Journal of Advanced Nursing, 1997, 26, 444–448

In praise of ivory towers

Ernest Chapman MA BD PGCE RGN

Nurse Teacher, The Robert Gordon University, Aberdeen, Scotland

Accepted for publication 2 September 1996

CHAPMAN E. (1997) Journal of Advanced Nursing 26, 444–448In praise of ivory towersMrs Gillian Shepherd, during her tenure as the United Kingdom’s Secretary ofState responsible for education, announced proposals for a national curriculumfor the preparation of teachers — prescribing, for the first time in the UnitedKingdom, the skills that all teachers should be taught. It seems timely, therefore,to reflect on exactly what is happening to education in general and nursingeducation in particular in the United Kingdom. The developing climate ofopinion (at least from the politician’s viewpoint, and perhaps the generalpublic’s) is that education should be skills-based — that is, that certain actionsand behaviours should be taught that will produce an end product that is‘marketable’ and competent to carry out certain ‘tasks’. These tasks may bemathematical skills, applying a wound dressing, writing correct English, or anyprecise measurable activity. The philosophical foundation of this approach istwo-fold: (a) with limited resources, it is right to target education towards thevocational needs of an industrial and commercial society improvingcompetitiveness; and (b) that which produces practical end results has moremoral worth than pure academic pursuits, no matter how intrinsically valuablethey may seem to be.

Keywords: education, theory, hands-on-care, ethics, critical thinking

the Royal Aberdeen Hospital Trust said recently that hePROJECT 2000

would like to get nurses out of the classrooms — nursing,in his view, is not academic but practical — suggestingProject 2000 (UKCC 1986) was to set the trend for the next

century, where we had the best of both worlds of academic that instead of producing the knowledgeable, thinkingdoer, we should aim at producing the ‘doer’.and vocational training: the knowledgeable, thinking doer.

This was why nursing students became ‘supernumerary’. Even within nursing a constant refrain is that nursing isbecoming too academic. Nursing, after all, is a practicalThis was why subjects such as sociology, psychology and

ethics were introduced into the curriculum — while still profession. As a nurse teacher, I have had to reflect on thisas some length. Am I a nurse? I trained as a nurse, and Imaintaining ‘nursing’ as the major core subject with its

emphasis on practical skills. spent 20 years in the clinical area but these days, I havelittle contact with patients or clients, and even when I doHas this initial objective been achieved? Nursing stud-

ents may be ‘supernumery’ but they are often still used as it is not to give care.I am registered as a nurse on the UKCC register, but dida pair of hands (which stresses the application aspects).

With the coming of the recent National Health Service my nursing career stop when I left the bedside? If nursingmeans to physically care, that is surely a reasonable con-reforms, trusts have tended towards using less skilled wor-

kers to carry out ‘basic’ nursing care. A senior manager in clusion. Many of my colleagues would be horrified at thethought. However, when we insist that nursing is a practi-cal profession, concerned with direct physical andCorrespondence: Ernest Chapman, Bothwellseat, Gartly, Huntly,

Aberdeenshire, AB54 4RL, Scotland. emotional care of individuals we imply that a nurse

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In praise of ivory towers

teacher is not a nurse. This is true even though the National it would be foolish to do so; but to advance nursing it issurely the radical thinkers and practitioners who shouldBoards for Nursing, Midwifery and Health Visiting insist

that teachers spend time in the clinical area ‘updating’ be heeded. If politicians take over education it will be thedeath blow of creative thought — so it will be when thethemselves; for a week there or a week here is hardly

satisfactory for ‘updating’. health service dictates educational paradigms for nursing.The issue concerns precision in language. I looked at

the word ‘nurse’ and how nurses defined it, and examinedPURPOSE OF NURSING EDUCATION

the rhetoric of nursing organizations. What was beingmaintained was a fiction. University nurse lecturers, nurse There is an obsession, bordering on neurosis, that all

nurses’ teachers do and say should be rooted in practiceteachers and nurse managers are not nurses. How can theybe when they do not nurture client or patient, when they and be relevant to their students. Sometimes nursing edu-

cation has shown a perversity in that it not only insistsrarely make a patient comfortable, or bath a patient, or givean injection? Of course, there is the lecturer/practitioner that what is practised in the classroom be practised on the

hospital wards, but also that all theory must be applicable.role — but pure logistics suggests that not all teachers ofnursing can have this role. Even if it were possible, there This approach ignores much that is good in education. Not

all that we learn is immediately relevant. (I could neverare problems with the tensions involved in the split role.Does the teacher help the patient by supporting, with understand the relevance of Pythagoras’ Theorem, the

English Civil War or the Battle of Bannockburn inknowledge and insight, the nurse who gives the care? Isthis what makes the teacher a nurse? I would argue that it Scotland). Not all theory has immediate practicable appli-

cation. Sometimes the attempt to make all theory appli-does. It is this aspect that is totally ignored by the presentemphasis on vocational skills. Do not misunderstand; if a cable in the classroom trivializes conceptual issues.

