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Journal of Computing in Higher Education

https://doi.org/10.1007/s12528-019-09213-2

Evaluation of mobile learning for the clinical practicum


in nursing education: application of the FRAME model

Kam Cheong Li1   · Linda Yin‑king Lee1 · Suet‑lai Wong1 · Ivy Sui‑yu Yau1 ·


Billy Tak‑ming Wong1

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
This paper presents an evaluation of mobile learning practice for the clinical practi‑
cum in nursing education. Nursing students need to practise nursing skills and fol‑
low specific clinical procedures in wards. In this study, they were provided with a
mobile device for learning purposes, with mobile apps preinstalled for watching
nursing videos and conducting clinical assessments. The evaluation was conducted
following the Framework for the Rational Analysis of Mobile Education (FRAME).
It included a questionnaire survey involving 265 nursing students and focus group
interviews with 20 nursing students, the course coordinator of the clinical practi‑
cum and the instructional designer of the mobile apps. The participants shared their
views, perceptions and experiences of mobile learning for studying nursing skills
and conducting clinical assessment in the practicum context. The results showed the
participants’ overall satisfaction with the mobile learning practice. They gave posi‑
tive feedback on the use of the mobile apps in terms of enabling ubiquitous access
to materials for situated learning in wards, and offering effective support for teachers
to keep track of students’ learning progress. They also suggested areas for improve‑
ments, which emphasised the hardware capacity of devices, training on the use of
apps and institutional support for the maintenance of devices. The results of factor
analysis showed a composition of underlying factors different from that of the origi‑
nal FRAME model, which suggests contextual variation in the application of the
model.

Keywords  Mobile learning · Nursing education · Learning motivation · FRAME


model · Clinical practicum

* Billy Tak‑ming Wong


tamiwong@ouhk.edu.hk
Extended author information available on the last page of the article

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Introduction

Scholarly interest in mobile learning has been growing steadily across a range of
diverse disciplines, covering theorisation, implementation, practice and evaluation.
Mobile learning has been defined as learning through the use of mobile and wire‑
less technologies without being confined to a fixed time or location (Hwang et  al.
2008). It has been identified as conducive to pedagogical flexibility and innovation
on the strength of its “on the move” nature. Learning materials in textual, visual, or
aural forms can be easily accessed by, and delivered to, learners (Evans 2008; Koole
2009). This facilitates particularly situated learning which occurs beyond the con‑
fines of classroom settings and conventional academic schedules.
Clinical practicums in nursing education present a proper scenario for using
mobile learning. Nursing education involves not only the mastery of conceptual
knowledge in classrooms and laboratories, but also the acquisition of practical and
social skills in clinical wards. Through the use of mobile devices, nursing students
can better access just-in-time information and participate in situated, experimental
and contextualised learning activities (Kukulska-Hulme and Traxler 2005). Numer‑
ous studies from regions such as Taiwan (Wu et  al. 2011), Canada (Kenny et  al.
2012) and Australia (Hay et al. 2017) have confirmed the benefits of mobile learning
in nursing education. However, nursing education is context-dependent by nature
(McHugh and Lake 2010), and therefore the extent to which mobile learning has an
impact on nursing students demands consideration of the environment of the nursing
practicums.
This study aimed to evaluate nursing students’ perceptions of using mobile
devices in the clinical practicum. It conceptualised mobile learning using the Frame‑
work for the Rational Analysis of Mobile Education (FRAME) model (Koole 2009).
This model posits that mobile learning is a process driven by the interaction of
mobile technologies, human learning capacities, and the social dimensions of learn‑
ing. It has been widely applied in studies on the evaluation of mobile learning prac‑
tices (Koole et al. 2018).
This paper1 uses the FRAME model to highlight nursing students’ perceptions of
mobile learning, showing the effectiveness of mobile learning in a clinical practi‑
cum context. It is based on the mobile learning practice for nursing education in a
university in Hong Kong, and summarises the views of nursing students, the course
coordinator of the clinical practicum and the instructional designer of the mobile
apps from different perspectives. The results also reveal possible ways to improve
the effectiveness of mobile learning to address the diverse learning needs of nursing
students.

1
  An earlier version of the paper was published as Li et al. (2018a) in the 2018 International Conference
on Blended Learning. This extended version provides further findings, analysis and discussion on nurs‑
ing students’ perception of mobile learning in a clinical practicum context.

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Evaluation of mobile learning for the clinical practicum in…

