Journal of Clinical Nursing 1993; 2: 173-177

Closing the theory-practice gap: a model of nursing praxis

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GARY ROLFE BSc, MA, RMN, PGCEASenior Lecturer, School of Health Studies, University of Portsmouth, Portsmouth, UK

Accepted jor publication hS December 1992

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Summary

• Despite the efforts of nursing theorists, educationalists and practitioners, thetheory-practice gap continues to defy resolution. This paper argues that only byreconsidering the relation between theory and praetiee ean the gap be closed.

• Drawing upon ideas from teaching and other practice-based disciplines,including nursing, the article suggests that tbe eurrent model of viewing theory asinformitig and eontroUing praetiee should give way to a mutually enhancingtnodel in wbich tbeory is derived from practice, and in turn influences futurepractice.

• This coming together of theory and practice is referred to as nursing praxis,and suggests that informal theory should be unique to each individual encounterwith each patient.

• The clinical nurse is thus not only a practitioner, but a tbeorist and researcher,who responds to patients not according to some grand, inflexible theory, but bythe process of refleetion-in-action, drawing upon their expertise and a repertoireof past experiences and encounters.

Keywords: theory-practice gap, nursing praxis, reflection in action.

Introduction i l .V ll-Jii.l.

One of the tnost contentious and enduring probletns innursing is the observation that what happens in clinicalsituations rarely, if ever, matehes what the textbooks sayought to happen. Mt)st nurses w ill have had some experi-enee of this so-ealled thet)ry-practice gap, but it is probablyfelt most acutely by student nurses, who often findthetnselves torn hetween the detnands of their tutors toimplement what they have learnt in theory, and pressurefrotn practising nurses to conform to the constraints of reallife clinical situations. According to the theorists, tbe gap isbetween what researeh and theory says should ideally be

Correspondenee: Gary Rolfe, luluealion Centre, St James' Hospital,Locksway Road, Portsmotith I'O4 SLD, UK ..,,. .,,., ..._.,...,,,

happening, and what actually happens in the 'imperfect'clinical area. From this perspective, the gap will beredueed by nursing praetiee moving closer to theory. Yetaccording to the practitioners, the gap is between whattheory says should happen and what actually works. Fromthis perspective, the gap will be reduced by nutsing tbeorytnore closely reflecting tbe realities of clinical life.

The fact that the gap is still with us, suggests thatneither view is an aecurate representation of the actualsituation. This paper will argue that the gap is based on atnisconception about the nature of nursing theory and therelationship of tbeory to practice. Furthermore, it will beargued, the gap is a neeessary consequence of the way inwhich theory has developed over the years. It is a logicalgap, predieated by a body of theory which can never fullyaccount for what happens in clinical practice. As such, the

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theory-practice gap cannot be bridged either by practicemoving closer to existing theory or by theory conformingto the constraints and limitations of real-life practice.Rather, a new relationship between theory and practicemust be sought, which will be referred to as nursing praxis.

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The theory-practice gap

Nursing theory has developed according to the paradigmof the natural sciences, what Schon (198.3) refers to as thetechnical rationality model. Thus, in regard to nursing, theterm 'theory' is generally used in its scientifie context asmeaning 'a systematic set of interrelated concepts, defini-tions, and deductions that describe, explain, or predictinterrelationships' (Pinnell & de Meneses, 1986). Theoryand research in nursing has tried to emulate diseiplinessuch as physics and chemistry, in the attempt to build afirm foundation of nursing knowledge. Despite a small butgrowing body of research grounded in phenomenology,this paradigm is now so established that it is generallyaecepted without question. However, it has serious impli-cations for practice, because the paradigm of the naturalsciences generally differentiates between the scientist orpure researcher who makes the discovery, and the techni-cian or engineer who then develops its practical uses.

Applying this to nursing, theory becomes elevated instatus compared with practice, and theorists become separ-ated from practitioners, with research being somethingmainly carried out by the former. Thus, according to thisparadigm, practitioners are merely the passive implemen-tors of theories which they had no part in developing. Forexample, a theorist may produce a nursing mt)del, wbicbpractitioners then attempt to put into action with theirpatients in their particular clinical setting.

