There are a range of known educational benefits in using a portfolio-type document, including an improvement in student knowledge and understanding, increased self-awareness, and greater engagement in reflection and student-tutor relationships (Buckley et al, 2009). The use of an electronic personal academic record was launched in 2014 to enable students in the School of Health Science at the University of Nottingham to develop, shape and share their academic and clinical learning experiences. The electronic personal academic record was so successful that, in preparing for the undergraduate midwifery programme's re-approval, the decision was made to develop the online component further to provide an online portfolio to record all clinical competencies, reflective experiences and assessments (including grading) in practice. There were a number of clear advantages of using an electronic practice document to support a new innovative curriculum: increased accessibility of the document for the student, the clinical midwifery mentors and the midwifery lecturers, which thereby enabled instant access from any location; immediate feedback; and the use of hyperlinks to organise material and link to relevant content and objectives (Sánchez Gómez et al, 2013). In addition, the student does not have to carry around a large practice document while on placement, reducing the possibility of it being lost and the risk of any fraudulent entries. Another key advantage to an electronic portfolio is that all sign-off mentors who work with the student over the 3-year programme can access the entries if required. Once qualified, students will be be able to access the portfolio and use as part of their revalidation requirements, should they choose to develop it once registered (Nursing and Midwifery Council (NMC), 2018).
This article will present the preparation and launch of the e-practice document, and discuss the practicalities of its introduction and continued use in the midwifery undergraduate curriculum. Firstly, a review of the literature in respect to portfolios and e-portfolios was conducted.
Literature review
A portfolio is a record of evidence that can demonstrate a professional's experience, achievements and competencies. It is also a platform for independent reflection on practice. Lorenzo and Ittelson (2005:2) defined the e-portfolio in web-based interface as:
‘A digitalised collection of artifacts, including demonstration, resources and accomplishments that represent an individual, group, organisation, or institution.’
Additionally, Bryant and Chittum (2013:189) state that the e-portfolio offers:
‘Greater flexibility and fluidity than their traditional paper-based counterpart, which opens the door for a more streamlined, iterative reflective process.’
E-portfolios are well established in medical education for practitioners' 5-yearly revalidation and yearly appraisal of their work experience, and as demonstration of safe practice (Wan and Metcalfe, 2016). Some studies have demonstrated that trainees prefer the portfolio to be electronic, due to the nature of clinical working practice (Garrett and Jackson, 2006; Belcher et al, 2014). However, while the portfolio is recognised as important, some practitioners have found it time-consuming alongside a busy schedule (Vance et al, 2013).
In Bryant and Chittum's (2013) literature review, they found that articles on e-portfolio use had shifted from descriptive accounts to more empirical studies. Nevertheless, the literature suggests that what is needed is research into the impact of e-portfolios on student outcomes. Negative findings in the use of e-portfolios were attributed to the tool used or the way it was implemented (Bryant and Chittum, 2013). The authors urged that research should be conducted into how students develop their critical thinking and reflective skills, as well as their engagement with the e-portfolio. Their criticisms also reflect that research often does not have a control group, so it is difficult to determine whether learning or positive growth are a result of the e-portfolio or not.
Belcher et al (2014) described the use of an ‘authentic’ portfolio, without explaining what they meant by this term in this context. However, they did propose that the authentic portfolio mitigated some of the challenges associated with maintaining a portfolio. These authors found that the participants did not see the purpose of maintaining a portfolio, finding that it was time-consuming and that feedback about their learning experiences was unhelpful. Nevertheless, Belcher et al (2014) proposed that better engagement with students increased the understanding of the purpose of the portfolio, as well as ensuring accessibility.
The role of the student's mentor in providing feedback through the portfolio was also seen as crucial. However, students cited their vulnerability in reflecting honestly in case any declaration of any mistake or weakness could ultimately affect their assessment (Belcher et al, 2014).
Contreras-Higuera et al's (2018) research concurred with previous studies in that they found differing student perceptions of the e-portfolio, particularly in their first year of study. The negative views in the first year of study seems to be related to selecting materials and organising the portfolio where an e-portfolio was not being used. The participants reported that the e-portfolio did not affect their motivation to learn or in supporting the transferability of skills. Of note is that where the portfolio received weighting in the assessment, it was viewed by students more positively.
Also highlighted were the time pressures that students faced to complete the portfolio. It has been stressed that students require guidance and support when questions and issues arise in relation to the e-portfolio (Contreras-Higuera et al, 2018).
