European Journal of Dental Education ISSN 1396-5883

Acceptability of a reflective e-portfolio instituted in an

orthodontic specialist programme: a pilot study
I. Tonni1 and R. G. Oliver 2
1
University of Brescia, Brescia, Italy
2
Cardiff University, Cardiff, UK

Keywords Abstract
reflection; e-portfolio; orthodontics.
Aim: The purpose of the study was to highlight students’ and mentors’ acceptability
Correspondence of a reflective e-portfolio instituted in a postgraduate orthodontic programme in the
Ingrid Tonni UK.
University of Brescia
Pza Spedali Civili 1
Methods: A reflective e-portfolio was developed on the basis of principles provided
25123 Brescia, Italy
by a literature search and was piloted for 2 months with six students and seven men-
Tel: +39 0303995789
tors. At the end of the experience, mentors’ and students’ acceptability of the e-portfo-
Fax: +39 030303194
lio with a reflective component was studied using questionnaires. The data were
e-mail: itonni@med.unibs.it
analysed using basic quantitative and qualitative methods.
Accepted: 21 January 2013
Results: Students’ response highlighted acceptability issues related to each aspect of
doi: 10.1111/eje.12038 the e-portfolio derived from the literature: relevance of the e-portfolio reflective part;
time required for the process; support and mentoring; the implementation method;
and the electronic medium. Mentors showed a more positive attitude towards the
e-portfolio, expressing only some concerns about the time involved in using it. Fur-
thermore, the analysis of the data highlighted some other acceptability matters: the
specificity of the e-portfolio, the communication amongst students and the relationship
between students and mentors.

Conclusions: The future successful implementation of the reflective e-portfolio will

depend on the productive management of the acceptability issues identified by students
and mentors, in particular:(i)the specificity of the e-portfolio that would avoid its
overlapping with other part of the programme;(ii)the increasing communication
amongst students to improve their knowledge of the reflective writing process; and
(iii)the development of a relationship between students and mentors helping to create
the appropriate environment for reflection.

Introduction • Flexibility,
changes;
creativity and the capacity to cope and manage

Portfolios are used for a range of purposes in undergraduate • Capacity for systematic, conceptual and critical thinking;
and postgraduate healthcare education in the UK, including • Decision-making, clinical thinking and judgement;
encouraging reflective practice, facilitating engagement with • Manage information effectively
Communication and interpersonal skills;
learning, supporting professional development and delivering
formative and summative assessment (1–3). They are popular
• Reflection is central to the development
in a range of media.
of these generic
to stimulate and assess the generic learning outcomes that are learning outcomes (5). Reflection, verbally or in written form,
present alongside the programme-specific ones in outcome- supports autonomous and deep learning (6, 7) and professional
based education. The generic learning outcomes, which are development (8) in health care higher education. The reflective
considered important for the personal and professional devel- process allows students to improve critical thinking ability and
opment of an individual, are as follows (4): existing understanding (9, 10), to learn from experience

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Acceptability of a reflective e-portfolio Tonni & Oliver

