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R E S E A R C H A R T I C L E Open Access
The art of note taking with mobile devices
in medical education
Eeva Pyörälä
1*
, Saana Mäenpää
2
, Leo Heinonen
3
, Daniel Folger
2
, Teemu Masalin
4
and Heikki Hervonen
5
Abstract
Background: Students use mobile devices extensively in their everyday life, and the new technology is adopted in
study usage. Since 2013, the University of Helsinki has given new medical and dental students iPads for study use.
Simultaneously, an action research project on mobile learning started focusing on these students’mobile device
usage throughout their study years. Note taking is crucial in academic studies, but the research evidence in this
area is scarce. The aims of this study were to explore medical and dental students’self-reported study uses of
mobile devices and their best practices of mobile note taking.
Method: An action research project began in 2013 and followed the first student cohort (124 medical and 52
dental students) with iPads from the first until the fifth study year. We explored students’descriptions of their most
important study uses of mobile devices and their perceptions of note taking with iPads. The longitudinal data were
collected with online questionnaires over the years. The answers to open-ended questions were examined using
qualitative content analysis. The findings were triangulated with another question on note taking and focus-group
interviews.
Results: The response rates varied between 73 and 95%. Note taking was the most frequently and consistently
reported study use of iPads during the study years. While taking notes, students processed the new information in
an accomplished way and personalised the digital learning materials by making comments, underlining, marking
images and drawing. The visual nature of their learning materials stimulated learning. Students organised the notes
for retention in their personalised digital library. In the clinical studies, medical students faced the teachers’
resistance and ambivalence to mobile device usage. This hindered the full-scale benefit of the novel technology in
the clinical context.
Conclusions: Efficient digital note taking practices were pivotal to students in becoming mobile learners. Having all
their notes and learning materials organised in their personal digital libraries enabled the students to retrieve them
anywhere, anytime, both when studying for examinations and treating patients in the clinical practice. The
challenges the medical students met using mobile devices in the clinical setting require further studies.
Keywords: Note taking, Mobile learning, Digitality, Annotation, Medical and dental students
Background
Students use mobile devices extensively for communica-
tion and information seeking in their everyday life. With
the development of mobile technology and students’
self-directed study use of smart phones and tablet com-
puters, several medical schools have incorporated mobile
devices into their learning environment [1,2]. Tablet
computers, especially iPads, have been piloted and these
devices have been reported to invigorate students’
information seeking, time-management and note taking
[2–5]. Students have had mostly positive attitudes to-
wards mobile learning [6]. They have benefited from
using mobile devices as an online information resource
[7,8], valued having digital course materials always at
hand and expressed that information technology in clas-
ses improved their learning [9]. Applications for mobile
devices have been developed to assist students and clini-
cians in clinical decision making and have provided stu-
dents with timely feedback in the workplace [10–12].
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: eeva.pyorala@helsinki.fi
1
Center for University Teaching and Learning, University of Helsinki, P.O. Box
21, 00014 Helsinki, Finland
Full list of author information is available at the end of the article
Pyörälä et al. BMC Medical Education (2019) 19:96
https://doi.org/10.1186/s12909-019-1529-7
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The art of note taking is crucial in academic studies
but research on how students take notes with the digital
technology is scarce [13]. While taking notes, learners
interpret, filter and process the information at hand,
make connections between new information and their
prior knowledge and produce a format that enables
them to retrieve information later. The seminal work by
Di Vesta and Gray [14] showed that note taking served
primarily two functions: encoding and storage. In the act
of note taking, students encoded information by actively
transcribing, selecting and summarizing relevant
information. The second function was the organising
and storing of information for later retrieval. Subsequent
studies [15] showed that students’proficient self-
produced note taking practices led to efficient studying,
improved retention and learning outcomes.
For centuries, the students’task was to take notes with
a blank paper and a pen with which to record as much
information as they could, following the order of the in-
structor’s presentation. This type of linear note taking
recorded all the content of the lectures in the order in
which it was received. However, the paper and pen
method also enabled non-linearity, i.e., moving back and
forth in their notes, underlining, drawing and making
visual representations and connections between different
parts of the notes [16].