Contreras-Higuera et al (2018) also considered the use of rubrics for assessment within the portfolio, which they found was valued by students and promoted awareness of the competencies to be achieved. These authors made several recommendations for teaching practice:
Garrett and Jackson (2006) reported on the use of a electronic clinical e-portfolio, which was designed for students to access resources and record their clinical experiences. Their evaluation revealed positive student attitudes but concluded that the tool had limitations due to the interface restriction on the small device. The authors considered that recording reflections while in practice was also difficult to achieve. However, students in the study did report that the tool prevented clinical isolation as it kept them connected. It should be noted that internet access via Eduroam (a secure, worldwide roaming access service developed for the education community) has only been available recently, as has the potential for NHS employees to use electronic devices in clinical practice.
Vance et al (2013) stressed the importance of continued support to both learners and their supervisors in the use of the e-portfolio. In this study, participants reported the difficulties in achieving peer-assessment due to the busy clinical setting, which potentially exacerbated the perception of the portfolio. Many supervisors reported not being familiar with the system.
In summary, the e-portfolio appears in the literature to have many benefits and, overall, students value its use. With this in mind, the rest of this article will detail the introduction of an e-practice portfolio into the midwifery undergraduate programme at the University of Nottingham, addressing some of the issues raised in the literature. The literature uses the terms ‘portfolios’ and ‘e-portfolios’ interchangeably. For the purpose of our midwifery undergraduate curriculum, we use the term ‘webfolio’, which encompasses all areas of student activity on the platform, including an online practice competency assessment area, ongoing achievement record, reflections, feedback from women, and the opportunity to use a range of media after the elective placement in year 3 to develop a reflective assessment.
‘The main aim in the development of the e-practice webfolio was to ensure that all the essential components were incorporated into a user-friendly portfolio that would demonstrate that the required competencies had been met’
Project management of the introduction of the e-practice webfolio
Following the successful NMC approval of the midwifery curriculum, the webfolio development team was formed. A collaborative approach was adopted between midwifery academics and the School's Health E-Learning and Media (HELM) team and led by a project manager. The learning technologists provided essential technical expertise and support in the development and design of the portfolio, using a proprietary site to which the School already subscribed for a range of other student learning records. The project team initially met every 2 weeks and one of the first aims of the team was to complete a feasibility study to look at the technical roll-out of an e-portfolio system across all midwifery placement areas. The key consideration in the project implementation was to ensure the engagement of stakeholders, namely Trust managers, clinical mentors and academic staff. It was essential that all partner Trusts fully adopted the e-practice webfolio in both the hospital and community settings for it to be successful with students.
The Division of Midwifery allocates students across five NHS Trusts and it was assumed that the level of information technology infrastructure would vary across the sites. A mapping exercise was conducted in each Trust to assess the potential availability of both hardware and Wi-Fi connection to student midwives. As a result of these individual meetings, all Trusts confirmed that they were happy to support access to the website that hosted the e-practice webfolio. Clinical managers and midwife mentors were also consulted about any potential problems they envisaged from their perspective. During the consultation, it became apparent that the practice partners had two main concerns: the availability of appropriate hardware to access the student's webfolio, and the accessibility to the internet via the Trust Wi-Fi or 3G, particularly in a community setting. With this in mind, the project team needed to consider any indicative costs or further resources that might be needed for successful implementation. These issues were in fact quickly resolved, as there was already a planned roll-out of access to Eduroam in the majority of hospital sites and a large number of Trusts were increasing their use of internet-enabled devices for clinical observations and patient records.
The main aim in the development of the e-practice webfolio was to ensure that all the essential components were incorporated into a user-friendly portfolio that would demonstrate that the required competencies had been met. The webfolio used two platforms: the student-facing side and the mentor-facing side, which ensured that the mentor entries could not be altered. Shroff et al (2011) considered students' behavioural intentions to use an electronic portfolio system and found that when students perceived the e-portfolio system as easy to use, they had a more favourable attitude towards the usefulness of the system. The e-practice webfolio was therefore designed to be as intuitive as possible, with a range of resources available to support the users. The literature had highlighted the need to provide students with extensive support and to include them in the implementation stages of the webfolio (Strudler and Wetzel, 2011). Resources were developed, and included a mock document on a dummy site for lecturers, students and mentors to view and navigate; a podcast with a step-by-step voiceover covering all aspects of the document; and three printed guides specific to all users.
Pilot study
Following the consultation with the practice partners, it was decided that a pilot study should be conducted, and the project team decided that it should be conducted with a small number of midwifery students from one year group, rather than across all year cohorts. The students were asked to review the content of the e-practice webfolio and the supportive aids. They provided feedback on the webfolio's accessibility and ease of use, and were invited to make any further comments that would help in the development of the platform.
The pilot study highlighted some minor issues around what the document would be called, but fundamentally the students were positive about the e-practice webfolio. Four months before the intended launch of the e-practice webfolio, the fundamental principles of it were presented at mentor update sessions provided by university lecturers to all of the Trusts. This gave mentors an opportunity to discuss any issues or concerns they had and allowed the team to address any questions in a timely manner. These sessions also included how the mentors would access the document and how they would be issued with a secure log-in. In the past, there were a number of issues with paper-based documents around the signing of competencies by midwives who were not sign-off mentors; therefore, the team made the decision to only issue sign-off mentors on the Trust live register with a log-in to ensure that documentation complied with NMC (2009) requirements.
