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 Physiotherapy Theory and Practice

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The theory-practice gap and physiotherapy in the

UK: Insights from the nursing experience

Carolyn Roskell, Alistair Hewison & Stuart Wildman

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practice gap and physiotherapy in the UK: Insights from the nursing experience, Physiotherapy
Theory and Practice, 14:4, 223-233

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 Physialhem@ Thmy andPmclicc (1998) 14,223-233
0 1998 Paychology Press

The theory-practice gap and physiotherapy in the UK:

Insights from the nursing experience

Carolyn Roskell, Alistair Hewison and Stuart Wildman

The existence of a theory-practice gap in physiotherapy has not attracted wide

attention or been the focus of sustained analysis within the profession. This is in
stark contrast to nursing, where consideration of the relationship between theory
Downloaded by [University of Birmingham] at 02:21 23 November 2015

and practice has received extensive coverage. The argument presented here
suggests that it is an appropriate time for an examination of the role of theory and
its relationship to practice in the discipline of physiotherapy and to draw on the
experience in nursing as a basis for this enterprise. The overall contention is that,
if debate and research around these issues is encouraged, subsequent
examinations of the physiotherapy knowledge base may become better informed.

INTRODUCTION professional education and clinical practice, and

The recent publication of the new curriculum
framework document for undergraduate physio-
therapy education by the Chartered Society of
Physiotherapy (1996) in the UK, highlights a
number of issues in contemporary practice. The
document may be viewed as an attempt to recon-
cile areas of conflict which have developed in the
discipline of physiotherapy and have been thrown
into sharp relief by changing demands on the UK
National Health Service (NHS) as awhole. Central
to this conflict is what has been described as the
'theory-practice gap', which can be viewed from a
number of perspectives. These include the diver-
gence of holistic and biomechanical approaches
to therapy, perceived inconsistencies between
C. Rorkell, Department of Physiotherapy,
S. Wildman, Department of Nursing, University of
Birmingham, Edgbaston, Birmingham 815 2lT, UK
A. Hewison, School of Health Sciences, Coventry
University, Priory Street, Coventry CV1 5FB, UK
(Reprint requests to CR)
Accepted forpublication July 1998
the gap between research evidence and the reality
of practice in the clinical setting.
The aim of this paper is to explore the nature of
the theory-practice gap in physiotherapy, an area
that, until recently, has received little attention in
the literature. It is suggested that a theory-practice
gap has always existed but has not attracted a great
deal of interest or formal analysis because the pro-
fession as a whole has not regarded the issue as
problematic. The close relationship of physiother-
apy to medicine has led to a largely reductionist
approach to practice (Parry, 1997) in which con-
cern relating to professional identity and a knowl-
edge base are minimised through a focus on the
individual patient-practitioner relationship and
the physiological basis of practice. However,
changes in health care organisation in the UKand
the professional response to them make this an
appropriate time to evaluate how the physio-
therapeutic knowledge base is developing and
assess what impact the theory-practice gap is
having on this development. Similarly, the whole-
sale relocation of physiotherapy education into
the higher education sector has prompted a more
 224 PHISIOTHERAPY
THEORYAND PRACTICE
evaluative orientation with respect to all facets of
professional affairs. First, however, it is necessary
to c l a m the theory-practice gap to inform subse-
quent examinations of knowledge development.
The terms theoryand practiceare defined to it and its relationship to practice. Argyris and
clarify the interpretation to be used in the discus-
sion. Then, in view of the paucity of relevant p h p
iotherapy literature, the extensivework conducted
in nursing is reviewed and, through a similar
review of physiotherapy literature, comparisons
made which provide evidence of a theory-practice
gap in physiotherapy. Nursing is used as a com-
parator, because although it has close working
links with and similarities to physiotherapy as a
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profession, its response, in terms of the develop
ment of the discipline, is quite different. Although
both professions have been exposed to a changing
organisationaland professional climate in the UK,
nursing has actively explored theory-practice
issues whereas physiotherapy has not. This situa-
tion is of interest, worthy of comment and serves as
a useful starting point for analysis. Finally, the
implicationsof this situation for physiotherapywill
be considered and recommendations made con-
cerning potential courses of action. Health care is
changing and physiotherapy must change with it;
and if the change is to come from within, the
debate must begin. Failure to review the bases of
practice is likely to result in change being imposed
on the profession.
THE NATURE OF THEORY AND
PRACTICE
The relationship between theory and practice has
been of interest to people in a range of disciplines
and professions over a considerable period of
time. The result of this interest would seem to be
somegeneral agreement that theory is necessaryto
describe, explain, control and predict events and
phenomena. There is also a presumption that
theory and practice are linked and that the appli-
cation of theorywill improve and enhance profes-
sional practice. Thompson (1995) maintains there
is a need for theory as it helps to debunk the
commonsense explanations and traditional views
that professionals often adhere to. Theory pro-
vides a framework of ideas and values that guide
and define the nature and direction of practice
(Thompson, 1995).
However, the nature of theory is itself multidi-
mensional and there are different ways of viewing
Sch6n (1974) refer to espoused theory and the-
ory-in-useas a means of conveyingthis complexity.
An espoused theory is one to which someone, or in
this case a profession, pledges allegiance and is
used to explain certain courses of action. On the
other hand, a theory-in-use actually governs peo-
ples actions and may or may not be compatible
with espoused theories. Incongruity and inconsis-
tency between these two types of theory may occur
and the behaviour that a practitioner exhibits may
not correspond to the theories he or she claims to
use. In a similar way, Thompson (1995) refers to
formal and informal theories. Formal theories are
published, form the basis of teaching and are open
to debate, whereas informal theories are based on
practicewisdom developed through experience,
are often covert and not amenable to testing. Con-
sequently, there is an inherent potential for the
development of a gap between theory and
practice.
Acomponent of this incongruityisthe difficulty
practitioners experience in recognising the rele-
vance of espoused theories to professional
practice:
Since students are already anxious about the rele-
vance of their education, they may become even
more anxious when they are exposed to difficultnew
concepts that have little apparent connection to the
problems they believe they will face. They may react
negatively to theory that does not immediately apply
to realityand may therefore partly or totally reject the
new inputs as not relevant to their profession.
(Argyris and Schijn, 1974)
There are also particular difficultieswhen pro-
fessionsdepend on different disciplinesto provide
theoretical input to professional courses. In the
field of education, for example, Hirst (1993)
regards the contribution of the disciplines of phi-
losophy, sociology, psychology and history, which
have traditionally formed the curriculum for
teacher training, as essentiallyproblematic.There
is little agreement among these disciplines con-
cerning what practice should entail, because they
all have different perspectives,ways of interpreting