reducing the theory–practice gap (11), to integrate new and e-portfolio and improved it without the attempt to generalise
prior knowledge and to organise experiences in relation to the the findings of this study to other situations.
outcomes that need to be achieved. In addition, the analysis of
reflective writing enables students to identify their strengths
The orthodontic portfolio development
and weaknesses and progression towards the achievement of
the learning outcomes of the programme. A reflective e-portfolio, called the ‘orthodontic e-portfolio’, was
The reflective requirements of a portfolio can be used by developed using a list of principles provided by a literature
learners to develop and demonstrate the cited generic learning search (7, 8, 10, 12, 14–17, 27, 28). There was an induction
outcomes. Different factors are important in promoting a period to introduce the orthodontic e-portfolio to students and
reflective process (9, 12–14): the Personal Development Plan mentors by means of emails, meetings and training sessions.
(PDP) as the reflective component of a portfolio, mentoring, The orthodontic e-portfolio was structured around the learning
structure and guidelines of the portfolio, information on ‘how’ outcomes of the orthodontic postgraduate programme in Car-
to reflect, teaching staff engagement in the process of reflection, diff. It had an introduction section providing students and
assessment of reflection, experience and training. Furthermore, mentors with a description of the concept of reflection and of
the reflective portfolio provides an ideal context to assess reflec- its assessment. Figure 1 describes the different steps in the
tive ability (15) as a key component of personal and profes- students’ e-portfolio building:
sional development.
To improve the overall flexibility of portfolio use, they may
• It required students to select, collect, synthesise and orga-
nise relevant evidence in two folders called ‘Recommenda-
be in electronic format (16) and on mobile devices (17, 18). tions’ and ‘Personal folder’ with reference to the learning
The success of portfolios depends on overcoming a number outcomes. ‘Clinical’ mentors could help students in select-
of obstacles: ing the appropriate evidence;
• Learners and teachers often do not see the relevance in
reflective learning and assessment of reflection (1, 19);
• The portfolio had a reflective component, and some sec-
tions of the portfolio were intended to be ‘Private’ to
• Maintaining a portfolio is a time-consuming process and encourage honest reflection;
more energy must be invested by learners and mentors
(1, 19);
• Students summarised the evidence and reflections collected
on a monthly basis, self-assessed their progress towards the
• Students’ and mentors’ enthusiasm is important in the suc-
cess of the portfolio, and their enthusiasm is proportional
learning outcomes and created an action plan for the fol-
lowing period completing the first part of the ‘Monthly
to the information that they receive about the process (20, review and meeting form’;
21); • Each student had his/her own ‘academic’ mentor with
• Learners approaching portfolios need support not only in
portfolio building but also in the process of recording
whom they met and discussed the summaries of evidence
and reflection, the progress achieved and the future action
reflection (19, 22, 23); plan, and completed the second part of the ‘Monthly review
• There are some concerns about technical difficulties related
to the use of an e-portfolio (16, 24). There are barriers to
and meeting form’. During these meetings, students
received support and formative assessment of their reflec-
using a Personal Digital Assistant (PDA) version of an tive abilities;
e-portfolio in a clinical environment (e.g. loss, limited
memory, interface restrictions, patient data security-17, 18).
• At the end of each year, the two mentors (‘clinical’ and
‘academic’) could evaluate their mentee’s progress towards
The introduction of an e-portfolio with a reflective compo- the generic learning outcomes.
nent to an orthodontic specialist training programme as a tool The e-portfolio was developed using standard commercially
for supporting and assessing students’ reflective ability was con- available and customisable software (‘Microsoft Word’ and
sidered beneficial. However, before evaluating the effectiveness ‘Microsoft Excel’) and hardware linked to the University’s
of the reflective component of the portfolio as a learning and Virtual Learning Environment (VLE-Blackboard Academic
assessment tool, it was considered prudent to analyse the Suite - version 6, Blackboard Inc.). The ‘outreach’ aspect of
acceptability of and the factors influencing the use of the reflec- training meant that a portable means of contemporary data
tive portfolio. collection was necessary. A web-based PDA (hp iPAQ PDA)
Hence, the aim of this study is to conduct a pilot study to and an hp iPAQ ‘foldable’ keyboard offered (at the time)
highlight students’ and mentors’ acceptability of a reflective appropriate technology for use in the clinical learning environ-
e-portfolio introduced to a postgraduate orthodontic pro- ment (29; Fig. 2).
gramme in a UK dental teaching hospital. Recording of data, reflections and discussion with the aca-
demic mentor was a 3-stage process:
Materials and methods • At the chair side (either in their home unit or in an out-
reach unit), they could record the appropriate information
using the PDA and keyboard;
Research method
A formative ‘evaluation research’ approach (25) was applied to
• Once they had access to the university network, they could
then download their recorded information into their own
address the study aim. It involved the implementation, evalua- ‘account’ within the university’s VLE;
tion and modification of a reflective e-portfolio (26). It iden-
tified the issues related to the acceptability of the reflective
• The academic mentor could then access the appropriate
parts of the ‘account’ on the VLE via their own desktop

178 ª 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Eur J Dent Educ 17 (2013) 177–184
Tonni & Oliver Acceptability of a reflective e-portfolio

Fig. 1. Steps of the orthodontic e-portfolio building.

