The theory-practice gap and skill acquisition: An issue for nursing education
Article Outline
Abstract
Matching textbook descriptions of clinical situations with the reality of practice is an ongoing problem faced by members of the nursing profession and is commonly referred to as the “theory-practice gap”. This ubiquitous gap is inevitably encountered by all nurses at various times; yet it is widely agreed that it is student nurses – given their novice, rule governed status – who find themselves in the midst of the theory-practice void.
This paper will discuss the nature of the theory-practice gap and skill acquisition, in relation to a personal experience of mine as an undergraduate nursing student, and its significance in relation to student anxiety levels, nurse education (specifically the roles of the classroom teacher and clinical educators), teaching methods and the responsibility of the student to become accountable for their own education. I intend to communicate how my personal situation was dealt with and evaluate that experience in relation to current nursing literature. Ultimately, this discussion will demonstrate the value of reflection underpinning the development of competency in nursing and its role in bridging the theory-practice gap.
Keywords: Theory-practice gap, Nursing education, Nursing student, Undergraduate, Reflection
Introduction
Matching textbook descriptions of clinical situations with the reality of practice is an ongoing problem faced by members of the nursing profession and is commonly referred to as the theory-practice gap (Rolfe, 2002). This ubiquitous gap is inevitably encountered by all nurses at various times; yet it is widely agreed that it is student nurses who, given their novice more rule governed status, find themselves in the midst of the theory-practice void. This paper will discuss the nature of the theory-practice gap and skill acquisition, in relation to a personal experience of mine as an undergraduate nursing student, and its significance with regard to student anxiety, nurse education and teaching methods (specifically the roles of the classroom teacher and clinical educators), the responsibility of the student to become accountable for their own education and the overall value of reflection as a learning tool. Skill acquisition is an essential component of gaining clinical competence, along with knowledge, attitudes, values, beliefs and behaviours appropriate to professional nursing practice (ANMC, 2006). I intend to focus on how I dealt with my personal situation and evaluate the experience in relation to criteria raised in current nursing literature. Ultimately, this discussion will demonstrate the value of reflection underpinning the development of competency in nursing and its role in bridging the theory-practice gap.
Background
The theory-practice gap
Corlett, Palfreyman, Staines, and Marr (2003) contended that the complex nature of the theory-practice gap is not fully understood. Many authors concur with this opinion and agree the term is generally one that is too often defined imprecisely and subject to differing and individual interpretations (Corlett et al., 2003, Gallagher, 2004, Higginson, 2004, Maben et al., 2006, Rolfe, 2002, Spouse, 2001). However, there is widespread agreement within the scholarly literature that it relates to the distancing of theoretical knowledge from the practical dimension of nursing and indeed this definition has been utilised to illustrate the issue I faced as an undergraduate nursing student (Corlett et al., 2003, Higginson, 2004, Maben et al., 2006, Rolfe, 2002, Scherer and Scherer, 2007, Wolf et al., 2004).
The theory-practice gap is arguably the most important issue in nursing today, given that it challenges the concept of research based practice, which is the basis of nursing as a profession. Rolfe (2002) argues that the gap exists as a result of outdated theoretical concepts and a misconception about the relationship of theory to practice. Other authors agree with Rolfe to the extent that the problem lies within the relationship of theory and practice, yet the concept of outdated theories is more an issue of the socialisation of these theories into the clinical setting and the integration of current research into the modern practice setting, along with a need for more structured reflection on clinical experience (Alexander et al., 2002, Gallagher, 2004, Higginson, 2004, Maben et al., 2006, Martin and Mitchell, 2001, Ousey and Gallagher, 2007, Sharif and Masoumi, 2005) Although merely outlined in this paper, the utilisation of current research is an issue for continuing education in nursing and has implications for teaching methods, such as the use of human simulators to provide a more realistic, yet controlled practice environment (Alexander et al., 2002, Rhodes and Curran, 2005, Wilson et al., 2005). The focus here is on my own experience with the theory-practice gap and a discussion of its significance and implications for a more effective future practice.
Recalling the clinical event
The theory-practice gap became apparent to me whist I was an undergraduate student in the second semester of my second year of study. I had just come off an intense four-week placement on a somewhat difficult ward with my confidence elevated (naively, as it turned out). The two-week placement that ensued proved to be a very steep learning curve: I was challenged by my experience and emerged with a confidence based on a more substantial foundation than merely “good experiences” can provide. The reflective journal entry that follows is an account of a demoralising event which I turned into a positive one that influenced the way I now function as a nurse.
