1. University of Oxford
__________________________________________________________
Institutional, Cultural and Design Factors Influencing
Coursework-related iPad Use by Medical Students
__________________________________________________________
Candidate No. 481129 St. Anne’s College
Thesis submitted in partial fulfillment of the requirements for the degree of MSc in Social Science of
the Internet in the Oxford Internet Institute at the University of Oxford.
01 August 2012 9,999 words

2. i
Abstract
In December 2011 the University of Manchester’s Medical School deployed 16GB, Wi-Fi
enabled Apple iPad 2s to 457 year-four students as a pilot project. This research identifies the
design, institutional and cultural factors influencing student use and non-use of the iPads and
determines whether the medical schools’ aims in deploying the devices are being achieved. The
author approaches the research from a social informatics perspective. The research is a qualitative
case-study of the iPad deployment, utilising interviews and student focus groups. A wide range of
factors encouraging and deterring use are identified. Factors deterring use include a lack of Wi-Fi
signal and safe storage at hospitals, a lack of training for students on use of the iPads, and the size of
the device. The lack of training for students was partly motivated by a popular notion of students as
digital natives. A recommendation is strongly made that the medical school provide training on the
devices when the project is expanded this autumn. This is the first research of its type on an iPad
deployment to medical students and the first research on a mobile device deployment to take a
social informatics approach.
Keywords: Apple iPad, mobile devices, medical school, social informatics, case study, digital native

3. ii
Acknowledgments
I would first like to thank Dr. Colin Lumsden at the University of Manchester’s Medical
School for allowing me to conduct research on the school’s iPad project. I would also like to thank
him, the teachers and staff at the university and the associated base hospitals, and the school’s
students for so generously giving me their time. Thanks also to my supervisor, Dr. Eric T. Meyer for
his support, guidance and patience. And also to the faculty at the Oxford Internet Institute who
have taught and supported me this year, particularly Dr. Ralph Schroeder, who has always been
generous with his time and encouraging of my interests. Thanks to St. Anne’s College, who provided
me with a grant that allowed me to travel to Manchester from Oxford several times to collect data.
Finally, thanks to my family and friends who have supported me in this degree: Heather Ford, Susan
Glass, Jeremy Barrett, Carol O’Kane and Irene Barrett-Locke, and to my partner, Chauncey Glass,
who is ever-patient and willing to copyedit.

4. iii
Table of Contents
1 Introduction 1
1.1 The Social Informatics Approach………………………………. 2
1.2 Research Questions…………………………………………….. 3
2 Literature Review 5
2.1 Apple Newton: The First Handheld Computer………………… 5
2.2 Personal Digital Assistants: Their Deployments and Uses……… 6
2.3 Smartphones and Tablet Computers…………………………… 9
2.4 The Manchester Medical School iPad Project………………….. 11
3 Research Design and Methods 13
3.1 Research Design: Single, Exploratory Case Study……………… 13
3.2 Research Method 1: Semi-structured Interviews……………….. 13
3.3 Research Method 2: Focus Groups…………………………….. 15
3.4 Analysis………………………………………………………... 18
3.5 Ethics………………………………………………………….. 20
4 Findings 22
4.1 Motivations and Expectations………………………………… 22
4.2 Deployment Strategy………………………………………….. 23
4.3 Student Users and Uses……………………………………….. 25
4.4 Factors Influencing Use……………………………………….. 26
5 Discussion 31
5.1 iPad Project Aims Achieved? …………………………………. 31
5.2 The Need for Student Training………………………………... 32
5.3 Developing eLearning Content………………………………... 33
5.4 iPhone v. iPad: Advice to Other Medical Schools……………… 34
6 Conclusion 36
Appendixes 38
Appendix A – Semi-structured Interview Questions……………………… 38
Appendix B – Focus Group Questions…………………………………… 39
Appendix C – Niche and Non-user Meeting Questions…………………… 41
Appendix D – Coding Scheme……………………………………………. 42
Bibliography 48

5. iv
List of Figures
2.1 Apple Newton…………………………………………………. 6
2.2 Personal Digital Assistant……………………………………… 7
2.3 Apple iPhone…………………………………………………... 10
2.4 Apple iPad……………………………………………………... 10
3.1 Student iPad Home Screen…………………………………….. 19
List of Tables
2.1 Selection of PDA Deployments to Medical Students…………... 8
3.1 iPad Project Actors Interviewed……………………………….. 14
3.2 Student Participant User Types………………………………... 17
4.1 Uses of the iPads and Locations of Use……………………….. 26
4.2 Factors Influencing iPad Use………………………………….. 30

6. 1
Chapter 1
Introduction
In December 2011, the University of Manchester’s Medical School (MMS) deployed 16GB,
Wi-Fi enabled Apple iPad 2s to 457 year-four medical students at a cost of £148,359.20 as a pilot
project lasting through the summer of 2012 (University of Manchester, 2011).1
There were various
aims in deploying the iPads to students, but the principal motivation behind the project was to
improve the students’ experience and the medical school’s results in the annual National Student
Survey. This was the first deployment of iPads to students by a medical school in the United
Kingdom. There had been earlier deployments of the device to medical students in the United
States, including at Stanford University and the University of California, Irvine in the autumn of
2010. MMS has already decided to expand the iPad project to include all year three-through-five
students, or roughly 1500 students, this autumn.
There is a history of deploying mobile devices to medical students in Europe and the United
States. The first such deployment was The Constellation Project at Harvard Medical School in 1994,
in which twenty-eight medical residents were each given an Apple Newton handheld computer to
use for one-hundred days (Labkoff, Shah, Bormal, Lee & Greenes, 1995). Since then the technology
and deployments have progressed through more sophisticated personal digital assistants (PDAs), to
smartphones, like the Apple iPhone, and now to tablet computers, like the Apple iPad. These
devices were seen as particularly useful for medical students who were often on the move in
hospitals and for whom access to information at the point-of-care could be an aid for learning.
Much of the research on these deployments was conducted by medical doctors, who were
1 The medical program at Manchester is a five-year, undergraduate degree. In years three-through-five, students spend
most of their time at one of four base hospitals in the Manchester area being taught by lecturers and clinicians.

7. 2
sometimes involved with overseeing the deployments, and focused on if and how students were
using the devices and factors deterring use, with the aim of mitigating those deterrents (e.g. Helwig
& Flynn, 1998; Beasley, 2002; Zaroukian & Sousa, 2002).
In this tradition, I have conducted a study of the iPad pilot project at the Manchester
Medical School. The study lasted, inclusive of analysis and writing, from the end of April 2012, when
the students had had the iPads for roughly four months, to end of July 2012. The purpose of the
research was to understand if and how students were using the iPads to do coursework, the factors
influencing students’ use and non-use of the devices, and to assess whether the aims of the
deployment were being achieved. No similar research on the deployment of iPads to medical
students has been published; this research fills that gap.
1.1 The Social Informatics Approach
I approached the research from a social informatics perspective. Social informatics is a multi-
disciplinary field that developed in the 1970s and 1980s. It arose in response to deterministic views
of technology, which posited that technology, acting as a singular force, could change organisations
and society. Social informatics’ practitioners believed instead that when a piece of technology was
deployed into an organisation or released into society, the design, as well as institutional and cultural
factors influenced if and how the technology was used (Kling, 1999). Other theories of technology
and society, like the social construction of technology or actor-network theory, focus on how a
technology is developed, while social informatics focuses on how a technology comes to be used
(Meyer, 2006). Researchers taking this approach in an organisational context sought to identify why
and how the technology had been deployed, the technology’s uses by different actors, and the
factors influencing use or non-use (e.g. Davenport, 1991; Orlowski, 1992). Previous research on the
deployment of mobile devices to students had often unknowingly taken a social informatics

