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Implications of the theory/practice gap for Project 2000 students Dawn Rafferty, Hereford and Worcestershire College of Nursing and Midwifery, Redditch Nursing has frequently attempted to address the gap between theory and practice. This article explores their relationship and the implications of any theory/practice gap for emergent Project 2000 students. Mrs Rafferty is a Nurse Tutor at the Hereford and Worcestershire College of Nursing and Midwifery based at the Alexandra Hospital, Redditch, and is the Course Tutor for Project 2000 students undertaking the Common Foundation Programme

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J L he nature of the relationship be­ tween theory and practice is dependent upon two main variables: education and practice. Education is affected by factors such as the educational setting, quality and methods of teaching, and the curriculum and its interpretation. Practice issues are concerned with the environment in which care is given, the skills, knowledge and atti­ tudes of the practitioners, and the factors that make practice meaningful and which forge links between theory and practice, e.g. working relationships between service staff and colleges of nursing, and tutor in­ put in the clinical setting. The term theory can be broadly inter­ preted as that which is taught or espoused in the classroom and can be used in the con­ text of interrelated ideas about nursing (Ste­ vens, 1984). Dickoff et al (1968) identify a four-tier concept of theory that places nursing practice, supported by theory, at the highest level, with the earlier three levels being prerequisites. The acknowl­ edgement of the pragmatic nature of nurs­ ing within this interpretation provides a useful model in terms of theory definition for this work and is represented in Fig. 1. It is not Project 2000 (United Kingdom Central Council for Nurses, Midwives and

1. Situation providing

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2. Situation relatjng 1 1 3. Factpr relating 4. Fact >r isolatic n

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Concepts to guide action Concepts in context (predictive, promoti ng or inhibiting) Relationship15 of concepts to each other Identification of concepts

Fig. 1. A representation of Dickoff et al's (1968) four-tier theory hierarchy

Health Visitors (UKCC), 1986) itself that is revolutionary but its implementation. It represents the first major statutory attempt to create an effective alternative to the apprenticeship system in which students are heavily involved in meeting service needs. Because of this emphasis, nursing has lost out educationally and a dichotomy exists because of the ambivalent status of the student as a learner and an employee. The introduction of supernumerary status removes the responsibilities and con­ flicts of the dual role with its inherent unre­ alistic expectations. Supernumerary status is also seen as a key factor in reducing the theory/practice gap (Webster, 1990). Emergent Project 2000 students will have more opportunity to consider and reflect on practice and in the long run this is likely to be advantageous in achieving the goal of ‘knowledgeable doer’. There is, however, a danger that the limited exposure to the real­ ities of patient care will be meaningless un­ less learning opportunities are made avail­ able to meet the educational needs of the new students.

Application of learned theory There is evidence that learners do not al­ ways learn from clinical experience (Birch, 1975; Reid, 1985) even though nursing is a practice-based discipline. Powell’s (1989) work on the reflective practitioner in nurs­ ing is supportive of earlier work (Argyris and Schon, 1974) and demonstrates that learning opportunities in the clinical area are extensive but not necessarily identified by the practitioner. Powell (1989) noted that nurses who did indicate an awareness of learning opportun­ ities also demonstrated ‘reflection in action’ in which the learning model is based on a problem-solving approach within partner­ ship relationships with the patient. The ap­ proach also fosters generalization, i.e. using the knowledge of past experiences to solve

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Implication» of the theory/practlce gap for Project 2000 students

Table I. Representative comments from foundation programme students _______________________ There is a lim it as to how much I can retain without seeing some of this theory w orking out in practice.’____________________ __ ‘After 6 months as a student I have found that the theory has prepared me well for the role of observer on my placements. However, I did not wish to be an observer but to participate in the giving of care.’______________________________________ _ _ _

‘I have had no opportunity to practise the limited clinical skills that I have learned. My early eagerness has now diminished and in the last week of my placement I found it hard to be enthusiastic and interested.’ ___