Education should be fun, an exercise of the mind, butnurse knows in depth the sociological background of thepatients, or their psychological need for touch, or appreci- we may be in danger of turning it into a learning of practi-

cal skills devoid of all creativity. We talk of the theory–ates the stress they are going through, or their need forhealth education, or the intricate ethical issues in caring practice gap. We consider this a serious problem; and,

when we stop to analyse the deep philosophical questionsbut cannot recognize their need for skin care, elimination,or oral hygiene and be competent in dealing with these involved in the theory–practice gap, we increase our neur-

osis by asking how we might apply this analysis to prac-needs — then the nurse is not much use to anyone, leastof all the patient. tice! It might make more sense to talk of the theory–theory

gap, since the theory in the clinical area does not alwaysIndeed, the nurse may be a positive hinderance to healthand well-being. However, all professions are more than match the theory in the classroom.their mechanics. The product which we call a nurse is atthe end of a long continuum. To see nursing as an academic

The ‘application’ neurosisdiscipline is no less strange than to view medicine or soci-ology or physics as academic disciplines. Each of these is This neurosis concerning ‘application’ may be seen in any

brief reading of the nursing literature. No sentence, italso a practical occupation.It is possible to recognize that one can be a nurse without seems, can be written without a reference: one must dem-

onstrate that one is applying one’s reading to one’s argu-hands-on care. After all, some ward managers and consult-ant physicians and surgeons rarely touch or speak to a ment. This is normally acceptable in an academic work,

but compare the nurse writer with the writer on other sub-patient, but few would doubt their contribution to care.Similarly, the contribution of nurse teachers is vital to jects (for instance, by comparing nursing journals with

medical journals). In well-researched articles there will beexcellence in nursing; yet that contribution may not lie intheir ability to teach clinical skills so much as in their references, but their purposes are di�erent from how they

are used in nursing.ability to facilitate thinking.To despise intellectual pursuits is to do a disservice to In the academic paper references support arguments.

With the nurse the support is for simple words and clearnursing. Without thinkers, philosophers and idealistsnursing will remain in a backwater of academic credibility. statements. Take the following hypothetical example:(Not that we should do it in order to be credible, but in

The elderly, defined as over 65 (Smith 1990), are not a homo-order to advance the art and science of nursing for the

geneous group (Brown 1994) of individuals (Jones 1991 andbetterment of all people.) There is pressure to despise such

Donnaldson 1994).interests.

This was illustrated at a recent meeting I attended where Of course, this is nonsense — and I exaggerate, for thereare many examples of good academic writing by nurses.one nurse teacher said that we must give the health service

what it wants. This is the language of the Philistines. Of Nevertheless, the above example is not uncommon. Anarticle written in this vein, is not only boring — it losescourse, in the real world, we cannot ignore the customer —

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E. Chapman

the reader and insults the intelligence. Yet, in nursing, This is not application as many nurses understand‘application’. It is to a certain extent intangible and intel-such writing may pass as ‘academic’. Not to quote, or not

to reference is, by implication ‘non-academic’. Of course, lectual. What we are witnessing in society and in nursingwith the present stress on the useful and the practical isthere is a di�erence between a research article and a

general piece of work (such as this). an anti-intellectual stance.Knowledge is surely greater than what people research;

it has also to do with intelligent opinion and thought. TheINTELLECTUAL ACTIVITY

intelligent reader can discern that which is questionableor needs evidence to support it. To regard writing that is The word ‘intellectual’ is di�cult to define, but it seems

related to an enjoyment of thinking, debating and the spiritnot peppered by quotes and references as ‘non-academic’is based on an exactitude that illustrates an immature of enquiry. This does not have to be purely esoteric.