Over recent decades, teachers began to deliver
students printed handouts of their lectures. Students
underlined, made comments and complemented the
condensed information the teachers provided instead of
selecting, writing down and synthesizing the information
themselves. Along with the digitalisation of the learning
environment, teachers’handouts were delivered in ad-
vance in an electronic format, and it was for the stu-
dents to decide whether they printed the handouts or
learned effective ways of using electronic annotation
tools [17].
Note taking practices changed when students began to
use laptops in the classroom. Mueller and Oppenheimer
[18] compared longhand and laptop strategy and
reported that the use of laptops led to the verbatim
repetition of teachers’speech instead of active informa-
tion processing. Laptop writing advanced linearly,
whereas handwriting enabled the student to make con-
nections between sections of notes and draw. Further
studies [19] claimed that the students who took notes
using paper and pen performed better than those who
took notes digitally. In addition, they reported that when
the students were online, multitasking had a detrimental
impact on learning.
The new technology and digitalised learning materials
call for research on the students’mobile note taking
practices [20]. When the first generation of students
using tablet computers was asked about their favoured
handouts format, they declared preferring printed over
digital handouts [3]. Ellaway and her colleagues [21]
reported that less than a third of medical students to
whom mobile devices were delivered used them for note
taking. Instead, they favoured laptops and paper-based
notes. Students’ability to use mobile technology for note
taking varied and students needed support for the active
usage of these devices for educational purposes [21,22].
Students’mobile learning strategies are still evolving.
It is vital for both the students and teachers to update
their perceptions of efficient note taking strategies. In
2013, the Faculty of Medicine at the University of
Helsinki began to deliver tablet computers to first-year
medical and dental students for their personal study use.
Since only iPads were compatible with interactive elec-
tronic books (Inkling books) and medical applications
such as three-dimensional anatomy applications, these
devices were chosen over other tablet computers. At that
time, the learning materials were already provided in a
digital format for the students in their first two study
years.
The aims of this study were to explore students’per-
ceptions of the study use of mobile devices and digital
note taking practices in the first cohort of tablet com-
puter users during their studies. We sought to answer
the following questions: 1) What were the students’
most important self-reported study uses of mobile
devices? 2) How did the note taking practices change
over the study years? 3) What were the students’
perceptions of the best practices of note taking with
mobile devices?
Methods
Research strategy
Action research was chosen as the research strategy
of this project in 2013. It is a participatory and col-
laborative strategy designed to explore evolving prac-
tices and solve educational challenges together with
the participants [23,24]. The research group involved
teachers, students, information technology and peda-
gogical experts and a representative of the university
library. In an iterative process, the group recognized
problems by collecting and analysing versatile data
and communicating the possible solutions to the
teaching and learning community to improve educa-
tional practices [25].
Setting and participants
The research data were collected at the University of
Helsinki in Finland. The target group was the first
student cohort to whom iPads were delivered for their
study use: 124 medical and 52 dental students. The
cohort under scrutiny entered the Faculty of Medicine in
2013 and in 2018 were in their fifth study year. When
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they began their studies, 80% of the respondents had a
smartphone, 21% also had another tablet computer in
addition to the iPad and 77% had a laptop. The students
with another tablet computer reported only the occa-
sional every-day use of these devices. As they started
studying medicine or dentistry, they rapidly adopted
iPads for study purposes.
The duration of basic medical education was six years
and that of dental education five and a half years. For
full authorisation, students had to undergo an additional
training for primary health care. The two first study
years were mainly the same for medical and dental stu-
dents. They studied biomedical topics in problem-based
tutorials and lectures in mixed groups of medical and
dental students. In their third study year, students
continued separately in their respective medical and
dental units. Dental students began clinical studies in
the autumn term and medical students in the spring
term. Clinical studies included lectures, small-group
teaching, skills lab exercises, bedside/chairside teach-
ing and hands-on clinical teaching and learning. In
Finland, both medical and dental students participated
in the clinical work and treated patients under
supervision.
Data and method
The data were collected with online questionnaires in-
cluding closed-ended (multiple choice and 5-point Likert
scale questions) and open-ended questions on the study
use of mobile devices. There were no suitable validated
questionnaires available on review of the literature. The
questionnaires were developed from themes arising from
the literature and the teaching and learning practices in
our unit. In the first and second study years, students
completed the survey in autumn and in the third, fourth
and fifth study years, the data were collected in the
spring term to ensure students’experiences of clinical
settings. The questionnaire was originally in Finnish.
