To fill the gap between theory and practice: a model of clinical nursing

Despite the efforts of nursing theorists, educationalists and practitioners, the theory-practice gap continues to defy resolution. This paper argues that only by reconsidering the relation between theory and practice can the gap be closed. Drawing upon ideas from teaching and other practice-based disciplines, including nursing, the article suggests that the current model of viewing theory as informing and controlling practice should give way to a mutually enhancing model in which theory is derived from practice, and in turn influences future practice. This coming together of theory and practice is referred to as nursing praxis, and suggests that informal theory should be unique to each individual encounter with each patient. The clinical nurse is thus not only a practitioner, but a theorist and researcher, who responds to patients not according to some grand, inflexible theory, but by the process of reflection-in-action, drawing upon their expertise and a repertoire of past experiences and encounters.     

Bonding theory–tying mothers in knots? A critical review of the application of a theory to nursing

• ? In recent times, nursing has witnessed a growing support for the notion of theory as being instrumental in enhancing nursing practice and ultimately patient care (Marriner, 1986). Whether generated from nursing practice, or ‘borrowed’ from other fields, the use of theory is viewed by some as the key to the ultimate recognition of nursing as a scientific, professional discipline in its own right (Stevens, 1984). Parallel to this view, there is a research perspective that questions the ultimate contribution of certain theories to health-care practice, particularly those emanating from other disciplines, urging caution in their practical utility. This paper enlarges upon this theme, focusing specifically upon the psychological theory of bonding, attempting to explore critically the degree to which it can be used in nursing practice, and to which it contributes towards our understanding of the attachment behaviour between a mother and her infant.
• ? A brief outline is given of the theory and its impact on health-care practice, and possible limitations discussed with reference to the conceptual origins of bonding theory, the validity of its research methodology, and its use within the wider health-care setting.
• ? A feminist sociological perspective is used in a brief attempt to explore the wider implications of the bonding theory in relation to the position of women.

     

The development of research in nursing in the United Kingdom

• ? The last 30 years have seen considerable development in research in nursing.
• ? Nursing is building a repository of research-based knowledge.
• ? Formal structures around which research can be developed and organized are being established.
• ? Research findings are still not being implemented in practice, but strategies to address this issue are being developed.
• ? Nurses are being educated to utilize research findings in practice.
• ? The Report of the Task-force on the Strategy for Research in Nursing, Midwifery and Health Visiting was published in May 1993 (DoH, 1993). It advocates that research in nursing should be fully integrated in health-services research and outlines future strategy in four key areas: priorities, education, practice and careers.

     

The contribution of lecturer practitioners to theory and practice in nursing

• ? Problems surrounding the relationship between the theory and practice of nursing have been pervasive for decades. Whilst, traditionally, concerns have been mainly expressed by nurse educators, and solutions offered from an educational perspective, increasingly the issues are seen as those of practitioners and managers as well, and as broader than the integration of theory and practice in the education of nurses.
• ? Many of the attempts to bring theory and practice together by the development of an educationally driven model, or by the introduction of new roles into an existing system have been problematic, leading to the desire for a more radical proposition.
• ? The development of lecturer practitioners, who aim ‘to identify and maintain the standards of practice and policies in a defined clinical area, and to prepare and contribute to the educational programme of students in relation to the theory and practice of nursing in that unit’ (Vaughan, 1987), offers one such approach.
• ? This article reviews the main empirical literature in relation to issues of theory and practice, as well as reporting on some preliminary findings from a research project aimed at studying the implementation and development of lecturer practitioner roles in one health authority.

     

Reflecting on clinical practice: hectoring talk or reality?

• Reflection can be seen as a useful tool to enable the practitioner to explore the everyday world of clinical practice. This paper reviews the background to reflection and its relevance to nursing in reducing the theory - practice gap and its role in generating theory from practice.
• Exemplars from clinical practice are reflected upon and Carper's (1978) ‘Patterns of Knowing’ are used as a framework to identify nursing knowledge embedded in practice.
• The process of reflection is critically discussed in the light of the author's experience.

