02606917/90/0010-0070/$10.00
NursrEd~ahonToday(1990)10,7~79 @ Longman GroupUK Ltd 1990
_WORK Developing the credibility of continuing education Mary Chiarella
The paper begins by acknowledging both the need for nursing to be a research based profession, and the reasons for the well-documented theory-practice gap. It goes on to suggest that what is not so well-documented is an examination of the reasons for the commitment gap between basic and continuing education. The relevance of continuing education to clinical staff will be discussed in relation to the change in the content of nursing theory - from the unwieldy ‘certainty-based’ medical model, to a more flexible, thus perhaps ‘uncertainty-based medical model. The paper will explore the author’s belief that clinical staff need to feel a sense of security in their knowledge base, which therefore leads them at times to reject nursing theory. The paper proposes that a legal framework for nurses practice gives the clinical staff the security in their practice to view the relevance of new nursing theory.
DEVELOPING THE CREDIBILITY OF CONTINUING EDUCATION As the debate over
the
value
of mandatory
continuing education develops in this country, it seems pertinent
to consider
lity of continuing
the current
education
within
credibithe
pro-
fession. In America, continuing
26 States have now legislated
education,
and
using pre and post-continuing
some
recent
education
for
work audits
does seem to indicate that pertinent continuing education can have the effect of improving the quality of direct patient care (Meservy & Manson 1987).
However,
in the past in England
of mandatory 2000,
the
packages
70
continuing
education
proliferation
of
has at least indicated
not necessarily
a professional,
Notwithstanding
these
in Project
distance
learning
a commercial, commitment
developments,
if
to it. there
does appear to be a lack of commitment to continuing education at managerial level, both in service and education there
is evidence
management,
that
the
Board has brought pressure cational and service managers commitment to it in order learning environment. In this paper
Mary Chiarella RGN SCM (NSW) RNT LLB Senior Nurse Educator, NSW College of Nursing, 55 Hereford Street, Glebe, NSW 2137, AUSTRALIA (Requests for offprints to MC) Manuscript accepted 1 June 1989
continuing
education has been very much the Cinderella of the education field, although since the whisper
English
National
to bear on eduto increase their
to improve
it is intended
although
the ward
to explore
some
possible reasons why that lack of managerial commitment has existed and also to examine why there appears to be a concomitant lack of desire on the behalf of the trained staff to continue their education, particularly when the
NURSE EDUCATION
topics on offer
relates
to nursing,
rather
than
medical matters. The
it is not a crucial ingredient
TODAY
71
of staff development
and progress.
need for nursing
to be a research-based
However,
there
is also a certain
element
of
profession has long been documented (Briggs 1972), as has the theory-practice gap which
resistance amongst tutorial staff to teaching staff, which would not bear out this theory, as
learners
they have all had to undertake
experience
between
what
they
are
further
education
taught in the schools of nursing and what they do
to qualify for their posts. Whether
in the wards (Kramer 1974). It is also well-documented that the ward sister,
is due as Shuldham (1988) suggests, to the fact that some nurse teachers feel that their clinical
and not the nurse
skills are becoming
and that other role
models
Fretwell
tutor is the key to learning,
ward staff also make
(Orton
1981;
Ogier
powerful
1981,
1982). Given all these factors,
lack
1986;
it is small
wonder that many of us in continuing education should have thought that the answer to the
the
out of date, and thus, they
confidence
whether
to teach
their remit, is difficult to ascertain, which still exists in some quarters. However,
the shift from
orientated
curricula
inevitably
strengthen
balance
long progression This previous
up the equation. the solution is clearly not that simple
- as many tutors in continuing education will attest - getting funding from nursing service or education
is extremely
difficult,
often
will to fund
it
that
present.
