CIN: Computers, Informatics, Nursing & Vol.

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F E A T U R E

A R T I C L E

I N T E R N A T I O N A L
Using M-Learning on
Modern handheld devices and wireless commu-
Nursing Courses to nications foster new kinds of communication and
interaction that can define new approaches to
Improve Learning teaching and learning. Mobile learning (m-learning)
seeks to use them extensively, exactly in the same
way in which e-learning uses personal computers
LUIS DE MARCOS ORTEGA, PhD and wired communication technologies. In this new
ROBERTO BARCHINO PLATA, PhD mobile environment, new applications and educa-
MARÍA LOURDES JIMÉNEZ RODRÍGUEZ, PhD tional models need to be created and tested to
confirm (or reject) their validity and usefulness. In
JOSÉ RAMÓN HILERA GONZÁLEZ, PhD
this article, we present a mobile tool aimed at self-
JOSÉ JAVIER MARTÍNEZ HERRÁIZ, PhD assessment, which allows students to test their
JOSÉ ANTONIO GUTIÉRREZ DE MESA, PhD knowledge at any place and at any time. The de-
JOSÉ MARÍA GUTIÉRREZ MARTÍNEZ, PhD gree to which the students’ achievement improved
SALVADOR OTÓN TORTOSA, PhD is also evaluated, and a survey on the students’
opinion of the new tool was also conducted. An
experimental group of 20- to 21-year-old nursing
students was chosen to test the tool. Results show
that this kind of tool improves students’ achieve-
ment and does not make necessary to introduce
substantial changes in current teaching activities
INTRODUCTION and methodology.
With the new ‘‘anytime, anywhere computing’’ paradigm
(ubiquitous computing), a shift from ‘‘electronic’’ to ‘‘mobile’’ KEY WORDS
services has begun. So, just as e-commerce has extended to Mobile assessment & Mobile computing &
m-commerce, e-learning now includes m-learning (mobile Nursing studies & Online education
learning).1 In the field of teaching and learning, the ex-
pected benefits of this new mobility include, among others,
more efficient instruction along with an improvement in the
learning outcome. In this framework, it is crucial to create the latest developments in m-learning along with the moti-
new tools that add value to the teaching-learning process, vation for our research is presented. In the third section,
but it is also important to have tools that allow us to exert The System, the mobile application and the system that
some control over the results of the learning process. Within provides the appropriate support for the learning action are
this context, this article presents a new mobile application presented. In the fourth section, The Experiment, we de-
designed for self-assessment. It allows students to test their scribe the experiments carried out, and finally, Results and
knowledge and expertise on a specific topic using question- Conclusion include the results, analysis, and conclusions.
naires designed by their teachers. Young students use mobile
phones as an integral part of their lives and think of them
as a crucial communication tool. Therefore, providing them
with learning tools that work on these mobile applications Reprinted from Ortega LD, Plata RB, Jiménez Rodrı́guez ML, et al.
Using m-learning on nursing courses to improve learning. Comput
is important because this will increase their motivation to Inform Nurs. 2011;29(5):311–317.
learn. However, designing and implementing new tools are DOI: 10.1097/NCN.0b013e3181fcbddb.
not enough; they must form an integral part of learning ac- Author Affiliation: Computer Science Department, University of
Alcala, Madrid, Spain.
tivities, and their usefulness must also be measured. For
Corresponding author: Roberto Barchino Plata, PhD, Computer
these reasons, this article also describes the actions under- Science Department, University of Alcala, Campus Universitario,
taken to test the new application on a group of nursing Alcalá De Henares, 28871, Madrid, Spain (roberto.barchino@uah.es).
students. In Background and Motivation, a brief review of DOI: 10.1097/NCN.0b013e3182285d2c

