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Contents lists available at SciVerse ScienceDirect

Women and Birth
journal homepage: www.elsevier.com/locate/wombi


Making practice transparent through e-portfolio
Sarah M. Stewart *
Professional Development Officer, Australian College of Midwives, PO Box 87 Deakin West ACT 2600, Australia



Article history: Received 10 March 2012 Received in revised form 11 February 2013 Accepted 19 February 2013 Keywords: E-portfolio Midwifery Social networking Learning Blogging Reflection

Background: Midwives are required to maintain a professional portfolio as part of their statutory requirements. Some midwives are using open social networking tools and processes to develop an eportfolio. However, confidentiality of patient and client data and professional reputation have to be taken into consideration when using online public spaces for reflection. Question: There is little evidence about how midwives use social networking tools for ongoing learning. It is uncertain how reflecting in an e-portfolio with an audience impacts on learning outcomes. This paper investigates ways in which reflective midwifery practice be carried out using e-portfolio in open, social networking platforms using collaborative processes. Methods: Using an auto-ethnographic approach I explored my e-portfolio and selected posts that had attracted six or more comments. I used thematic analysis to identify themes within the textual conversations in the posts and responses posted by readers. Findings: The analysis identified that my collaborative e-portfolio had four themes: to provide commentary and discuss issues; to reflect and process learning; to seek advice, brainstorm and process ideas for practice, projects and research, and provide evidence of professional development. Conclusions: E-portfolio using open social networking tools and processes is a viable option for midwives because it facilitates collaborative reflection and shared learning. However, my experience shows that concerns about what people think, and client confidentiality does impact on the nature of open reflection and learning outcomes. I conclude this paper with a framework for managing midwifery statutory obligations using online public spaces and social networking tools. ß 2013 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

1. Introduction To meet statutory requirements for registration midwives are expected to provide evidence of their competency, and make professional development plans for the future.1 In some countries, midwives use professional portfolios as a vehicle for their ongoing professional development.2 Reflection is an integral part of portfolio development, and is a statutory requirement for midwives in countries such as New Zealand.2 E-portfolio using open, social networking tools is portable and flexible in where, when and how it can be accessed; tracks and records reflections and learning processes; and facilitates sharing, feedback and dialogue with others.3,4 However, there are questions that must be answered

before e-portfolio is likely to be taken up by regulatory and professional bodies, such as how appropriate is social networking for professional e-portfolio?5 How is reflective learning influenced when carried out in open digital and collaborative spaces? Can midwives reflect and learn in a safe way, and provide authentic evidence of their learning? In this paper I will share my experience as a midwife, educator and student who uses social networking tools to maintain a professional e-portfolio. I describe how I employ social networking tools and processes for reflective practice and professional development. Finally, I discuss how I manage statutory obligations with e-portfolio using online public spaces and tools. 2. Literature review

* Correspondence address: Professional Development Officer, Australian College of Midwives, 115 Canberra Avenue, Canberra, PO Box 87, Deakin West, ACT 2600, Australia. Tel.: +61 420714031. E-mail address: sarahstewart07@gmail.com

2.1. Midwifery and professional portfolios Since the early 1990s midwives have been using professional portfolio as a way to provide evidence of competency, and to show

1871-5192/$ – see front matter ß 2013 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