The term ‘political will’ is used because
all funding
the political
and
appears
in the National
to be unavailable
Health Service seems
unless urgently
thus in many instances
continuing
not being viewed as an urgent In
addition,
extremely
service
reluctant
is not
required,
and
education
is
requirement.
managers
are
to release staff if by doing so,
being
sympathetic
and acknowledging that on many occasions undoubtedly genuine, one may question political will to release week on a regular raise staff morale),
it is the
the staff. Some units are
able to release much-needed
staff for 2 hours a
basis (which does appear
to
whereas on other units which
are said to have problems with absenteeism due to low morale staff are never released and the long
term
planning
benefits
of
such
careful
forward
do not all perceive
the need
for continuing education; nor is it necessarily an essential prerequisite for promotion to nurse management posts. Indeed, Stapleton’s work (1982)
showed that only 24% of nurse managers
would look to the district for continuing education, which could perhaps indicate a belief that
or
but it is a view
product
in schools
to process
of nursing
the philosophy
by nursing
will
of a lifeto con-
management
is a
worrying issue, as a recent report released by the University Advisory
Grants
Committee
should
that statutory
no
determine
longer
have
the nature Health of
Education
Service
continuing
has
bodies in nursing the
sole
right
of continuing
but that the Department control
and the National
Body for Public Sector
recommended
to
education,
of Health and thus, the in general
should have
education
for
nurses,
which could result in a shift away from a nursing emphasis
Whilst
ment to continuing
nurse
in future continuing
management
education
commit-
may be growing,
one can only hope that it is not too little, too late. The
other
issue which
this paper
address is the lack of commitment education
from some of the trained
opportunity
-
certainly
an
seeks
to
to continuing
selves. Much of this has to be attributed
staff themto lack of
American
study
shows that 10 years on from the introduction of mandatory continuing education, all but 24% of trained
are not realised.
Service managers
education
education.
to this argument,
peers,
of learning. lack of commitment
to a management
the wards will be understaffed. Whilst
tinuing
National often
their
they feel that it is simply not part of
theory-practice gap was to offer the trained staff that which was offered to the students in order to However,
the reluctance
staff
would
regular continuing
voluntarily
education,
undertake
even if it were not
mandatory (Puetz 1983), whereas in the early studies the commitment was much lower (Weiss & Willie 1988). Thus,
when
continuing
education
becomes
part of the professional culture, the commitment does appear to be present, and I would hasten to
72
NURSE EDUCATION
add,
is already
England
TODAY
present
for
many
nurses
in
today.
Nevertheless
Study days on the latest research care, pressure
there
is still a large number
of
do not get the same response
trained nurses today who do not have a commit-
AIDS or recent
ment to continuing
has to ask oneself
education,
even when it is
available, and it is essential that we ask why this is so. Perhaps
the most obvious reason - hopefully
soon to be resolved - is the problem based
training.
In order
to feel
of servicea need
for
nurses
advances
ignorant
there
some
findings
about
indicate
Resistance
Under a system where, after 6 weeks in a School
see themselves
numary
status for students
come this problem the development ‘competency
may help to over-
it is still worrying
to witness
of what may be termed
culture’
in
where competency-based can also foster appear not.
of super-
manifests
Maura
Hunt’s
instigators
derision
assessment
nursing
to
it not be better
studentship,
rather
to assess students
than competence,
in the early stages of their assess for competence still retaining
(Clarke
case,
then
of why nurses
rewarded staff,
and
nor
rated
they
highly
can’t
all
by some be
at
St.
antipathy
to the introduction
of
but why should this
because
nurses do not
or even the relevance
what can be done
of
and if this is the to remedy
this
that this is because the teaching in the past was based on a
that sort of science-based
leave nursing, to know that these qualities of enquiry and acknowledgement of limitations are neither
1987)
‘which nurses received
example,
if X happens,
of certainty
teaching
brings,
that for
the nurse must do Y, and
so on. Developments nursing,
trained
reported
situation?
Lindop’s
stories
than the
198 1), and in one case even
and only
particularly in
that nurses
rather
theory to their practice,
overturned
horror
have
the necessity,
the clinical setting? One only has to read Edward (1988)
(1987),
medical model, with the degree
score for enquiry and
of limitation,
to
are confronted
as the victims,
especially
towards the end; even so
a percentage
acknowledgement
training,
for
observation
authors
It is suggested
Would
is not exclusive
nurses
be the case? Is it perhaps,
continuing
(s)he is
is
has a great deal to do with
nursing theory and research, perceive
in the student
practice
of change.
