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Clinical nurse preceptors' perception of e-portfolio use for undergraduate students
YJPNU-01021; No of Pages 6 Journal of Professional Nursing xxx (2016) xxx–xxx
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Journal of Professional Nursing
Clinical nurse preceptors' perception of e-portfolio use for undergraduate students Chi-Ping Chang a, Ting-Ting Lee b,⁎, Mary Etta Mills c a b c
Department of Nursing, Tzu Chi University of Science and Technology, 880, Sec 2, Chien-kuo Rd, Hualien 970, Taiwan School of Nursing, College of Nursing, National Taipei University of Nursing & Health Sciences, 365 Ming-Te Road, Taipei 11219, Taiwan School of Nursing, University of Maryland, 655 West Lombard Street, Baltimore, MD 21201, USA
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Available online xxxx Keywords: Clinical nurse preceptors E-portfolios Internship Last Mile practicum
a b s t r a c t Nursing schools and hospitals form partnerships to foster nursing education. Clinical nurse preceptors (CNPs) have a profound influence on nursing students' Last Mile practicum. Assisting preceptors to prepare students as future staff nurses has become a critical issue. E-portfolios utilize digital access and hyperlinks to integrate student knowledge, skills, and achievements with teaching assessment, process and evaluation. Based on the school–hospital partnership, preceptors require a teaching application to facilitate student learning. This descriptive qualitative study explored preceptors' perceptions regarding the use of e-portfolios. Data were collected from November 2012 to March 2013. One-on-one in-depth interviews with preceptors from different hospitals in Taiwan were examined using content analysis. Four key themes were revealed: utilizing students' learning experiences to design the CNP's teaching plan; a group-based discussion platform as a communication channel is needed; posting teaching content to facilitate student learning process; and, motivation usage factors in ease of use, sustaining use and win (student) – win (preceptor) outcomes. The use of e-portfolios allows preceptors to prepare for the learning needs of students. By considering preceptors' preferences, the design of e-portfolios may become more user friendly and useful for preceptors to expedite their teaching process and enhance student learning experiences. © 2016 Elsevier Inc. All rights reserved.
Introduction For nursing school graduates, the transition from school to clinical work presents many challenges and setbacks. Identifying methods to prepare nursing students for clinical practice and to ensure their performance has been an issue of concern in nursing education literature (Takase, Nakayoshi, & Teraoka, 2012; Takase, Teraoka, & Kousuke, 2015). The Last Mile practicum course (i.e. final semester internship program) was one of the required courses designed to improve baccalaureate students' clinical competence. This last semester course includes cooperative education and internship programs offered through school and hospital partnerships whereby students can have their clinical education and continue to work for the same hospital upon graduation. In this partnership, masters' prepared nurse staff are invited to serve as clinical nurse preceptors (CNPs) to provide clinical instruction to help students adapt to the hospital environment and develop required clinical practice skills. Since research has shown that attrition of new graduates in the first year of practice may reach up to 58% (Cheng, Liou, Tsai, & Chang, 2014; Dow, Lee, Chang, & Wang, 2013; ⁎ Corresponding author. E-mail address: [email protected] (T.-T. Lee).
Missen, McKenna, & Beauchamp, 2014), the practicum course is intended to increase student preparation for entry into practice and reduce reality shock. It is anticipated that students gaining clinical competence and confidence through their practicum will stay employed in the clinical setting after graduation and reduce future nursing shortages. Over the last decade, a significant change has occurred in nurse education. The focus of curricula has shifted from the acquisition of knowledge to the achievement of clinical competence by applying evidence based knowledge to patient care (Garrett, MacPhee, & Jackson, 2013; Wassef, Riza, Maciag, Worden, & Delaney, 2012). Portfolios are considered a student-oriented learning method that supports this effort. By combining students' knowledge, skills, and previous achievements, instructors can better design teaching programs or develop strategies to enhance student learning experiences. The digitization of the portfolio (e-portfolio) not only creates an electronic version of the paper-based teaching and course portfolio but is designed to record the learning progress of students systematically, and link to their career choice and future professional development (Green, Wyllie, & Jackson, 2014). Although research has focused on students' use of e-portfolio for their learning, instructors' perception of e-portfolio use in the nursing practicum course has seldom been studied and needs further exploration. As a result, the purpose of this qualitative study was to explore the clinical
http://dx.doi.org/10.1016/j.profnurs.2016.11.001 8755-7223/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Chang, C.-P., et al., Clinical nurse preceptors' perception of e-portfolio use for undergraduate students, Journal of Professional Nursing (2016), http://dx.doi.org/10.1016/j.profnurs.2016.11.001
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nurse preceptors' perceptions of e-portfolio use as a means of facilitating their teaching experience in an internship practicum.
Literature review E-portfolio Electronic portfolio (e-portfolio) is a web-based application which contains the course records of students and instructors. Instructors can place their teaching content on this platform for students to download, and students can upload their completed tasks such as homework, assignments and reflective journeys for instructors to comment on or grade. Student achievements such as completed projects, photos/pictures, reflective thoughts/journeys or awards can be kept in the eportfolio for future use in continued professional development (Moores & Parks, 2010). This system is superior to conventional paper based portfolios, where data access is often difficult due to the large amount of paper documents involved (Tsai, Lee, Lin, Lee, & Mills, 2015). Students and instructors, via instant messages, are able to engage in discussions and knowledge-sharing that enhances their motivation to use the platform. By using e-portfolios, instructors can encourage learners to actively develop their own learning plans and to organize their personal experience and achievements. By more comprehensively collecting what students have learned throughout their education, the e-portfolio can support students in feeling a sense of accomplishment (Ehiyazaryan-White, 2012; Pink, Cadbury, & Stanton, 2008). Although e-portfolios gained wider use in medical and nursing education (Forte, de Souza, da Silva, do Prado, & Rodrigues, 2013; Green et al., 2014; Haverkamp & Vogt, 2015; Hsieh, Chen, & Hung, 2014), the perspectives of instructors using this teaching tool deserves further attention.
Technology acceptance model (TAM) Since preceptor technology acceptance is a crucial factor in the determination of successful implementation of e-portfolios instructors need to recognize their value and usefulness (Bogossian & Kellett, 2010). When preceptors use this teaching platform there can be a significant enhancement of teaching and effectiveness of learning (Andrews & Cole, 2015; Balaban, Mu, & Divjak, 2013; Moores & Parks, 2010). Technology acceptance remains a key factor in determining the success or failure of this system. The technology acceptance model (TAM) provides a theory base for the technology adoption process. It posits that if a person perceives technology as useful or easy to use, then he/she will form a positive attitude toward it, develop an intention to use it, and lead to actual use (Davis, 1993). In order to improve instructor acceptance of e-portfolios and their intention to use them, a school-hospital partnership was proposed. The desired e-portfolio function was explored with the CNP and it was decided that e-portfolios could enhance student care competence in the clinical practice arena. The present study was conducted to explore the CNPs' perceptions toward the use of eportfolios. The research question was stated as the following: What are CNPs' perceptions of e-portfolios as a teaching tool for nursing students during the internship (Last Mile) practicum?