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 BACKGROUND AND MOTIVATION feedback between educators and learners. These authors
emphasize the essential role that tests and questionnaires
A number of definitions, covering a wide range of as- play in knowledge acquisition and consider that mobile
pects, have been used to denote the term ‘‘m-learning.’’ devices are especially suitable to the questionnaire for-
Some of them identify m-learning as a mere evolution mat, considering the special circumstances of mobility
of e-learning, while others define it as an independent that students face nowadays.
trend that has its origins in the ubiquitous nature of present- The research presented here is based on these ideas. Our
day communication systems. These identify m-learning aim was to build a mobile application that could be used
as ‘‘location-independent and situation-independent.’’2 as an aid to students’ self-evaluation. Teachers first design
McLean3 considers m-learning to be a term coined to their learning action in a traditional way, but use the new
cover a wide range of issues created by the convergence tool as support. They are now able to provide the students
of new mobile technologies, a wireless infrastructure and with a set of questionnaires designed to reinforce learn-
development in e-learning. Further analysis of available ing. With this tool, we are able to demonstrate how
definitions allows us to summarize the two essential fea- current technologies enable mobile learning initiatives to
tures of m-learning: (1) because it is mobile, m-learning be conducted in accordance with the aforementioned
allows the educational process to take place anywhere trends. However, it probably will not make a real con-
and at anytime; and (2) any kind of handheld device tribution to the present state of the art. Therefore, the
(small and easy to carry) along with a communication second objective of this research was to assess the real
technology is required. usefulness of the application in terms of how it performs
A recurring theme in different works on m-learning4,5 is with one group of learners and also in terms of the
that mobile/electronic education should not attempt to students’ attitude toward the new tool and the methods
replace traditional education, but should instead support that its inclusion in the course gives rise to. None of the
both students and teachers by providing them with ser- previously cited works include similar surveys that allow
vices that facilitate teaching, learning, and/or any related us to draw any real conclusion about the real effects of
administrative tasks. The basic approach is integrative, com- mobile self-assessment on learning actions, and our aim is
bining a variety of (mobile and nonmobile) devices and to fill that gap.
using either wired or wireless transmission technologies.1 There are many works in the different educational levels
This hypothesis is supported by Houser et al.6 After that incorporate m-learning as a tool in the teaching and
analyzing successful m-learning projects, they conclude learning process. As it is shown in Martı́n and Carro’s9
that all the projects they studied used mobile devices as part article from the Universidad Autónoma of Madrid that
of a mixed educational program (b-learning or ‘‘blended presents a system to support the generation of adaptive
learning’’) that combined traditional attendance-based mobile learning environments, the work by Ktoridou
education with Web learning and mobile components. et al10 evaluates the viability of integrating mobile tech-
Shepherd7 proposes three possible uses for m-learning. nology into the teaching and learning processes in higher
(1) The first is to use m-learning to help during the pre- education, and Park11 discusses, in his article, the char-
paratory phase, before any learning actually takes place, acteristics and requirements of m-learning based on ubiq-
through the use of ‘‘diagnosis.’’ This includes pretests, uitous computing. In the field of nursing, there are also
learning-style tests, attitudinal surveys and the gathering many works, such as that of Tilley12 or the work by
of prerequisite data about the learner’s experience, job, Crane,13 about improvements in learning, although these
and qualifications. This useful data can then be used to contributions use a Web environment (e-learning), but
avoid wasting time during teaching by adapting the learn- Maag’s14 work from the University of San Francisco is
ing experience to each learner’s profile. (2) The second is focused on the use of m-learning in nursing education.
to use m-learning as a means of support for students
when they are preparing for their examinations, reviewing
content, and reinforcing the knowledge they have THE SYSTEM
acquired so far. Finally (3), the most interesting challenge
for m-learning (according to Shepherd) is the contribution A Web-based system was designed and built to support
it can make to continuous on-demand learning (usually mobile self-assessment in traditional class-based learning.
applied to real-world problems). The architecture (Figure 1) comprises three different sys-
Another issue that must be considered is the kind of tems: (1) A Web server to store, deliver, and evaluate
content that can be delivered by means of m-learning. As online tests; (2) the mobile application that students use
Wuthrich et al point out,8 the special features of the to connect to the server, download questionnaires, and
mobile devices used in this type of initiative mean they complete them; and (3) a Web-based front-end that of-
can be used as a conduit for distributing self-evaluation fers different functionalities to each kind of user. The
tools and study guidelines and, in some cases, enable latter can be used by students to complete their tests, and

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FIGURE 1. The system architecture.

