Introduction

This article describes a portfolio assignment that is one assessment tool in a psychiatric mental health course. The course is required for online students in the Post LPN to BN (Bachelor of Nursing) program at the Center for Nursing and Health Studies, Athabasca University, Athabasca, Alberta, Canada. Post LPN to BN students are adult learners who have approximately two years of vocational education and who have practiced as Licensed Practical Nurses for at least 1 year. In addition to the portfolio assignment, students are required to complete both a scholarly paper and an examination.

In Canada, provincial nursing associations have recently initiated a process of requiring graduates to demonstrate an annual competency profile. While this process has become more established in other jurisdictions such as the United Kingdom, Australia, the United States and other Canadian provinces, it is still a new task for some Registered nurses in Alberta. Portfolios, which have traditionally been used to showcase artists’ creations, practitioners’ professional development as well as students’ progress, are one approach nurses can use to demonstrate ongoing competency. For Post LPN to BN students, their psychiatric mental health portfolio assignment is a section of an ongoing portfolio that they continue to add to throughout their program. On graduation, the variety of artifacts they have constructed provides evidence of meeting different sets of course objectives and the beginning a professional practice competency profile.

A hybrid program, the Post LPN to BN is completed both online using a WebCT course management system as well as at institutions such as hospitals for clinical practicums. Students come from all across Canada, and in their psychiatric course, they spend 60 h in a self-selected mentored placement in their home community and a further 80 h at a provincial mental institution as a cohort. However, the primary medium for ongoing communication, instruction and assessment within the program is asynchronous text-based threaded discussions within a WebCT environment. Table 1 situates the specific portfolio artifacts discussed in this article in relation to the course objectives and one key overarching practice competency identified by the provincial nursing association.

Table 1 Linking artifacts to course objectives and competencies

Literature review

A portfolio has been defined as ‘a collection of evidence’ which is selected for a particular purpose and for the attention of a particular audience (Brown, 1995). While the evidence, purpose, and audiences for portfolios may differ, a process of reflective thinking is central to the meaningful construction of portfolios (Barrett, 2005; Pietroni, 2000; Zubizarreta, 2004).

And yet, understanding the process of reflective thinking is not straightforward. Dewey (1933) established that reflective thinking requires ‘active, persistent, and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusions to which it tends’ (p. 118). Scho¨n (1983) described reflective thinking as processes that have been triggered by confusion, that question how a present experience relates to past understanding in order to generate new knowledge (reflecting-in-action) and that explore how the outcome of previous experience could be improved (thinking-on-action). Theoretical approaches that underpin reflection further suggest that the process involves ‘deliberate learning’ (Boud et al., 1985) and ‘critically challenging assumptions and imagining alternatives’ (Brookfield, 1991). Johns (2000) described reflection as a window through which the practitioner can view experiences, working towards the resolution of contradictions between what may be desirable and what is realistic in actual practice. Moon (2004, 2005) asserted that, in academic settings, since the process and outcome of reflection is most likely represented in written form and will be used to assess learning outcomes, student definitions of the construct include ‘what our professor want to hear’. Freshwater et al. (2005) call for more integration of reflective activities in nurse education and practice.

The benefits of portfolio construction among nurses are well documented. In professional nursing practice, Jasper (1995a) identified that portfolios provide potential for recording nurses’ embedded practical knowledge. They can list professional goals to be achieved, related time frames and individual progress towards meeting those goals (Oermann, 2002). They provide an invaluable reference source of nurses’ achievements (Shakespeare, 2002) and an accurate record of the skills and accomplishments nurses must present when they are seeking new employment opportunities or promotion (Hutt et al., 2004). From a global perspective, regulatory bodies worldwide are increasingly considering requirements for portfolio development (Meister et al., 2002).

In nursing education, Williams (2001) posited that linking portfolio assignments to clinical practice expectations enhances program credibility. Portfolios are evolving as authentic (Wenzel et al., 1998) and holistic (McMullan et al., 2003) tools for assessing practice competencies in ways that tests or grades may not. In her seminal work with graduate students, Jasper (1995b) presented a portfolio workbook assignment that invited student self-direction and reflection to meet identified course outcomes. She asserted that the approach could be incorporated into all forms of education and training events with both a practical and theoretical element.