A Journal Entry:
“I had an interesting day today, to say the least! It all started when I was asked to perform a systems assessment of one of my patients- a simple enough task, one might think. Having learned a few different methods of assessment, this seemed to me a matter of pulling the “systems assessment” folder from the filing cabinet in my brain and applying it to the situation at hand. Simplicity was far from what I experienced today. I fumbled my way through what systems I could remember off the top of my head, all the while my heart racing at a million miles an hour and anxiety rising by the second. I remember thinking the whole time: “why am I finding this so difficult?” About half way through my clinical teacher stopped me, perhaps sensing my fragile emotional state, and we left the room to go through the principles involved. I was feeling very upset and frustrated- I just want to be the best nurse possible and I get annoyed with myself if I forget things or cannot do things straight away.
“I don’t think I had trouble with the concept of performing a systems assessment- the patient had to be fully assessed and this method is systematic and I had the background knowledge to apply. I think the main problem was that I hadn’t actually practiced it properly- we had only been given one-hour practical classes per week for the past year and we found it difficult to get much beyond ‘demonstrating’ skills”.
My investigation into this event and my response has brought many issues surrounding the theory-practice gap and nurse education to the surface. By identifying, and engaging in, the reflective process and by recognising and discussing other prominent factors I aim to demonstrate, through a comparison of my experience with current research, the invaluable nature of reflection.
The reflection process
Rolfe (2002) describes a cyclical reflection process he refers to as the “model of nursing praxis”. To begin the reflection process, students must engage in the reflection-on-action process (Rolfe, 2002). This involves an evaluation of the clinical experience using any personal knowledge the student currently possesses (Rolfe, 2002). The result of this initial process is the construction of informal theory, created by the student; with the assistance of research and formal theory in existence, the student is able to develop their own hypotheses regarding their personal practice and clinical nursing practice in general (Rolfe, 2002).
After my personal clinical experience, I initially became upset and discouraged, however, this incident became somewhat of an epiphany for me. From the outside, looking back on the events it is interesting to note, as my journal entry stated, the basic concepts of the task were not the issue, I believe it was my personal attitude and experience which contributed to the demise of my assessment attempts. Through initial reflection, I understand now that I set high standards for myself, yet my university achievements and standards are both the result of the serious nature with which I regard nursing. Upon further contemplation on why things went so badly, I realized lack of practice was the explanation lurking behind my poor performance. I had always understood the importance of self-guided learning and indeed instigated my own learning on several occasions, yet through this experience the practical reality of its importance became clear. This demonstrates my personal reflection-on-action process leading to informal theory. The following discussion surrounds how I was able to take steps toward creating practice hypotheses by utilising current research and formal theories with regard to my personal experience.
Discussion
In a qualitative survey of nursing students performed by Sharif and Masoumi (2005), initial clinical anxiety was identified as a major theme amongst the students at the beginning of a clinical placement. This illustrates several issues as barriers to skill acquisition in nursing education: the need for more realistic practice time in a controlled setting in university laboratories, the socialisation to the environment in which the clinical placement is taking place, the role of the clinical teacher in transferring academic skills to practice and the importance of collaboration between university and clinical education.
University based teaching, classroom practice and skill acquisition
Baille (2001) identified that to learn the motor dimension of a skill in reality requires practice in addition to studying the theory behind the skill; with this practice the skill becomes refined and coordinated in execution. The amount of practice required will vary according to the motivation level, physical resources and coordination of the student (Baille, 2001). After a brief reflection on the event, I decided to take responsibility for my own education, demonstrating my motivation to learn and improve, by partaking in further practice. There is no doubt nurse educators have an invaluable role to play, yet ultimately the conscientious student must identify and accept their own weaknesses before utilising resources to rectify them and improve their practice to an optimal level, thus taking steps toward developing into a competent nurse providing optimal patient care.
I have identified a lack of practice at the specific method of assessment required of me in the above scenario as contributing to my increased anxiety levels. This experience is shared by the students in the Sharif & Masoumi (2005) study, who expressed the stress of not having enough practice during their nursing studies to take into clinical practice. Baille (2001) identified an archaic theory whereby learning skills in the classroom setting was out of favour; an on-the-job model was instead preferred. The result of this theory corresponded with my personal experience and echoed the experience of the students interviewed in the later study by Sharif et al. (2005): without any classroom based practical skills learning, students report feeling unprepared and lacking in confidence. When the skill can be taught in the classroom setting, primary focus can be put into the cognitive and affective dimensions and not merely the manual dexterity, which is often the focus in the clinical setting (Baille, 2001, Farrand et al., 2006). Adequate classroom teaching in this manner can minimise the theory-practice gap. The student is able to equate the philosophy and research behind the skill being taught, and they have learned why it is done a particular way; and as a result they are not merely doing, they are learning to do. This method of teaching has been found to reduce the anxiety levels, increase feelings of confidence and enhance patient safety and provide improved practice (Baille, 2001, Pender and Looy, 2004, Sharif and Masoumi, 2005). Given that mastering a skill in the classroom can help facilitate closing the theory-practice gap when applying the same skill to the clinical setting, the need for adequate practice time in a controlled setting in university laboratories is essential.
