Keynote paper given  by Gary Rolfe at the 6th Annual Practice Development Conference, Earth Centre, Doncaster, 16 October 2003


None of us should really be here today, because in a way it is ludicrous that we should need to have practice development conferences at all. Practice development shouldn't be something different and special. Everything we do, as practitioners, managers and academics should be concerned with practice development - it should be at the core of our being.  Especially academics.

I can see no reason or justification whatsoever for academics in a practice-based discipline other than the development of practice. And I hope to show this morning that this does not mean teaching. For me, practice development has nothing to do with the mug and jug theory of education - you know, the students are the mugs and I come along with my jug of knowledge and top them up. This has also been called the 'top down' or shower model of education. I want to argue that practice development requires a 'bottom up', or what I like to think of as a 'bidet' model.

I’ve taken an active interest in practice development for a number of years. I was involved in the original Kings Fund Nursing Development Unit initiative in the early '90s, and in a number of Practice Development Units since. My previous job title even had the words ‘practice development’ in it, but it wasn’t until I came to think about this paper that I first seriously asked myself the question: ‘What is practice?’. And the more I thought about it, the more I realised what a good question it was.

Of course, the word has two spellings (unless you’re American) and a number of meanings. Spelt with a ‘C’, as it is in the title of this conference, it is a noun. When we talk about the practice (with a ‘C’) of nursing or the practice of medicine, we are referring to a thing, in this case, an institution, a profession or a general way of doing things. When we talk about a medical practice (also with a ‘C’), we are sometimes referring to a building, sometimes to the group of people who operate out of that building, and sometimes to their agreed way of working. Practice development means to improve or develop the institution or profession of nursing, medicine and so on. A practice (with a ‘C’) development unit is therefore concerned with developing this thing that we call professional practice. The outcome of practice development (with a ‘C’) is a better thing, either an entire profession or a group of clearly identified individuals within that profession.

Then, of course, there is practise with an ‘S’. Practise with an ‘S’ is a verb. To practise is to do something in a certain way. Practise development means to improve or develop what we do as professional practitioners. The outcome of practise development (with an ‘S’) is better action.

Perhaps I’m being pedantic here, but I only realised when I was thinking about this paper that I rarely distinguish between the two. It was only then that it occurred to me that I had been misrepresenting myself and what I do for almost my entire career. Although my previous job title said that I was a Reader in practice development with a ‘C’, I actually had little interest in developing the profession of nursing or the general principles by which nurses work. For me, practice development with a ‘C’ is largely a matter of policy and politics. I suddenly realised that my interest is, in fact, in practise development with an ‘S’. I want to influence directly what individual nurses do rather than generally what nursing is.

But to say that practise with an ‘S’ is what we do is only half the story. Why is it that we refer to all doctors as medical practitioners, to all lawyers as legal practitioners, to some nurses as nursing practitioners, but never to postal delivery practitioners or bricklaying practitioners? You might argue that it is something to do with belonging to a profession, but that only begs the question of why medicine is regarded as a profession whilst bricklaying isn’t. Clearly, not all doing is practise and not all doers are practitioners. There has to be something more.

Some years ago, I wrote about the distinction between nurse technicians and nurse practitioners. They can be seen as two stages in the development of the nurse, but they are also two modes of working. Nurse technicians adhere to the technical rationality model of nursing, and their modus operandi can be summed up by the following definition:

Nursing is a science and the application of knowledge from that science to the practice of nursing. (Andrews & Roy 1996, my italics)

This technical rationality model assumes a hierarchy in which knowledge and theory inform practice in a one-way flow. Nurse technicians are concerned with what we might call ‘the appliance of science’, with the scientifically proven ‘best’ intervention for each nursing problem. Perhaps I was being less than charitable when I described this technical approach to nursing:

almost as a branch of engineering, and the goal of nursing knowledge and theory as finding the most efficient and effective ways of carrying out nursing procedures. (Rolfe 1996)

Well, perhaps, and yet I continue to find the same sentiments echoed in the rhetoric of evidence-based practice, which appears to have as one of its goals the search for the holy grail of the most efficient and effective generalisable intervention for each generalised nursing problem. This can lead to some disturbing trends. For example, in my own field of psychiatric nursing, cognitive behaviour therapy has been found in RCTs to be the most effective and cost efficient nursing treatment for depression. This has been interpreted (quite wrongly, I believe) by some nurses to mean that all depressed patients should be offered CBT, almost regardless of who they are as individuals. Physicians have treated the disease rather than the patient for very many years; indeed, the medical model is predicated on the idea that it is the disease rather than the patient that responds to medication. If the patient presents with signs and symptoms of depression, she will probably be prescribed the drug that has been found in clinical trials to be the most effective treatment for her general condition. I am concerned that nursing is heading the same way.

