The Clinical Portfolio
Lynette J. Stockhausen Dip TeachNsg, BEdNsg,
MEd St., RN
This paper discusses the use of a clinical portfolio for assessment purposes within in a problem based learning undergraduate preregistration nursing degree. The theoretical development of portfolio assessment is founded on constructivism and problem based learning (PBL). Definitions and ways the portfolio can be used are presented to assist the reader to develop portfolio assessment procedures in clinical practice. The need to develop self reflective life long practitioners and the unpredictable nature of clinical practice provides an impetus for educators of nurses to examine alternate procedures for assessment.
The term portfolio has traditionally been associated with the "arts". It involves the presentation, usually by an artist or musician, of a collection of individual accounts of their work evidencing the learner's endeavours, progress and achievements. The notion of portfolio assessment within a problem based learning (PBL) approach extends the arts portfolio. Based on a constructivist view of learning and assessment the portfolio becomes an avenue to promote reflection and demonstratable, student centredness and responsibility for learning development (Paulson and Paulson, 1994).In the development of a new clinical assessment process concerns were raised in a Faculty of Nursing in South East Queensland, Australia. These were:
(1) that the theoretical framework of our course, PBL, was not being integrated into the clinical component of our course and students were unable to demonstrate their interpretations and construction of their learning.
(2) without prior knowledge of where students had had previous clinical experiences, and what students had previously achieved during that placement, it was difficult for clinical teachers to know if students were extending and involving themselves fully in their clinical experience.
(3) how to integrate the student's self assessment with clinical teacher's assessment.It was decided to examine the use of a clinical portfolio as part of the overall assessment of students during their clinical rotations.
On review of the literature the clinical portfolio appeared to bridge our concerns. The portfolio became a portable learning assessment item which demonstrates developmental progress in differing clinical settings during the three years of our PBL undergraduate degree in nursing.A further impetus to explore portfolios as an assessment strategy was that prospective employers of our graduates were requesting demonstratable evidence of students' clinical achievements and the types of venues they had experiences in (maternity, paediatrics, medical/surgical). This type of information was also being sought by students trying to gain overseas registrations.
Problem Based Learning and Constructivism.
Problem based learning has been defined by Barrows and Tamblyn (1980) as an approach to learning that results from the process of working toward the understanding or resolving a problem. The problem is encountered first in the learning process and serves as a focus or stimulus for the application of problem solving or reasoning skills. It includes the search for, or study of, information or knowledge needed to understand the mechanisms responsible for the problem and how it might be resolved.Constructivism is a broad theory about knowledge and learning from an ecclectic synthesis of cognitive psychology, philosophy and anthropology (Candy 1990, Brooks and Brooks 1993). Brooks and Brooks provide a concise definition;
The theory defines knowledge as temporary, developmental, socially and culturally mediated, and thus non objective. Learning from this perspective is understood as a self regulated process of resolving inner cognitive conflicts that often become apparent through concrete experience, collaborative discourse and reflection. (1993,xii)
Both PBL and Constructivism actively encourage the learner to be a creator rather than a passive recipient of knowledge (Barrows 1985: von Glaserfeld 1987). It places the learner at the centre of the learning. The learning is dependent on the student's needs at a particular time, their interpretation and construction of meaning from the learning environment. Paulson and Paulson (1994) indicate that meaning varies from individual to individual, over time and with purpose. The centrality of the PBL process is its ability to stimulate a questioning attitude and a search for understanding (Margetson 1993). PBL encourages students to actively learn through questioning, probing, showing curiosity, discussing, hypothesising, making decisions and cooperating with others to work towards and resolve problems representative of practice. On campus students rehearse these skills ready to apply them to the real life nursing situations during their clinical placement.
Aligning PBL and constructivism von Glaserfeld (1987) suggests that the best way to assess a student's understanding of a particular discipline is to present the student with a perplexing problem. The application of skills and knowledge to "problems" prompts students to develop, apply and evaluate their understanding of concepts being studied to on campus simulated clinical situations. However, in the off campus clinical practice environment, in which students are engaged, these skills are applied to the real context of nursing.
