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Nursing and Health Sciences (2014), 16, 141–142
Editorial
The theory–practice gap: Well and truly alive in mental health nursing Mental health is well and truly on the international agenda of healthcare reform. Yet, globally, there are significant differences in the quality and extent of mental health systems and care delivery. For example, a number of countries remain burdened by outdated mental hospitals, built by colonial masters, where custodial care is often commonplace for in-patients. In many settings the medical model of care dominates, but in others there is evidence of growth of strong consumer-focused services. In my experience, the theory–practice gap is alive and well in many areas of nursing, including mental health settings. The theory–practice gap is where the transition to practice is complex, multifaceted, and all too frequently not smooth (Chang & Daly, 2008). It is manifest on two main levels: first, for students on their clinical practicum placements, and second, for newly qualified nurses. Many causes have been identified. There is criticism of the universities for not providing students with appropriate information, for producing nurses who do not know about mental illnesses and are viewed as being insufficiently prepared to fully participate in patient care. Criticism is also directed at those in healthcare settings for being ill-informed and having unrealistic expectations of students or new graduates still in the formative stages of their learning: in short, the universities prepare them, the health services employ them. The challenge is to prepare nurses who can meet the needs of individuals, families, communities, and the country at large within time spans, resources available, and educational outcomes. Nurses need to have satisfaction and pride in their achievements. Many within the international community of mental health researchers, nurses, and other professionals strive to ensure that the treatment and care of people with mental health problems is informed by evidence of the diverse range of causation, care, and best practice. The research agenda has two major areas of focus: the need to examine and validate the most effective and efficient treatments and approaches; and the need to explore many aspects of therapeutic relationship, the foundation of mental health nursing, and how nurses can provide better, more effective care. We need evidence for how to manage and achieve the best care. Increasingly consumers and families are collaborating in and influencing care, research studies, discussions, and outcomes related to mental health. The role of universities or colleges is to prepare mental health nursing graduates with the ability to: think critically and problem solve; research and plan care based on evidence and best practice principles; act as change agents, challenge the status quo; demonstrate life-long learning to maintain contemporary and culturally appropriate practice; and be prepared to undertake further education. In mental health, © 2014 Wiley Publishing Asia Pty Ltd.
this presents another set of challenges. Health services want students and graduates who can “do” and “know” all about the multitude of illnesses and disorders they encounter and the appropriate treatment and care. Another perspective focuses on what needs to be taught. Healthcare policy makers, planners, and community groups want education that emphasizes positive images of mental health, to create healthy societies where major issues like stigma and marginalisation are addressed. Practitioners and health managers want students and graduates with a sound working knowledge of mental illnesses and their treatments. With a heavy reliance on the bio-psychosocial model to inform care and the medical model to structure and deliver services, consumers are generally cast into the role of the sick requiring treatment. The Recovery Model of care advocates person-centered care and collaboration with consumers and families and the mental healthcare team, which often creates tensions (Jacobson & Greenley, 2001). Increasingly, nurses are adopting the philosophy and practices of Recovery as they are consistent with holistic care and the humanistic approaches favoured by many nurses. Consistent with the Recovery movement, many services worldwide are embracing the Tidal Model of Mental Health Recovery and Reclamation, developed and promoted by co-authors Phil Barker and Poppy Buchanan-Barker (2011). These conflicting expectations and demands need to be challenged and resolved. Some academics want nurses in health service areas to be more aware of a range of theories and models that inform care, while the practitioners want academics to prepare nurses for the real world of practice. Renowned educationalist Donald Schon (1987) referred to this dichotomy as conflict between the hard high ground of theory and the swampy lowlands of practice. Resolution of this conflict requires mutual understanding of the goals and expectations of all the key stakeholders, beginning with the two major players and including students, new graduates, consumers, and carers. First, the involvement of practitioners, managers, and consumers in curriculum development, implementation, and monitoring ensures a curriculum that acknowledges contemporary practice; second, and ideally, the involvement of academics in the clinical areas.The critics will argue that this is impossible, that “teachers are teachers and clinicians are clinicians.” However, collaborative approaches to education work well, to bring practitioners into the academic settings, to introduce students to the world of practice before they set foot outside the university doors.This includes bringing consumers and carers to present their stories, experiences, and expectations of mental health care and nurses. Academics attend and participate in the clinical settings where opportunities for practice-based research doi: 10.1111/nhs.12156