Several
assessment,
even when perhaps
when
(Myco 198 1, Bernett
clinical
a felt need
competent,
the
current
to change
of Nursing, a student nurse has to appear confident in front of a patient, is it any wonder
the introduction
or is
nurses, but it seems likely that the sense of guilt, with such findings,
arguably,
research,
that if the research
that their
which
Although
nursing
belief
One
be so - are
that they are then in some way at
continuing education in nursing, there has first to be an ability to confess a learning deficit.
that after a three year exercise in plausibility, we find it difficult to admit that we don’t know?
as a study day on
in microsurgery.
why this should
innate
inappropriate, fault?
on catheter
sores, and mouth care, inevitably
in
many
nursing of
the
research
old
have
certainties
and yet for some reason,
nurses
in find
this harder to accept than changes in medical techniques and practice - possibly because it affects
us more
personally,
some of the cultural
and
undermines
norms into which we have
Elsewhere.
been socialised.
From previous annual exercises on identification of training needs in continuing education, it
Heisenberg (1927), in his search for a description of the electron, characterised it by a method which he called The Principle of Uncertainty -
became evident that nurses were quick to request updating in medical techniques, but less freupdating
or
education
in
he explained
that one can never precisely define
quently
requested
what an electron
nursing ‘nursing
topics. The notable exception was process’, although this was often
be in a state of change, but it will always be possible to recognise it as an electron, because
looks like, because it will always
because, the documentation was handed out before any teaching had been carried out, and trained staff were desperate.
one is familiar with its overall structure - he likens the principle to the identification of a well-loved face. Bronowski (1976) renames this
NURSE EDUCATION
principle than
The
Principle
Uncertainty.
of Tolerance,
perhaps
this
required
in nursing - to develop
tolerance
to our nursing theory.
is
rather what
is
a principle
of
This will only be achieved when nurses recogresearch,
in all its uncertainty
in order
and newness, but
to achieve this credibility,
they require
confidence
in their professional
confidence
could follow from understanding
the legal and professional nurses
practice,
independent feeling
which
framework provides
legal ‘personality’,
of professional
rateness
identity.
Such of
in which
a sense and
uniqueness
and
of which they were often
of
fosters
a
sepa-
previously
unaware. The law, in so much as it provides a framework for practice, offers nurses that certainty of which many
currently
somewhat their
feel bereft.
overawed
responsibility,
information whelming
Initially
by discussing but
they
reassuring,
and
they feel
the reality of
then have
find
the
an
over-
desire to know more (Roberts
1987;
1988). This sense of professional
indentity will then
give
and
them
explore
the
confidence
the changing
and to regard
it as their professional
bility to do so - understanding work
for
themselves victims
practice
facilitates
as the instigators,
of change,
continuing
tolerance
face of nursing
and
education
instead, continuing
thus,
to
practice, responsi-
their legal frametheir rather
view than
of the
the credibility of
ceases
to be an issue -
education
becomes a neces-
sary focus for the fulfilment of their duty of care.
References Bernett D E 1981 Do Nurses 2131-2133
Read?
Nursing
Times
77:
73
Briggs A 1982 (Chairman) Report of The Committee on Nursing Cmnd 5115 HMSO Bronowski J 1976 The Ascent of Man. Science Horizons Inc, London 364-365 Clarke M 1987 Frontline Revolt. Nursing Times, 83: 16,
6o
nise that nursing is a credible entity to study and
TODAY
Fretwell
J 1982 Ward
Teaching and Learning. Royal London Heisenberg W 1927 Uber den onschaulichen Inhalt der quanten-theoretischen Kinematik and Mechanik. Zeitschrift fur Phvsik, 43: 172 Hunt M 1987 The Process of Translating research findings into practice. Journal of Advanced Nursing, 12: 101-l 10 Kramer M 1974 Reality Shock. C V Mosby Co, St. Louis Lindop E 1988 Giving Up. Nursing Times, 84, 5: 54-55 Merservy D, Manson A 1987 Impact of continuing education on nursing practice on quality of patient care. Journal of Continuing Education in Nursing, 18,6, Nov/Dec: 214-220 Myco F 1981 The Implementation of nursing research related to the nursing profession in N. Ireland. Journal of Advanced Nursing, 5: 637-646 Ogier M 198 1 An Ideal Sister. Royal College of Nursing, London Ogier M 1986 An ideal sister seven years on. Nursing Times Occasional Paper, 82, 2: 54-57 Orton H D 198 1 Ward Learning Climate. Royal College of Nursing, London National Advisory Body for Public Sector Higher Education and The University Grants Committee. Professional Needs for Continuing Education: The Health Care Professions Report of The Health Group to The Continuing Education Standing Committee. London 1988 Peutz B E 1983 Providing an empirical basis: Legislating a continuing education requirement for licensure renewal. Journal of Continuing Education in Nursing, 14, 5: 5-12 Roberts J 1987 and 1988 Unpublished evaluations from professional development courses. Liverpool Health Authortiy Shuldham C 1988 The new nurse teacher: myth or reality? Senior Nurse, 8. 2: 68 Stapleton M 1982 Update, top-ranking. Nursing Mirror, 154: 38-40 UKCC 1986 Project 2000: A New Preparation for Practice: UKCC London Weiss Farnan P, Willie R 1988 Mandatory Continuing Education: The Discussions a Decade Aoart. The Journal of Continuing Education in N&sing, 19, 2: 73-75.
