Editorial

Clinical experience as the panacea!: Acknowledging the importance of theory

Brenda Happell
Professor of Contemporary Nursing, Department of Health Innovation; Centre for Social Science Research, Central Queensland University, Rockhampton QLD

PP: 166 - 168

Article Text

The importance of clinical experience to nursing education is a common feature of the nursing literature. A data base search using the term 'clinical nursing education' reveals almost 4,000 articles on this topic. Clinical experience is viewed as the opportunity to translate theoretical knowledge into actions, by performing the tasks and functions that underpin contemporary nursing practice. Clinical experience also provides an invaluable opportunity for students to become familiar with the health care environment in preparation for their future roles as registered nurses. They learn to become part of a team, to interact with their nursing and multidisciplinary colleagues, and most importantly they learn to care for and communicate with the people receiving health services and their families and loved ones.

The theory-practice gap is a familiar concept in nursing and reflects the challenges faced by nursing in enhancing a symbiotic relationship between the theory and practice of nursing, so that what is taught in the classroom underpins what is practiced in the health care facility. It is not uncommon for there to be considerable discrepancy between what is considered appropriate practice by the universities and the clinical settings. I would be surprised if any nursing student had not, at least once, heard words to the effect of: 'You might have learnt that in class, but this is how it's done out here'. Clinicians often view university academics as out of touch and holding unrealistic expectations of what can actually be done in a busy and demanding clinical environment.

The benefits of clinical experience are seen to extend well beyond the issue of skill acquisition. Exposure to the 'real world' of health care provides students the opportunity to see it as it is, to go beyond the often stereotypical depiction of nursing on popular television shows and movies and to challenge their own assumptions and attitudes about what it is to be a nurse. This is particularly important in the less popular areas of nursing such as mental health and aged care. For example, in mental health there is now a significant research base about nursing students' attitudes to this field as an area to pursue a future career. Many students are highly anxious about working with people diagnosed with a mental illness; they fear the possible physical and emotion harm that they believe may result. Many students see mental health nursing as a boring alternative to the more dynamic high-tech areas, where patients rarely if ever improve. In short they do not readily identify the skills of mental health nursing.

Clinical experience has frequently been identified as the panacea to overcoming these challenges. A positive and well supported placement in a mental health facility can change attitudes to mental health nursing and working with people diagnosed with a mental illness. Mental health nurses from academia and practice have enthusiastically embraced supportive roles like preceptorship knowing that the more positive the placement, the more likely that attitudes will improve, and that some students may consider the idea of becoming a mental health nurse even if previously it couldn't have been further from their minds (Happell 2008a, 2008b).

The research suggests that investing in clinical experience in this way is worth the effort, students do change their attitudes and some even indicate they plan to become mental health nurses. Great news, but of itself insufficient to address the recruitment crisis currently facing the mental health nursing profession. While students tend to overcome their negative view of people with mental illness, there are other barriers to them considering mental health nursing as a career that are not so easy to address. They may come to see mental health nursing as interesting and perhaps even enjoyable, but most still prefer the high-tech areas and see mental health nursing as relatively unskilled in comparison (Rushworth & Happell 2000).

It would seem that clinical experience can only do so much. Perhaps we should look at theoretical education. Interestingly, a data base search using the terms 'theory' and 'nursing education' located less than a third the number of articles found with the 'clinical experience search'. Does this reflect the not uncommon view that what students learn in the classroom has far less bearing on their attitudes and perhaps even their knowledge acquisition, than what is learn through hands on practice?

In the case of mental health nursing there would seem to be some truth in this assumption, most of the research focuses on ensuring more positive clinical experiences. Theory is rarely mentioned, which by definition gives the impression that it is not important, or at least not nearly as important. Research I was involved with suggests it may be time to take far greater notice of theory and its potential to influence attitudes (Happell 2009; Happell, Robins & Gough 2008; Henderson, Happell & Martin 2007). Using a pre- and post-test design, students from universities with a larger theoretical component tended to have more positive attitudes towards people with mental illness and to mental health nursing even before they commenced their clinical placement. We could easily get into the quality vs. quantity debate and no doubt a quality theoretical program is about more than extra time, but the differences in results between eight universities before students have commenced their clinical experiences is surely a justification for looking more closely at theory as an influencing factor.

Nursing curricula have been criticised for being too focused on the highly technical areas of health care at the expense of the less technical areas such as mental health and aged care. The overcrowded curriculum is often put forward as the justification for failing to address this problem. Statements like: 'there isn't room for any more', 'what would you take out?' or 'mental health is just another specialty and all specialties want more', are common defensive statements. No doubt the curriculum is already sliced very thinly, particularly in Australia and other countries restricted to three-year programs. But these arguments demonstrate a misinterpretation of the term 'mental health'. It is unfortunate that mental health has in many respects become a euphemism for mental illness. Mental health services are in fact services design to treat mental illness, not mental health. Similarly mental health nursing involves the provision of care for people with a mental illness and not people with good mental health.

Mental health is in fact a state of health defined by the World Health Organisation (2008) as 'a state of well-being in which people realise their own potential, can cope with normal life stresses, can work productively, and can contribute to their community'.

Given this definition and given the available evidence demonstrating the clear link between mental illness and physical health problems (Happell & Platania-Phung 2005), mental health should be featured throughout curricula and promoted as equally important to physical health. Such an approach would enable students to see and appreciate the importance of mental health for nursing practice irrespective of where they choose to work after graduation. Through developing such awareness they would be more likely to see mental illness as a variation from mental health just as physical illness is a variation from physical health. Hopefully this would contribute to the de-stigmatisation of mental illness and a greater acceptance of those people who experience it and its consequences.

Furthermore, by not including mental health throughout the curriculum and in assessment exercises students very clearly get the message that mental health is not as important as physical health and it is less likely to be in their minds when they work with patients. The nursing goal of providing holistic care is not realised. It is very easy to talk about holistic care at a philosophical level, but if this is not clearly demonstrated throughout the curricula, it becomes meaningless and ineffective.

Clinical experience cannot become the panacea to right the wrongs created by inadequate theory. Part of the solution to closing the theory-practice gap is to acknowledge that both are important for the education of our future nurses and to recognise that they need to be congruent. If we believe that mental health is crucial to good health (and surely we do) then that needs to be demonstrated. Just telling students it is important is not enough. Mental health has been presented here as an example, the same principle applies to all areas of nursing practice, in particular those that students tend to find less attractive.

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