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Contemporary Nurse - who are you?
Saras Henderson
School of Nursing, Curtin University of Technology, Perth WA
Article Text
The journal Contemporary Nurse provides a forum where current issues in nursing can be presented and shared with others. Recently, I was taking an undergraduate semester for tutorial in professional practice issues when one student bravely sat up and uttered 'you are teaching us all this idealism but when we get to clinical practice it is only perceived reality that counts, only tasks ... maybe what you are teaching us is futuristic, not here and now'. This statement was rather disconcerting even though inwardly I suspect, as I am sure many nurses do that we are still some way from closing the theory- practice gap. The question in my mind now is 'why haven't we broken the cycle'? Nursing students learn about providing care that is client-centred, ethical, and within the legal boundaries throughout their course. Why then are students and graduates not able to maintain care that goes beyond task orientation and is of a high standard, encompassing learned ideals? Can we then say that there are two faces to the contemporary nurse? One that knows and carries with him/her the learned ideals of nursing care and the other that practices using less than ideal principles of care. As a hospital and University educated nurse and having worked with students in the clinical area, I believe I am able to provide some insight into what may be happening with regards to this theory-practice gap.
For a long time now, I have rationalised that nurses generally do not have the time to practice the ideal, hence the adherence to completion of tasks. This may be true in some instances but not always the case. Can we afford to continue rationalising or should we take the matter seriously and do something about it, to bring about change. From my own observations with students in the clinical areas, it seems to me that nurses do not always encounter other nurses who practice within the realms of idealism even when contextual conditions are conducive. This has resulted in the absence of a reference group whom neophyte registered nurses and students alike can use as role models or mentors. Meleis (1975), some two and half decades ago, stated that professional reference groups are essential in the practice setting if student nurses are to embrace learned concepts and gain clarity. Other studies (Chapman 1997, Kelly 1993, Macleod-Clark et al. 1997) support Meleis's view, claiming that student nurses often find their learning experiences in the practice setting related to procedural tasks rather than providing care that addresses both the technical and affective aspects of care. Kelly (1993) also found in her study that neophyte nurses and students readily succumbed to the pressures of compromise in clinical practice because of their perceived lack of self-confidence and the need to survive. This consequently had resulted in them deviating from what they have learned about care at University to favoring what is being practiced on the wards. Hence is created the dichotomy between what is taught and learned and what is practiced and sanctioned to practice. It almost seems like a split identity that nurses take on. Could it be said then that student nurses and new graduates come to the practice setting with factual and practical knowledge but that they lack development in experiential knowledge relevant to the contextual meaning of practice. Would it be reasonable to say that these nurses have no choice but to fit into the dominant culture of a given practice area?
One can therefore argue that the manner in which student nurses are socialised into professional practice is important. For students to enact upon learned ideals, there needs to be consistent application and reinforcement of it in the practice setting. Greenwood (1993) is supportive of this view claiming that students are especially prone to following examples of poor or less than ideal care from repeated exposures to such practices by other nurses. Poor role modeling and the perpetuation of task-oriented nursing may have also blocked new graduates from actively reflecting on their learned ideals and enacting them. You may ask the question, 'surely new graduates can bring about change, they are no longer students'. The answer to this question is not simple. In my own research (Henderson 1998) I found that graduates continually faced pressure from their peers to sacrifice learned knowledge about what constituted excellence in nursing care to task management in the practice setting. This is supported by Australian and New Zealand studies which found that many graduates faced conflict between their professional ideals and having to accept nursing as task management (Ambler 1995, Clare et al. 1996). Some nurses in my research also claimed that they 'were brought into line' to fit in with everyone on the ward and that if 'you did not conform, you are viewed by senior staff as sabotaging the ward's established system'. Duffy (1991) sums this up beautifully by stating that the way nurses practice is shaped by their socialisation and that the continuation of traditional (task management) values by nurses created conflict between the traditional and non-traditional practice. Kramer's (1985) seminal work on how new graduates assimilate into the work force is supportive of this situation. Although Kramer's work was completed twenty years ago, her work is frequently quoted in nursing literature claiming that graduates often face discrepancies between their idealised role conceptions of care and that which are sanctioned and operating in the practice setting.
It seems, from the student's words uttered recently, that idealism and realism are concepts that exist at the same time in nurses but remain in conflict. So where do we go from here in order that the contemporary nurse is able to practice ideal care within the context of the real world of nursing? I think this responsibility lies with all of us, whether we are an academic or clinical practitioner. We need to be good role models to our students and new graduates. We need to ensure that we aim to provide a high standard of care at all times possible and not become complacent and continue perpetuating what we did 30 years ago. If contemporary nursing is to survive into the 21st century, we must meet the demands of the 21st century. Instead of providing essential care to a patient, we must provide quality care to a customer.
References
Ambler, N. 1995. The beginning practitioner: First year RN adaptation to the workplace. Conference Proceedings Research for Practice Newcastle University.
Chapman, R. 1997. The nursing student's lived experience of clinical practice. Unpublished Masters thesis. Curtin University of Technology, Perth, Western Australia.
Clare, J., Longson, D., Glover, P., Schubert, S., Hofmeyer, A. (1996). From university student to registered nurse: The perennial enigma. Contemporary Nurse, 5(4), 169-176.
Duffy, E. (1991). A critical exploration of powerlessness amongst nurse practitioners. Unpublished Masters thesis. Phillip Institute of Technology, Bundoora, Victoria.
Greenwood, J. (1993). The apparent desensitisation of student nurses during their professional socialisation: A cognitive perspective. Journal of Advanced Nursing, 18, 1471-1479.
Henderson, S. (1998). The phenomenon of patient participation in their nursing care: A grounded theory study. Unpublished Doctoral thesis. Curtin University of Technology, Perth, Western Australia.
Kelly, B. (1993). The real world of hospital nursing practice as perceived by nursing undergraduates. Journal of Professional Nursing, 9(1), 27-33.
Kramer, M. (1985). Why does reality shock continue? In J. McCloskey, & J. Grace (Eds.), Current issues in nursing (pp. 891-902). Boston: Blackwell Scientific.
Macleod-Clark, J., Mahen, J., & Jones, K. (1997). Project 2000: Perceptions of the philosophy and practice of nursing: Shifting perceptions-a new practitioner. Journal of Advanced Nursing, 26, 161-168.
Meleis, A. (1975). Role insufficiency and role supplementation: A conceptual framework. Nursing Research, 24, 264-27
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