Barriers to electronic portfolio access in the clinical setting

Barriers to electronic portfolio access in the clinical setting

Nurse Education Today 30 (2010) 768–772 Contents lists available at ScienceDirect Nurse Education Today j o u r n a l h o m e p a g e : w w w. e l s...

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Nurse Education Today 30 (2010) 768–772

Contents lists available at ScienceDirect

Nurse Education Today j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / n e d t

Barriers to electronic portfolio access in the clinical setting Fiona E. Bogossian ⁎, Susan E.M. Kellett 1 The University of Queensland, School of Nursing and Midwifery, Edith Cavell Building, Herston Campus, Queensland, 4029, Australia

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Article history: Accepted 7 February 2010 Keywords: Electronic portfolios Clinical education Computers Student nurses

s u m m a r y Background: The University of Queensland has developed the Clinical Practice Performance electronic Portfolio (CPPeP) as a learning and assessment tool for third year nursing students. To promote effective use of the CPPeP in the clinical setting, barriers must be identified and strategies developed to overcome them. Methods: A 24-question survey exploring the use and perceptions of the CPPeP was administered to 42 third year nursing students. Questions explored actual barriers encountered while eight open-ended questions were thematically analysed for perceived barriers. Results: A 100% response rate was achieved. Students were comfortable with working with computers. Twenty nine students (69%) encountered specific barriers. Of the 152 written comments to the open-ended questions, perceived barriers were evident in 72 of them. Barriers experienced related to gaining access, finding time and staff attitude. The majority of students made their portfolio entries at home. Conclusion: Students enjoyed using the CPPeP but competed with staff for the limited numbers of computers available. Heavy workloads and ‘busyness’ of the wards also prohibited access along with negative staff attitudes and reluctance of registered nurses to engage as student preceptors. The issue of overcoming barriers is more complex than simply providing more computers or overcoming staff prejudices. Finding time is a barrier not easily overcome given the current and projected nursing shortage. © 2010 Elsevier Ltd. All rights reserved.

Introduction Undergraduate health science education requires assessment practices which, in addition to the graduate attributes of the university, demonstrate student learning and outcomes in a manner that proves attainment of professional and regulatory attributes. While this is not an unreasonable expectation, it is complicated by realities of the contemporary health workplace. The industry demand to provide a more work-ready graduate has resulted in increasing clinical exposure of students, sometimes in a health care environment characterised by skills shortages. Students and clinicians often find it difficult to articulate the complex range of knowledge, skills and attributes they are required to demonstrate as beginning health practitioners. The School of Nursing and Midwifery at The University of Queensland (UQ) has developed a suite of Clinical Practice Performance electronic Portfolios (CPPePs) in response to this challenge. Despite the emergence of electronic portfolios (or e-portfolios) as an educational tool in nursing and other health care disciplines (Garrett and Jackson, 2006; Harden, 2007; Lawson et al., 2004), little has been published addressing barriers encountered by students who use these instruments in the clinical environment. This paper identifies barriers

⁎ Corresponding author. Tel.: +61 7 3346 4853; fax: +61 7 3346 4851. E-mail addresses: [email protected] (F.E. Bogossian), [email protected] (S.E.M. Kellett). 1 Tel.: +61 7 3346 5269; fax: +61 7 3346 4851. 0260-6917/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2010.02.003

encountered by final year nursing students using the CPPeP in order to develop strategies to overcome these barriers. The CPPeP In Australia, students must successfully complete a three year Bachelor of Nursing program in order to attain licensure as a registered nurse (RN) by the regulatory authority. Students at UQ complete the nursing CPPeP in the final year of their studies. The CPPeP offers advantages over traditional portfolios in that it: requires systematically guided attainment of national discipline-specific professional competencies; incorporates graduate transition skills; translates the University generic graduate attributes into practice; and is applicable to a diversity of practice settings while overcoming some limitations of paper-based portfolios experienced by students and teaching staff. The CPPeP, the digital progression of the School's paper-based portfolio in line with contemporary educational developments and technological capabilities, was implemented in 2006. Students complete their CPPeP as a mandatory academic component. While the setting for CPPeP completion is flexible, students are encouraged to use computers available in the clinical setting. It is anticipated that the ability of students to make and receive contemporaneous entries and feedback at the bedside will enhance the accuracy of their entries and their ability to integrate theory with practice (Bogossian et al., 2009). A survey of computer accessibility and availability in the clinical setting and for students' personal use was not undertaken before the CPPeP was launched. However, the initial evaluation of the CPPeP (Cooper et al.,

