Mobile learning devices in the workplace: ‘as much a part of the junior doctors’ kit as a stethoscope’?

Seeking information is a critical skill within medicine, yet how information is acquired and applied by newly qualified doctors, remains widely unexplored within sociological and medical education literature. New modes of information delivery have moved information seeking from the ‘back-stage’ of libraries and offices to the ‘front-stage’ of clinical encounters. Smartphone technology offers doctors the opportunity to access up-to-date, reliable information at the bedside. While developments in information technology have contributed to an information explosion, they have also provided dynamic modes of information delivery. The ever-increasing information needs of doctors and the considerable difficulties of keeping personal stocks of knowledge up-to-date was noted almost 20 years ago [1]. With the introduction of smartphone technology, a mobile phone has become a viable tool to address clinical questions and mobile learning holds the potential to revolutionize medical education and medical practice, supporting the transition from novice to expert [2].

Much has been written about the distinction between novice and expert [3]. Distinguishing characteristics include a greater base of knowledge which experts can quickly recall and deploy and effective automated procedures which lessen the burden on working memory [4]. Clark and Clark [5] explain how cognitive load is affected by the amount of automated prior knowledge: less prior knowledge means more mental effort is needed to perform the task, and “the more automated the prior knowledge, the less cognitive effort required” (p209). Although this paper is concerned with the ready access to explicit or declarative knowledge, rather than automated (or implicit, procedural) knowledge, novice doctors depend on this as a stage in their development of automaticity over time. Further, by enhancing access to knowledge, smartphone technology may support an immediate benefit in lessening the load on working memory.

The use of mobile resources within medicine appears widespread, with many studies reporting positive attitudes of health professionals and medical students [6–8] and calls to encourage and support greater use [6, 9, 10]. However, smartphones also attract apprehension, reflecting continuing fears about the use of new technology to access medical information [11] with appeals for more stringent policies [12, 13]. Concerns have been expressed about dependency on technology and its substitution for clinical thinking [14], the potential for distraction [12] and the conceivable threat to patient privacy due to photographic facility [15]. There are considerable barriers to using smartphones to access textbooks within a learning environment, including problems of synchronisation with alternative resources and the cost, not only in terms of producing text books in a ‘mobile’ format, but also the cost of personal smartphone ownership [6].

With an ever increasing number of apps available, there is also the question of the reliability of an information source [16]. The blurring of the boundary between apps and ‘plug-ins’ (hardware extras which convert the smartphone into a medical device such as thermometer, blood pressure or heart rate monitor) raises regulation issues. Medical devices used in the diagnosis or treatment of patients need to be registered with the Medicines and Healthcare Products Regulatory Authority (MHRA) in the UK or comply with the Food and Drug Administration (FDA) in the US or the CE mark in Europe [17, 18]. The iDoc Project remains one of the few studies which aims to consider how smartphones are used within medicine to support workplace learning. Our focus is the ‘foundation’ years of medical training in the UK, which are recognised as a period of transition following medical school to workplace, associated with high levels of cognitive demand and stress [19], and increased patient mortality [20]. At a time when doctors need to gain the skills and confidence to work without supervision, this transition can be supported by providing rapid access to reliable information via a smartphone [21].

After reporting evidence that demonstrates how the textbook app supports new doctors in their provision of safe and efficient patient care, we explore challenges arising from the social rituals and expectations associated with smartphone use. Our research questions are twofold: Does usage of a mobile textbook app (a) support newly qualified doctors in providing safe and efficient patient care and (b) present boundary challenges to the doctors’ workplace practice?

The aim of the iDoc Project is to support newly qualified doctors by providing internet-free access to reliable information on a mobile device. The iDoc Project is a collaboration between a postgraduate educational organisation (Wales Deanery) who fund the textbook smartphone app for all newly qualified doctors working in Wales, and the researchers based at Cardiff University School of Social Sciences who evaluate its use. When the project was initiated (2009–2010) newly qualified doctors were offered personal digital assistants (PDAs) preloaded with text books, and in the second phase (2010–2011) smartphones were offered. Following feedback from participants about the problems of carrying two devices (the project phone and their own, often more up-to-date device), participants were provided with a licence key to download the text books, via an app, onto their own device (Phase 3).