Without such debates the practice of nursing would notprecociousness, in my view.The stress on nursing as a purely practical profession exist nor would it change for the better. We arrive at theory

through intellectual debate, challenges, questions, obser-has ramifications for academic acceptance. Nursing edu-cation seems to find it di�cult to think purely in concep- vation, research and thinking. There is therefore a place

in nursing for those who make philosophical enquiry theirtual ways — everything must have an application. This,like the ill-fated Red Flag Act that prevented the develop- sole occupation. As the political climate everywhere

becomes increasingly geared to the needs of industry andment of the car industry, prevents nursing education inthe United Kingdom joining mainstream thinking and commerce in education nursing should recognise, as uni-

versity education once did, that the basic aim of educationcreativity.My own areas of interest are ethics, education and geron- is the quest for knowledge and truth as a justifiable quest

in its own right, regardless of the product. Without suchtology. Gerontology is seen as eminently practical, whilethe others are not. The truth is that gerontology has theor- quests in the past, advances in all aspects of human behav-

iour and endeavour would not have been possible.ies and philosophical foundations that analyse the practi-cal and the social–psychological situation of ageing. These,perhaps, suggest appropriate practice, but they are not

Ethicsthemselves capable of direct application. I cannot, forinstance, apply the disengagement theory of ageing to the No more is the danger to this principle seen more clearly

than in the introduction of ethics into the nursing curricu-elderly woman who has a venous leg ulcer.lum. The stress is on applied ethics. This is a worryingtrend. It is worrying because its approach to ethics is

Theory helpssimplistic. It suggests that ethics somehow can be learntin the same way as learning any other skill. Once, havingMy concern is the care of the patient and the healing of

the leg ulcer. Does that make the theory irrelevant — a learnt it, the application follows.The disease has even spread to universities, so we havematter of pure intellectual interest? No, for even if I dis-

agree with the theory, it has helped me understand, it has departments of applied ethics. I am never quite sure whatis intended by the term. Ethics is the study of morality andhelped me to analyse reasons for the way the patient is,

although it may do little for the leg ulcer. Objectors might an investigation into how people make moral judgements.From this definition (and of course the definition itself isargue: ‘Well, if it does nothing for the leg ulcer — there is

not much point in learning the theory’. At the level of open to challenge) all ethics can do is to describe howmoral judgements are made or arrived at. Ethics cannotphysically caring they are right. However, such an attitude

will return us to the days of ‘training’ when nurses produce a grid (as Seedhouse (1988) does) or a formula (asTschudin (1992) does), suggesting that if you consider a,were mere mechanics (or hand maidens) practising and

acquiring skills that were never questioned. b or c, you can make the correct ethical decision. That isnot to say that some people cannot use these grids or for-In this type of debate medicine itself could be reduced

to a series of practical skills. We could dispense with all mulas to help in ethical decision making. I am merelystating that ethics is more complex than that. There are nomedical theory and knowledge and train automatons,

probably more cheaply than we train doctors. Are all social ethical experts. There are people who know about ethics.To know about ethics is to be aware of the ethical issuestheorists practising social workers, are all medical scien-

tists practising doctors, are all physicists working in indus- and principles involved in each situation. If any appliedskill is brought into play, it is the skill to ask pertinenttry? If theory governs practice, to dispense with it is

ultimately to endanger the patient. In looking at ageing questions, to discover issues and aspects hitherto unsus-pected, to dissect language and meanings.theories I am entering a debate about the nature of growing

old in society which is vital to my understanding of the Of course, Seedhouse (1988) and Tschudin (1992) mayhave been misunderstood. However, most of the books onpatient’s condition and perspective.

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nursing and ethics that have recently flooded the market intertwined with the culture, beliefs and background ofthe nurse and patient than the grids and formulas allow,seem to suggest (with a few notable exceptions) that

nurses are looking for information which they can apply an intellectual rigour of a high order is required. Ethicalstudy informs us of the issues involved and from these weto practice. The fact that Tschudin’s background is in

counselling is significant — for she applies the same draw our own conclusions. Highlighting these issuesenables us to reach decisions, or no decisions at all.approach to ethics. Most counsellors would stress that

their task is not to give advice, but to let the client discover Applied ethics seems a contradiction in terms. Ethics isan exploration of the unknown. It is as exciting as explor-their own solutions. The same holds true of ethics, except

in ethics there are imprecisions and ambiguities that ing deep space. Issues such as accountability, autonomy,infertility, termination of pregnancy and euthanasia areextend far outside most that are encountered in the

counselling situation. serious. They deserve prolonged intellectual questioningand discussion by those who care. If nursing seeks credi-bility as a serious academic discipline then the depth of