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how they have acquired skills, learned from experience, and grown as practitioners.6 In some countries such as the United Kingdom, Ireland, and New Zealand, professional portfolio is a statutory requirement.2,7,8 In other countries including Australia, it is a professional activity that is encouraged, but not yet legislated.9 Standard practice favors the use of paper-based portfolios, usually in the form of a commercial, or ‘‘home made’’ folder.7 2.2. What is an e-portfolio? The web-based e-portfolio is a digital container that allows practitioners to record professional and educational activities, and attach accompanying evidence in the form of text, audio, video and images.3 The move from paper-based to electronic portfolio in the midwifery context has been led by education, especially at undergraduate level.9 In part, this has been a pedagogical development to encourage reflective practice, and support work-based learning.4 But it has also been a response to the increase in blended and online delivery of midwifery programs, which has caused logistical issues when working with students who live at a distance from campus. The result has been a need to simplify administration and collation of artifacts and evidence about competency, in readiness for registration.10 Some institutions and organizations are using proprietary (commercial) eportfolio platforms or developing their own.11 However, questions remain about how students can take their e-portfolio with them once they leave the educational institution, and start work as registered midwives. This problem is solved by using open social networking tools such as blog, wiki, Youtube, Slideshare and Flickr, which are for the most part free and have wide spread availability.5 However, how to integrate such an e-portfolio with statutory and professional registration processes and systems has not been addressed.5 Nor is there consensus on how appropriate it is to use social networking for professional development.11 2.3. Personal reflection and e-portfolio Reflection is a key element of a portfolio, be it in a paper or electronic format.12 Reflection is the process of thinking about practice and making meaning of experience.13 Deep learning occurs when practitioners describe or explain practice, and then critically examines specific aspects.12 Ideally these reflections and insights lead ‘‘to decisions for action..achievement of goals and changes to immediate and future practice’’.14 However, studies have shown that some e-portfolio users do not progress past the descriptive stage, and thus do not acquire deep learning.15 2.4. Collaborative reflection and e-portfolio One way to support practitioners to move from description into deeper thinking and learning is through collaborative reflection.16 Such reflection draws on multiple views and perspectives which allow practitioners to learn with and from each other. Reflecting with peers enhances collaboration and collegiality, and increases problem-solving and goal-setting capability.17 Sharing questions, information and resources support practitioners to clarify, confirm and re-frame knowledge which can add to the depth of learning.18 However, collaborative reflection can be challenging when irresolvable conflict emerges and issues of confidentiality, trust and respect are not carefully managed.19 Collaborative reflection can take place in online environments as well as face-to-face conversations. E-portfolio facilitates collaborative reflection by means of computer-mediated communication. Research has shown that students who have interacted with each other in eportfolio platforms have valued the opportunity to give and receive mutual feedback.20 This way of working has also enabled them to

work together in communities of practice to share knowledge and develop collective expertise, which has resulted in enhanced reflection and deeper learning.21 The main barrier to deep learning in this environment is implementation of the technology itself. Students require support and scaffolding to develop the digital literacy skills they need in order to be able to communicate and expand their practice in their space [22] 2.5. E-portfolio and social networking Social networking tools and processes encourage collaboration and sharing because they are specially designed to bring people together. E-portfolio using public online spaces has no boundaries, and thus has the ability to reach a larger audience and increase opportunities for collaboration.23 Reflecting in open online spaces can affect what and how practitioner communicates. Commentators may have their own agenda and distort the practitioner’s thinking and learning, be that knowingly or unknowingly.20 Open reflection may have consequences when practitioners come up with conclusions that do not necessarily fit with the view of the commentators or indeed, the wider professional community. Thus, practitioners may not be authentic and honest in their reflections but rather articulate what they think others want them to say.20 Alongside the worry about what others may think is the major concern about talking in public online spaces about patients and clients.24 Divulging confidential patient and client information, as well as unprofessional online behavior can lead to litigation and breach of professional standards.25 Regulatory and professional bodies have developed policies and guidelines for the professional use of social media.26 However, there continues to be debate about what is and what is not acceptable online behavior. On the one hand, anecdotal stories of the unprofessional use of social media by health practitioners cause consternation, such as the anesthetist who called birthing suites ‘‘birthing sheds’’, and intensive care units ‘‘cabbage patches’’ on Twitter.27 This episode generated international discussion about the doctor’s lack of empathy and use of dehumanizing language.28 On the other hand, regulatory and professional bodies have been accused of developing social media policies that demonstrate a lack of understanding of how people communicate these days.29 Advocates of social media fear that punitive policies will impact on midwives’ engagement with social media, and adversely restrict its use for personal learning.30 Whilst there are a number of empirical studies and theoretical musings about e-portfolio for midwifery education especially at undergraduate level,5,9,31 there is little evidence about how midwives use e-portfolio for ongoing learning. What is also uncertain in the literature is how reflecting in e-portfolio using open online spaces with an audience changes learning outcomes compared to private media, such as a paper portfolio. As yet midwives who use e-portfolios do not know how concerns about patient and client confidentiality impacts on the quality of reflection. This investigation explores ways in which reflective midwifery practice be carried out using e-portfolio in open, social networking platforms and collaborative processes. 3. Methods My research tool is my e-portfolio which I have maintained since 2007 using a combination of free, online social networking tools including a blog, which is a web-based journal22 (http:// sarah-stewart.blogspot.com), YouTube, Blip.TV, Animoto, Flickr, SlideShare. All these elements are coordinated, integrated and presented in my e-portfolio wiki (http://sarahstewart-eportfolio.wikispaces.com). For this investigation I chose to focus on my blog,