Study setting and participants The Last Mile practicum is a required course in the undergraduate program. It is designed to be taken in the last semester so students can continue to work in the same unit whey they complete the internship. The Last Mile practicum course extended over a 6-week period and included 37.5 practicum hours per week for a total of 225 practicum hours over the semester. Twelve nurse supervisors served as preceptors from four hospitals. The school of nursing recruited preceptors as parttime faculty to teach this course. Preceptors were from the same hospital where the practicum took place. In order to qualify as a CNP, nurses must be master-prepared in nursing and be full-time supervisors or managers at the practicum site. After obtaining the IRB (Institutional Review Board) approval, the first author called each of the 12 CNPs (total group) to ask their permission to conduct a study interview with them. These subjects were recruited due to their part-time teaching faculty status in this internship program. The participants were all females, between the ages of 28 and 55 years old, and all held nursing master's degrees. Each preceptor supervised 10 intern nurses on one of 5 patient care units (2 in each). Intern nurses were under the direct supervision of seasoned nurses in the practicum units, and the preceptor visited each unit daily to provide instruction. Students met for case report or seminar discussion with the CNP once a week. Preceptors graded students' daily practice logs and assignments. At the end of the practicum, the intern nurses completed an anonymous, online survey to evaluate the course and the CNPs who worked with them. The program was also evaluated by alumni via an annual mailed survey. Feedback will be incorporated into the design and development of the program. Interviews of CNPs were conducted by the first author in a conference room of the preceptor's hospital of employment, during the day shift, and required 40–90 min to complete. The e-portfolios were available for every student and teaching faculty. The guided interviews included the following questions: 1) If you could use e-portfolio in your clinical teaching, what would be your functional requirements for this platform? 2) How do you expect the use of e-portfolio to impact your teaching method? 3) What issues concern you regarding the use of eportfolio? Ethical considerations The study received approval from the IRBs of the study hospitals. Interviews were recorded with participant consent. Anonymity of participants and the organization were guaranteed throughout the research process. Right of withdrawal from the study at any time during the interview was made known. Data analysis
Methods
Recorded interviews were transcribed verbatim and analyzed as proposed by Miles and Huberman (1994). Data saturation occurred on the tenth participant, nonetheless, the last two CNPs were interviewed to confirm that no new themes emerged. The qualitative data analysis was run using the Atlas.ti software (Muhr, 1991). Two research teammates performed data coding and data reduction by comparing and contrasting the interview content. Identified concepts or themes were arranged using tables or diagrams indicating patterns and relationships among the themes. Major concepts were labelled and themes were categorized to draw conclusions about the participants' descriptions.
Design
Rigor
This descriptive, qualitative research study employed semistructured one-on-one, in-depth interviews (Miles & Huberman, 1994). Purposive sampling was used to recruit participants. Interviews were conducted between November 2012 and March 2013.
Credibility, transferability, dependability, and confirmability were established to ensure trustworthiness of the qualitative data (Houghton, Casey, Shaw, & Murphy, 2013). The researcher's ability to capture the interviewees' reality refers to its credibility. Interviews
Please cite this article as: Chang, C.-P., et al., Clinical nurse preceptors' perception of e-portfolio use for undergraduate students, Journal of Professional Nursing (2016), http://dx.doi.org/10.1016/j.profnurs.2016.11.001
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were transcribed word for word and then confirmed by the participants to ensure accuracy of communicated intent. Transferability was enhanced by including numerous quotations from participants' verbal descriptions of their experience and their opinions during this study. To confirm dependability, two investigators separately reviewed the reflective thoughts of the participants recorded during the interview process. This data was used to examine the appropriateness of emergent themes and the logic of the explanations between the principle investigator and the second researcher. This was necessary to ensure and confirm the meaning and understanding of the study's phenomena. For conformability, data labels were continuously discussed with a doctorprepared nursing professor having a specialization in nursing informatics and proficiency in qualitative data analysis. Results This study identified four major themes for successful e-portfolio development: 1) utilizing students' learning experiences to design the CNP's teaching plan; 2) a group-based discussion platform as a communication channel is needed; 3) posting teaching content to facilitate student learning process; and 4) motivation usage factors in ease of use, sustaining use, and win (student) – win (preceptor) outcomes. Information about the four themes was collected from the interviews with the participants of this study, and are provided as follows. Theme 1: utilizing students' learning experiences to design the CNP's teaching plan The CNPs indicated that background information about the students provided by schools is insufficient. This information is necessary in order for the CNPs to provide adaptive teaching and to develop clinical learning goals according to the students' ability and needs. Presently, CNPs await the development of an e-portfolio platform designed to provide comprehensive student background data, such as work experience and prior internship performance. “For students with previous work experience, I need to know what it was and how long they worked, and which unit they worked in. Due to the huge differences that exist between the students, we need to know about them to plan their learning objectives accordingly.” The CNPs also indicated that most students do not inform them about their own competency unless the CNPs ask them. If the CNPs are aware of the students' experiences, especially clinical practice, certifications, or English proficiency test results, they could have an understanding of the students' abilities, and could adjust their teaching content and plan accordingly. “We need to know about the students' grades, what awards have been won and certificates acquired in clinical nursing abilities, and evidence-based nursing competitions (i.e., important nursing contests held in Taiwan every year). Tests, such as the English proficiency test, are also crucial which has an immense effect on their learning performance.” The CNPs believe that an internship at hospitals includes multiple types of stressors that might be mitigated by their use of adaptive strategies for students, if they were aware of student needs.
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performance, clinical practicum experiences and even learning styles or behaviors to assist in designing an effective approach to teaching. Theme 2: a group-based discussion platform as a communication channel is needed The CNPs maintained that interactive functions provided by online platforms are a suitable communication method for students. Responding to questions in a timely manner is a critical platform function. “We should have learning platforms that allow instant interactions. Students are more comfortable voicing their thoughts and opinions online than in face-to-face interactions. I experienced that students described internship problems with their peers at the end of the course; if they had told me earlier, I would have done something about it.” E-portfolio platforms allow students from different units to share their learning experiences during their internship. This exchange facilitates the interactive caring experiences (such as different nursing diagnoses or nursing interventions for adult patients or pediatric patients). “Students are assigned to different units and it is not easy for them to get together for case studies. The introduction of a learning platform solves this problem. Students or I may post a case scenario to encourage other students to share their points of view. Their participation and experience-sharing process are examples of active learning.” CNPs indicated that the learning platform must feature a work display area, particularly one that allows students to write down their personal experiences. Informative internship experiences could be shared or serve as excellent reference materials for both CNPs and students. “I believe when students post reviews of their personal internship experiences, these reviews allow other students to understand and acquire what their peers have learned, as well as how they reflect on such experiences. Of course, for these postings, patient privacy is the first concern as part of this learning process.” In the past, the instructor would book a conference room for group discussion on case studies, but now they can use the platform for online discussion. Patient privacy is maintained by de-identification of data in the case report, similar to its previous management in traditional paperbased case studies. Theme 3: posting teaching content to facilitate student learning process While the school of nursing has a general nursing skill list, patient care units also have their own skill requirements. The CNPs believed hospitals should take advantage of the e-portfolio use. For example, hospitals could post nursing task-related materials on the e-portfolio to enrich the teaching resources or multi-media videos for enhancement of students' care skills. “Videos covering topics such as infection control, hand-washing procedure, and quarantine measures can be posted on the platform prior to the students working as an intern at our hospital. Compared to paperbased teaching guidelines (or reading references), video-based teaching materials better demonstrate actual practice.”
“Students may have different coping behaviors that need extra assistance. When students experience learning difficulties, we need to know whether the stress is a result the students' particular learning style or whether the context in which teaching takes place is too difficult for students.”
