CIN: Computers, Informatics, Nursing

& Vol. 33, No. 1, 21–27 & Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.

F E A T U R E A R T I C L E

Nurses’ Perceptions of e-Portfolio Use for On-the-Job Training in Taiwan PEI-RONG TSAI, MS, RN TING-TING LEE, PhD, RN HUNG-RU LIN, PhD, RN JANE LEE-HSIEH, MS, RN MARY ETTA MILLS, ScD, RN

Electronic portfolios (e-portfolios) are information system aids for teaching and learning. They can aid the student in self-learning and provide instructors with a reference for planning teaching content. The interaction between teachers and learners elicited through the information platform can assist the student to obtain designated skills that can be applied to future jobs. Because patient care is the primary focus of nursing, participation in continuing education and earning in-service education credits designed to increase care quality is part of the nurses’ job description. An e-portfolio is a learning tool and an electronic data system that can support continuous and repeated evaluation of the learning process. However, in order to facilitate the use of the technology for practice, studies have shown that an information system for nurses must satisfy their needs when providing clinical care to patients, for example, ease of use and adaptable to the clinical workflow process.1,2 To support new graduates in developing the knowledge and skills required for clinical practice, postgraduate training/ education programs have been designed with certain credits or hours to strengthen professional competencies.3 In Taiwan, the so-called ‘‘2-year postgraduate training program for nurses’’ (nursing postgraduate year [NPGY]) was applied to nurses who had just graduated from school. They can join this 2-year program to work with their preceptors and managers on strengthening professional competencies. The course content includes the following: basic

Electronic portfolios can be used to record user performance and achievements. Currently, clinical learning systems and in-service education systems lack integration of nurses’ clinical performance records with their education or training outcomes. For nurses with less than 2 years’ work experience (nursing postgraduate year), use of an electronic portfolio is essential. This study aimed to assess the requirements of using electronic portfolios in continuing nursing education for clinical practices. Fifteen nurses were recruited using a qualitative purposive sampling approach between April 2013 and May 2013. After obtaining participants’ consent, data were collected in a conference room of the study hospital by one-on-one semistructured in-depth interviews. Through data analyses, the following five main themes related to electronic learning portfolios were identified: instant access to in-service education information, computerized nursing postgraduate year training manual, diversity of system functions and interface designs, need for sufficient computers, and protection of personal documents. Because electronic portfolios are beginning to be used in clinical settings, a well-designed education information system not only can meet the needs of nurses but also can facilitate their learning progress. KEYWORDS E-portfolio & Information needs assessment & Interviews & Learning experiences & Nurse postgraduate year (NPGY)

training courses (eg, fundamental care) for 3 months, core competency courses (eg, surgical care) for 9 months, and professional clinical training courses (eg, critical care) for Author Affiliations: Nursing Department (Ms Tsai), Hualien Tzu Chi Hospital, Hualien; and School of Nursing, College of Nursing (Drs Lee and Lin), and Graduate Institute of Health Allied Education (Ms Lee-Hsieh), National Taipei University of Nursing & Health Sciences, Taipei, Taiwan; and School of Nursing (Dr Mills), University of Maryland, Baltimore, MD. This work was supported by a grant (NSC-101-2511-S-227-007) to T.-T.L. from National Science Council, Taiwan. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Ting-Ting Lee, PhD, RN, School of Nursing, College of Nursing, National Taipei University of Nursing & Health Sciences, 365 Ming Td Rd, Taipei 11219, Taiwan ([email protected]). DOI: 10.1097/CIN.0000000000000112

CIN: Computers, Informatics, Nursing & January 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

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12 months. It is hoped that by having well-trained new postgraduates to perform patient care activities, healthcare quality and patient safety can be ensured.4 Studies also found that using e-portfolios in nursing education programs could enhance students’ professional competency and capability.5,6 However, Anderson et al5 proposed that because of the complexities of e-portfolios, a qualitative research method is suggested to explore students’ experiences with or perceptions of e-portfolio use. Therefore, a qualitative approach was applied to understand how new nurses view the potential use of e-portfolios to meet current on-the-job training requirements. The results of this study can serve as references in building e-portfolio systems to increase new nurses’ ability for daily practice.