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because that is where I do most of my reflection. At the time of writing this paper I had written 1097 blog posts which have attracted 194,000 page views, 133,700 unique visitors and generated 4253 comments. I selected to analyze blog posts that had attracted six or more comments, which totaled 243 posts and 2218 comments. I chose six comments and more because I felt conversations were more likely to reveal learning, as opposed to one-off comments. I used an auto-ethnographic approach to identify themes within the textual conversations in the blog posts and responses posted by readers. Auto-ethnography is the process of examining and reflecting on one’s personal experience, and relating themes to wider contexts.32 I chose this approach because I was researching myself, in a qualitative, subjective paradigm. I advised readers that I was writing this paper via a generic post in my blog, and gave them the option to remove their comments, or ask me not to discuss them in this paper. I did not obtain individual consent because the comments were already in the public space.33

I am wondering how much I will be able to talk about my new role and my experiences of teaching under-graduate midwifery students [in my blog]? Will processing my thoughts here make it look like I don’t know what I am doing? Will that impact on students’ perceptions of my knowledge and expertise? I am mindful of the potential for criticism by the profession. I wrote a reflective blog post some years about my experiences of burnout when midwives were being advised about time and caseload management in New Zealand. I felt vulnerable writing that post because I feared I would be criticized and told that my burnout was my fault for mis-managing my workload. There was a danger that fear would either prevent me from reflecting on or telling my story, or not being honest about my feelings and experience. However, I felt so strongly about the topic that I was driven to write about it. The crunch came for me when I attended a home birth which I spent the whole time in a state of fear: I felt like a rabbit frozen in a car’s headlights. There was no joy or excitement from the home birth which usually makes up for the more complicated births that happen in hospital and invigorates my midwifery soul. Looking back on this year, I was exhibiting all the symptoms of burnout. Sometimes I feel it is important to speak out, to bring issues out into the open to facilitate honest discussion, rather than being swept under the carpet. Or as a reader put it: Hopefully blogging will offer us the opportunity to get outside our insulation from time to time. Every now and then we might find an ah ha moment that we can bring back to our work and transform something for the better - or worse... The blog post actually generated lots of conversation which gave validity to my experience, which helped me come to terms with it. 4.3. Seek advice, brainstorm and process ideas for practice, projects and research The collective wisdom of the community who interact with me via my blog has been invaluable to me in my practice. At one time I was struggling to think how to teach midwives about social networking without access to a computer laboratory in a conference workshop. When I posted this dilemma I received a number of suggestions which I incorporated into my workshop. One reader suggested Record a video of what you would like them to see if you did have an Internet connection. Another said Do a simulated Twitter with your audience using ‘‘post-its’’ One reader passed on a resource. Not sure if this would suit this situation, but there is a social media game that helps people understand the implications of using online tools. You find out more: http://socialmedia.wikispaces.com/Social+media+game Indeed, the workshop was so successful it led to an invitation to be a keynote speaker at another midwifery conference. Another example is when I was debating how to frame up a literature review question for my educational doctorate. One reader advised Your plan follows a logical path but feels like you go beyond your questions leading to a big, big review. It may be more managable to really focus on your questions - keep focused - that will in