This article draws on data and evaluation from Phase 3 of the iDoc Project (August 2012 – July 2013). Newly qualified doctors (foundation years one -F1- and two -F2) throughout Wales were offered Dr Companion© software with access to five key medical texts (the British National Formulary (BNF), the Oxford Handbook of Clinical Medicine, the Oxford Handbook of Emergency Medicine, the Oxford Handbook of Clinical Specialities and the Oxford Handbook of Clinical Surgery). The selection of these books was led by author, clinician and medical educator Mark Stacey and informed by feedback from trainees from early phases of the project. Unlike e-books, these app books are specifically formatted for use on mobile devices and the software includes a cross-search facility. Participation in the project was optional and in phase 3 overall uptake was 58 % (374 out of a total of 643 foundation doctors), an increase on earlier years. The sample comprised 70 % F1s and 60 % females.

Completion of a baseline questionnaire was required before a licence was allocated. This collected data on frequency, type, perceived value and variation in use of workplace information sources. At the end of the year participants completed an exit questionnaire. The analysis of the questionnaire data has been published previously [22]. During the year, participants were asked to submit narrative case reports which detailed use of the mobile resource in action. Participants were encouraged to submit at least two case reports, although this remained voluntary and there were no penalties for users who did not submit case reports. The case reports were submitted via a structured online form (using Bristol Online Survey - BOS) which gave participants headings to elicit a description of: the setting/context; the problem/issue addressed; what happened; any obstacles involved; and their reflections on the event. Participants were asked to describe what they would do if they did not have the app on their device. Collected data were confidential but not anonymous, and all questions were open and optional. To encourage participants to submit case reports, word length was unrestricted, leading to variable accounts (word length ranged from 33–996) although most were between 250 and 450 words. Of those who submitted case reports, 37 % submitted one case report, 60 % submitted two and 4 % submitted three or more. Data reported here are from these phase 3 case reports (n = 293). Research ethics approval for the iDoc evaluation was obtained from Cardiff University (02/12/2010). Consent was taken from participants as part of the on-line sign up process.

We began by asserting that a smartphone is a valuable tool for a newly qualified doctor. The development of smartphone technology, particularly in terms of portability and multi-functionality, has brought into sharp focus the possibilities of information seeking at the ‘point-of-care’, particularly in time-critical situations [25]. Smartphones are unrivalled as an information resource - these devices are light and portable and because of personal ownership, easily accessible. This contrasts with more traditional resources such as textbooks which are often out-of-date, heavy to carry or hard to find; ward-based computers which can be difficult to locate or are occupied by others and senior staff who might be busy and might see minor questions as disruptive. However, like Aubusson et al. [26] we also highlight how even within the context of a professional working and learning environment, social and cultural meanings associated with mobile technology remain significant.

The social consequences of mobile phones are well documented. The speed of development of mobile technologies and the power of the mobile phone to influence the social arena has led to its identification as a cultural icon of the 21st century [27]. However, as highlighted by Agger [28] ‘iTime’ can also be associated with a degree of powerlessness, where ‘smartphones use us, bending us to their compulsive rhythms and demanding our attention’ (p.119). Indeed, the power of the smartphone to influence and disrupt social relations, particularly within a learning environment, has been noted [12, 29].

Mobile devices complicate our understandings of place and space, facilitating both ‘absent presence’ and ‘isolated connectivity’ [30]. As communication devices, mobile phones have been lauded because they let people be ‘distant yet close’ [31], yet also criticised for allowing users to be ‘mentally and socially elsewhere’ [32] thus creating a conflict with the norms of expected behaviour. Drawing on Goffman’s [33] rules of social interaction, Ling [27] highlights how talking on a phone in public forces others to become an ‘audience’, often drawn unwittingly into the conversation. He suggests how this conflict was managed by mobile phone users, for example, by creating a ‘symbolic fence’ such as turning away from others or talking in hushed tones. However, when using a smartphone as a resource within a hospital environment, some trainee doctors appear to do the opposite, by attempting to make their use overt, transparent and public. The new doctors in our study highlight how they make considerable attempts to identify and engage their audience in an effort to dispel potential criticism. Whereas some might choose to move away from the patient, others will go to great efforts to tell people what they are doing, share images from the app or leave their phone open for anyone passing to see. This suggests new possibilities for patient engagement.