Research debateits discussion should go beyond simplistic applications ofethics and attempts should be made to research andI am not a counsellor and I could be wrong. I will try to

illustrate the point by an example. It is commonly held explore in depth the theoretical concepts that impinge onthe major ethical issues confronting nursing.that, when doing research with children, only therapeutic

research is permissible. There is often a debate over what Nursing should take on board many subjects that do notappear to have immediate bedside application, not leastis therapeutic research and what is non-therapeutic. The

debate, however, focuses on the di�erence between the of all, ethical teaching at a higher level in the classroom.two types of research. What is rarely debated is whetherindeed there is any di�erence. There tends to be no dis-

STRESS AND EDUCATIONcussion as to what is actually happening when the terms‘research’ and ‘therapeutic’ are used together. If then It could be argued that stress is created in our nursing

students by introducing them to issues that are outsidethe question arises as to whether a nurse should takepart in research using children, the grid or formula their experience, or by discussing topics when students

have little clinical background. However, we must avoidapproach may simply ask, ‘Is the research therapeutic ornon-therapeutic?’ a paternalistic approach to nursing education. It is not

possible to avoid stress in nursing — dealing with people,If the answer is that it is therapeutic then, other ethicalconsiderations being acceptable, the nurse may well make healthy or otherwise, will always produce stress —

although one ought to try to reduce it. That is why therethe decision to go ahead. Ethics of a more rigorous naturewould insist in going further and asking, for instance, if is a case for moving from the practical to the conceptual.

Obviously one should use examples from life to identifythere is any such thing as beneficial therapeutic researchon children? The whole concept is challenged in the inter- conceptual issues.

Nursing students are not morons, nor do they come toest of the child. This puts the cat among the pigeons as faras ethical decision-making is concerned: simple decision- college with no experience of life (although it may be lim-

ited). There are plenty of ethical issues raised by storiesmaking then becomes a nightmare.in newspapers, films and television news programmes.The media is full of life or death issues — therefore to

Autonomy of the patientdiscuss what is meant, for instance, by personhood, is aconceptual issue where the implications for care can easilyThis arises again when nurses talk about the importance

of the autonomy of the patient. The concept seems fine, be made relevant. Relevancy does not have to be rooted inthe student’s experience. A student need never have seenuntil a more rigorous approach to ethics starts to dissect

the concept of autonomy and its meanings. Are choices a patient, but it will be the unusual student who has nointelligent view on the matter.ever free and how free should they be anyway? Critics of

this approach might point out that really what nursesshould be interested in is practical ethics, not this intellec-

ACADEMIC FREEDOM ANDtual approach. Yet at the heart of education related to

RESPONSIBILITYethics is the critical mind, and without that ethicaldecision making loses its credibility and can be positively In the end are we prepared to fight for subjects that do

not have immediate application? Nurses seriously havedangerous and unethical.This argument is not contending that ethics loses its to ask themselves if they desire intellectual rigour in the

interests of the patient and the profession — in the wayrelevancy for the clinical area, with the nurse left in somesort of ethical limbo, unable to make decisions. It is sug- that academic medicine has often shown itself — or will

they steer clear of it for fear of upsetting the politicallygesting that, because ethical decision-making is far more

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E. Chapman

correct and in order to maintain the sometimes less ardu- knowledgeable theories or conceptual awareness andthought, it might be positively dangerous.ous task of producing what is easier for the service side

to cope with?This opens up a can of worms, not least the concept of

academic freedom, which is sadly lacking in nurse edu-cation. National boards might have to be less prescriptive Referencesin what type of curricula they validate. Colleges of nursing

Seedhouse (1988) Ethics: The Heart of Health Care. John Wileyand midwifery might have to assess theoretical knowledge

& Sons, Chichester.as well (or instead of ) practical application. Critics will Tschudin V. (1992) Ethics in Nursing 2nd edn. Butterworth-talk about ‘ivory towers’ — but the products of ‘ivory Heinemann, Oxford.towers’ seep out and drip down upon the minions below UKCC (1986) Project 2000: A New Preparation for Practice. Uniteddistilling much refreshing dew. Being practical is often Kingdom Central Council for Nursing, Midwifery and Health

Visiting, London.seen as a virtue but, where it is not intertwined with

448 © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 444–448