CNPs suggested that the e-portfolio platform incorporate a function that shows the amount of time students spend on reviewing materials. Also, CNPs could post information required by the hospital department on the platform prior to the course's start date. It was felt that by preparing for the internship through the use of e-portfolio, students could reduce their stress level.
The above scenarios indicate that the CNPs preferred the e-portfolio provide information regarding students learning background, school
“I will post essential materials on the platform which will subsequently be taught. … By studying such information, students can develop basic
Please cite this article as: Chang, C.-P., et al., Clinical nurse preceptors' perception of e-portfolio use for undergraduate students, Journal of Professional Nursing (2016), http://dx.doi.org/10.1016/j.profnurs.2016.11.001
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knowledge about patient care and reduce their stress when the internship begins.” The CNPs also suggested that hospitals should provide their existing resources to students, such as instructional videos and practice test questions. Information, such as the amount of time taken to answer test questions, and the scores achieved must be available to both the CNPs and students. This information will serve to inform students of their progress, and identify areas in need of improvement. Rather than remediation, this is intended as an ongoing process to facilitate learning. “Instructors can post videos and write test items for pre-internship training. Scores are provided based on their answers, and students can search for correct answers from the teaching materials should they answer incorrectly. The platform should provide data on the frequency and the amount of time spent by the students on reviewing the content to show their progress.” The above examples showed that the e-portfolio could be used to post learning references in advance of students starting their internship in order to reduce learning stress, and promote instructor understanding of the students' learning progress for the internship program. Theme 4: motivation usage factors in ease of use, sustaining use, and win (student) – win (preceptor) outcomes CNPs state that ease of use of the computer program is the most important factor influencing the successful implementation of e-portfolios. There was concern that if instructors spent too much time learning the e-platforms, they would go back to using conventional, paper-based, teaching methods (e.g. asking students to hand in printed homework and to make an appointment for one-on-one discussion). “The e-portfolio has to feature a design that is easy to learn and use, otherwise, people will not use it. Clinical instructors have a heavy workload. If the e-portfolio takes too much time to learn, we will just resort back to the traditional paper teaching method.” The CNPs hope e-teaching platforms not only enable students to share information, but also will be used long-term to provide future learners an opportunity to watch, read and learn to improve the outcomes of learning. In addition, teaching materials can be evaluated, and used by the hospitals, creating a win-win situation. “When students complete their internship program, the platforms should be saved for preceptors as de-identified historical course content for future reference as teaching resources.” The CNPs were happy to see students engaging in this internship practicum course. They felt that this indicated the student's interest in continuing to work in the department post internship, and that students would experience a more rapid adaptation to the working environment resulting in benefits for both students and hospitals. “We will be willing to use e-portfolios if they can help us inspire students and increase the number of students who stay with us after completing their internship.” These illustrations demonstrated that if the use of e-portfolios proves helpful to the CNPs, it will reduce employment attrition rates in new graduates. The CNPs found that the e-portfolio could assist them in accessing students' learning background data, serve as a communication channel and facilitate students' learning processes if designed as a useful and easy to use technology. Discussion The application of knowledge and skills in the clinical practice arena is an area that has gained increasing importance in nursing education.
Innovative methods are employed to help students engage in active learning, self-reflection, in demonstrating professional skills, and in making a successful transition from school to the work setting. Eportfolios solve problems related to: data storage requirements; data management used in conventional teaching processes; and storage of student learning results. These results can subsequently be used to outline the future staff orientation needs and goals of individual students. In addition, e-portfolios enable instructors to provide timely individual responses and feedback to learners. In the present study, the CNPs used e-portfolios to learn about students' strengths and weaknesses in order to develop effective teaching goals that could allow students to successfully engage in clinical learning and promote a smoother transition from school to work. Research conducted in Canada by Garrett et al. (2013) argued that eportfolio learners are concerned about personal privacy and preceptor/ student trust-related issues. These learners felt their instructors should only focus on the current internship courses; similarly, the instructors hoped to evaluate new student interns based on their current clinical performance rather than historical grade records. The present study differs from that of Garrett et al. (2013). These differences may be attributed to the fact that the Last Mile practicum course is only six weeks long, and that longer term clinical performance effects could not be assessed from the interviews. CNPs do not have access to students' personal or medical information. In the future, preceptors will be asked to sign a confidentiality statement to ensure the privacy and security of student's information. Previous studies have shown that including instructors' feedback on learner performance in portfolios can improve student learning motivation due to instant and constructive feedbacks from instructors (Moores & Parks, 2010). Andrews and Cole (2015) found that immediate feedback increased the speed at which students completed their learning tasks. The CPNs indicated that clinical learning includes multiple types of stressors. The immediate feedback function of e-portfolio platforms facilitates the provision of timely advice that could prevent problems due to these learning stressors. E-portfolios used in medical education have been shown to be suitable for sharing teaching-related information among a small group of learners (Forte et al., 2013). The eplatform allows learners from different internship departments to discuss and share their thoughts and ideas online. Students can reference the contributions made by each other over the course of their internships. Outstanding internship work can be noted by the instructor and used as learning materials for reference by other students. The Internet remains a convenient tool, however, due to instructors' and learners' varied locations, not all students enrolled in the course may have the same access to the Internet. This means that the socio-economic background and geographic location of users must be considered when introducing e-portfolio platforms. Teaching institutions have found that immediate feedback and interactions improve student performance. Because of this, institutions must guarantee accessibility and provide discussion guidelines to this online resource to assure that it enriches the learning experience and ensures student and patient privacy (Bogossian & Kellett, 2010; Tsai et al., 2015). The ultimate goals of using e-portfolios are to: educate students; ensure the student's future employability; and aid in developing the student's sense of control at work (Tsai et al., 2015; Wassef et al., 2012). The CNPs hoped that e-portfolio platforms would feature the elearning function, as well as provide information pertaining to nursing skills used in hospitals. Such information would effectively reduce nursing students' sense of uncertainty about the work environment and would allow a smooth transition from the school environment to the clinical practice arena. This would serve to achieve the goals of preparing the intern nurse to successfully graduate and continue practice in the clinical setting. Although the standardization of methods used to assess the value of portfolios can only be deduced by performing multiple empirical studies (Chang & Wu, 2012; Garrett et al., 2013), CNPs proposed the use of the
Please cite this article as: Chang, C.-P., et al., Clinical nurse preceptors' perception of e-portfolio use for undergraduate students, Journal of Professional Nursing (2016), http://dx.doi.org/10.1016/j.profnurs.2016.11.001