8. 3
approach, to a degree, in that it sought to identify uses of the device and factors deterring use. By
taking this approach I ground my research in a theory of how technology is integrated into an
organisation and seek to gain a more comprehensive understanding of use and the factors
influencing use.2
1.2 Research Questions
I sought to answer two, principal research questions, one which took what Kling termed the
‘analytical’ social informatics approach, and a second question that took a ‘critical’ social informatics
approach (1999, Section 6.0):
1. What are the design, institutional and cultural factors influencing student use and non-use of
the iPads for coursework at the University of Manchester’s Medical School?
2. Are the medical school’s aims in deploying the iPads being achieved?
My data collection was guided by five sub-questions, designed to lead to the information necessary
to answer the research questions:
1. What are the aims of the Medical School’s iPad project?
2. What actors at the university and base hospitals have become involved with the project?
3. What was the strategy for deploying the iPads?
4. How are students using the iPads to do coursework?
5. What are the design, institutional and cultural factor that are influencing student use and
non-use?
2
The social informatics approach does not shed light on whether use of the iPads is contributing to improved learning
outcomes. This is an interesting question, however data was collected over a four week period, four-five months after
the devices had been deployed, and this is arguably too short a period and too early to attempt measuring such impacts.
The medical school administers an annual progress exam to students in all years, which may as an indicator of improved
learning outcomes.

9. 4
I begin below by reviewing the literature on mobile device deployments to medical students.
A description of my research methods follows; this includes a case-study design, interviews and
student focus groups. In my findings section I tell the story of the MMS iPad project, from the aims
of the project to the factors influencing use and non-use; in doing so my first research question is
addressed. In my discussion section, I begin by arguing that the aims of the iPad project have only
been marginally achieved, thereby answering my second research question, and I then provide two
recommendations for the future. I recommend, strongly, that training on the devices be provided to
students and that the medical school designs eLearning content to suit the times and locations that
students use their iPads.

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Chapter 2
Literature Review
2.1 Apple Newton: The First Handheld Computer
The history of deploying handheld computers to medical students begins with The
Constellation Project at Harvard Medical School in 1994. Twenty-eight students in the second year
of their program were each given an Apple Newton (Figure 2.1) for one-hundred days, to integrate
into their coursework on hospital wards. The study of the deployment (Labkoff et al., 1995) found
that a small number of students used the device daily, a small number stopped using the device
entirely after approximately ten days, but the majority of students used the device occasionally
throughout the week. Students accessed medical texts and drug references on the devices at the
point-of-care, and used the calendar tools and address book for organisational purposes. Factors
deterring use included the device’s size and weight, the incompleteness of the reference texts, and
the poor results of the handwriting recognition software.
This study set a trend of medical doctors, often involved with the deployment of a mobile
device to students, studying that deployment. A mixture of quantitative research methods (surveys)
and qualitative methods (interviews and focus groups) are employed in these studies to determine if
and how the devices are being used and factors deterring use. The research is practical in that the
aim is to establish whether the devices can be useful to students and, if so, what steps can be taken
to improve usefulness and integrate non-users. The researchers do not seek to determine whether
use of the devices contribute to improved learning outcomes.

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Figure 2.1
Apple Newton
Creative Commons Licence: Brian Madden
2.2 Personal Digital Assistant: Their Deployments and Uses
In the early 2000s, smaller, more powerful handheld computers, commonly called personal
digital assistants (PDAs – Figure 2.2) grew greatly in popularity amongst medical doctors. They were
cheaper than the Apple Newton, easier to carry, stored more information and could perform more
sophisticated tasks. Surveys of doctors in the US and UK, conducted between 2001 and 2004, place
ownership of a PDA at between 40% and 67%, and predicted continued growth (American College
of Physicians, 2001; Criswell & Parchman, 2002; Horsely & Forster, 2005). The list of medical
schools and hospitals deploying PDAs to students during this period is extensive. I have included a
table with a selection of deployments below (Table 2.1). Research on these deployments was
normally led by the medical doctors administering them, used similar methods, and had the same
aims as the research on the Apple Newton.3
3 There are several systematic reviews of the literature on this topic that reveal the volume and the similarity of this
research: Torre and Wright, 2003; Fischer, Stewart, Mehta, Wax and Lapinsky, 2003; Lu, Xiao, Sears and Jacko, 2005;
Kho, Henderson, Dressler and Kripalani 2006; Luanrattana, Win and Fulcher, 2007; Templehof, 2009; Gagnon et al.,
2012.

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Figure 2.2
Personal Digital Assistant
Creative Commons Licence: Goodreads
Different amounts of training on using PDAs were provided with each of these
deployments. Training ranged from as little as a thirty-minute, introductory session on the devices
(Sullivan, Halbach and Shu, 2001), to a required certification course with four, assessed modules
(Rao, 2002). It is clear that it is not absolutely necessary to provide extensive training on use; even in
cases where little training was provided, students still used the devices. However, extensive training
can have benefits. The researcher studying the deployment that included a certification course felt
that the course led to all of the students acquiring a broad set of uses for the devices, instead of just
a few enthusiasts. While at UCLA, where the PDA project ran and developed over three years, the
administrators learned to take an increasingly structured approach to training each year to ensure
that all students knew how to successfully incorporate the devices into their learning (Relan, Parker,
Wali, Guiton & Fung, 2004). To provide little training is to risk more inconsistent levels of use
amongst students.

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Table 2.1 – Selection of PDA Deployments to Medical Students
School or Hospital Deployment
Date
Article
University of Kansas School of Medicine at
Wichita
1998-1999 Beasley (2002)
Medical College of Wisconsin 2000 Bower & Bertling (2000)
New York Medical College 2000 Sullivan, Halbach and Shu (2001)
Uniformed Services University of the Health
Sciences
2000 Moore, Richardson and Williams (2002)
University of Pittsburgh 2000-2001 Manning & Gadd (2001)
School of Medicine, University of Oslo 2002 Smordal & Gregory (2003)
School of Medicine, UCLA 2004 Relan et al. (2004)
University of Maryland and George
Washington University
2004 Grasso, Yen and Mintz (2005)
University of Louisville School of Medicine 2006 Patel et al. (2008)
University of Brighton and University of
Sussex
2006-2007 Davies et al. (2012)
Levels of student use ranged from highly-sophisticated, frequent users to non-users.
McAlearney, Schweikhart and Medow (2004) researched PDA use amongst medical doctors, not
students, but provide a useful typology of users that can be extended to students. Their typology has
four categories:
 The Power Users, who are the technophiles that push the device to its functional limit and
develop novel uses.
 The Routine Users, who have integrated the devices into their daily workflow and use a
number of applications for different purposes.
 The Niche Users, whose regular use is limited to a single application.
 And the Non-Users, who never used the device or abandoned it.

