Clinical environment

The problem in which the theory-practice gap is embedded may be in the clinical environment because it is a forever changing environment (McCaugherty, 1991a:1059). The clinical environment forms an important component of the student nurse’s learning environment (Meyer &

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Van Niekerk, 2008:168). The clinical environment as a reason related to the theory-practice gap is not discussed in detail because it was not the focus area for this study. Only a list is provided containing the reasons identified by the various authors for poor theory-practice integration in the clinical environment.

• Actual deficiencies in the practice of nursing (Elkan & Robinson (1993); Teracy (1987) in Fealy, 1999:76).

• Contrasting approach to nursing care. Nurse educators educate student nurses to be autonomous, self-directed, professional and independent and provide holistic individualised patient care. The practice, however, focuses on a businesslike approach that demonstrates achievement in terms of efficiency, effectiveness and economy. This perpetuates a task- oriented and fragmented approach to patient care (Hewison & Wildman, 1996:758).

• A focus which is on the service needs and not the students’ needs. The practice is geared for the care of patients and not on providing a learning environment for students to learn in (Hewison & Wildman, 1996:759).

• Increased teaching responsibilities for clinical staff members and their lack in educational skills, theoretical knowledge, and time. The teaching of students in the clinical environment is doomed to fail because the unit staff are not always aware of the theory content of the course or do not have time to do the clinical accompaniment of the students. Thus, it is not designed as a setting to learn the practice (Reynolds (1990) in Ferguson & Jinks, 1994: 688).

• The strong influence of the hidden curriculum in the clinical (or practical) environment also seems to be a cause of the theory-practice gap (Cook (1992) in Ferguson & Jinks, 1994:689). The hidden curriculum is defined as the “unspoken values and message within the curriculum” (Meighan (1981) in Ferguson & Jinks, 1994:689). This is portrayed in the conflicting philosophies of nursing in the classroom and what the student experiences in the clinical environment. While the theory focuses on healthcare which benefits the patient, the services rendered the clinical environment serves to meet the requirement of the clinical environment (organisation) rather than the patients’ requirements (Ferguson & Jinks,

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1994:689,693). Therefore, the focus in the clinical (or practical) environment is a task- oriented and fragmented approach (which is the most cost-effective approach) and not on the comprehensive care of the patient (Hewison & Wildman, 1996:759). Student nurses tend to adopt the work ethic of the clinical environment as a way to fit in. They will therefore learn the routine, work quickly and look busy because if they question the standards and / or practice they face the possibility of rejection by the unit staff members (Ferguson & Jinks, 1994:689). For these reasons the professional socialisation of student nurses as a basis for their actions in the clinical environment seems to facilitate the theory-practice gap.

• The physical separation of nurse practitioners and nurse educators with the former responsible for patient care and the latter for teaching nursing theory with the student nurse struggling in-between (Ferguson & Jinks, 1994: 688).

2.2.3 Theory-practice integration

According to McCaugherty (1991a:1060), many researchers stated they achieved better theory- practice integration by using appropriate teaching methods. These methods were related to ‘clinical’ instruction and the presentation of ‘theory’ to maximise theoretical knowledge and skills development and to close the theory-practice gap. Numerous research studies found by the researcher revealed that student nurses should learn from the classroom as well from the practice. Dale (1994:523) stated theory provides the basis for the understanding of nursing science. Therefore, nurse educators should make effort to reduce the theory-practice gap when it exists. According to Mellish et al. (1998:207), student nurses must “learn to apply the theory of nursing so that an integration of theoretical knowledge and practical skills in the clinical environment becomes the art and science of nursing”.

Successful nursing education blends the practical and theoretical components of nursing. Nursing education consists of two aspects, namely clinical teaching which is seen as the teaching that takes place by the patient’s bedside, and the presentation of theory through the means of academic teaching methods. These two aspects must not be seen as separate entities, but as a whole because student nurses must be able to apply the theoretical knowledge gained in the classroom to make educated judgements and skilled observations during patient care delivery (Mellish et al., 1998:207).

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Many initiatives have been implemented to reduce the theory-practice gap but only partial success was achieved (Rafferty et al., 1996:685). To Cook (1991:1462), Upton (1999:554) and Ousey and Gallagher (2007:204) this was not problematic as these authors conceded that the gap must not be fully bridged. A fully bridged gap will make it difficult for the nurse educator to ensure that student nurses develop a questioning frame of mind which stimulates them to question the practice. The aforementioned authors shared the viewpoint that a gap is essential to ensure that change in the clinical (or practical) environment occurs. The learning of the student nurses must, however, be facilitated in such a way that it helps them to adapt to the constant changes and to integrate the theory with practice. This will ensure that a safe competent practitioner, who has the ability to focus on individualised comprehensive patient care, is developed. It is therefore essential that the nurse educator recaps the theory while teaching the student nurse clinical skills in the simulation laboratory. This will reduce the fear the student nurses may experience before entering the clinical (or practical) environment where they will come face-to-face with real life situations (Maginnis & Croxon, 2010:2).

The nurse educator is the most suitable person to assist the student nurse to link theory to practice due to his or her dual role (Gerrish, 1992:227). It is therefore essential that the nurse educator utilises appropriate teaching methods to enhance the student nurses’ ability to link the theory to practice. Apart from facilitating the theoretical knowledge, the nurse educator must further fulfil his or her dual role by doing the clinical accompaniment of the student in the clinical environment. Research showed that a division in the dual role widened the theory-gap instead of narrowing it (Ferguson & Jinks, 1994:688).

The actual transfer of theory to practice is not an easy process. It is a complicated process influenced by many factors such as learning styles, preferred learning senses, and teaching methods. As mentioned, various studies over many years have been conducted to find solutions for the transfer of theory to practice. These studies indentified approaches to teaching and learning which enhance the integration of theory and practice and narrow the gap. McCaugherty (1991b:534) emphasised that nurse educators and the teaching methods they use play an important role in integrating theory and practice. This is a role that cannot easily be filled by others. Not only do nurse educators have to ensure that theoretical knowledge is structurally aligned, but they must also demonstrate how such knowledge can be integrated and applied in practice (Landers, 2000:1551).

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The most favoured teaching methods in nursing education are those that link theory to practice (Akinsanya & Williams, 2003:41). Educationalists have identified various teaching methods to help the student to make this transfer (Phillips, Donald, Mousseau-Gershman & Powell, 1998:12). Meyer and Van Niekerk (2008:82) point out these are methods that are student-centred, entail active student involvement, problem identification, and facilitation of the learning process. This viewpoint concurs with that of Mashaba and Brink (1994:272) in that a variety of teaching methods must be used as no one teaching method is suitable for the learning needs, learning senses, and learning style of every individual student in the classroom. The nurse educator must decide which teaching method is suitable for the subject type in question and also how to enhance the transfer of theory to the practice.