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following methods to evaluate the effectiveness of internship: 1) collect objective data (i.e. number of times and the amount of time needed to study the designated materials); and 2) document the length of time required before students can correctly answer the required test questions as posed by the instructor. The results of this assessment can be provided to both the students and CNPs as a review of the students' learning progress. Students can also learn how to perform a self-evaluation of their knowledge and skills by using this assessment. Technology use is based on two factors: perceived ease of use and the perceived usefulness of the technology (Davis, 1993; Venkatesh & Davis, 2000). The CNPs agreed to use the new system because of its perceived ease of use. A study conducted in Australia demonstrated that the workload of preceptors and their level of technology literacy were factors that influenced the intention to use a system (Bogossian & Kellett, 2010). Therefore, during the early stage of e-portfolio implementation, the following factors must not be overlooked: education of the CNPs about e-portfolio use; avoidance of introducing too many functions to the CNPs; and, finally, using an incremental addition of system functions over time to meet the users' needs (Andrews & Cole, 2015; Bogossian & Kellett, 2010). CNPs indicated they would appreciate the technology more if the value of e-portfolios was recognized through their continued use by the schools and if they were retained for future use (with students' permission) by other students as teaching material and as support for hospital accreditation. The shortage of nursing manpower is a global problem. Researchers have found that university students believe that e-portfolios improve their potential for obtaining future employment (Tzeng & Chen, 2012). Similarly, in this study, CNPs indicated that the use of e-portfolios is a must, if such a teaching tool proves it value in preparing and retaining the number of graduate nurses vital to meeting the needs for quality patient care in clinical settings. Although the use of an e-portfolio teaching approach requires a large investment of CNPs' time and effort (Forte et al., 2013) if it can be shown to reduce the attrition rate of new graduates, nursing schools and hospitals will both experience beneficial outcomes. There are implications for nursing education as a result of this study. Since CNPs served as full time employees at the hospital as well as parttime faculty of the nursing school, there were many demands on their time. This made it especially important that the e-portfolio be designed as useful and easy to use. Transitioning from conventional paper systems to an e-portfolio is challenging. Understanding the CNPs' perception regarding e-portfolio use could enhance the relationship between the hospital and the nursing school to enrich the student internship experience. A further implication is the necessity of creating an ethical code document for students and clinical preceptors to ensure patient and student privacy and data confidentiality. Study limitations and suggestions The purpose of this study was to explore clinical nurse preceptors' perceptions of the use of e-portfolio. The individuals interviewed were all preceptors. Since e-portfolio is designed to be used by both instructors and students, the interpretation of study findings should be used with caution. For comparison and contrast purposes, it is suggested that future studies should include perspectives of nurse interns who had experience with the e-portfolio system. Conclusion Reducing the time required to interact with and counsel new clinical personnel to support their adaptation to the work environment is an important issue within the nursing industry. The use of e-portfolio education can combine knowledge, skills, and student achievements through an on-line assessment and teaching process designed to improve knowledge application by students in the clinical setting. Perceptions of e-portfolios by CNPs teaching the Last Mile (final semester)
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practicum course included the ability to access student data in order to understand the students' background and to facilitate the use of adaptive teaching. This requires that instructors maximize the use of the online platform, achieve immediate feedback to students; implement teaching strategies through knowledge sharing and interactions; and upload relevant teaching materials to the platform. This should take place before the beginning of the internship to allow students to prepare before arriving at their clinical site. If these factors are incorporated in the implementation of e-portfolio, it can be a valuable tool for CNPs and students to measure and demonstrate clinical skill competence. Funding This study was funded by a grant (NSC-101-2511-S227-007) to Ting-Ting Lee from National Science Council. Conflict of interest The authors declare that they have no conflict of interest. References Andrews, T., & Cole, C. (2015). Two steps forward, one step back: The intricacies of engaging with e-portfolios in nursing undergraduate education. Nurse Education Today, 35(4), 568–572. http://dx.doi.org/10.1016/j.nedt.2014.12.011. Balaban, I., Mu, E., & Divjak, B. (2013). Development of an electronic portfolio system success model: An information systems approach. Computers & Education, 60(1), 396–411. http://dx.doi.org/10.1016/j.compedu.2012.06.013. Bogossian, F. E., & Kellett, S. E. (2010). Barriers to electronic portfolio access in the clinical setting. Nurse Education Today, 30(8), 768–772. http://dx.doi.org/10.1016/j.nedt. 2010.02.003. Chang, C. C., & Wu, B. H. (2012). Is teacher assessment reliable or valid for high school students under a web-based portfolio environment? Journal of Educational Technology & Society, 15(4), 265–278. http://dx.doi.org/10.1007/BF00148970. Cheng, C. Y., Liou, S. R., Tsai, H. M., & Chang, C. H. (2014). Job stress and job satisfaction among new graduate nurses during the first year of employment in Taiwan. International Journal of Nursing Practice, 21(4), 410–418. http://dx.doi.org/10.1111/ ijn.12281. Davis, F. D. (1993). User acceptance of information technology: System characteristics, user perception and behavioral impact. Journal of Man-Machine Studies, 38(3), 475–487. http://dx.doi.org/10.1006/imms.1993.1022. Dow, W. J., Lee, T. Y., Chang, L. H., & Wang, K. -Y. (2013). A novel thought on the clinical nursing care model [Abstract]. Leadership Nursing, 14(3), 2–16 (in Chinese with English abstract). Ehiyazaryan-White, E. (2012). The dialogic potential of e Portfolios: Formative feedback and communities of learning within a personal learning environment. International Journal of e Portfolio, 2(2), 173–185. http://dx.doi.org/10.4135/9781452219493.n6. Forte, M., de Souza, W. L., da Silva, R. F., do Prado, A. F., & Rodrigues, J. F. (2013). A ubiquitous reflective e-portfolio architecture. International Journal of Medical Informatics, 82(11), 1111–1122. http://dx.doi.org/10.1016/j.ijmedinf.2013.06.005. Garrett, B. M., MacPhee, M., & Jackson, C. (2013). Evaluation of an eportfolio for the assessment of clinical competence in a baccalaureate nursing program. Nurse Education Today, 33(10), 1207–1213. http://dx.doi.org/10.1016/j.nedt.2012.06.015. Green, J., Wyllie, A., & Jackson, D. (2014). Electronic portfolios in nursing education: A review of the literature. Nurse Education in Practice, 14(1), 4–8. http://dx.doi.org/10. 1016/j.nepr.2013.08.011. Haverkamp, J. J., & Vogt, M. (2015). Beyond academic evidence: Innovative uses of technology within e-portfolios in a doctor of nursing practice program. Journal of Professional Nursing, 31(4), 284–289. http://dx.doi.org/10.1016/j.profnurs.2015.03. 007. Houghton, C., Casey, D., Shaw, D., & Murphy, K. (2013). Rigour in qualitative case-study research. Nurse Researcher, 20(4), 12–17. http://dx.doi.org/10.7748/nr2013.03.20.4. 12.e326. Hsieh, T. C., Chen, S. L., & Hung, M. C. (2014). Longitudinal test of e-Portfolio continuous use: An empirical study on the change of students' beliefs. Behaviour & Information Technology, 34(8), 1–16. http://dx.doi.org/10.1080/0144929X.2014.907344. Miles, M., & Huberman, A. (1994). Qualitative data analysis: An expanded sourcebook, 2nd ed. SAGE: Thousand Oaks, CA. Missen, K., McKenna, L., & Beauchamp, A. (2014). Satisfaction of newly graduated nurses enrolled in transition-to-practice programs in their first year of employment: A systematic review. Journal of Advanced Nursing, 70(11), 2419–2433. http://dx.doi.org/ 10.1111/jan.12464. Moores, A., & Parks, M. (2010). Twelve tips for introducing E-Portfolios with undergraduate students. Medical Teacher, 32(1), 46–49. http://dx.doi.org/10.3109/ 01421590903434151. Muhr, T. (1991). ATLAS/tiXA prototype for the support of text interpretation. Qualitative Sociology, 14(4), 349–371. http://dx.doi.org/10.3109/01421590903434151.