142
abound and must be fostered (Rolfe, 1998). Collaborative approaches have been tried with varying degrees of success, and some are now described. A different approach by Munnukka et al., (2002), described an action research project in Finland that brought together two major parties, an institute of nursing and health care and a university hospital. Students had theory classes and practical training together in a novel way in the practice domain. Project evaluations were positive, and though they encountered many hurdles and problems, the authors recommended the adoption of this approach. A similar approach was advocated and adopted by Boardman (2007) who held a joint academic and a clinical position, and took the teaching of the mental health theory elective unit into her workplace in Melbourne, Australia. Reported benefits included greater access to clinical staff, enhanced relationships, greater insight for students, and high levels of satisfaction, with very successful rates of employment in mental health on graduation. Evans (2009) in the UK interviewed senior mental health professionals, who expressed their concern about graduates and pointed to the division of responsibility between the service sector (the mental health trusts) and universities as the cause of problems related to the theory–practice gap. His recommendations included greater collaboration, sharing responsibility, and the creation of an overarching professional body with the authority to monitor, insist on standards, and importantly to hold both parties accountable. The idea of yet another professional body and therefore another layer of responsibility for the preparation of nurses for practice seems excessive. So, what to do? We can bridge the theory–practice gap. Focused research will ensure the development and testing of the most appropriate theories for mental health nursing and workable models of care. Research and experience confirms that collaboration and closer working ties between the educational and health service providers will achieve results. There is, however, no easy answer. It requires careful planning, implementation, monitoring, and persistence. Students and new graduates need effective learning experiences to prepare them to contribute to contemporary systems of care, but more importantly to help provide a better future for our consumers, families, communities, and society at large. They need contemporary knowledge and skills but more
© 2014 Wiley Publishing Asia Pty Ltd.
Editorial
importantly are required to be future agents of change and to progress mental health reforms locally, nationally, and internationally. As with all approaches to change, these need to happen at all levels. Strategies must begin with the academic/student relationship to excite students about the value of and need for theory to inform practice. New graduates must accept the responsibility for integration between theories and practice, guided by clinical educators and senior clinical nurses. Required within the healthcare system, there needs to develop a culture, strategies and practices that support these measures and ideals, with champions to drive the changes. Managers can provide support and resources such as in-service training, clinical supervision and continued professional development with time and access to ensure that they are embedded into the practice and not seen as optional luxury items. We owe it to our consumers, families, and the profession. Kevin James Kellehear, BA MHPEd, Doctoral Candidate, HOPE School of Nursing, Wuhan University, Wuhan, China
REFERENCES Boardman J. Focus mental health. Aust. Nurs. J. 2007; 14: 36. Barker P, Buchanan-Barker P. Mental health nursing and the politics of recovery: a global reflection. Arch. Psychiatr. Nurs. 2011; 25: 350–358. Chang E, Daly J. Managing the transition from student to graduate nurse. In: Chang E, Daly J (eds). Transitions in Nursing (2nd Edn). Sydney, NSW: Churchill Livingstone Elsevier, 2008; 1–4. Evans M. Tackling the theory–practice gap in mental health nursing training. Ment. Health Pract. 2009; 13: 21–24. Jacobson N, Greenley D. What is recovery? A conceptual model and explication. Psychiat. Serv. 2001; 52: 482–485. Munnukka T, Pukuri T, Linnainmaa P, Kilkku N. Integration of theory and practice in learning mental health nursing. J. Psychiatr. Ment. Health Nurs. 2002; 9: 5–14. Rolfe G. The theory–practice gap in nursing: from research-based practice to practitioner-based research. J. Adv. Nurs. 1998; 28: 672– 679. Schon D (ed.). Educating the Reflective Practitioner. San Francisco, CA: Jossey Bass, 1987.