Further to ensuring adequate practice time, strategies for teaching must also be considered. Bradley and Postlethwaite (2003) identify that student nurses often take on board the stereotypical culture and values of all novice practitioners in that they cannot see the forest for the trees: to be often too focused on the long term outcomes; and opportunity to reflect and learn from practice is delayed or embedded in a broader context. Using my experience as an example, the student can become lost in considering the whole care of the patient and lose focus on simply performing a patient assessment. Many authors argue that the focus should perhaps be on smaller components such as remembering the individual body systems and going through each separately at a slow pace (Bradley and Postlethwaite, 2003, Jerlock et al., 2003, Pender and Looy, 2004, Rolfe, 2002). With more practice starting at this pace these authors have discovered that students soon become familiar with the process involved in the task, become more confident, less anxious and able to perform with more proficiency (Jerlock et al., 2003, Pender and Looy, 2004). This appears to be a task-oriented approach to patient care, however as an advanced beginner it allows mastery of skills and building of confidence and this can be further developed into the skill of coordinating total patient care (Bradley and Postlethwaite, 2003, Jerlock et al., 2003, Pender and Looy, 2004).
Socialisation to the clinical environment
From a recent study by Maben et al. (2006), it was found that student nurses emerge from clinical experiences with a strong set of nursing values. This study identified that these values are often sabotaged by covert rules governing the practice of nursing in reality (Maben et al., 2006). This poor professional socialisation has not only proven to create increased anxiety levels in students, but also places a barrier between theory students are taught and how they are permitted to apply it in the clinical setting, hence contributing to the phenomenon of the theory-practice gap (Maben et al., 2006, Sharif and Masoumi, 2005).
The Maben et al. (2006) study identifies role models as agents of socialisation and support, the most important of which to the student is the clinical teacher. Role models facilitate positive and constructive socialisation into nursing practice to allow for theories learned at university to be implemented without experiencing the wrath of the this is the way it's done here attitude (Maben et al., 2006).
The role of the clinical educator
The clinical nurse educator plays a pivotal role in skill acquisition and the process of closing the theory-practice gap (Landmark, Hansen, Bjones, & Bohler, 2003). Role modelling, socialising to the culture of the unit and assistance in the establishment of workplace relationships as well as education are among the roles of the clinical educator (Baltimore, 2004). Landmark et al. (2003) reveal that clinical supervision has, in the past, often been implemented as a form of managerial surveillance rather than as a valuable learning tool. These authors suggest that clinical supervision should not merely be a learning by doing model but constitute a support learning through reflection approach (Landmark et al., 2003). The clinical practice setting is where the student gains the most valuable feedback as it occurs concurrently with the tangible learning process (Baille, 2001, Martin and Mitchell, 2001). Recent studies have shown that nurses integrate knowledge and develop competency by reflecting on their practice during clinical supervision and debriefing (Landmark et al., 2003, Corlett et al., 2003). Learning from experience and reflection, although ultimately the responsibility of the student, should be initiated by the clinical educator—what follows and how much the student learns is then placed in their hands.
The clinical educator should be seen as a role model or mentor; with part of their role being to both facilitate mechanical proficiency and challenge the student to build on existing theoretical and contextual knowledge bases. As the experience I have described occurred early in my placement, I was able to utilise my clinical teacher to rectify this and she herself was unquestionably supportive and obliging in her help. This was extremely encouraging and consequently, I opted to redefine the scenario as a challenge to advance in future clinical situations and hence endeavour to attain a more substantial level of confidence than that which I had before. There is no doubt that a good relationship with a mentor facilitates the integration and understanding of theoretical knowledge to clinical practice as well as set the reflection process in motion.
Collaboration between university and clinical education
Corlett et al. (2003) emphasise the need for a close partnership and collaboration between classroom educators and off campus teachers. The methods of patient assessment taught at my university differed from those utilised by the clinical placement educator, this disparity contributed to my unsatisfactory encounter, demonstrating the importance of a partnership between university and clinical education. Corlett et al. (2003) found that meaningful peer collaboration would result in clinical placement teaching reflecting academic sessions and better service perspectives of students’ knowledge and needs. Indeed, the literature on this topic emphasises the benefit of close collaboration between classroom and clinical teaching in both closing the gap between theory and practice and assuaging student anxiety as was indeed the experience I underwent (Baltimore, 2004, Corlett et al., 2003, Jerlock et al., 2003, Spouse, 2001).
