When the theory/practice gap is discussed there is a tendency for nurses to think of theory and practice as separate endeavours. Nurses in practice and nurse educators have tended to focus on how to achieve greater theory/practice integration.

Carr (1986) developed an approach using four factors to help link educational theory with the theory/practice gap. In his model, he considered the following factors:

•The ‘applied science approach’: helping relate theory as objective evidence, used to guide and regulate practice.

•The ‘common-sense approach’: identifying theory as being within the collective understanding of practitioners. Theory can be extracted from ‘good’ practice. This is an example of theory actually being ‘driven’ by practice.

•The ‘practice approach’: identifies theory as being knowledge derived from practical activities, which can then be used to guide decision making. There is also the belief that the nurse has a moral commitment to ‘good’ practice.

•The ‘critical approach’: brings together ‘applied science’ and ‘practical’ approaches of care. Theory, therefore, is derived by nurses gaining further insight into practice, increasing their autonomy.

Theory and practice can work in both directions: theory informs practice and practice helps to develop theory. Theory and practice can be considered as quite distinct; it becomes clear that if the two are not used in conjunction, research-based nursing may not occur. This therefore makes the assumption that a gap does exist and that there are ways of reducing this gap. Theory is what is taught in school, practice is what happens on the wards and in the community; the theorist, usually perceived as an educator or researcher, and the practitioner are seen as different and separate beings (Ellis 1992).

The reality is that practising nurses are often actually developing theory as they nurse and, in addition, are sometimes basing their practice on existing theories (Benner and Wrubel 1989).

Theory is derived from practice and the most effective care is embedded in expert nursing practice, which is greatly influenced by the context of practical situations. Lauder’s position of ‘practical wisdom’ (1994) brings together theoretical, moral and tacit knowledge, which then provides a union of theory and practice within clinical experience.

Conflicts

Action point

into action. • Let’s say you want to put some research that you have found Are there any constraints that you know of that could prevent you from implementing them?

Nursing is at a crucial stage in its development, and the perception of a theory/practice gap must be of concern to all nurses, whether engaged in clinical practice, education, management or research. Partnership between these important elements of nursing science is vital if we are to provide the very best care possible for our patients.

The move of nurse education into universities has contributed to the perceived widening gap, as has the growing impact of managerialism on UK healthcare. The separation of providers of healthcare (the hospitals and community trusts) and the educators of healthcare must be taken into account, and attempts must be made to reduce the gap. Financial limits and governmental performance targets now heavily influence healthcare. Nurses undertake a great deal of the administration of audits, and budget management is now often devolved to ward level.

All of this would perhaps appear to be in direct conflict with the role of the nurse as intuitive carer, focusing on the patient as an individual person. As long ago as 1972, Briggs commented on the theory/practice gap in nursing, and many other authors have raised numerous complaints that the separation of theory and practice in the classroom setting would only exacerbate this problem. Classroom teaching can never exactly replicate what happens in a range of different clinical areas. However, if theory is explained and examples given from practice to illustrate meanings, this must go some way towards reducing the gap.

Rightly or wrongly, nursing theories are seen to be created by educators and researchers, who tend to live in a different world from those involved in the sometimes harsh reality of clinical practice. There also appears to be a higher level of status attached to nursing theorists than to those who deliver clinical skills, but for many nurses, delivering clinical skills is the most important and rewarding aspect of their work, and indeed is the most valued aspect of the job from the patient’s perspective. This situation cannot help when a nurse is unable to utilise theory because it bears no relation to the reality of his or her practice.

Student nurses are encouraged to be independent and enquiring, yet are often considered to have the lowest status within the clinical setting. Although their education and approach to care is based on holistic and humanistic principles, in the organisation-led NHS, the approach of the mangers sometimes seems to encourage the exact opposite, that is a task-oriented, functional approach to care. The potential for philosophical conflict is enormous and often offers unrealistic goals for students, who then ultimately face disillusionment and disaffection with nursing.

Solutions

The introduction of Project 2000 training was an attempt to reduce the theory/practice gap, although the higher academic content of the ensuing curriculum appears to be more theory-focused than ever before. During the 1980s and 1990s joint appointments such as lecturer-practitioners were seen as a way forward, ensuring that teachers were clinically credible and were able to bridge the class-room-clinical setting divide. Another idea was to increase the time spent by lecturers as clinical links with community and ward areas, thereby following the progress and supporting students through practice experiences.