teachers can use it to configure questionnaires and re-

view students’ results. The administrator’s role also exists,
and his/her responsibilities are linked to user (students,
teachers, and other administrators) management.
The system was developed using Java technology (Java
Micro Edition for the mobile application) (both by Oracle FIGURE 3. Web application for the students (in Spanish).
Corporation, Redwood Shores, CA) and XSLT transfor-
mation sheets. The latter technology makes it easier to use that format. Question and Test Interoperability is a
adapt output to Web and mobile system requirements. The widely adopted specification that ensures interoperability
mobile application was tested on a wide range of available between systems. In this way, tests that conform to the
devices. Mobile devices must be Java enabled to run the specification can later be moved to any other compliant
applications, and they must also be open to current Internet system. The QTI specification takes into account a wide
connection technology (eg, GPRS or UMTS). range of question types including multiple choice, gap fill,
Every student is provided with a log-in and password ordering, association, and open answer, among others.
so they can access both the mobile and Web application. However, at present, the mobile application supports only
First, they must connect to the server where a list of all multiple-choice questions. So, teachers must design ques-
available subjects and tests is displayed. They can then tionnaires using this format. The number of answers per
complete any of the available tests, get their results, and question varies, depending on how many the teacher feels
review their answers (Figure 2). The Web application in- are suitable. Teachers are also able to review each stu-
cludes the same features. The only difference being that dent’s achievement as all their personal scores are stored
all questions are presented in a row (Figure 3). (Figure 4).
Teachers can upload and configure tests. One important
feature of the system is that it supports the IMS Question
and Test Interoperability (QTI) specification15: the system
internally stores and manages all tests and questions that

FIGURE 2. Mobile application screenshots (in Spanish). Left, A FIGURE 4. Web application showing a student’s achievement
question. Right, Posttest results. (in Spanish).

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 The architecture and systems are easy to install, use, and to every student by installing the application on his/her
maintain. This ensures that many institutions can afford mobile phone. Although this is probably the best option, it
the cost of using them. However, the features currently on must be said that there are some disadvantages to this.
offer are limited, making it difficult to use the system as First, technical problems may arise due to the many dif-
the sole or central part of a learning action. Indeed, it is ferent kinds of devices that students have. Technical sup-
designed to be used as a complementary system that can port was provided, but sometimes it proved impossible
be incorporated into a new or existing learning action. to run the application because of hardware, software, or
However, the underlying architecture and technologies communication requirements that terminals did not meet.
used also ensure that it can quickly be extended at a low Second, the mobile application must have an Internet con-
cost. We cite just one example. The QTI questions and tests nection so the questionnaires can be downloaded and the
are stored and delivered using an XML dialect. The use of response sent back to the server. This obviously requires an
XSLT technology makes it easy to transform XML data appropriate device, but it should also be noted that this
to any output (user readable) format used by mobile and communication has a cost. And although this is not high,
Web applications (please note that from a technological it may be beyond the limited budget of a young adult.
point of view, these two formats are rather different). To solve these problems, teachers were temporarily pro-
vided with a set of five preconfigured mobile phones so
that they could schedule different sessions in which the
THE EXPERIMENT students were able to use these devices to perform their
self-assessment. Two 50-minute sessions were scheduled
Learning Actions and Experimental Groups for the group. During these sessions, assistance was avail-
able from the students’ teacher and also from technicians
Our aim was to test the degree to which mobile self- who were in attendance. Finally, if they preferred, students
assessment improves the achievement of nursing students. were also able to use the Web front-end to access the ques-
So, as our experimental group, we chose a group of 28 tionnaires from any computer with an Internet connection
third-year students aged between 20 and 21 years. We were and a Web browser. A few of them used this method, but
able to collect accurate data enabling us to reach con- only after they had taken the mobile test and usually
clusions on the improvements that mobile self-assessment because they wanted to recheck their answers. The idea
can produce when it is targeted at a specific group. was to provide every student with a variety of ways to com-
The next step was to arrange the subjects being assessed plete the tests.
into a set of learning objectives (LOs). For the nursing As all the mobile sessions were intended for self-
course, the LOs were drawn from the official syllabus ap- assessment, no limit was set on the number of attempts
proved for that degree by the National Council of Uni- the students could perform. This was reasonable as the
versities. The LOs were the following: mobile assessment results do not carry any weight in the
students’ final grade. And what is more, the Web system
 Objective 1 (NLO 1): to become acquainted with also records all of a student’s attempts and makes this in-
the vaccination schedule for the region. formation available to the teacher for him/her to use if
 Objective 2 (NLO 2): to understand and use the he/she considers it worthwhile. For both these reasons,
Mantoux test. imposing any limitation on the number of attempts makes
 Objective 3 (NLO 3): to become acquainted with no sense. Through a process of trial and error, the students
the complementary feeding of healthy 0- to can make repeated attempts to answer correctly. This will
18-month-old infants. not affect their final grade unless they really gain some
 Objective 4 (NLO 4): to understand and apply the understanding of the concepts being studied. Students
treatment for diabetes. were graded (for each module) using the method that each
teacher normally used depending on his/her preference
Teachers designed a self-assessment test with 10 ques- and experience, but also in accordance with the require-
tions for each LO. Single-choice questions with four to five ments imposed by his/her own institution or any other
options were used. Questionnaires were later adapted to public regulations. Examination methods include papers,
conform to the QTI specification and uploaded to the Web examinations, and practical tests. Final grades were also
server. Teachers and students were finally provided with provided by the teachers; to compute them, it was as-
their log-in and password. sumed that each module carried the same weight. All the
experiments and grading were conducted during the
Conducting the Experiment 2008–2009 spring semester, and all the aforementioned
LOs form part of the course syllabus taught during that
The mobile learning tool is designed for self-assessment, semester. It is also important to note that the control group
so the obvious way to distribute it is to make it available was selected from the same institution taking care to

