Integrating mobile devices into nursing curricula: Opportunities for implementation using Rogers' Diffusion of Innovation model

Nurse Education Today 34 (2014) 775–782

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Nurse Education Today journal homepage: www.elsevier.com/nedt

Review

Integrating mobile devices into nursing curricula: Opportunities for implementation using Rogers' Diffusion of Innovation model Glynda J. Doyle a,⁎, Bernie Garrett b,1, Leanne M. Currie b,2 a b

School of Health Sciences, British Columbia Institute of Technology, 3700 Willingdon Avenue, Burnaby, BC V5G 3H2, Canada University of British Columbia, School of Nursing, T201-2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada

a r t i c l e

i n f o

Article history: Accepted 30 October 2013 Keywords: Mobile device Handheld computer PDA Smartphone Nursing education Diffusion of innovation Change management

s u m m a r y Objectives: To identify studies reporting mobile device integration into undergraduate and graduate nursing curricula. To explore the potential use of Rogers' Diffusion of Innovation model as a framework to guide implementation of mobile devices into nursing curricula. Design: Literature review and thematic categorization. Data sources: Literature published up until June 2013 was searched using EBSCO, PubMed, and Google Scholar. Review method: The literature was reviewed for research articles pertaining to mobile device use in nursing education. Research articles were grouped by study design, and articles were classified by: 1) strategies for individual adopters and 2) strategies for organizations. Rogers' Diffusion of Innovation theory was used to categorize reported implementation strategies. Results: Fifty-two research studies were identified. Strategies for implementation were varied, and challenges to integrating mobile devices include lack of administrative support and time/funding to educate faculty as well as students. Overall, the use of mobile devices appears to provide benefits to nursing students; however the research evidence is limited. Conclusion: Anticipating challenges and ensuring a well laid out strategic plan can assist in supporting successful integration of mobile devices. Crown Copyright © 2013 Published by Elsevier Ltd. All rights reserved.

Introduction The use of mobile devices at the point of care has become a growing trend in nursing practice (Mosa et al., 2012; Phillippi and Wyatt, 2011). Many terms are used to describe mobile devices including portable computing devices, personal digital assistants (PDAs), smartphones, and handheld computers; the term ‘mobile devices’ will be used for the purposes of this paper. The complexity of patient health issues is intensifying (Billings et al., 2012), and nurses are facing the challenge of effectively managing an increasing amount of clinical information while also managing technological advances (Doran, 2009). Mobile devices have significant potential to support nursing students' decision making and patient care planning because these technologies can quickly bring relevant and evidence-based resources to the point of care (Doran et al., 2010). Nursing schools and nurse educators are being encouraged to support nursing students in their use of mobile devices to document clinical activities, direct students to reputable information

⁎ Corresponding author. Tel.: +1 604 765 8913; fax: +1 604 436 9590. E-mail addresses: [email protected] (G.J. Doyle), [email protected] (B. Garrett), [email protected] (L.M. Currie). 1 Tel.: +1 604 822 7443; fax: +1 604 822 7466. 2 Tel.: +1 604 822 7485; fax: +1 604 822 7466.

resources, and ensure that students understand how to use devices in alignment with professional standards (Altmann and Brady, 2005; Arhin and Cormier, 2007; Bakken et al., 2004; Cornelius, 2005; Griffin-Sobel et al., 2010; Huffstutler et al., 2002; Kenny et al., 2009a; McLeod and Mays, 2008). Rogers' Diffusion of Innovation theory provides a useful theoretical framework for nursing schools that are considering integrating mobile devices as a tool to enhance learning. This framework can support the planning and adoption of these new technologies because the integration of mobile devices into the nursing curriculum represents a new innovation to many schools and educators. Methods A literature review was undertaken to examine publications describing the use of mobile devices in nursing education. The following databases were searched up to June 2013: EBSCO (Academic Search Complete, CINAHL, Medline), PubMed, and Google Scholar. Search terms included: personal digital assistant, PDAs, handheld computers (computers, handheld), mobile (computing) device, pocket computer, wireless device, mobile learning, nursing education, nursing, education, and also ‘diffusion of innovation’. No date constraints were applied to the search and only English language articles were included. Articles in domains other than nursing education were excluded. The database