College of Nursing,
NursrEd~ahonToday(1990)10,7~79 @ Longman GroupUK Ltd 1990
_WORK Developing the credibility of continuing education Mary Chiarella
The paper begins by acknowledging both the need for nursing to be a research based profession, and the reasons for the well-documented theory-practice gap. It goes on to suggest that what is not so well-documented is an examination of the reasons for the commitment gap between basic and continuing education. The relevance of continuing education to clinical staff will be discussed in relation to the change in the content of nursing theory - from the unwieldy ‘certainty-based’ medical model, to a more flexible, thus perhaps ‘uncertainty-based medical model. The paper will explore the author’s belief that clinical staff need to feel a sense of security in their knowledge base, which therefore leads them at times to reject nursing theory. The paper proposes that a legal framework for nurses practice gives the clinical staff the security in their practice to view the relevance of new nursing theory.
DEVELOPING THE CREDIBILITY OF CONTINUING EDUCATION As the debate over
the
value
of mandatory
continuing education develops in this country, it seems pertinent
to consider
lity of continuing
the current
education
within
credibithe
pro-
fession. In America, continuing
26 States have now legislated
education,
and
using pre and post-continuing
some
recent
education
for
work audits
does seem to indicate that pertinent continuing education can have the effect of improving the quality of direct patient care (Meservy & Manson 1987).
However,
in the past in England
of mandatory 2000,
the
packages
70
continuing
education
proliferation
of
has at least indicated
not necessarily
a professional,
Notwithstanding
these
in Project
distance
learning
a commercial, commitment
developments,
if
to it. there
does appear to be a lack of commitment to continuing education at managerial level, both in service and education there
is evidence
management,
that
the
Board has brought pressure cational and service managers commitment to it in order learning environment. In this paper
Mary Chiarella RGN SCM (NSW) RNT LLB Senior Nurse Educator, NSW College of Nursing, 55 Hereford Street, Glebe, NSW 2137, AUSTRALIA (Requests for offprints to MC) Manuscript accepted 1 June 1989
continuing
education has been very much the Cinderella of the education field, although since the whisper
English
National
to bear on eduto increase their
to improve
it is intended
although
the ward
to explore
some
possible reasons why that lack of managerial commitment has existed and also to examine why there appears to be a concomitant lack of desire on the behalf of the trained staff to continue their education, particularly when the
NURSE EDUCATION
topics on offer
relates
to nursing,
rather
than
medical matters. The
it is not a crucial ingredient
TODAY
71
of staff development
and progress.