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Please cite this article as: Chang, C.-P., et al., Clinical nurse preceptors' perception of e-portfolio use for undergraduate students, Journal of Professional Nursing (2016), http://dx.doi.org/10.1016/j.profnurs.2016.11.001
Contents lists available at ScienceDirect
Journal of Professional Nursing
Clinical nurse preceptors' perception of e-portfolio use for undergraduate students Chi-Ping Chang a, Ting-Ting Lee b,⁎, Mary Etta Mills c a b c
Department of Nursing, Tzu Chi University of Science and Technology, 880, Sec 2, Chien-kuo Rd, Hualien 970, Taiwan School of Nursing, College of Nursing, National Taipei University of Nursing & Health Sciences, 365 Ming-Te Road, Taipei 11219, Taiwan School of Nursing, University of Maryland, 655 West Lombard Street, Baltimore, MD 21201, USA
a r t i c l e
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Available online xxxx Keywords: Clinical nurse preceptors E-portfolios Internship Last Mile practicum
a b s t r a c t Nursing schools and hospitals form partnerships to foster nursing education. Clinical nurse preceptors (CNPs) have a profound influence on nursing students' Last Mile practicum. Assisting preceptors to prepare students as future staff nurses has become a critical issue. E-portfolios utilize digital access and hyperlinks to integrate student knowledge, skills, and achievements with teaching assessment, process and evaluation. Based on the school–hospital partnership, preceptors require a teaching application to facilitate student learning. This descriptive qualitative study explored preceptors' perceptions regarding the use of e-portfolios. Data were collected from November 2012 to March 2013. One-on-one in-depth interviews with preceptors from different hospitals in Taiwan were examined using content analysis. Four key themes were revealed: utilizing students' learning experiences to design the CNP's teaching plan; a group-based discussion platform as a communication channel is needed; posting teaching content to facilitate student learning process; and, motivation usage factors in ease of use, sustaining use and win (student) – win (preceptor) outcomes. The use of e-portfolios allows preceptors to prepare for the learning needs of students. By considering preceptors' preferences, the design of e-portfolios may become more user friendly and useful for preceptors to expedite their teaching process and enhance student learning experiences. © 2016 Elsevier Inc. All rights reserved.
Introduction For nursing school graduates, the transition from school to clinical work presents many challenges and setbacks. Identifying methods to prepare nursing students for clinical practice and to ensure their performance has been an issue of concern in nursing education literature (Takase, Nakayoshi, & Teraoka, 2012; Takase, Teraoka, & Kousuke, 2015). The Last Mile practicum course (i.e. final semester internship program) was one of the required courses designed to improve baccalaureate students' clinical competence. This last semester course includes cooperative education and internship programs offered through school and hospital partnerships whereby students can have their clinical education and continue to work for the same hospital upon graduation. In this partnership, masters' prepared nurse staff are invited to serve as clinical nurse preceptors (CNPs) to provide clinical instruction to help students adapt to the hospital environment and develop required clinical practice skills. Since research has shown that attrition of new graduates in the first year of practice may reach up to 58% (Cheng, Liou, Tsai, & Chang, 2014; Dow, Lee, Chang, & Wang, 2013; ⁎ Corresponding author. E-mail address: [email protected] (T.-T. Lee).
Missen, McKenna, & Beauchamp, 2014), the practicum course is intended to increase student preparation for entry into practice and reduce reality shock. It is anticipated that students gaining clinical competence and confidence through their practicum will stay employed in the clinical setting after graduation and reduce future nursing shortages. Over the last decade, a significant change has occurred in nurse education. The focus of curricula has shifted from the acquisition of knowledge to the achievement of clinical competence by applying evidence based knowledge to patient care (Garrett, MacPhee, & Jackson, 2013; Wassef, Riza, Maciag, Worden, & Delaney, 2012). Portfolios are considered a student-oriented learning method that supports this effort. By combining students' knowledge, skills, and previous achievements, instructors can better design teaching programs or develop strategies to enhance student learning experiences. The digitization of the portfolio (e-portfolio) not only creates an electronic version of the paper-based teaching and course portfolio but is designed to record the learning progress of students systematically, and link to their career choice and future professional development (Green, Wyllie, & Jackson, 2014). Although research has focused on students' use of e-portfolio for their learning, instructors' perception of e-portfolio use in the nursing practicum course has seldom been studied and needs further exploration. As a result, the purpose of this qualitative study was to explore the clinical
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Please cite this article as: Chang, C.-P., et al., Clinical nurse preceptors' perception of e-portfolio use for undergraduate students, Journal of Professional Nursing (2016), http://dx.doi.org/10.1016/j.profnurs.2016.11.001
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nurse preceptors' perceptions of e-portfolio use as a means of facilitating their teaching experience in an internship practicum.
Literature review E-portfolio Electronic portfolio (e-portfolio) is a web-based application which contains the course records of students and instructors. Instructors can place their teaching content on this platform for students to download, and students can upload their completed tasks such as homework, assignments and reflective journeys for instructors to comment on or grade. Student achievements such as completed projects, photos/pictures, reflective thoughts/journeys or awards can be kept in the eportfolio for future use in continued professional development (Moores & Parks, 2010). This system is superior to conventional paper based portfolios, where data access is often difficult due to the large amount of paper documents involved (Tsai, Lee, Lin, Lee, & Mills, 2015). Students and instructors, via instant messages, are able to engage in discussions and knowledge-sharing that enhances their motivation to use the platform. By using e-portfolios, instructors can encourage learners to actively develop their own learning plans and to organize their personal experience and achievements. By more comprehensively collecting what students have learned throughout their education, the e-portfolio can support students in feeling a sense of accomplishment (Ehiyazaryan-White, 2012; Pink, Cadbury, & Stanton, 2008). Although e-portfolios gained wider use in medical and nursing education (Forte, de Souza, da Silva, do Prado, & Rodrigues, 2013; Green et al., 2014; Haverkamp & Vogt, 2015; Hsieh, Chen, & Hung, 2014), the perspectives of instructors using this teaching tool deserves further attention.
Technology acceptance model (TAM) Since preceptor technology acceptance is a crucial factor in the determination of successful implementation of e-portfolios instructors need to recognize their value and usefulness (Bogossian & Kellett, 2010). When preceptors use this teaching platform there can be a significant enhancement of teaching and effectiveness of learning (Andrews & Cole, 2015; Balaban, Mu, & Divjak, 2013; Moores & Parks, 2010). Technology acceptance remains a key factor in determining the success or failure of this system. The technology acceptance model (TAM) provides a theory base for the technology adoption process. It posits that if a person perceives technology as useful or easy to use, then he/she will form a positive attitude toward it, develop an intention to use it, and lead to actual use (Davis, 1993). In order to improve instructor acceptance of e-portfolios and their intention to use them, a school-hospital partnership was proposed. The desired e-portfolio function was explored with the CNP and it was decided that e-portfolios could enhance student care competence in the clinical practice arena. The present study was conducted to explore the CNPs' perceptions toward the use of eportfolios. The research question was stated as the following: What are CNPs' perceptions of e-portfolios as a teaching tool for nursing students during the internship (Last Mile) practicum?