Since then, in different clinical areas and with different undergraduate learners, a variety of approaches to creating portfolio assignments have been described. For example, Sorrell et al. (1997) collaborated with faculty from the English department to use writing portfolios as tools for learning academic writing as well as assessing critical thinking. Thompson and Farrow (1999) used portfolios to provide ongoing formative assessment and feedback throughout a psychiatric mental health practicum without assigning a formal grade. Tracy et al. (2000) used portfolios to systematically document select student achievements throughout all of their clinical placements. Lettus et al. (2001) used portfolios with adult students returning to university to help them demonstrate competence in unfamiliar acute hospital settings. Williams (2001) used portfolios to facilitate reflection with senior students in an acute adult oncology placement. Corcoran and Nicholson (2004) used portfolios with Specialist Practitioner Qualification students in the critical care area. And Schaffer et al. (2005) used portfolios with learners in a public health course to achieve population-based public health nursing competencies.

Problems with portfolio use include a limited evidence base regarding their effectiveness (Bowers and Jinks, 2004), issues of rigor in measurement (McMullan et al., 2003) and an increase in evaluation time compared to traditional methods (Cole et al., 1995; Lettus et al., 2001). Artifacts may be considered less credible because they are subjective and personal (Ball et al., 2000). A focus on learning how to complete the portfolio can distract from clinical learning, particularly in the early stages of students’ careers (Scholes et al., 2004). Further, an inherent philosophical conflict exists between institutional needs for valid and reliable data for accreditation and learner needs for support, collaboration and formative assessment (Barrett, 2005). A final barrier is that students may be unclear on the benefit of using a learning portfolio, and fulfilling the criteria for the portfolios can remain a low priority (Corcoran and Nicholson, 2004).

The psychiatric mental health portfolio assignment

Learners develop their comprehensively referenced portfolios as an ongoing activity throughout their psychiatric rotation. At the beginning of the course, instructions are provided online within a WebCt course platform and note that completed portfolios are expected to illustrate self-reflection on educational and professional experiences, to demonstrate ability to apply theory and to make clinical decisions in practice.

Throughout the course, both in online and clinical discussions, students are invited to share the work they are doing on each of the artifacts with classmates, members of the staff teams and instructors. With this approach, the final product learners submit for marking includes input from a variety of sources and will be familiar to instructors. And, the completed artifacts are also all posted in online discussion forums for classmates to read. The portfolios consist of four different assignments that examine incidence and prevalence of a mental health issue, explore nursing and psychological theorists, analyze referral instruments and construct case studies.

The first artifact: examining incidence and prevalence

The first artifact examines the incidence and prevalence of mental health issues in the learner’s own community. Since students in the Post LPN to BN program live all across Canada, issues differ between regions. Students are required to initiate e-mail or telephone contact with the national mental health association office in their area and inquire about the specific programs offered. They pose questions that will enable them to identify three or four keys mental health needs in their own community. The work is evaluated in a twopage summary of the findings that includes a minimum of two references.

Examples of issues that emerged for students in core urban areas included homelessness among individuals diagnosed with a psychiatric illness such as schizophrenia. Issues in suburban city areas included the stigma of seeking help for psychiatric illnesses such as depression, stimulant medication for children diagnosed with attention deficit disorder and eating disorders. Students in rural areas targeted similar issues and included a limited access to treatment in their discussions. One student, who lived near a First Nations reserve for Canada’s aboriginal peoples, commented on the increased incidence and prevalence of suicide within this community. Another student, from a small northern mining town, noted the pervasiveness of alcoholism in his area. And, issues of drug and alcohol addiction were certainly apparent in all areas of the country.

References used for the incidence and prevalence artifact included local reports and strategic plans from hospital or regional treatment centers, national government publications and World Health Organization documents. For many students, accessing a web or print publication from a local health care agency and comparing the information with national and international data was a new experience. The collaborative nature of the portfolio assignment invited learners to seek help from instructors and the mental health professionals in their community to access and interpret appropriate references.

The initial contact students made to complete this aspect of their portfolio was also valuable in seeking practicum placements at a later time. The student who contacted a First Nations reserve nurse for more information on the high incidence and prevalence of suicide among native Canadians was later able to complete her individual practicum with this nurse. Similarly, the student who contacted a Fetal Alcohol Syndrome agency for more information about the pervasiveness of alcoholism in his northern mining town also obtained an individual practicum with this agency.