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The typology is useful because it is more fine-grained than a user-and-non-user dichotomy, and
most users will fit into one of the four categories.4
PDAs were used by medical students in much the same way that the Apple Newton was: to
access medical information at point-of-care and for organisational purposes. Two significant new
uses emerged, though. The first was using the device as medical calculator or as a clinical decision
support tool – in other words as a more active reference – enabled by the PDAs’ greater
computational power (e.g. Beasley, 2002; Criswell & Parchman, 2002). The second use was as a
patient log, in which students could record their clinical interactions, enabled by improved
handwriting-recognition software or the inclusion of a keyboard, and greater storage capacity (e.g.
Moore et al. 2002; Barrett, Strayer and Schubart, 2003). The factors influencing use also remained
largely similar, although instead of complaining that the devices were too big to carry on hospital
wards, students now complained that the screen-size was too small to comfortably read from (e.g.
Bower & Bertling, 2000; Ho, Forman & Kannry, 2000).
2.3 Smartphones and Tablet Computers
As the decade progressed, smartphones (Figure 2.3) grew in popularity amongst medical
doctors. They were more powerful than PDAs, they provided easy access to many inexpensive
medical applications, their larger and higher-resolution touchscreens were easier to read and enter
data on, and their telephone-function and connectivity to the Internet made them additionally useful
for communication (Burdette, Herchline & Oehler, 2008). In a large survey of American physicians
4 McAlearney et al.’s typology is similar to Rogers’s (1962) typology, which has five categories of user: Innovators, Early
Adopters, Early Majority, Late Majority and Laggards. Rodgers’s typology captures how technology diffuses into society
over time, beginning with the Innovators. McAlearney et al.’s typology works well to describe organizational
deployments, in which a group of people are simultaneously given a technology and then fall into a user category, from
which they might move over time.

15. 10
in 2011, researchers found that 85% of respondents owned a smartphone (Franko & Tirrell, 2011).
Smartphones, instead of PDAs became the device of choice to deploy to medical students.
Figure 2.3 Figure 2.4
Apple iPhone Apple iPad
Creative Commons Licence: Elizabeth McIntire Creative Commons Licence: NerdyScienceDude
Since the release of the Apple iPad in April 2010, though, tablet computers (Figure 2.4) have
emerged as a competing option to smartphones. They have similar functionality to a smartphone,
but with a larger screen – the iPad screen is 25cms diagonally, compared to the Apple iPhone’s
8.9cm screen. Stanford Medical School and the University of California, Irvine Medical School were
the first to deploy iPads to students. Stanford gave iPads to a class of ninety-one first-year students
in the autumn of 2010. The university was uncertain about how students would use the devices, but
had great confidence they would be used. Dr. Henry Lowe, Stanford’s Associate Dean of Medical
Education said of the iPad project: ‘Because the population of new students is extremely tech-savvy,
it makes sense to teach them through the use of the electronic devices they’re familiar with… we
embrace who they are’ (White, 2010). His comments reflect a popular notion of students as ‘digital
natives’ (Prensky, 2001); young people who have grown up and are confident with technology.5
By
5
Prensky believed that the entire generation born after 1980 were digital natives. He argued that this generation thought
differently than the previously generation, who he termed ‘digital immigrants’. He also argued that teachers must use
digital technologies to engage and educate their students. Prensky has since distanced himself from his concept (2011)
under the pressure of evidence from other academics (e.g. Bennet, Maton and Kervin, 2008; Herring, 2008; Helsper and
Eynon, 2010), but the concept persists in the popular imagination.

16. 11
May of 2011, however, The Chronicle reported that in most classes over half of the students had
stopped using their iPads a few weeks into term (Keller, 2011).6
No research on uses of the iPads
and factors influencing use, in the tradition of research on the deployment of mobile devices to
students, has yet been published.
2.4 The Manchester Medical School iPad Project
In early March of 2012, roughly two months after the iPads had been deployed to students
at the Manchester Medical School, the school’s Education Informatics officer, conducted the first
research on students’ uses of the iPads. She sent all year-four students an online survey to complete.
273 students participated, a 54% response rate. 82% of participants reporting using the devices daily
for a learning-related purpose. Participants reported using the devices in many expected ways: to
access information and for organisational purposes. Participants also reported a preference for using
the devices in gap-times throughout their day: while in transit, between a lecture and a clinic, etc.
The most significant factor deterring use was the lack of Wi-Fi signal in the base hospitals
(Manchester Medical School, 2012).
There is some reason to doubt how representative these survey results are of the year-four
students. The survey asked about use of the iPads and the incentive to participate was an Apple
Store voucher, which likely would not have enticed niche or non-users to participate. The Education
Informatics officer acknowledged this possibility when I spoke with her, saying of the survey: ‘I
think there’s still a silent half… and I’m concerned that the silent half, quite a lot of them – and we
have no idea how many – may be getting, I’m not saying no use out of it, but not optimal use.’ By
6 The Chronicle reported that this was due to the Wi-Fi network in the classrooms failing to support the volume of
students attempting to simultaneously connect via their iPads, although a number of factors were likely at play.

17. 12
using qualitative methods, like interviews and focus groups, this research reaches out to that silent
half, complicating the survey findings.

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Chapter 3
Research Design and Methods
3.1 Research Design: Single, Exploratory Case Study
This is an exploratory case study of the Manchester Medical School’s iPad project. Single,
exploratory case studies are common in research on mobile device deployments to medical students
(e.g. Labkoff et al., 1995; Helwig & Flynn, 1998; Beasley, 2002). By maintaining consistency with
past research on mobile device deployments, my own research fits into a tradition that reveals the
evolution of mobile devices and their deployments to medical students.
There are potential benefits to using multiple, comparative case studies, instead of a single
case study (Yin, 1989). Multiple case studies of iPad deployments, or a comparative case study with
an Apple iPhone deployment, could lead to more robust results or address additional research
questions. There was the opportunity to bring a comparative case into the research – the University
of Manchester Dentistry School deployed 3G iPads to their students in December 2011 – but this
was unfeasible for logistical reasons.
3.2 Research Method 1: Semi-structured Interviews
Data collection for this research began with semi-structured interviews of the actors
involved with implementing the iPad project. The medical school’s Academic eLearning Lead
provided the names of six people involved with the project and face-to-face interviews in
Manchester were set-up with these people. I then snowball sampled out from these initial six
interviews. In total, fifteen people involved with the iPad project were interviewed, including the key
actors and several peripheral actors at the university and from two of the four base hospitals (Table
3.1). These interviewees provided a variety of perspectives on the iPad deployment, enriching the

19. 14
data and adding to the credibility of the research.7
The strategy of pushing beyond the interviewees
recommended by an elite insider, who may or may not have an agenda to forward, is advocated in
the methodology literature as a way to aid in ensuring research credibility (Wagner, Rau &
Lindemann, 2010).
Table 3.1 – iPad Project Actors Interviewed
Name Title Affiliation
Dr. Tony Freemont Head of Undergraduate Medical
Education
Manchester Medical School
Dr. Colin Lumsden Academic eLearning Lead Manchester Medical School
Royal Preston Hospital
Timothy Cappelli Project Manager Manchester Medical School
Hilary Dexter Education Informatics Manchester Medical School
Dr. Kurt Wilson Lead for Prescribing Training Manchester Medical School
Dr. Rachel Lindley Clinical Training Fellow Manchester Medical School
Dr. Rebecca Farrington Clinical Lecturer Manchester Medical School
Wythenshawe Hospital
Rob Cutforth eLearning Technologist University of Manchester
Simon Hardaker eLearning Technologist University of Manchester
Lee Moffatt Infrastructure and Operations
Manager
University of Manchester
Olivia Walsby Faculty Librarian University of Manchester
Michael Masterman IT and Communications Lead Manchester Royal Infirmary
Dr. Alastair Duncan Education Fellow Manchester Royal Infirmary
Nick Smith Clinical Skills Program Manager Manchester Royal Infirmary
Aiden Blunt Clinical Skills Facilitator – Year 5 Royal Preston Hospital
The interviews lasted 25 minutes each, on average. Fourteen of the interviews were
conducted face-to-face and recorded in Manchester and one was conducted over the telephone for
7 ‘Credibility’ is used here in the sense that Lincoln and Guba (1985) used the term, as a standard of the ‘truth’ of a
qualitative research project that is enhanced by having a variety of rich data.

