Nursing Theory: A Microscopic Perspective on the Theory-Practice Gap
A paradigm in nursing theory exists today that equates nursing theory to a mirror, a microscope or a telescope. Meleis talks about this equation of nursing theory to a mirror, microscope, or telescope (2007). According to Meleis nursing theory that is like a mirror will reflect reality, but give it different shapes. Nursing theory that is like a microscope will focus in on a part of reality or magnify it, which may or may not be within the context of reality. And, nursing theory that is like a telescope will bring faraway objects and events into closer view. When searching through the literature for articles about nursing theory one related phrase comes up frequently along with this search. That phrase is, "theory-practice gap." For example, "Tackling the theory-practice gap in mental health nursing training," (Evans, 2009); "Theoretical vs. pragmatic design in qualitative research," (Smith, 2011); Bridging the theory-practice gap in perioperative theatre placement in, "A critical analysis of theatre as a learning environment in relation to placement duration," (Barry, 2009); bridging the theory-practice gap in, "Iranian nurses; constraint for research utilization," (Salsali, 2009); and bridging the theory-practice gap by using scholarship in, "Scholarship in nursing: not an isolated concept," (Robert, 2011). The theory-practice gap is what occurs when useful theories about nursing are not applied or applied well in the practical, clinical setting. This gap indicates that theories may be too focused or may scrutinize an aspect of nursing outside of its practical setting so as to make the theory not applicable in reality. This presents a perspective of nursing theory that is like a microscope. Therefore, in this perspective of nursing theory one way to alleviate the theory-practice gap might be to widen the scope of the theory or to put it into context so that it more closely reflects reality.
Nursing has undergone several stages of development to get to this point in history. Meleis outlines several stages of nursing development that include: practice, education and administration, research, theory, and integration (2007). Nursing in Western cultures has its beginnings at the time of the Crimean War. It all began with Florence Nightingale who, along with battle field surgeons, supervised other nurses. She sought to aid the sick and enhance their health with increased hygiene by making environmental changes. Her writings were posthumously formulated into a theory. Formulating a nursing theory in this manner by bringing a concept from the past into closer view could be considered like a telescope.
From practice came apprenticeship as the first form of nursing education. Nursing education began as a more hands on application within the clinical setting. But, over the course of thirty years, curricula were developed as well as how to train teachers, administrators and nurse practitioners. This early focus on education and teaching may have paved the way for the development of theoretical nursing. Again this pulling together of past and distant events from previous stages in nursing history into a nursing theory is like a telescope bringing objects and events from far away into closer view.
Nursing research was developing throughout the stages of practice and education, but became a necessity in post-war America. During this stage more emphasis was put on the process of research rather than the content (Kuhn, 1970). This focusing of research findings on one aspect, the process, is like the narrowing perspective of a microscope. It is no surprise that in this era of narrowing of perspectives the stage of nursing theory emerges.
Nursing theory came about at the same time that the nursing profession emerged as an autonomous science rather than an arm of medicine. Theories stem from the philosophical underpinnings of the time in which they are formulated. The early theories sought to address the nature of the human being in interactions and transactions with the health care system. Also, the theories addressed the interactions and transactions with the process of problem solving and decision making for assessment and intervention. Some early recognizable theories include that of therapeutic touch (Rogers, 1970) and self-help (Henderson, 1966). These early theories seem to be relevant and easily applicable to practical situations. These early theories are more like mirrors reflecting reality, but giving it a new shape. This is unlike the current problem of the theory-practice gap.
This brings one up to the twenty first century and the era of integration in nursing stages. In this era, one important aspect of integration is the revisiting of old theories and reflecting on them, like a mirror. From this new perspective that is more like a reflection of reality the problem of the theory-practice gap may be corrected.
The theory-practice gap can be found in abundance within literature. In an interesting article by Smith the researchers argue that potentially adhering to qualitative methods because of their underpinning philosophical origins may cause the research to deviate from its stated purpose (2011). They feel that it is especially challenging for novice researchers because of the range and diversity of qualitative methods available. Also, they feel that researchers should be free to choose any qualitative method, even a general method, without criticism (Holloway, 2003).
There are three common qualitative methods used in nursing research that have varying theoretical underpinnings that of ethnography, grounded theory or phenomenology (Sandelowski, 2000). Ethnography has its roots in anthropology and describes a social or cultural group. Grounded theory has its roots primarily in sociology and is used to develop theory. Phenomenology has its roots primarily in psychology and creates an understanding of the participant's lived experiences (Smith, 2011). The authors found that when utilizing all three of these common qualitative methods the original intent of the research was narrowed to only one aspect of the original research question. This is much like a microscope focusing in on one aspect of reality and magnifying it. The researchers suggest using a general qualitative method with no theoretical basis to alleviate this problem. However, it is possible that within the forty qualitative methods available (Tesch, 1990) the authors could find one more suited to their research questions.
Another aspect of the theory-practice gap is that of the gap existing between highly theory knowledgeable nursing students lacking in the technical skill and confidence to apply that theory in the practical, clinical setting upon entering the workforce. Several articles on this subject exist. In an article by Prue Barry the gap between theory and practice in perioperative theatre student placements is widening due to a decrease in length of placement and lack of learning objectives (2009). Kolb's experiential learning theory (1984) was applied to the perioperative environment by Sewchuck (2005). Sewchuck explains that learning styles progress from experience to reflection, conceptualization and experimentation and then back again to experience. And limiting the exposure of students to the environment will hinder the learning experience (Barry, 2009). Maslow also points out that there is a hierarchy of human needs, whereby the most basic needs must be met before learning can occur (1954). This narrowing of teaching to focus on the theoretical learning of students is like a microscope that narrows in on one object and magnifies it. Two successful routes of overcoming this problem were found. One is to increase specific knowledge about the perioperative theatre prior to a student placement so that students can be more confident to participate and thereby take more from the experience (Gentz, 2004). The second way would be to return to the longer placements and if this is not possible to at least augment the shorter placements with learning goals and pre-training (Barry, 2009 and Radford, 1999). The link between theory and practice is a recurring theme in the literature and supporting learning is the joint responsibility of service providers and higher education institutions (Burns, 2005).
On a similar note, Evans found that the gap between theory and practice only widened with competing interests between universities and practice in the mental health nursing field (2009). The competing needs of practice and academia can lead to ill prepared nurses entering the clinical setting. This is compounded by the fact that nursing is not just a job, but a vocation (DH, 2006). Suitability of nursing students for continuance in a program should be the joint decision of universities and clinical placements. Evans notes that the gap between theory and practice in nurse education has widened since the responsibility of nurse training was transferred from hospitals to universities (2009). A similar issue in the training of acupuncturists was pointed out by Rohleder (2009). One argument is that the therapeutic relationship between patient and nurse is the heart of good nursing care. And, numerous theories exist to bring this caring relationship about. It is the lack of hands on training and confidence on the part of students and new nurses that keeps them from applying their theoretical knowledge. Sharing the responsibility of fully educating nurses for the future will help bridge the theory-practice gap. One can see that the dual focusing…