Lifelong learning is vital to keep up to date with evidence based practice. This article reveals how to structure portfolios to best present your professional development
Alison C Clark, MSc, BN, Dip Ned, RNT, practice teacher, Rn, is a lecturer, division of nursing, University of Nottingham, Queens Medical Centre.
Clark AC (2010) How to compile a professional portfolio 1: aims and intended learning outcomes. Nursing Times; 106: 41, early online publication.
Portfolios are a valuable tool that allow nurses to demonstrate their learning and professional development over a period of time. This first in a two part unit on developing a professional portfolio provides a framework for nurses to consider how best to collect, collate and compile a professional portfolio of practice.
Keywords Portfolio, Mind maps, Continuing professional development
- This article has been double-blind peer reviewed.
- To describe the purpose of a portfolio.
- To summarise the key elements of a portfolio.
Professional portfolios are an essential resource for nurses to record their developing skills and knowledge as they progress in their career, and are equally vital for student nurses. The key to compiling a strong portfolio is knowing what constitutes meaningful evidence of their achievements, and how to structure one to best represent their professional and personal development. This applies equally whether the portfolio is being used to record career development or learning on an academic course.
The portfolio needs to reflect the nurse’s approach to patients, their growing skills in meeting patients’ needs, the rationale for their care, and how they work alongside other healthcare professionals and agencies. In some instances, the content of portfolios may have to verified by others to show achievement of the pre-determined outcomes and or standards, such as those from the Nursing and Midwifery Council (2004). The portfolio may also need to demonstrate an ability to carry out a specified role, for instance in relation to the Department of Health’s Knowledge and Skills Framework (2004).
Principles and processes
Regardless of the reason for producing a portfolio, the principles and processes are similar. Scholes et al (2004) define a portfolio as something that: “captures learning from experience, enables an assessor to measure student learning, acts as a tool for reflective thinking, illustrates critical analysis skills and evidence of self directed learning and provides a collection of detailed evidence of a person’s competence.”
This definition can equally apply to portfolios used to reflect professional development and staff job performance. Coffey (2005) suggests the collated evidence provides a “series of snapshots” over time, which represent an individual’s experiences and learning from and about practice.
Judith, (name changed) a second year adult branch student, recently wrote in her learning log that for her: “A portfolio tells a story … of what I have experienced and learnt about myself … about the needs and experiences of clients and their families … about my approach to clients and their families, about how I work” (Clark, 2009).
A portfolio is therefore not just a description of care activities. It needs to demonstrate learning from a range of care experiences. This is not always obvious, and can be missed when giving everyday care. Also, some learning occurs at a subconscious level - from being socialised into the nursing role and through role modelling professional colleagues’ practice.
However, learning can be lost if we do not stand back and look at what we do and how we practice. We do not necessarily question what we are doing. To capture learning we need to take time out to consciously identify with, and review care events to:
- Appraise interactions with patients and/or their carers and the factors influencing them;
- Consider the consequences of the care event from the patient’s perspective;
- Review professional activity and competence, working alongside others, within local or national guidelines.
Competence has been defined in many ways. A commonly used formula identifies the attitudes, skills and knowledge needed to act professionally (Neary, 2001). As early as 1956 Bloom et al devised “a taxonomy of learning objectives”. The objectives were based on the three domains of attitudes, skills and knowledge, and defined different levels of learning within each one. This formula is still relevant and each domain has a particular focus.
Professional attitudes and approach
The Nursing and Midwifery Council Code of Conduct (2008) requires nurses to “work with others to protect and promote the health and wellbeing of those in your care, their families and carers and the wider community”. Nurses’ understanding of, and ability to act within the NMC Code should be evident in their portfolio, for example, protecting the dignity and privacy of patients. They will need to consider how a range of moral and/or ethical issues might influence their practice - such as when a patient refuses treatment - acting as an advocate, delaying discharge when it is deemed unsafe and making decisions about an individuals’ mental competence. This domain is concerned with how they approach, patients and their carers, meet their needs with regard to their dignity and privacy and collaborate within the team providing the care.
The ability to use a range of skills in providing a high standard of care, working within a team, and across agencies is often described as “know how”. Skills can be observational, communicative, interpersonal, practical and technical. Some are now defined as:
- Essential care skills, for example, aseptic technique and nutritional assessment (NMC, 2007);
- Key skills, namely numeracy, literacy and competence in using information technology (NMC, 2004).
Nurses are also being asked to develop new skills in relation to patient and public involvement; working with patients and their informal carers in partnership to consider, design, develop and or improve services (Department of Health, 2010). They may have an opportunity to attend a local engagement group, or a patient experience group, working with members of the public and service providers to inform future health and social care delivery.
Evidence based practice is about knowing “why, what, where and when” as well as “how” to care for people. Helen, a mentor, sees her role as ensuring that students learn to look at patients’ and carers’ needs from different perspectives. She called this “looking through different spectacles”, which means thinking about sociological, humanistic, economic or political perspectives that influence nursing practice, and what patients and carers expect from care services.