issues and contrasting priorities in describing and
defining practice. Consequently, it is clear that
this scheme of proceeding from disciplines to
principles to particular activities, simply will not
work (Hirst, 1993).
This problem is exacerbated by the fundamen-
tal differences between academic and practice
contexts (Eraut, 1994). In the academic context,
value is attached to theory in the traditional disci-
plines, activity is dominated by the written word
and characterised by open-mindedness through
the exploration of challenging concepts and theo-
ries. This contrasts with the reality of the
skills-based practice setting where practitioners
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have little time to examine the implications of
theory for practice and the ability to write well is
not a priority. It is an action-oriented environment
where the need is for practical abilities to deal with
real problems and issues from a basis of perceived
certainty.
Schdn (1987) further contends that theory
developed through technical-rational means such
as research is of limited value to professional prac-
tice in disciplines, such as medicine, law and busi-
ness. He uses the metaphors of the high ground
and the swampy lowlands of professional prac-
ticed to illustrate particular dilemmas profession-
als experience as a result of this uneasy
relationship between theory and practice. The
high ground consists of manageable problems that
lend themselves to solutions through the applica-
tion of research-based theory and techniques. The
swampy lowlands, however, consist of messy and
confusing real-life problems which are often
unique to a particular context and fall outside the
category of existing theory. Schdn contends that
the practitioner has a choice, either to stay on the
high ground where he or she can solve relatively
unimportant problems according to prevailing
standards of rigor, or descend to the swampof
important problems and more arduous inquiry
(Schdn, 1987).
If the professions and professional educators
continue to adhere to a model that searches for a
body of professional knowledge that is generated
solely by technical-rational means, then a gap can
occur between the theory and practice of the pro-
fession and also between what is taught to students
and what is carried out in the practice context.
PHBIOTHERAPY THEORYAND PRACTICE 225
This is a situation that has been recognised in areas
as diverse as social work, teacher education, law,
architecture, medicine, management and town
planning (Payne, 1991; Eraut, 1994; Schdn 1983,
1987). However, in the discipline of nursing, this
issue has been a subject of debate for many years.
Consideration of the dominant themes in this dia-
logue will now be presented as a means of identify-
ing related areas of concern in physiotherapy.
THE THEORY-PRACTICE GAP IN
NURSl NG
The term theory-practice gap has become some-
thing of a shorthand expression in nursing to
describe situations where there is a divergence
between what is stated or taught about practice
and what actually occurs. Through its use in the lit-
erature, the meaning of the word theoryhas been
transformed into a catch all designation for edu-
cational, theoretical and research issues which are
perceived to have little relevance to practice. For
example, Hislop et a1 (1996) carried out a study
into theory and practice in nurse education and
used theory as a summary term for the college
course of the students involved in the research.
However, this is only one element of the gap and
the multifaceted nature of the problem is per-
haps best summarised as a series of contrary pair-
ings of the key issues, which are: educational
theory and practice; clinical theory and practice;
research theory and practice; professional opera-
tional theory and management practice (Table 1).
It is recognised that placing these elements in
opposition is a crude analytical device which does
not fully convey the complex nature of the p r o b
lem, and that a more accurate characterisation
may be to regard each pair of factors as extremes
on interlocking and overlapping continua. Never-
theless, the notion of contrary pairings is a useful
framework which can be used to structure the dis-
cussion and highlight the way the theory-practice
gap has been portrayed.
Educational theory and practice
The basic premise underlying the education and
practice of the gap is that the separation of nurse
 226 PHBIOTHERAPYTHEORYANDPRACTICE