Study setting and participants The Last Mile practicum is a required course in the undergraduate program. It is designed to be taken in the last semester so students can continue to work in the same unit whey they complete the internship. The Last Mile practicum course extended over a 6-week period and included 37.5 practicum hours per week for a total of 225 practicum hours over the semester. Twelve nurse supervisors served as preceptors from four hospitals. The school of nursing recruited preceptors as parttime faculty to teach this course. Preceptors were from the same hospital where the practicum took place. In order to qualify as a CNP, nurses must be master-prepared in nursing and be full-time supervisors or managers at the practicum site. After obtaining the IRB (Institutional Review Board) approval, the first author called each of the 12 CNPs (total group) to ask their permission to conduct a study interview with them. These subjects were recruited due to their part-time teaching faculty status in this internship program. The participants were all females, between the ages of 28 and 55 years old, and all held nursing master's degrees. Each preceptor supervised 10 intern nurses on one of 5 patient care units (2 in each). Intern nurses were under the direct supervision of seasoned nurses in the practicum units, and the preceptor visited each unit daily to provide instruction. Students met for case report or seminar discussion with the CNP once a week. Preceptors graded students' daily practice logs and assignments. At the end of the practicum, the intern nurses completed an anonymous, online survey to evaluate the course and the CNPs who worked with them. The program was also evaluated by alumni via an annual mailed survey. Feedback will be incorporated into the design and development of the program. Interviews of CNPs were conducted by the first author in a conference room of the preceptor's hospital of employment, during the day shift, and required 40–90 min to complete. The e-portfolios were available for every student and teaching faculty. The guided interviews included the following questions: 1) If you could use e-portfolio in your clinical teaching, what would be your functional requirements for this platform? 2) How do you expect the use of e-portfolio to impact your teaching method? 3) What issues concern you regarding the use of eportfolio? Ethical considerations The study received approval from the IRBs of the study hospitals. Interviews were recorded with participant consent. Anonymity of participants and the organization were guaranteed throughout the research process. Right of withdrawal from the study at any time during the interview was made known. Data analysis
Methods
Recorded interviews were transcribed verbatim and analyzed as proposed by Miles and Huberman (1994). Data saturation occurred on the tenth participant, nonetheless, the last two CNPs were interviewed to confirm that no new themes emerged. The qualitative data analysis was run using the Atlas.ti software (Muhr, 1991). Two research teammates performed data coding and data reduction by comparing and contrasting the interview content. Identified concepts or themes were arranged using tables or diagrams indicating patterns and relationships among the themes. Major concepts were labelled and themes were categorized to draw conclusions about the participants' descriptions.
Design
Rigor
This descriptive, qualitative research study employed semistructured one-on-one, in-depth interviews (Miles & Huberman, 1994). Purposive sampling was used to recruit participants. Interviews were conducted between November 2012 and March 2013.
Credibility, transferability, dependability, and confirmability were established to ensure trustworthiness of the qualitative data (Houghton, Casey, Shaw, & Murphy, 2013). The researcher's ability to capture the interviewees' reality refers to its credibility. Interviews
Please cite this article as: Chang, C.-P., et al., Clinical nurse preceptors' perception of e-portfolio use for undergraduate students, Journal of Professional Nursing (2016), http://dx.doi.org/10.1016/j.profnurs.2016.11.001
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were transcribed word for word and then confirmed by the participants to ensure accuracy of communicated intent. Transferability was enhanced by including numerous quotations from participants' verbal descriptions of their experience and their opinions during this study. To confirm dependability, two investigators separately reviewed the reflective thoughts of the participants recorded during the interview process. This data was used to examine the appropriateness of emergent themes and the logic of the explanations between the principle investigator and the second researcher. This was necessary to ensure and confirm the meaning and understanding of the study's phenomena. For conformability, data labels were continuously discussed with a doctorprepared nursing professor having a specialization in nursing informatics and proficiency in qualitative data analysis. Results This study identified four major themes for successful e-portfolio development: 1) utilizing students' learning experiences to design the CNP's teaching plan; 2) a group-based discussion platform as a communication channel is needed; 3) posting teaching content to facilitate student learning process; and 4) motivation usage factors in ease of use, sustaining use, and win (student) – win (preceptor) outcomes. Information about the four themes was collected from the interviews with the participants of this study, and are provided as follows. Theme 1: utilizing students' learning experiences to design the CNP's teaching plan The CNPs indicated that background information about the students provided by schools is insufficient. This information is necessary in order for the CNPs to provide adaptive teaching and to develop clinical learning goals according to the students' ability and needs. Presently, CNPs await the development of an e-portfolio platform designed to provide comprehensive student background data, such as work experience and prior internship performance. “For students with previous work experience, I need to know what it was and how long they worked, and which unit they worked in. Due to the huge differences that exist between the students, we need to know about them to plan their learning objectives accordingly.” The CNPs also indicated that most students do not inform them about their own competency unless the CNPs ask them. If the CNPs are aware of the students' experiences, especially clinical practice, certifications, or English proficiency test results, they could have an understanding of the students' abilities, and could adjust their teaching content and plan accordingly. “We need to know about the students' grades, what awards have been won and certificates acquired in clinical nursing abilities, and evidence-based nursing competitions (i.e., important nursing contests held in Taiwan every year). Tests, such as the English proficiency test, are also crucial which has an immense effect on their learning performance.” The CNPs believe that an internship at hospitals includes multiple types of stressors that might be mitigated by their use of adaptive strategies for students, if they were aware of student needs.
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performance, clinical practicum experiences and even learning styles or behaviors to assist in designing an effective approach to teaching. Theme 2: a group-based discussion platform as a communication channel is needed The CNPs maintained that interactive functions provided by online platforms are a suitable communication method for students. Responding to questions in a timely manner is a critical platform function. “We should have learning platforms that allow instant interactions. Students are more comfortable voicing their thoughts and opinions online than in face-to-face interactions. I experienced that students described internship problems with their peers at the end of the course; if they had told me earlier, I would have done something about it.” E-portfolio platforms allow students from different units to share their learning experiences during their internship. This exchange facilitates the interactive caring experiences (such as different nursing diagnoses or nursing interventions for adult patients or pediatric patients). “Students are assigned to different units and it is not easy for them to get together for case studies. The introduction of a learning platform solves this problem. Students or I may post a case scenario to encourage other students to share their points of view. Their participation and experience-sharing process are examples of active learning.” CNPs indicated that the learning platform must feature a work display area, particularly one that allows students to write down their personal experiences. Informative internship experiences could be shared or serve as excellent reference materials for both CNPs and students. “I believe when students post reviews of their personal internship experiences, these reviews allow other students to understand and acquire what their peers have learned, as well as how they reflect on such experiences. Of course, for these postings, patient privacy is the first concern as part of this learning process.” In the past, the instructor would book a conference room for group discussion on case studies, but now they can use the platform for online discussion. Patient privacy is maintained by de-identification of data in the case report, similar to its previous management in traditional paperbased case studies. Theme 3: posting teaching content to facilitate student learning process While the school of nursing has a general nursing skill list, patient care units also have their own skill requirements. The CNPs believed hospitals should take advantage of the e-portfolio use. For example, hospitals could post nursing task-related materials on the e-portfolio to enrich the teaching resources or multi-media videos for enhancement of students' care skills. “Videos covering topics such as infection control, hand-washing procedure, and quarantine measures can be posted on the platform prior to the students working as an intern at our hospital. Compared to paperbased teaching guidelines (or reading references), video-based teaching materials better demonstrate actual practice.”
“Students may have different coping behaviors that need extra assistance. When students experience learning difficulties, we need to know whether the stress is a result the students' particular learning style or whether the context in which teaching takes place is too difficult for students.”