LITERATURE REVIEW E-portfolios are an Internet-based platform for a learning process that integrates electronic files and information technology. This learning and documentation tool could assist students to develop their professional competency for future job requirements. Different from a regular data collection of learners’ documentation, the platform allows users to store learning records, reflections, and outcomes and may include text, electronic documents, digital images, multimedia posts, and hyperlinks to present evidence of physical learning.2 Learners can make files to document this learning process in response to changes and complexities in nursing practice. Course instructors and clinical preceptors can use this platform to assess learners’ outcomes and personal qualities (such as critical thinking) to revise teaching plans. In addition, for employment references, educational certificates and awards that are built into the e-portfolio are evidence of personal outcomes pertaining to professional development goals.2,6,7 Previous researchers have identified factors that could influence the use of these systems such as implementation strategies, initial training, peer effects, and user satisfaction; moreover, the privacy of information was shown to be a highly prioritized issue.6,7 E-portfolios have been studied as a way to influence changes in university curricula.7 These changes can be classified as occurring before, during, and after implementation. Students, teachers, and administrators actively worked on e-portfolios under the guidance of a task group. While using and managing the e-portfolios, learners increased their core skills and required competencies and achieved the goals of lifelong learning. Results indicated that learners gained a sense of accomplishment and satisfaction in the learning process by editing their e-portfolios.7 The successful implementation of e-portfolios can produce positive effects on increasing personal learning outcomes and the cultivation of professional abilities.8,9 Graduate students valued the development and use of e-portfolios; however, concerns regarding privacy and re22

source sharing were mentioned for clinical practices.10 Other researchers have found that e-portfolios with diverse content and functions, such as automatic links to students’ course enrollment status, academic and extracurricular activity performance records, customized Web sites, and unrestricted (neither time nor space) access to portfolios, can satisfy learners’ needs to maintain or update records to assist in future promotions or professional licensing.11 When incorporated into nursing courses or clinical care, e-portfolios emphasize the efforts, improvements, and overall achievements of learning.12 Professional abilities involve not only knowledge accumulation, but also the nurturing of attitude and values, communication, and clinical reasoning skills.13 Although these learning processes are not easily assessed using traditional pen-and-paper methods, e-portfolios can record these learning experiences. In one study, mixed-methods research was used to investigate final-year medical students’ satisfaction with e-portfolio. Results revealed that the students liked portfolios that presented their strengths and weaknesses in a structured manner, and they were satisfied that the system contained a mechanism for instructor feedback to improve their reasoning skills.13 Current challenges lie in how to continue recording student grades and provide evidence of their abilities to assess and evaluate learning outcomes.9,12 E-portfolios must be designed with an understanding of user attitudes and preferences to enable successful technology use.11 One study explored nurses’ experiences of using a nursing information system (NIS). The results indicated that if the systems had been designed around the classification of nursing instead of medical diagnoses, the nurses would have been more willing to use the system.14 Another study found that while using the NIS, nurses preferred an instant display of search results instead of going through numerous screens to locate the response to a query.15 These findings showed that satisfying user requirements is a key factor in the success of system use and that users should participate in the design process to improve system development to enhance their work productivity.16,17 Nurses’ ability to search for information has been correlated with their clinical competency, and e-portfolios support this by integrating in-service education, clinical care systems, and clinical nursing course modules. This type of e-portfolio also serves the purpose of maintaining course records and providing a reference that can be accessed by prospective employers. Nurse practitioner students can use this kind of information system to record their learning processes and to enhance their expert knowledge as proof of their professional competency in clinical care.5 As a result, e-portfolios can assist users in presenting their learning outcomes and increasing their competitiveness in the workplace. Furthermore, the convenience and efficiency of use provided by the electronic learning system also increase the user’s motivation for a self-learning approach.

CIN: Computers, Informatics, Nursing & January 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

METHODS Research Design A qualitative research method was used to conduct an initial assessment of the information requirements related to e-portfolio use. It was determined that in-depth interviews were the optimum tool for understanding the participants’ related experiences regarding incorporating new technology or concepts into their daily practice, for example, onthe-job training program. Based on the research purpose to explore users’ perceptions toward the use of e-portfolios, a semistructured interview guide was developed. One-onone interviews were conducted to explore their perceptions, requirements, and suggestions regarding e-portfolio from the perspective of new nurses. It is assumed that competencies could be strengthened by educational procedures such as building portfolios and using technology to enhance this learning process. Because nurses came from different nursing schools with varied learning backgrounds regarding the use of technology, their expectation toward the future use of e-portfolios as part of their current job training program deserves further study to analyze their needs. The research question was as follows: What are the new nurses’ perceptions regarding the use of e-portfolios to meet the current on-the-job training requirement?