20. 15
scheduling reasons. The telephone interview was not recorded, but thorough notes were taken
during and after the conversation. The interviewees were asked about their roles at the university or
hospital, their involvement with the iPad project, and their opinions about the project. A list of the
interview questions is attached (Appendix A). The interviews provided an understanding of the
actors involved with the project, their expectations of the project, and the strategy for deployment.
3.3 Research Method 2: Focus Groups
Having gained an understanding of the iPad deployment during the interviews, I then
organised focus groups with the students. Focus groups were chosen instead of one-to-one
interviews because I was uncertain about whether the students would yet have formed a clear vision
of their uses of and attitudes toward the iPads. Focus groups allowed students to explore and clarify
their individual visions together; this has been referred to by researchers as ‘the group effect’ (e.g.
Carey & Smith, 1994; Barbour, 2007; Stewart, Shamdasani & Rook, 2007).
Two focus groups were conducted. The first focus group was with students assigned to the
Royal Preston Hospital (RPH). This is where the Academic eLearning Lead additionally worked, and
he assisted me in recruiting participants at the hospital. He sent an email to the fifty-six, year-four
students at RPH soliciting their participation and I followed up with them, using emails to
encourage participation. Seven student participants were recruited. This was an ideally-sized group,
an opinion which is confirmed in the literature (Dawson, Manderson & Tallo, 1993; Kitzinger, 2005;
Liamputtong, 2011). There was a near-equal gender split: four women and three men. There was
also a good range of user types: two power users, three routine users, a niche user and a non-user.8
Having a heterogeneous group of participants was a benefit, because it again, added to the variety
and richness of the data and the credibility of the research.
8 I determined these user types by comparing the students’ own descriptions of their uses or non-use of the iPads with
McAlearney et al.‘s (2004) typology.

21. 16
A decision was then made to run a second focus group, this time with students assigned to
the Manchester Royal Infirmary (MRI). This decision was made, in part, because during the
interviews and in the first focus group, participants had indicated that the students at RPH were
more likely to be active iPad users. This was because the Academic eLearning Lead worked there,
assessments of the project were directed toward these students and a Wi-Fi signal was available at
the hospital. MRI did not share these qualities. I believed the students’ experiences with the iPads
there might be different for those reasons. A contact had been made at MRI while interviewing, the
Communications and IT Lead, and he assisted me in recruiting focus group participants at the
hospital. He forwarded my recruitment emails to the ninety-six, year-four students at MRI. Five
students were recruited, four from MRI and one from Wythenshawe Hospital, who had heard of the
focus group from a friend. This was fewer students than was hoped for, but still above the threshold
of four students that some researchers identify as a minimum (Kitzinger, 2005; Liamputtong, 2011).
Again, there was a near-equal gender split: three women and two men. Unfortunately though, the
participants were all active users; two were power users and three were routine users.
Based on the absence of niche or non-users in this second focus group, and on the fact that
the participants in the second group mentioned knowing non-users at MRI, an attempt was made to
organise a third focus group, specifically for MRI niche or non-users. I again enlisted the help of the
Communications and IT Lead to recruit students, but I additionally contacted students who
participated in the second focus group to snowball sample participants. Despite these efforts, only
two non-users volunteered to participate. Wyatt (2003) has written about how non-users can be a
disparate and difficult-to-engage group, and for those reasons are a challenge to recruit as
participants. The meeting, which was too small to be called a focus group, went ahead. There was
one male and one female participant. They were both non-users. They interestingly had different
reasons for not using their iPad: the female user was unsure of how to integrate the device into her

22. 17
learning and the male user had alternative devices that he preferred. A third niche-user who was
unable to attend the meeting, responded to a list of questions via email. A table of the number of
users of each type from each hospital that I spoke or corresponded with is below (Table 3.2).
Table 3.2 – Student Participant User Types*
User Types
Base Hospital Power Users Routine Users Niche Users Non-Users
Royal Preston Hospital ●● ●●● ● ●
Manchester Royal Infirmary ● ●●● ● ●●
Wythenshawe Hospital ●
Totals 3 7 2 3
* Each ● represents a single user or non-user.
I moderated the two focus groups and the meeting. All three were video and audio recorded.
Written notes were taken during and after the focus groups. Each focus group and the meeting
lasted roughly ninety minutes; this is in keeping with normal duration for a focus group
(Liamputtong, 2011). The first thirty minutes were dedicated to a free lunch, during which
introductions were made, setting a relaxed mood. The focus groups were held in seminar rooms at
RPH and MRI and the meeting was held in a seminar room in a university building near to MRI; all
environments that the students could feel comfortable in. During the focus groups and meeting I
made an effort to include all participants and asked probing questions, as is advocated in the
methodology literature (Stewart et al., 2007; Liamputtong, 2011). The questions asked related to
four, principal areas: students’ expectations of the iPad project, their uses of the iPads, the factors
influencing use and non-use, and how they thought the project should evolve. The list of questions
differed between the focus group and the meeting to account for the fact that the meeting

23. 18
participants were non-users; both lists are attached (Appendices B & C). The focus groups and
meeting provided an understanding of student use and non-use of the iPads, and the factors
influencing use and non-use.
Running two-to-three focus groups with a range of user-types at each of the four base
hospitals would have provide more comprehensive data and ensured that saturation, which is
normally advocated with focus groups, was reached (Liamputtong, 2011). However, this was both
unfeasible for logistical reasons and unnecessary as the focus groups and meeting provided sufficient
data to answer my research questions.
3.4 Analysis
I transcribed all of the interviews, the two focus groups and the meeting myself. Notes and
memos were made during the transcription phase, which built initial evidence to answer each
research sub-question and also covered themes that were emerging from the data. Notes and memo
taking is advocated in the methodology literature to aid in transitioning from data to ideas (Richards,
2005), and they served that purpose in this case.
The interviews, focus group and meeting transcriptions were loaded – along with the notes
from the unrecorded interview, the single email response received from a niche user, and images of
students’ iPad home screens, requested during the focus groups – into the qualitative analysis
software, QSR NVivo 9. An example image of a student’s iPad home screen is below (Figure 3.1);
these images provided additional insight into students’ uses of the devices.