Literature review

Mobile learning in nursing education

Nursing education is a discipline which has incorporated mobile learning widely


into pedagogical practice (Chang et al. 2018). Integrating mobile technology and
digital literacy into nursing education has been deemed necessary by numerous
councils and associations of nurses across the world (Raman 2015). The use of
mobile devices in teaching and learning is expected, even if not currently being
adopted, for nursing educators and students (Button et  al. 2014). Nursing edu‑
cational programmes have also attempted to transform curricula with the aid of
mobile devices in response to technological advances (Clark et al. 2017; Sargent
and Miles 2016).
As nursing education involves both the acquisition of conceptual knowledge
and practical skills, it takes place in a variety of learning contexts, not only in
classrooms but also in clinical wards. The situated, experiential and contextual
nature of nursing education is therefore an ideal platform for mobile learning to
take effect and realise its potential. For example, mobile devices can allow stu‑
dents to access the most up-to-date information and reliable resources on the
internet without the constraints of physical location and time (Kukulska-Hulme
and Traxler 2005), and thus can enhance their learning motivation and study per‑
formance (Li et al. 2018b, 2019). The advantages of using mobile devices in nurs‑
ing practice have been identified as the enhancement of information access, time-
saving, patients’ safety, the quality of medical care, and confidence in performing
professional tasks (Johansson et  al. 2012, 2013). Other possibilities include the
use of mobile devices to establish virtual communication among instructors,
peers, and resources at the point of care (Park et al. 2010); the use of iPods for
face-to-face instructor-student interactions, including presentation and feedback
(Maag 2006); an e-portfolio that allows remote access to clinical expertise and
resources; and a multi-media record of students’ clinical experiences (Garrett and
Jackson 2006). Studies have also indicated the benefits of using mobile-based
video clips to assist in clinical teaching, which ultimately increased students’
motivation, confidence, and satisfaction throughout the learning process (Lee
et al. 2016).
In nursing education in Hong Kong, nursing students have to gain most of their
practicum experience outside classrooms and prepare themselves for professional
adaptability in realistic contexts such as health care institutions and hospitals (Ip
and Chan 2005). It has been suggested that nursing students in Hong Kong pri‑
oritise “support, respect, and recognition by all personnel in the clinical environ‑
ment” as fundamental to their learning satisfaction—and so a supportive learning
environment is vital (Chan and Ip 2007). Building on previous studies’ insights
into nursing education in the Hong Kong context, it is very important to inves‑
tigate the role that mobile learning can play in facilitating students’ learning in
practicums (Lee et al. 2010; Lee and Tsang 2006).

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K. C. Li et al.

Clinical practicums

Nursing students need to practise their nursing skills and become familiar with spe‑
cific clinical procedures in wards through clinical practicums. However, they may
suffer from anxiety over insufficient proficiency in their nursing skills, which may
result in improper treatment for patients (Sun et al. 2016). For clinical assessment
of students’ performance, Wu et al. (2015) found that assessors (i.e. nurses serving
as students’ mentors) may be unfamiliar with the assessment items as well as the
knowledge and skills students have learned in the academic setting; and this may
result in communication problems between students and assessors. If, in the clinical
practicum, there are practices that students do not need to report to the nursing pro‑
gramme’s academic staff, the staff would have difficulty in keeping track of students’
progress during the practicum (Li et al. 2017).
Despite mobile learning being widely applied in nursing education, the specific
context of clinical practicums has been rarely addressed. By examining the trends
in mobile learning research, Hung and Zhang (2012) found that the most common
research issue was the evaluation of effectiveness. However, Chang et  al.’s (2018)
review of mobile learning publications on nursing education showed that relevant
studies focused mostly on basic nursing concepts and skills, various learning strate‑
gies, and technological acceptance. The mobile learning practices in various learn‑
ing environments for nursing education (e.g. the classroom, laboratory and ward)
remain to be examined.

FRAME model

Koole’s (2006, 2009) FRAME model suggests that mobile learning consists of an
interaction among three factors: the mobile technologies (device), human learning
capacities (learner), and the social aspects of learning (social). This model has been
widely employed in evaluating, improving and further developing mobile learning in
nursing education (e.g. Kenny et al. 2010, 2012; Parscal et al. 2012). It has provided
a theoretical foundation for advancing and assessing the development of learning
materials and pedagogical strategies in this field.
The FRAME model contends that the effectiveness of mobile learning is highly
correlated to whether the three aspects—device, learner and social—have fulfilled
their potential during the process of their interaction. The model includes 26 key
elements categorised under the three aspects and their interaction (Koole 2009):

• Device aspect—physical components; input capabilities; output capabilities; file


storage and retrieval (e.g. internal storage size and support for external media);
processor speed (e.g. reaction time in relation to human input); and error rates
(e.g. hardware or software malfunctions).
• Learner aspect—prior knowledge; memory (e.g. use of contextual cues for
memorisation); context and transfer (e.g. use of information aids for understand‑
ing and transfer of concepts to varied contexts); discovery learning (e.g. filtering,
choosing and recognising relevant information for solving novel problems); and

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Evaluation of mobile learning for the clinical practicum in…

emotions and motivations (e.g. feelings towards a task and reasons for accom‑
plishing it).
• Social aspect—conversation and cooperation (e.g. following the maxims of com‑
munication); and social interaction (e.g. use of agreed signs and symbols in com‑
munication).
• Device usability—portability; information availability (e.g. access of informa‑
tion anytime and anywhere); psychological comfort (e.g. intuitiveness and com‑
prehensibility of mobile app design); and satisfaction (e.g. physical appearance
and functionality of devices).
• Social technology—device networking (e.g. support for various network stand‑
ards); system connectivity (e.g. support for various document transfer protocols);
and collaboration tools (e.g. tools for co-authoring documents).
• Interaction learning—interaction (e.g. learner–learner, learner–instructor,
learner–content); situated cognition (e.g. learning tasks situated within authentic
contexts); and learning communities (e.g. communities of practice).
• Mobile learning process—mediation (e.g. changes in interaction between learn‑
ers and information); information access and selection (e.g. recognition of rele‑
vant and accurate information); and knowledge navigation (e.g. selection, manip‑
ulation and application of information).

