Scoping of mobile apps for the education of healthcare professionals: issues of pedagogy and use

1. Scoping of mobile apps for the education of healthcare professionals: issues of pedagogy and use Heather Wharrad University of Nottingham

2. Health E-learning & Media Group Developing Health and Social Care learning resources and elearning interventions Partnerships – HE, FE, NHS Trusts, charities, institutes and EU partners Research & Evaluation programmes

3. Reusable learning objects

4. Questions • What is the evidence that smartphones and apps are being used for learning by healthcare professionals? • Acceptance of m-learning amongst HCPs • Scope and quality of apps available for learning • Evidence of effectiveness in different learning contexts

5. Outline • 2 studies –focus on learning in the workplace • Smartphone and app use among medical students and doctors – small, unfunded, regional study in Trent region • Scoping project to inform the development of mobile applications for the education of healthcare professionals. Funded by NHS education Scotland (NES). (December 16th- January 15th 2012) • Reference to another study ‘Mobile learning for the NHS’ (Norman, 2011)

6. Smartphone and app use among medical students and doctorsPI:Karl Payne (doctor working in Trent Deanery)CI: Kim Watts (midwife lecturer) • 257 medical students (response rate 15%) • 131 junior doctors (22%; 8 different hospitals) • Online questionnaire – use and type of smartphone; ownership and use of apps; types of apps used; time spent using apps for education/practice purposes

7. Smartphone ownership iPhone Android Other Smartphone ownership amongst adults in the general population increased from 13% in 2010 to 31% in 2011. Ipsos-Mori (2011) http://www.ipsos-mori.com/

8. Types of mobile devices used in or outside work Norman (2011) From: ‘Mobile learning for the NHS’ EPIC

9. Ownership of smartphone apps • Significantly more males than females owned apps (p<0.05) • iPhone owners were significantly more likely to own apps (p<0.001) • For both groups, the majority of those who use apps use them daily and the approx average time spent in a working day using apps was between 1 and 30 minutes

10. Types of apps used Medical students (n=203) Doctors (n=98)

11. Future app development Medical students Doctors Antibiotic formulary app Hospital management guideline app Rota and Annual leave app Electronic patient record app On-call contact details app Acute medical/surgical conditions app • Quiz/test app • Timetable linked app • Objectives for lectures/modules in an app • Revision note app • Logbook • Hospital map • University “to do list” app

12. Desired Apps Medical Students Doctors “I would use an app with clinical guidelines that are hospital specific, including management advice for common conditions. This would be very useful on a busy ward because with only a few computers it is difficult to get a monitor when they are needed for urgent clinical work” Doctor 6 “Please make a hospital app this will save so much time, we can actually treat patients and not spend all day sat at a computer!!” Doctor 19 • “I believe smartphone use is ideal for medical students as it allows easy access to material within seconds, which would take longer searching a textbook. If the university had an app it would assist in accessing lecture notes and enhance student learning” Student 13 • “Revising using an app is easier, in a car or plane and on holidays” Student 22

13. Negative aspects of smartphone use for learning in the clinical environment Medical students Doctors “I think it appears extremely rude both to patient and colleagues to appear to be looking at your phone whilst on the ward, as it is usually misinterpreted as checking texts or emails” Doctor 8 “The culture of looking lazy or uninterested by playing on your phone needs to be overcome. Once patients and consultants realise the phone use is work related I will feel more comfortable” Doctor 31 • “I find it very annoying that so much emphasis is placed on smartphones, as not everyone can afford one” Student 45 • “I would love to use the BNF on the iPhone but it is very expensive!” Doctor 29 • “It is difficult to find free or cheap apps that contain enough material to last longer than a few uses, before all the material has been seen” Student 26

14. Discussion points: Benefits • apps use over a year is 73 hours per clinician – ? improved access to accurate, evidence based information in line with EU time directive for junior doctors and more time for patient contact. • Timely learning – apps were providing knowledge at point of care – also Norman 2011 study – ‘reassurance about professional judgements’ • Supported decision making – (drug) reference material • Maximise use of ‘dead time’

15. Challenges • Still large number NOT using smartphones • Not universal acceptance • This professional group likely to be highest users (least need for training in Norman study) • Cultural shift – use of mobiles in hospitals; patients’ views of mobile phone use • Consent, confidentiality • Inequality of access – cost; training need; resistance

16. Experience of m-learning in interprofessional healthcare practitioners and managers Practitioners Managers 70 of 125 respondents had little or no experience of mobile learning (Nov-Mar2011) From: ‘Mobile learning for the NHS’ Norman (2011) EPIC

17. Scoping project to inform the development of mobile applications for the education of healthcare professionalsPI: Charles Crooke RA: Anupama Roy • Scoping of existing mobile applications which are used for the education of healthcare professionals • Review of the evidence – of app use by practitioners and perceived benefits of this technology • Recommendations of new apps to develop • List of ‘recommended’ apps for the NHS Education Scotland Effective Practitioner website

18. Healthcare & Medical Apps • Apps for HCP education/learning not patient education; health promotion • Estimated 17,000 mobile medical apps currently available1 • Downloads to reach 44 Million next year, rising to 142 million in 20161 1. http://juniperresearch.com/mobile_markets_and_strategies

