We often think and talk about practice as though we all share the same understanding of what the term means. Indeed, we usually use the term to refer to the sum total of what nurses and other health care professionals do as they go about their daily business. However, if we wish to improve, innovate or develop practice, it would be helpful to think more carefully about it in a more considered way.
I first made the distinction between the nurse technician
and the nurse practitioner in my book Closing
the Theory-Practice Gap in 1996, and it has remained the focus of my work
for the past 20 years. The nurse technician follows what Donald Schön referred
to as the model of technical rationality, where action is based on technical
knowledge from research. In recent years this approach has come to be known as
Evidence-Based Practice (EBP), with the gold standard research methodology for
generating evidence for practice being the randomised controlled trial.
Technical rationality demands two separate and distinct
groups: technologists who usually work in universities and who generate
evidence by conducting research; and technicians who apply the findings of
research in what Schön referred to as the ‘swampy lowlands’ of practice. The
relationship between these groups is hierarchical and one-way. Technologists
communicate with technicians by publishing the findings of their research in
academic journals, but there is little scope for technicians to respond if they
discover that those findings do not translate easily into practice. Technologists
therefore operate more or less independently of technicians and the value of
their work is judged primarily by the extent to which it is cited and discussed
by other technologists. Technicians, on the other hand, depend on technologists
to provide them with research-based evidence and guidelines for practice.
In contrast to the nurse technician, the nurse practitioner does
not rely primarily on external knowledge and theory supplied by researchers and
academics, but pays far more attention to the internal body of knowledge that
arises out of practice itself. In fact, we might go further and suggest that
the very idea of practice is defined by the extent to which its knowledge base
is generated by practitioners themselves through contemplation and critical
examination of their own actions. Practitioners are therefore autonomous
theorists and researchers of their own practice and the technical rational hierarchy
of evidence is turned on its head.
This expanded view of practice suggests a new paradigm for nursing and health care praxis with its own philosophy and methods for generating, evaluating, applying, and transmitting knowledge and theory, and which seeks to integrate them into an organic whole. |
The process of thinking critically about our own practice is
usually referred to in nursing and the health care disciplines as reflection or
reflection-on-action, which has been defined as the retrospective contemplation
of practice in order to learn from it. Reflection-on-action, as its name
suggests, usually happens at a distance from practice and offers the
practitioner an opportunity to recollect, analyse and process prior experiences
in order to develop new practice knowledge. Reflection-on-action can happen
informally and spontaneously or it can be planned and structured, often by
using a reflective framework. It can occur through introspection, by keeping a
reflective journal, or through clinical supervision. Wherever, whenever and
however it is done, reflection-on-action is the primary means by which the
practitioner builds her own unique body of experiential knowledge and theory on
which to make informed clinical decisions.
Reflection-on-action is a useful and valuable tool for the
practitioner, but it is essentially a theory of learning rather than a theory
of practice. Reflective practice, as opposed to reflective learning, can be
traced back to the work of John Dewey in the early years of the twentieth century,
and more recently to Donald Schön and his book The Reflective Practitioner. For Schön, the challenge for
practitioners is that practice is hardly ever straightforward; the everyday problems
encountered in professional settings can rarely be anticipated in advance and often
cannot be resolved through the application of generalisable findings from research.
The nurse technician who is dependant on technological theory and scientific
evidence will struggle to respond to the unique one-off situations facing her
as she goes about her day to day work, since her textbook theories will rarely
match the messy realities which she regularly encounters. What the nurse
requires in these situations is a more experimental approach to practice based on
her own experiential knowledge, which she can further develop and test in
practice through a process referred to by Schön as on-the-spot experimenting or reflection-in-action.