Each student was given a PDA pre-loaded and configured

with the e-portfolio elements and a foldable keyboard. The stu-
dents compiled the orthodontic e-portfolio for the first
2 months of their second year of training. ‘Clinical’ mentors
helped students to use the e-portfolio day by day, and the ‘aca-
demic’ mentors met the students after the first month in the
‘monthly meeting’ for formative assessment of reflection.
Following the two-month period, data regarding the
acceptability of the reflective e-portfolio were collected
through two questionnaires, one for students and one for
mentors. The semi-structured questionnaires were distributed
using Blackboard, and participants were asked to complete
and return them within 1 week. Students and mentors were
asked to rate the statements regarding the reflective e-portfo-
lio on a Likert-type six-point scale from 6 – very strongly
Fig. 2. The use of a Personal Digital Assistant and a ‘foldable’ keyboard disagree to 1 – very strongly agree. They were also given the
in clinic. opportunity to comment on their experiences. A mentor and
two students of the previous year in the programme, who
computer to read prior to their meeting with their did not take part in this study, read the questionnaire state-
mentee. ments to modify or eliminate poorly worded questions and/
or ambiguities. The answers and the comments from students
and mentors were anonymous, and participants’ confidential-
The orthodontic e-portfolio evaluation
ity was ensured using unique subject ID codes to identify
The sample, chosen through a ‘purposive sampling’ technique participants.
(30), consisted of:
• All the second-year postgraduate students (2 men, 4
women) of the orthodontic programme;
Quantitative and qualitative analysis

• All the seven members of the staff of the orthodontic pro-

gramme, who were recruited as mentors.
A quantitative and qualitative analysis of the data collected with
the questionnaires showed students’ and mentors’ perceptions
Students, ‘clinical’ and ‘academic’ mentors received a letter on the five aspects of the reflective e-portfolio acceptability
inviting their participation. All the subjects consented to take derived from the literature and listed in the introduction:
part to the study. Ethical approval for this part of the research • Relevance of the e-portfolio reflective part;
was granted by the Medical and Dental School Research Ethics • Time required for the process;
Committee (MDSREC). • Support and mentoring;

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Acceptability of a reflective e-portfolio Tonni & Oliver

• The implementation method; Results

• The electronic medium.
Response rate and missing data
Quantitative analysis A total of 11 (84.6%) of the 13 questionnaires were returned.
Responses were received from 100% (6/6) of students, whereas
The agreement/disagreement of students and mentors with each
71.4% (5/7) of the mentors replied. The questionnaires from
statement in the questionnaire was measured on the interval scale
the mentors had fewer missing responses compared with those
from 6 – very strongly disagree to 1 – very strongly agree. Each
from the students, but students added more comments.
statement in the questionnaires was associated with one of the
above five aspects, and a group data analysis allowed highlighting
the students’ and mentors’ total agreement and total disagreement Students’ and mentors’ perceptions
with the five aspects of the reflective e-portfolio acceptability.
The frequency of distribution of the Likert-type scale scores for
each questionnaire statement and for group of statements
Qualitative analysis together with the qualitative analysis of the comments made it
possible to individualise students’ and mentors’ opinions on
Content analysis (31) was used for qualitative investigation of
the five aspects of the e-portfolio acceptability previously con-
the comments. They were organised by questionnaire state-
sidered.
ments and by groups (mentors and students) to look across all
The results of this pilot study are presented in Fig. 4 and
respondents and their answers in order to identify consistency
Table 1. Figure 4 summarises and compares the mentors’ and
or differences. The first author read through the text to identify
students’ total agreement and disagreement to the five aspects
significant themes, which were tagged with codes. The next step
of the reflective e-portfolio. Mentors showed a more positive
was to organise the themes into categories that were also iden-
attitude towards the five aspects of the reflective e-portfolio
tified with codes. The categories were pre-set instead of emerg-
acceptability, expressing only some worries about the time
ing from the data analysis and were represented by the five
involved in using it. Conversely, students’ response highlighted
aspects of the orthodontic e-portfolio acceptability. Once the
more concern regarding each aspect of the reflective e-portfo-
categories had been found in the text and the data labelled with
lio.
the category codes, grouping the data into categories was per-
Table 1 summarises the qualitative findings and is divided
formed using the ‘Cut and Paste’ function. All the citations
into three sections, with the categories in the left-hand column,
representing a category were saved in a Microsoft Excel sheet
emerging themes in the middle column and quotations in the
that included columns for participants’ ID, theme codes and
right-hand column. Students’ and mentors’ positive and nega-
quotations (Fig. 3). Finally, the author analysed the frequency
tive opinions related with the five aspects of the reflective
that a theme occurred to identify patterns in the connection
e-portfolio are presented in the middle column of Table 1.
between themes and categories.