present problems. Shotter (see Clarke, 1986) refers to this type of performance as ‘responsible action’ and states: ‘If we can extract from our everyday practice a theory of those practices, that theory may be ap­ plied in deciding what to do next.’ In other words, from a choice of actions the practi­ tioner selects one that is reasoned and in­ tended. This is the ‘knowledgeable doer’ in action and represents the highest level of Dickoff et al’s (1968) hierarchy. The concept of reflection in action sup­ ports the view that theory and practice are inseparable and that there is congruence be­ tween theories in use and professed theor­ ies. Schon (1983) points out the complexity of clinical problems that have no readily available theory to effect resolution, and which cause practitioners to ‘reframe’ prob­ lems in order to find solutions. It is at this point that theory and practice may part company, the practitioner having found an apparently workable solution, although un­ founded in theory, which causes the prac­ tice to become a routine, i.c. practice in use. This has significant implications for emergent Project 2000 students whose edu­ cation is designed to effect and promote re­ flective and critical thinking skills. How­ ever, unless learning opportunities are used to formulate and guide clinical practice, learners will not necessarily make links themselves. Powell (1989) supports this view and asserts that ‘application of this knowledge should be given more emphasis and monitored more clearly through train­ ing and education rather than left to the individual nurse’. It is evident that quality clinical exposure is vital so that emphasis can be placed on the application of knowledge to practice rather than on knowledge for its own sake. Practice may otherwise be a damaging ex­ perience in terms of learning, and theory

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may not develop beyond the situation-re­ lating stage (Dickoff et al, 1968). Within the wider curriculum, Project 2000 students observe caring roles inside the complexity of social and healthcare provision, thus fa­ cilitating a health-to-illness continuum. One of the problems here is that there is a long delay before students have the op­ portunity to practice hands-on care. This situation may well produce a gap between learned theory and the opportunity to put it into practice. Gott (1982) states that for cognitive changes to take place, teachers must ensure that students have the opportunity to apply learning to practice as soon as possible otherwise it is likely to become distorted. Lack of opportunity to practice may thus result in incomplete learning; there are al­ ready indications that this is happening. Students who were 6 months into their common foundation programme were ask­ ed to evaluate the application of theory to practice for their course. The comments shown in Tabic 1 are representative of many learners’ opinions. These feelings may quickly lead to disil­ lusionment, frustration and insecurity, and unless the total learning experiences are carefully monitored and acted upon, theor­ etical experiences will have limited mean­ ing. Some learners may leave while others may not cope with the frustration of being unable to do the very thing that they enter­ ed nursing to do — to nurse. For some stu­ dents, problems may arise later when they encounter realities of the clinical environ­ ment as a rostered member of the staff.

T eacher/practitioner Birch (1975) identifies elements of the theory/practice gap as significant reasons for learner attrition. These include lack of ward teaching, differences in classroom/ward practices, lack of clinical support/supervision and absence of tutors in the clinical areas. The implications of a lack of teacher presence at the bedside is obviously an im­ portant issue for the emergent Project 2000 student who will be dependent on experi­ ences in the clinical placements being teach­ er-led or teacher-facilitated. Mathieson (1988) suggests a merger of teaching and clinical roles with the teacher/ practitioner developing specialist knowl­ edge that can be imparted in the clinical area or classroom. The teacher/practitioner issue is highlighted in Project 2000 (UK.CC, 1986) recommendations: ‘Practitioners should have formal preparation for teaching

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Implications of the theory/practice gap for Project 2000 students (For the first time, training is education led and the skills, knowledge and attitudes acquired by the students. . . will be influenced primarily by the integrity and skills o f teachers and by the curriculum and its interpretation. 5

roles in practice settings.’ The project, how­ ever, recognizes that it is not feasible for all teaching to be done by the clinical staff. Some clinical settings may be supporting up to five different types of learners. This places a heavy commitment on clinical staff who are the learners’ role models, assessors and mentors, all of whom have different educational or training criteria to meet. To avoid overburdening practitioners it is im­ portant that curriculum and college com­ mitments are flexible enough to allow teachers to be present in the clinical envi­ ronment to act as facilitators in applying learned theory to practice. Not only is there a danger of flooding the placement areas but also there is the danger that patient care will become more fragmented, with different learners only be­ ing able to carry out certain aspects of care depending on their level of competence. This situation is compounded by the fact that learners are transient. Procter (1989) suggests that there is a correlation between a transient workforce and a reliance on nursing routines and that conversely a stable workforce situation helps to promote individualized care. The holistic model at the forefront of the nursing theory and practice aspects of the curriculum may be­ come detached from the actual practice be­ cause of Project 2000 itself.