Nursing and Health Sciences (2014), 16, 141–142
Editorial
The theory–practice gap: Well and truly alive in mental health nursing Mental health is well and truly on the international agenda of healthcare reform. Yet, globally, there are significant differences in the quality and extent of mental health systems and care delivery. For example, a number of countries remain burdened by outdated mental hospitals, built by colonial masters, where custodial care is often commonplace for in-patients. In many settings the medical model of care dominates, but in others there is evidence of growth of strong consumer-focused services. In my experience, the theory–practice gap is alive and well in many areas of nursing, including mental health settings. The theory–practice gap is where the transition to practice is complex, multifaceted, and all too frequently not smooth (Chang & Daly, 2008). It is manifest on two main levels: first, for students on their clinical practicum placements, and second, for newly qualified nurses. Many causes have been identified. There is criticism of the universities for not providing students with appropriate information, for producing nurses who do not know about mental illnesses and are viewed as being insufficiently prepared to fully participate in patient care. Criticism is also directed at those in healthcare settings for being ill-informed and having unrealistic expectations of students or new graduates still in the formative stages of their learning: in short, the universities prepare them, the health services employ them. The challenge is to prepare nurses who can meet the needs of individuals, families, communities, and the country at large within time spans, resources available, and educational outcomes. Nurses need to have satisfaction and pride in their achievements. Many within the international community of mental health researchers, nurses, and other professionals strive to ensure that the treatment and care of people with mental health problems is informed by evidence of the diverse range of causation, care, and best practice. The research agenda has two major areas of focus: the need to examine and validate the most effective and efficient treatments and approaches; and the need to explore many aspects of therapeutic relationship, the foundation of mental health nursing, and how nurses can provide better, more effective care. We need evidence for how to manage and achieve the best care. Increasingly consumers and families are collaborating in and influencing care, research studies, discussions, and outcomes related to mental health. The role of universities or colleges is to prepare mental health nursing graduates with the ability to: think critically and problem solve; research and plan care based on evidence and best practice principles; act as change agents, challenge the status quo; demonstrate life-long learning to maintain contemporary and culturally appropriate practice; and be prepared to undertake further education. In mental health, © 2014 Wiley Publishing Asia Pty Ltd.
this presents another set of challenges. Health services want students and graduates who can “do” and “know” all about the multitude of illnesses and disorders they encounter and the appropriate treatment and care. Another perspective focuses on what needs to be taught. Healthcare policy makers, planners, and community groups want education that emphasizes positive images of mental health, to create healthy societies where major issues like stigma and marginalisation are addressed. Practitioners and health managers want students and graduates with a sound working knowledge of mental illnesses and their treatments. With a heavy reliance on the bio-psychosocial model to inform care and the medical model to structure and deliver services, consumers are generally cast into the role of the sick requiring treatment. The Recovery Model of care advocates person-centered care and collaboration with consumers and families and the mental healthcare team, which often creates tensions (Jacobson & Greenley, 2001). Increasingly, nurses are adopting the philosophy and practices of Recovery as they are consistent with holistic care and the humanistic approaches favoured by many nurses. Consistent with the Recovery movement, many services worldwide are embracing the Tidal Model of Mental Health Recovery and Reclamation, developed and promoted by co-authors Phil Barker and Poppy Buchanan-Barker (2011). These conflicting expectations and demands need to be challenged and resolved. Some academics want nurses in health service areas to be more aware of a range of theories and models that inform care, while the practitioners want academics to prepare nurses for the real world of practice. Renowned educationalist Donald Schon (1987) referred to this dichotomy as conflict between the hard high ground of theory and the swampy lowlands of practice. Resolution of this conflict requires mutual understanding of the goals and expectations of all the key stakeholders, beginning with the two major players and including students, new graduates, consumers, and carers. First, the involvement of practitioners, managers, and consumers in curriculum development, implementation, and monitoring ensures a curriculum that acknowledges contemporary practice; second, and ideally, the involvement of academics in the clinical areas.The critics will argue that this is impossible, that “teachers are teachers and clinicians are clinicians.” However, collaborative approaches to education work well, to bring practitioners into the academic settings, to introduce students to the world of practice before they set foot outside the university doors.This includes bringing consumers and carers to present their stories, experiences, and expectations of mental health care and nurses. Academics attend and participate in the clinical settings where opportunities for practice-based research doi: 10.1111/nhs.12156