The clinical context is viewed as a rich problem solving environment in which developing problem solving skills, expanding creative thinking and building confidence are valued. Constructivism offers students the opportunity for concrete clinical experiences through which they can discover patterns and build upon concepts to act as a more solid foundation for more abstract understanding. Only through active cognitive involvement do conceptual understandings and problem solving skills develop (von Glaserfeld 1987).
Active cognitive involvement refers to making connections to past learning, constructing new representations and modes of reality, and struggling with the conflict between existing personal modes of the world and discrepant new information. In this sense Creedy, Horsfall and Hand (1992) note that PBL philosophies are derived from assumptions of constructivism whereby students actively construct and arrange their knowledge of the world as they develop their personal interpretational schema.
Assessment to the constructivist then, examines the way students construct their knowledge. That is, the assessment item will challenge and develop the student's ability to think in novel situations rather than simply regurgitate standard answers or undertake standard procedures (Wiggens, 1989). Gruender (1989) suggests that assessments based on constructivism seek to assist students to understand the concepts of the discipline, foster pleasure and mastery of their use, as well as motivate students to undertake these activities.
The learning processes inherent within portfolio development are philosophically aligned to PBL and in particular within a constructivist framework. The intention of the portfolio is to make explicit the active cognitive exploration of "clinical nursing problems" through the use of artefacts, reflections and reconstructions. Therefore, students discover, through a process of constructing meaning from learning, their own achievements, abilities and areas in need of improvement for future learning.
The portfolio as a process that documents the developmental progress of a student has a powerful influence on the capacity to reflect and change. New problems or practice situations are solved by building on previous understanding. A type of 'recycled' learning occurs as the student generates new knowledge by linking previously known information with new insights.
Seldin (1991:3) proposes that the portfolio is a representation of gathered and presented hard evidence and specific data about ones learning and "... effectiveness for those who judge performance and/or to provide the needed structure for self reflection about which areas of performance need improvement". Murray (1994) extends Seldin's (1991) definition by indicating that a portfolio is a collection of documents that represents the best of one's discipline and provides one with the occasion to reflect on his or her discipline with intensity. The portfolio becomes a tool for an individual to reflect on real client "problems" in real clinical contexts. Urbach (1992:71) reports the intended outcome goal of a portfolio is to "describe, through documentation over an extended period of time, the full range of your abilities". As a newly favoured technique, Arter and Spandel (1992) view the portfolio as a collection of individual work that documents the learner's perspective on their efforts, progress and achievement. Bull, Montgomery, Coombs, Sebastian and Fletcher (1994:160) acknowledge that for students portfolio assessment "encourages choice, revision, and reflection related to their own work."
Portfolios therefore present an opportunity for the student to investigate and reflect on individual learning related to clinical problems of practice that they find unique (Barrow, 1993). Ohlhausen and Ford (1992) identify that the portfolio "engages students in a continual process of self reflection, goal setting and attempts to change". This view is supported by Gerrish (1993:173) as she identifies the main aim of the portfolio is "to maximise learning by providing the student with the opportunity to maintain continuing awareness of their progress". Boud (1990:185) promotes self assessment schedules which provide opportunities for students to "reflect on their learning and give a public account of what they have learned." In advocating self directed and student centred learning Boud (1990:186) believes a framework, such as a portfolio, "focuses attention on the goals and criteria of learners, elicits evidence of achievement and provides an opportunity for learners to make judgements about how successful they may have been in meeting their goals".
In making judgements about their learning, one of the most important outcomes for the students of a portfolio is self reflection and the construction of clinical knowledge. The capacity to reflect upon previous representations and their construction is essential in developing and evaluating more adequate conceptions. The introduction of the clinical portfolio into our course became a chronicle of the different clinical settings students attended documenting the complexity and individual progression of their nursing practice development. However, we were mindful that some studies have questioned the usefulness of the portfolio as an effective assessment process (Oeschle, Volden and Lambeth, 1990). Cayne (1995) believes that, while portfolio assessment has been identified as fostering self awareness, personal growth and the stimulation for independent learning, there is little research to support these assumptions. Therefore we were keen to develop a portfolio assessment based on the theoretical framework and assumptions of our curriculum to address these criticisms.