The translation of the questionnaire is provided in
Additional file 1. Two members of the research group
(EP and TM) also conducted three focus-group inter-
views in the spring of 2014 with the first-study year
medical and dental students, and two focus-group inter-
views in the spring of 2016 with the third-year medical
and dental students. In 2014, three focus-groups were
mixed groups of medical and dental students, the size of
focus-groups varied from four to seven students and the
length of the interviews from 49 to 89 min. In 2016, we
made one 46-min interview with three medical students
and another 48-min interview with three dental stu-
dents. The focus-group guide and questions are provided
in Additional file 2. These interviews were transcribed
verbatim and used to test and clarify our preliminary
finding based on the surveys. Therewith, we triangulated
our preliminary research results to ensure the
consistency of these results [26,27].
We analysed open-ended questions in which we asked
the students to describe in their own words the three
most important study uses of iPads. The responses were
examined using inductive qualitative content analysis
[28,29]. The data consisted of more than 2000 short de-
scriptions of students’three most important study uses
of iPads. The students’answers were read, openly coded
by two authors (EP and TM) and the first version of
themes was established. Two authors (EP and TM) com-
pared their results of coding and discussed the themes.
The inter-coder agreement was high, ranging from 90 to
100%. The difference between the two coders was the
lowest (90%) in coding the students’descriptions of
having notes anywhere, anytime. The authors entitled
the theme “Having notes always at hand”and revised the
coding in this theme. Furthermore, the two authors (EP
and TM) discussed all the themes until an inter-coder
agreement was reached. All themes were discussed and
examined with the student authors (SM, DF and LH).
To test our preliminary result of the priority of note
taking in mobile learning, we analysed another item on
the frequency of using the mobile device for note taking
in the surveys and triangulated the findings with the
transcripts of the focus-group interviews.
Results
The most important self-reported study uses of mobile
devices
The response rates were high, ranging from 73 to 95%
(Table 1). Students’open-ended answers referring to the
three most important study uses of iPads were coded
and calculated in percentages to provide a comparable
figure for medical and dental students. The overall per-
centages exceeded 100% since nearly all students named
several items.
In the analysis of the students’open-ended answers
about their study uses of iPads, we recognised six
themes that frequently emerged in their writing and
continued over the study years. These were [1] note tak-
ing, [2] notes always at hand, [3] information seeking on
the Internet, [4] access to the digital learning materials,
[5] use of electronic books and [6] digital applications.
The two most consistently mentioned themes were note
taking and information seeking on the Internet. We
present the occurrence of all the six themes over the
medical and dental students’study years in Fig. 1.
Taking notes was the most frequently and consistently
referred study use of iPads among the first iPad student
cohort (Fig. 1). Mobile note taking was at its peak in the
biomedical studies in the first and second study years.
We observed a drop in the digital note taking in the
clinical studies, both among the medical and dental
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students. The focus group interviews explained the de-
cline in the clinical context in dentistry and medicine. In
the dental clinic, note taking with the students’own
devices was forbidden in patient care for information
security reasons. Otherwise, the mobile device use was
well accepted. Most dental teachers revised their mate-
rials into a compatible format for iPads, produced new
materials such as videos on procedures and encouraged
students to use mobile devices in skills labs. Students
valued having their digital notes at hand for retrieval
both for preparing for the patients’care and using the
spare time between patients for studying.
In medicine, the reasons for the decline in mobile de-
vice usage given in the open-ended answers and focus
group interviews were more complex than in dentistry.
Medical students complained that the attitudes towards
the usage of mobile devices were ambivalent; they varied
from one clinical teacher to another and some teachers
denied the use of mobile devices entirely. Teachers
forbade using the device on the wards and students were
hesitant about using them with patients. Students
claimed that iPads could not be used in the wards, be-
cause they did not fit into the pockets of the white coat.
When the students were allowed use the mobile devices,
Table 1 The response rates and number of participants and the response rates of the study cohort in 2013–2018
Fig. 1 The most important self-reported study uses of mobile devices in the first student cohort using iPads (%)
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the learning materials were not always delivered in time
or in a compatible format for annotation.