24. 19
Figure 3.1
Student iPad Home Screen
The data was then coded to nodes within NVivo 9. My initial node structure was guided by
the research sub-question, the social informatics framework, the notes and memos made during the
transcription phase, and information from the literature on mobile device deployments to students.
The top-level nodes were organised chronologically, so that they unfolded the story of the iPad
project and answered my research questions along the way. These top-level nodes were as follows:
1. Expectation for the project
2. People who became involved
3. Deployment strategy
4. iPad student uses
5. iPad student non-use
6. Factors influencing use and non-use
7. Additional outcomes

25. 20
8. Plans for the future
Under each top-level node was a series of sub-nodes. I then went through the data and coded it to
nodes. New nodes were added and some merged in an inductive process as the coding progressed.
This process of developing an initial set of nodes based a variety of sources, and then allowing those
nodes to evolve during the coding is an established strategy in the methodology literature (Miles &
Huberman, 1994). It leads to a confirmable analysis in that the analysis is grounded in a variety of
sources, but has the flexibility to evolve in response to the data.9
A complete coding scheme is
attached (Appendix D).
3.5 Ethics
A CUREC form was submitted to the University of Oxford and was approved before data
collection began. There were no ethical concerns associated with the research. Before each
interview, focus group and the meeting, participants were provided with a consent form to read and
sign and the purpose of the research and absence of potential harm was described to them.
Participants were not anonymised because of the absence of potential harm and the usefulness of
identifying the role of the interview participants in the iPad project, as part of answering the research
questions. One interview participant withdrew from the research six weeks after the interview had
taken place, with no explanation.
I made one mistake during my data collection that damaged trust with people at the
university. In my enthusiasm to collect data and to confirm or complicate the narratives that I had
gathered in the interviews I requested meeting minutes related to the iPad project from the
university document office under a freedom of information request. The request caused the
university’s communications office to put pressure on the faculty and staff to stop speaking with me.
9 ‘Confirmable’ is used here in the sense that Lincoln and Guba (1985) use the term, as a standard of the ‘neutrality’ of a
research project, enhanced by grounding the analysis in past research and process.

26. 21
I apologised and withdrew the request. The Academic eLearning Lead was gracious, but I fear that
my error may still inhibit future researchers’ access to the MMS iPad project.

27. 22
Chapter 4
Findings
Addressing my research questions about what factors are influencing student use and non-
use of the iPads and whether the original expectations of the iPad pilot project are being achieved
involves telling the story of the project. I will do this in the section below, progressing through the
motivations for implementing the project and the expected outcomes, how the iPads were deployed,
if and how students chose to use the iPads, and what factors were influencing student use or non-
use. I will use the voices of my participants to aid in telling this story.
4.1 Motivations and Expectations
There were several different reasons why the iPad project was implemented. However, the
underlying motivation for the project’s implementation was to improve the school’s feedback in the
annual National Student Survey (NSS). The medical school had received poor feedback in certain
areas of the NSS over the previous two years. In the most recent survey, conducted in 2011, 67% of
the graduating, year-five class who participated (364/445 students) expressed overall satisfaction
with the course, placing Manchester twenty-fifth of the thirty medical schools surveyed (The
Guardian, 2011). The university received low scores in the areas of academic support, organisation
and management of the course, and assessment and feedback (Unistats, 2011). The iPads were seen
as a way to help address issues in these areas and to improve student feedback.
There was a desire by some interviewees to diminish how important improving the NSS
feedback was as a motivator, I believe to combat the notion that the iPad was simply a gift given to
students with the expectation of improved feedback. The Academic eLearning Lead and the driving
force behind the iPad project, framed improving feedback on the NSS as the way he pitched the
project to move it forward, but not the principal motivation for the project:

28. 23
So, did we do this for the NSS? I didn't do it for the NSS because I thought it was genuinely a good
idea and wouldn't have done it just for that. But did I use that as leverage to do it? Certainly. And to
be fair that's the only reason it happened. Not the only reason, but people recognized that we needed
to do something major.
The hope and expectation was that the students, who in their clinical years spent their time
away from the university at hospitals, would be and feel more in touch with the university, with the
university delivering content and messages to students electronically, and the students, with their
iPads to-hand, accessing that content and receiving those communications. There was also a hope
that the students would be able to access information on their iPads in gap-times and at point-of-
care, possibly encouraging learning. And there was a hope that the iPads would help to equalise the
experience of the students across the four base hospitals by delivering centralised university content
to them via the device. If the iPads were able to fulfill these hopes then the underlying goal of
improving feedback would follow.
There was no attempt made during the pilot to connect the iPads with the learning outcomes
in the curriculum. As the Education Informatics officer for the project recalled:
…rather than a curriculum written for mobile learning or a whole set of resources and ways of going
about mobile learning, it wasn't done like that. It was: We feel that this technology can help with
communication and the learning experience with students who are off campus a great deal…
This strategy is understandable in the pilot phase of the project; investing the effort into a
redesigned curriculum that incorporated the iPads without the certainty that the project would
continue beyond the pilot is a presumptive risk.
4.2 Deployment Strategy
The university deployed the iPads to students with little guidance on how to use them. The
iPads were given to students and a short presentation about the devices followed. One student at
MRI, a female non-user, recalls the hand-over and presentation in this way:
It was more of a like 'Happy Christmas, here you go' kind of hand over, wasn't it? It was quite quick.
There was a bit of information about confidentiality and they mentioned the iCloud, but I didn't

29. 24
really understand what they were talking about. I think confidentiality was the key thing they
mentioned and what to do if it breaks, but apart from that there wasn't anything. They mentioned the
website that had a few of the ‘How to Set it Up’ videos, but there wasn't any more than that at ours.
This experience of little guidance on use was echoed by students in the other focus groups. The
website that she mentions is the mobile learning website set up by the eLearning technologists, on
which was hosted the how-to videos, documents related to the project, a page of recommended
application, and a forum for discussion. According to the accounts of the students and of the
eLearning technologists who set up the site – and as is partly evidenced by the paucity of posts on
the website’s forum (twenty-five posts, some of which were from faculty or staff) – the website was
little used.
One reason that the students were given little guidance on how to use the iPads was that the
decision makers and others were confident that students would explore and develop educational
uses for the devices on their own. This confidence was grounded in a belief that the students were
digital natives. The Academic eLearning Lead discussed his confidence in the students’ ability to
develop uses on their own when I interviewed him:
A lot of things I’ve learnt how to do have come out of the students, which I think is incredible. I
think the days of us telling people how to do stuff are gone. You [a student] know yourself. You guys
have all gone ‘Hold on, we’ve got a DropBox folder here, we can share all the resources and it’s
fantastic.’ [A reference to a story I had told him about the use of DropBox amongst the students on
my own program.]
The Head of Undergraduate Education, was explicit in his belief that technology is an integral
component in students’ learning and thinking, telling me that: ‘eLearning is key. That’s the way that
modern students think.’
The notion also arose in my conversations with teachers. Amongst the teachers, both power
users and the non-users embraced the idea of the students as digital natives. The Lead for
Prescribing Training, a power-user, described students in this way:
I think that’s how students all work, isn’t it? They want immediacy, they want immediate feedback,
they want to immediately be able to access things, they want to be able to find any resource they
want, when they want it. And that maybe is the culture that students come with now and we need to