142
abound and must be fostered (Rolfe, 1998). Collaborative approaches have been tried with varying degrees of success, and some are now described. A different approach by Munnukka et al., (2002), described an action research project in Finland that brought together two major parties, an institute of nursing and health care and a university hospital. Students had theory classes and practical training together in a novel way in the practice domain. Project evaluations were positive, and though they encountered many hurdles and problems, the authors recommended the adoption of this approach. A similar approach was advocated and adopted by Boardman (2007) who held a joint academic and a clinical position, and took the teaching of the mental health theory elective unit into her workplace in Melbourne, Australia. Reported benefits included greater access to clinical staff, enhanced relationships, greater insight for students, and high levels of satisfaction, with very successful rates of employment in mental health on graduation. Evans (2009) in the UK interviewed senior mental health professionals, who expressed their concern about graduates and pointed to the division of responsibility between the service sector (the mental health trusts) and universities as the cause of problems related to the theory–practice gap. His recommendations included greater collaboration, sharing responsibility, and the creation of an overarching professional body with the authority to monitor, insist on standards, and importantly to hold both parties accountable. The idea of yet another professional body and therefore another layer of responsibility for the preparation of nurses for practice seems excessive. So, what to do? We can bridge the theory–practice gap. Focused research will ensure the development and testing of the most appropriate theories for mental health nursing and workable models of care. Research and experience confirms that collaboration and closer working ties between the educational and health service providers will achieve results. There is, however, no easy answer. It requires careful planning, implementation, monitoring, and persistence. Students and new graduates need effective learning experiences to prepare them to contribute to contemporary systems of care, but more importantly to help provide a better future for our consumers, families, communities, and society at large. They need contemporary knowledge and skills but more
© 2014 Wiley Publishing Asia Pty Ltd.
Editorial
importantly are required to be future agents of change and to progress mental health reforms locally, nationally, and internationally. As with all approaches to change, these need to happen at all levels. Strategies must begin with the academic/student relationship to excite students about the value of and need for theory to inform practice. New graduates must accept the responsibility for integration between theories and practice, guided by clinical educators and senior clinical nurses. Required within the healthcare system, there needs to develop a culture, strategies and practices that support these measures and ideals, with champions to drive the changes. Managers can provide support and resources such as in-service training, clinical supervision and continued professional development with time and access to ensure that they are embedded into the practice and not seen as optional luxury items. We owe it to our consumers, families, and the profession. Kevin James Kellehear, BA MHPEd, Doctoral Candidate, HOPE School of Nursing, Wuhan University, Wuhan, China
REFERENCES Boardman J. Focus mental health. Aust. Nurs. J. 2007; 14: 36. Barker P, Buchanan-Barker P. Mental health nursing and the politics of recovery: a global reflection. Arch. Psychiatr. Nurs. 2011; 25: 350–358. Chang E, Daly J. Managing the transition from student to graduate nurse. In: Chang E, Daly J (eds). Transitions in Nursing (2nd Edn). Sydney, NSW: Churchill Livingstone Elsevier, 2008; 1–4. Evans M. Tackling the theory–practice gap in mental health nursing training. Ment. Health Pract. 2009; 13: 21–24. Jacobson N, Greenley D. What is recovery? A conceptual model and explication. Psychiat. Serv. 2001; 52: 482–485. Munnukka T, Pukuri T, Linnainmaa P, Kilkku N. Integration of theory and practice in learning mental health nursing. J. Psychiatr. Ment. Health Nurs. 2002; 9: 5–14. Rolfe G. The theory–practice gap in nursing: from research-based practice to practitioner-based research. J. Adv. Nurs. 1998; 28: 672– 679. Schon D (ed.). Educating the Reflective Practitioner. San Francisco, CA: Jossey Bass, 1987.