Reality versus the ideal ‘Between the idea/And the reality/Between the motion/And the act/Falls the shadow’ (TS Eliot, 1888-1965). Miller (1985) states that there is a major barrier between nurs­ ing ‘as it ought to be’ and nursing ‘as it is’ with educationalists expounding the for­ mer and practitioners the latter. Changes to realize the linking of the real­ ity and the ideal have been initiated through the UKCC’s (1990) Post-Registration Edu­ cation and Practice Report (PREPP) and the English National Board’s (ENB) (1991) Framework and Higher Award for Con­ tinuing Professional Education for Nurses, Midwives and Health Visitors. It is envisag­ ed that ongoing education will bring a more insightful and questioning practitioner to the bedside. By the same token, if teachers are able to maintain or regain clinical credi­ bility, they need to be given time and op­ portunity to practise their skills and devel­ op firm links with the clinical environment. It is only through the understanding of each other’s worlds that consensus-based theor­ ies can be developed, for unless theory can be applied to enhance practice, it has no British Journal of Nursing, 1992, Voi l,N o 10

meaning in the real world. The learning opportunities for exploring theories on which practice is purported to be based or ought to be based are much greater for Project 2000 learners. This means that when they eventually experience clinical practice they may readily perceive that there is a considerable gap between the presentation of frameworks for nursing care and their application to practice. It is hoped that by extending the knowledge base of such students, theories may be more extensively tried and applied in the future. However, where current practice bears little resemblance to theory, students may dismiss the latter as idealistic and the di­ chotomy will be perpetuated. Although it is envisaged that students will critically evaluate clinical practice, it is unlikely that they will challenge the status quo. If important issues such as primary nursing and nursing models are not ad­ dressed as practice initiatives, they may be­ come compartmentalized into a theoretical category in the minds of emergent students; thus, any beneficial impact on patient care could remain largely undeveloped. For the first time, training is education led and the skills, knowledge and attitudes acquired by the students, at least for the first 18 months, will be influenced primar­ ily by the integrity and skills of teachers and by the curriculum and its interpreta­ tion. If students are not to be caught be­ tween unrealistic expectations on the part of educationalists and the real world of practice, then teachers must teach realisti­ cally and apply the curriculum accordingly. This is not to say that there should be any compromise of standards, but if teaching is esoteric and unrealistic, students will have false expectations and may be frustrat­ ed and confused when they encounter the clinical environment.

Teaching methods With the increased theoretical input, the in­ fluence of teaching method will have an im­ portant bearing on learning outcomes and on students’ ability to relate theory to prac­ tice and to transfer knowledge to a variety of situations. As Vaughan (1990) points out, ‘nursing is a practice-based profession; over-indulgence in teaching knowledge through teaching-centred methods may not result in competently skilled practitioners’. Vaughan’s (1990) research indicates that students have a preference for studentcentred methods. Farfitt (1989) found that creative teaching

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Implications of the theory/practice gap for Project 2000 students

(The practice of nursing has long been regarded as an art, while traditionally the knowledge base for practice has its roots firm ly planted in science. 5

produced significantly better results in terms of problem identification and plan­ ning than did didactic teaching. According to Sweeney (1986), the creative approach encompasses three concepts: self-directed learning reflecting the increased responsi­ bility and autonomy of the learner; stu­ dent-centred learning which stresses the importance of the holistic approach and the democratic relationship between learner and teacher; and andragogy which identif­ ies the learner as an adult who comes to the learning situation not as a blank slate but with a wealth of experiences. The concept thus goes beyond the learn­ ing of a body of knowledge which can be regurgitated at some later time, towards self-fulfilment through reasoning, critical thinking and self-motivation for life-long learning. If students do not develop inde­ pendent and critical thinking skills, their ability to make decisions in the clinical area may be adversely affected and they are like­ ly to become dependent on rules and rou­ tines (Menzies, 1960). This in turn may re­ sult in resistance to change, unwillingness to acknowledge or implement research and lack of theory development in clinical prac­ tice. The degree of learner centredness in teaching and the extent to which the cur­ riculum is flexible have major implications for practice and theory-practice cohes­ iveness which extend beyond immediate educational considerations (Sweeney, 1986).

a danger of undergraduate nurses moving out of the clinical setting. This will increase the chances of more and more direct care being carried out by healthcare assistants and will be a retrograde step not only for patient care but also for any credibility in the claim for professional status. What other profession leaves its primary function to inexperienced and unqualified person­ nel?

H ealth issues w ithin the curriculum

Professional issues w ithin the curriculum

There is a much greater emphasis on health and health matters in the Project 2000 cur­ riculum. While it is desirable for students to develop an awareness and understanding of the social conditions and healthcare needs of their community, this emphasis may not match either the students’ perspec­ tive of nursing or the realities of practice. Leaving aside the issue of whether nurs­ ing needs to be redefined, the problem is that implicit in the layman’s view of nursing is the notion of looking after the sick. When candidates are asked why they want to nurse, the vast majority identify their desire to ‘help people’ and ‘look after the sick and indeed, the reality is that, for those nurses who choose the hospital setting, ex­ cept for maternity care, nursing interven­ tion is with the ill and injured. Educating the well public and the sick towards a healthier and improved quality of life is a vital part of the nurse’s role. However, we have to be mindful not to create an expecta­ tion for a health model while in reality managing an illness one.