The challenge for educators is to produce students who adapt formal, generalised knowledge to solve specific problems in local settings and develop critical thinking and practical problem solving skills (Jerlock et al., 2003, Martin and Mitchell, 2001, Pender and Looy, 2004, Scherer and Scherer, 2007, Spouse, 2001). Without this adaptation the practice of the impending nurse would carry beliefs and values that bear little relationship with the research into effective practice, further widening the theory-practice gap (Spouse, 2001). Teaching the formal, generalised knowledge in the classroom in preparation for practice is the role of the university, the transference of those knowledge and skills and their application to the practice setting is the domain of the clinical educator. The relationship between the two parties is inevitably enmeshed and is of utmost importance when developing education strategies.
Conclusions
Nursing education has both theoretical and practical elements. Students have substantial theoretical education prior to their opportunity to apply this knowledge to practical situations in the clinical component of the course. As Jerlock et al. (2003, p. 221) explain, the intended goal is the production of a confident student who is “capable of independently making decisions and performing nursing activities towards patients, relatives and other health professionals”. As mentioned above, Spouse (2001) identifies the challenge faced by nurse educators (both classroom and clinical) is to convince students to adapt formal, generalized knowledge to solve specific problems and to develop beliefs, values and critical thinking in the practical environment.
Jerlock et al. (2003) performed a study in an attempt to develop education guidelines that could be used by nurse educators as a tool for the integration of research, theory and practice to produce optimal academic nursing education based on knowledge, experience and practical skills. The outcomes of this study found that problem solving and reflection are foundations of the learning process; it therefore follows that it should form the basis of our current education (Jerlock et al., 2003). It is not necessarily inevitable that experience will lead to learning and improved practice, thus implying that reflection is necessary to facilitate this (Baille, 2001, Jerlock et al., 2003, Martin and Mitchell, 2001). As Baille (2001), Rolfe (2002) and Greenwood (2001) emphasise, reflection is not merely the recalling of events but a purposeful activity which requires nurses to want to change their behaviour. As described, my clinical teacher helped me work through this to a large extent, yet I acknowledged that I had to possess the motivation to make use of the resources around me and take responsibility for the extent of my own learning.
If students are given the opportunity to combine clinical experiences with evidence based practice, this would develop their decision-making processes and nursing actions (Greenwood, 2001, Jerlock et al., 2003). Indeed if students were to follow the advice of Rolfe as mentioned above, reflection, among many benefits, enables the student to consider what was done and why and provides opportunities to develop knowledge from experience, develop individual theories of nursing and to link theory and practice (Baille, 2001, Greenwood, 2001, Jerlock et al., 2003, Martin and Mitchell, 2001, Rolfe, 2002). By considering the relationship between theory and practice and utilising a reflective process, the gap between the two can begin to close (Greenwood, 2001, Martin and Mitchell, 2001, Pender and Looy, 2004, Rolfe, 2002, Sharif and Masoumi, 2005).
A systematic approach to education is needed to facilitate the student to bridge theory, research and practice as well as create a starting point for reflection (Martin & Mitchell, 2001). It then becomes the responsibility of the student to utilize the system, seriously reflect and ultimately be accountable for their learning. Competence has been described as “the ability to create conditions in a practical situation, where theoretical and practical knowledge and experiences are integrated and become apparent through intellectual and practical actions” (Jerlock et al., 2003, p. 221). Skill acquisition is one element of attaining competence in nursing practice and this can be achieved through the interaction of classroom education, clinical supervision and the constant feedback and reflection tailored to the individual student's needs based on their self-motivated identification. Jerlock et al. (2003) also identified the importance of a student's ability for self-directed learning through identifying human and material resources and formulating their individual educational deficits. This concept was something I found particularly comforting to read, as it is precisely what I identified and utilised after the clinical experience outlined above.
I have discussed various explanations for the student experience of the theory-practice gap and put forward some suggested strategies for closure of the gap in the future. It is widely agreed that the theory-practice gap is a major and pervasive issue existing in nursing. There is no doubt that collaboration between classroom teachers and clinical educators would be invaluable to create an environment of continuity and lower anxiety for the student through familiarity. While classroom and clinical teachers have their responsibility for imparting their knowledge on to their students in the best way possible to facilitate maximum learning in the limited time allocated, it is up to the student to progress this. Serious reflection was reported in the academic literature as being one of the best ways in which to bridge the gap between theory and practice and it is beginning to quash the covert rules that are part of the nursing culture in many clinical settings. Further research is necessary for the identification of positive factors contributing to the closure of the theory-practice gap relating to skill acquisition and education in nursing. The utilisation of the topics discussed here along with further investigation can contribute to optimal nursing education and closure of the theory-practice gap by producing future nurses who are capable and willing to implement a positive and hospitable culture of reflective evidence based practice.
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PII: S1322-7696(10)00021-1
doi:10.1016/j.colegn.2010.04.002
© 2010 Royal College of Nursing, Australia. Published by Elsevier Inc. All rights reserved.