Table 1
Elements of the theory-prectice gap
Element
(exDressed as a series of continua)
Educational theory and practice
Clinical theory and practice
Research theory and practice
Professional operational theory
and management practice
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Form
Knowledge generated in educational institutions bearing little
relationship to the reality of practice experienced by practitioners
The theory of the discipline being derived increasingly from the social
sciences and the work of influentialleaders and academics
The care delivered in clinical areas that does not conform to principles
of intervention derived from research. Ritual and tradition as a basis
for practice
Fundamental divergence of views arising from conflicting professional
and manaaerial DersDectives of contemporary service deliverv

training from the delivery of the service has entrepreneurs (Porter, 1995), the concepts of
resulted in a situation where knowledge generated humanism and reflection have become key com-
has little relevance for the realities of practice. In ponents in the nursing curriculum. The short-
the past, this occurred partly because of the physi- hand term that now seems to be used to describe
cal distance between education and practice, this blend of concepts is the New Nursing (Sal-
where educational institutions and the hospi- vage, 1990), wherein the nurses role changes
tals/communities they serve are often geographi- from one of dependence upon the doctor to one
cally distant (Colleen-Stainton, Rankin and of greater autonomy in clinical decision making,
Calkin, 1989), and partly because teachers too working in partnership with the patient. This also
often deliver content in the classroom which is requires a broader knowledge base, which, being
unrelated to practice (Jolley, 1987). This was also derived largely from the social sciences, has fur-
the view of Vaughan (1987), who maintained that, ther potential for introducing students to material
while practice and teaching remain separate in that is difficult to apply directly in the work setting.
nursing, students will experience a disparity In developing an approach to practice which
between theory and practice. In a later study, derives not from experience but from abstract
McCaugherty (1991) suggested theory consisted research, socio/psychological theories about the
of books, nursing curricula and what is taught in nature of man and philosophical discourses about
the classroom. He found that student nurses felt the definition of health and health care, the
these media conveyed an imperfect representa- formal knowledge base of nursing has moved away
tion of practice which made integration of theory from the concrete realities of practice (Procter
and practice difficult. He also commented: To and Reed, 1993). Nurses are also expected to take
move from the generalities of lectures to the spe- responsibility for their own learning and actively
cifics of patient care can require a leap across the reflect on and learn from their practice (UKCC,
theory-practice gap (McCaugherty, 1991).This is 1994). Consequently, leading practitioners and
indicative of one theme in the literature, which academics have re-shaped the academic basis of
suggests that disparities between what is taught nursing and new dilemmas concerning the
and what goes on in the reality of practice consti- theory-practice gap have emerged.
tutes a theory-practice gap.
Research theory and practice
Clinical theory and practice In terms of the discrepancies between what
This situation has been compounded by the i n t r e research evidence demonstrates and what actually
duction of new areas of study to the nursing curric- occurs in practice, it could be argued that this
ulum. Influenced by the work of nursing manifestation of the theory-practice divide has a
 PHBIOTHERAPY THEORYAND P R A ~ I C E 227