0260-6917/$ – see front matter. Crown Copyright © 2013 Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.10.021

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searches yielded 615 articles, of which 363 were duplicates, leaving 252 articles. Abstracts were reviewed by an individual researcher initially, and then two other researchers independently, yielding 40 research articles, 73 opinion articles and 19 articles related to diffusion of innovation. An additional 12 research articles were identified by searching the reference lists of identified articles. The results of the 52 research studies were grouped by study methodology, and Rogers' Diffusion of Innovation theory was used as the framework for analysis of the implementation strategies reported in the papers. Articles were then grouped by theme related to best practice recommendations for diffusing the innovation of mobile technologies in nursing education. Summary of Research Studies Table 1 provides a summary of research studies identified including four randomized controlled trials, 13 quasi-experiments, four qualitative studies, and 18 descriptive studies, and 13 studies using mixed methods. In several studies students reported that using mobile devices to access information saved time (Brubaker et al., 2009; Clay, 2011; Koeniger-Donohue, 2008; Smith and Pattillo, 2006; Thomas et al., 2001; Trangenstein et al., 2007), and that having access to information resources was useful (Cibulka and Crane-Wider, 2011; Fisher and Koren, 2007; Garrett and Jackson, 2006; Miller et al., 2005; Pattillo et al., 2007; Schnall et al., 2011; Stroud et al., 2005; Trangenstein et al., 2007; Williams and Dittmer, 2009; Wittmann-Price et al., 2012), while others reported improvement in student learning (Chioh et al., 2013; de Marcos Ortega et al., 2011; Dearnley et al., 2008; Elliott et al., 2012; Galvao and Püschel, 2012; Kuiper, 2008; Lai and Wu, 2006; Schlairet, 2012; Wu et al., 2012; Wu et al., 2011). Studies that explored student perceptions found that the use of mobile devices for information resources increased student self-efficacy (Bauldoff et al., 2008; Goldsworthy et al., 2006; Kuiper, 2010; Thomas et al., 2001; WittmannPrice et al., 2012), decreased clinical information stress (Jamieson et al., 2009), and decreased student cognitive load (Wu et al., 2012). Several studies that explored types of information resources used found that drug reference guides were the most common resource used by students (Altmann and Brady, 2005; Berglund et al., 2007; Clark et al., 2009; Colevins et al., 2006; Farrell and Rose, 2008; Garrett and Jackson, 2006; George et al., 2010; Hudson and Buell, 2011; Kenny et al., 2009b). Several studies found the use of mobile devices for student assessment via clinical logs, interaction between faculty and students, and peer-to-peer support useful (Bakken et al., 2006; Jenkins et al., 2006; Kneebone et al., 2003; Wu and Lai, 2009). A study by Lee (2007) found that the use of decision support integrated into mobile device-based student clinical logs improved adherence to screening guidelines and Greenfield (2007) found that students using mobile devices had decreased medication calculation errors, but no improvement in course performance. Three studies found that students with previous computer experience found mobile devices easier to use than those who did not have previous experience (Farrell and Rose, 2008; Kenny et al., 2009a; Wang et al., 2012). In addition, several studies found that access to technological support was integral to the success of deployment of mobile devices in nursing education (Carlton et al., 2007; Cibulka and Crane-Wider, 2011; Schnall et al., 2011). Only three studies found a negative impact of mobile devices including podcasting showed no improvement over classroom learning (Johnston et al., 2010), tablet computers were inconvenient for clinical use (Bogossian et al., 2009), and no added value to student learning when using PDA-based information resources (Morris and Maynard, 2010). In summary, the literature to-date suggests an improvement in nursing education from the use of mobile devices, however, most study designs provide weak evidence. Of the literature we identified 15 articles that specifically described the integration of mobile devices into nursing curricula. Three of these articles were research studies, the other 12 were review articles. We used Rogers' Diffusion of Innovation theory to analyze these articles.