Reflective practice and research

In recent years, all nurses have been greatly encouraged to use reflective practice as an educational, personal development tool or for clinical supervision (Bassett 1999). It has also been suggested as a method of applying theoretical perspectives to practical experiences as a way of learning. The role of the student as a catalyst for changing practice based on his or her theoretical knowledge has also been implicit when educators specifically instruct students to question practices if they feel they are not based on sound theory. However, even very experienced nurses are unable to influence change if they do not have the power and authority in a hierarchical system to do so.

Increasingly, we hear of the growing professional status of nursing, holistic approaches towards patient care and nurse education, but arguably this is incongruent with the NHS of today. After 10 or more years of the market system in health, many healthcare workers feel alienated and that the caring principles that were the basis of the NHS have been seriously eroded. Nurse education has quickly realised that it has a new role as provider in the current marketplace of education; the educational consortia are the new purchasers, and the services offered by universities need to meet the needs of the hospital and community trusts. This is indeed an opportunity for NHS trusts and other healthcare providers to press for a more practical and evidence-based focus in education provision, and to share equally in that responsibility. Until education and healthcare providers work together and have joint ‘ownership’ of both pre- and post-registration students the theory/practice gap will continue to exist.

Future initiatives

There are several innovative projects currently in development, one of which is the role of hospital-based clinical demonstrator in Sheffield. This scheme utilises the clinical skills of staff from the ward setting by supporting them in teaching up-to-date, evidence-based skills to students in a clinical skills laboratory (mock ward) setting, alongside experienced teachers. The clinical demonstrators also work in the clinical areas with the same students they have taught in school. This innovation has proved to be an exciting and highly effective innovation for linking school and ward, theory and practice.

Education needs to prepare students to become nurses in the ‘real world’ as well as giving them the academic preparation needed today. Researchers, educationalists and practitioners seem at times to be working with different imperatives and to have divergent priorities. Is it any wonder that a gap exists? Nursing theories are prescriptive, to be used in the practical application of knowledge in the clinical environment. Practitioners must be aware of and able to choose the most appropriate theoretical principle to use in each situation to achieve the best result for the patient.

Research is often seen as an elitist pastime, irrelevant to everyday clinical practice, yet research without application to the real world is of little use to the nurse caring for patients. It is obvious therefore that researchers and practitioners need to be working in collaboration, or that the two functions need to be invested in the same person. The dissimilar cultures of university (researcher, educator) and clinical (practitioner) setting hold separate values and beliefs, and are believed by many to be different worlds. If the clinician is to utilise research/theory in practice, it is the responsibility of the researcher/educator to ensure there is guidance to enable him or her to do so.

Barriers to research utilisation

A significant barrier to the use of research in practice is the readability of the research findings for those who may wish to apply it. If the academic style and jargon prevent this, then the research is to all intents and purposes lost. Nurses who can write in a nurse-friendly manner are often not encouraged to do so or have little time or inclination, therefore reports are left to academics, for whom it is a requirement to write, in a particularly scholarly and sometimes in incomprehensible, academic style.

It is clear that there is a dilemma for researchers and educators who may have two masters to please. However, the system of nursing should be firmly grounded in practice and academics must never forget this. There is a similar dilemma for students. The disparate cultures of the university and clinical settings clearly exist, but both cultures have to be socialised into. This could be seen as a major contributor to the gap between the development of a nursing research culture and the real practice of nursing. At the moment, the worlds of research and practice are essentially different, but bridging the cultural divide may help to reduce or even close the theory/prac-tice gap. The importance of how research findings are communicated in both content and style cannot be overemphasised – it needs to be clear and accessible to those expected to put it into practice.

Conclusion

In the light of national and regional imperatives for nursing research, a positive research culture must evolve among nurses, encouraged and enabled by researchers, educators and nurse managers. Many trusts now have research strategies for nurses in place in an attempt to do this.

The overall aim of this book is to help redress the balance, giving power to the clinical nurse and enabling the more effective integration of research into the clinical setting. This is essential in today’s NHS – the very future of nursing and the first-class care of our patients depends on it.