Communication strategy
Following the success of the feasibility pilot study, the project team focused on a communication strategy to launch the e-practice webfolio to all midwifery placement areas, concentrating initially on making sure that all midwifery lecturers who were personal tutors were happy with the webfolio and confident in using it.
A programme of training sessions led by the project team was provided for the midwifery lecturers, and regular updates on the implementation process were given at the monthly education meetings. It soon became apparent that titles of these sessions needed to be reviewed, as the word ‘training’ had the potential to be viewed as something that needed learning and intensive effort. The project team decided that the word ‘familiarisation’ should be used instead of the word ‘training’, to avoid any inference that the e-practice webfolio could only be accessed if training had been completed.
The first cohort of students, and community midwives who were allocated to a student midwife, attended the familiarisation sessions in October 2015, 4 weeks before the students commenced their initial community placement. This was to ensure that the students and midwifery mentors who would be using the platform first were prioritised. The familiarisation sessions were rolled out to the hospital-based sign-off mentors in January and February 2016 and were subsequently incorporated into mandatory sign-off mentor updates.
The School's HELM team were and continue to be available to field any queries from mentors or students on any technical issues, and university midwifery link tutors have supported mentors with the e-practice webfolio and during the tripartite summative assessments in practice.
Compliance with the use of the webfolio
The Project Team considered its position in relation to insurmountable technical issues and the webfolio not being able to be accessed. A copy of the approved practice document was available as an electronic document in the event of there being any difficulties in completing the online version. However, it was decided that a hard copy of the document would only be issued by the practice module leader, who would determine whether all options for accessing the online version had failed. This was to encourage the use of the webfolio in the first instance and discourage reticent users being allowed to use the non-electronic copy.
The student midwives were fully compliant with completing the necessary documentation online for the placement area (Table 1). The sign-off mentor compliance appeared to be greatly influenced by the clinical setting, with community mentors being more likely to complete the document than hospital mentors. The high compliance percentage (85%) of community mentors was unexpected, as this group had expressed a concern about accessing the document online during the familiarisation sessions.
| No. of students | Student compliance (%) | Community mentor compliance (%) | Hospital mentor compliance (%) | |
|---|---|---|---|---|
| Trust 1 | 16 | 100 | 63 | 56 |
| Trust 2 | 8 | 100 | 98 | 50 |
| Trust 3 | 12 | 100 | 83 | 67 |
| Trust 4 | 6 | 100 | 83 | 83 |
| Trust 5 | 6 | 100 | 99 | 50 |
| Total/average | 48 | 100 | 85 | 61 |
In response to the compliance figures, the midwifery academic team offered sign-off midwifery mentors who were having difficulties bespoke sessions to familiarise them with the online platform.
The compliance figures from this inaugural cohort were reviewed again after the year-long midwifery practice module had been completed, and all students and mentors had successfully used the practice records in the online format (Table 2).
| No. of students | Student compliance (%) | Community mentor compliance (%) | Hospital mentor compliance (%) | |
|---|---|---|---|---|
| Trust 1 | 16 | 100 | 100 | 100 |
| Trust 2 | 8 | 100 | 100 | 100 |
| Trust 3 | 12 | 100 | 100 | 100 |
| Trust 4 | 6 | 100 | 100 | 100 |
| Trust 5 | 6 | 100 | 100 | 100 |
Reflections on the introduction of a practice webfolio
At the time of writing (February 2018), the webfolio has been used with six cohorts over a period of 2 years since its launch. The platform is reviewed each year and has evolved to continue to make it as student- and mentor-friendly as possible.
Reflections on its use over the past 2 years have come from different user groups. Feedback from students through the practice learning committees has been invaluable, and they have reported that once they are familiar with the navigation of the e-practice webfolio, it is easy to use. In response to this feedback, extra drop-in sessions have been timetabled with the first-year practice module leader to support familiarisation before students commence their first placement. Practice partners have provided feedback through quarterly Practice Learning Team meetings; although they reported some issues with remembering log-in details, overall the comments have been positive, particularly as they can access the e-practice webfolio at a time of their choosing, including when student is not present.
As the webfolio directly reflected the competencies of the NMC Midwifery Pre-Registration Midwifery Standards (2009), it is recognised that it will need be reviewed and amended with the launch of the awaited revised standards. Additionally, adjustments will be needed as the software for the webfolio is updated. Nevertheless, the platform has been well received and is fit for purpose, and any new versions will be able to to build on what is already used in practice.