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 experimental groups are 0.6904 and 0.7615, respectively.
That represents an improvement of 10.3%. Similar results
were returned for NLO 1, NLO 2, and NLO 3, with in-
crements of 12.64%, 11.95%, and 11.78%, respectively. A
more moderate effect can be observed in NLO 4 because
the mean score has increased to just 5.25%. Teachers of
this course may feel, when designing future learning
actions, that the mobile application contributed little or
nothing to the students’ achievement in NLO 4. A sub-
sequent analysis carried out with the help of teachers on
the course upheld the validity of this result: it seems that
the topics covered in this LO are mainly practical and as
such are difficult to test with a mobile-assessment applica-
FIGURE 5. A box plot of the final scores for the nursing group. tion. As will be discussed later, a new and interesting line
of research remains open here. Table 1 also gives the com-
parison results of independent-samples t test for the control
choose one that had shown a similar achievement (up until and experimental groups. This study found that the dif-
the time of the experiment) as the experimental group. ference of the mean scores does not reach the significant
This selection was an easy task because every teacher had level for any LO as well as for the final mark (P 9 .05 in all
performance data from the previous semester. cases). However, because of the small sample size and
limited functionality of the application, we cannot general-
ize these results.
RESULTS AND CONCLUSION
Outcome data collected on the group are presented and Attitudinal Survey
discussed in this section. It must be borne in mind that
The students were also asked to answer a questionnaire of
every teacher provided a grade for every LO for each stu-
10 items designed to evaluate their opinion of the learning
dent, along with a final mark for the course. Students’
tool and their level of satisfaction. The instrument used
opinions were also appraised in an attitudinal survey.
was a questionnaire based on a five-point Likert scale,
with the items shown in Table 2, with all the sentences
Achievement Improvement scored on a positive scale. Similar instruments have been
used by other researchers.16 The most important results
The students’ achievements were collated into the set of are summarized in Table 2. The average for these ques-
defined LOs for both the experimental and the control tions is 4.08 on the five-point scale, indicating that the
groups. They were also normalized in the 0-to-1 range. It students’ attitude to this experience was very positive.
should be noted that, in accordance with our national The lowest rated statement was item 2, which is related
system and after this normalization, a final mark of 0.5 or to the students’ learning. This is reasonable as the appli-
above is a pass mark. cation is designed for self-assessment and reinforcement.
The results for the nursing course are shown in Figure 5 Another statement with a low rate is item 9, which refers
and Table 1. No significant differences could be deter- to the students’ motivation toward new learning. We feel
mined between the final score of both groups in Figure 5. that it would be worth the effort for both teachers and
As for the results of descriptive statistics listed in Table 1, researchers to design new experiments and learning ac-
the final mean scores of 28 learners for the control and tions that would increase student motivation as lack of

T a b l e 1
Grades for the Nursing Group
Control Group (n = 28) Experimental Group (n = 28)
Measure Mean SD SE Mean SD SE P
NLO 1 0.6692 0.2213 0.0614 0.7538 0.2106 0.0584 .328
NLO 2 0.7077 0.2178 0.0604 0.7923 0.1935 0.0537 .305
NLO 3 0.6538 0.2504 0.0694 0.7308 0.2175 0.0603 .411
NLO 4 0.7308 0.1974 0.0548 0.7692 0.1797 0.0499 .608
Final score 0.6904 0.2050 0.0569 0.7615 0.1802 0.0500 .357