30. 25
have insight into that way of working and look at how we can develop that. Not switch it off and say
‘No, you can't use your iPhone, that's naughty.’
While the Clinical Lecturer I spoke with, a non-user, less enthusiastically acknowledged the students
as digital natives:
I just think it would feel more intuitive to them to do it that way. As I say, I have two seven year old
daughters and they do their homework on the computer sometimes and that just amazes me that
they’re just growing up to expect to have that around them and the students are the same really.
They’ve always got a mobile phone. Before the iPads, quite often somebody would pull out their
mobile phone and say, ‘Oh, can I just Google this? Because I think I need to know a bit more
information here.’ And that’s fine.
The notion of the digital native, in part, drove a policy of allowing students to develop their own
uses of the devices. Alongside this notion was also a desire to empower students to guide their own
learning and an uncertainty within the university about how the students could best use the devices
for learning purposes.
4.3 Student Users and Uses
There was a range of user-types amongst the students I spoke with. Students who were niche
or non-users were resistant to the notion that they were digital natives. When asked what they
thought of the notion, a niche-user in the RPH focus group responded viscerally, sitting up in her
chair and replying: ‘That’s poppycock!’ While her fellow student, a non-user, expressed a personal
lack of interest in technology that cut against the digital native concept:
I don’t have a lot of interest in technology. I just want it to be quite straight forward and be able to
do it. And other than that I’m not too interested in playing around to see what I can find.
The power-users and routine-users in the focus groups were more willing to accept a degree
of truth in the concept of the digital native, taking pride in it in some cases, but also acknowledged
that there was, in fact, a range of user types amongst the students. A routine-user at MRI expressed
this perspective:
I think in terms of describing our generation as digital natives, you can’t use that; it’s not an all-
encompassing term. It’s very much down to the individual. And I think this whole project has
definitely identified that because there are lots of people who are very enthusiastic about these iPads.

31. 26
I mean these guys [the other power and routine users in the room] are doing lots of new and
different things. But for a lot of people it just sits there. I know somebody who’s got it out the box
less than five times and it just sits there, and they’re not interested, and they don’t care, and they’re
not bothered.
Uses were very similar to past deployments of mobile devices, including use of the iPads to
access information and for organisational purposes. Recreational use was also frequently mentioned.
The students often use the devices in gap-times during the day: while in transit or between a lecture
and a clinic, for example. Some used their iPads to do coursework in this time and others used the
device for recreation. A full list of locations and purposes of use, mentioned in the focus groups and
the meeting, is below (Table 4.1).
Table 4.1 – Uses of the iPads and Location of Use
Uses Locations of Use
As an additional screen
As an aid in creating and delivering presentations
For communication
For form entry
For organisational purposes
For recreation
To compile an ePortfolio
To do calculations
To do a research project
To do revision
To look-up information
To read documents
To take notes
To view hospital eLearning videos
To view MMS eLearning videos
At home
During field research
In hospital lectures
In hospital libraries and learning centres
In meetings with tutors
On the hospital ward
In problem-based learning sessions
While in transit
4.4 Factors Influencing Use
My first research question asked what institutional, cultural and design factors were
influencing student use and non-use of the iPads to do coursework. These factors and the ways in
which they pushed against one-another, some encouraging and some deterring use, emerged during
the interviews, the focus groups and the meeting. A small selection of prominent factors deterring
use is discussed below and a full table of factors is available at the end of the section (Table 4.2).

32. 27
Prominent institutional factors deterring use, mentioned by participants, are the lack of Wi-
Fi access and the lack of safe storage for the devices on the hospitals wards. A student from the
MRI non-user meeting succinctly described the importance of not having Wi-Fi access as a deterring
factor:
I don’t take it to the hospital very much because we don’t have Wi-Fi there, or at any of the hospitals
I've been placed at. Because I can't use the Internet it’s [the iPad’s] not been that useful.
While the Head of Clinical Skills at MRI summarised the student dilemma with carrying the iPad
around with on hospital wards:
Where do you put them? There’s nowhere safe to store them. It’s Manchester Royal Infirmary and
everything will go missing if it’s not tied down.
The lack of Wi-Fi access at hospitals has now been addressed in most of the hospitals that students
are assigned to. It should be noted, though, that the existence of a Wi-Fi signal does not necessarily
mean easy Internet access. At RPH for example, there is an available Wi-Fi signal, however the
password to login to the network is randomly generated and can be difficult to remember, and the
network is set to automatically log users out after approximately ten minutes of inactivity.
Additionally, the MRI IT and Communications Lead has informed me that while there will be Wi-Fi
access at the hospital this autumn, that access with not extend to the hospital wards. The issue of
storage of the iPads on the hospital wards is more difficult to address and I have not been informed
of any solution to this problem.
Lack of training for students on the devices is another institutional factor deterring use. The
Academic eLearning Lead is interested in continuing to allow the students to learn about the devices
from one-another and in improving the mobile learning website as a hub for discovering
information about the iPad and for facilitating peer-sharing:
I think that this year, it’s been a disappointment, the website. But actually I think we need to put a
little more work into it, because the next two years, when they [the students] come to it, we’ll be
starting completely afresh and they may go ‘Ok, well I’ll have a look on there.’ So I think over the
course of time it might become more… Hopefully when all clinical years have them, hopefully there

33. 28
will be a critical mass; there will be enough people around that will help, because there are certain
students that people will approach and others that people will not approach.
This thinking is in-line with his confidence in the students’ ability to develop uses for the devices on
their own and his desire to empower students to guide their learning and share the uses of the iPad
that they discover.
A third institutional factor deterring use is the lack of training on the iPads provided to
teachers. The Academic eLearning Lead justified this lack of training by pointing out that the
numbers of teachers and their work locations across the Manchester area and further afield made
training logistically difficult. This is understandable, but as a result some teachers, like the Clinical
Lecturer I spoke with, remain unfamiliar with and uncertain about the devices:
My first thought as a digital immigrant was ‘Oh my goodness, I don’t know how they [the iPads]
work’, which hasn’t really changed much. I still don’t know how they work, although I had a play on
one. Which, I think, it could be an issue for tutors, certainly tutors of my age... Because I don’t have
an iPad it’s very difficult for me to know - I don't know what its potential is…
These lecturers are ill-prepared to integrate the devices into their teaching and in some cases have
responded negatively to the devices, asking students to put them away. The Academic eLearning
Lead’s hope is that over time and once the project expands this uncertainty and the negative
reactions will dissipate.
A notable cultural factor deterring use on hospital wards was that some students were
uncomfortable using the iPads in front of patients. Students felt that the iPads either acted as a
physical barrier or that patients perceived them to be playing games on the devices, inhibiting the
development of a doctor-patient relationship. A routine-user at RPH described this feeling:
I’ve not got mine out in front of a patient and I’m not sure I have the nuts to try it. Where I’ve seen
patients with a couple of other medical students have had their iPads out, it does seem to shift the
focus so that the patient focuses on whoever doesn’t have the iPad out. And you end up with a one
way involvement then and the ones with the iPads out are aside; they get excluded from the
consultation. The patient will focus on whoever is not distracted.
However, other students found that if they properly introduced the iPad to patients then it helped to
shift the device from being an impediment to interaction to being a talking-point and a means of

34. 29
building rapport.
Design factors deterring use focused on the size of the device, particularly in relation to the
smaller iPhone. The iPad was seen as less portable than the iPhone, and was therefore less likely to
be taken onto and used on a hospital ward. As the Education Informatics officer pointed out:
The thing about a phone is you can put it in your pocket; you can’t do that with an iPad and people
don’t wear white coats anymore. It’s very hard, if you want them [students] to use them in the clinical
settings.
Some students, though, felt the larger screen on the iPad was significantly better for accessing and
reading information on, and so were more likely to use it to do coursework.