Underlying the technical rationality model is the as-sumption that people are as predictable as inanimateobjects. However, whereas one piece of steel, for example,will always behave in the same way as another similar pieeeof steel under the same conditions, whether in a laboratoryor as a component in a bridge, with people we can onlymake statistical predictions ba.sed on the law.s of proba-bility. For this reason, the application of theory to practiceis problematic—we can never be certain that what theorytells us should happen, actually will in a consistent fashion.

This observation, that theory can never fully account forwhat happens in practice, is sometimes referred to asunderdetermination—we say that practice is underdeter-mined by theory, unlike in physics, where theory deter-mines precisely what will happen to a pieee of steel underany given conditions and for any application. The conceptof underdetermination was developed by Steven Lukes

(1981), who put forward the thesis that, particularly in thesocial sciences, ' . . . . theories may be underdetermined bydata: that is, that theories may be incompatible with eachother and yet compatible witb all possible data'. Thus tnthe soeial sciences including nursing, theories can never beaccepted with eertainty, hecause there will always be othereontesting theories whieh are equally accounted for by thesame empirical research data.

The reasons for this underdetermination in nursing arepartly due to the nature of nursing theory, and partly to thenature of nursing praetiee. Theories in nursing aregenerally derived from one of two sources. Either they aresynthesized from theories in one of the so-called founda-tion disciplines of psychology, sociology, philosophy andbiology; or tbey are generated from nursing research. Inthe former case, Carr (1982) pointed out that not only isthere conflict and disagreement between each of thesefoundation diseiplines, but also within them, because they,too, are subjeet to underdetermination.

In the case of theory generated from nursing research,we are confronted with the probletn of induction. Popper(1969) argued that this problem is inherent in all etnpjricalresearch carried out within the paradigm of the naturalsciences, which includes most nursing research. Briefly,the process of induction is the generalizing of findingsfrom individual research studies into a global theory whichapplies to all people in all situations all of the titne.However, Popper claimed that no matter how many timessomething is observed to happen, we can never logieallyconclude that it will always happen—the next observationmight reveal something different.

For example, a research project may conclude tbatmethod X is a more eflective form of mouthcare thanmethod Y, and may therefore recotntnend that method Xis used in preferenee to method Y. But Popper argued thatjust because method X was associated with better mouth-care in the research project, that does not mean that it willalways be assoeiated with better mouthcare in all situa-tions—a replication of the study might show method Y tobe more effective. '^' . - . J . > [< , f i - ) i j . i H H

As well as the problem of induction, it must be borne inmind that research with human subjects usually deals inprobabilities and significant differences. Regarding theissue of probability, it would be very unusual for a researchstudy such as the one above to find that all the subjectsresponded better to method X. It may be possible to saythat on average 90% of all patients will respond better tomethod X, but it eannot tell us whieh 90%. Therefore, it isonly probable that a certain patient will respond. Regard-ing the related issue of significant differences. Gross (1987)pointed out that a study of this kind usually, 'involves the

A model of nursing praxis 175

use of statistical procedures which . . . tell us the proba-bility of our t-esults having occurred by chance alone. It isimportant to note here that probability is the best we canhope for there is no no certainty in science.' (p.30) It isthe researcher who must make the decision as to the levelof significance that is acceptable, that is, the degree ofprobability that the differences between method X andmethod Y is due to chance factors. Levels of one in athousand or one in two thousand are usually consideredsignificant. Thus, nursing knowledge is largely statisticalin nature—nui-sing theory can never predict with absolutecertainty what will happen in practice in any individualcase.

As with nursing theory, pt-actice is also concet-ned withindividual people in individual situations, and unlikepieces of steel each is unpredictable and unique. Forexatnple, a nurse faced with a question from a terminally illpatient as to whether he is dying, may turn to theory for ananswer as to how to respond. She will first have to siftthrough psychological theories of communication andcounselling, philosophical theories of ethics, and nursingresearch studies about the effects of giving information topatients, all of which will provide her with conflictingadvice. Even once she has decided which theories to acceptand which to t-eject, she is still faced with the problems ofunderdetermination and induction. She can never becertain that the theory on which she chooses to base heractions will t-esult in the best nursing intervention for thispat-ticular patient in this particular setting. This then is theproblem of the theory-practice gap. It is a gap that isinherent in the nature of nursing theory, and as such, cannever be bridged.