Helen works in an integrated discharge team. It is important that students working with her learn to plan safe discharge for older people and understand the political and social factors that influence planned care, whether it is for rehabilitation or if a patient needs to move to a supported environment such as a nursing home.
However, in some instances nurses will need to justify practice where no formal evidence base exists. For example, this could be when care is being role modelled by experienced practitioners who know something works, but which as yet is not supported by research.
In the portfolio nurses therefore need to show:
- How they have gained insight into people’s needs and recognised and managed their health problems;
- That all care is supported, where appropriate, by up to date research findings, protocols and guidelines, which may be from a range of disciplines.
In order to start building a portfolio it is useful to ask three key questions:
- What have I done today in terms of patient care activities or team activities?
- What have I learned today about:
- My approach to …;
- How much I know about …;
- How skilled I am becoming in…
- What do I need to do now to enhance my knowledge, skills or approach?
I call this a “practice note”. Using these three questions is a way of describing and summing up practice experiences and what has been learned. This could be recorded in a learning diary, log or journal.
Activity 1: How to make a practice notation about developing competence to care
What have I done today?
Identify a care activity you undertook recently, such as giving the medicines, toileting or feeding a patient.
Note what happened briefly. Some points to consider in outlining the care activity would be:
- State who and what the activity involved.
- State if you were observing, assisting, or leading the care activity.
- Identify any social, psychological, physical issues and environmental factors that had to be considered in providing the care.
- Note if you knew the underpinning rationale for any of the different aspects of the individuals’ care.
- Comment on how skilled and confident you felt in providing the care both socially, practically and technically.
What have I learnt?
Identify one thing you have learned from outlining this care activity. It may be that although the patient had the same care needs as others you might have had to adapt how you met them or taken a different approach. Map this learning to any outcomes, standard or job descriptors.
What do I need to do now?
Identify your strengths and limitations in giving the care. You might want to consider how much you were able to lead and manage the care activity and how much input you needed from a mentor, clinical supervisor or colleague. You could learn more about the patient’s health problem and how to manage their medication, or teach them to be self medicating. Alternatively, you may decide to spend some time with the speech and language therapist to see how they work so you can understand the full patient journey and experience.
This strategy helps students and their mentors to capture their learning from everyday practice events. Often students can describe what they have done but they do not always see what they have learned. This exercise helps develop students’ and mentors’ awareness of what it means to be competent to practise and to identify further learning needs.
In describing and recording the care given, what happened and why, students can begin to formulate evidence for their portfolio using the above three key questions as a framework to analyse their practice. This exercise is mainly descriptive (see Box 1).
As nurses become more senior, further analysis and critique of their practice is required. There might be a particular aspect of the patient’s care they want to address, such as learning assessment skills - how we act professionally when we might not always be happy with the patient’s choices. A way of developing critical thinking around practice is through reflective discussion. It is useful to do this at first with mentors and clinical supervisors.
According to Howatson-Jones (2010) critical reflection “examines and questions all the factors involved in a situation” to enable the practitioner to see the situation from different perspectives; perhaps taking into account factors that they would not consider relevant without prompting from another. Intentions, assumptions, decisions and actions can be explored in more depth. This enables practitioners to take a longer, more detailed view of their practice.
Students often ask me how to record reflective discussion in their portfolios. Mind mapping and spider diagrams can be a used to précis the depth and breadth of the discussion. Mind maps can help organise thoughts and capture the understanding of a topic or issue on paper (Buzan, 2006/9). Students can formulate them independently or with others. They help to visualise an issue by breaking it down to its key components, and then to see the connections between components.
I use a triangular framework – the PASK triangle (Fig 1) - to help students map the learning from our reflective discussions. Central to the triangle is the care activity and/or proficiency we are trying to define, the need to identify the current level of care required and to assess the student’s ability to perform the care competently. Each corner of the triangle represents a domain of learning, namely professional approach, underpinning knowledge, and skilled care.
Use the PASK triangle to map your knowledge, skills and professional approach to an aspect of your recent practice experience.
Think about an assessment you have recently undertaken. This could be, say, on admission, a re-assessment during the patient’s stay to see if the care plan is still appropriate, or a risk assessment.
Map your thoughts
Why was the assessment being undertaken? (K)
What research, policy or protocols offered guidance for your approach to his or her assessment? (K)
How did you approach the client (staff member), and what influenced how you approached the patient? (PA)
What combination of skills did you need or use to undertake the assessment, and how well developed are these skills?(S)
Draw two lines as in Fig 2, then mark a cross on each continuum to indicate how competent and confident you feel you are in assessing clients or staff.
Reflect on, and summarise what you have learned from this activity about yourself, your competence and confidence in your practice. Identify if there is an area for development to discuss with your mentor or clinical supervisor. Map the results of the mind mapping to any proficiencies or job descriptors you need to show you have achieved in your portfolio.
One area that is perhaps the most difficult to assess and to develop self awareness in, is how nurses’ approach to practice may be influenced by pre-existing beliefs and attitudes. As nurses we all need to be seen to be “non judgemental towards others” in order to provide equitable, fair and just care (NMC, 2008).