long history. Walsh and Ford (1989) examined principles and been replaced by a hate culture
some of the fundamental areas in which the prac- which is antipathetic to the values of nursing. Simi-
tice of nursing bears little resemblance to the rec- larly,Antrobus contends that there is a fundamen-
ommendations arising from research and tal clash between current managerial and nursing
suggested that what practitioners do is dominated approaches to the organisation of patient care:
by ritualand habit.More recently, the dissemi- Adopting an approach which involves measure-
nation of research findings to influence practice ment and tests using a reductionist, quantitative
was identified as an issue requiring more collabo- aspect does not fit with a contemporary ideology
rative work between researchers and practitioners for nursing practice within a humanistic aesthetic
ifprogress is to be made (Dickson,1996). Itwould framework (Antrobus, 1997).
seem that a practice lag in nursing remains, This brief review of the main components of the
whereby the reality of clinical care is not always theory-practice gap in nursing is by no means
based on the most recent evidence.The increasing exhaustive; rather, it is intended to serve as a refer-
demand for evidence-based care (Dunning, 1996) ence point in the discussion to follow, which con-
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is stimulating discussion of the nature of practice siders the current state of physiotherapy. Indeed,
and this trend is also likely to focus greater atten- there are many detailed analyses of this phenome-
tion on the theory-practice gap. non in nursing (for example, see Fealy, 1997;
Carter, 1996;Rafferty,Allcock and Lathlean, 1996;
Cook, 1991; McCaugherty, 1991; Antrobus, 1993;
Professional operational theory
Reed and Procter, 1993; Nolan and Grant, 1994).
and management practice
The suggestion here is that these issues are of rele-
Recent events and changes in the organisation of vance to physiotherapy and, through the process
health care have introduced another set of ten- of identifjmg them, an opportunity is created to
sions which may perpetuate the theory-practice understand more about the current state of the
problem. A more subtle yet perhaps more perva- discipline.
sive separation, namely the contrast between the
values of nurse education and those of the new
managerialism,is evident in the reformed NHS in THE THEORY-PRACTICE GAP AND
the UK. The values underpinning much of con-
PHYSIOTHERAPY
temporary nursing education are rooted in con-
cepts of humanism, holism and adult education, In contrast to the high level of interest in the
whereas the contemporary organisation and deliv- theory-practice gap in nursing, there is little p h p
ery of care has, of late, been based on management iotherapy literature on the subject. Relevant issues
principles, derived to a large extent from a superfi- regarding the phenomenon are raised in a variety
cial interpretation and application of manage- of articles, but there is a shortage of papers dedi-
ment theory, which gives undue emphasis to cated solely to the examination of this important
measurement and quantification (Pollitt, 1993). area. Interestingly, however, the physiotherapy lit-
The reality of the environment in which nurses are erature that exists reveals a theory-practice gap
expected to practise is one oriented to through- evident in the areas described in Table 1.
put, numerical targets and financial constraints,
whereas as learners they are exhorted to treat
Physiotherapy educational theory
patients as individuals, implement nursing theory
and advance their own learning. The result of this
and practice
set of circumstancesis that the theory-practice gap The movement of physiotherapy education into
has taken on a new guise (Hewison and Wildman, higher education led to concerns that a reduction
1996). Wilkinson (1995) and Antrobus (1997) in the practical skill component would occur with
have been particularly outspoken in this respect. a corresponding increase in academic content.
Wilkinson (1995) believes that current practices Potts (1996) maintains that these fears have not
within the NHS have moved away from its guiding been realised. However, at a recent meeting of
 228 PHSIOTHERAPYTHEORYAND PRACTICE
clinically based and university-based educators of
the Association of Chartered Physiotherapists in