Posting the incidence and prevalence reports in the online discussion forum for classmates provided the class with a variety of information on mental health issues across the country. Reading classmates’ work stimulated useful reflection on both the content of the reports as well as the process of seeking out information about mental health issues from local, national, and international resources.

The second artifact: exploring theorists

The second artifact explores nursing and psychological theorists. As learners can find the scope of theories underpinning psychiatric nursing approaches overwhelming, this artifact seeks to demystify the information by personalizing the theorists themselves. Students are invited to imagine that they have an opportunity to join Hildegard Peplau and two psychological theorists for lunch.

In their portfolios, students write up a one or two page account of the kind of conversation that might occur amongst the group. While no references are required, the work is expected to demonstrate an understanding of the ideas and thinking purported by the theorists. Students are encouraged to incorporate humor, to present the disagreements that would be expected between members of the lunch group and to join in the discussion and interject their own thoughts.

This assignment is due after the online groups have met one another and completed their group practicum at a psychiatric hospital. Therefore, in addition to instructors, classmates, and practitioners from community agencies, input from practitioners on acute psychiatric units can also be incorporated. Students have reported that this artifact is the one they have had the most fun with.

Reading about the theorists with the intention of literally inviting them to join the mental health team over lunch in a hospital cafeteria calls for innovative interpretations of textbook material and has produced stimulating discussions. Students individualized this artifact in a variety of different ways. Melrose (in press) elaborated on how students created lively lunch conversations centering on patients they met in the clinical area as well as on their own families and workplaces.

The third artifact: analyzing a referral instrument

The third artifact analyzes a referral instrument relevant to the learners’ current or future practice and notes author, reliability and validity. Students are required to select one assessment tool that would be useful in their own workplace. The tool may be applicable for clients with an identified psychiatric problem or for functioning individuals seeking balance and mental well being. Students must identify the original creators of the instrument and at least one research study testing reliability and validity. They are to include both an electronic blank copy of the instrument for future reference and an example of the completed tool in a Word document. They are reminded to include the source of the tool and any copyright restrictions on any copy used. Instructions include a comment that students may need to communicate with the original author or institution to obtain permission to use the instrument. And they are required to follow the American Psychological Association guidelines.

Examples of instruments that students have presented in this artifact include the Global Assessment of Functioning Scale, the Folstein Mini Mental State Examination, the Hamilton Rating Scale for depression, the Edinburgh Post Natal Depression Scale and the CAGE alcohol abuse screen. With this learning experience, students commented that they gained a deeper understanding of how they might use reliable and valid referral instruments to advocate for patients beyond the psychiatric specialty.

For instance, on a post natal home visit, in addition to noticing that a new mother seemed sad, the student who researched the Edinburgh Post Natal Depression Scale reflected on how she could use this tool to obtain psychiatric intervention for her patient if necessary. As a reflective tool, this artifact calls learners to examine ways they can incorporate evidence based psychiatric documentation in to their existing nursing practice.

The fourth artifact: constructing case studies

The fourth artifact constructs inpatient case studies that summarized learners’ inpatient clinical experiences at the psychiatric hospitals. Students present case studies of two patients they met or worked with and include medical diagnosis (all DSM IV axis), relevant mental status examination findings, all prescribed medications (classification and expected side effects), any presenting side effects and multidisciplinary treatment approaches. Instructions placed an emphasis on nursing care approaches and entry to practice competencies. Case studies were expected to conclude with a reflective analysis of the personal learning achieved. Students were invited to work on drafts of their case studies throughout their practicum and to critique writing within the clinical groups before submitting work for marking. Data from patient’s charts as well as practical tips gleaned from interviews with staff and unit care plans were expected to be included. Students were told that the case studies would serve as a remembrance and summary of their inpatient practicum and of all the people they met during their stay at the institution. They were encouraged to have fun with this section of their portfolio and create a product they felt proud of.

Lessons learned

Overall, feedback from participants about the process of co-creating and sharing their portfolio artifacts was positive. Initially, the requirement to read local, national, and international publications on the incidence and prevalence of psychiatric mental health disorders seemed daunting. Although these adult learners were employed in health care facilities, few were familiar with the formal publications such as strategic plans and community reports that their agencies published. Posting this artifact in the online WebCT classroom offered opportunities to compare and contrast issues among different geographical communities. Associating a member of the class with a report from a particular region helped bring the issue to life. And, in several instances, students began asking questions in their workplaces when mental health issues were targeted in strategic plans but not followed up by actions. While this first artifact in the portfolio was clearly challenging for learners, by sending incomplete assignments back with revisions and suggestions before marking, instructors modeled both the high expectations inherent within the course and opportunities for collaboration.

