing education by improving our understanding of the impact of mobile technology and providing an insight into developing strategies in mobile technology application in nursing education.

### 1. Aim

This systematic review aimed to identify and appraise studies on the use of mobile technology in undergraduate nursing education. The major learning outcomes of students were evaluated in this review to determine the educational effectiveness of mobile technology in nursing education.

### 2. Search Strategy

On February 14, 2018, search strategies and subsequent literature searches were performed by an experienced systematic review researcher in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [10]. Literature searches of the Ovid-MEDLINE, Ovid-EMBASE, Cochrane Library, and CINAHL databases were conducted to identify articles evaluating the efficacy of mobile education in nursing undergraduate students. The following search terms were used: “{(nursing or nurse) AND (student OR students)} AND (mobile OR handheld OR PDA OR smartphone OR tablet PC OR tablet computer OR wireless).” For example, we searched Ovid-MEDLINE using the following strategy: {(“nursing” [TW] OR “nurse$1” [TW]) AND “student$1” [TW]} AND (“computers, handheld” [Mesh] OR “mobile” [TW] OR “handheld*” [TW] OR “PDA” [TW] OR “smartphone” [TW] OR “tablet PC” [TW] OR “tablet computer\$1” [TW] OR “wireless” [TW]).
The inclusion criteria for this review were: (1) primary empirical studies, (2) studies involving undergraduate nursing students, and (3) studies reporting findings on mobile technology implemented in nursing education. The exclusion criteria were: (1) proceedings, discussions, dissertations, editorial articles, and reviews, and (2) studies involved postgraduate or other allied health professionals. Only experimental design studies such as randomized controlled trials (RCTs) and quasi-experimental studies were considered. Studies were limited to those published in either Korean or English between 2000 and 2018.

### 3. Search Outcomes

We retrieved 956 citations from four databases. After deleting duplicate citations, the abstracts of 439 studies were independently screened by two reviewers using the inclusion and exclusion criteria. All reasons for exclusion were recorded. The full texts of 88 studies were reviewed and finally 14 studies were identified for data extraction and synthesis (Figure 1).

### 4. Data Extraction and Synthesis

The data were extracted using predetermined themes of methods/research design, study purpose(s), sample population, mobile device and intervention, outcome measures, and key findings. The synthesis of the studies was conducted by addressing key learning outcomes of knowledge, clinical skills (performance), self-efficacy, and student satisfaction.

### 5. Quality Appraisal

All 14 studies were appraised for methodological quality by two independent reviewers using a critical appraisal tool adapted from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBIMAStARI) [11]. The critical appraisal tools included 13 items for the RCT and 9 for quasi-experimental study with four possible responses: yes (the criteria are clearly identifiable through the report description and assigned 1 point), unclear (the criteria are not clearly identified in the report), and no (the criteria failed to be applied appropriately). The 13 items for the RCT assess the following domains: randomization, allocation, similarity between groups, blindness, treating identically, dropout, intention-to-treat analysis, outcomes measured, and statistical analysis [11]. The 9 items for quasi-experimental study assess the following domains: cause and effect, similarity between groups, control group, multiple measurements, dropout, outcomes measured, and statistical analysis [11]. After independent review, the results were collected and discrepancies were discussed with a third reviewer experienced in systematic reviews. Each study was displayed with its total points and classified into one of the following categories: low risk of bias as all criteria were met, moderate risk of bias as one or more criteria were unclear, high risk of bias as one or more criteria were unmet (Table 1).

### III. Results

Of 14 studies, seven were RCTs. The publication years ranged from 2006 to 2018. Studies were conducted in five countries, and 9 (64.3%) studies were conducted in Korea.

### 1. Method/Research Design

The quality of the studies varied from high to low risk of bias. The quality of all RCT studies was weak due to high risk of bias, whereas most quasi-experimental studies were rated as having a low risk of bias. Among RCT studies, many studies did not appropriately discuss the aspects of the blindness of the treatment group, participants, and researchers to treatment. One quasi-experimental study had a high risk of bias from the lack of homogeneity of the two groups and another showed a moderate risk of bias due to unreliable outcome measures.

### 2. Sample Population

The sample sizes for the studies ranged from n = 11 to 45 in each group. Most studies recruited over 30 students in each group, and 6 described the sample power in the report. The students recruited for the studies ranged from the second to fourth year of nursing college.

### 3. Types of Mobile Device and Intervention

The studies published in the early 2000s used PDAs such as Hewlett Packard iPAQs (the most popular brand) and MP3, whereas later studies frequently used smartphones. The most commonly downloaded application or database for PDAs was drug or clinical reference information. The video and audio features of smartphones were extensively used in inculcating the fundamental clinical skills of Foley catheterization. Infant airway management and academic electronic medical records were also tested in two studies. The duration of intervention varied from 1 to 10 weeks. The wide variation in devices and interventions in the studies reviewed made the data synthesis difficult.

### 4. Key Findings

The synthesis of results on effectiveness of mobile devices in nursing education focused on the following main outcomes: knowledge, clinical skills performance, self-efficacy, and satisfaction (Table 2).

#### 1) Knowledge

No study reported an improvement in pharmacological knowledge in nursing students [12,13], but one found improved knowledge related to lung assessment [14]. Most students' knowledge was evaluated by quizzes developed for the studies.