35. 30
Table 4.2 - Factors Influencing iPad Use
Design Cultural Institutional
Encouraging Deterring Encouraging Deterring Encouraging Deterring
Able to synch
with other
devices
Better than the
iPhone
Fast to start-
up
Few technical
problems with
iPads
Intuitive
touchscreen
and use
Autocorrect
Awkward to
stand and type
notes
Cannot be
used outdoors
Easier to use a
device with a
keyboard
Has to be
charged
Heavy to carry
Less portable
than a
smartphone
Convenience
Device
improves
learning
Elite users
providing
guidance
Enthusiasm for
technology
Environmental
(saving paper)
Previous
experience with
Apple products
Rapport
building
Additional costs
Competitiveness
factor deterring
sharing of uses
Concern about
loss or damage
Detriment to
learning
Friends are non-
users
Lack of interest
in technology
One more thing
to worry about
Prefer another
technology
Rudeness factor
in front of
patients and
teachers
Unsure of how
to use device or
no perceived
need for it
Want to keep
hands-free on
the wards
Application
recommendations
Faculty and staff
acceptance of use
Having Wi-Fi
access at
hospitals
Institutional
guidance on use
provided
Confidentiality and
infection control
standards
Difficulty accessing
Manchester content
on iPads
Difficulty logging-
in to hospital Wi-Fi
network or iPads
Faculty and staff
resistance to use
Institutional
uncertainty about
uses
Insufficient
eLearning
resources available
iPad not tied to
assessment
Lack of
communication
between university
and base hospitals
Lack of safe
storage on hospital
wards
Lack of training for
students
Need for tutors,
not technology
No or limited Wi-
Fi access
No transition of
services
School
unresponsive to
criticism

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Chapter 5
Discussion
5.1 iPad Project Aims Achieved?
My second research question asked whether the aims of the iPad project had been achieved.
In terms of achieving the underlying motivation for the project, improving the medical school’s
result on the NSS, it is too soon to tell. The NSS is open annually to graduating, year-five students
and the year-four students who received the iPads last December will not be eligible to participate
until 2013. Even if there is an improvement in the NSS scores in 2013, it will be impossible to
determine how significant the iPad was in producing those results; other factors, like curriculum
changes, for example, may play a far more important role in improving the survey results.
In terms of the other aims of the project, it is too soon to make a declaration of success or
failure, but it is possible to say whether the medical school is moving toward achieving those aims.
The aims of improving communication between the university and students and of improving
student access to information while at hospitals appears to have improved marginally, but are
impeded by the lack of, or difficulty of logging-on to, a wireless Internet network at the hospitals.
Improved Wi-Fi signal and ease of access to the Internet are necessary to allow for use of the iPad
for communication and to access online information. As these things are accomplished, then a
barrier to the iPads aiding in achieving these aims is removed, and a different determination about
these aims can be made.
There are signs that the iPad project is having an impact on the third aim, equalising the
student experience across the base hospitals. The presence of the iPads has encouraged the further
development of university eLearning lectures and hospital clinical skills videos that all students can

37. 32
access online. This means that consistent educational content is now available to students across the
base hospitals, and some students enthusiastically reported accessing that content. There are plans
to continue to develop eLearning content. As this content becomes increasingly available, the
students’ educational experience may become more consistent across the base hospitals.
5.2 The Need for Student Training
A major threat to the aims of the iPad project, in my view, is the lack of training for students
on use of the iPads. There is a belief amongst the project decision-makers and teachers that the
students are digital natives, and for that reason, in part, are best left to develop uses for the devices
themselves. The overwhelming evidence in the literature and from this research is that the concept
of the digital native, as it was originally articulated by Prensky and in the popular imagination at
MMS, is inaccurate. There is, in fact, a range of different user types amongst young people, from
power-users to non-users, as Helsper and Eynon (2010) identified in their UK-wide study, and as is
in evidence amongst the MMS students I spoke with. A small number of students develop
sophisticated uses for devices, but most students, unless trained, do not progress beyond basic uses,
as Bennet, et al. (2008) found in their review of empirical work on the subject and as I gathered
from my conversations with MMS students. And the concept of the digital native is an adult
construction that is projected onto students for a variety of reasons, to which some students are very
resistant, as Herring (2008) has stated and as was expressed by the niche-user at RPH who exclaimed
‘That’s poppycock!’ when presented with the concept.
The concern is that by not providing students with training on the devices, those students
who are niche or non-users, not by choice, but because of their own uncertainty about how to use
the devices, will not be able to take advantage of the potential of the iPad and may be left behind the
power and routine users, educationally and then professionally. The evidence in the literature is that

38. 33
these niche and non-users can often be women, minorities and students of lower socioeconomic
status (Hargittai, 2010). While my sample of fifteen students at MMS is small, it is worth noting that
the three power-users that I spoke with are all male, while three of the five niche and non-users I
spoke with were female; those females were all niche or non-user because of an uncertainly about
how to use the device. The university is arguably doing a disservice to these groups by not providing
them with training on the iPad.
The Academic eLearning Lead’s strategy to rely on the mobile learning website to act as a
hub for communicating and exchanging information about the iPad, and for students to teach each
other uses of the device this autumn is a risk. The mobile learning website failed in that function
during the pilot and there is no good reason to believe it will be any different in future. While the
students, in my experience of speaking with them, are highly competitive and only willing to share
uses with close friends, which could lead to great inconsistency of use within and across the base
hospitals, and may perpetuate a digital divide based on gender, race and socioeconomic status. If the
university wants to achieve its aims of improving communication and access to information amongst
all clinical-years students it should, I believe, implement a training program on uses of the iPad.
There are successful models of training programs on mobile devices for medical students, from the
series of assessed modules at a residency program to UCLA’s PDA deployment, both mentioned
above.
5.3 Developing eLearning Content
As the university develops more eLearning content for students with the intention that they
access that content on their iPads, it is worth keeping three things in mind:

39. 34
 The evidence in the survey (Manchester Medical School, 2012) and in the focus groups is
that students who use the iPads often do so during gap times throughout the day. These gap
times can last from anywhere from five minutes to a couple of hours.
 Gap time uses are normally in public spaces: on the bus, in a hospital library, or on a hospital
ward. These public spaces, as Haddon (2004) has pointed out, are governed by rules of
behaviour. For example, one should be quiet on a bus or in a library, or be alert to others on
the ward.
 While Wi-Fi signal coverage is improving at the hospitals, it may not extend to the hospital
wards in some cases and logging in to the networks may remain difficult. There is no Wi-Fi
signal available in locations like a Manchester city bus.
Based on this evidence, it would be advisable to develop eLearning content that can be broken into
small chunks or easily opened to the place last viewed, to suit the short timeframes that students
may access the content in. Students should be able to view the content silently to avoid breaking the
rules of public spaces; videos, for example, should come with subtitles. And the content should be
downloadable to the iPad, so that it can be accessed offline.
5.4 iPhone v. iPad: Advice to Other Medical Schools
What is different about the Apple iPad from other devices, like the Apple iPhone, is its size.
Size has always been an issue with mobile device deployments to medical students, from the
complaints that the Newton was too large to comfortable carry on hospital wards to the feeling that
the screen size of PDAs were too small to comfortably read from. The iPad addresses the difficulty
of reading that comes with a smaller device, but in doing so sacrifices portability, which diminish the
likelihood that it will be used on a hospital ward and undermines one of the original benefits of
these devices, that they allowed for access to information at the point-of-care. If the priority of a

40. 35
medical school considering a mobile device deployment to students is that the devices be used at
point-of-care, then they would be better-off opting to deploy a smartphone to students. If the
priority is for the device to be used outside of hospital wards, in hospital libraries, at home or in
transit, then the question arises of whether a device deployment is necessary, or whether the laptops
that most students already have serve to fulfill the same purpose.