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2006) occurred concurrently with its implementation and identified barriers to its use including lack of access to computers and availability of email account preceptors. RNs, who act as clinical preceptors, provide feedback to students on their performance and have access to clinical lecturers – UQ faculty staff – for support in this role. On initial implementation of the CPPeP, preceptors received training for the system from Nurse Unit Managers who attended an education session on the e-portfolio. For additional support, a CPPeP user manual was located in each clinical area. Clinical preceptors make CPPeP entries but are not involved in summative assessment of the student's competence with respect to specific professional standards or the portfolio in general. To provide feedback, clinical preceptors must have an email address enabling them to log-on to the CPPeP with a student in order to review the student's evidence of performance.

Literature Students have reported paper-based portfolios being bulky and containing too much documentation (McMullan, 2008). One study (Timmins and Dunne, 2008) identified paper-based nursing portfolios can weigh between 0.5 and 1.5 kg. Excessive volumes of paperwork make portfolio maintenance difficult, time-consuming and stressful to students (Davis et al., 2009; Timmins and Dunne, 2008) as upkeep of the document detracts from clinical contact (Davis et al., 2009; McMullan, 2008) and overall educational value and relevance (Williams et al., 2008). Portfolios may result in learning that becomes disjointed if students perceive each semester to be separate from their overall development without seeing connections across the broader span of their education (Sher et al., 2002). The bulkiness of the portfolio may also conceal incomplete aspects of students' learning through omission or lack of depth of comprehension and reflection (McMullan, 2008). This can also be time-consuming and stressful to academic staff who must “... wade through the portfolio” (p. 339) in order to confirm and assess its content (Timmins and Dunne, 2008). E-portfolios overcome bulkiness (Hawthorne and Bogossian, 2005) and can significantly reduce the volume of paperwork generated (Lawson et al., 2004). Learning becomes participant-centred and promotes creativity (Lewis and Baker, 2007). While located in the clinical setting, students can access competencies and concepts previously learned thereby integrating learning into a more cohesive structure (Bogossian et al., 2009) and reflect upon and receive feedback contemporaneously to the activity undertaken (Lawson et al., 2004). Other advantages to students include the ability to recognise connections between different aspects of their education (Hayward et al., 2008); identification and assessment of personal strengths and weaknesses; and observation of their progress and development over the course of their studies (Hayward et al., 2008; Skiba, 2005). Eportfolios have been associated with reduced workloads for students and staff and engagement of students with reflective learning (Pink et al., 2008). While the transition from the paper-based portfolio to the digital format clearly offers advantages, it is not without its own barriers. Eportfolios are regarded as a form of electronic learning (e-learning) whereby electronic technologies are used to facilitate learning (Farrell, 2006). The advantages of e-learning include cost effectiveness, flexibility of access, and a learner-centric focus. E-learning methods require minimal information technology (IT) literacy but high levels of personal motivation in order for students to be successful (Farrell, 2006). Washer (2001) concluded women were generally disadvantaged when using computer technology and web-based learning methods. They were less likely to embrace e-learning and, “ ... given that the profile of nursing students is still predominantly female, this points to the need for teacher input to instruct (and enthuse) about how useful the internet can be for students” (p. 459).