Nursing theory, nursing practice and nursingpraxis

If, as is being argued in this paper, theory can never fullyexplain or predict what will happen in practice, it mightappear that theory is of no l-elevance to nut-sing. Fortuna-tely, there is a way out of the dilemma, but it involves re-examining the nature of nui-sing theory. We need todiscover new ways of conceptualizing what happens inpractice, ways that are more closely related to practiceitself We must thet-efot-e t-eplace the scientific notion of'theory', as defined earlier by Pinnell & Meneses (1986),with one that mote accut-ately t-efiects the realities of theclinical world. This is difficult however, because the term'theory' is often used to denote the opposite of practice, forexample when we say 'its all very well in theory, but will itwork in practice.'''. In order to develop a theory of practice,we must distinguish it from both the scientific definition of

the term, and also from its more popular usage. Benner(1984) made the useful distinction between 'knowing that'and 'knowing how', and argues that knoxving how to dosomething does not always require theoretical knowledge,or knowing that something is the case. Beeoming an expertin practice requires the development of 'know-how', ofknowledge embedded in practical expertise.

Carr (1980, 1986) suggested that practice is an intentio-nal activity located in conceptual frameworks, and as suchcontains its own internal theory. This kind of theory is notsomething which is applied to practice, but rather, theoryis implicit in practice, because without it practice degener-ates into random and meaningless behaviour. Usher &Bryant (1989) referred to this as 'informal theory' incontrast to the formal theory of the technical rationalitymodel, and argued that: 'Informal theory enables practi-tioners to work within the situations in which they findthemselves, by relating their activities to both what isdesirable and what is possible within those situations andto assess the outcomes of their activities in the light ofthese considerations.' (p. 80). Furthermore, this informaltheory is not 'scientific' in the sense of being abstract anddecontextu-alized, but nor does it suffer from being unsys-tematic and intuitive. Rather it transcends the dualism ofthe positivist/phenomenological distinction by its locationwithin practice.

The relationship between theory and practice is to someextent revet-sed. Theory does not determine practice, but isgenerated from practice. In fact the process is circular,with pt-actice generating theory, theory modifying practice,which generates new theory and so on. In this way arguedSchon (1983); each practitioner builds a situational reper-toire which is forever being expanded and modified tomeet new situations. Often, the alternating from practiceto theory to practice and so on is so fast as to seem like oneintegrated proeess, what Schon referred to as reflection-in-action, and,'it is this entire process of t-eflection-in-actionwhich is central to the 'art' by which practitioners some-titnes deal xvell with situations of uncertainty, instability,uniqueness and value conflict.' (p. 50)

This is primary nursing in its truest sense, where notonly is each patient responded to as an individual, in someways similar but in many ways different frotn all otherpatients; but each individual encounter xvith each patient istreated as a new situation which requires a fiexible ap-proach and which will, in turn, modify all futureencounters with all future patients. For example, whenconsidering the tnouthcare needs of a particular patient,the nurse xvill dt-axv on her situational t-epertoire of mouth-care interventions to find similar cases to the one she isnow faced with. She will also take into account the unique

176 G. Rolfe a lo b u m A

situation of this individual patient, and provide care thatwill best meet his individual needs. This approach issimilar to that de.scribed by Benner (1984), in which,'expert nurses develop clusters of paradigm cases arounddifferent patient care issues, so that they approach a patientcare situation using past concrete situations much as aresearcher uses a paradigm.' (p. 8) Informal nursing theoryis therefore not generalizable in the same way that formalscientifie theory tries to be. We eannot argue that becausemouthcare method X proved to be better than method Y inelinieal trials, then it will be better for this patient in thissituation. Nevertheless, informal theory is generalizable inthe sense that theory derived from reflection-in-action canbe used to modify future practice. However, the relation-ship between theory and practice is not a deterministic orcausal one, but a mutually enhancing one. Theory andpractice are locked in an inseparable whole, such thatreflective practice produces informal theory, and reflexivetheory modifies and develops practice (Fig. 1).

We can .see from this model that the gap between formaltheory and practice has been bridged by the generationinformal theory out of practice itself. This process hasbeen referred to as praxis, a Greek term for 'action' whichKarl Marx used to denote 'the unity of theory andpractice'. Praxis or 'doing action' effectively dissolves thetraditional theory-practice gap by making theory andpractice mutually dependent on one another.