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 T a b l e 2 tem. A nursing course has been adapted to include support
for this tool, and different sessions were scheduled to test
Attitudinal Survey Resultsa its usability, usefulness, and performance. The students’
Question Mean SD achievement for a number of the LOs of this course was
1. Questionnaires were 4.00 0.71 collected for statistical analysis. Results show that there
presented effectively was an improvement in students’ achievement: it returned
2. I learned about the course topic 3.23 1.01 a 10.3% improvement in 65% of cases, although there is
3. I enjoyed the experience 4.23 0.93 no statistical significance. Results suggest that the inclusion
4. Using the mobile tool was easy 4.62 0.51 of this new tool in the learning actions produces a mod-
5. The proposed practice activities 4.54 0.66 erate improvement in the students’ achievement. An at-
were useful titudinal survey was also carried out, and results from it
6. There was a sufficient number 4.00 0.58 suggest a fairly positive attitude by the students.
of exercises
Apart from these results, additional conclusions may be
7. There was sufficient time to 4.62 0.51
drawn. First, the decreasing level of improvement that
complete the exercises
8. My level of involvement was high 3.62 0.87 occurred on the nursing course must be considered. It
9. I would like to learn more about 3.39 0.87 could be argued that it may have been related to the
the course topic students’ age. It seems that teenagers feel more at home
10. This was a worthwhile 4.62 0.51 with new technologies, and this familiarity increases their
learning experience motivation and as a result improves their performance.
Average 4.08 — Older students are not as motivated by the mobile ap-
a
Answers were provided on a five-point Likert scale (1 = strongly disagree,
plication as are their younger colleagues, and this may
2 = disagree, 3 = undecided, 4 = agree, 5 = strongly agree). explain their lower (but still important) improvement.
Conversations with teachers point in this direction, but
additional research will be required to confirm it and find
empirical evidence to support this point. Further research
motivation was caused by a number of aspects that are
will be conducted in this area with a larger sample of
not easy to summarize here. All other items were rated
learners and courses.
above 3.5. The ratings for items 4, 7, and 10 are espe-
We have also observed that improvement in LO NLO 4
cially significant. Item 4 demonstrates how user-friendly
(to understand and apply the treatment for diabetes) is
the tool is. Students very quickly became acquainted
with it: it is worth stating that it took longer to train the remarkably low. This was due to the fact that the principal
component of applying treatments is of a practical nature,
teachers than it did the students. Item 7 is related to the
making it extremely difficult to include in a self-assessment
time available to complete the activities. Given the positive
activity such as the one incorporated into the proposed
rating the tool achieved, it would appear that the learning
mobile application. As such, it is necessary to look for al-
activities and sessions were adequately scheduled with
ternative ways to design the LOs and the way they are
enough time to complete them. The high rating given to
assessed within this type of course. The easiest way would
item 10 reflects a very positive attitude toward the learn-
be to exclude the LO from the m-learning activity, but
ing experience.
Answer variability is low because overall SD is 0.93, we think that research into new mobile applications could
be carried out. 3D applications use three-dimensional
which represents less than one-fourth of the mean. So it
graphics to provide visual representations that are more
can be said that the answers are homogeneous. To com-
appealing to the human eye because they represent reality
plete the analysis of the attitudinal survey, Cronbach ! was
more precisely than traditional two-dimensional applica-
computed to measure the internal consistency of the sur-
tions. They have shown their learning potential,17 and 3D
vey. The result returned was .86. This value was higher
technology for mobile devices and its application in
than .7, which suggests that the test items measure the
learning is also becoming a reality.18 Mobile 3D learning
same construct.
applications can be investigated to determine its applica-
bility to teach practical competencies.
Conclusions and Future Work It is also important to take into account the fact that the
attitudinal survey suggests that students do not learn using
A new system of m-learning, which consists of a mobile this tool. Although this result is to be expected as the tool
application for student self-assessment, the server side and is designed for self-assessment and therefore used to
a Web front-end are presented in this article. Its confor- reinforce acquired knowledge rather than gain new knowl-
mance with current specifications is a remarkable feature edge, we feel it is important that this issue is given greater
of this system, as it ensures that the questionnaires designed consideration in the future. The low rates obtained by
for it can later be transferred to any other compliant sys- items related to this in the attitudinal survey suggest that

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