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To participate in e-learning methods, specifically e-portfolios, students need access to computers in the clinical setting. An initial evaluation of the CPPeP identified barriers to its use by students and clinical preceptors (Cooper et al., 2006) and confirmed assertions that limited computer access in clinical areas constrained e-portfolio effectiveness (Lawson et al., 2004). Students located in high dependency areas like ICU, where nursing care occurs exclusively at the patient's bedside, were geographically separated from desktop PCs. The limited numbers of computers in clinical areas were generally used for specific administrative purposes or data entry and students had little opportunity to access them unless they were working on night duty when demand for computers was low. When computers were available, lack of time during shifts precluded their use by students and clinical preceptors (Cooper et al., 2006). Lack of time was a barrier to e-portfolio completion by nursing and medical students in the clinical area along with heavy workloads (Garrett and Jackson, 2006). Lack of computers in the workplaces and “ ... the hectic, intense, interrupted nature of nursing work and lack of time” (p. 29) have been reported as obstacles by RNs undertaking computer-based education in the clinical area (Atack, 2003) along with deficiencies in users' basic IT skills (Wright and Bingham, 2008). CPPeP access in the clinical area was restricted to clinical preceptors with email accounts (Cooper et al., 2006). To develop a successful eportfolio, students need access to “ ... a technologically successful mentor” (p. 35) as well as appropriate hardware, software, and networking tools (Ramey and Hay, 2003). The average age of RNs in Australia is 45 years (Australian Institute of Health and Welfare, 2008). Significantly, this group of clinicians “ ... will have completed their education before information technology became imbedded in everyday activities” (Huntington et al., 2009, p. 1314) and may not be technically proficient in or comfortable with using digital technologies. Deficient preparation of students and their mentors for e-portfolio use was reported when IT skills of both were initially overestimated by researchers (Lawson et al., 2004) and ongoing e-portfolio technical support has been recommended (Garrett and Jackson, 2006). Negative attitudes from preceptors towards the CPPeP may also be influenced by their “ ... lack of consultation and inclusion when designing the portfolio system” (Cooper et al., 2006). Although staff unfamiliar with digital technologies may be reluctant to engage with their use, involving them in planning of digital education strategies may enhance their acceptance (Miller et al., 2005). Use of handheld, wireless digital devices such as the personal digital assistant (PDA) and tablet PC is becoming more widely reported (Bogossian et al., 2009; Harden, 2007; Ramey and Hay, 2003) as a means by which students can utilise e-learning methods in the clinical environment. The portability inherent in these devices overcomes some of the desktop PC's limitations. However, they are not immune from barriers of their own: small screen size along with difficulties using the hand-writing applications (of PDAs in particular) discourages use of these devices at the bedside (Garrett and Jackson, 2006). These relatively new technologies may challenge traditional nursing culture. Senior nurses may not support use of these devices by students (Berglund et al., 2007) and professional jealousy from other allied health members has been reported (Bogossian et al., 2009). Students report fearing patients will perceive them as ‘unprofessional’ (Berglund et al., 2007) or ‘incompetent’ when using wireless devices at the bedside (Bogossian et al., 2009). Cultural change is required if e-learning methods are to be successful (Farrell, 2006) and resistance may be reduced when benefits of the technologies are recognised by their critics (Thompson, 2005) and their use sanctioned by management (Berglund et al., 2007). Security of handheld devices poses a major barrier to their use. Students may fear their loss, accidental erasure of the applications they contain (Scollin et al., 2007) or theft of the device (Bogossian et al., 2009). Finding appropriate space and time to use a tablet PC and ‘busyness’ of the wards also precludes e-portfolio completion. Students preferred to make their entries at home rather than contemporaneously

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while in busy clinical settings (Bogossian et al., 2009; Garrett and Jackson, 2006). They indicated ambivalence about the e-portfolio's ability to increase the accuracy and authenticity of their entries at the point of care (Bogossian et al., 2009). Healthcare professionals in general prefer to undertake computer-based professional education at home (Dames and Handscomb, 2002). Methods Approval to conduct the study was granted by the University's Ethical Review Committee and informed consent was implied by completion of the survey. A participant information sheet describing ethical approval for the study and the consent process was administered. A 24-question paper-based instrument was distributed to 42 third year nursing students on their last compulsory day on campus. A postal survey mailed to 36 clinical preceptors to determine their perceptions of CPPeP use by students included a reply-paid envelope. Surveys were assigned a sequential number in order of return (S1, S2 etc). Five questions addressed demographics with the remaining 19 questions exploring use and perceptions of the CPPeP. Of the latter, eight questions were open-ended and thematically analysed. Results The response rate was 100% for the student surveys. Forty (95%) of the students were female. Thirty-five (83.5%) students were aged 20 to 25 years with three (7%) less than 20 years of age and four (9.5%) aged 26 to 55 years. Twenty-eight students (66.5%) were located in public hospitals and fourteen (33.5%) in private hospitals. Only one hospital was regionally-based. The majority of students (90%) indicated being comfortable working with computers by responding they were ‘extremely comfortable’ (52%) or ‘very comfortable’ (38%). Only four (10%) admitted to being ‘somewhat comfortable’. All were female and aged 36 to 55 years (n = 1) or 20 to 25 years (n = 3). No student identified being ‘not comfortable’ using computers. Only 9.5% (n = 4) believed they had not received an appropriate level of CPPeP training with two students (5%) feeling they needed additional training. Both were female and aged 20 to 25 years. The majority (88%) of students preferred using the e-portfolio over the paper-based version finding it more convenient, less bulky and unable to be misplaced or lost. Of the remainder, two students did not state a preference and three preferred the paper version because of issues related to computer access in the clinical area or reluctance of RNs to act as preceptors. Just over half (57%) the students reported the CPPeP facilitated integration of theory and practice to a greater degree than the paperbased portfolio while the majority of students (69%) thought access to the CPPeP in the clinical setting increased both accuracy of their entries and motivation to complete their portfolio. When asked “Did you experience any barriers to using the CPPeP in the clinical environment?”, 29 students (69%) identified specific obstacles encountered. A total of 152 written responses were made to the other open-ended questions. Of these, 72 comments related to perceived or actual barriers. Six students (14%) experienced barrierfree access to CPPeP within their clinical setting. All but one of these students were located in a public hospital. Four main themes relating to barriers emerged from the open-ended questions: (i) Gaining Access, the access to computers and the internet; (ii) Finding Time, the demands of clinical loads which affected students' ability to use the CPPeP and engage with their preceptors; (iii) Staff Attitude, the negative reaction of clinical staff to students accessing the CPPeP or their inability to support students in its use; and (iv) Overcoming Barriers, the strategies employed by students to overcome perceived barriers.

