Learning contracts, the trained nurse and the implementation of the nursing process : comparative case studies in the management of knowledge and change in nursing practice
The adoption of a " nursing " model in practice and education
is discussed in relation to the socio-cultural and
organisational factors which have shaped the traditional
care giver role. Issues arising out of this change in
the "practitioner" role are identified. The changing
roles of the nurse and the teacher are described and
discussed. The move toward an autonomous role for the
clinical nurse is seen to require a change in the nurseteacher
relationship. Learning contracts are perceived
to be a vehicle for implementing the new roles of the
nuise and the teacher.
The writer in the role of an observer-who-participates
negotiates learning contracts with nurses working in
four wards of four hospitals in one Health Authority.
The clinical areas are described as one community hospital,
one long-stay geriatric unit, one psychiatric rehabilitation
unit and one psycho-geriatric assessment unit.
Thus, community, general and psychiatric nursing are
included in this study of the management of knowledge
and change in nursing practice.
A variety of data collecting techniques are employed to
give an illuminative evaluation of the outcomes of the
learning contracts and the effect formal and non-formal
education have on the implementation of the nursing
process. The formal approach to education takes the form
of the Diploma in Nursing (London University, Old and
New Regulations) and the Joint Board of Clinical Nursing
Studies Course in Care of the Elderly (940/941). The
non-formal inputs are the clinically based learning
contracts negotiated with the nurses in the four clinical
areas.The data are presented as comparative case studies which
record the organisational policies adopted by the Health
Authority and the outcomes of the learning contracts in
the four clinical areas. From the case studies two
"themes" emerge: that of role conflict and the problems
of assessing thedegree of change achieved.
A theoretical framework of "codes and control" is
developed from that originally presented by Bernstein (1975)
for general education and adapted to health care organisations
by Beattie and Durguerian (1980). This framework
is used to interpret the changing roles of the
nurse and the teacher, and the division of labour between
the professional nurse and the woman in her own home.
It is argued that the implementation of the "practitioner"
role demands a redistribution of power and control in
favour of the patient and the nurse vis-a-vis the
manager, the teacher and the doctor. Further, in addition
to the teacher's and the clinical nurse's dependence
on the manager for the resources required to implement
the desired change in practice, nurse-practitioners are
dependent on the knowledge held by doctors, clinical
psychologists and occupational therapists to implement
the nursing process. In the presence of an inadequate
basic education programme and a limited access to
continuing education, the data suggest that the literature
on the nursing process and the key documents
distributed by the R.C.N. (1981) and the U.K.C.C. (1982)
are making demands upon the clinical nurse with which
she is unable and sometimes unwilling, to comply.
It is argued that a "codes and control" framework identifies
the complexities of the change toward the "practitioner"
role and thereby, clarifies the existing role. In this
way concepts of care held by the nursing staff are
identified which in turn, can be utilised in model building
to promote a "grounded" theory of nursing in the cultural
and organisational context of nursing in the United
Kingdom. Thus the use of learning contracts which identify the nurse's need for continuing education, in
conjunction with an action research mode utilising case
studies, can assist in the development of a theory for
nursing practice and education. In this way the theory
for nursing has its basis in clinical practice, is refined
through research, and is returned to practice through the
education programme. It is therefore argued that learning
contracts have a useful role to play in bridging the
gap between theory and practice in the school of nursing
and institutions of higher education.
The data recorded in the case studies suggest that in the
absence of a redistribution of power and control and/or
supportive education programmes during and after the
period of transition between the old and new roles, the
implementation of the nursing process will merely continue
the existing Nightingale strategies. The formalisation
of the present problem-solving approach to care in the
form of care plans will not necessarily promote the
"practitioner" role desired by the profession. Instead
the clinical role will continue to be defined by physicians
and management will consolidate its position in the
hierarchy of the bureaucratic organisation of the National
Health Service. This will not be challenged by nurses
in that it will continue the existing strategy of
"reifying" the presence of the "professional" nurse and
an particular, her position in institutions of higher
education. Such a strategy although satisfying in terms
of status will lead to the clinical nurse being asked
to implement a role with which she is unable to comply.
This in turn will lead to role conflict and a greater
division between the "theory" of the school and the
"reality" of the ward.