Previous studies adopting the model have similarly given particular attention to
whether the three aspects of the model have been fulfilled (e.g. Kenny et al. 2009a;
Park et al. 2010). According to Koole (2009), in the most ideal case, through mobile
learning, learners can “assess and select relevant information, redefine their goals,
and reconsider their understanding of concepts within a shifting and growing frame
of reference” (p. 38).

Method

This study aims to find out the effectiveness of the use of mobile devices for learn‑
ing in the clinical practicum. It covers the perceptions of nursing students, as well as
the course coordinator of the clinical practicum and the instructional designer of the
mobile apps.

Participants

A total of 265 year 3 and year 4 undergraduate nursing students studying in a uni‑
versity in Hong Kong were recruited to participate in the study. For learning pur‑
poses, each student was supplied with an iPod Touch when they enrolled in the nurs‑
ing programme. The device was used by the students throughout their study of the
nursing programme and they did not need to return it. Two mobile apps which were
specially developed for the students’ learning in the clinical practicum were installed
in the devices in advance; and training was provided to the students on their use. All
of the participating students had experience in using the mobile apps for learning

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K. C. Li et al.

in the clinical practicum for one to 2 years. The course coordinator of the clinical
practicum and the instructional designer of the mobile apps also participated in the
study. All the participants were introduced to the tasks involved in the study, and
their consent to participate was obtained.

Experimental procedure

The study focused on the students’ mobile learning practice in the clinical practi‑
cum. The students needed to use one of the apps to conduct clinical assessments
with their mentors in the wards. The other app provided nursing videos on a broad
range of clinical skills and procedures which the students had to master in order to
pass the practicum. Therefore the use of mobile devices in the practicum was com‑
pulsory for the students, meaning that the devices served as a tool which integrated
with the students’ learning, instead of being something “superimposed on” their
practice (Park et al. 2010).
The study involved interviews and a questionnaire survey. Two sessions of focus
group interviews were conducted with a total of 20 students, and two individual
interviews were held with the course coordinator and the instructional designer.
The interviews focused on the participants’ perceptions of mobile learning based on
their experiences in the mobile learning practice. The structure of the interviews was
based on the FRAME model. The participating students also took part in a question‑
naire survey which studied their perceptions of the mobile learning experience. A
total of 231 completed questionnaires were received.

Instruments

Mobile learning apps  One of the mobile apps installed in the students’ iPod Touch
was used for clinical assessment (Fig. 1). It contained a list of clinical assessment
items which students had to achieve. During the assessment, the students had to
demonstrate their mastery of clinical skills, which were rated by the students and
their mentors as ‘achieved’ or ‘not achieved’. After the rating, the students had to
communicate with their mentors for further feedback on their performance, and
upload the assessment results to an online system for a review of their learning pro‑
gress by themselves and the course coordinator of the nursing programme. The app
thus served to enhance the efficiency of clinical assessment, facilitate communi‑
cation between students and their mentors, and enable the students and the course
coordinator to keep track of the students’ learning progress effectively. The other
app with nursing videos on a range of topics (Fig. 2) was produced to help the stu‑
dents to revise the relevant clinical skills and procedures.

Questionnaire  The questionnaire, which was developed to collect the students’ per‑
ceptions of their mobile learning experience, followed the FRAME model for under‑
standing how the mobile learning process was perceived by the students. It con‑
tained 66 items covering various aspects of the model. The questionnaire had been
reviewed by an expert panel, followed by a pilot test conducted with 10 students

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Evaluation of mobile learning for the clinical practicum in…

Fig. 1  Screen captures of the mobile learning app for conducting clinical assessment

Fig. 2  Screen capture of the


mobile learning app for watch‑
ing nursing videos

(who were not involved in this questionnaire survey) to check their understanding
of the items. A 7-point Likert scale was used for the questionnaire—ranging from
‘1 Completely dissatisfied’ to ‘7 Completely satisfied’, ‘1 Not at all familiar’ to ‘7
Extremely familiar’, ‘1 Not at all useful’ to ‘7 Extremely useful’, and ‘1 Strongly
disagree’ to ‘7 Strongly agree’—depending on the different types of items. The sur‑
vey was paper-based, and the students spent around 15 min on average to complete
it.

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Results

Focus group and individual interviews

In the interviews with the different parties in mobile learning practice—the students,
the course coordinator, and the instructional designer—the responses reflected
the benefits and obstacles they perceived in practising mobile learning. They also
revealed the major concerns that need to be addressed in using mobile learning in
the clinical practicum setting. The interview data were analysed by categorising the
participants’ feedback into themes according to the FRAME model.