Setting and Participants Data were collected at a hospital located in eastern Taiwan with 966 beds. The study participants were nurses who had been employed for 3 months to 2 years and had used the in-service education information system and were capable of searching the credits obtained through classroom and online courses. All 15 of the nurses voluntarily participated in this study. Interviews were conducted between April 2013 and May 2013.

The Education System at the Research Site The study hospital provides in-service education system for both classroom and online courses. Records of these courses are used as a basis for year-end performance evaluations, and some courses are provided and certified by certain nursing associations and could be credited for continuing education. For those certified courses, nurses need to register online, and once they have completed the credits, these records could automatically be sent to their national license credit system as proof of their continuing education credits. In addition, these continued education hours also could be counted as their NPGY hours and documented on their paper manual system to fulfill training requirements.

However, the information regarding classroom courses could be accessed only through the hospital intranet, whereas the online courses were available both on intranet and Internet. Two methods to search for courses existed. One was through posts of the new classroom courses offered every week provided on the hospital Web page. The other method involved a personal attendance system, which was available only on intranet and contained information on both classroom and online courses offered in that specific year. The online course records, evaluations, and feedback could be accessed and stored linked to the in-service education information system, which could be accessed both inside and outside the hospital. Records of classroom courses, however, were stored in a personal attendance system and could be accessed only in the hospital. Thus, while nurses could access the online courses from both inside and outside the hospital, a request for the total number of continuing education credits obtained through both online and classroom courses could be retrieved only by logging on to the personal attendance system from the intranet. For new nurses, the in-service education information system also served as an important tool for assisting them in completing the NPGY training manual. This manual covers the necessary clinical training forms for postgraduate nurses and must be completed in stages within 2 years. The content of the manual includes professional nursing skills, an introduction to medication administration and patient care, reflections on learning experiences, and in-service education records such as case report, conferences, or seminar attendance. In order to complete this manual, nurses are required to discuss different task items with their assigned clinical instructors. Supervisors would then collect the documented forms at regular intervals such as every 3 months as evidence to understand each learner’s progress and use these paper records as references for their yearly job performance evaluation.

Data Analysis The first author conducted the interview process and performed data analysis. Because this was her master’s degree thesis, she discussed data collection and coding processes with her committee members on a regular basis. Interview results were examined by content analysis using the qualitative research approach. Recorded interviews were transcribed word by word and then reviewed carefully line by line. Meaningful words, phrases, sentences, or paragraphs related to the study phenomenon were identified. These sections were coded, classified, and referenced with the findings of literature reviews such as learning needs for postgraduates, nursing professional competencies, or technology usage concerns. Information that appeared relevant to study topics was assigned an appropriate theme according to their significance and implications. Based on the

CIN: Computers, Informatics, Nursing & January 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

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assigned theme, description regarding the text content background was provided to ensure the analysis results were relevant to the study phenomenon of interest.18,19

Ethical Considerations Before beginning the research, this investigation was evaluated and approved by the institutional review board of the study hospital. Prior to interviews, the data collector (the first author) explained the research purpose and data collection process to the participants. Every participant was given a paper copy of the instructions and consent form to complete. Paperwork related to the interviews was stored in locked cabinets or password-protected digital files to prevent disclosure of the material.

Some participants mentioned that using the e-portfolio system off site would assist them in reflecting on the contents of the learning portfolio. If we could use and access the e-portfolios at home, then I would not be so rushed in thinking about my selections. In contrast to using this system at the busy workplace, you will be a little more easygoing about it (N13).

To ensure timely access to in-service education information, participants preferred an instant information retrieval after work, just like they do for patient care information in daily care. Available outside hospital e-portfolios access would increase the convenience of use.

Computerized Nursing Postgraduate Year Training Manual

RESULTS Participant Demographics Fifteen nurses, one male and 14 female, participated in the interviews. Their work experience varied from 4 to 22 months, for an average of 10.5 months. Surgical nursing was the most common major, and the largest proportion of nurses possessed a bachelor’s degree. The nurses had graduated from 5 different nursing schools. Participant data were coded as N1-N15.

Themes The following five major themes were identified: instant access to in-service education information, computerized NPGY training manual, diversity of system functions and interface designs, need for sufficient computers, and protection of personal files.

Instant Access to In-service Education Information Because both forms of course information are limited to within the hospital intranet, the nurses could search only for relevant courses in their spare time, which could prolong their time in the workplace. In addition, if the participants took some workdays off, they might miss the opportunities to register for the courses they needed. After the shift handover and after I’ve finished typing up patient records, all I want to do is leave and go home. I do not want to stay late to look for classes just like I have to retrieve information for patient care. The system would be more convenient if I could perform these searches at home, that is, search and register for classes at ease (N15).