41. 36
Chapter 6
Conclusion
By taking a social informatics approach to this research, I have shown that there is a
complex range of design, institutional and cultural factors working to encourage or deter student
uses of the iPads. Significant factors deterring use include the lack of Wi-Fi signal and safe storage in
hospitals, the lack of training on uses of the iPad, students discomfort using the devices in front of
patients and the large size of the device. These deterrents are working together to diminish the
degree to which the medical school’s aims in deploying the iPads – including improving
communication and access to information, equalising the student experience and eventually
improving the NSS results – are being achieved. The medical school is working toward addressing
some of these deterrents, particularly the availability of Wi-Fi signal in the hospitals, but others like
the size of the device and the lack of safe storage on the hospital wards, are difficult to solve. While
other more easily solvable deterrents, like the lack of training for students on using the devices, go
unaddressed, in part because of a perception of students as digital natives, and threatens to
undermine aims like equalising the student experience. As the medical school expands the project
this autumn, it is worth keeping in mind how students have used the devices during the pilot and
utilise that knowledge to guide future actions, like training and the design of eLearning content.
Beyond the context of the medical school this research serves, firstly, as a reminder that
technology implementation involves more than simply deploying a device. Design, institutional and
cultural factors are part of a network of which iPads are only one node; the entire network strongly
influences how the humans within it interact with the iPad. It is also a reminder that the work that
academics do can capture the popular imagination, as Prensky’s concept of the digital native has

42. 37
done. When that work is not grounded in empirical research, is inaccurate, yet comes to guide
behaviour and policy, it can have detrimental effects. There is a continuing need to debunk or
reinvent the concept of the digital native.

43. 38
Appendixes
Appendix A - Semi-Structured Interview Questions
Could you describe your role at the Medical School for me please? Title, responsibilities, etc.
Could you tell me what your involvement with the iPad project has been?
Has your role evolved since the project was implemented? How?
Do you recall what your expectations of the project were? For example: How it would affect your
role at the school? How it would affect students learning?
How do you think students use the iPads?
Do you feel that how students do their work for the course has changed since getting the iPads?
How? Why?
Are iPads particularly useful for problem based learning do you think?
Students are reporting using less paper, productively using time that was previously wasted
communicating with each other more, developing new skills because of the iPads; do you see
evidence of these benefits amongst the students? Do you thing the work students do is improved by
having the iPads? Why do iPads improve work?
Do you think the iPad project is worthwhile? Why or why not?
Is there anything that I didn’t ask that, that you were expecting me to or that you would like to add
about the iPad project?
Is there anyone else on the faculty and staff who you would suggest I speak with regarding the iPad
project?

44. 39
Appendix B – Focus Group Questions
(Round table) Begin by saying who you are and what sort of things you’ve been using your iPad to
do.
Expectations
Wanted to get sense of what the group’s initial reactions to getting an iPad were. Excited? Anyone
sceptical or upset about the resources devoted to it?
Why do you think the medical school gave you iPads?
Are you more in touch with lecturers and peers as a result of having iPads?
Do iPads lead to better learning outcomes? And how do you achieve better learning outcomes with
an iPad?
Uses
How much of your coursework / practical work do you do on your iPad? Do you have a
supplementary device (like a laptop)?
There’s a question on the survey about using time that was once wasted more productively now that
you have iPads. Can you explain how time was being wasted in the past and how it is more
productive with an iPad? Where was time being wasted?
Are there any detriments to having an iPad? Distraction or dependency? What kind of things don’t
you do on your iPad?
Influences
What has influenced the way that you use iPads? Peers, the school, teachers, certain websites,
personal exploration?
How do you feel about the support the school, teachers and doctors have given you in learning
about and using the iPad (in terms of training, online support, personal direction)? Has this support
influenced the way you use the iPad?
What do think of your teachers’ involvement with the iPad project?
Moving forward
What do you think the medical school should do in future years with regard to the iPad project?
Continue it? Do things differently?

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There is the belief amongst some people that I’ve spoken with that the iPads are driving forward
other projects at the school and hospitals (Wi-Fi, storage, digital curriculum). Do you have any sense
of this being the case? And what projects do you see being driven forward?
General
There seems to be an assumption amongst some people that I’ve spoken with that young adults are
more familiar and comfortable with technology than people twenty years older. Do you think that’s
the case or is that a myth?
Do you get the sense that there’s a group of your peers who simply aren’t using the iPad for
coursework or practical work? Why not?
Are iPads particularly well-suited to medical school students? Why?
Final Requests
Would it be possible to send me a screen-capture of the desktop on your iPad?
Is there anything that we haven’t covered that you’d like to mention about the iPad project?
Feel free to contact me by email if you think of anything that you think is interesting after you leave.

46. 41
Appendix C – Niche and Non-user Meeting Questions
(Round Table) What school are you from, do you use your iPad at all and what do you use it for?
Has there been an evolution in your use of the iPads over the last five months? Are there any pivotal
moments that have shaped that evolution?
Do you have any sense of why you haven’t found a place for the iPad in your coursework?
What has your experience with lecturers and clinicians with regard to the iPad been like?
Have you used the iPad in front of patients? What has that experience been like?
How have you found that things like Wi-Fi access and storage at the hospitals? Has this influenced
your use at all?
The medical school went with a fairly unstructured deployment of the iPads. Is that fair to say? Did
you receive any training? Is that unstructured deployment a good strategy do you think?
There is a concept of the digital native that I hear from some lecturers. What do you think of that
concept?
54% of students replied to the iPad survey. The survey results have been largely positive – a large
percentage of students report using their iPads for one thing or another and a large percentage
report being satisfied with the devices. Did you participate in the survey? And do you think it is
representative of the student body?
Part of the university’s motivation for giving students iPads was to improve students’ connection
with the university and level the experience between the four hospitals that students are located at in
their third-through-fifth years. Do you feel the iPads have helped to achieve this?
Are there devices that you own and use for coursework other than the iPad? Why do you prefer
those?
Is there anything that we haven’t discussed that you think would be worth mentioning about the
iPad project?
Can you tell me a little bit more about the experience of students in year four? How much time do
you spend at a hospital? What do you do on an average day?

47. 42
Appendix D – Coding Scheme

48. 43

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51. 46

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53. 48
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