Fig. 3. Themes and quotations related to the category: ‘The electronic medium’.

180 ª 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Eur J Dent Educ 17 (2013) 177–184
Tonni & Oliver Acceptability of a reflective e-portfolio

Fig. 4. Mentors’ and students’ quantitative response from the questionnaire.

Furthermore, some other acceptability issues rose from this mentors described the orthodontic e-portfolio as a positive
study: learning tool because it facilitates the reflection process, stu-
• The lack of specificity of the e-portfolio (‘If we were given
the portfolio at the start of the programme I think it would
dents described the orthodontic e-portfolio as a file containing
materials collected during the programme and used as records
have been more beneficial – at the moment I feel the bulk of Continuing Professional Development and for Curriculum
of it is repetition’); Vitae building. Four students did not think that the reflective
• The communication amongst students (‘Not really with my
classmates, but maybe it is just a matter of time’);
writing process in the portfolio helped them to grasp on their
learning process, and they were focussed upon the ‘log-book’
• The relationship between students and mentors (‘A friendly
environment has to be created to promote communication
aspect of the portfolio and commented:
I don’t think writing it down added much to my learning.
between students and mentors’). The orthodontic e-portfolio was structured around the 16 out-
comes of the postgraduate orthodontic programme in Cardiff
(13). The majority of students and mentors agreed that the learn-
Discussion
ing outcomes in the e-portfolio were well defined, covered all the
This discussion focuses on the acceptability issues highlighted aspects of the orthodontic programme and helped students with
by students and mentors related to the introduction of a reflec- direction in learning, as shown by this comment from a student:
tive e-portfolio in a postgraduate orthodontic programme. The ‘It’s a good idea to break your learning so that you have a
research method used and the small sample do not make possi- better understanding of what are your strong areas and what
ble to generalise the findings of this study to other educational areas you need to work on.’
programmes. However, the discussion deals with matters sur- Students and mentors had different opinions on the use of
rounding the introduction of reflection and its assessment and the orthodontic e-portfolio as a summative assessment tool for
the implications from the study to improve a future implemen- reflection. Mentors thought that the portfolio could be used as
tation of the reflective e-portfolio in Cardiff. summative assessment, but only after a period of training that
Despite the small number of students and mentors who was allowed students and mentors to understand exactly the
involved, questionnaires were used instead of interviews or dynamics of the assessment process and the criteria used as
focus group because they could provide quantitative data previously supported by teachers in Driessen et al. (13). On the
related to the pattern of frequency of agreement and disagree- other hand, four students would not believe in the authenticity
ment of all the participants in the sample to the five aspects of of the evidence collected in the portfolio if this was used as a
the e-portfolio acceptability. Interviews would have allowed the summative assessment tool, and one commented (demonstrat-
capture of new ideas regarding the acceptability of a reflective ing an awareness of the Hawthorne effect):
e-portfolio; however, comments were used to obtain qualitative ‘I believe people would be careful of what they put in the
data, on which a later structured interview could take place. portfolio if that was the case.’
A detailed description of the qualitative research design and It is likely that students had misunderstood that the purpose
data analysis applied and the use of quotations in the descrip- of the reflective e-portfolio was to assess the process of reflection
tion of the results helped to assure an accurate interpretation and not the product of reflection, as explained by Moon (8).
of the data collected in this study.
Time required for the process
Relevance of the e-portfolio reflective part
Students felt that building the e-portfolio reflective part was
One of the factors that influence the acceptability of a reflective time-consuming and interfered with their academic and clinical
portfolio is the limited relevance that learners and teachers see learning, as showed in previous studies (1, 19). One student
in the reflective process and its assessment (1, 19). Whereas commented that it was:

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Acceptability of a reflective e-portfolio Tonni & Oliver

TABLE 1. Students’ and mentors’ positive and negative opinions related to the five aspects of the reflective e-portfolio

Categories Themes Examples of quotations

Relevance of the It is a repository ‘I think the idea of an e-PDP is good – it would let you have an electronic
reflective e-portfolio portfolio (st) portfolio of your entire 3 years worth of training – in theory this could
then be easily accessed, presented to others and useful for updating
things like your CV’
It is a reflective tool(st) ‘It permits to reflect on the experience’
It is a useful learning experience (me)
The portfolio structured around the 16 learning ‘It’s a good idea to break your learning so that you have a better
outcomes help students in self-learning(me+st) understanding of what are your strong areas and what areas you need
to work on’
Reflective writing is not useful for the ‘I don’t think writing it down added much to my learning’, ‘sometimes I
learning process(st) feel I need to write something in the boxes just to-fill the gaps’
It is a summative assessment tool for reflection ‘only after a long lead-in to gain experience in using as an assessment tool’
after training (me)
A formative/summative conflict exists (st) ‘I believe people would be careful of what they put in the portfolio if
that was the case’
Time required for It is a time-consuming process(me+st) ‘Time consuming to type it all out , especially when it’s a daily process’
the process Different forms to collect evidence (audio, video) ‘Probably audio and video could help’
may be useful (me)
Building the portfolio gives no sense of ‘I did not feel it had any effect on my achievements’
achievement (st)
Support mentoring An isolate meeting is not useful for the ‘Different students may need different intervals between meetings’
learning process (st)

Monthly meeting helps students to reflect (me+st) ‘I think that meetings with mentors are a fundamental element of the
PDP process for feedback reflective skills’
Implementation Instruction on the e-portfolio are clear and ‘There are clear and enough instructions on how to build the portfolio’
method informative (me+st)
Broader and continuous information on ‘It is a steep learning curve and probably needs more support
reflection and assessment are needed(me) than we realise’
E-portfolio design is not concise, too many ‘It duplicates a lot of work’
e-portfolio form(st)
The electronic E-portfolio is more flexible then a paper ‘More environmental friendly’, ‘Blackboard is an appropriate and quick
medium based (me+st) communication tool
IT component is time-consuming(st) ‘Although could, I preferred to fill the PDA after clinic, as what with
notes to write, appointments to make, audit to fill I find just I do not
have time’ ‘PDA is too time consuming’
IT component is complex (st) ‘PDA is not user friendly in clinic’
PDA and a foldable keyboard are not very ‘ PDA small, easy to carry….another piece of expensive equipment to
supported(me+st) keep track off’ ‘Foldable keyboard is not so easy to connect to the PDA
using Bluetooth and the batteries run down too quickly’
An individualised trainings is needed (st) ‘Although most people should be fairly IT competent there is a lot to take
on board and I think there should have some formal individual
training beforehand’

me: mentor st students.