Rogers' Diffusion of Innovation Theory Rogers' Diffusion of Innovation theory was first described in 1962 and characterizes people based on their likelihood to adopt technology and categorizes organizations based on their stage of adoption of a new technology. Rogers suggests there are five types of ‘adopters’ based on their relative likelihood to try out new things including: innovators, early adopters, early majority, late majority and laggards. Table 2 summarizes the characteristics of each type of adopter. According to Rogers, diffusion of innovation at the individual level occurs in five stages: 1) knowledge, 2) persuasion, 3) decision, 4) implementation, and 5) confirmation, with five characteristics of innovations that influence an individual's decision to adopt or reject an innovation: i) relative advantage, ii) compatibility, iii) complexity, iv) trialability, and v) observability. Rogers suggests that these stages and characteristics be recognized when persuading users to adopt an innovation. Individual Stages of Adoption and Adopter Groups Several authors cite Rogers' Diffusion of Innovation (DoI) as a useful framework to guide innovations in nursing (Starkweather and Kardong-Edgren, 2008), to create a culture of innovation in organizations (Melnyk and Davidson, 2009), and to guide research designs (Doran et al., 2010). DoI was used here to categorize adoption strategies for mobile devices in nursing education. Once a decision to incorporate mobile devices into a nursing program is made, applying the phases of DoI to the process may improve the likelihood of acceptance by various stakeholders (Barr, 2002; Huffstutler et al., 2002; Scollin et al., 2007). Table 3 shows strategies to engage individual adopter types at different phases of integrating mobile devices into the curricula. Although Table 3 appears linear, the process may be iterative, and individuals may appear to be ‘laggards’ when in fact, they might be ‘early majority’ types who will engage in the technology when offered the opportunity at the right time. Organizational Stages of Adoption According to Rogers, the process of adoption for organizations consists of: initiation phase, decision, and implementation phase. During the initiation phase, the need for an innovation is identified in two steps: agenda setting and matching. In the agenda setting step individuals in an organization start mobilizing towards a change. During the matching step the best fitting solution is found. The initiation phase ends when a decision is made. The decision is followed by the implementation phase with three stages: redefining, clarifying and routinizing. During the redefining stage the innovation goes through the first modification to fit the organization's needs. Clarifying follows, when the innovation is gradually embedded in the organization and then routinizing in which the innovation is fully incorporated in the organization. Each stage of adoption is outlined below and organizational strategies for adoption are presented. Stage 1: Agenda Setting Executive Support & Adequate Funding A key factor for the effective adoption of mobile devices into nursing curricula is project support from the management/leadership team (Griffin-Sobel et al., 2010; Huffstutler et al., 2002; Melnyk and Davidson, 2009). Lack of administrative support has been noted as a factor in projects that fail (Rogers, 2003). When funding and release time is available for team members projects are more likely to achieve the implementation goals (George et al., 2010; Griffin-Sobel et al., 2010; Huffstutler et al., 2002). Many projects fail due to insufficient funds and/or human resources including technological support (Carlton et al., 2007).

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Table 1 Summary of research articles by study design (most recent first). Author/date/location

Program/device/measures

Study design/sample size

Main findings

Randomized controlled trials Wu et al., 2012 Taiwan City, Taiwan Wu et al., 2011 Taiwan City, Taiwan Johnston et al., 2010 Arizona, USA Lee et al., 2009, New York, USA

BSN students; decision support during simulation BSN students; mobile learning system in skills training BSN students; podcasts via iPods in med/surg course NP students; PDA-based decision support in clinical log

Pilot RCT; N = 23 (intervention); N = 25 (control) Pilot RCT; experimental group N = 22; control group N = 24 RCT, pre-post-test, N = 31 (intervention), N = 12 (control) RCT; patients: N = 807 (intervention); N = 997 (control)

PDA use ↑ information acquisition & decreased cognitive load. ↑ learning outcomes with use of mobile learning system. Classroom attendance resulted in better grades than podcasts. Increased compliance with obesity screening guidelines.