Developing a clinical portfolio
It is only the student who can decide what goes into their portfolio. In this respect the portfolio's development placed control and responsibility in the hands of the students (Murray, 1994; Barrow, 1993; Candy, 1990). In the initial stages of students using the clinical portfolio, as part of the assessment process, we were deliberately vague about what should be included in the portfolio. The reason for this was that the portfolio is designed as a record of the student's development. We were mindful not to impose a structure that became too formalised and stifled creativity. However, we were also aware that both students and clinical teachers needed an beginning edifice. The literature, mostly from the fine arts and teaching, does identify a number of ways to structure and organise portfolios that we found helpful (Barton and Collins, 1993; Urbach, 1992, and Bull et.al., 1994).
Barton and Collins (1993) identify four categories of evidence for inclusion in the portfolio. These are artefacts, reproductions, productions and attestation.
Artefacts are identified as products constructed as part of the learning experience. They generate the substance of the construction of the student's understanding. The type of information students seek as artefacts may also be indicative of the type of learner they are, visual or auditory, surface or deep, reproductive or transformative. Students may gather research articles, pamphlets, ward-produced documents or information from other health professionals; view videos; develop client specific assessments or health education material; produce audio or video recordings; generate questionnaires or conduct research projects. The range of artefacts that a student can access to substantiate their range of knowledge, skills and affective development is limited only by our imagination.
Reproductions are documents describing typical events which portray the experience of the portfolio developer. Within this section some students have used photography, their own art work, such as sketches and diagrams, poetry or essays.
Production documents within the clinical portfolio are produced particularly for the portfolio. These maybe such items as a learning contract, extracts from journal writing or captions. Barrow's (1993:150) believes the production category is the essence of the portfolio as this section allows the developer to tell their story of the why, how and what worked or went wrong and how they felt about this. In the production category students can display their "thoughtful knowhow" through explanations of what the evidence represent. The evidence provides the building blocks on which the student construct, reflect and reconstruct their knowledge development. Some students may use concept maps to display how they have arrived at particular answers. Whatever means the student uses to demonstrate evidence and process of learning, the production category infuses the portfolio with meaning.
Attestation are evaluative descriptions of the developer's work which are created by the developer or others vouching the authenticity of the specific claims made throughout the portfolio. These can take the form of recommendations, peer reviews, other practitioners or the clinical teachers evaluations. However, it is also important that the students self assess their achievements. For example, if students have been unable to successfully complete their learning contract, for whatever reason, they are encouraged to offer suggestions on how they can be fulfilled in the future. One strategy that students have found successful is to use the unachieved goals as a beginning point for the next clinical experience.
Gerrish (1993:174) identifies personal objectives, a learning diary, self evaluation of competencies and comments by supervising staff as the tools which "contribute towards providing a comprehensive picture of student progress and performance". Other authors (Barrows, 1993; Murray, 1994 and Cooper, 1995) suggest that a statement of purpose at the beginning of the portfolio be articulated with the overall goals and prospective outcomes of the portfolio. In our Faculty of Nursing, students' statements of purpose and goals are often articulated with the Australian Nursing Council Incorporated (ANCI) competencies. These statements are a set of competencies that define a beginning practitioner for registration as a nurse. Students often construct their portfolio to show how, over the period of the three years of their course, they have demonstrated progression or development to achieve these beginning nurse practitioner competencies.