4. Findings The blog posts were initially sorted according to their labels, which are the categories I award posts when I first write them, including teaching and learning, education, midwifery practice, and personal learning. The labels were then sorted into four main themes. 4.1. Provide commentary and discuss issues My blog posts cover a wide range of midwifery and educational issues. Sometimes this is a one-way process whereby all I aim is to publish a personal opinion as a cathartic release. Other times I deliberately choose issues that I think may interest others and generate conversation. Here is an example of an opinion post. I am 1000% behind making caesarean section as family-friendly as possible and I totally applaud obstetricians and midwives who encourage things such as immediate mother-to-baby skinto-skin contact. But please don’t try to sell caesarean section to mothers or midwives as being ‘‘natural’’. . .it isn’t and never will be!!! 4.2. Reflect and process learning My blog posts contain reflections about my practice and professional development activities. Reflecting in my open blog has facilitated continuous peer review via the comments left by readers. Readers discuss what I have written, challenge me and provide multiple perspectives and alternative views. The quality of comments varies and I use my professional judgment to decide how much attention I pay to the comments. When talking about ultrasound scans, I was concerned that one hospital was turning them into mp3 files which I considered was another way of ‘‘selling’’ unnecessary scans to women. But one of my male readers had this to say: I look at this as just an extension of the family photo, and a little way of getting excited about the new member to be. I may not have changed my mind on this issue, but the reader put forward an opinion from the perspective of a father-to-be which resulted in me thinking about how I could include fathers in my midwifery practice more than I did at the time. Reflecting in the open is also a way of seeking validation and support from the community. In one post I talked about a new role as midwifery lecturer.

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depth rather than trying to go too broad. As a colleague once said it’s a doctorate not a Nobel prize:) Another wrote I think one of the most interesting areas here is the differences (if any) between networked learning and Communities of Practice. If you haven’t already looked at it, Etienne Wenger stuff on COPs - albeit quite old now is interesting. . . I found this article quite useful too: http://www.irrodl.org/index.php/ irrodl/article/view/523/1103 All the advice and comments enabled me to focus my literature review more effectively. 4.4. Provide evidence of professional development I embed evidence of my activities into my blog. For example, when I give a conference presentation, I upload my presentation slides into a website called Slideshare.net, and then link to it in my blog, along with my reflections on how the presentation went. I have had to think about the authenticity of the evidence I provide in my e-portfolio to ensure others do not ‘steal’ my identity. I have branded myself online as ‘Sarah Stewart’ which makes it very easy to track my work. I also publish my work with a Creative Commons Attribution license which means that people can use my work for their own purposes. These precautions make it difficult for people to ‘steal’ my work because I have already ‘gifted’ it to the wider community. As a result I have become a resource for others, both in terms of the content I publish, as well as the e-portfolio itself. Nevertheless, I do not publish work or details about myself that I am not prepared to share with others.