#### 2) Clinical skills performance

Fundamental nursing skills including Foley catheterization were investigated to determine whether students improved their skills by reviewing the procedures on their own smartphones multiple times [15,16,17]. None of the three studies reported improved performance in the experimental groups as measured with a skill checklist. Infant management skills improved in nursing students [18].

#### 3) Self-efficacy

Self-efficacy in drug knowledge and dosage calculation improved in two studies [19,20], but efficacy in Foley catheterization skills did not improve in students who used their smartphones for practice [15]. Communication competency using smartphone video clips [21] and academic motivation using smartphone applications (Kakao Talk) [22] significantly increased in the experimental group of students during the classroom activities.

#### 4) Student satisfaction

In majority of studies, nursing students expressed satisfaction with the mobile technology applied in education and found it useful for clinical learning sources during clinical practicums [23,24]. However, neither the study comparing smartphone applications for cardiopulmonary assessment skills with a high-fidelity human simulator [14] nor that using an application for infant airway management reported higher satisfaction in the experimental group students [18]. Using the mobile-device-based academic electronic medical record did not affect students' clinical practicum satisfaction [25].

### IV. Discussion

With the recent explosion in the use of wireless device, nursing faculties have become more interested in incorporating mobile technologies into their teaching and learning strategies. This timely study systematically reviewed the experimental studies investigating the effects of mobile technology on learning outcomes in undergraduate nursing students. The overall findings of this review did not provide consistent results on the improvement of knowledge and clinical skills of nursing students, but noted students' satisfaction and preference for these methods over the traditional teaching methods.
Studies published early in the 2000s focused on the use of PDAs and downloaded databases in nursing education. Since 2010, smartphones have been quickly replacing PDAs, as they have more advanced functionality with a wealth of applications. The advanced features of smartphones, including text, audio, and images, have changed the way they may be employed in clinical and classroom teaching. The recorded video clips of the students' performance of the Foley catheterization procedure allowed them to remodel their skills immediately upon viewing their performance [15,16,17]. Similarly, communication training using smartphones' audio-video recording capabilities could improve students' communication competencies [21]. These multimedia capabilities of mobile devices can be further incorporated in more complex ways in nursing education to stimulate students' learning motivation.
Pharmacology was the most popular subject in the studies reviewed. This may be attributed to concerns over medication errors in clinical practice. Using a pharmacology database through the mobile device did not increase the students' pharmacology knowledge and thus, did not seem to improve the contextual knowledge retention of students [12,13]. However, the improved efficacy of drug dosage calculations might be considered a facilitating factor for better clinical practice in the future [20].
No improvements in skill competency or knowledge of Foley catheterization were found in students with mobile devices [15,16,17] as evaluated using a checklist, which is a more objective skill measure. Unlimited viewing of the self-performance of student procedures was assumed to be beneficial due to possible self-directed practice. Strategies to maintain students' interest in correcting their nursing skills still need to be developed because student interest decreases over time after repeated views of the clips. The video clips of communication among students helped increase competence in the mobile device groups [21]. Attitudes and communication skills seem to be rather better modified through self-reflection on the video recordings using mobile devices.
The overall quality of the 6 RCTs was evaluated as showing a high risk of bias due to a failure to appropriately describe the blind aspects in the treatment and subjects. This is readily understood because the educational treatments given to the participating students are not easily concealed from the other group of students in confined classroom or clinical settings. Interestingly, over half the identified studies were conducted in Korea. The higher computer literacy and possession of smart devices among Korean students might stimulate nursing researchers to investigate the application of mobile devices to education. Three studies investigated the use of smartphones to enhance the fundamental nursing skills practice of students. This appears to reflect the current emphasis on clinical skills in nursing education in Korea [26]. The mobile-based applications developed for these studies, such as infant airway management and cardiopulmonary assessment, were evaluated as effective in student learning outcomes. These studies can be considered as yielding worthwhile results in terms of creative ways to develop the educational contents. As many mobile applications currently lack an evidentiary base [2], the quality and suitability of educational contents need to be validated.
The weaknesses in the methodologies of the studies reviewed allow only a limited overall generalizability from their results. Objective measures including standardized knowledge test and skill performance checklist assessed by a third party can be better used to evaluate the outcomes of learning and benefit from the implementation of mobile technology, which are needed for future studies.
The younger generations that have grown up in our environment of rapid developments in mobile devices may become more motivated to learn when these technologies are incorporated in education. However, apparently, we are currently in the early stages of the implementation of mobile devices in the nursing education curricula. This systematic review found no support for consistent positive effects of mobile device use on undergraduate nursing students' knowledge and clinical skills outcomes. The use in clinical environments of mobile devices loaded with appropriate databases may help close the gap between theory and practice and enhance the evidence-based practice of undergraduate students. Mobile technology can support innovative teaching strategies for nursing education once rigorous studies provide consistent results on the pedagogical effectiveness of mobile device.

### Notes

Conflict of Interest: No potential conflict of interest relevant to this article was reported.

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### Summary and quality appraisal scores of the included studies (n = 14)

RCT: randomized controlled trial, PDAs: personal digital assistants.

### Effectiveness of mobile devices in nursing education

PDA: personal digital assistant.

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