Quasi-experiments Chioh et al., 2013 Singapore, Singapore Schlairet, 2012 Georgia, USA

Diploma nursing students; opinions about PDAs BSN students; use of PDAs for knowledge acquisition

Pre-post survey; N = 450 (pre) N = 456 (post) Pre-post survey; N = 44

Clay, 2011 Coventry, UK Hudson and Buell, 2011 Texas, USA

Midwifery students; use of PDAs for clinical skills BSN students; PDA use in clinical & class

Post survey; N = 8

Students perceived PDAs beneficial to learning. PDAs support learning, prompt reflection and trigger connections. Mobile learning afforded flexibility in time and place of learning. 40% students used PDA at time 3, drug guide most common resource.

de Marcos Ortega et al., 2011 Madrid, Spain Morris and Maynard, 2010; Plymouth, UK Clark et al., 2009 North Carolina, USA Jamieson et al., 2009 Nova Scotia, Canada

BSN students; PDA use with self-assessment tool BSN & PT students; PDA to access EBP resources RN refresher program; PDA use in clinical area BSN students; Effect of PDA on stress and confidence

Williams and Dittmer, 2009; Illinois, USA Greenfield, 2007 New York, USA Goldsworthy et al., 2006 Ontario, Canada Lai and Wu, 2006 Taiwan City, Taiwan Miller et al., 2005 Oregon, USA

BSN students; e-books in PDAs as clinical resource BSN students; PDA impact on medication error reduction BSN students; use of PDAs; perceptions of self-efficacy BSN students; PDAs in a cooperative classroom BSN students (accelerated); PDAs to access information

Pre-post survey; N = 63 (pre), N = 61 (post) Quasi-experiment; N = 37 (PDA), N = 50 (textbook) Pre-post survey, N = 18 (PDA), N = 18 (control) Post survey; N = 50 (PDA), N = 49 (control) Comparative group design; N = 84 (pre), N = 74 (post)

Mixed Methods Galvao and Püschel, 2012 Sao Paulo, Brazil

BSN students; PDA for central venous pressure

Needs assessment, post implementation survey; N = 18 Survey & focus group; N = 6

Wittmann-Price et al., 2012 South Carolina, USA Kuiper, 2010 North Carolina, USA Bogossian et al., 2009; Queensland, Australia Kenny et al. (2009a) Alberta, Canada Kenny et al. (2009b) Alberta, Canada

BSN students; smartphone use during clinical rotation BSN students; PDAs and metacognitive factors BSN students; tablet computers for e-portfolios BSN students; feasibility of the use of PDAs BSN students; PDA use

Wu and Lai, 2009 Taipei, Taiwan Farrell and Rose, 2008 Melbourne, Australia

BSN students; PDA use during practicum course BSN students; PDA use for knowledge acquisition

Berglund et al., 2007 Kalmar, Sweden Pattillo et al., 2007 Alabama, USA Scollin et al., 2007 Massachusetts, USA Garrett and Jackson, 2006, British Columbia, Canada Smith and Pattillo, 2006; Alabama, USA

BSN students & RNs; PDA function and usability needs BSN students; PDA resource use

Qualitative Wang et al., 2012 Nottingham, UK

Repeated measures study, N = 105 (time 1), N = 94 (time 2), N = 75 (time 3) Post survey; N = 28 (intervention), N = 28 (control) Pre-post study; N = 9 BSN students; N = 10 PT students Pre-post survey; N = 9 Pre-post survey; N = 22 (PDA); N = 106 (control)

Repeated measures survey; verbal protocol; N = 26. Focus group and survey; N = 3 Survey and focus group; N = 3 (students) N = 2 (faculty) Surveys and interviews; N = 11

BSN students; student attitude to PDA training type NP & medical students; PDA based e-portfolio tool BSN students; PDAs versus textbooks

Surveys, interviews, analysis of reflection journals; N = 6 Focus groups & pre-post pharmacology exam; N = 41 (PDA) N = 35 (control) Case study; surveys N = 84 (students); Interviews N = 12(RNs) Survey and interviews; N = 28 (PDA); N = 62 (control) Comparative design; N = 45 (site 1) and N = 46 (site 2) Focus groups, log file analysis; N = 10 Surveys; N = 90

Doctoral nursing students; PDA for research activities

Interviews & phenomenological interpretivism; N = 6

Moderate improvement in students' course achievement with PDA. Problem with accessibility/small screen size; PDA added no value. Drug guide most common resource; PDA skill increased. ↓ clinical information stress for PDA group, but not control; ↑ computer confidence in both. ↑ usefulness of PDA resources while ↓ textbook usefulness. PDAs decreased calculation errors but did not improve application. Increased self-efficacy among BSN students. PDA use enhanced student learning attitudes and performance. PDA effective learning resource.