Respiratory Care (September 1996), the prevail-
ing view was that skill levels had decreased among
students and newly qualified graduates. A theory-
practice gap is evident when fitness for purpose,
as perceived by clinicians, is not observed in learn-
ers entering the clinical setting.
Another contributory factor is that the tradi-
tional organisation of physiotherapy education
has delivered course content in compartmental-
ised subject domains which limit the ability of
learners to integrate information from different
sources, thereby reinforcing the theory-practice
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gap (Richardson, 1992). Richardson states that
even the introduction of problem-solvingmethods
of teaching and learning cannot recreate the com-
plexity presented to the learner in real-lifeclini-
cal situations:
It would seem of paramount importance to buildup a
profile of physiotherapy practice today and to try to based in a classroom using normal subjects is also
explore any discrepancy which may exist between the subject to the same limitations. Reduction of this
kinds of knowledge credited in the schools of physio-
therapy and the kinds of competence which are val-
ued currently in professional practice. (Richardson, appropriate context-specific experience - that is,
1992)
The presence of physiotherapy in higher edu-
cation has also led to an expansion in postgraduate
opportunities. However, concern has also been
expressed that this provision may not meet the
needs of practice: Academics offering higher
degrees should address the issue of pursuing phys-
iotherapy excellence in practice as well as pushing
back the frontiers of knowledge (Thomson,
1994). However, the geographical distance
between educational institutions and the clinical
context have reduced the opportunities for uni-
versity-based s t a f to have contact time with
patients. A theory-practice gap exists for the edu-
cators who may see a refinement of their educa-
tional and knowledge-based skills at the cost of
degradation of their previously well-honed clinical
skills. This was recognised by Lane (1992), who
stated that skills need to be taught well by experts,
and therefore lecturers need to maintain clinical
contacts and develop their clinical expertise. The
recruitment of lecturer/practitioners and the
involvement of specialised external speakers may
go some way to reducing this effect, but until these
types of approaches are fully evaluated, such
claims cannot be made with any certainty.
The education process may promote a theory-
practice gap by selecting simpler ways of communi-
cating difficult ideas; however, these may become
so far removed from the real world that they
cease to provide a useful basis for practice. For
example, Hollenberys concept of physiothera-
peutic intervention illustrates this point:
Its easy to teach physiotherapy as an academic sub-
ject whereby in response to a given set of symptoms,
there is a set response to treatment. It is much harder
to teach physiotherapyas treatmentwhich is sensitive
and responsive, which changes appropriately to the
patient and not to a predetermined set of rules
which apply to each specific condition. (Hollenbery,
1994)
This highlights the limits of textbook cases, which
are often simplistic representations of complex
real-world phenomena. Practical experience
component of the theory-practice gap requires
suMicient quantities of clinical practice.
Physiotherapy clinical theory and
practice
The establishment of physiotherapy departments
in universities has been accompanied by an
increased interest and involvement in research
and scholarly activity. This is indeed timely, as the
drive towards evidence-based practice has
assumed a high profile. However, the theoretical
base on which clinical physiotherapists can draw to
support their practice is lacking. Parry (1992) con-
tends that, Much of what physiotherapists do is
passed on by tradition, guesswork and faith.
Others have expressed similar concerns regarding
the lack of established theory (Tyni-LennC, 1989;
Bell, 1994; Richardson, 1993; Krebs and Harris,
1990; Robertson, 1995a), and Roberts has noted
that physiotherapy should stop borrowing others
theory and create its own:
A profession which is attempting to define its own
knowledge base without an examination of the fun-
damental beliefs which underpin it is bound to be
 PHYSIOTHERAPYTHEORYANDPRACTICE 229

