Why such a gap between theory & practice?

Teresag_CNS · Oct 8, 2009

I have PhD in nursing, and I practice in a Trauma ICU. I agree fully that standardized tests, esp. NCLEX, focus on minutiae, not the important issues in nursing. I have heard that NCLEX item writers are primarily MS-prepared educators from community colleges. So please do not blame us PhD-prepared faculty for the poor quality of the items. I guess the solution is for those of us who are dissatisfied with the items to get ourselves on the item writing committees to improve the quality of the exams from within.

dorimar, BSN, RN · Oct 8, 2009

Tereasq,

My apologies for implying it was the fault of doctorate prepared nurses. I guess I am just wondering if it is practicing nurses that write these tests. Actually, perhaps it isn't even so much just the tests, but the fact that standardized testing is the way we assess competence... I don't think it is a very good measure of competence. I wish there was a better way. I recently worked with a nurse who went to nursing school in Australia, and she said that the nursing board actually came to the clinical settings regularly and assessed practice and knowledge of the students in the clinical setting. Students were required to answer questions about the care of their patients, as well as be observed giving the care. What a phenomenal idea!

llg, PhD, RN · Oct 8, 2009

Tereasq,
Students were required to answer questions about the care of their patients, as well as be observed giving the care. What a phenomenal idea!

Don't the faculty members in your school do that before they graduate students and certify them eligible to take the NCLEX? The US system is based on the assumption (which is not always upheld) that the individual school faculty assess teh students' ability to practice safely at the bedside -- by supervising their student clinical experiences, asking questions, requiring that the students meet clinical practice standards before they pass the course. If students don't meet those standards, they the instructor is supposed to FAIL them. Does your school not do that? If that's the case, then you are teaching for a school that is not doing it's job. The NCLEX is designed to measure other things -- while the school faculty are supposed to be assessing bedside abilities.

Some states are increasing their required clinical hours for RN graduates before giving licenses -- because more and more schools are failing to uphold their end of the evaluation process. As schools scrimp on clinicals and provide more "observational" or "simulation" than "direct hands-on care" time, people are growing concerned about the lack of the type of evaluation you speak of. A student cannot be adequately assessed with written assignments and simulations alone. It's the job of the school (and faculty) to do the bedside teaching and the bedside evaluation. Too many schools are straying from that -- and that is dangerous for our profession and dangerous for our society.

The NCLEX is properly seen as only 1 piece of an evaluation process. It should not be seen as standing alone in the evalutaion of the student's readiness for professional practice.

Just my $.02

SuesquatchRN, BSN, RN · Oct 8, 2009

I believe that almost all nursing programs, LPN and RN, are woefully lacking in clinical training. The didactic portion has overtaken the practical. While students can learn once they hit the floor it places an unfair burden on preceptors, and contributes to the "nurses eating their young" phenomenon.

Jami RN, BSN, RN · Oct 8, 2009

I believe that this disparity between actual practice and nursing theory is pervasive not only in exams, but in the nursing profession as a whole. I agree with the poster that stated that the PhD nurses who drive the theory and make the guidelines for the profession are very, very far removed from the realities of bedside care within a medical setting. These "leaders" and policy-makers are oblivious to the "what is" of the profession, and concern themselves only with the "what could be in a perfect world."

Nurses at the bedside should step up and try to overthrow these ivory tower scholars, but unfortunately, most of us are exhausted, disenfranchised, cynical and overworked, and therefore unwilling to put forth more effort without guaranteed results. I guess it's a viscious circle and I don't know the solution.

JMHO,

Jami

llg, PhD, RN · Oct 8, 2009

I believe that this disparity between actual practice and nursing theory is pervasive not only in exams, but in the nursing profession as a whole. I agree with the poster that stated that the PhD nurses who drive the theory and make the guidelines for the profession are very, very far removed from the realities of bedside care within a medical setting. These "leaders" and policy-makers are oblivious to the "what is" of the profession, and concern themselves only with the "what could be in a perfect world."
Nurses at the bedside should step up and try to overthrow these ivory tower scholars, but unfortunately, most of us are exhausted, disenfranchised, cynical and overworked, and therefore unwilling to put forth more effort without guaranteed results. I guess it's a viscious circle and I don't know the solution.
JMHO,
Jami

I disagree. It's not a case of "good guys vs bad guys" etc. It's wrong to think that one side of the theory/practice split is 100% wrong and the other is 100% right. That kind of thinking is part of the problem and not part of the solution.

Just as those in "ivy-covered halls" need to come out and look around once in a while ... those at the point of patient care need to acknowledge the need for the further development of the scholarly, academic side of our profession. Both types of knowledge are needed to maximize nursing's potential. We need scholarly activities to provide the research/knowledge to provide good care -- and that type of knowledge development requires scholarly theories that might not be directly relevant to the bedside care-giver. Bedside care-givers need to realize that they are only one part of the profession -- and that the other segments of the professional ALSO contribute things of value.

To need to work together and recognize the value of all segments of the profession in order to bridge the theory-practice gap. We can all learn from each other. Throwing stones at each other is not the answer.

llg, PhD, RN · Oct 8, 2009

I believe that almost all nursing programs, LPN and RN, are woefully lacking in clinical training. The didactic portion has overtaken the practical. While students can learn once they hit the floor it places an unfair burden on preceptors, and contributes to the "nurses eating their young" phenomenon.

