ePortfolio in Midwifery Practice: “The Way of The Future”

Planning 

The initial planning phase explored the notion of using ePortfolio in midwifery education through discussions with midwifery academic staff reflecting on anecdotal accounts from students regarding the current paper-based portfolio. Most of these accounts indicated that students believed that the current portfolio could be improved. A review of contemporary literature regarding portfolios and ePortfolios was undertaken in order to provide background to the study and inform the development of the ePortfolio.

An action research group (ARG) was established consisting primarily of academic and research staff, including staff from the Flexible Learning Centre, midwifery lecturers and IT staff. The ARG met regularly through the development process and notes were collected during each discussion. Further to this, an advisory committee was established to contribute to development of the portfolio and participate in the reflective phase of the project. This committee represented university staff, students and industry partners. Participants were invited to participate by a letter of invitation. The planning phase identified specific concerns and requirements for the ePortfolio.

Action 

During the action phase ePortfolio requirements, including design interface, organisation and display, were developed in collaboration with technical staff. The design was based on the existing paper-based portfolio with the necessary modifications to construct an accessible, online learning space managed by students themselves, enabling students to electronically document, store, and reflect on learning activities. Specifically, provision was made for students to create a cumulative record of practice experiences and a clinical experience assessment form was made available to students to complete with regards to the level of skill attained for each competencies. The option for staff or peers to collaborate and provide prompt feedback was developed. The capacity for continuing assessment of course requirements, both formative and summative, was created. Importantly, it provided a location for students to accumulate evidence for professional registration requirements. Privacy and confidentiality issues were addressed by creating password protected access to the ePortfolio.

The study used a purposive sample of 39 midwifery students who were undertaking year one of the Bachelor of Midwifery Program at UniSA, a large university in Adelaide, South Australia. Once the ePortfolio was developed, several academic staff and a student reviewed the program for ease of use and clarity. No changes were recommended at this stage and it piloted with first year students undertaking their second clinical placement across several large tertiary maternity hospitals. First year midwifery students were selected for the pilot study as they were considered the most appropriate student cohort. These students had been required to record clinical experiences during their first clinical placement as part of the paper-based portfolio and assessment criteria. This ensured that the students were familiar with the process of maintaining a portfolio record and also provided students with a means to compare practice between electronic and paper-based portfolio without having established a familiarity or preference for either. One of the clinical facilitators responsible for these students had participated in the advisory discussion and was familiar, to some extent, with the pilot ePortfolio.

Students were recruited to participate in the project by personal invitation or email. Each student was provided an information letter regarding the ePortfolio and asked to sign a written consent form. Students were provided a face-to-face training session about the ePortfolio with university IT staff before using the ePortfolio. Eighteen students maintained the ePortfolio throughout their clinical placement representing a diversity of student participants (Table 1).

Table 1. Student participant demographics.

	Demographics	Number of students	%
	Age range
	>25 years	10	55.6
	26–30 years	4	22.2
	31–35 years	1	0.5
	<35 years	3	16.7
	Nationality
	Australian	14	77.8
	Swedish	2	11.1
	Other	2	11.1
	Suburb region
	North	5	27.8
	North Eastern	4	22.2
	South	3	3.7
	East	2	1.1
	West	2	1.1
	Country South Australia	2	1.1
	Marital status
	Married	6	33.3
	Not married	12	66.7
	Grade-point average
	>6	3	16.7
	5–5.9	7	38.9
	4–4.9	8	44.4

Observation 

During the observation phase students who maintained the ePortfolio were asked to complete an electronic questionnaire and participate in face-to-face interviews providing feedback regarding their experience in using the ePortfolio. The questionnaire and interviews were conducted following completion of the clinical placement experience. The questionnaire was anonymous and designed to collect feedback from students regarding the use of the ePortfolios. It also gave students an opportunity to comment on the current paper-based portfolio. Eleven students completed the questionnaire online.

Eight students agreed to participate in the interviews and were asked to complete a written consent form giving permission for the interviews to be taped. Two interviews were conducted face-to-face but due to difficulties in connecting with students the remaining six were conducted as phone interviews. Confidentiality was assured by de-identifying each student and their comments. Similar to the questionnaire, the interviews sought specific feedback from students regarding their experience with both paper-based and ePortfolio, with specific questions to guide the discussion bases on the data from the survey. Consequently, the interviews provided additional understanding and were valuable in being able validate the project results.

Reflection 

During the reflection phase the analysed data from the questionnaire and interviews were reviewed. The findings were presented to the ARG, including the advisory committee, and contributed to an evaluation of the ePortfolio and recommendations.

An ethics proposal was submitted and approved by the UniSA Human Research Ethics Committee prior to commencing the study.