Gaining access Barriers associated with access related to: numbers of computers available in the clinical area; their location; competition for their use with clinical staff; and inability to access the internet. Twenty students (47.5%) commented on the limited numbers of computers available while seven students (16.5%) reported specific clinical locations, such as the Emergency Department and ICU (n = 3), the Nurses' Station (n = 3) and a busy surgical ward (n = 1) as limiting factors to accessing PCs. Additionally, some students (n = 7) admitted competing directly with clinical staff for access to any available computers: “There were only two computers accessible to nurses on the ward. As it was a busy surgical ward, doctors, physios and nurses fought over computer use. When I did have access, I only had a short time to use the computer” (S.39). Two students were further frustrated when institutional gateways prohibited access to many internet sites, including the CPPeP. Finding time Finding time was a barrier heavily influenced by clinical workloads and ‘busyness’ of the wards. Competition was again evident as 14% of students (n = 6) prioritised the need to complete nursing care, acquire new clinical skills and help other nurses over portfolio requirements. Specific shift times emerged as barriers. Four students reported difficulty on morning and/or evening shifts when PCs were in high demand by RNs, doctors and other allied health workers while two students were only able to access their e-portfolio on evening and/or night shifts “when the ward was quiet” (S.25) and workloads less demanding. Finding time was also identified as a barrier to engagement of clinical preceptors. Three students believed their preceptors did not have enough time, or it wasn't convenient, to log-in, mark attributes and “ ... put a lot of thought into their comments” (S.9) while working in the clinical setting. Staff attitude Five students (12%) reported negative attitudes from RNs when using their CPPePs with all but one of these students located in private hospitals. Two students felt nursing staff perceived ward computers as their personal property and experienced resentment from RNs when using ‘their’ computers. The ward was not seen as an appropriate place to study and if students were found using PCs they were quickly allocated a task to perform, the inference being “ ... if you have time to sit at the computer then you must need something to do!” (S.33). A student working in a regional, public facility stated being specifically prohibited from accessing their CPPeP by ward staff who did not believe using the computer was appropriate as “ ... I should be getting ‘clinical experience’” (S.22). Additionally, two students reported feeling self conscious when using the CPPeP, often needing to justify their use of the PC and perceiving staff were scrutinising their activities. Nineteen percent of students (n = 8) were frustrated by RNs who were reluctant or unavailable to act as clinical preceptors or appeared to have difficulty supporting the e-portfolio. Heavy workloads, lack of email addresses, restrictions on email access, poor IT abilities and general dislike of computers emerged as reasons restricting ability of RNs to act as preceptors. Two students felt the paper-based portfolio would have facilitated better preceptor engagement as it could overcome many issues cited by preceptors. Overcoming barriers The majority of students made their CPPeP entries at home (71.5%). Just over one-third of students (n = 15) used the words