Interaction learning through  clinical assessment with  the  mobile app Despite the
design and function of the assessment app satisfying the participants overall, some
students mentioned issues which hindered effective communication during the
assessment. Student ‘J’ mentioned the difficulty of understanding some assessment
items in the app:

There was a time I had to consult my mentor about what an assessment item
was asking. It seemed that I had communication problems with my mentor
because I misunderstood the item.
Some students raised the issue of flexibility in assessment using the app, claiming
that the assessment app—which offers only binary options of ‘achieved’ and ‘not
achieved’ for students’ clinical procedures—was too simplistic and did not provide
further comments or suggestions for students. Student ‘J’ indicated:
It may be better to rate our performance using a number point scale. The cur‑
rent assessment method giving only ‘achieve or not achieve’ cannot distinguish
the best performing students from the others who perform less well.
From the perspective of the course coordinator, the assessment app did benefit the
teaching and learning process, as it released the teachers’ burden to a large extent by
enhancing the efficiency of the data entry process, and allowed them to access stu‑
dents’ assessment records at any time. It was also seen as helping students to do
revision and access what they had learned through the mobile devices. The assess‑
ment process was viewed as simple for the students and mentors—the students only
needed to upload their results through the app after the practicum.
It was also clear that some mentors, who had used the conventional paper-based
assessment for years, took a longer time to become familiar with and used to the new
way of assessment through the mobile devices. The course coordinator mentioned:
For many years our nursing training relied on hardcopy materials for assess‑
ment. Some mentors may not be familiar with and have not got used to the
app.
In summary, the assessment app has improved the conventional clinical practi‑
cum in terms of allowing the assessment process to be completed conveniently, so

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that the course coordinator can be released from a considerable workload, and stu‑
dents can benefit more from mentors’ immediate feedback during the assessment.
However, miscommunication existed occasionally in understanding the assessment
criteria. The responses of both the students and the course coordinator showed that
sufficient training and clear instructions on the use of the mobile devices for assess‑
ment are significant for the success of the new practice of mobile assessment, espe‑
cially for those who have for long been using the conventional approach.

Learning materials delivered with a mobile app  The other app for accessing the nurs‑
ing videos received a positive reaction from the participants for revising the nursing
skills and procedures in the clinical practicum. For example, student ‘S’ said that
the nursing videos helped students to visualise the clinical procedures and promoted
retention of the content:

I often use the app for revision, because it contains a lot of videos that were
helpful for us to practise nursing skills especially before assessment.
According to the course coordinator, the videos are comprehensive, updated, and
appropriate for the skills in practicum training, as they serve as a means to standard‑
ise the basic nursing skills taught in different courses and by different instructors.
The course coordinator said:
The videos are common to all nursing practises and comprehensive enough.
We produced a lot of videos ourselves that all students can access through the
nursing video app.
To further improve the app, the course coordinator suggested extending it to
support learning in both the classroom and practicum contexts, where students can
access the materials on common topics in various courses and situated cognition can
be facilitated. The course coordinator commented:
There is an app introducing electrocardiography used in some courses. It can
also be used by the students when seeing such real examples in the practicum.
In addition to the nursing videos, the instructional designer introduced current
work and future plans to provide interactive, multimedia content on difficult topics:
In the app, technology will be used to enhance the students’ understanding of
how the cardiovascular system works, such as interactive illustrations of the
heart. There will be scenarios and case studies on heart diseases to help stu‑
dents learn how to identify where the problems lie within the cardiovascular
system and the heart.
Teacher–learner interaction and  learner–learner interaction The mobile app for
assessment facilitated interaction between students and teachers/mentors. How‑
ever, the interviewees pointed out areas for improving communication, especially in
terms of getting mutual agreement on the key requirements for the assessment. For
instance, some students raised the discrepancies between the students and mentors

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K. C. Li et al.

on understanding the materials and guidelines for assessment, which require further
communication to resolve the issues. Student ‘C’ said:
The mentors might not be very clear about the assessment system. Some
of them thought that giving a result of ‘not achieved’ for a few assessment
items was acceptable since they did not usually give full marks. However, it
is mandatory for us to get all items ‘achieved’ to pass the practicum.
The course coordinator explained that communication between students and
mentors was mainly through discussion during the assessment process:
There are two parts in the assessment via the mobile app: the student first
self-rates his/her performance and then the mentor gives another rating.
It is expected that they will communicate during the process. The mentor
is expected to explain and discuss with the student the differences, if any,
between the student’s self-rating and the mentor’s rating, which is a part of
the student’s learning during such interaction.

Device usability  The participants pointed out the benefits of iPod Touch’s portability
for use in the ward environment. Some students emphasised that a larger device was
not preferred because it was heavier and inconvenient to carry. Student ‘J’ noted:

We have to carry our own stuff and walk around in the ward while working.
It is not comfortable if I carry a large device and I worry about dropping it.
There were also other student views. For instance, student ‘C’ preferred a device
with a larger screen size for reading lecture notes:
There are a lot of notes since we study the nursing programme for a total of
five years. If we have an iPad or a tablet, we can check the notes anytime we
want.
In general, the students were satisfied with the functions of the device in support‑
ing learning. However, more user support is needed, such as a warranty and repairs,
to enhance the students’ motivation to use the devices. As student ‘D’ suggested:
It would be better if there are staff on campus responsible for technical sup‑
port. It is important that there are clear instructions on who we can seek
help from.
Social technology  The limitation of the iPod Touch that it only has Wi-Fi connectiv‑
ity was highlighted and such a limitation might constrain its use. The students had to
connect the device to the internet through sharing their own mobile phone’s 3G/4G
network. As student ‘M’ put it:
I have to use my own smartphone’s mobile network to access the nursing
videos with the iPod Touch when there is no Wi-Fi. I have to bring and use
two devices at the same time which is inconvenient.