To test our findings based on the analysis of
open-ended question and focus-group interviews, we
analysed a statement in the surveys asking students to
report the frequency of using the mobile device for note
taking (Fig. 2). The analysis of this item confirmed that
the use of the mobile device in note taking was at its
highest in the second study year and that dental students
used the mobile device more actively than medical
students. The percentage of students who reported they
always used iPads for note taking was lower among
medical than dental students throughout the study years.
Furthermore, the proportion of students who never used
iPad for note taking increased among medical students
during their study years, whereas the percentage of den-
tal students who did not use the mobile device for note
taking at all remained low during all years.
Students mostly described the note taking as process-
ing digitalised learning materials in the classroom and
retrieving notes for examinations. The students persona-
lised the teachers’handouts and electronic books by
underlining, highlighting and commenting on them. It
was vital to have all the learning materials in the mobile
device compatible format before class to enable students
to use the materials as a platform for their own note tak-
ing. During the first two years, all the learning materials
were delivered in the digital format before class and the
electronic learning environment was well designed and
structured. Students appreciated the large range of
digital resources. They described studying with
interactive e-books, handouts and learning materials for
problem-based tutorials in the digital format and using
tablet computer applications such as a three-dimensional
anatomy application and a note taking application
(Fig. 1). They also mentioned using iPads for e-mails,
problem-based learning tutorials, communication and
time management, but the references to these themes
were few.
Another large theme of self-reported study use of
iPads was information seeking on the Internet (Fig. 1).
Students valued the instant access to online information
sources to consult online dictionaries or look up facts
and unknown concepts. In the clinical studies, online
information resources grew even more important. The
students consulted databases and care guidelines for
health professionals with their mobile devices, especially
with their smartphones, which were always at hand.
Students wished that the clinical teachers would actively
recommend quality online data sources.
Students with mobile devices preferred a full-scale
digital learning environment and paperlessness, did not
want any printed papers or handouts nor carried text-
books to the campus, but wanted to have all the learning
materials in the digital format. If students were asked to
deliver a certificate of attendance, they preferred to take
and send a photo instead of delivering it on paper. This
pattern continued throughout their academic years. Even
though mobile devices were not allowed in all clinical
teaching activities, students used them for self-directed
studies. Students were aware of the potential online
distraction via the social media and online entertainment
but reported mostly using the devices for study
purposes.
Students’perceptions of the best practices of note taking
Students’descriptions of their most important study
usages of iPads revealed that learning to take digital
notes was pivotal to medical and dental students. The
crucial elements of mobile note taking were annotation
and visual elements in the learning materials. Managing
the learning materials was a challenge initially and the
students had to develop a system to organise the notes
in personal, digital libraries that could be used to
retrieve information for examinations and/or clinical
practice.
Mobile devices and digital materials profoundly
transformed students’note taking. Paper and pens were
Fig. 2 Medical and dental students’use of iPads for note taking among the first student cohort
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replaced by annotations with iPads using such note
taking applications Notability, Evernote, OneNote, and
PDF Expert. Students downloaded lecture handouts and
processed the information by underlining, drawing or
importing images, adding their own remarks and margi-
nalia commentaries by typing or hand-writing with a
tablet stylus or a finger (Fig. 3). Students were able to
further edit the handouts by inserting photos, screen
shots, charts and web links.
Traditional word-processing programmes, though
used by some, offered less freedom in interaction and
annotation of material and usually required the stu-
dent to produce learning material from scratch in-
stead of being able to build upon given material. The
students who used laptops were often those who had
previous academic studies where they had used lap-
topsandexpressedthatadoptinganewdigitalnote
taking strategy only caused them additional stress.
Students varied their note taking strategy according
to the context and access to the digital materials.
They annotated the daily handouts and used a word
processing application for writing minutes of
meetings. Likewise, when the materials were not de-
livered in time or in the right format, they switched
from annotation to a word processing programme.
Students valued the visual elements in handouts
and other learning materials. The iPads had a fine
screen resolution and provided a powerful tool for
visual perception and learning by drawing. Images
and photos that the students could personally
annotate were crucial for learning anatomy and
interpreting diagnostic images. Therefore, the
students desired that the number and quality of
elucidating photos and illustrations be maximised
and teachers include visual assignments as parts of
their learning materials by asking students to draw
and complete images, describe and explain the
human anatomical structures, systems and their
functions. Visual assignments were successfully inte-
grated into the second-year studies of anatomy
where students collaboratively studied histological
images with a virtual microscopy application.