I strongly agree that the burden of providing basic clinical education to new grads (and students) is becoming unbearable. Schools have to beef up their programs -- not streamline them to graduate more students with shorter educations who are woefully under-prepared.

elkpark · Oct 8, 2009

I strongly agree that the burden of providing basic clinical education to new grads (and students) is becoming unbearable. Schools have to beef up their programs -- not streamline them to graduate more students with shorter educations who are woefully under-prepared.

(As usual,) ITA. It appears to me that, as time goes on, the more complicated and demanding nursing becomes and the more accountability and responsibility is demanded of nurses, the less and less we're teaching in nursing programs. Florence Nightingale fought to move nursing away from OTJ training and into formalized academic programs -- now, well over a century later, it often looks like we're moving back to OTJ training ...

dorimar, BSN, RN · Oct 8, 2009

My school does assess practice in clinical, as does every nursing school in my region. However many of the new nurses I have worked with over the past several years seem to be lacking in critical thinking, practical knowledge, and skill. This is why I chose to go into education. I thought I could really help. However, the clinical time is very limited. I do take advantage of my didactic time in trying to bring the theory home to the students with real applicable examples. But again, I was hit in the face with this standardized testing, that I feel often does not test some of the most important things. I found myself having to spend most of my time preparing students for these standardized tests and not reality.... I know I am not explaining myself well.

None of the didactic instructors where I teach currently practice at the bedside, and some have not for many years. I think it is important to maintain clinical knowledge and skill when teaching. However, it is near impossible with the hours expected for nursing instructors. It is unfortunate. My friend who is a phenomenal critical care nurse, recently started doing clinicals. She told me that some students were discussing something for a test, and she told them they did not need to know that. I teach critical care, and I told her that yes they do need to know it. She was shocked. She stated that she would like to spend more time in the didactic realm just to know what the students are required to know for these standardized tests. Really it would be nice if the clinical instructors could have more experience with theory instruction, and the didactic teachers could have more clinical experience...

I realize this is not really possible. I have never put in so many hours as I have in teaching. I had no opportunity to work the bedside at all (except for clinicals, and it is not the same). I killed myself trying to make sure I taught what was needed for a standardized test, but also what was needed for good practice. I do feel I made a difference, but it wasn't worth what it did to me or my family.

So, I don't know what the answer is. I just think we are way off the mark.

Jami RN, BSN, RN · Oct 8, 2009

I disagree. It's not a case of "good guys vs bad guys" etc. It's wrong to think that one side of the theory/practice split is 100% wrong and the other is 100% right. That kind of thinking is part of the problem and not part of the solution.

I agree that it's not a case of "good guys vs bad guys." I think everyone involved in the nursing profession would like to see nurses garner more professional respect and be treated as educated, self-directed professionals. I believe there is great value in compassion and universal caring, and my values align with many of the modern nursing theories. Unfortunately, I do see that the course of the nursing profession is often charted by nurses with PhDs who have been away from actual patient care for a long, long time.

I think that part of the problem is that the nursing profession has tried very hard to separate itself from the medical profession through nursing theory, even though the majority of nurses not employed in education work in facilities that are governed by a medical model. While nursing diagnoses are seen as the hallmark of our profession by academics, they are viewed by those outside the profession as inane nonsense that talks around the real reason that most patients are receiving care in an institutional setting.

Unfortunately, nurses of any educational level make up a very small percentage of upper administration in any health care institution, although they provide the majority of the care in said institutions. In the last 20 years, our health care system has evolved into a business model ruled by insurance executives, finance officers and businessmen, with little input from doctors and even less from nurses. I think that one of the biggest issues facing our profession is the lack of acknowledgement by our leaders and theorists of the fact that healthcare is not driven by philanthropists and religious orders anymore, and much of the nursing process is a luxury that is not viewed as valuable or profitable by hospital administrators, insurance execs or politicians. Unfortunately, that is the reality for the bedside nurse who struggles on a daily basis to complete her designated tasks and goes home feeling guilty that not much true "nursing care" by definition of the theorists was given during her shift.

Although I digress and am not sure what this has to do with the questions on standardized tests...

Respectfully,

Jami

SuesquatchRN, BSN, RN · Oct 8, 2009

I think that part of the problem is that the nursing profession has tried very hard to separate itself from the medical profession through nursing theory, even though the majority of nurses not employed in education work in facilities that are governed by a medical model. While nursing diagnoses are seen as the hallmark of our profession by academics, they are viewed by those outside the profession as inane nonsense that talks around the real reason that most patients are receiving care in an institutional setting.

I completely agree.

One problem that I find is that many nurses do not view education as valuable. I have heard more than one BSN student say, "I don't know what 'insert subject' has to do with nursing."

Well, maybe it has to do with broadening one's scope, enhancing one's frame of reference... I have gotten grief from co-workers for continuing my education. I have had higher-ups get angry at my offering training classes - while I was the informatics nurse - on using the computers on work time. That has happened to me solely in nursing.

I have also had instructors tell me that statistics are meaningless, make amazing conflations of causation from mere correlation, and tell me that she couldn't explain the disease process she was teaching because "I'm L&D."

I don't know. I spend my days banging out meds like a trained chimp. Nursing process? I just spent the shift picking a 300 pound guy off the floor four times because we can't restrain him and he likes the attention he gets when we have to call all hands to hoist him and fill out incident reports.

I don't know what the answer is, but I am really disappointed in nursing as I have experienced it.