CNPs suggested that the e-portfolio platform incorporate a function that shows the amount of time students spend on reviewing materials. Also, CNPs could post information required by the hospital department on the platform prior to the course's start date. It was felt that by preparing for the internship through the use of e-portfolio, students could reduce their stress level.
The above scenarios indicate that the CNPs preferred the e-portfolio provide information regarding students learning background, school
“I will post essential materials on the platform which will subsequently be taught. … By studying such information, students can develop basic
Please cite this article as: Chang, C.-P., et al., Clinical nurse preceptors' perception of e-portfolio use for undergraduate students, Journal of Professional Nursing (2016), http://dx.doi.org/10.1016/j.profnurs.2016.11.001
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knowledge about patient care and reduce their stress when the internship begins.” The CNPs also suggested that hospitals should provide their existing resources to students, such as instructional videos and practice test questions. Information, such as the amount of time taken to answer test questions, and the scores achieved must be available to both the CNPs and students. This information will serve to inform students of their progress, and identify areas in need of improvement. Rather than remediation, this is intended as an ongoing process to facilitate learning. “Instructors can post videos and write test items for pre-internship training. Scores are provided based on their answers, and students can search for correct answers from the teaching materials should they answer incorrectly. The platform should provide data on the frequency and the amount of time spent by the students on reviewing the content to show their progress.” The above examples showed that the e-portfolio could be used to post learning references in advance of students starting their internship in order to reduce learning stress, and promote instructor understanding of the students' learning progress for the internship program. Theme 4: motivation usage factors in ease of use, sustaining use, and win (student) – win (preceptor) outcomes CNPs state that ease of use of the computer program is the most important factor influencing the successful implementation of e-portfolios. There was concern that if instructors spent too much time learning the e-platforms, they would go back to using conventional, paper-based, teaching methods (e.g. asking students to hand in printed homework and to make an appointment for one-on-one discussion). “The e-portfolio has to feature a design that is easy to learn and use, otherwise, people will not use it. Clinical instructors have a heavy workload. If the e-portfolio takes too much time to learn, we will just resort back to the traditional paper teaching method.” The CNPs hope e-teaching platforms not only enable students to share information, but also will be used long-term to provide future learners an opportunity to watch, read and learn to improve the outcomes of learning. In addition, teaching materials can be evaluated, and used by the hospitals, creating a win-win situation. “When students complete their internship program, the platforms should be saved for preceptors as de-identified historical course content for future reference as teaching resources.” The CNPs were happy to see students engaging in this internship practicum course. They felt that this indicated the student's interest in continuing to work in the department post internship, and that students would experience a more rapid adaptation to the working environment resulting in benefits for both students and hospitals. “We will be willing to use e-portfolios if they can help us inspire students and increase the number of students who stay with us after completing their internship.” These illustrations demonstrated that if the use of e-portfolios proves helpful to the CNPs, it will reduce employment attrition rates in new graduates. The CNPs found that the e-portfolio could assist them in accessing students' learning background data, serve as a communication channel and facilitate students' learning processes if designed as a useful and easy to use technology. Discussion The application of knowledge and skills in the clinical practice arena is an area that has gained increasing importance in nursing education.
Innovative methods are employed to help students engage in active learning, self-reflection, in demonstrating professional skills, and in making a successful transition from school to the work setting. Eportfolios solve problems related to: data storage requirements; data management used in conventional teaching processes; and storage of student learning results. These results can subsequently be used to outline the future staff orientation needs and goals of individual students. In addition, e-portfolios enable instructors to provide timely individual responses and feedback to learners. In the present study, the CNPs used e-portfolios to learn about students' strengths and weaknesses in order to develop effective teaching goals that could allow students to successfully engage in clinical learning and promote a smoother transition from school to work. Research conducted in Canada by Garrett et al. (2013) argued that eportfolio learners are concerned about personal privacy and preceptor/ student trust-related issues. These learners felt their instructors should only focus on the current internship courses; similarly, the instructors hoped to evaluate new student interns based on their current clinical performance rather than historical grade records. The present study differs from that of Garrett et al. (2013). These differences may be attributed to the fact that the Last Mile practicum course is only six weeks long, and that longer term clinical performance effects could not be assessed from the interviews. CNPs do not have access to students' personal or medical information. In the future, preceptors will be asked to sign a confidentiality statement to ensure the privacy and security of student's information. Previous studies have shown that including instructors' feedback on learner performance in portfolios can improve student learning motivation due to instant and constructive feedbacks from instructors (Moores & Parks, 2010). Andrews and Cole (2015) found that immediate feedback increased the speed at which students completed their learning tasks. The CPNs indicated that clinical learning includes multiple types of stressors. The immediate feedback function of e-portfolio platforms facilitates the provision of timely advice that could prevent problems due to these learning stressors. E-portfolios used in medical education have been shown to be suitable for sharing teaching-related information among a small group of learners (Forte et al., 2013). The eplatform allows learners from different internship departments to discuss and share their thoughts and ideas online. Students can reference the contributions made by each other over the course of their internships. Outstanding internship work can be noted by the instructor and used as learning materials for reference by other students. The Internet remains a convenient tool, however, due to instructors' and learners' varied locations, not all students enrolled in the course may have the same access to the Internet. This means that the socio-economic background and geographic location of users must be considered when introducing e-portfolio platforms. Teaching institutions have found that immediate feedback and interactions improve student performance. Because of this, institutions must guarantee accessibility and provide discussion guidelines to this online resource to assure that it enriches the learning experience and ensures student and patient privacy (Bogossian & Kellett, 2010; Tsai et al., 2015). The ultimate goals of using e-portfolios are to: educate students; ensure the student's future employability; and aid in developing the student's sense of control at work (Tsai et al., 2015; Wassef et al., 2012). The CNPs hoped that e-portfolio platforms would feature the elearning function, as well as provide information pertaining to nursing skills used in hospitals. Such information would effectively reduce nursing students' sense of uncertainty about the work environment and would allow a smooth transition from the school environment to the clinical practice arena. This would serve to achieve the goals of preparing the intern nurse to successfully graduate and continue practice in the clinical setting. Although the standardization of methods used to assess the value of portfolios can only be deduced by performing multiple empirical studies (Chang & Wu, 2012; Garrett et al., 2013), CNPs proposed the use of the
Please cite this article as: Chang, C.-P., et al., Clinical nurse preceptors' perception of e-portfolio use for undergraduate students, Journal of Professional Nursing (2016), http://dx.doi.org/10.1016/j.profnurs.2016.11.001
