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Title: 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
Author: Keyzer, Dirk Mitchell
ISNI:       0000 0001 3597 935X
Awarding Body: Institute of Education, University of London
Current Institution: University College London (University of London)
Date of Award: 1985
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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.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available
Keywords: In-service training; Nurse practitioners