unsure if the learning outcomes are different compared to situations where I can be totally honest. As a reflexive researcher, I must acknowledge that the analysis, findings and meaning of this research is heavily influenced by how I see the world.34 My experience of e-portfolio has been hugely positive, and my blog is an essential part of my day-to-day learning. However, I recognise that I cannot generalize my findings, and e-portfolio using social networking will not be appropriate for all midwives. Many midwives lack digital and computer literacy required by e-portfolio, as well as time to develop those skills.35 A lack of integration of e-portfolio into statutory registration processes and systems also acts as a barrier for midwives.5 When I attempted to present my e-portfolio for my bi-annual midwifery review several years ago in New Zealand,2 I was asked to print it out on paper. The reviewers felt they did not have the time to engage fully with my e-portfolio, and had difficulty accessing the websites because of slow internet connections. As more midwives are taught computer skills pre-registration, and e-portfolio is introduced into educational programs, it may be time for statutory and professional bodies, as well as employers, to examine how eportfolio can be smoothly transitioned from education into practice. What I hope to have done in this paper is to have contributed to this discussion, and raised issues for further exploration. 6. Recommendations The UK Nursing and Midwifery Council have issued detailed and balanced guidelines on how to use social networking in general.26 Here are some additional recommendations for midwives who wish to use social networking platforms such as blogs and wiki to develop their e-portfolio. (1) Use technologies that are supported by reputable companies such as Blogger, Google Documents, Google Sites and Wikispaces. Reputable companies will keep data secure and private. However, be mindful that no website is totally secure, so do not post any information that is sensitive and you want to keep confidential. (2) Take time to ‘‘play’’ with the technology so that you become confident with the use of social networking tools as well as the hardware that supports them including video cameras, audio recorders and cell phones. (3) If you do not have digital skills, go to YouTube (http:// www.youtube.com) where you will find lots of videos that will show you how to set up a blog, wiki, etc. (4) If you wish to use an online tool to develop your e-portfolio but you do not wish to make it open, choose a platform that you can keep private and invite selected readers. Most blogs and wiki have that functionality. (5) Think carefully about what you say in an open online environment and how you say it. Talk about clinical practice in generalities, as opposed to specific cases that can be identified. This is no different in the online environment, as it is in the face-to-face context. The difference is that if you say something unprofessional online, many more people have access to it, and it’s always available in one form or another on the internet. (6) Always respond to people who comment on your blog or wiki. But do not expect visitors or comments overnight. It takes time and work to develop a community of practice based around your e-portfolio. (7) Be creative. Your reflections don’t necessarily need to be written pieces. Explore the internet for tools that will help you make videos, photo collages, word puzzles, mindmaps and so on.

5. Discussion An e-portfolio provides a viable avenue for midwives to fulfill statutory obligations, and supports life-long learning which drives professional development. Social networking platforms and tools can be used effectively to support open and collaborative reflection as part of the e-portfolio process. Open discussion allows midwives to engage with others both inside and outside midwifery, which provides another perspective to their reflection. The readers of my blog take me beyond a surface exploration of thoughts, activities or achievements. By asking critical questions, passing on their perspectives and sharing information, readers support me to think deeper, which results in additional learning and enables me to make changes to practice. This is one advantage of collaborative reflection over personal reflection.16 Talking about practice in open online spaces is problematic for midwives and continues to be debated at the highest professional level.26 Discussing practice online can be inappropriate, not least for legal reasons. It can also make the midwife vulnerable to criticism by the profession, especially if the conclusions of her reflection do not concur with the general opinion of the profession.20 Thus, open reflection can lead to ‘mind control’, whereby the midwife is unable to think in an autonomous way for fear of professional ramifications. There is no doubt that I have been aware of what others think of me as a result of what I have written in my blog, and there have been times when I have not been as open as I would have liked. Yet there are aspects of my midwifery practice that I can make open to the public. For instance, my practice statistics are available to help pregnant women make an informed choice about choosing me as their midwife. However, I use a closed, private space to reflect on specific clinical cases, take key learning from the cases and write about learning in a generic way in my open blog. Whilst this approach has led to learning, I am

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(8) Turn your paper evidence in pdf files, such as certificates of attendance and upload them into your e-portfolio to accompany your stories and reflections. (9) If you are required to present your portfolio in paper form, either ‘copy and paste’ into a document, or use tools that turn web pages into pdf files such as Eco-Safe (http://eco-safe.com). (10) Back-up your e-portfolio regularly onto your computer hard-drive, in case the technology you use becomes unavailable.

7. Conclusion E-portfolio provides a viable option to paper-based portfolio for midwives. It allows a creative approach to telling stories about professional learning and life-journeys. Social networking tools provide the ability to showcase work, provide evidence of learning, and reflect on practice. However, midwives need to carefully consider how to do this in a way that protects their professional reputation and client information. In order to be able to develop open e-portfolio to support their learning, midwives need to be educated about the professional use of open spaces. Open reflection, which is social and collaborative, result in shared learning and support. Whether e-portfolio is implemented using open social networking tools or closed proprietary platforms, it needs to incorporate a social aspect. Social interaction and collaboration encourages deep learning and ensures the eportfolio isn’t just a repository for information. Additional research is required to find out what effect reflecting in an open e-portfolio environment has on learning and clinical practice outcomes. References
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