Becoming a professional nurse means we have to consider how our own set of values and beliefs will influence how we relate to and care for others. Our socialisation and life experiences result in our developing attitudes that will become the norm unless challenged. But what does that really mean?
Professionally it is important we recognise personal viewpoints on issues and ensure they do not impact on how we act towards individuals. Goldsborough (1970) offered some points about how we can become non judgmental in our practice by being open to new insights about ourselves, learning to set aside personal beliefs and to behave in a professional and empathetic way towards the client.
It can be useful to repeat activity two using the triangular framework, to explore an issue which has challenged previously held beliefs and values about people, the care they do and could receive. For instance, I work with students undertaking placements in the community learning to care for people with drug and alcohol problems, or who are homeless. We often do this exercise at the beginning of placement and again at the end to reflect if they can challenge prevailing media stereotypes, or have changed their outlook about people with these problems.
Students should ask themselves: how does quickly mapping their thoughts around this area of practice reflect their depth of understanding and appreciation of the client’s situation and their role in enabling them to meet their health needs? Would it work as a piece of evidence in their portfolio? How does using the PASK triangle help to identify areas for development?
Building a meaningful portfolio involves exploring a series of practice experiences - working with colleagues, caring for patients, and or their carers. The questions nurses ask themselves or others ask will influence how well they analyse their experience and capture their learning. The key is in keeping the patient and their family central to the evidence, for example caring for people requiring surgery. This will assist nurses in thinking, talking and writing about their practice.
A portfolio is about capturing learning. This requires an ability to question, critique and see how well they can direct and provide consistent and high quality nursing care within a multi-disciplinary and/or multi-agency setting and to justify when and why that care is needed.
It also means being able to identify factors influencing a patient’s health status and the health and social care they receive, to pinpoint factors that influence their practice, to consider the positive attributes of the care they deliver and to develop their knowledge and skills where there is a need.
- Part 2 of this unit, to be published in next week’s issue, explores in more depth what is meant by quality evidence and how to develop it meaningfully.
Box 1. Example of a practice notation
- What did I do today?
Today I went to the cancer support group as usual. I was met by D and the first thing he said to me was “Well that’s it then, Alison, they told me today there is nothing more they can do for me”. I remember thinking “How do I respond to that?” while almost simultaneously replying “that must have been something of a shock”, and sitting down with him and saying: “What do you think they meant?” and “How do you feel?”
I felt it was important to let him talk about what had happened. He told me the doctors had said there was nothing more they could do to halt the cancer, his options and the risk if he chose to undergo major surgery. A year ago I would have felt quite helpless in this situation, not knowing quite what to say, how to respond. I felt this time though it was ok to just be there and listen.
- What did I learn?
I coped with the situation, felt I was able to listen despite feeling sorry for what was happening to him. I was able to reflect with D what the choices in ongoing care meant and the difficult choice he had to make. I am now aware that listening is more important than talking.
- What do I need to do now?
To go on setting time aside to listen to members of the group. Perhaps I could get some feedback on how my non verbal and verbal communication skills “tell” the members it’s ok to sit and talk to me. There must be some theory that supports how non verbal signs make it easy for people to approach or stop people approaching for support. I had better go and look this up.
Bloom B S (1956). Taxonomy of Educational Objectives, Handbook I. The Cognitive Domain. New York: David McKay Co Inc.
Buzan T (2006–9) Mind mapping for dyslexics. The mind mapping resource centre.
Clark A (2009) Capturing Learning in Practice from Practice. Case Study for the Centre of Integrated Learning University of Nottingham. Internal publication in print.
Coffey A(2005) The Clinical Learning Portfolio: a practice development experience in gerontological nursing. Journal of Clinical Nursing; supplement S2, September, 14: 75-83.
Department of Health (2010) The Prime Minister’s Commission on the Future of Nursing and Midwifery inEngland- 2010 Front Line Care.
Department of Health (2004)The NHS Knowledge and Skills Framework (NHS KSF) and the DevelopmentReviewProcess. London: DH.
Goldborough J D (1970) On becoming non judgemental. American Journal of Nursing; 70: 11, November, 2340-2343.
Howatson-Jones L (2010) Reflective Practice in Nursing Exeter: Learning Matters.
Nursing and Midwifery Council (2008). The Code: Standards of Conduct, Performance and Ethics forNursesand Midwives. London: NMC.
Nursing and Midwifery Council (2007) Essential Skills Clusters (ESCs) for Pre-registrationNursingProgrammesAnnexe 2 to NMC Circular 07/2007. London: NMC.
Nursing and Midwifery Council (2004) Standards of proficiency for pre-registration nursing education. London: NMC.
Neary M (2001) Teaching Assessing and Evaluating Clinical Competence: a practical guide for practitioners andteachers. Cheltenham: Nelson Thornes.
Scholes J et al (2004) Making Portfolios Work in Practice. Journal of Advanced Nursing; 46: 6, 595-603.