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On the other hand, there was also a view that Wi-Fi connectivity is enough for
accessing learning materials (i.e. knowledge function), and students can use other
devices such as smartphones to fulfil the social function (e.g. instant messaging). It
is not necessary to integrate the knowledge function and social function in one sin‑
gle device for learning.
Institutional support The importance of institutional support for the use of the
devices was emphasised in the interviews. Overall, the students wished to have more
convenient channels for solving technical problems, and a longer warranty period for
the devices covering the whole nursing programme. The staff interviewed stressed
that the training provided to university staff and hospital mentors would be reviewed
and improved to enhance the students’ motivation for using the devices for learning.

Questionnaire survey

Descriptive data analysis  To evaluate the effectiveness of mobile learning in the clin‑
ical practicum following the FRAME model, the ratings on each of the elements of
the FRAME model were summarised. Table 1 presents the descriptive statistics. The
reliability of the ratings, as assessed by Cronbach’s α, ranged from .78 to .96, indi‑
cating that the internal consistency of the composite items was at overall acceptable
to excellent levels (Tavakol and Dennick 2011). Using a seven-point Likert scale
(with ‘7’ as the highest), the mean scores ranged from 3.48 to 5.21, thus showing a
considerable variation across different elements in the FRAME model.

The device aspect received the highest mean rating (M = 4.69, SD = 0.90), reflect‑
ing a relatively high level of student satisfaction with the physical, technical and
functional characteristics of the mobile devices. Among the elements of the device
aspect, physical characteristics had the highest mean rating. File storage and retrieval
received a relatively lower rating (M = 4.42, SD = 1.33), showing that the devices
were perceived as less convenient in areas such as file storage capacity.
The social technology aspect was rated with lower mean scores. The networking
functionality of the device (i.e. device networking) was the highest rated compo‑
nent (M = 4.37, SD = 1.23), followed by the device capability for connecting to other
devices, i.e. system connectivity (M = 4.27, SD = 1.34). Collaboration tools received
a relatively low mean rating of 3.83 (SD = 1.41), which reflected the nature of stu‑
dents’ learning in the clinical practicum which does not involve much collaborative
work among students.
The device usability received a relative large variance in the ratings of its ele‑
ments. The students indicated a relatively high level of satisfaction with the satis‑
faction element (M = 4.52, SD = 1.17), i.e. the physical appearance, functions and
user-friendliness of the mobile devices and mobile apps. Comparatively, the rating
on information availability (M = 3.69, SD = 1.42) was lower. The results were con‑
sistent with the interview findings where the Wi-Fi-only network connectivity of the
mobile devices was viewed by some students as inconvenient for using the devices
anywhere.

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K. C. Li et al.

Table 1  Descriptive statistics for ratings on elements of the FRAME model (n = 231)


Elements of the FRAME model Number of M SD SE Cronbach’s α
items

Device (D) 17 4.69 0.90 0.06 .93


 Physical characteristics 3 5.21 1.12 0.07 .78
 Speed 3 4.68 1.09 0.72 .90
 Output capacities 3 4.67 1.15 0.08 .84
 Error rates 3 4.57 1.11 0.73 .89
 Input capacities 3 4.51 1.20 0.08 .81
 File storage and retrieval 2 4.42 1.33 0.09 .91
Social (S) 6 3.77 1.21 0.08 .93
 Social interaction 2 4.10 1.35 0.09 .93
 Conversation and cooperation 4 3.61 1.24 0.82 .90
Learner (L) 13 3.93 0.95 0.06 .89
 Context and transfer 1 4.13 1.26 0.08 –
 Prior knowledge 7 3.97 1.06 0.07 .81
 Memory 2 3.90 1.34 0.09 .86
 Discovery learning 1 3.90 1.26 0.08 –
 Emotions and motivations 2 3.71 1.34 0.09 .91
Social technology (DS) 5 4.24 1.16 0.08 .92
 Device networking 3 4.37 1.23 0.08 .95
 System connectivity 1 4.27 1.34 0.09 –
 Collaboration tools 1 3.83 1.41 0.09 –
Device usability (DL) 11 4.10 1.10 0.07 .93
 Satisfaction 3 4.52 1.17 0.08 .80
 Portability 2 4.45 1.49 0.10 .96
 Psychological comfort 4 3.82 1.34 0.09 .96
 Information availability 2 3.69 1.42 0.09 .89
Interaction learning (LS) 7 3.97 1.24 0.08 .93
 Interaction 4 4.04 1.30 0.09 .94
 Learning communities 2 3.85 1.32 0.09 .80
 Situated cognition 1 3.48 1.55 0.10 –
m-learning process (DLS) 7 3.83 1.19 0.08 .96
 Knowledge navigation 2 4.01 1.27 0.08 .93
 Information access 2 3.93 1.27 0.08 .94
 Mediation 3 3.64 1.23 0.08 .91

Interactive learning received a mean score of 3.97 (SD = 1.24), which reflected


mainly the students’ experience in their interaction with mentors during clini‑
cal assessment with the app. The moderate ratings for the composite items on
this aspect were consistent with the interview findings that the students wished
to have more effective learner–teacher and learner–learner communication, and
a supportive environment for them to study and apply clinical skills in a real-life
situation.