Fig. 3 Example of student’s annotated notes
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To foster their diagnostic image perception, students
suggested having a medical image reservoir for
self-directed studying. In Finland, dental students in
their clinical studies took and interpreted X- rays,
treated patients and wrote patient records accordingly.
As a concrete example of the way this type of visual
learning can enhance diagnostic image perception, the
dental students expressed a wish for access to a reservoir
of anonymous, digital dental radiographs so that they
could self-directedly practise interpreting dental prob-
lems and oral infections by drawing and writing their
clinical observations on the X-rays themselves (Fig. 4).
Organising notes was as important as creating them,
as digital notes had to be logically arranged and easily
retrievable. All note taking applications provided a per-
sonalised digital library for this purpose with search and
automated backup options in cloud services (e.g., iCloud,
Google Drive, DropBox). Consequently, students’notes
could be simultaneously stored in multiple locations and
on different devices such as a student’s own smart phone
or computer. Students created personalised digital librar-
ies by organising their notes into thematically specific
folders (e.g., Respiratory System, Cardiovascular System),
and created subfolders (e.g., Anatomy, Physiology,
Pharmacology) for different types of notes (handouts,
written notes, articles). With progression into clinical
studies, the students found that their notes became a
viable tool for practical patient work, demanding cat-
egorisation more suitable for clinical practice.
Well-organised digital notes with annotations and
links to additional readings and resources, made the
materials more accessible and personalised. With these
notes, students made connections between prior know-
ledge and new information; thus, their study became
effective. For busy students who wanted to revise a
specific topic, it sufficed to type the keyword(s) in the
search function of a note taking application and display
all the relevant materials. When retrieving for examina-
tions, students valued having their notes and electronic
books always at hand, during breaks between classes,
seeing patients and on their way to the campus or back
home.
Discussion
As students rapidly adopt new technology in both their
everyday lives and studies, medical education must seek
to take advantage of its potential benefits to the learning.
For five years, this research project followed the medical
and dental students who began to study in the Faculty of
Medicine in 2013 and were delivered iPads for their per-
sonal study use. We discovered that digital note taking
was along with online information seeking the most im-
portant study uses of mobile devices. Note taking was
the main usage of iPads during the first two biomedically
oriented study years but dropped sharply in the clinical
context, especially among the medical students.
The research evidence on mobile note taking is limited
[13]. Most studies focused on handwritten notes and
emphasised that self-produced notes improved retention
and the learning outcomes [15]. Studies comparing
handwritten and digital note taking, claimed that the
students using a paper and pencil strategy outperformed
digital note takers [18,19]. More recent studies on novel
technology use reported that a minority of students to
whom mobile devices were delivered used them for note
taking. Instead, they preferred laptops, printed handouts
and paper-based notes [3,21].
In our study, we discovered that once learned, students
valued digital note taking with a mobile device. As sug-
gested in a previous study [22], students needed support
to learn to use these devices for educational purposes. At
the outset of their studies, one of the questions students
most frequently asked the iPad expert was related to note
taking; subsequently, low threshold and tailored support
was provided. We discovered that most of the students
were persistent in learning to use the new device as a
study tool and reservoir for learning materials.
This study revealed that mobile note taking basically
served the same two functions as traditional paper and
pen note taking: encoding and storage [14]. Annotation
enabled students to combine the linear and non-linear
note taking strategies [16]. They followed the teachers’
presentation and appreciated the potential for the
non-linear way of organising the information at hand by
moving back and forth in their notes, drawing, making
visual representations and mind-maps. Thus, they made
connections between new information and prior know-
ledge to foster deeper processing of ideas and strengthen
the retention of content.
Fig. 4 Example of student’s annotated dental X-ray
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The longitudinal data on one student cohort provided
us with a unique perspective on how the new technology
was integrated into teaching and learning practices in
different phases and contexts of the basic degree studies.
In these years, teachers in the biomedical studies suc-
ceeded in integrating mobile devices into their teaching
activities in the same way as reported in previous studies
of the preclinical studies [3,4]. In clinical study years,
the compact and practice-oriented dental clinic accepted
better the students’new technology. Despite a decline in
note taking in the clinical context, the dental students
continued to use the mobile device in their studies.