A smartphone is a multi-functional tool to support medical education and practice but it also presents challenges. How to use a ‘personal’ device within a ‘public’ professional workspace remains a challenge for newly qualified doctors [34], and here it has been important to show how the trainee doctors describe their own use of their mobile phone since ‘no technology ever speaks for itself’ [35]. Put simply, our data suggest that just because a resource has the potential to support mobile learning, it does not mean that it will be used for that purpose or have that desired outcome. The introduction of any new technology brings with it the potential for new uncertainties and opens up the space for both innovation and resistance. What is clear from our analysis is that the use of a smartphone as a work device requires negotiation. It has yet to achieve the unambiguous status of a stethoscope.

Smartphone resources are introduced within existing frameworks of policy and practice, where social encounters and the rules of behaviour are ritualised [33]. Using a mobile as a resource brings with it new rules of behaviour and also reveals ‘hidden’ expectations, particularly when the rules are challenged or broken. Many hospitals continue to regulate the use of mobile phones through formal policies, restricting their use within certain parts of the hospital or within departments. Our study also reveals the implementation of informal policies, where ward staff maintain surveillance to prevent mobile use. Advertising that doctors are using their mobile phones as an information resource might be useful in this case, to enhance both patient and staff awareness. Although it is outside of the remit for this project, it would be informative to examine how hospital regimes, for example, the use of iPad records at the end of patient beds could support smartphone use and enable greater integration.

We have a lot more to learn about how mobile technologies are used in practice, and how rules are decided and enacted within the hospital environment. Indeed our lack of understanding of smartphone use and associated etiquette is partly a reflection of the discrepancy between the speed of development in technology and the much slower academic model of research and dissemination. Breaches in expectations of behaviour, such as glancing at a phone from time to time, or it ringing on inappropriate occasions, can be collectively tolerated [27]. However, there is a lot at stake for doctors who violate social and professional norms. At the moment, we have a complicated picture where the rules of information seeking at the bedside are being constantly negotiated. Indeed, it will be important that smartphone use becomes not just tolerated but socially accepted and ritualised within the medical setting, if the possibilities of information technology are ever to be realised in practice.

In the rapidly changing landscape of information technology, ‘what works’ in medical education can be difficult to answer. This study has several limitations, highlighting the practical aspects of introducing new mobile learning resources and how to evaluate them. Despite the large number of participants who were offered licence keys, the overall uptake of the app was fairly low at around 58 % of all newly qualified doctors in Wales (although it is noted that this rate was higher than in previous phases). Additionally, we know very little about the information seeking practices and challenges of those who chose not to use the textbook app or those who did not submit case reports. A more stringent approach has been put in place for later phases, where access to the app will only continue if case reports are submitted and data tracking is being used to identify those using the app and those who are not. It will be interesting to note whether such surveillance practices influence information seeking behaviour. Another major limitation is that users who did not submit their case reports were not penalised, and therefore, there was little incentive for them to comply with requests from the evaluation team. We also did not stipulate that all fields had to be filled in, which meant that some data were missing. This of course makes a difference in evaluation, and highlights the tension that educational researchers experience between supporting education and training on the one hand, and ensuring that data collection is adequately robust on the other.

Despite these limitations, we have extensive data to suggest how a mobile app which enables access to key medical textbooks can support newly qualified, novice doctors. By supporting effective, evidence-based decisions and reducing delays, use of the app inspired confidence in the newly qualified doctors. Yet in some cases, the social rituals surrounding mobiles impeded their use. This study therefore highlights that users of technology need technical skills, but also practical knowledge about how to use the tools appropriately. Newly qualified doctors might be ‘digital natives’ [36], yet we know little about how they gain tacit knowledge of how to integrate mobile resources with patient care and questions remain about how mobile etiquette is produced in medical spaces. It might be significant for the users of the resource, for example, that the app is only offered to F1s and F2s, and not their seniors. How to adapt to the changing pace of technology is an important question for educators [37] and future research needs to address the critical question of how to explore the social implications of technology within an ever changing environment. The rapid development of smartphone technology has meant that research surrounding mobile phone use already appears outdated. We encourage those who are introducing new technologies in medical education and professional practice to share their experiences, and for rapid publication of research results.