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Evaluation of mobile learning for the clinical practicum in…

The learner aspect received a mean score of 3.93 (SD = 0.95). Among its ele‑
ments, context and transfer was rated better (M = 4.13, SD = 0.26). The results
showed that the students performed cognitive tasks using the mobile apps, especially
in transferring the knowledge and skills learned in class to a real-life context at an
acceptable level. Comparatively, the emotional and motivational aspect of mobile
learning was rated at a lower level (M = 3.71, SD = 1.34). Together with the relevant
interview findings, the results suggested that further institutional support is desirable
to enhance the students’ motivation to engage in mobile learning activities.
The social aspect had the lowest mean rating (M = 3.77, SD = 1.21), which was
mainly attributed to the mean score for conversation and cooperation (M = 3.61,
SD = 1.24). Such results reflected that the communication and interaction with the
aid of mobile devices, both among students and with teachers/mentors, was not
highly regarded by the students.
The mobile learning (m-learning) process, which integrates all elements in the
FRAME model, represents the overall effectiveness of the mobile learning practice.
It received only a moderate mean score (M = 3.83, SD = 1.19). Two of its elements—
knowledge navigation and information access—were rated relatively high among
the three, with mean ratings of 4.01 (SD = 1.27) and 3.93 (SD = 1.27), respectively.
They represent how effectively the students learned to locate accurate and suit‑
able online information, and learned to select, manage, and apply the information
for their needs. Comparatively, the mediation elements was rated lower (M = 3.64,
SD = 1.23). The students showed less confidence in stating that they were able to use
the mobile devices to adjust their learning strategies, and reshape their interaction
with peers/mentors in the clinical practicum setting using the devices.

Factor analysis  A factor analysis was conducted to identify the underlying factors, as
a succinct summary of the multitude of elements measured in the survey, for under‑
standing the key considerations in the design and implementation of mobile learn‑
ing in the clinical practicum context. A correlational matrix was computed for the
26 mean sub-scores on the FRAME elements of the survey participants, which was
used for an Exploratory Factor Analysis (EFA).

The factor structure was first tested by retaining factors with an Eigen value
greater than 1 using Principal Component Analysis. After Varimax rotation, a
scree plot was obtained for judging the number of factors to be retained, which
showed that there were three datapoints above the bending point. A subsequent
analysis also indicated a three-factor structure with a factor loading matrix of low
ambiguity, with only four out of the 26 elements having cross-loadings above
.400. The three-factor solution accounted for 62.14% of the total variance (with
the first factor accounted for 30.29%, the second 16.12%, and the third 15.73%).
The Kaiser–Meyer–Olkin index = .91. Given the sample size of 231 participants
and 26 elements, the ratio of the number of participants to the number of ele‑
ments = 8.9, which meets the conventional requirement for conducting a valid
EFA (Henson and Roberts 2006). Therefore, the three-factor solution was chosen
to account for the variance in different FRAME elements measured in the survey.

13
K. C. Li et al.

Table 2  Factor loadings of the 26 FRAME elements in a 3-factor structure (n = 231)


Elements Aspect of the FRAME model Factor loading
F1 F2 F3

Mediation m-learning process (DLS) .879


Information access m-learning process (DLS) .820
Knowledge navigation m-learning process (DLS) .813
Situated cognition Interaction learning (LS) .810
Learning communities Interaction learning (LS) .806
Interaction Interaction learning (LS) .762
Emotions and motivations Learner (L) .739
Conversation and cooperation Social (S) .730
Context and transfer Learner (L) .638
Memory Learner (L) .627
Social interaction Social (S) .618
Discovery learning Learner (L) .610
Prior knowledge Learner (L) .431
Device networking Social technology (DS) .717 .407
System connectivity Social technology (DS) .707
Satisfaction Device usability (DL) .685
Collaboration tools Social technology (DS) .413 .661
Information availability Device usability (DL) .452 .651
Psychological comfort Device usability (DL) .530 .640
Portability Device usability (DL) .586
Output capacities Device (D) .784
Speed Device (D) .774
File storage and retrieval Device (D) .770
Input capacities Device (D) .735
Error rates Device (D) .720
Physical characteristics Device (D) .664

For each element, the highest factor loading is in bold type and only factor loadings greater than .400 are
shown. F1 = mobile learning and communication processes; F2 = the supportive function of the device in
learning and communication; and F3 = the device

Table 2 presents a complete list of the 26 FRAME elements and their factor load‑
ings on the three factors. The first factor, which included the elements classified as
belonging to the aspects of learner, social, interaction learning, and the m-learning
process could be interpreted as a factor on “mobile learning and communication
processes”. These aspects were shown to be highly interrelated. Any deficit in one
would influence the performance of another. For instance, the ability to transfer
knowledge acquired to another context could be important for students to navigate
through different modalities of knowledge; and the extent to which social interaction
is supported by a mobile learning environment could be vital for the establishment
of learning communities.