Multiple forms of media promote learning and exploration. Resources considered useful, ↑ confidence in delivering medications. ↑ confidence in computer ability, self-efficacy, clinical reasoning. Tablet PCs good for portfolio use but inconvenient during clinicals. PDAs easier to use for those with computer experience. PDA use to communicate w/instructors rare; drug guide most common resource. PDA provided peer support and interaction with faculty. ↑ pharmacology knowledge in PDA group.↑ PDA ease if ↑ computer experience. Need access to drug guide, lab guide, calculator and camera. PDA-based nursing text used more frequently than textbook. Most students very satisfied with PDA information resources. Drug reference most commonly used resource; PDAs positive tools. PDAs to increase effectiveness in clinical role and save time. Digital fluency important to explore mobile learning research. (continued on next page)

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Table 1 (continued) Author/date/location

Program/device/measures

Study design/sample size

Main findings

Brubaker et al., 2009 Illinois, USA Koeniger-Donohue, 2008 Massachusetts, USA Fisher and Koren, 2007 Massachusetts, USA

BSN students; usefulness of PDAs in the clinical setting NP students; PDA use and clinical decision making BSN students; perceptions of PDA use in clinical practice

Content analysis of reflective journals; N=7 Action science study; N=6 Exploratory qualitative analysis, N = 28

PDAs convenient, saved time, and provided up-to-date information. PDA saved time and facilitated patient diagnosis. Information resources useful at point of care.

Descriptive Elliott et al., 2012 North Carolina, USA Cibulka and Crane-Wider, 2011 Missouri, USA Joseph and Guttman, 2011 New Jersey, USA Schnall et al., 2011 New York, USA

NP students; PDA use with high-fidelity simulation BSN & NP students; introduction of PDAs BSN students; PDAs to calculate medication dosages BSN & MSN students; PDA-based decision support

Observation of use of PDAs during simulation, N = 12 Survey; N = 95

BSN & MSN students; PDA use in educational context BSN students; PDA integration

Survey; N = 48

High-fidelity simulation with PDA was a positive learning experience. Information resources useful; need access to technical support. PDA use has potential to decrease medication errors. Three factors: usefulness, clinical support & barriers to use of PDA. Drug guide most frequently used resource. ↑ confidence and ↓ rote memorization.

Midwifery students & faculty; PDA to record assessment BSN students; PDA effect on clinical reasoning BSN students; PDA integration into clinical NP students; PDA based clinical log

Case study; N = 24 (students), N = 5 (faculty) Comparative descriptive design; N = 20 PDA use in classroom and clinical setting N = 14 Retrospective study of clinical logs; N = 200 Clinical log file analysis; N = 8 (students), N = 1571 (patients) Survey; N = 9

George et al., 2010 Pennsylvania, USA Bauldoff et al., 2008 Ohio, USA Dearnley et al., 2008 Bradford, UK Kuiper, 2008 North Carolina, USA Carlton et al., 2007 Indiana, USA Trangenstein et al., 2007; Tennessee, USA Bakken et al., 2006 New York, USA Colevins et al., 2006 North Carolina, USA Jenkins et al., 2006 New York, USA Scollin et al., 2006 Massachusetts, USA Altmann and Brady, 2005 California, USA Stroud et al., 2005 South Carolina, USA Kneebone et al., 2003 London, UK Thomas et al., 2001 New York, USA

NP faculty; usefulness of PDA-based clinical log RN refresher course; PDA use in clinical setting NP students (women's health); NP clinical log files BSN students & faculty; librarians' role in PDA use BSN students & faculty; PDA for information competency NP students & faculty; PDA use NP students & faculty; PDA use for learning clinical skills BSN students; mobile tracking system