‘Time consuming to type it all out, especially when it’s a to help students in the reflective process as showed in the com-
daily process.’ ment:
Mentors agreed that alternative forms to writing, such as ‘I think that meetings with mentors are a fundamental element
audio or video, could be useful to collect evidence and speed of the PDP process for feedback of reflective skills.’
up the reflective process. However, most students added that the one isolated meeting
with the mentor, which they attended during the 2 months’
experience, was not enough and that the communication
Support and mentoring
between students did not seem to have increased. A student’s
Driessen et al. (13) described portfolio coaching as a condition comment about communication was as follows:
for successful reflective use of portfolios. Mentors and students ‘Portfolio doesn’t help at all with communication just adds to
in this study agreed that the monthly meeting was a useful tool the paperwork!!.’

182 ª 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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Tonni & Oliver Acceptability of a reflective e-portfolio

Communication and continuous support are fundamental to objectives of this study were to evaluate the acceptability of the
develop a reflective attitude (9, 13). A better relationship PDA as a tool to promote reflective learning in practice as pre-
between mentors and students and more communication viously discussed by Ranson et al. (18) and Garrett and Jackson
amongst the members of the same group (mentors or students) (17). In the present study, students did not show great support
should increase the acceptability of the reflective process. A for the use of the PDA and the ‘foldable’ keyboard in the clinic
future development might include dedicated group time for within current structures due to the clinical workload, the
PDP development, perhaps with a ‘neutral’ moderator to interface limitations and the time required for the process to be
facilitate. completed. A student commented as follows:
‘Although I could, I preferred to fill the PDA after clinic, as
what with notes to write, appointments to make, audit forms to
The implementation method
fill I find just I do not have time.’
The orthodontic e-portfolio as structured in this study was To encourage the use of a mobile device for students’ reflec-
considered too comprehensive. A student commented as tion in clinic, there would need to be:
follows: • An advancement in technology (e.g. tablet devices);
‘At the moment I feel the bulk of it is repetition.’
highlighting the fact that much information collected in the
• Changes in the current structure of the orthodontic
programme clinical environment;
portfolio (e.g. details of treated patients, case presentations,
MSc meetings, etc.) was already recorded elsewhere. It would
• A single unifying data collection vehicle acceptable to the
university, specialist training authorities and local NHS
be more beneficial to introduce reflection as the main activity trusts;
of the portfolio and spend more time explaining to students
and mentors the process of reflection, its relevance and its
• A more individualised and ongoing training programme on
the handheld equipment and its application.
assessment as showed in the comment:
‘It is a steep learning curve and probably needs more support Conclusion
than we realise.’
Simply giving the definition of reflection to learners and ask- This study confirmed that the acceptability issues related to
ing them to reflect is not sufficient, reflection should be taught the five aspects of the reflective e-portfolio have to be cleared
to students and mentors. However, Race (32) discussed the fact when it is introduced in a higher education programme in
that reflection is very difficult or probably impossible to teach order that it is successful. Other barriers to the introduction
in the traditional way, and so alternative approaches, such as of a reflective e-portfolio in higher education are highlighted
workshops for mentors and students with two or more stages in this study:
in guidance process of reflection (8, 10), should be introduced. • The lack of specificity of the orthodontic e-portfolio that
leads its overlapping with other part of the programme;
The electronic medium • The inadequate interaction and communication between
students that might improve their knowledge of how to
The present study, unlike previous ones (16, 24), includes both reflect and of the reflective writing process;
the students’ and mentors’ perspective regarding the use of an • The absence of a good relationship between students and
mentors that should be fostered to create an environment
e-portfolio instead of a paper one. Three students and five
mentors considered the electronic portfolio more flexible than where students feel safe to reflect, to embrace challenges
a paper one. However, a student commented as follows: and to accept getting things wrong as part of the process of
‘Although most people should be fairly IT competent, there is a learning.
lot to take on board and I think there should have been some
formal training beforehand.’ Acknowledgement
This comment expresses three important variables that
should be considered in the development of an e-portfolio: The authors are grateful to the Teaching and Learning Fund
• Complexity of the system; from Cardiff University for financial support for the purchase
• IT competence; of the PDAs and the ‘foldable’ keyboards.
• Training needed.
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