The notable drop in medical students’mobile device
usage in the clinical studies called for attention. Medical
students reported clinical teachers’resistance and am-
bivalent attitudes towards the usage of iPads and men-
tioned that iPads did not fit into the pockets of their
white coats and hence were not practical to carry in the
hospitals. Students and teachers were particularly
ambivalent about using the device with patients. Similar
attitudes and norms discouraging the use of mobile de-
vices at bedside have been reported in previous research
[8,10,11] and the problems in the portability of iPads in
the clinical context had also been reported earlier [22].
Positive findings of mobile device usage in the clinical
context had also been reported. Mobile devices, either
publicly or privately used, supported the novice doctors’
self-efficacy in the challenging clinical work [2,11,22,30].
The devices were used for timely seeking online informa-
tion and revising notes and electronic textbooks before
encountering a patient [7]. All studies called for ethically
sustainable guidelines and a transparent code of conduct
for the use of mobile devices with patients.
Trustworthiness of the study
The research data were collected using online question-
naires and were examined using inductive, qualitative
content analysis [28,29]. To improve the trustworthi-
ness of this analysis [26,27], two of the researchers (EP
and TM) encoded the data independently, tested the
inter-coder agreement and discussed the results of
coding until an agreement was reached. To further test
our findings, we triangulated the results of the
open-ended question with the survey question concern-
ing note taking and transcripts of focus-group interviews
with medical and dental students in the first and the
third study year. These three data types provided us with
a fuller picture of the phenomenon studied.
We used member checking [31], involving the partici-
pants of the study to evaluate whether the results were
credible from their perspective. We tested our prelimin-
ary findings of mobile note taking firstly in focus-group
interviews with the students of the first study cohort in
2013 and 2016 and secondly in discussions with the
student authors (SM, DF and LH). Two of them (DF and
LH) were of the student cohort studied; one was a med-
ical student and another a dental student. The student
authors were indispensable in interpreting the
phenomenon from the students’perspective.
Strengths and weaknesses of the study
The strength of our study lies in the fact that we started
to collect longitudinal data from the first study cohort
with mobile devices in 2013 and continued to follow
their mobile learning throughout their academic years.
We also constantly collaborated with both students and
teachers as participants in the study; they proved to be
innovative in generating new learning designs and mate-
rials for mobile devices. Thus far, we have yet to discover
a comparable longitudinal and participatory study in the
research literature on these subjects.
To improve the extent to which the results of research
can be generalized or transferred to other contexts or
settings, we provided contextual information about the
project for readers to evaluate whether our findings
could be transferred to their own settings [26]. We
believed that our experiment of integrating iPads into
student learning could be transferred to some other
medical education contexts and that the results could be
applicable not only to iPads but also to different kinds of
mobile devices.
There were limitations in this study. One limitation
was that it was performed over one student cohort at a
single institution. The authors thought that this cohort
was an interesting representation of the medical and
dental student population but acknowledged that since
this cohort was the pioneering one in new technology
usage, they might have experienced more hurdles in
their mobile device usage than the following ones.
Future directions
We collected a large data set on mobile learning
between 2013 and 2018. There are several questions to
be analysed in the surveys and topics to be reported in
our project. We will report the students’collaboration
using social media, the innovative learning design
applying virtual microscopy in histology, the mobility of
mobile learning, the special features of mobile learning
and the hurdles in adopting mobile devices in clinical
studies in medicine. This study also calls for further
research on the patients’perceptions on mobile device
use in different types of healthcare settings.
Conclusion
There were two main findings in our study. First, digital
note taking was the medical and dental students’most
important study use of mobile devices during the first
two study years. We mirrored our findings with the
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prior research on the learning functions of note taking
and discovered that our students had developed refined
digital note taking strategies allowing them process and
personalise their learning materials and have their notes
always at hand for retrieval. Second, we observed a con-
siderable decline in the digital note taking in the clinical
setting, especially among medical students. The medical
students reported resistance towards the usage of iPads
as they entered clinical studies.Identifying the hurdles
to overcome in the clinical setting will enable us to
discover feasible ways of using mobile devices, and to
discover ways to make the most use of the potential of
the new technology in the hands of the future healthcare
providers.
Additional files
Additional file 1: Message to the students and the questionnaire
translated into English. (DOCX 27 kb)
Additional file 2: Focus-group interview formats translated into English.