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Evaluation of mobile learning for the clinical practicum in…

The second factor was characterised by the elements in the social technology and
device usability aspects. It refers to how the mobile device was perceived to support
learning and communication, i.e. the “supportive function of device in learning and
communication”.
The elements in the device aspect composed the third factor, i.e. “device”. As
shown in the descriptive statistics, the device-related elements were rated the high‑
est in our context. Since the mobile learning process involves all the three aspects
following the FRAME model, the design and implementation of mobile learning
should, in addition to choosing a device with proper characteristics and capacities,
also address how the device could support the learner and social aspects.

Discussion

This study reveals the benefits and limitations of using mobile devices in clinical
practicums. Nursing students can access learning materials in wards, which is con‑
sidered important for revising and fostering their mastery of nursing skills and clini‑
cal procedures. The mobile app for clinical assessment facilitated their interaction
with mentors, where useful feedback about their performance and ways of improv‑
ing could be obtained. For teachers/course coordinators, the clinical assessment
conducted via mobile devices substantially reduced their effort in keeping track of
students’ learning progress, and they could discover students’ problems early and
provide timely assistance if needed. Such findings supplement the benefits of mobile
learning which have been widely reported (Li and Wong 2016) by providing specific
advantages of using devices for nursing students in the practicum context. The app
for mobile access of nursing videos extended the findings reported in Ma and Yeh
(2015) on their use in supporting the situated learning of nursing students.
Institutional support on the warranty and repair of the devices was suggested,
which can enhance the students’ motivation to bring and use the devices. The fear
of losing the devices or breaking them was reported as a demotivator for learners to
actively use them (Kenny et al. 2009a, b). Initiatives such as bring-your-own-device
and a mobile personal learning environment have been proposed (García-Peñalvo
and Conde 2014). Despite concerns being raised about their suitability in the ward
environment (Colton and Hunt 2016), the feasibility of such initiatives should be
explored, given the growing acceptability of the use of mobile devices in every
aspect of our lives.
The results on clinical assessment using the mobile app suggest the issues to
consider when implementing mobile-based clinical assessment. Different from the
mobile-based assessment which usually involves learners’ self-assessment using
mobile devices (Nikou and Economides 2018), the clinical assessment in this study
was conducted by both the nursing students and their mentors through the mobile
app, together with follow-up communication between the two parties to review the
students’ performance. The app was shown to achieve its original design goals as to
enhance the efficiency of clinical assessment, and enable the students and the course
coordinator to keep track of the students’ learning progress effectively. However, the
results also reveal the need of a longer time for some mentors, who had used the

13
K. C. Li et al.

conventional paper-based assessment for years, to become familiar with and get used
to the app. As found in Nikou and Economides (2019), the major factors influencing
teachers’ behavioural intention to adopt mobile-based assessment include perceived
ease of use and facilitating conditions. In this regard, the user-friendliness of app
design as well as user training and support should be emphasised when implement‑
ing mobile-based clinical assessment.
The use of the FRAME model for the evaluation provides a recognised conceptu‑
alisation of mobile learning, covering its device, learner and social aspects. In rela‑
tion to the device aspect, the students had diverse preferences for the features of
mobile devices (e.g. screen size) for use in practicums, and on whether their own
smartphone or a separate device is to be used. For the instructional designer, the
standardisation of mobile devices has lowered the cost of developing the mobile
apps and offering technical support. While the effectiveness of mobile learning has
attracted most interest in mobile learning studies (Hung and Zhang 2012), the issues
related to feasibility, cost-efficiency and cost-effectiveness—which have a greater
impact on an institution’s decision on practising mobile learning—have been exam‑
ined less often. Further work on this area will help to broaden the scope when con‑
sidering practising institution-wise mobile learning for nursing education.
On the social aspect, the students’ experience showed that effective communi‑
cation with mentors during the clinical assessment was perceived as a challenge.
The mobile-based assessment was shown to facilitate just-in-time communication
between the students and their mentors about the students’ performance in the clini‑
cal assessment, by enabling the assessment to be conducted efficiently in the ward
environment right after the students had demonstrated their clinical skills. However,
effective student-mentor communication requires both parties to be familiar with the
use of the mobile app and have the same interpretation of assessment criteria. In this
regard, the students’ evaluation did not focus on the app itself but its use in prac‑
tice—particularly the consistency of interpretation of the app’s contents among the
relevant parties—which may be affected by other factors such as the effectiveness of
content presentation and user training. Further studies should be conducted to exam‑
ine the causes of the communication problem. The finding also suggests the need
of covering the non-functional requirements for evaluation of mobile apps which
has been less studied (Sarrab et al. 2016). While institutional support such as extra
user training was recommended in relevant studies to help improve communication
between different user groups of mobile apps (Nikou and Economides 2019), it may
not be suitable for the context of clinical assessment as it creates an additional bur‑
den and workload for the mentors (Colton and Hunt 2016). The simplicity of the
app design with built-in assistant features, which was shown effective in Gan and
Balakrishnan (2014) for facilitating student–teacher interaction, would be helpful for
both the students and mentors.
On the learner aspect, the students’ positive feedback on the apps suggests that
the mobile access of nursing videos and mobile clinical assessment satisfied their
learning needs. The results are consistent with previous studies on the effects of
mobile learning for nursing students in terms of enhancing their learning motivation
and social interaction (Li et al. 2017, 2018b, 2019). Follow-up work may focus on
evaluating the extent to which students’ study performance in clinical practicums