There is much emphasis on professional studies in the new curriculum, i.e. issues such as accountability, autonomy and other factors that affect the professional status and responsibilities of the nurse. The ques­ tion is whether nursing practice can provide a model that matches the theoretical presen­ tation, and whether new students will be given sufficient opportunity to develop de­ cision-making skills to prepare them for the professional role. The answer can only be one of conjecture at present for we have little experience upon which to draw. When the new training is established and the early students become qualified, it is hoped that the ‘new profes­ sional’ with diploma status will have a firm footing on the undergraduate ladder and greater insight into professional matters, and will contribute to promoting a more professionally prepared bedside nurse. Should the conflicts be too great, there is

Holden (1991) states: ‘The caring role, intrinsic to the mean­ ing of the word “nurse”, constrains nursing under the rubric of the arts, while nursing that embraces high tech­ nology constrains the discipline under the rubric of science.’ The practice of nursing has long been re­ garded as an art, while traditionally the knowledge base for practice has its roots firmly planted in science. Clarke (1986) as­ serts that the differing perspectives of nurs­ ing as an art and a science create differences for nursing theory and practice and ‘help to widen the gap between the two’. Within the academic sector there is tradi­ tionally a bureaucratic divide between the arts and the sciences; nursing, however, does not fit neatly into either. It is a com­ plex and social activity that takes place in

British Journal of Nursing, 1992, Voi l,N o 10

A rt versus science

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Implications of the theory/practice gap for Project 2000 students

(Nursing theory and research are at a comparatively early stage in their development and nursing has attempted to make them fit into practice without . . . questioning whether knowledge borrowed from other disciplines is valuable to nursing. 5

a social setting. The base for interactional skills lies within the realms of psychology and sociology while the rationale for nurs­ ing intervention, when it is not simply bas­ ed on tradition, routine and the needs of the organization, is based on science. The two disciplines should thus be integrated in the practice of nursing. The application of the scientific aspects have been the most difficult to achieve and it is this lack of scientific application that has hindered the development of the pro­ fession away from the ritualistic and routinized care. The wide application of the problem-solving approach undoubtedly changed the emphasis of nursing from a medical, science-based model towards a more social interactionalist one that em­ bodies the concepts of holism and of care rather than cure. However, the model re­ quired, through intellectual reasoning of problems and setting of goals, the applica­ tion of a scientific knowledge base which was frequently found wanting. In terms of Dickoff et al’s (1968) fourtier hierarchy, students and qualified nurses had identified concepts and were attempt­ ing to use them to guide action without having gained an understanding of the in­ termediate stages, i.e. how the concepts re­ late to one another or how they relate to the particular situation, e.g. to use theory to predict an expected outcome of a plan­ ned intervention.

Early development Nursing theory and research are at a com­ paratively early stage in their development and nursing has attempted to make them fit into practice without always exploring their philosophical base and the values im­ plicit in them, and without questioning whether knowledge borrowed from other disciplines is valuable to nursing. It is re­ freshing to see cohesive arguments address­ ing some of the potentially negative aspects of nurses’ continued acceptance of the traditional view of science. Yeo (1989), for example, regards Roy’s (1976) model as pa­ ternalistic with the nurse in a position of authority and the patient disadvantaged by lack of familiarity with the language used: ‘The nurse is in a privileged position to set goals and plan interventions mandated by his or her guiding science’ (Yeo, 1989). Hardy (1990) regards the macro theory language in nursing as ‘controlling with as­ sertive and authoritarian statements which appear to demand conformity’. If this is the case, it is hardly concomitant with the prac­

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tice of an art that espouses a philosophy of the partnership role of the patient. If nursing as an art and a science is to develop, promote and enhance practice, it is important that nurses are not too con­ strained by theories. In addition, partly de­ veloped theories must not be imposed in a dogmatic fashion on Project 2000 students simply because there is more curriculum space and because this is the knowledge base that the teachers perceive as correct.

Conclusion It is hoped that emergent Project 2000 stu­ dents will be better equipped and therefore will be more creative, more questioning and free in their thinking. Certainly, the new curriculum offers a much greater opportun­ ity to develop and cultivate a scientific foundation, but the perceived value to the art of nursing can only be actualized through the mutual development of theory and practice. The pertinent issues are the sensitive and insightful management of placement experi­ ences, development of the teacher/practitioner role and the application of a dynamic curriculum through student-centred methods. If a new professional is to emerge, every aspect of education must be carefully planned, otherwise Project 2000 nurses could emerge from the education process ill-equipped to practise what they have been educated for and the profession will have prepared an unmarketable commod­ ity: ‘. . . a professional cannot just watch, cannot just do, and cannot just hope and dream’ (Dickoff and James, 1968).