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Because I was away on sick leave for a week, my work inbox e-mail contained numerous messages about classes, but I was unable to view them (ie, had to do it from the personal attendance system in the hospital). Switching to an e-portfolio would be the only way (N12).

Nurses with less than 2 years’ work experience need to complete the required task forms in the NPGY training manual. Participants stated that the information recorded afterward in these paper forms often differs from their actual experiences, and the forms are inconvenient for portable use. Most of the participants preferred that these forms be digitized to ensure that the information they obtained was accurate. We now have the NPGY training manual, which contained the information very similar to that required for our licenses. Everything in the manual should be computerized. In other words, we should not have to submit a paper copy, but could instead upload it, as an evidence for our license renewal. (N2).

Some participants viewed the training manual as a large work or assignments storage. It’s like a learning portfolio. For example, we have a case report assignment every month. If we want to review these cases, which were accumulated day by day, computerization would be an alternative, because data retrieval would be easier, and the text would be clearer to read as well (N3).

New nurses could use the information system to assist in recording seminars they attended or annotating special nursing experiences. We currently have a case (ankylosing spondylitis) that has attracted international interest in our departmentI. Suppose I provided care for the patientI I could use the e-portfolio to record the care process. Thus, if I need to produce a case report or something, then at least I could go back and look it up (N14).

The participants expressed a desire for electronic documentation of the data they obtained or created; thus, they would not have to maintain or keep paper copies.

CIN: Computers, Informatics, Nursing & January 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Diversity of System Functions and Interface Designs The participants preferred that future e-portfolios have linkage to the published literature database, thereby facilitating the timely completion of documentation or reports required for their duties. If my case required knowing the contraindications for total knee replacement, then the system could help me locate related articles immediately (N9). The system must include information of common diagnoses and what we should be careful of. For example, for patients who have undergone surgery, information regarding postsurgery care and what rehabilitation treatment they will receive could be included. Then, we could just review this information for care purposes (N8).

Furthermore, the participants would like the information that they require, such as common diagnoses and drugs, nursing care skills, or postsurgery care instructions, to be stored in a database according to their care specialties. Categorization should be according to the characteristics of care specialty. For example, this care unit uses only specific nursing skills. If someday I transfer to another unit, I can go to that specific section to learn a new skill and keep it in my e-portfolio. I don’t have to search for a certain unit to learn these skills, although that would be okay. The information I need could be embedded in a column labeled as ‘‘xxx specialties.’’ Then, this column can become a part of my personal learning portfolio (N13).

Nurses need to perform a literature review to complete clinical reports and case studies; thus, the linkage to literature databases in the education system would be valued.

In Need of Sufficient Computers Participants also complained that when they stayed in the hospital after work to perform a course search, few computers were available, and the unstable hospital intranet often stalled computer operations. After work, everyone including the students scrambles to use the computers. In addition, after the shift handover, we cannot use the mobile nursing carts because the staff covering that shift needs to use them. In fact, the number of available computers is insufficient to use for continuing education course purposes (N7).

The software and hardware provided by the clinical unit are supposed to be used for patient care, and nurses sometimes need to use the computer to retrieve certain information necessary for completion of the NPGY training manual. However, the use of the computer must be reserved for colleagues staffing the next shift or other coworkers to fulfill their job responsibilities. When you finish work and try to work on course selections, other people need to use the computer too. You are

embarrassed to use for education purpose while someone needs to use it for patient care (N13).

Furthermore, the condition of the equipment may also increase the difficulty of use. If I use the computer in the hospital, the network is not very easy to use because sometimes the computers freeze; actually, they freeze very often (N15).

Protection of Personal Files The participants stated that their personal information or their written reports should be considered private and should not be shared. Many were also worried that using the Internet increased the likelihood of their personal information being leaked. I entered an essay contest before, and it was later discovered that my articles could be found on the InternetI. If I create some file, and then it is copied with little change, because it is electronic, and it can be made public at any time, how do you feel about it? Maybe e-portfolios are different from what I thought. However, if an essay can be copied despite you spending some time writing it, what’s the purpose of working on it? (N3). With the Internet being thus developed, if the security of the system is not well designed and can be hacked by someone else, some personal information could be leaked. Others might even be cheated by fraud syndicatesI (N5).