Project Leadership Team A leadership team with input from key stakeholders can coordinate activities (Altmann and Brady, 2005; George et al., 2010; Griffin-Sobel et al., 2010). Key stakeholders include faculty, students, information technology staff, librarians, and educational technologists (Burnette, 2011; Colevins et al., 2006; Scollin et al., 2006). Stage 2: Matching Technology as a Philosophy Integrating technologies throughout a curriculum promotes ‘technology as a philosophy’ and provides educators with support for mobile device use (Joseph and Guttman, 2011; White et al., 2005; Zurmehly, 2010). Several groups advocate that technologies be integrated into the entire curricula (Cibulka and Crane-Wider, 2011; Huffstutler et al., 2002; Zurmehly, 2010). Resources that are in alignment with the school's philosophy and curriculum are more likely to be adopted (Huffstutler et al., 2002; Mosa et al., 2012; Skiba, 2011; White et al., 2005). Evidence-based Practice (EBP) The use of mobile devices can also help support EBP. Using mobile devices to access credible evidence at the point of care provides efficient access to up-to-date information resources, while maintaining student satisfaction and supporting student's decision making and clinical

Laboratory study; N = 10 (PDA); N = 10 (textbook & calculator) Psychometric evaluation of PDA use tool; N = 103

Content evaluation; N = 164

Log file analysis; N = 9 (students), N = 1449 (patients) Interviews; N = 43 Cross-sectional survey; N = 190 (students), N = 34 (faculty) Correlational descriptive design; N = 227 Focus groups; N = 14 (students), N = 7 (faculty) Case study; N = 8

PDAs support the assessment process and student reflection. PDAs support clinical reasoning during reflective activities. Access to information effective; Some device issues encountered. PDAs effective to document content/ quality of clinical time. Faculty found clinical log useful for student monitoring and evaluation. Drug guides and medical dictionary used most frequently. 59% of diagnoses had a teaching intervention. Librarians important to facilitate information resource selection. 67% students owned PDA, drug guide most common resource. PDAs facilitate the application of knowledge to practice. Potential to use PDAs as a formative assessment tool. ↑ student self-efficacy, immediacy and time efficiency.

judgment (Garrett and Jackson, 2006; Williams and Dittmer, 2009; Wittmann-Price et al., 2012). Partnerships with Healthcare Agencies Clinical sites may disagree with students' use of mobile devices at the point of care (Cibulka and Crane-Wider, 2011). Partnerships with healthcare agencies can be encouraged to facilitate acceptance and support of mobile devices and shared policy development. Software and Hardware Costs Mobile device and software costs are a factor when considering device integration into curricula (Altmann and Brady, 2005; Hudson and Buell, 2011). Some nursing schools have provided devices for students, but a relatively short device lifespan makes them a poor investment (McLeod and Mays, 2008; Phillippi and Wyatt, 2011). Pharmaceutical, software and hardware companies have provided funding for devices for some projects, although the funding is not perpetual (Altmann and Brady, 2005; Huffstutler et al., 2002; Scordo et al., 2003). Nursing school requirement of mobile devices may allow students with socio-economic challenges the option of using scholarship money and student loans (McLeod and Mays, 2008). Many organizations are considering bring your own device (BYOD) strategies in which mandatory student ownership of mobile devices might provide motivation for integration and application, ensure the latest models,

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Table 2 Description of adopter groups. Adopter group

Description

• Innovators

• Venturesome types who are typically well educated, more likely to take risks, enjoy being on the cutting edge, and are motivated by the idea of being a change agent (Rogers, 2003). • The depth to which the innovators implement and confirm a new innovation will particularly influence subsequent decisions of other potential adopters (Orr, 2003; Scollin et al., 2007). • Play a gatekeeping role in the introduction of new ideas into a system (Rogers, 2003). • Use the data provided by the innovators to make their own adoption decisions (Rogers, 2003). • Usually respected social leaders, visionaries in their field, often considered as key decision makers (Rogers, 2003). • Ultimately help with triggering the critical mass when approving an innovation (Orr, 2003). • Will adopt an innovation before the average individual (Rogers, 2003). • Make up about one third of all members of a system (Rogers, 2003). • Tend to be slower with the adoption process than the early adopters (Rogers, 2003). • Typically not leaders per se, but are willing to adopt change (Barr, 2002). • Adopt an innovation after the average member of a system (Rogers, 2003). • Approach new innovations with a high degree of skepticism and are slow in adopting the innovation (Rogers, 2003). • Tend to need intense encouragement (Barr, 2002). • The last to adopt an innovation (Rogers, 2003). • Are typically focused on tradition with a strong aversion to change (Orr, 2003).