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following methods to evaluate the effectiveness of internship: 1) collect objective data (i.e. number of times and the amount of time needed to study the designated materials); and 2) document the length of time required before students can correctly answer the required test questions as posed by the instructor. The results of this assessment can be provided to both the students and CNPs as a review of the students' learning progress. Students can also learn how to perform a self-evaluation of their knowledge and skills by using this assessment. Technology use is based on two factors: perceived ease of use and the perceived usefulness of the technology (Davis, 1993; Venkatesh & Davis, 2000). The CNPs agreed to use the new system because of its perceived ease of use. A study conducted in Australia demonstrated that the workload of preceptors and their level of technology literacy were factors that influenced the intention to use a system (Bogossian & Kellett, 2010). Therefore, during the early stage of e-portfolio implementation, the following factors must not be overlooked: education of the CNPs about e-portfolio use; avoidance of introducing too many functions to the CNPs; and, finally, using an incremental addition of system functions over time to meet the users' needs (Andrews & Cole, 2015; Bogossian & Kellett, 2010). CNPs indicated they would appreciate the technology more if the value of e-portfolios was recognized through their continued use by the schools and if they were retained for future use (with students' permission) by other students as teaching material and as support for hospital accreditation. The shortage of nursing manpower is a global problem. Researchers have found that university students believe that e-portfolios improve their potential for obtaining future employment (Tzeng & Chen, 2012). Similarly, in this study, CNPs indicated that the use of e-portfolios is a must, if such a teaching tool proves it value in preparing and retaining the number of graduate nurses vital to meeting the needs for quality patient care in clinical settings. Although the use of an e-portfolio teaching approach requires a large investment of CNPs' time and effort (Forte et al., 2013) if it can be shown to reduce the attrition rate of new graduates, nursing schools and hospitals will both experience beneficial outcomes. There are implications for nursing education as a result of this study. Since CNPs served as full time employees at the hospital as well as parttime faculty of the nursing school, there were many demands on their time. This made it especially important that the e-portfolio be designed as useful and easy to use. Transitioning from conventional paper systems to an e-portfolio is challenging. Understanding the CNPs' perception regarding e-portfolio use could enhance the relationship between the hospital and the nursing school to enrich the student internship experience. A further implication is the necessity of creating an ethical code document for students and clinical preceptors to ensure patient and student privacy and data confidentiality. Study limitations and suggestions The purpose of this study was to explore clinical nurse preceptors' perceptions of the use of e-portfolio. The individuals interviewed were all preceptors. Since e-portfolio is designed to be used by both instructors and students, the interpretation of study findings should be used with caution. For comparison and contrast purposes, it is suggested that future studies should include perspectives of nurse interns who had experience with the e-portfolio system. Conclusion Reducing the time required to interact with and counsel new clinical personnel to support their adaptation to the work environment is an important issue within the nursing industry. The use of e-portfolio education can combine knowledge, skills, and student achievements through an on-line assessment and teaching process designed to improve knowledge application by students in the clinical setting. Perceptions of e-portfolios by CNPs teaching the Last Mile (final semester)
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practicum course included the ability to access student data in order to understand the students' background and to facilitate the use of adaptive teaching. This requires that instructors maximize the use of the online platform, achieve immediate feedback to students; implement teaching strategies through knowledge sharing and interactions; and upload relevant teaching materials to the platform. This should take place before the beginning of the internship to allow students to prepare before arriving at their clinical site. If these factors are incorporated in the implementation of e-portfolio, it can be a valuable tool for CNPs and students to measure and demonstrate clinical skill competence. Funding This study was funded by a grant (NSC-101-2511-S227-007) to Ting-Ting Lee from National Science Council. Conflict of interest The authors declare that they have no conflict of interest. References Andrews, T., & Cole, C. (2015). Two steps forward, one step back: The intricacies of engaging with e-portfolios in nursing undergraduate education. Nurse Education Today, 35(4), 568–572. http://dx.doi.org/10.1016/j.nedt.2014.12.011. Balaban, I., Mu, E., & Divjak, B. (2013). Development of an electronic portfolio system success model: An information systems approach. Computers & Education, 60(1), 396–411. http://dx.doi.org/10.1016/j.compedu.2012.06.013. Bogossian, F. E., & Kellett, S. E. (2010). Barriers to electronic portfolio access in the clinical setting. Nurse Education Today, 30(8), 768–772. http://dx.doi.org/10.1016/j.nedt. 2010.02.003. Chang, C. C., & Wu, B. H. (2012). Is teacher assessment reliable or valid for high school students under a web-based portfolio environment? Journal of Educational Technology & Society, 15(4), 265–278. http://dx.doi.org/10.1007/BF00148970. Cheng, C. Y., Liou, S. R., Tsai, H. M., & Chang, C. H. (2014). Job stress and job satisfaction among new graduate nurses during the first year of employment in Taiwan. International Journal of Nursing Practice, 21(4), 410–418. http://dx.doi.org/10.1111/ ijn.12281. Davis, F. D. (1993). User acceptance of information technology: System characteristics, user perception and behavioral impact. Journal of Man-Machine Studies, 38(3), 475–487. http://dx.doi.org/10.1006/imms.1993.1022. Dow, W. J., Lee, T. Y., Chang, L. H., & Wang, K. -Y. (2013). A novel thought on the clinical nursing care model [Abstract]. Leadership Nursing, 14(3), 2–16 (in Chinese with English abstract). Ehiyazaryan-White, E. (2012). The dialogic potential of e Portfolios: Formative feedback and communities of learning within a personal learning environment. International Journal of e Portfolio, 2(2), 173–185. http://dx.doi.org/10.4135/9781452219493.n6. Forte, M., de Souza, W. L., da Silva, R. F., do Prado, A. F., & Rodrigues, J. F. (2013). A ubiquitous reflective e-portfolio architecture. International Journal of Medical Informatics, 82(11), 1111–1122. http://dx.doi.org/10.1016/j.ijmedinf.2013.06.005. Garrett, B. M., MacPhee, M., & Jackson, C. (2013). Evaluation of an eportfolio for the assessment of clinical competence in a baccalaureate nursing program. Nurse Education Today, 33(10), 1207–1213. http://dx.doi.org/10.1016/j.nedt.2012.06.015. Green, J., Wyllie, A., & Jackson, D. (2014). Electronic portfolios in nursing education: A review of the literature. Nurse Education in Practice, 14(1), 4–8. http://dx.doi.org/10. 1016/j.nepr.2013.08.011. Haverkamp, J. J., & Vogt, M. (2015). Beyond academic evidence: Innovative uses of technology within e-portfolios in a doctor of nursing practice program. Journal of Professional Nursing, 31(4), 284–289. http://dx.doi.org/10.1016/j.profnurs.2015.03. 007. Houghton, C., Casey, D., Shaw, D., & Murphy, K. (2013). Rigour in qualitative case-study research. Nurse Researcher, 20(4), 12–17. http://dx.doi.org/10.7748/nr2013.03.20.4. 12.e326. Hsieh, T. C., Chen, S. L., & Hung, M. C. (2014). Longitudinal test of e-Portfolio continuous use: An empirical study on the change of students' beliefs. Behaviour & Information Technology, 34(8), 1–16. http://dx.doi.org/10.1080/0144929X.2014.907344. Miles, M., & Huberman, A. (1994). Qualitative data analysis: An expanded sourcebook, 2nd ed. SAGE: Thousand Oaks, CA. Missen, K., McKenna, L., & Beauchamp, A. (2014). Satisfaction of newly graduated nurses enrolled in transition-to-practice programs in their first year of employment: A systematic review. Journal of Advanced Nursing, 70(11), 2419–2433. http://dx.doi.org/ 10.1111/jan.12464. Moores, A., & Parks, M. (2010). Twelve tips for introducing E-Portfolios with undergraduate students. Medical Teacher, 32(1), 46–49. http://dx.doi.org/10.3109/ 01421590903434151. Muhr, T. (1991). ATLAS/tiXA prototype for the support of text interpretation. Qualitative Sociology, 14(4), 349–371. http://dx.doi.org/10.3109/01421590903434151.
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Please cite this article as: Chang, C.-P., et al., Clinical nurse preceptors' perception of e-portfolio use for undergraduate students, Journal of Professional Nursing (2016), http://dx.doi.org/10.1016/j.profnurs.2016.11.001