13
Evaluation of mobile learning for the clinical practicum in…

improves after providing them with the nursing videos. Also, Sidhu et  al. (2016)
showed that students are highly dependent on their mentors/supervisors for aca‑
demic matters—and so the effects of clinical assessment with mobile devices on
student-mentor communication and students’ learning are also worth further study.
The various ratings of the FRAME elements showed that certain aspects of the
mobile learning practice in this study were better received by the students. This
observation has also been reported in other studies using the FRAME model to eval‑
uate mobile learning effectiveness (Kenny et al. 2009b). As a heuristic model in its
form originally proposed (Koole 2011), the hypothesised state of effective mobile
learning practice—addressing all the three aspects (device, learner and social) of the
model—could be revisited. The results of the factor analysis showed that the under‑
lying constructs are different from the composition of the model proposed in Koole
(2009). For example, the elements which belong to social technology and device
usability in Koole were found to be under the same construct in this study, which
means that the nursing students’ perceptions of them based on their mobile learning
experience are highly intercorrelated. Further studies at a larger scale should be done
to explore and confirm the constructs of the model, and investigate if the focus of
the model varies in different learning contexts. Future work could also examine the
factors affecting students’ perceptions so as to understand their interrelationships.

Conclusion

Focusing on the clinical practicum context, this paper has revealed the benefits of the
use of mobile devices for facilitating nursing students’ learning, and concerns which
may hinder its effectiveness. The feedback from nursing students, course coordina‑
tor and instructional designer presented different perspectives on these issues. The
findings showed that nursing students in clinical practicums need learning materials
which can be accessed in a ubiquitous manner for situated learning in wards. The
clinical assessment conducted with mobile devices facilitated student-mentor inter‑
action, and supported academic staff in keeping track of students’ learning progress.
The results also revealed areas for improvements, covering the hardware capacity of
the devices, training on the use of apps and institutional support for the maintenance
of the devices. These results contribute to informing the design of mobile learning
practices to cope with the specific learning environment in nursing education. In
addition to students, other parties in the mobile learning practice, such as teachers
and mentors, should also be taken into consideration in assessing the benefits of the
practice.
This study focused on the context of Hong Kong nursing education. As the prac‑
tice of clinical practicums is context-dependent and may vary across countries or
institutions, students’ needs for mobile learning may also change in relation to their
specific learning contexts. For example, whether the clinical assessment is con‑
ducted by hospital nurses or academic staff in the nursing programme would affect
students’ support needs for the assessment. The effects of learning contexts on stu‑
dent needs are another potential direction for future study.

13
K. C. Li et al.

The study showed the application of the FRAME model to conduct both qualita‑
tive and quantitative evaluation of mobile learning practice. It suggested potential
variations in the realisation of the model according to different device users, set‑
tings, and purposes. Future work could also be done on capturing the influence of
such variations, if any, on devising and evaluating mobile learning experiences, and
investigating the roles of the model in this regard.

Acknowledgements The work described in this paper was substantially supported by a grant from
the Research Grants Council of the Hong Kong Special Administrative Region, China (UGC/FDS16/
H10/14).

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Publisher’s Note  Springer Nature remains neutral with regard to jurisdictional claims in published maps
and institutional affiliations.

Kam Cheong Li  is the Director of Research at the Open University of Hong Kong. He oversees research
of the University and has been actively involved in open and innovative education for more than 20 years.
His research interests lie in educational technology, innovative pedagogy, and modes of university educa‑
tion, with more than a hundred publications including journal articles, academic papers, monographs, and
edited books.

Linda Yin‑king Lee  is Associate Dean and Professor of School of Nursing and Health Studies at the Open
University of Hong Kong. Her major areas of teaching include nursing research and evidence-based nurs‑
ing. She is an active researcher, particularly in the areas of teaching methodology, gerontological care and
community care.

Suet‑lai Wong  is Assistant Professor of the School of Nursing and Health Studies at the Open University
of Hong Kong. She is interested in educational technologies and has applied technologies such as mobile
learning application to facilitate students’ learning on health assessment.

Ivy Sui‑yu Yau  is Associate Professor of the School of Nursing and Health Studies at the Open University
of Hong Kong. She serves as the Editor-in-Chief, Editorial Board member and reviewer for various inter‑
national journals. Her research interests include mobile learning, nursing education, physical activity and
health.

Billy Tak‑ming Wong  is Research Coordinator at the Open University of Hong Kong. He has been
involved in various research projects related to technology-enhanced education. His research interests lie
in the areas of mobile learning, blended learning, open educational resources, and learning analytics.

13
Evaluation of mobile learning for the clinical practicum in…

Affiliations

Kam Cheong Li1   · Linda Yin‑king Lee1 · Suet‑lai Wong1 · Ivy Sui‑yu Yau1 ·


Billy Tak‑ming Wong1
Kam Cheong Li
kcli@ouhk.edu.hk
Linda Yin‑king Lee
yklee@ouhk.edu.hk
Suet‑lai Wong
slwong@ouhk.edu.hk
Ivy Sui‑yu Yau
isyyau@ouhk.edu.hk
1
The Open University of Hong Kong, Hong Kong, China

13

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