• Early adopters

• Early majority

• Late Majority

• Laggards

and facilitate the transition of mobile device use as graduate nurses (Kuiper, 2010; McLeod and Mays, 2008; Phillippi and Wyatt, 2011). Stage 3: Redefining Incentive for Educators Incentives to use of new technologies can help in their adoption. Providing faculty with free or discounted hardware and/or software may be considered (Miller et al., 2005). This can help to promote educator buy-in, and allow pilot studies and opportunities to assess relative advantages, complexity, compatibility, trialability and observability (Rogers, 2003). Incentive for Students Research related to student satisfaction with use of mobile devices is generally positive. Students report that having access to information resources at the point of care improves learning (Wu et al., 2012), saves time (Smith and Pattillo, 2006), increases students' self-efficacy (Goldsworthy et al., 2006) and helps reduce clinical information use stress (Jamieson et al., 2009). Addressing Concerns Policies and education must stress patient confidentiality specific to mobile devices, the de-identification of patient data, password use, and secure device storage (Goss and Carrico, 2002; Hohler, 2004; Kuiper, 2010; Peterson, 2003; Phillippi and Wyatt, 2011; Thede and Sewell, 2010; White et al., 2005). Many authors maintain that an infection control policy with clear guidelines should be implemented for students and educators, and shared with the relevant healthcare agencies (Bauldoff et al., 2008; Goss and Carrico, 2002; Hudson et al., 2009; Phillippi and Wyatt, 2011; White et al., 2012). Ensuring that core values of nursing, such as caring, respect and dignity, are not lost in the teaching of nursing under the influence of technological advances is important (Gillespie and McFetridge, 2006; Rosenthal, 2003). In 1979, Virginia Henderson pointed out that technical skills should not replace the nursing core values (Hendersen, 1979). Promoting thoughtful use of technologies can ensure adherence to core nursing values.

incorporate mobile devices into activities (McLeod and Mays, 2008), and ‘trialability’ such as use of mobile devices as a reference resource in a pharmacology course (Huffstutler et al., 2002), and use of mobile devices during activities, scenarios, and games in the classroom and simulation lab using mobile devices (Elliott et al., 2012; Garrett and Jackson, 2006). Students who are comfortable using their devices in the classroom and simulation lab may find it easier to transition to the clinical setting (Cornelius and Gordon, 2006; Kneebone et al., 2003). It is possible that some educators and students may retreat back to a previous phase before coming to full acceptance of the new initiative (Barr, 2002; Petersen, 2009). Individual meetings with educators and students may help clarify individual barriers to adoption (Rogers, 2003). Ongoing Technological Support Differences in technology comfort levels for students and educators must be considered when adopting mobile devices and learning opportunities ranging from webinars to personalized face-to-face sessions may be offered (Bauldoff et al., 2008). Use of educators or students as the technical support or trainers may create problems and setbacks for educators and students, and non-student/educator technical support staff must be strongly considered (Billings et al., 2012; Fisher and Koren, 2007; Hall, 2009; Martin, 2007). Intranet An Intranet may be developed as a way to share information, resources, and concerns between educators and students, and student peers (Wu and Lai, 2009). Intranet site maintenance will require management by a key person who might be an educator, student or technical staff (Farrell and Rose, 2008). Routinizing Formative and Summative Evaluation Regular formative evaluation of the advantages and disadvantages of mobile technologies (Huffstutler et al., 2002), their relevance to education and practice (Clark et al., 2009) and currency of information resources should be maintained. Summative evaluation can be disseminated to share knowledge with other education institutions. Conclusion

Stage 4: Clarifying Allow Time for the Process of Integration Several educators suggest methods for students and educators to be successful with mobile devices including: sufficient time to gradually

Technology is impacting nursing schools globally and educational institutions are adapting their learning environments to ensure that the use of mobile devices improves patient care without detriment to the patient–nurse relationship. Educators who are planning to

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Table 3 Strategies for engaging educators in mobile device integration. Type

Knowledge

Persuasion

Decision

Implementation

Confirmation

Innovators

• Introduce to initiative before other faculty • Organize orientation and training sessions that provide for individual learning needs • Integrate device into personal and work lifea • Join email distribution lists/listservs/networking sites for mobile device use and supportb • Introduce concept of mobile devices to other educators and stakeholdersa,c • Involve as ‘champions’f • Involve with process before, during and after adoptionh • Introduce concept of mobile devices to other educators and stakeholdersa,c