ARG and advisory committee 

The initial ARG discussions presented anecdotal accounts of issues with the current paper portfolio and were reviewed in light of contemporary literature. These discussions provided a means to articulate the research problem and subsequent proposal. Through these early discussions, several key concerns were identified and it is agreed that there was a need for a well designed ePortfolio interface that was able to meet the specific needs of midwifery students, academic staff and clinical facilitators. Specifically, it was acknowledged that key stakeholders needed to be involved with the finalisation of the design and specifications of the ePortfolio and an advisory committee was formed.

An initial design interface for the ePortfolio was developed by the university IT department consisting of a two tier web application with a presentation layer, a database backend and normal login security features. It was written using a standard methodology within Microsoft's Dot Net 2.0 framework. The initial ePortfolio was presented to the ARG and advisory committee and was well received although; a number of issues were raised. All stakeholders commented that the design appeared “user friendly” and thought that the ePortfolio was a “positive step” with “huge potential.” The issues raised by stakeholders centred around IT, such as access to computers for hospital staff, computer literacy, back-up, safety and confidentiality of electronic data. These issues were considered and adjustments made to the final design of the ePortfolio.

Questionnaire 

Eighteen students maintained the ePortfolio and 11 of these students completed the electronic survey. Students were provided five statements and asked to rate the degree to which they agreed or disagreed with the statements, ranging from strongly agree to strongly disagree. The first two statements specifically asked students to reflect on their experience with the paper-based portfolio. Seven (63.7%) students indicated that they agreed or strongly agreed with the statement that the paper-based portfolio process in the Bachelor of Midwifery Program was user-friendly. Three (27.3) students disagreed or strongly disagreed with this statement (Table 2).

Table 2. Paper-based portfolio user-friendly.

	Rating	n=11	%
	Strongly agree	1	9.1
	Agree	6	54.5
	Unsure	1	9.1
	Disagree	1	9.1
	Strongly disagree	2	18.2
	Total	11	100.0

Seven (63.7%) agreed or strongly agreed that they had found it easy to keep track of the paperwork for clinical experience during their first course of the program, while only one (9.1%) student disagreed with this statement (Table 3).

Table 3. Paper-based portfolio easy to manage.

	Rating	n=11	%
	Strongly agree	2	18.2
	Agree	5	45.4
	Unsure	3	27.3
	Disagree	1	9.1
	Strongly disagree	0	0.0
	Total	11	100.0

Students were asked to provide additional comments following each statement. Comments were both positive and negative for the first two statements and included the idea that a paper copy of the portfolio provided a sense of satisfaction when reflecting on experience, such as “it's a record of my progress”. Also, students commented that it felt ‘safe’ knowing that there was a hard copy available. Negative comments reflected on the size and complexity of the document suggesting that a significant degree of organisational skills was necessary to manage such a large document, one student commented “if you’re organised it's simple.” Other students admitted to redesigning the portfolio “I had to (re)create the entire document myself on computer” and “I have simplified (it) a lot.” There were some students who felt that more guidance would have been beneficial. While some students felt that a paper copy was a safe option, most felt that there was risk of losing the portfolio, particularly when on clinical placement.

The following three statements were designed to gain feedback from students regarding the ePortfolio. The first statement, which aimed to gain a response from students regarding the ease of use of the ePortfolio did not appear to be well understood by students with six (55.0%) students responding with unsure. However, comments following this statement indicated that while the process allowed for easier maintenance of their record students at first, they found it was quite a “tedious” process. In addition, it was suggested that there was not always enough space or detail for the specific entries required, for example one student commented, “the ePortfolio itself is not specific enough about the context (follow-throughs, placements) or detail of learning experience.” Some students also identified that their work load was doubled; however, this was due in part, to the misunderstanding that students had to maintain a paper-based portfolio at the same time and were reluctant not to do so as this represented a critical piece of assessment during their course.

The statement “I would prefer to use an ePortfolio to a paper-based portfolio” was presented to the students. Seven (63.7%) students agreed or strongly agreed with this statement. Four (36.3) students disagreed (Table 4). Comments following this statement included, “would prefer if it totally replaced the paper version and was user friendly for clinicians” and “I would prefer the ePortfolio over the paper, but I do think the ePortfolio needs a few changes to make it easier.” Interestingly, comments were made by several students indicating that they would still like a paper copy of the portfolio on completion of their degree. Also, queries were raised regarding the collection of signatures from midwives and facilitators while on clinical placement.

Table 4. Prefer ePortfolio to paper-based portfolio.