19. Apps • 82 apps catalogued • 19 selected for EP website Anatomy (9) Calculators (3) Cardiology (7) Clinical Decision Support/EBP (2) Clinical Laboratory (2) Diagnostic (6) Dictionaries (4) Eyecare(1) Recording data (1) Reference information (19) Decision Making (3) Training/Learning (18) Medical news/Information (1) Non-Clinical Staff/Patient Interaction (1) Pharmacology/Drug Reference (2) Psychiatry/Mental Health (2) Study Tools/Exam Ultrasound images (Sonoaccess) Jordan, V (2011) Useful iphone Apps Guide Countess of Chester Hospital Education and Training Centre Library Over 200 apps for clinical/non-clinical staff & Patients Little information on their effectiveness – evaluation restricted to customer rating scores

20. Evidence of Use/Effectiveness • Effective usability and effective engagement • Effective usability – Zhang & Adipat (2005) – 9 attributes (learnability, efficiency, memorability, errors, user satisfaction, simplicity, comprehensibility, learning performance) • Effective engagement – how welcome are opportunities of such apps within the community: are they taken up/used frequently? How do they integrate with ongoing practice and to what benefit for the user at the moment of use, or in some longer term?

21. There were relatively few studies looking at effective usability or engagement in this population • Effective engagement needs to be judged against particular ecologies of use and cultures of users • No classification system for apps or quality criteria

22. ‘Contexts of Learning’ Situated, just-in -time learning - in the workplace Anytime, anywhere ‘private study’ decoupled from the workplace Pedagogical design Situated learning Consolidation of practice by learning – deeper more active engagement. Also reflection, recording and sharing experiences

23. Engagement and m-learning Ready-to –hand reference materials valued by learners (Hansen et al 2011) Learners don’t engage if they have to carry more than one mobile device Just-in-time information at point of contact with patients improves confidence and supports decision making (cited in Norman 2011) Learners will tend not to carry out substantive study on small screen devices (Nestel et al, 2010) Learners will use and value audio modality for ‘anytime anywhere’ study Learners will use m-learning in ‘deadtime’ or on the bus but materials need to be designed for this purpose ie short nuggets of learning Mobile apps incorporating blogs and social media to allow timely reflection on practice along with collaboration with tutors and peers (Boulos & Wheeler, 2007) Assessment and reflection through improved access to e-portfolios (cited in Norman ,2011)

24. LOAM tool

25. Pedagogy of Mobile apps: Class 1 Interactivity: • Reference material with little pedagogical structure or sequencing Environment: • low granularity and exclusively text based • searchable databases of static information Role: • learner is passive recipient of information • targeted at broad groups of health care learners • performance support; reassurance egEponyms, HD antibiotics, medical encyclopedia , Epocrates Rx

26. Pedagogy of Mobile apps: Class 2 Interactivity • Some interaction with the content and/or manipulate the content Environment • Reference materials, question banks, calculators, charts with minimal or no pedagogical structure • Low granularity but with some multimodal media richness eg short videoclips to demonstrate a skill Role • Some pre-requisite specialist knowledge egBlausen Human atlas; ABG medical calculator, iResus;

27. Pedagogy of Mobile apps: Class 3 Role • Addresses a learning issue not always explicitly stated but implicit in the content eg takes the learner through guidelines Environment • multimodal media richness/choice of media to suit learning styles eg podcasts • Minimal scaffolding/feedback but some sequencing of learning tasks Interactivity • Apps contain some activities/assessments • Eg STAT cardiac clearance; ECG Guide, Nurse Central

28. Pedagogy of Mobile apps: Class 4 Role • -problematized learning goals with tasks that the learner has to actively solve Environment • - media rich with high quality and appropriate media for knowledge transfer on a mobile device • excellent scaffolding, sequencing of tasks and feedback for the skill level of the learner eg small performance support nuggets or feedback on inputted data Interactivity • - interactivities and self-assessments appropriate to the learning tasks • - -may stimulate social learning by linking to networks of learners or tutor via blogs or txts • Eg ACLS simulator; diagnose the disease game; medical educator

29. Alignment of apps design with the learning context

30. Some Conclusions • Smartphones are being increasingly used for learning by HCPs • Acceptance of smartphones for learning is not universal across professional groups • Evidence of the effectiveness of apps for learning is growing but difficult to interpret because of lack of classification of apps and the different contexts of learning. • Principles established in RLO design, pedagogy and use may transfer to developing content for m-learning.

31. Apps for Effective Practitioner Website • ‘3D Brain’ App provides image and reference material for the brain • Muscle in Head and Neck System’ App helps you to memorise the muscles in the head and neck. • Adult Drug Calculations UK is designed for nurses and midwives • ECG Guide is a comprehensive ECG app in the iTunes Store • Heart Murmur Pro App is a heart sound recognition app. available from the iTunes Store. • Medical Lab Tests App covers the most common laboratory tests and their interpretation. • BMI Tool App is a weight management tool • Bio Dictionary developed by the University of Nottingham covers most of general biological terms. • Critical Care ACLS Guide gives immediate access to critical information... • Dynamed a clinical reference tool created by physicians for physicians and other health care professionals for use primarily at the 'point-of-care'. • iMedicalApp is the leading online destination used by medical professionals for coverage of mobile medical technology and apps. • iResus is provided free of charge by the Resuscitation Council (UK) to provide its most up to date guidance in the hands of those who need it. • Medscape is a medical resource app most used by physicians, medical students, nurses and other healthcare professionals for clinical information. • Skyscape is a clinical decision-support tool app. • Shoulder Dystocia is an interactive experience, the user is guided through the management of the obstetric emergency • BoardReview contains 20 electronic review cards that help you learn important drug information on your iPhone or iTouch anytime, anyplace. • Student BMJ is a monthly international medical journal for medical students and junior doctors.