Some believed that if they were allowed control over the security of their information, they would not be so concerned about information disclosures. I would set limitationsI If I have to provide information for my work, my new employer could view it, but would not be able to download my data. Otherwise, I would set some restrictions, such as what is accessible, partially accessible, or completely accessibleI. Personal information is private and should be set up with a way to determine what I want to be accessible and what I do not want to be accessible (N14).

Some of the participants exhibited two views regarding the use of Internet; that is, they enjoyed the user-friendliness and convenience of technology, but were concerned about whether personal information could be adequately protected. Therefore, security access controls based on user preferences could protect the accessibility of personal information.

DISCUSSION To increase attendance of in-service education courses, hospitals often link course credits to year-end performance evaluations or license renewals; thus, the nurses who attend such classes can typically acquire dual benefits. Because these courses are mandatory, nurses must search and schedule continuing education classes during their spare time within the hectic hospital environment. They cannot

CIN: Computers, Informatics, Nursing & January 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

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access the course query network outside the hospital after work, when they hope to have leisure time. Without work interruption, nurses can contemplate and arrange necessary in-service education courses. Therefore, ability to search for pertinent information at any time, any place (similar to data retrieval for patient care) is the first priority. Nurses could also avoid taking the same course again and make this registration vacancy available to others for the best use of resource sharing.20 Because current clinical practice emphasizes the development of an NIS focused on patient care, and e-portfolios have not been promoted among major health care systems, computers provided at work are mostly for patient care information retrieval and documentation, not designed specifically for education use. However, in addition to patient care, participants were most worried about earning sufficient in-service education course credits to satisfy the hospital’s requirements for license renewal and performance evaluations. Therefore, the participants were more concerned with courses provided in the hospital and were less likely to participate in or search for off-site courses. Because educational credits are mandatory for nurses, if access permissions could be granted to allow employees to use the system off-site, the problem of waiting to use computers at the hospital could be relieved. New nurses are eager to become proficient with their job duties as quickly as possible. Although the hospital provides some professional competency assistance, this is mostly in paper form such as instructions or learning records. Hard-copy manuals are used to record the acquired experiences, yet relying on memory to complete such forms often leads to missed or incomplete information. An online documentation or record information system could capture the learning experience instantly and precisely. Most nurses agree with digitizing the NPGY training manual, because the novice might forget the skills they have learned or the unique patient cases, which hinders the presentation of their full learning process. Regarding the education purpose of e-portfolios, participants hoped that the content design could meet the needs of each work unit and that the interface could be customized according to users’ preferences. Course display without sorting or certain rules to follow could confuse users and cause them to spend extra time searching for the desired courses. An information system design based on user needs is the only strategy that ensures the system is used. An understanding of user requirements regarding the system interface preference can increase the frequency of its use.21 E-portfolios can help users exhibit their obtained learning experiences through posting the study process and results. However, considerable concerns regarding the privacy of personal information have been mentioned if e-portfolios are implemented in clinical environments. The privacy concerns varied from information that could be shared, to information that should be kept completely confidential. 26

Thus, only by allowing individuals to set their own privacy settings can user requirements regarding information safety be achieved. Therefore, it is suggested that a comprehensive access system and verification channels be established to ensure users comfort in using e-portfolios.22,23

Limitations The participants of this study were nurses who were new employees or had worked for less than 2 years; therefore, the description of their perceptions toward use of e-portfolios within the clinical information system might be based on their previous school experiences and focused more on the convenient use of technology but less on the educational or developmental values. However, education is a lifelong learning process, and e-portfolios are designed for users who would like to continue utilizing this knowledge and skill accumulation procedure. Therefore, the interpretation of results should take into consideration that these nurses were still within the training process timeframe, and their perceptions could be influenced by previous experiences with other online or e-learning information systems, not specifically designed as e-portfolios. Nurses with longer work experience could be approached in the future with regard to e-portfolio use.

CONCLUSION The use of technology has been incorporated into clinical settings for patient care and offers an opportunity to implement in-service education courses as one method to increase quality of nursing care. An e-portfolio system can record users’ learning process and is available for future retrieval for review purposes. Nurse interviews demonstrated that users require timely access to in-service education information combined with privacy controls. The main factors affecting nurses’ willingness to use the new system include convenience and ease of use, good system interface functions, and sufficient numbers of computers to satisfy needed access. If these factors are considered in the implementation of e-portfolios, the outcomes of technology use can be more effective and beneficial for nurses.

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CIN: Computers, Informatics, Nursing & January 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

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Nurses' perceptions of e-portfolio use for on-the-job training in Taiwan.

Electronic portfolios can be used to record user performance and achievements. Currently, clinical learning systems and in-service education systems l...
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