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‘easier’ and/or ‘more convenient’ to justify working on their e-portfolio in this location while others (n = 14) referred to lack of time in the clinical setting or availability of time at home. Students also enjoyed unrestricted access to a computer and internet sites as well as a quiet, relaxed environment. Some students made entries in the clinical setting (12%); both at home and in the clinical setting (12%); and two students used the university library. One student, who completed the majority of their entries in the clinical setting, commented that this occurred only on night duty. In relation to barriers to CPPeP access in the clinical area, Student 19 summed it up succinctly when they reported: “... there were some issues concerning the convenience of CPPeP which include the availability of nurses, availability of computers on the ward and finding a convenient time”. Clinical preceptor surveys Only two clinical preceptors (5.5%) returned the survey. Located in a public and a private facility, both stated they were ‘somewhat comfortable’ working with computers and had not received adequate training in the use of the CPPeP. Surprisingly, neither indicated they needed ongoing support. “The only education and training I received was from what the student taught me.” (Clinical Preceptor 1). Both believed the CPPeP facilitated students' integration of theory to practice and motivated them to complete the portfolio to a greater degree than the paper-based portfolio. One preceptor perceived a barrier to CPPeP use in the clinical setting: availability of computers. Discussion At UQ, students generally spend the majority of their clinical placements at the same institution and are managed by the same clinical lecturer for the duration of their three year degree. Therefore, while a 100% response rate is unusual in voluntary surveys, this was largely influenced by two factors: it was administered by clinical lecturers, faculty with whom students had developed close and trustful professional relationships; and high morale related to the last day of undergraduate life. Both were key strategic considerations in the administration of the survey. The assertion that women are culturally disadvantaged in utilisation of computers and less likely to embrace e-learning for educational purposes (Washer, 2001) was not supported by this study. Students were predominately female and comfortable using computers. Only two desired additional training specifically related to the e-portfolio. Three women preferred the paper-based portfolio. However, their motivation was related to lack of computers and preceptors rather than IT fluency. Washer's conclusions were drawn from literature published in the mid-to-late 1990s and may be considered redundant in a society increasingly reliant on IT. This study confirms findings that lack of computer access in the clinical area limits students' effective use of an e-portfolio (Cooper et al., 2006; Lawson et al., 2004). Competition for access was a factor experienced by students as they struggled with the demands of their own clinical workloads to find time to use their e-portfolios. This finding is supported when tablet PCs are utilised (Bogossian et al., 2009). Students of this study also competed directly, and often unsuccessfully, with clinical staff for use of a limited number of computers. While allocating students with their own wireless device could overcome this obstacle, students using tablet PCs in the clinical area continue to compete with staff for computer access albeit indirectly: they experience difficulty finding a secure space in which to set up and use their computers in a busy workplace (Bogossian et al., 2009). Clearly access to CPPeP in the clinical area is more complex than simply providing appropriate numbers of computers for students to use. Students accepted frustrations associated with CPPeP access in the workplace with grace. Many perceived that clinical staff had greater

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need for available computers or that care requirements of patients took precedence over academic requirements of the e-portfolio. Morning shifts were perceived as inappropriate times to access the CPPeP due to the busy and competitive nature of the clinical area and patient care needs. Several students accessed their e-portfolio only on night duty or during evening shifts. This concurs with findings that CPPeP access is generally easier on quieter nocturnal shifts (Bogossian et al., 2009; Cooper et al., 2006) and that lack of time associated with clinical workloads effectively prohibits access to e-portfolios by students (Garrett and Jackson, 2006). It is not surprising that most students preferred to make e-portfolio entries at home: they did not have to compete with other staff for computer access or the conflicting demands of patient care in a busy environment characterised by interruptions and distractions. Home was quiet and afforded the luxury of being able to concentrate and use a variety of additional sources, including internet sites, not always accessible on the wards. Additionally, students did not have to contend with perceptions of intimidation from staff “looking over my shoulder” (S.41) or displaying displeasure at the use of ‘their’ computers by students. Home was also the commonest location for students using tablet PCs to access their CPPeP (Bogossian et al., 2009) along with clinical staff undertaking computer-based education (Dames and Handscomb, 2002). The negative attitude towards the CPPeP experienced by some students supports assertions that others may not readily accept use of new technologies by students in the workplace (Berglund et al., 2007; Bogossian et al., 2009) regardless of whether they use handheld devices or desktop PC. Nurses may perceive students using their e-portfolio as interfering with the process of ‘learning by doing’ while in the clinical area and distracting them from patient care (Hyde and Brady, 2002). This is reflected by the attitude that a student working on a computer ‘ ... must need something to do’ (S. 33). Acceptance can be influenced by benefits of the technology being demonstrated (Thompson, 2005), however, this is not readily achievable with a digital portfolio. While the CPPeP contributes to the development of a more work-ready graduate, its benefits may not be demonstrated until the postgraduate is working as an effective member of the nursing team. Even then, e-learning methods in general may not be perceived as credible educational strategies by senior clinicians (Farrell, 2006) and the perception that elearning does not receive the same recognition in the workplace as traditional on-campus tertiary courses has been reported (Atack, 2003). These professional prejudices may further conceal benefits of the eportfolio. It is noteworthy that nursing staff in public hospitals appeared to be more supportive of students' access to the CPPeP than those in private facilities. In Australia, public hospitals are funded and managed by state governments whereas private facilities are owned and administered by religious orders or private corporations that are reliant on income sustained. Four students located in private hospitals reported negative attitudes from nursing staff compared to only one in a public facility. Additionally, five of six students who did not experience any barriers were located in public hospitals. Perhaps the profit-dependent nature of the private hospital industry engenders a culture heavily reliant on immediate and quantifiable work outcomes and this influences staff attitudes to activities not directly related to achieving this goal. RN reluctance to act as preceptors, as evidenced by student comments, is difficult to interpret. Whether RNs were reluctant to be preceptors or reluctant to complete the CPPeP as part of their preceptor role requires further investigation. However, difficulties with engaging RNs to act as preceptors appeared to be influenced by: heavy workloads; IT proficiency; email access; and, possibly, education issues relating to the CPPeP. Most facilities have provided institution-based email accounts to their staff in the period since this study was completed. The issue of IT proficiency influencing RNs' reluctance to act as preceptors should be overcome as Baby Boomer and older Generation X