• Ensure rapport with other educatorsd • Analyze and report on pilot studies • Address concerns that arise from surveys • Synthesize evidence from literaturee • Document and share benefits and challenges with others • Demonstrate how devices can be integrated into clinical and classroomb,f

• Involve with maintaining resources through website • Implement pilot studies or small scale trialsg

• Provide ongoing support and info sharingf • Develop policies of use that include patient confidentiality, professional etiquette and infection control

• Ensure ongoing evaluation and adaptation in accordance with results of evaluationb • Explore opportunities for research

• Provide with orientation and troubleshooting sessions • Share stories and examples of mobile device usek • Involve with pilot studiesg • Allow time for process of integrationb

• Continue with training and troubleshooting sessionsb • Continue to share stories and examples of mobile device use

• Involve with research/ evaluation • Continue to share stories and examples of useb • Share results of evaluations • Offer opportunity to be involved with research studies

• Provide with orientation and troubleshooting sessions • Share stories and examples of mobile device usek

• Continue with training and troubleshooting sessionsb • Continue to share stories and examples of mobile device usek

• Continue to share stories and examples of useb • Share results of evaluations • Offer opportunity to be involved with research studies

• Provide with ongoing personalized orientation sessions available as needed • Share stories and examples of mobile device usek

• Continue with training and troubleshooting sessions as neededb • Continue to share stories and examples of mobile device usek

• Continue to share stories and examples of useb • Share results of evaluations • Offer opportunity to be involved with research studies

• Provide with ongoing personalized orientation sessions available as needed • Share stories and examples of mobile device usek

• Continue with training and troubleshooting sessionsb • Continue to share stories and examples of mobile device usek

• Continue to share stories and examples of useb • Share results of evaluations • Offer opportunity to be involved with research studies

Early adopters

Early majority

Late majority

Laggards

• Increase critical mass by involving early adoptersh • Demonstrate how devices can be integrated into clinical and classroomb,f • Provide opportunity to gain comfort with devices in ‘safe’ setting such as simulation labi,j • Address fears, anxiety, concerns • Provide with examples of case studies, models of usek • Share analysis of literature • Involve with pilot studiesm • Info sharing sessions • Provide opportunity to gain from innovators and comfort with devices in ‘safe’ early adoptersl setting such as simulation labi,j • Peer mentoring and coaching from innovators and • Allow time for process of early adoptersb integrationb • Address fears, anxiety, concerns • Provide with examples of case studies, models of usek • Share analysis of literaturen • Provide personalized face • Provide opportunity to gain to face orientation sessions comfort with devices in ‘safe’ • Determine and address setting such as simulation labi,j concerns and reasons • May need more time with for being reluctant devices, likelihood of feelings of to use devices fear and anxiety due to • Ensure aware of advantages unfamiliarity and disadvantages • Share analysis of literaturen • Address skepticismd • Remind of professional responsibility to stay currento • Provide personalized face • Provide opportunity to gain to face orientation sessions comfort with devices in ‘safe’ • Determine and address setting such as simulation labi,j concerns and reasons • May need more time with for being reluctant devices, likelihood of feelings of to use devices fear and anxiety due to Ensure aware of advantages unfamiliarity and disadvantages • Share analysis of literaturen d • Address skepticism • Remind of professional responsibility to stay currento

a

Scollin et al. (2007). Huffstutler et al. (2002). c Starkweather and Kardong-Edgren (2008). d Barr (2002). e White et al. (2005). f Cibulka and Crane-Wider, 2011. g Rogers (2003). h Shankman and Malcolm (2002). i Di Pietro et al. (2008). j Cornelius and Gordon (2006). k McLeod and Mays (2008). l George and Davidson (2005). m Scollin et al. (2006). n Orr (2003). o Fisher and Koren (2007). b

incorporate mobile devices into the curriculum may benefit from the application of a theoretical framework to support implementation and to design an evaluation plan prior to execution. Rogers' Diffusion of

Innovation Model may offer a useful starting point, but there is a clear need for further research in this area. Implementing technological change in an organization is likely to remain a challenge, but use

G.J. Doyle et al. / Nurse Education Today 34 (2014) 775–782

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