'A 'practice', then, is not some kind of thoughtlessbehaviour which exists separately from 'theory' andto which theory can be 'applied'... . The twinassumptions that all 'theory' is non-practical and allpractice is non-theoretical are, therefore, entirely

P mi.sguided.' (Carr & Kemmis, 1986, p. 113) '•'.'nt

Formal theoryempirical research

nursing models

INFORMALTHEORY

Reflexive theory

Leading to newhypotheses to betested in practice

Reflective proctice

Leoding to modificationof existing theory

PRACTICE

Situational repertoireof paradigm cases

Figure 1 A model of nursing praxis.

Informal theory is contained in practice by definition,because without it practice is merely random and uncoor-dinated activity. Similarly informal theory is by definitiongenerated from practice by the process of reflection-in-action. Nursing praxis is a bringing together of theory andpractice which involves a continual process of hypothesiz-ing and testing out new ideas, and modifying practiceaccording to the results. The argument here is that this issimilar to the method of doing research known asgrounded theory which is 'the discovery of theory fromdata systematically obtained from social research' (Glaser& Strauss, 1967). Therefore the contention is made that allpractitioners are not only 'theorists', but 'researchers',engaged in numerous pieces of 'action research' and thegeneration of informal theory. Schon referred to thisresearch as on-the-spot experimenting, generating whatPolanyi (1962) called 'personal knowledge'. This role ofpractitioner-as-researcher does not fit the traditional roleof the nurse researcher as specialist, coming into theclinical area to 'do' research. In fact, the role of researchercannot be separated from the role of practitioner, beeauseto practice is to research. However, this research will notfit the tecbnical-rationality paradigm, in which findingsfrom large samples are generalized to whole populations.Indeed, the kind of research that takes place withinnursing praxis might have a sample of one, and might notbe generalizable beyond that single person. Nevertheless itis still valid research, and not subject to the same problemof induction and statistical generalization as positivistscientific research.

Conclusion

This paper has argued that the gap between theory andpractice in nursing is largely due to the inability of nursingtheory to adequately account for what happens in real-lifeclinical situations, and that this inability stems from thelocation of nursing within the traditional scientific para-digm in which theory informs and determines practice. Ifthe theory-practice gap is to be closed, then theory tnustrelinquish its hierarehical position and develop from prac-tice, sensitive to the needs of individual practitioners inunique situations. A model of nursing praxis has beenproposed, in which informal theory is generated frompractical situations by reflection-in-action, and practice ismodified by the reflexive applieation of that theory backinto practice. This model has several profound impli-cations for nursing.

Firstly, traditional 'formal' nursing theory would bereplaced in importance by grounded or 'informal' theory.The role of formal theory would now be supportive in that

A model of nursing praxis 177

it provides the 'tools' for praxis. Let us take the example ofthe terminally ill patient who asks the nurse if he is dying.In deciding how to respond, the nurse will refiect onsimilar situations which she has found herself in previouslywith other patients, and will draw on her relationship withthis particular patient, and her knowledge of how heresponded in different situations. Although these will hethe main factors in coming to a decision, she may also drawon principles of counselling or humanistic psychology, onethical considerations, and on experimental research.However, these considerations will be secondary—theywill provide supporting matet-ial for her refiection-in-action. Thus, what is normally considered as nursingtheory will have the role of praxis of information ratherthan knowledge.

Secondly, and following on from this first point, becausethis model does not allow for general, universal theories innursing, the nature of nurse education would be funda-mentally different. Knowledge is constantly developingand changing, and no single theory can account for thecomplexities of any given situation. Thus, each encounterby each nurse with each patient is unique, and whileformal theories can provide information on which to baseaction, the nurse would generate her own informal theorythrough refiection-in-action and on-the-spot experiment-ing. Nurse education would therefore need to take moreaccount of the clinical settings in which students findthemselves, and the traditional division between theoryand practice would be largely abolished. There would beless time spent on attempting to apply theories and modelsto practice, and moi-e titne on refiecting on individualclinical situations through role-play, refiective diaries,portfolios and critical incident work.

Finally, the status of nursing practice and of the ward-based nurse would be elevated in accordance with her newrole as action researcher and generator of theory. She

would no longer merely apply theories dictated by educa-tionalists and researchers—she would be an educationahstand A !-esearcher. In short, the clinical nurse practitionerwould be an expert, with 'a deep background understand-ing of clinical situations based upon many past paradigmcases' (Benner, 1984, p. 294). There would be a comingtogether of theory and practice, and the theory-practicegap would he abolished, to be replaced by a new model ofnursing praxis. ,., ,

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