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clinicians either develop their proficiency (Huntington et al., 2009) or retire and are replaced by the more techno-savvy Gen Y. Resolving heavy workloads cannot be viewed as optimistically with the global shortage of nurses predicted to continue impacting the provision of healthcare well into the next decade and beyond (Buerhaus et al., 2009). RNs may have been reluctant to engage as clinical preceptors simply because they did not know how to use the CPPeP. Certainly, responses of the two clinical preceptors suggests educational preparation to support clinicians was lacking. Despite the barriers to CPPeP access experienced in the clinical area, the majority of students preferred using the e-portfolio to the paperbased version and confirmed studies reporting traditional portfolios as being bulky, weighty, time-consuming (McMullan, 2008) and difficult to manage (Davis et al., 2009; Timmins and Dunne, 2008). Students perceived accessing their portfolio at the point of care positively influenced both accuracy of their entries and ability to integrate theory with practice, a perception shared by the two clinical preceptors. However, the very low response rate from clinical preceptors was disappointing and prevents any conclusions being applied with confidence to the general population. Generally, the ambivalence of students towards the CPPeP in promoting accuracy and integration of entries evident in our previously published study (Bogossian et al., 2009) was not supported here. Based on the findings of this and other studies (Bogossian et al., 2009; Garrett and Jackson, 2006), perhaps the question that needs to be asked is whether the clinical area is the appropriate place for students to access their e-portfolios? Although it was anticipated some barriers might be overcome with increased access to computers, this has not been demonstrated as heavy workloads and lack of time continue to inhibit their use (Bogossian et al., 2009). Perhaps the sentiments of some nurses that the wards are not “an appropriate time or place to study” (S. 31) should not be perceived negatively as an aversion to reflective practice but rather as the reality of contemporary healthcare. Conclusions This paper identified barriers encountered by third year nursing students when using the CPPeP in the clinical setting with four main themes emerging from the data: gaining access; finding time; staff attitude and overcoming barriers. Gaining access was associated with the limited number of computers available in the workplace and competition with clinical staff for their use. Finding time was influenced by clinical workloads and the ‘busyness’ of the wards while staff attitudes included negativity of staff toward e-portfolio use and reluctance to engage as student preceptors. Students accepted some barriers with grace, recognising the needs of staff to access the computers and provision of nursing care took priority over their use of the CPPeP. Students therefore made the majority of their portfolio entries at home. Even if access to computers in the clinical setting can be improved, negative staff attitudes to the CPPeP overcome and preceptor engagement promoted, e-portfolio use will still be complicated by a contemporary healthcare system characterised by heavy clinical workloads and lack of time. Despite these barriers, students were comfortable using the e-portfolio and preferred its use over the paper-based version. Acknowledgement The authors would like to thank Dr Anthony Tuckett for his scholarly input.

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