(DOCX 18 kb)
Acknowledgements
We thank the Dean Risto Renkonen for his support for the mobile learning
project and express our sincere gratitude to the iPad project group: Kalle
Romanov, Jukka Englund, Taina Joutsenvirta, Suvi Viranta-Kovanen, Maria
Sundvik, Kirsi Sainio, Antti Mauno, Rosa Nyberg, Tero Tamminen and Jussi
Merenmies.
Funding
This research was supported by the Jane and Aatos Erkko Foundation.
Availability of data and materials
The research data analysed during the current study are available from the
corresponding author on reasonable request.
Authors’contributions
EP was a medical education expert in the study, she designed the study,
analysed the data, drafted the manuscript and is responsible for the overall
content of the work. HH was an expert on biomedical sciences and
designed the study and contributed to writing. SM and DF were medical
student members and LH a dental student member in the study. SM, LH and
DF contributed to the conception of the study, data analysis and validation;
they drafted the manuscript. SM and LH provided the pictures of note
taking. TM was an information technology expert in the study and
contributed to the design of the study and analysed the data with EP. All
authors contributed to the revisions and approved the final manuscript.
Ethics approval and consent to participate
When the research project began in 2013, there was no research ethics
committee dedicated to educational research in the Faculty of Medicine at
the University of Helsinki. Therefore, ethics committee approval could not be
granted before the research started and could not be obtained
retrospectively. However, the research was carried out in accordance with
the guidelines of the Declaration of Helsinki and the Finnish National
Advisory Board on Research Ethics. Participants were informed by email of
the purpose of the study and contact information. Participation in the study
was voluntary and an informed consent was inquired in an electronic format
from all the participants at the end of the online questionnaire. The principal
investigator of the project (EP) oversaw data collection and anonymisation of
the data into a form that did not include any information allowing the
participants to be identified. This was particularly important because there
were two students from the student cohort in the research group. The
confidentiality and anonymity were guaranteed throughout the research and
publication processes.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Center for University Teaching and Learning, University of Helsinki, P.O. Box
21, 00014 Helsinki, Finland.
2
Clinicum, Faculty of Medicine, University of
Helsinki, P.O. Box 20, 00014 Helsinki, Finland.
3
Department of Oral and
Maxillofacial Diseases, Clinicum, Faculty of Medicine, University of Helsinki,
P.O. Box 41, 00014 Helsinki, Finland.
4
Faculty of Medicine, University of
Helsinki, P.O. Box 63, 00014 Helsinki, Finland.
5
Department of Anatomy,
Medicum, University of Helsinki, P.O. Box 63, 00014 Helsinki, Finland.
Received: 15 June 2018 Accepted: 21 March 2019
References
1. Masters K, Ellaway RH, Topps D, Archibald D, Hogue RJ. Mobile technologies
in medical education: AMEE guide no. 105. Med Teach. 2016;38(6):537–49.
2. Deutsch K, Gaines JK, Hill JR, Nuss MA. iPad experience during clinical
rotations from seven medical schools in the United States: lessons learned.
Med Teach. 2016;38(11):1152–6.
3. George P, Dumenco L, Doyle R, Dollase R. Incorporating iPads into a
preclinical curriculum: a pilot study. Medical Teacher. 2013;35(3):226–30.
4. George P, Dumenco L, Dollase R, Taylor JS, Wald HS, Reis SP. Introducing
technology into medical education: two pilot studies. Patient Educ Couns.
2013;93(3):522–4.
5. Lumsden CJ, Byrne-Davis LMT, Mooney JS, Sandars J. Using mobile devices
for teaching and learning in clinical medicine. Arch Dis Child –Educ Prac
Edition. 2015;100:244–51.
6. Wallace S, Clark M, White J. ‘It's on my iPhone’: attitudes to the use of
mobile computing devices in medical education, a mixed-methods study.
BMJ Open. 2012;2(4).
7. Tews M, Brennan K, Begaz T, Treat R. Medical student case presentation
performance and perception when using mobile learning technology in the
emergency department. Med Educ Online. 2011;16(1):7327.
8. Davies BS, Rafique J, Vincent TR, Fairclough J, Packer MH, Vincent R, et al.
Mobile medical education (MoMEd) - how mobile information resources
contribute to learning for undergraduate clinical students - a mixed
methods study. BMC Med Educ. 2012;12(1):1.
