30th Anniversary Invited Editorial reflecting on: Kitson A. (1999) The relevance of scholarship for nursing research and practice. Journal of Advanced Nursing 29(4), 773–775
In his seminal book, Innovation and Entrepreneurship, Drucker (1985) argued that the only way to sustain business enterprise and wholesale economic benefit to society was to base innovation and entrepreneurship on systematic management principles. Drucker traced the principles of innovation to the 1920s when managers began to talk about ‘new management’ and where collective experiences of managers began to add useful knowledge to the management discourse. New management developed as a practical occupation before coming to be recognized as a discipline in its own right in the 1950s.
Drucker has argued that it was this transformation from a practice into a discipline with an emerging theoretical and conceptual infrastructure that enabled experience to be systematically recorded, analysed and refined. In turn, this became the bedrock upon which new theories of innovation and entrepreneurship would be based. Throughout this process, the first-hand experience of managers remained central to shaping the emerging academic infrastructures. The close relationship between practice and academia meant that the outputs of scholarly activity found their way back into practice. Maintaining this connectivity meant that the value of scholarship was acknowledged and this created a willingness on the part of employers and businesses to invest in academic pursuits. The number, status and influence of the business and management schools in academic institutions around the world are a clear reflection of the success of a relatively young discipline in constructing the necessary infrastructure around it. How did it happen? And is it something that academic and clinical nursing could learn from? Do we need to consider how we could improve our existing academic infrastructures to embrace a more dynamic relationship with the practice of nursing? How could we create a virtuous cycle between scholarship, action and innovation as described by Drucker?
These questions are certainly not rhetorical. Since my guest editorial for JAN on the relevance of scholarship for nursing research and practice (Kitson 1999), I have been challenged to reflect more on the power, politics and policies that hinder progress in the sustained investment and valuing of nursing scholarship. Our problem is not the lack of talented and intellectually able individuals but, instead, the seeming absence of integrated systems and processes in universities and healthcare organizations that enable the ongoing dialogue to take place between nursing innovators in practice and their colleagues in academia. This leads to a loss of good ideas that need to be refined and evaluated in the way described by Drucker.
If we followed Drucker's analysis, sustained investment in nursing scholarship could emulate the transformation that has taken place in business schools, changing management from an atheoretical craft into a scholarly and influential discipline that has direct relevance to practice and is valued by investors. First, we would create strong conceptual and theoretical frameworks for the discipline (and, indeed, many of these already exist). Then we would test out these theoretical frameworks through empirical research, collecting evidence through case studies and other forms of clinical enquiry, and building up this knowledge into tried and tested interventions that improve healthcare outcomes and patient experiences (and, of course, we are doing this with increasing authority and effectiveness). And we would develop national programmes of research that are integrated into the knowledge generation systems of our respective countries (and, again, this is happening, with nursing now leading the way in areas of research into patient experience and coping with illness).
We would then think creatively about how to ensure that this new knowledge is systematically integrated in undergraduate and post-graduate curricula. We would use policy opportunities, such as the Bologna Declaration (http://www.bologna-berlin2003.de/pdf/bologna_declaration.pdf) to ensure that European standards for undergraduate education do not disadvantage nursing students anywhere across the new European Union. We also would ensure that such legal frameworks would become the basis for discussions with other developing health economies when they are ready to take the all-important step of pursuing cost effectiveness by investing in nursing and in nurses as a force for health improvement and as the backbone of a sustainable healthcare system.
At the same time, we need to ensure that clinical champions and entrepreneurs feel supported by their academic colleagues who can offer them new and systematic ways of finding solutions to everyday problems. This very practical value of scholarship needs to be communicated to policy makers, politicians and funders so that more investment in scholarship is made. Marketing such successes is of fundamental importance, as is consistency of message and solidarity within the nursing community. Simple images or symbols that market what we have to offer can be very effective.
Indeed, we might want to create the nursing equivalent of the Masters in Business Administration (MBA). The MBA has become the international kite-mark for all aspiring managers and for organizations wishing to invest in effective management and leadership development. What would be the equivalent to the MBA for nursing on an international stage? Could it be the Masters in Advanced Nursing Practice? Of course we already have many such programmes, but have we reached a point where we need to create an international currency around such programmes so that governments and employers will invest their funding accordingly? If so, it would mean that, in nursing, the equivalents of the Harvard and London Business Schools would be promoted to governments and funding bodies as the passport to more effective healthcare practices and, in particular, to stronger nurse leadership.
The other crucial lesson from our management and business colleagues is their ongoing commitment to ensuring that scholarship informs practice and that scholars sustain relationships with their clients. In the best management schools considerable effort is put into building effective relationships with multinational organizations, government and funding bodies. Management solutions are promoted as pragmatic and cost effective investments. Why would it not be the same for expert nursing teams, working with healthcare providers, policy makers and funders, to solve problems around how we manage chronic disease, for example, and how we establish a minimum data set of nursing care that allows us to judge quality, safety and the appropriate skill mix of nurses caring for patients? How can we ensure that the work around workforce reconfiguration and new roles takes account of demographic changes, the migration of health care out of institutions and into the community, and the skilling up of both service users (our patients) and nurses?
We do now acknowledge that scholarship equips nurses to be better prepared for employment: it furnishes them with the ability to problem solve and make sound decisions, generate new knowledge and protect basic values of health care for individuals and populations. But we need to be much more deliberate in our political lobbying and our influencing of policy makers in the way that we use the evidence of nursing's effectiveness. Why is it that, in the majority of healthcare systems, nursing-led innovations are still more likely to be invisible, or only acknowledged in a roundabout way rather than given primary recognition? An example is the recent publication of an United Kingdom (UK) document about primary healthcare policy (Department of Health 2006) where there was no explicit mention of the significant and innovative roles that nurses are playing in transforming key services. When this was pointed out to the government, the oversight was acknowledged, but why were they blinded in the first place? Was it a question of omission or our own oversight in not ensuring that nursing's contribution was made evident?
If governments, either consciously or unconsciously, ignore a significant group's contribution, what does this communicate about its perceived value and worth? Well, for me, it reminds me that we need to focus on our primary task, which is to improve patient care in the most clinically and cost effective way; build on our scholarship but, importantly, ensure that there is a strong relationship between the innovators in practice and their academic colleagues; and start to lead the agenda by solving problems and offering solutions to the multiple challenges facing our healthcare systems across the world. For the purpose of strengthening our political influence we would do well to establish the Harvard business school equivalent, in the form of elite international programmes for nurses, that would set the standard for innovation and entrepreneurship, thus elevating nursing scholarship and its application in practice to operate in the world of corporate and global politics. Ironically, perhaps, this is the competitive world we have to enter if we want scholarship to make a difference, and if we want to protect the central values of nursing, namely the protection and promotion of person-centred health care, in an era when ‘performance targets’ dominate the political agenda.
So what is nursing scholarship like today? My argument is that we should cease debating whether we need it. Of course we do: strong scholarship is integral to our contribution to patient-centred health care. But what we need now is the political and business acumen to improve and integrate our academic and practice infrastructures to enable nursing scholarship and nursing innovation to flourish. And we could do worse than emulate our business and management colleagues who have shown how to transform a practice discipline into one of the most high profile, prestigious, influential enterprises on an international scale. Nurses and innovators have a lot in common. My challenge is for nursing to work towards demonstrating the same kind of leadership, innovation and entrepreneurial spirit to maintain and grow nursing scholarship, research and practice. Scholarship has never been an end in itself: it is merely one of a set of attributes that comes together to strengthen and enable the honourable discipline of nursing to execute its key role in society.