Reflective practice can therefore be described as a response
to unique and messy problems in which the practitioner assesses the presenting
situation, constructs theories, explanations and hypotheses, applies them on-the-spot
to her practice, and evaluates the effects of her actions. The process is then repeated
until the problem is resolved or brought under control. The reflective
practitioner is therefore engaged in a series of reflexive cycles of thinking
and doing in which knowledge and theory generated from practice is immediately applied back to practice. |
Practitioner research, as its name suggests, involves practitioners in a critical and systematic exploration of their own practice. Practitioner researchers might confine their investigations to their own practice or they may look more widely at the organization in which they work; they can be the sole investigator or work in partnership with academic researchers; they can carry out their research as an integral part of their everyday practice or step back and look at their practice more objectively; they can work as individuals or as part of a critical community of practitioner researchers.
Practitioner research has its roots in a quite separate
tradition from other research paradigms in nursing and health care, and can be traced to the split between the
social sciences and the human sciences at the end of the nineteenth century.Social science is grounded in Auguste Comte's positivism and Durkheim and
Mill's quest to discover social laws based on large scale statistical research. Human science, which is the foundation for practitioner research, has its roots
in Wilhelm Dilthey's hermeneutics, which was concerned with understanding and
interpreting the experiences of the individual. In other words, social science
is the study of people, and human science is the study of persons; social
science makes generalisations from a sample to a population, human science explores single cases; social science seeks to explain, whereas human
science is concerned with deep understanding (Verstehen); social science is a science of large numbers; human science is a science of the unique.
Practitioner research combines the reflexivity and commitment to change of praxis with the concern of hermeneutics to understand and empathise with the individual. Reflective practice is itself a methodology for practitioner research, but the practitioner researcher can adopt a number of other more formal and structured approaches including action research, reflective case study research, single-case experiments, and auto ethnography.
Practitioner research has a number of distinct advantages over more technical research paradigms. Firstly, it is grounded in practice and is able to respond immediately to the concerns and problems of practitioners and service users. Secondly, the subjects of the research are the very same people who will benefit from it. Thus, the practitioner researcher is able to acquire a deep and specific understanding of the individuals to whom she is providing care. Thirdly, the findings from practitioner research can be applied immediately and reflexively back into the practice setting. Finally, practitioner research empowers and emancipates the practitioner by giving her control over the generation, evaluation, application and dissemination of her own body of professional knowledge.
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Technical rational education has two functions: the first is instruction through the transmission of information, facts and knowledge from master to pupil; the second is training through assisting the pupil to apply those facts and knowledge in a practical setting. Carl Rogers referred to this as the mug and jug theory of teaching, where the master fills up the empty brains of the pupils from his jug of knowledge. However, whilst this model of education might be appropriate for training nurse technicians, Donald Schön has pointed out that "what aspiring practitioners most need to learn, professional schools seem least able to teach".
What aspiring practitioners most need to learn is not how to apply theory and research findings to practice but how to reflect in and on action, how to develop and apply clinical reasoning and wise action (praxis), how to critically examine and evaluate their own practice, how to develop a deep hermeneutic understanding of their clients and patients, and how to integrate all of these things into a single seamless whole. And the reason that "professional schools" (which are nowadays mostly located in university departments) seem unable to teach these things is because they are not things which can be learnt in schools and universities.
Schools and universities are ideal settings for teaching the science and technology of large numbers, that is, for preparing students for the statistically probable, the generally expected and the usual. They can equip students to work in what Schön called "the high hard ground" where "manageable problems lend themselves to solution through the application of research-based theory and technique". But as he pointed out, and as we all know from our own experience, most practice encounters take place in what he called "the swampy lowland" where "messy, confusing problems defy technical solution".
Schön uses the term 'practicum' for any setting designed for the task of learning a practice. In the technical rational university department, the practicum is the classroom and the simulation laboratory, where facts can be learnt and applied to practice more or less unproblematically. Learning takes place, but what the student learns is how to deal with the usual and the expected. She also acquires professional knowing, that is, be able to 'think like a...'. However, this professional knowing is not knowledge the practice of nursing or the practice of health care, but the practice of the practicum. The student learns how to solve the artificial problems and puzzles posed by the simulated setting, but not the messy and confusing problems of the swampy lowlands.
Learning to think like a practitioner can only happen in practice. Practitioner education, as with practitioner research, involves a partnership between practitioner and academic in which the former plays the major role. |