     

Health promotion: a role for perioperative nurses

• ? British theatre nurses are reluctant to identify health promotion as part of their work and when asked if they are involved in health promotion the answer is likely to be an emphatic ‘no’.
• ? Many theatre nurses would be surprised by the shift of emphasis within nursing away from the medical model and towards a more holistic approach to care which encompasses the concept of health promotion.
• ? British perioperative nursing should draw on health promotion for the benefit of surgical patients and operating department staff.
• ? This paper outlines the contribution perioperative nurses can make to the creation of healthy life not only in their patients but also their co-workers using established health-promotion techniques. It is suggested that health promotion should be an essential part of the education of modern perioperative nurses.

     

The development of clinical leadership through supported reflective practice

• ? The notion of clinical leadership is significant in current nursing practice, particularly since recommendations made by the Department of Health in ‘The Strategy for Nursing’. However, while it is a concept that many nurses aspire to implement, in reality the operationalizing of such a concept is fraught with difficulty.
• ? This paper aims to explore the issue of clinical leadership through a collegiate model developed in a particular practice area.
• ? The development of this collegiate relationship is articulated through the mediums of reflective practice and clinical supervision.
• ? A model of collegiality is offered as an approach to the integration of the spheres of clinical leadership.
• ? If reflective practice is to be a reality then it is essential that both clinical leaders and practitioners engage in such processes within a supportive culture.

     

Beyond expertise: theory,practice and the reflexive practitioner

• ? This paper reconsiders Benner's book From Novice to Expert, in which the expert is portrayed as a reflective practitioner who works intuitively, drawing almost unconsciously on a repertoire of context-specific paradigm cases.
• ? In the light of more recent writings on informal, practice-based theory, it is suggested that there is a sixth level beyond expertise which is characterized by mindful practice and informal theory building. At this level, the practitioner constructs informal theory out of practice, applies that theory back into practice, and reflexively modifies the theory as a result of the changed clinical situation.
• ? Seen in this way, theory and practice are two parts of the same process, and the theory-practice gap is closed.

     

Advanced clinical practice—how do we promote it?

Summary This paper aims to examine the promotion of advanced clinical practice. It addresses questions such as:

• ? what is advanced clinical practice?
• ? what is the relevance of knowledge to clinical practice?
• ? what is the relevance of research to clinical practice?
• ? what is the relevance of the culture to clinical practice?
• ? what is the role of the clinical nurse? It does not present ready answers. Rather, it attempts to highlight difficulties and ambiguities originating from the contradictory goals and requirements of nursing education, research and practice.

     

A hermeneutic analysis of the lived experiences of associate nurses

• ? In order to understand better the role of associate nurse in the primary nursing model, narratives from associate nurses were analysed using hermeneutic approach.
• ? Major themes in the narratives included: connecting with patients, collaborating with other nurses, and making decisions.
• ? Associate nurses were found to define their practice as ‘primary’ in terms of their contributions to patient care and being a responsible professional.
• ? A better understanding of the associate role in clinical practice can enhance patient care and professional relationships.
• ? Further research into the philosophical nature of primary nursing is suggested.

     

Complementary therapies in practice: the ethical issues

Summary

• ? This article explores some of the ethical issues associated with the use of complementary therapies in practice.
• ? The adopted terminology and related concepts are clarified. The term ‘complementary therapy’ is compared and contrasted with ‘alternative medicine’ and ‘non-conventional therapy’.
• ? The increasing emphasis on holistic nursing care is also discussed.
• ? Ethical issues of patient choice, informed consent and the principle of beneficence are examined in relation to complementary therapies.
• ? The article highlights the obligation of the nurse, midwife or health visitor to provide or facilitate holistic care including complementary therapies, such as massage or aromatherapy, for those clients who request such care, and where it can be demonstrated that there will be benefits for the patient.
• ? It is concluded that nurses should consider the possibility of incorporating or facilitating certain complementary therapies in their practice in order to benefit their patients. There is a corresponding need for an appropriate knowledge base, founded on nursing research, into the effectiveness and outcomes of complementary therapies. In addition, relevant educational courses should be developed.