Given the diversity of potential products to include in a portfolio and the multiple ways it can be used to demonstrate understandings of problem situations, it does become confusing for the developer to decide on just what to put into, and leave out of, the portfolio. The unpredictability of clinical settings can create an extraneous amount of "evidence" within the portfolio. In the initial development of a portfolio some students find it necessary to gather and hoard anything remotely connected to their perceived development. The portfolio is not a folder full of photocopied articles, drug information sheets, check lists, assessments of numerous patients or several testimonials from staff. In the development of the portfolio one needs to present evidence in a concise and selective manner. Too much information can create, as Wolf (1991:131) notes, "a thick and unwieldy collection of documents and materials that would be indecipherable to anyone other than its owner". On the other hand Murray (1994) warns that if the portfolio becomes too streamlined it runs the risk of becoming "sterile". He goes on to say that a useful portfolio merges artefacts and reflections from the experience. More importantly it illustrates how the reflections on the artefacts demonstrate learning for the portfolio owner. It forces the student to become discriminatory selecting a range of "evidence" that demonstrates achievements, failures, insights and perceived progress yet to be achieved. As the students progress throughout the course they become more selective and present precise, relevant evidence of their learning development and outcomes.
In our course students are encouraged to include whatever information or evidence they feel will support their developing competence as nurses and their achievement of personal clinical goals. Flexibility, diversity and creativity are encouraged to foster innovative clinical decision making. Students are also encouraged to base justifications for their practice on research findings. Fostering in the students an ethos for exploring and challenging ideas on practice for themselves, their peers and others involved in their experience and patient care is highlighted. The personal ownership of the portfolio generates interesting and various interpretations of research, practice situations and evidence that learning is occurring.
Not all the gathered evidence from one placement is taken to the next clinical venue. For the next placement students are encouraged to include only that information that they feel is necessary to demonstrate achievement or further refinement of learning goals from the previous placement. A review of several clinical groups of students' portfolios between placements indicates most students have decided to include their: statement of purpose, previous learning contracts, their self and clinical teacher's evaluations and a client assessment tool which they are building concepts into from placement to placement. Some students have also provided a one page reflection on their growth and change that they perceived occurred during the placement. This concise information provides the clinical teacher at the next placement with, an indication of the types of clinical settings a student has attended and the types of experiences and learning that has already taken place. It further provides the student and the clinical teacher with a guide to structure, and build upon, prior learning experiences.
The intensely personal nature of the portfolio takes on the character and idiosyncrasies of its owner. Students have devised some interesting and creative ways to present their portfolios. They have used; colour coded entries; dividers for different sections, such as each placement they have been to, or set it out in sections that indicate learning goals, lists of artefacts collected or developed, journal extracts or activities they undertook in each clinical venue. For some students it was a way to show their artistic abilities as they created very personal and graphic covers or artefacts for their portfolios. Supporting the students' creativity and learning endeavours is therefore paramount.
The role of the clinical teacher is to guide and encourage, to challenge and question, and facilitate the student's development and understanding of concepts through the use of the clinical portfolio. Sadlo, Warren and Agnew (1994:51) note that the clinical teacher has "a unique opportunity to observe their students' thinking, and progress, assisting development at optimal moments". By generating an environment of trust the clinical teacher can extend student's learning by creating an atmosphere of freedom. This provides an opportunity for students to take risks, make choices and provides compelling evidence of developmental competence in nursing practice.
Evaluation of the Clinical Portfolio
As an assessment technology portfolios work best when students clearly consider the essence of self directed inquiry. Portfolios recognise the centrality of the learner to the learning process. The focus of the portfolio is on what stimulates students' interest in the clinical environment; how they seek solutions to these problems; how students use resources to generate understandings of problems in practice and how experiences of the problem generates new understandings and actions. Hence students' portfolios are assessed in terms of how well these students can articulate and demonstrate their understanding to solve perplexing individual problems of practice. The portfolio also serves as a valuable tool for diagnosing student learning difficulties.
The portfolio is documented evidence of the construction of a student's own understandings, therefore it is only the student who can determine what is appropriate. This creates making judgements on the quality of the learning both difficult for the student and the clinical teacher. Boud (1990) notes it is in the area of self assessment that students have the most difficulty. He (1990:186) acknowledges that the "involvement of learners in making decisions about criteria which are appropriately applied to their work and their making of judgements about achievements is the key characteristic of self assessment". Engagement in such activities encourages students' development as independent learners and critical thinkers (Falchikov and Boud 1989, Boud 1995).