In contrast to these nurse technicians, nurse practitioners are concerned with individual solutions to individual problems. They approach each clinical encounter as though it is unique, and seek out the best intervention for that particular patient in that particular situation, regardless of what the textbook might tell us is the ‘gold standard’ intervention. The technician’s solution lies outside of the situation and can usually be found in a book or journal, whereas the practitioner’s solution lies in the situation itself.

In a certain sense, then, the technician’s intervention is mindless, since all the decision-making is done beforehand; theory and practice are separate and self-contained, and the technician (as Andrews and Roy said above) merely applies knowledge from science to practice. The practitioner’s intervention, on the other hand, is mindful; the theory is to be found in the practice itself. As Carr and Kemmis note:

A ‘practice’, then, is not some kind of thoughtless behaviour which exists separately from ‘theory’ and to which it can be ‘applied’ … The twin assumptions that all ‘theory’ is non-practical and all practice is non-theoretical are, therefore, entirely misguided. (Carr & Kemmis 1986)

We can perhaps see, then, why architecture is regarded as a practice whilst bricklaying is not. The architect enters into a relationship with her work; the design of the building evolves in response to what Schön refers to as a ‘reflective conversation with the situation’ as she works. Knowledge is consciously extracted from the practice situation and is immediately fed back into it. The bricklayer, on the other hand, merely applies the theories of the architect and need give no thought at all to what she is doing as she is doing it. Indeed, the mark of a good bricklayer is that she is able to do the job without thinking about it, just as the mark of a good typist is that she doesn’t have to think about where each key is on the keyboard, and the good driver doesn’t have to think about when to change gear.

Similarly, nurses and doctors who act automatically, simply applying external theory or clinical procedures in an unconscious or mindless way could not, at least by my definition, be described as practitioners; they are technicians. Practitioners, on the other hand, need more than this global generalisable knowledge. The philosopher Hans-Georg Gadamer tells us that:

Once science has provided doctors with the general laws, causal mechanisms and principles, they must still discover what is the right thing to do in each particular case, and this is something which hardly seems to be predictable or knowable in advance. (Gadamer 1996, my italics)

Whilst the technician requires only a body of general knowledge which she applies to all relevant cases, the practitioner’s knowledge is somehow embedded in the practice situation itself. This amalgam of action and knowledge as intrinsic components of the same act is sometimes referred to as praxis, and for the sake of clarity, I’ll use that term from now on to refer to practise (with an ‘S’). 

I'd now like to think for a while about the development of praxis. Clearly, we firstly need to differentiate between technical development and praxis development. When a bricklayer goes on a course to learn a new method of laying bricks, she is developing her technical ability; her technique. Similarly, when a nurse goes on a course to learn how to give IV injections, she is also developing her technique.

In my opinion, this is not praxis development. She has merely learnt a new technique which, in time, she will perform mindlessly, perfectly and without conscious thought. I should perhaps make it clear that I don't wish to denigrate such courses. All practitioners need a grounding in technical knowledge and skills. But such courses merely make the student a better technician. Not all education and training is praxis development. However, if, as part of the course, she is asked to consider the problems of giving IV injections in individual cases, for example to a particular child with a needle phobia or to a particular woman with a compromised circulatory system, she will have started to develop her praxis.

I should make it clear that I am talking about individual cases here. Going on a course to learn how to work with ‘the needle phobic patient’ is technical development, not praxis development. Technical development is concerned with the global application of a (usually evidence-based) technique. The knowledge-base is public, it lies outside of the situation to which it is applied. Praxis development is concerned with unique individual instances. There is no global, universal, public knowledge base concerning how to give an IV injection to Mrs Jones; the knowledge base lies within the clinical encounter itself. The knowledge is part of the clinical encounter. It does not exist until the encounter takes place.





  Some further questions on the nature of caring (2009) 

Towards a geology of evidence-based practice (2006)
  Advanced nursing practice (1999)

  Closing the theory-practice gap (1996) 


    contact: praxis@garyrolfe.net