Argyris C, Schon D (1974) Theory in Practice: Increas­ ing Professional Effectiveness. Addison Wesley, Massachusetts Birch J (1975) To Nurse or N ot to Nurse: An Investiga­ tion into the Causes o f Withdrawal During Nurse Training. Royal College of Nursing, London Clarke M (1986) Action and reflection: practice and theory in nursing. ] A d v Nurs 11(1): 3-11 Dickoff J, James P (1968) A theory of theories, a posi­ tion paper. Nurs Res 17 (5): 197-203 Dickoff J, James P, Weidenbach E (1968) Theory in a practice discipline. Part 1: practice orientated the­ ory. Nurs Res 17(5): 415-35 English National Board (1991) Framework and Higher Award for Continuing Professional Education for Nurses, Midwives a n d Health Visitors. English N a­ tional Board, London G ott M (1982) Theories of learning and the teaching of nursing (Occasional papers). Nurs Times 78 (11): 41-4 Hardy LK (1990) The path to nursing knowledge — personal references. Nurs Educ Today 10: 325-32 Holden R (1991) In defence of Cartesian dualism and the Hermeneutic horizon. J A d v Nurs 16: 1375-81 Mathieson A (1988) Theoretical Nursing: Develop-

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Implications of the theory/practice gap for Project 2000 students

KEY POINTS • Project 2000 nurse education seeks to provide ‘knowledgeable doers’ at patients’ bedsides. • Learning opportunities in the clinical environment are extensive but may not be recognized by students unless they are actively helped to relate theory and practice. • Long gaps between learning theory and opportunity to practice may produce incomplete learning and may also result in frustration, insecurity and even increase attrition. • Overburdening of placement areas and unrealistic expectations of clinical staff who are required to support students may result in fragmentation of care and a widening of the theory/practice gap. • Issues such as primary nursing and use of nursing models need to continue to be addressed as practice issues, otherwise students may compartmentalize them as idealistic and theoretical. • Teachers need time and opportunity to maintain clinical credibility; they need to prepare students for the real world without compromising standards and to promote creative, student-centred teaching methods.

merit and Progress. Lippincott, USA Menzies I (I960) The Functioning o f Social Systems as a Defence Against Anxiety. Tavistock, London Miller A (1985) The relationship between nursing the­ ory and nursing practice. / A dv Nurs 10: 417-24 Parfitt B (1989) A practical approach to creative teach­ ing: an experiment. J A d v Nurs 14: 665-77 Powell JH (1989) The reflective practitioner in nurs­ ing. J A d v Nurs 14: 824-32 Procter S (1989) The functioning of nursing routines in the management of a transient workforce. ] A dv Nurs 14: 180-9 Reid N G (1985) Wards in Chancery f Nurse Training in the Clinical Area. Royal College of Nursing, London Roy C (1976) The Roy adaptation model. In: Riehl JP, Roy C, eds. Conceptual Models fo r Nursing Practice. Appleton Century Crofts, New York Schon D (1983) The Reflective Practitioner. Temple Smith, Lonaon Stevens BJ (1984) Nursing Theory: Analysis, Applica­ tion, Evaluation, 2nd edn. Little Brown, Boston Sweeney J (1986) Nurse education: learner centred or teacher centred. Nurs Educat To­ day 6: 257-62 UKCC (1986) Project 2000: A N ew Preparation fo r Practice. UKCC, London U KCC (1990) Post-Registration Education and Practice Report. UKCC, London Vaughan BA (1990) Student nurse attitudes to teaching/learning methods. J A dv Nurs 15: 925-53 Webster R (1990) The role of the nurse teacher. Sen Nurs 10 (8): 16-18 Yeo M (1989) Integration of nursing theory and nursing ethics. A dv Nurs Sci 11 (3): 33-42

JC N Exhibitions 1992 For 1992 we have a pro­ gramme of twelve exhibitions which features some new venues but still includes firm favourites from previ­ ous years.

The exhibitions will follow the same format, with the day divided into two separ­ ate sessions to enable you to choose the time which suits you best, i.e. 11.30am-2pm and 6.30-9pm.

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The Pennine Hotel

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A buffet lunch or supper will be provided and we re­ quest that you complete and return the invitation card as early as possible so that we can cater for you.

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Moat House

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practice gap for Project 2000 students.

Nursing has frequently attempted to address the gap between theory and practice. This article explores their relationship and the implications of any ...
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