Valencia and Place (1994), however, indicate that it is critical to establish common anchors, or criteria for determining the process and outcome of the portfolio. Because of the variable nature of student's self assessment combined with many of our teaching staff coming to terms with the role and purpose of the clinical portfolio, a set of criteria was established. The criteria address the developmental and individual character of students' learning. Elements of the criteria include:
(i) The student is motivated to maintain and contribute to the clinical portfolio.
(ii) The student incorporates previous learning experiences into the ongoing development of the portfolio.
(iii) Contributions to the portfolio reflect meaningful learning, including demonstrations of the students' learning process.(An example may be a concept map.)
(iv) The portfolio is presented and maintained in an orderly and concise manner.
(v) The student critiques a broad range of artefacts, values the significance nursing research has for nursing practice.
(vi) The student justifies nursing practices using appropriate research findings.
(vii) The student values and demonstrates the significance that the clinical portfolio holds to demonstrate ongoing personal and professional development.
The developmental aspects to each criteria acknowledge that the student could be demonstrating unsatisfactory progress, that they are making progress, have reached an expected standard, attained an above expected standard or that exceptional progress has been made. The criteria acknowledge that the student can choose the form of evidence they wish to present but, they must show how the evidence they present relates to the knowledge, skills and attitudes they are claiming to possess. Following self assessment the portfolio is jointly assessed with the clinical teacher and a grade is negotiated. This is perhaps where a deviation from PBL and constructivism occurs. A major criticism of the clinical portfolio is that a grading system has been applied to it. While advocates of PBL (Margetson, 1993; Barrows, 1985; Sadlo, Piper and Agnew, 1994) recommend the noncompetitive nature of assessment processes, the 'real world' of universities and employment opportunities necessitates grades be appointed to learning outcomes. This should not be seen to negate the importance of self assessment in PBL. The main thrust of the portfolio is still to help students self assess their learning in preparation for the lifelong need to be reflective and self critical (Candy 1990, Mills-Courts and Amiran 1991). Student's verbal comments regarding the use of clinical portfolios favour the uniqueness, empowerment and self evaluative control this assessment offers them. In this sense the clinical portfolio has been responsive to student needs. The requirement for documentation to show growth over a period of time has generated enthusiasm and motivation to maintain and contribute to their clinical portfolio. However, students, like those in Cayne's (1995) study, have indicated that the portfolio is time consuming and often conflicts with the demands of the placement. A small number of students also identified that the portfolio involves significant personal risk as unsuspecting deficiencies, imperfections and attitudes are revealled to the owner. These students were also reflective as they responded that this was also seen as a positive outcome as it identified areas for personal improvement.
The development of the clinical portfolio has attempted to address the original concerns of staff. The philosophy and theoretical integrity of the course has been upheld and incorporated into student's off campus clinical learning activities. As an assessment strategy the clinical portfolio has the capacity to uphold the tenets of PBL and constructivism. The development of a clinical portfolio shifts the ownership of learning to the student. With a clinical portfolio students create their own assessment documentation to explore clinical 'problems' and construct learning issues, related to these, that have personal relevance. Clinical teachers' concerns have been addressed as the clinical portfolio has allowed them access to students' previous learning experiences. This has afforded the clinical teachers an opportunity to relate previous learning outcomes to new and challenging student clinical experiences. As students identify their individual learning needs, clinical teachers can help students link these with course concepts within the clinical context. This provides a platform for both the student and clinical teacher to optimise the student's understanding and development of, knowledge, skills and appropriate attitudes to their nursing practice. For new graduates the portfolio documents evidence about how they think, construct personal learning from the clinical context, reflect and self evaluate. It displays to prospective employers a graduates abilities, professional development and potential. Through the use of a clinical portfolio students can actively demonstrate self directedness through the ways in which they construct learning and create meaning from their clinical knowledge within the practice environment. The clinical portfolio as an alternate assessment item, for documenting student progress, generates new possibilities in understanding and developing students' interpretations of nursing knowledge and practice. It will now depend on well formulated studies to research and evaluate clinical portfolios as an assessment technology and an avenue to explore student's learning potential.
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