     

Assessing health needs in people with severe learning disabilities: a qualitative approach

Summary

• ? The nursing assessment, and the contribution it makes to the identification of an individual's health needs, is often a complex and multidimensional process. This is always true when the individual concerned has a severe learning disability.
• ? The nurse should develop the assessment in partnership with individuals who may experience major communication difficulties, or have unappreciated levels of perceptual or cognitive dysfunction. They may also live with the ongoing possibility that their affective or behavioural responses may be misinterpreted as ‘challenging behaviour’.
• ? This case study focuses upon one particular young man with a severe learning disability living in a community home. Drawing upon the principles of qualitative research methods, especially those of ‘grounded theory’, this study aims to demonstrate how these can be used to develop a uniquely person-centred assessment.
• ? A systematic process of observation, analysis and reflection produces a detailed picture of the individual and his or her particular health states.
• ? The strength of this approach is threefold. Firstly, the person is considered as an active participant and remains the central focus. Secondly, in contrast to many other forms of assessment, the person is viewed as dynamic with ever changing needs. Thirdly, the process of nursing judgement is made explicit and integrated into the assessment process.

     

Eating despite severe difficulties: assessment of poststroke eating

• ? A programme for the assessment and nursing diagnoses of eating difficulties among stroke patients was tested. The patients' experiences regarding eating were expressed in interviews and dialogues. Eating was observed during both a test meal and regular meals.
• ? The assessments included the prerequisites for eating as well as oral, pharyngeal and oesophageal functions.
• ? General and specific nursing diagnoses as well as life consequences (handicap) were established, based on assessment of disabilities and impairments, and interviewing the patients and their families, respectively. The general nursing diagnoses were formulated on admission after the test meal and these were reformulated to form specific nursing diagnoses after assessments of the functions.
• ? The programme presented proved to be useful in clinical practice. It is emphasized that many assessments must be co-ordinated for each individual.

     

‘It's the little things that count’: the hidden complexity of everyday clinical nursing practice

• ? This article reports on one aspect of a phenomenological study of everyday experience in nursing and how it contributes to the development of nursing expertise.
• ? The study was carried out with 10 ‘excellent, experienced’ surgical ward sisters in two Scottish teaching hospitals.
• ? The ward sisters were found to help individual patients towards recovery by making the ward work for all.
• ? When moment-by-moment nursing practice, the context of nursing experience, is examined, it is found to be patient-centred and complex, geared towards multi-layered goals.
• ? Three distinct yet inextricably intertwined processes–noticing, understanding and acting–characterize how nurses practise nursing. The quality of these processes contributes to the effectiveness of nurses' caring practices.
• ? The ‘little things’ of nursing practice make a difference to patients because they are imbued with nursing knowledge and skill.

     

A study of nurses' views about the prevention of nosocomial urinary tract infections

• ? This study sought to discover the contribution of nursing practice to the prevention of hospital-acquired or nosocomial urinary tract infections (NUTIs), the most commonly occurring nosocomial infection.
• ? Seventy-five per cent of such infections are associated with urethral catheters.
• ? The practices of nurses who are caring for patients on a 24 h basis would appear to be fundamental to achieving any reduction in the incidence of NUTIs.
• ? This qualitative study utilized unstructured interviews to explore the views of 12 registered nurses about three key issues: first, what care do nurses give with the aim of preventing catheter-associated NUTIs; secondly, what improvements in practice would further prevent catheter-associated NUTIs; thirdly, what do nurses see as constraints to the prevention of catheter-associated NUTIs?
• ? The nurses identified many of the measures that were cited in the literature as effective for preventing NUTIs; however, in reality, they stated that their practice differed because of a lack of time to give care and to update themselves.
• ? The consequences of under-staffing were that junior and temporary staff (whose competence in preventing NUTIs was questioned) worked unsupervised.
• ? Those interviewed identified feelings of powerlessness in effecting preventative measures, and identified not only the role of medical staff in influencing NUTIs but also their inconsistent approach to care.
• ? All these forces effectively limited the nurses' ability to prevent NUTIs.
• ? The study is concluded with recommendations for changes in practice and further research.