	Rating	n=11	%
	Strongly agree	2	18.2
	Agree	5	45.4
	Unsure	0	0.0
	Disagree	4	36.4
	Strongly disagree	0	0.0
	Total	11	100.0

Students indicated that the ePortfolio would be good for keeping track of their progress over the program with 8 (72.7%) students responding with agree or strongly agree to this statement, however, 2 (18.2%) students did not agree (Table 5). Comments concerning the ability of the ePortfolio to track their progress suggested that potentially, it would provide a quick and easy way to review their progress at any stage of their program, highlighting the requirements that still need to be met. Comments included, “easier at a glance” and “it shows clearly the numbers that I have and what I still have to do.” This may be of particular concern for midwifery students who must fulfil a specified number of clinical experiences, including births and follow-through, for registration. Students did raise concerns regarding “losing data” and the need to “constantly put their experiences into the computer.”

Table 5. ePortfolio good for keeping track of progress.

	Rating	n=11	%
	Strongly agree	2	18.2
	Agree	6	54.5
	Unsure	1	9.1
	Disagree	2	18.2
	Strongly disagree	0	0.0
	Total	11	100.0

The questionnaire provided a final question asking students to comment from their experience with the ePortfolio, what improvements could be made to the technology itself, or to the user's experience. All but one student provided a comment. Comments regarding the technology suggested that the software needed to include more options, such as a broader list of clinical locations, or the ability of the system to record names that have been entered once, such as midwives and facilitators. Also, students recommended that being able to document more experiences per web-page, without having to “update the screen” would save time and be easier to track. Comments were made on the terminology employed at times, for example “women undergoing birth.” Students felt that the ePortfolio would be more user-friendly if there were prompts written into the program, such as details required for a abdominal palpation including, “gestation” and “fundal height.” In general, students were positive about the future of the ePortfolio suggesting that with further modifications it would be a useful tool and could eventually replace the paper-portfolio.

Interviews 

Eight students agreed to participate in face-to-face interviews. Seven out on the eight student interviewed completed both the paper and pilot ePortfolio. Each interview was recorded and transcribed verbatim. The data were then coded and sorted using thematic analysis. Demographic data were collected as shown in Table 5. The questions used during the interview process asked students to consider both the paper-based portfolio and the ePortfolio. Four themes were identified from the discussions for each type of portfolio providing a comparison between both types of portfolio (Table 6).

Table 6. Comparison between paper-based and ePortfolio.

	Paper-based portfolio	ePortfolio
	Cumbersome	Streamline
	Confusing at first	Simple
	Created anxiety	Safe
	Consolidating experience	Suggestions for improvement

Confusing at first 

On receiving the paper-based portfolio instructions for field placement, all participants interviewed expressed that they initially felt confused about what was required of them. However, they managed this confusion by seeking examples of portfolios from second and third year students. Based on these examples they created their own format to manage the information and requirements of their portfolio, according to personal preference. Once participants believed they understood what was required of them, recording their field placement experiences was considered by most as enjoyable. Comments included,

“Biggest issue was not understanding. Unsure about what was required.”

“Tried very hard to simplify it.”

“Initially it was confusing.”

Cumbersome 

Issues in the size and managing the portfolio emerged from the data. Students acknowledged that building a paper portfolio had some limitations describing this with words such as “awkward”, “wasteful” and “heavy.” Keeping entries up to date and managing lots of paperwork while on placement was expressed by participants as “stressful at times.” To manage the bulk of accumulating records participants often referred to the need to keep separate folders that later had to be collated to present for assessment. To ensure against losing these documents some felt the need to carry around their portfolios at all times and the burden of carrying such a heavy and bulky document was also expressed.

Created anxiety 

The fear of losing completed paperwork and signatures that verified their attendances was often foremost in their minds. All participants referred to this as a significant issue as documented,

“Worried about losing when have to leave at nurses station”

“Fear of losing it or it being stolen”

This anxiety regarding losing documents while on placement was referred to as stressful, although it was also acknowledged that after time it became a habit to make sure they had multiple paper copies for each experience, “I photocopy all my originals, signed materials and sort them into folders as I go, so if I lose one I have another.” However, the need to do so involved extra time and cost. Presenting the completed portfolio for assessment also involved a cost as often students found it difficult to hand this in to UniSA staff directly so that the cost of postage was also required and also created uncertainly about the reliability of reaching the university. Also, the requirement to chase up signatures, up to five for each follow-through experience, was often found to be difficult and stressful, most commonly, this involved pursuing busy midwives. Often, this was also time consuming and created anxiety if the midwives and/or facilitator were unavailable.