need for nursing
to be a research-based
However,
there
is also a certain
element
of
profession has long been documented (Briggs 1972), as has the theory-practice gap which
resistance amongst tutorial staff to teaching staff, which would not bear out this theory, as
learners
they have all had to undertake
experience
between
what
they
are
further
education
taught in the schools of nursing and what they do
to qualify for their posts. Whether
in the wards (Kramer 1974). It is also well-documented that the ward sister,
is due as Shuldham (1988) suggests, to the fact that some nurse teachers feel that their clinical
and not the nurse
skills are becoming
and that other role
models
Fretwell
tutor is the key to learning,
ward staff also make
(Orton
1981;
Ogier
powerful
1981,
1982). Given all these factors,
lack
1986;
it is small
wonder that many of us in continuing education should have thought that the answer to the
the
out of date, and thus, they
confidence
whether
to teach
their remit, is difficult to ascertain, which still exists in some quarters. However,
the shift from
orientated
curricula
inevitably
strengthen
balance
long progression This previous
up the equation. the solution is clearly not that simple
- as many tutors in continuing education will attest - getting funding from nursing service or education
is extremely
difficult,
often
will to fund
it
that
present.
The term ‘political will’ is used because
all funding
the political
and
appears
in the National
to be unavailable
Health Service seems
unless urgently
thus in many instances
continuing
not being viewed as an urgent In
addition,
extremely
service
reluctant
is not
required,
and
education
is
requirement.
managers
are
to release staff if by doing so,
being
sympathetic
and acknowledging that on many occasions undoubtedly genuine, one may question political will to release week on a regular raise staff morale),
it is the
the staff. Some units are
able to release much-needed
staff for 2 hours a
basis (which does appear
to
whereas on other units which
are said to have problems with absenteeism due to low morale staff are never released and the long
term
planning
benefits
of
such
careful
forward
do not all perceive
the need
for continuing education; nor is it necessarily an essential prerequisite for promotion to nurse management posts. Indeed, Stapleton’s work (1982)
showed that only 24% of nurse managers
would look to the district for continuing education, which could perhaps indicate a belief that
or
but it is a view
product
in schools
to process
of nursing
the philosophy
by nursing
will
of a lifeto con-
management
is a
worrying issue, as a recent report released by the University Advisory
Grants
Committee
should
that statutory
no
determine
longer
have
the nature Health of
Education
Service
continuing
has
bodies in nursing the
sole
right
of continuing
but that the Department control
and the National
Body for Public Sector
recommended
to
education,
of Health and thus, the in general
should have
education
for
nurses,
which could result in a shift away from a nursing emphasis
Whilst
ment to continuing
nurse
in future continuing
management
education
commit-
may be growing,
one can only hope that it is not too little, too late. The
other
issue which
this paper
address is the lack of commitment education
from some of the trained
opportunity
-
certainly
an
seeks
to
to continuing
selves. Much of this has to be attributed
staff themto lack of
American
study
shows that 10 years on from the introduction of mandatory continuing education, all but 24% of trained
are not realised.
Service managers
education
education.
to this argument,
peers,
of learning. lack of commitment
to a management
the wards will be understaffed. Whilst
tinuing
National often
their
they feel that it is simply not part of
theory-practice gap was to offer the trained staff that which was offered to the students in order to However,
the reluctance
staff
would
regular continuing
voluntarily
education,
undertake
even if it were not
mandatory (Puetz 1983), whereas in the early studies the commitment was much lower (Weiss & Willie 1988). Thus,
when
continuing
education
becomes
part of the professional culture, the commitment does appear to be present, and I would hasten to
72
NURSE EDUCATION
add,
is already
England
TODAY
present
for
many
nurses
in
today.
Nevertheless
Study days on the latest research care, pressure
there
is still a large number
of
do not get the same response
trained nurses today who do not have a commit-
AIDS or recent
ment to continuing
has to ask oneself
education,
even when it is
available, and it is essential that we ask why this is so. Perhaps
the most obvious reason - hopefully
soon to be resolved - is the problem based
training.
In order
to feel
of servicea need
for
nurses
advances
ignorant
there
some
findings
about
indicate
Resistance
Under a system where, after 6 weeks in a School
see themselves
numary
status for students
come this problem the development ‘competency
may help to over-
it is still worrying
to witness
of what may be termed
culture’
in
where competency-based can also foster appear not.
of super-
manifests
Maura
Hunt’s
instigators
derision
assessment
nursing
to
it not be better
studentship,
rather
to assess students
than competence,
in the early stages of their assess for competence still retaining
(Clarke
case,
then
of why nurses
rewarded staff,
and
nor
rated
they
highly
can’t
all
by some be
at
St.
antipathy
to the introduction
of
but why should this
because
nurses do not
or even the relevance
what can be done
of
and if this is the to remedy
this
that this is because the teaching in the past was based on a
that sort of science-based
leave nursing, to know that these qualities of enquiry and acknowledgement of limitations are neither
1987)
‘which nurses received
example,
if X happens,
of certainty
teaching
brings,
that for
the nurse must do Y, and
so on. Developments nursing,
trained
reported
situation?