     

Subjectivity and objectivity in the measurement of nursing workload

• ? This article identifies the factors which influenced the nurse staffing levels observed on three nurse training wards in one District Health Authority.
• ? Staffing levels reflected historical approaches to budget settings within the district as well as the characteristics of the local labour market for nursing.
• ? The article offers a critique of current manpower methodology in nursing which tends to focus on producing objective measurements of nursing workload.
• ? Factors such as budgets and labour markets may be more important in nurse manpower planning than measurements of workload because in practice nurses tend to identify only those patient care needs that can be met by the current staffing levels. Therefore, the prevailing staffing structure will tend to dominate any attempt to measure workload.

     

What are nurses doing to patients? A review of theories of nursing past and present

• ? This paper looks critically at the nature of nursing theory from three perspectives.
• ? Firstly, it examines the current state of nursing theory with a particular focus on Patricia Benner's work. This examination concludes that nursing theory is currently beset by the problems of scientific and moral relativism and philosophical incoherence because it has abandoned a traditional realist approach to the care of patients.
• ? Secondly, the roots of this contemporary nursing position are analysed and the conclusion is reached that nursing theorists are implicitly presuming this traditional ‘common sense’ view of nursing, although their own philosophical assumptions do not support it and indeed are removing the ground from beneath it.
• ? The traditional theory underpinning the quality of the nurse's care, and hence the ethos of nursing, is rearticulated.
• ? In conclusion it is suggested that nursing needs to debate the modernist views that are now holding sway in nursing and rediscover a theory for the care of patients that holds together the personal, the pastoral, the scientific and the technological aspects of patient care.

     

Caring: fitting the concept to nursing practice

• ? This paper explores the concept of caring when used to define the nature of nursing.
• ? It is suggested that explorations of caring in nursing fail to acknowledge the real world of work in nursing, which is influenced by personal career choice and the organization of the health-care systems in which nurses work.
• ? In some situations nurses delegate the caring role to others thus giving ‘care by proxy’, a factor that is not clearly acknowledged in the literature on caring.
• ? It is suggested that if caring in nursing practice was denned as ‘formalized caring’ it would offer a framework for the analysis of caring more conducive to the reality of nursing practice today.

     

Survivorship and breast cancer: the psychosocial issues

• ? This article addresses some of the psychosocial issues concerning survivors of breast cancer.
• ? Issues relating to employment and social support are discussed.
• ? Social support is also related to the significant other.
• ? Recommendations for nursing practice and research are made, including the need for a unilateral definition of ‘survivor’ and for attitudinal changes.
• ? As the number of survivors increase, psychosocial barriers need to be diminished by nursing practice and research.

     

A review of primary health-care organization

• ? A contract for the provision of community nursing and associated services was drawn up between the Plymouth Community Unit and general practitioners associated with a fundholding practice at a health centre in Devon in October 1991.
• ? This project, which aimed at applying purchaser/provider principles, contained some novel features and was subject to evaluation and review after 6 months.
• ? An evaluation which had four main aspects was carried out, consisting of interviews and questionnaire assessment of staff attitudes, patients' views of the effectiveness of aspects of the practice health-promotion activity, an analysis of staff activity data before and during the pilot phase and an examination of the documentation concerned with critical issues which had arisen.
• ? Questionnaire data indicated that staff motivation and enthusiasm for the project was high and that patients' views on the practice facilities were generally positive.
• ? The role of the Macmillan nursing service at this practice was greatly enhanced during the pilot project with a fourfold increase in the number of visits carried out.
• ? Over 120 h were spent by health visiting and district nursing staff on issues surrounding the pilot project including attending additional meetings.
• ? The results are discussed in relation to service benefits to patients, the effect on the cohesion of the primary health-care team and issues of fundholding and are considered in the context of models put forward for the future development of community-based nursing care.