Consolidating 

While students identified issues concerning the paper-based portfolio, one consistent notion that persisted was that the portfolio provided an overall consolidation of their learning experience, particularly authenticating their clinical experiences. Having a verifiable document of their placement experiences that was validated by a facilitator and/or midwife gave them a sense of security, especially for assessment purposes. Participants liked the fact that they had a visual, authentic document that was at hand whenever it was required. Many found that having this record to look back over was both encouraging, as they reflected on achievements to date, and motivating, as they anticipated competencies still to be achieved. Comments included,

“Good visual account, like to reflect–keeps you motivated”

“Evidence of what I’ve done–encouraging to see the folder build up”

Simple 

Participants who completed the ePortfolio found that creating their Midwifery portfolio using the online format was straightforward providing that the student had a degree of computer literacy. Students used descriptors such as ‘really easy”, “straight forward” and “all made sense” to describe their experience creating an ePortfolio. The visual layout was appealing and participants found their experiences could be easily quantified, showing those achieved to date and those still to be completed for assessment purposes. One student however, commented that they did not really understand it and “needed someone to go through it again,” identifying that computer literacy was a necessity. Interestingly, there may be a correlation between age group and acceptance of the ePortfolio, the youngest student who participated in the interviews appeared the most relaxed and accepting of the online format. This may need consideration in implementing the ePortfolio as standard practice

Streamline 

Participants found that keeping track of their experiences was easy, also due to the visual layout. A number of positive aspects were identified by participants in using the ePortfolio, such as the ability to ‘enter as you go’, change entries if necessary and the ePortfolio's user-friendliness. Less waste, less cost, and less hassle were also expressed as positive aspects. Using the ePortfolio was generally acknowledged as “the way of the future” for university courses requiring an ongoing clinical record. The accessibility of the document to all parties requiring access including staff, facilitators, midwives and students, was considered to be a better means of managing the portfolio as an assessment tool. One student described it as a “one stop shop” as it “accumulates everything in one place” another stated that it was “very good to quantify experiences.” Nevertheless, several students raised the issue of the time it took them to enter data such as “took a lot of time trying to upload 105 experiences” and “demanding course already, didn’t have time to learn it alone.” One student suggested that the ePortfolio would best be implemented at the beginning of the program as she was about to begin second year.

Safe 

The concern about loss of documentation was also resolved for many as they felt their ePortfolio was safely stored on the University system, they maintained that if it was lost from there, at least this was “someone else's problem”. It is possible that this cohort of students saw this as an additional back-up for their paper-based portfolios, as all maintained their paper-based portfolios as well. Further, students identified that there was less risk of physically losing electronic data compared to hard copies, “don’t have to carry it around, no risk of losing paper”. One concern that was raised was the issue of being able to validate the students experience and collect signatures as evidence of competencies achieved; students found this was an issue that would need to be addressed to ensure that the ePortfolio met registration requirements.

Suggestions 

All participants who completed paper and ePortfolio stated that they completed their paper portfolio first and transferred this information to the online version. While students were positive about the potential of the ePortfolio, a number of issues with managing the online interface and data entry did emerge. Consequently, participants offered a number of suggestions for the improvement of the ePortfolio that they believed were required before it could replace the current paper-based model.

The main requirements expressed by participants were the need for a means of validating a students practice experiences, and the ability to enter details for each practice experience. For example, students wanted to be able to enter more detail about their birth experiences and to add to this as necessary. They identified that documentation of follow-through experiences needed to include all stages of pregnancy and childbirth, so that one continuous record could be kept for each woman they provided continuity of care. Verification of attendance was also a major concern for students, many of whom were unsure how this could be managed using the ePortfolio. At the moment, this is achieved by gaining signatures on paper from hospital staff/facilitator. Students wanted to ensure that there would be an effective and easy means of gaining validation to ensure that registration requirements would be met. They identified the need for hospital facilitators and midwifery staff to have a working knowledge of the ePortfolio.

A number of other suggestions were made, such as giving attention to wording, arranging the presentation of the ePortfolio so that miscellaneous comments could be made, access to hospital computers, ongoing IT support and the need for all users, midwives, facilitators, academic staff and students had continual access to the ePortfolio interface.

In summary, when comparing the ePortfolio and paper portfolio, the paper model was found to provide a means of ‘action journaling,’ it could provide reflections, essays and information acquired that the student wished to record and access. As such, the portfolio of experiences was expressed by many participants as ‘more than just numbers’. The hardcopy was perceived to provide more detail for interviews, and was available at all times. However, the ePortfolio was considered by participants to be easier to use, easier to access and convenient. Overall, most participants appeared happy to move to online portfolio providing their concerns could be addressed, and providing that all students were required to use it. The ePortfolio “needs a bit of tweaking” but appears accepted as “the way of the future.”