Lindop’s
stories
than the
198 1), and in one case even
and only
particularly in
that nurses
rather
theory to their practice,
overturned
horror
have
the necessity,
the clinical setting? One only has to read Edward (1988)
(1987),
medical model, with the degree
score for enquiry and
of limitation,
to
are confronted
as the victims,
especially
towards the end; even so
a percentage
acknowledgement
training,
for
observation
authors
It is suggested
Would
is not exclusive
nurses
be the case? Is it perhaps,
continuing
(s)he is
is
has a great deal to do with
nursing theory and research, perceive
in the student
practice
of change.
Several
assessment,
even when perhaps
when
(Myco 198 1, Bernett
clinical
a felt need
competent,
the
current
to change
of Nursing, a student nurse has to appear confident in front of a patient, is it any wonder
the introduction
or is
nurses, but it seems likely that the sense of guilt, with such findings,
arguably,
research,
that if the research
that their
which
Although
nursing
belief
One
be so - are
that they are then in some way at
continuing education in nursing, there has first to be an ability to confess a learning deficit.
that after a three year exercise in plausibility, we find it difficult to admit that we don’t know?
as a study day on
in microsurgery.
why this should
innate
inappropriate, fault?
on catheter
sores, and mouth care, inevitably
in
many
nursing of
the
research
old
have
certainties
and yet for some reason,
nurses
in find
this harder to accept than changes in medical techniques and practice - possibly because it affects
us more
personally,
some of the cultural
and
undermines
norms into which we have
Elsewhere.
been socialised.
From previous annual exercises on identification of training needs in continuing education, it
Heisenberg (1927), in his search for a description of the electron, characterised it by a method which he called The Principle of Uncertainty -
became evident that nurses were quick to request updating in medical techniques, but less freupdating
or
education
in
he explained
that one can never precisely define
quently
requested
what an electron
nursing ‘nursing
topics. The notable exception was process’, although this was often
be in a state of change, but it will always be possible to recognise it as an electron, because
looks like, because it will always
because, the documentation was handed out before any teaching had been carried out, and trained staff were desperate.
one is familiar with its overall structure - he likens the principle to the identification of a well-loved face. Bronowski (1976) renames this
NURSE EDUCATION
principle than
The
Principle
Uncertainty.
of Tolerance,
perhaps
this
required
in nursing - to develop
tolerance
to our nursing theory.
is
rather what
is
a principle
of
This will only be achieved when nurses recogresearch,
in all its uncertainty
in order
and newness, but
to achieve this credibility,
they require
confidence
in their professional
confidence
could follow from understanding
the legal and professional nurses
practice,
independent feeling
which
framework provides
legal ‘personality’,
of professional
rateness
identity.
Such of
in which
a sense and
uniqueness
and
of which they were often
of
fosters
a
sepa-
previously
unaware. The law, in so much as it provides a framework for practice, offers nurses that certainty of which many
currently
somewhat their
feel bereft.
overawed
responsibility,
information whelming
Initially
by discussing but
they
reassuring,
and
they feel
the reality of
then have
find
the
an
over-
desire to know more (Roberts
1987;
1988). This sense of professional
indentity will then
give
and
them
explore
the
confidence
the changing
and to regard
it as their professional
bility to do so - understanding work
for
themselves victims
practice
facilitates
as the instigators,
of change,
continuing
tolerance
face of nursing
and
education
instead, continuing
thus,
to
practice, responsi-
their legal frametheir rather
view than
of the
the credibility of
ceases
to be an issue -
education
becomes a neces-
sary focus for the fulfilment of their duty of care.
References Bernett D E 1981 Do Nurses 2131-2133
Read?
Nursing
Times
77:
73
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