Where students experienced difficulty with this artifact was in interpreting statistical analysis of disease conditions. Also, in the smaller rural areas, agency documentation was less comprehensive than in the larger urban centers, leaving some students feeling disadvantaged.

The experience of looking for theorists to talk with, sitting around the lunch table ‘with’ them and discussing possibilities for bringing their work to life was enjoyable. The invitation to balance the previous artifact with this more lighthearted activity was welcome. And, the conversations this activity generated among students and practitioners were lively.

While students found this artifact engaging, instructors expressed some difficulties. As they began the project, students were not sure what the final product was expected to look like. Offering direction and constructing a fair marking rubric was not straightforward. Wherever possible, students were honored for their creativity and instructors sought to strengthen knowledge deficits through ongoing communication. And, when students’ public lack of understanding about a theoretical concept became apparent, it was not easy to build in private remedial strategies.

Analyzing referral instruments used in the psychiatric area was intriguing for most students. Previously, their experience with written tools for collecting patient information generally involved working with instruments their managers selected. Seeking out the original authors and reliability and validity studies of tools such as the mini mental status examination raised important questions. Students commented that the assignment helped them view forms used in their workplaces in different ways. And, several commented that they intended to incorporate the instrument they chose to their current practice.

Difficulties for students with this task involved seeking out concise instruments that would be available for nurses to use. Also, when several students in a cohort group all chose to work on the same tool, the postings become less varied.

Constructing case studies of their patients engaged students readily. Most had previous experience with this process but appreciated the additional learning of identifying and prioritizing mental health needs. And, the opportunity to analyze personal learning at the end of the course was well-received. Students did find the complexities of the psychiatric patient presentations difficult to understand, but the collaborative reflective nature of the portfolio construction encouraged questioning and communication with staff teams.

Conclusion

The psychiatric mental portfolio artifacts illustrated in this article were adaptable assignments for adult learners in both online and clinical practice educational events. Creating engaging collaborative activities that showcase knowledge, invite authentic assessment and meet rigorous professional competencies is both a challenge and an opportunity for nursing education practice.

References

Pietroni, R., 2000. The Toolbox for Portfolio Development: A Practical Guide for the Primary Healthcare Team. Radcliffe Medical Press, Abington, Oxon, UK.

Schaffer, M., Nelson, P., Litt, E., 2005. Using portfolios to evaluate achievement of population-based public health nursing competencies in Baccalaureate nursing students. Nursing Education Perspectives 26 (2), 104–113.

Scholes, J., Web, C., Gray, M., Endacott, R., Miller, C., Jasper, M., McMullan, M., 2004. Making portfolios work in practice. Journal of Advanced Nursing 46 (6), 595–603.

Scho¨n, D.A., 1983. The Reflective Practitioner: How Professionals Think. Temple-Smith, London.

Shakespeare, P., 2002. Building portfolios. Nursing Management 9 (1), 30–34.

Sorrell, J., Brown, H., Silva, M., Kohlenberg, E., 1997. Use of writing portfolios for interdisciplinary assessment of critical thinking outcomes of nursing students. Nursing Forum 32 (4), 12–13.

Thompson, R., Farrow, T., 1999. The workbook portfolio: facilitating undergraduate student learning in a mental health clinical area. Nursing Praxis in New Zealand 14 (2), 21–30.

Tracy, S., Marino, G., Richo, K., Daley, E., 2000. The clinical achievement portfolio: an outcomes-based assessment project in nursing education. Nurse Educator 25 (5), 241–246.

Wenzel, L.S., Briggs, K.L., Puryear, B.L., 1998. Portfolio: Authentic assessment in the age of the curriculum revolution. Journal of Nursing Education 37 (5), 208–212.

Williams, J., 2001. The clinical notebook: using student portfolios to enhance clinical teaching learning. Journal of Nursing Education 40 (3), 135–137.

Zubizarreta, J., 2004. The Learning Portfolio. Anker Publishing, Bolton, MA.