9. Law JK, Thome PA, Lindeman B, Jackson DC, Lidor AO. Student use and
perceptions of mobile technology in clinical clerkships –guidance for
curriculum design. Am J Surg. 2018;215(1):196–9.
10. Patel R, Green W, Shahzad MW, Larkin C. Use of Mobile clinical decision
support software by junior doctors at a UK teaching hospital: identification
and evaluation of barriers to engagement. JMIR mHealth and uHealth.
2015;3(3):e80.
11. Dimond R, Bullock A, Lovatt J, Stacey M. Mobile learning devices in the
workplace: ‘as much a part of the junior doctors kit as a
stethoscope’?(Report). BMC Med Educ 2016;16(1).
12. Mooney JS, Cappelli T, Byrne-Davis L, Lumsden CJ. How we developed
eForms: an electronic form and data capture tool to support assessment in
mobile medical education. Medical Teacher, 2014, Vol.36(12), p.1032–1037
2014;36(12):1032–1037.
13. Bui DC, Myerson J, Hale S. Note-taking with computers: exploring alternative
strategies for improved recall. J Educ Psychol. 2013;105(2):299–309.
14. Di Vesta FJ, Gray GS. Listening and note taking. J Educ Psychol.
1972;63(1):8–14.
15. Kiewra KA, Benton SL, Kim S, Risch N, Christensen M. Effects of note-taking
format and study technique on recall and relational performance. Contemp
Educ Psychol. 1995;20(2):172–87.
16. Piolat A, Olive T, Kellogg RT. Cognitive effort during note taking. Appl Cogn
Psychol. 2005;19(3):291–312.
17. Patrick Rau P, Chen S, Chin Y. Developing web annotation tools for learners
and instructors. Interact Comput. 2004;16(2):163–81.
Pyörälä et al. BMC Medical Education (2019) 19:96 Page 9 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
18. Mueller PA, Oppenheimer DM. The pen is mightier than the keyboard.
Psychol Sci. 2014;25(6):1159–68.
19. Wood E, Zivcakova L, Gentile P, Archer K, De Pasquale D, Nosko A.
Examining the impact of off-task multi-tasking with technology on real-time
classroom learning. Comput Educ. 2012;58(1):365–74.
20. Stacy EM, Cain J. Note-taking and handouts in the digital age. Am J Pharm
Educ. 2015;79(7):107.
21. Ellaway RH, Fink P, Graves L, Campbell A. Left to their own devices: medical
learners use of mobile technologies. Medical Teacher, 2014, Vol.36(2),
p.130–138 2014;36(2):130–138.
22. Archibald D, Macdonald CJ, Plante J, Hogue RJ, Fiallos J. Residents’and
preceptors’perceptions of the use of the iPad for clinical teaching in a
family medicine residency program. BMC Med Educ. 2014;14(1):174.
23. McNiff J, Whitehead J. All you need to know about action research. 2nd ed.
Los Angeles: SAGE; 2011.
24. Whitehead J. Generating living theory and understanding in action research
studies. Action Res. 2009;7(1):85–99.
25. Pyörälä E, Masalin T, Hervonen H. Faculty of Medicine as a mobile learning
community. In: Niemi H, Jiyou J, editors. New ways to teach and learn in
China and Finland: crossing boundaries with technology. Frankfurt am Main:
Peter Lang; 2016. p. 77–103.
26. Shenton AK. Strategies for ensuring trustworthiness in qualitative research
projects. Educ Inf. 2004;22(2):63–75.
27. Creswell JW. Qualitative inquiry & research design: choosing among five
approaches. 2nd ed. Thousand Oaks: Sage Publications; 2007.
28. Hsieh H, Shannon SE. Three approaches to qualitative content analysis. Qual
Health Res. 2005;15(9):1277–88.
29. Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs.
2008;62(1):107–15.
30. Boruff JT, Storie D. Mobile devices in medicine: a survey of how medical
students, residents, and faculty use smartphones and other mobile devices
to find information. (author abstract). J Med Libr Assoc. 2014;102(1):22.
31. Lincoln YS, Guba EG. Naturalistic inquiry. Beverly Hills: Sage; 1985.
Pyörälä et al. BMC Medical Education (2019) 19:96 Page 10 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
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2.
3.
4.
5.
6.
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