confused...[leading to] ...conflicts and tensions in to be fulfilling expectations. Ellis (1996) states:
practice, management, education and research. Currently much postgraduate work is laboratory
(Roberts, 1994)
focused. Robertson (199513) surveyed the journal
A theory-practice gap is very clear here. How can Physical Therapy and discovered that a large
practice be informed by theory that does not exist? number of studies utilised group designs, most
Given this deficit, it is little wonder cliniciansadopt commonly with normal subjects, despite evi-
custom and practice as a rationale for their own dence demonstrating the weakness of this
interventions. However, it is possible that this approach in providing generalisable results to
approach may lead to incorrect hypotheses being practice (Parry, 1991; Grieve, 1993). Physiothera-
formed and, as a consequence, the perpetuation pists appear to be choosing this method in prefer-
of less than optimal practices (Sim, 1995). ence to others. A trend was also observed towards
the study of topics not directly related to clinical
efficacy and, in response to this, Robertson
Physiotherapy research theory and (1995b) called for more research that is clinically
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driven.
practice
Some authors have suggested that research has
Another element in this dimension of the not informed clinical practice in more significant
theory-practice gap is the pressure on university ways because it fails to acknowledge the private
staff to pursue scholarly activity and contribute to knowledge (Robertson, 1996) and tacit skills
the body of knowledge arising largely from the (Richardson, 1993) which characterise expert
Research Assessment Exercise (RAE) in the UK. practice. These elements of intuitive practice are
The outcome of this exercise is used as a criterion difficult to verbalise to others and stimulating
for the allocation of research funds to universities. debate in these areas is vital if coherent research
Merely increasing the output of physiotherapy questions and appropriate methodologies are to
research is not in itself sufficient, as findings may be forthcoming.
actually contribute to the theory-practice gap if
they arise from poorly constructed studies and are
read uncritically by practitioners. Grieve (1993)
ProfessionaI operationa I theory
cautions that research with fundamentallyflawed
and management practice
methodology is being used to condemn practices A more recent factor in the divergence of theory
unjustifiably and to make false claims. and practice in physiotherapy is the widespread
Problems even exist with the limited amount of market-based reforms of the public sector in the
theory that is available. The UKChartered Society UK. The reshaped NHS, with its recent drive
of Physiotherapy Research Development Group towards promoting evidence-based practice,
(1996a) concluded, The problems of translating demands high-level technical skills and supporting
research into practice are well known; and the evidence for their use; in other words, evidence
Physiotherapy Research Society also acknowl- predicated on a technical-rationalmodel of knowl-
edged this problem at its recent meeting entitled edge. Physiotherapy curricula, in common with
From Theory to Practice - Bridging the Gap nursing, suffer from overload in terms of content,
(November 1996).Itwas noted that research capa- much ofwhich is from diverse disciplines. This puts
ble of informing practice was not being used by pressure on the time spent developing high levels
physiotherapists in the clinical setting. The UK of skill and, as a consequence, graduates ability to
Chartered Society of Physiotherapy Research provide what managers demand is reduced: If we
Development Group (1996b) concluded that do not produce graduates with the practical skills
increases in workload and productivity were ham- which are required, we can rest assured that some-
pering the utilisation of research in practice. one else will take over the job for us (Lane, 1992).
Given the calls for the development of physiu- This element of the theory-practice gap has the
therapy theory, it is surprising that the type of potential to enable managers, sceptical of the
research that has been undertaken does not seem claims of the efficacy of physiotherapy, to take
 230 PH~OTHERAPY
THEORYANDPRACTICE

unilateral decisions regarding service provision,
because the supporting evidence, in the form of
results from randomised controlled clinical trials,
is not available (Allison, 1996).
Future physiotherapy service provision, there-
fore, is under threat from a narrow perception of
what constitutes admissibleevidence in the new
health care environment.
DISCUSSION
The basic premise of this paper is that a
theory-practice gap exists in physiotherapy. In
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pendulum may swing the other way. Criticism of
teacher education in the 1980s centred on a belief
among politicians and others that it was too aca-
demicand did not prepare teachers adequately to
deliver real education. This led to pressure on
training/educational institutions to make teacher
education more practice-based. Will nursing and
physiotherapy suffer the same fate? Will courses
eventuallybe returned to the practice sector?Phys-
iotherapy must learn from nursing to the extent
that, although the issue of the theory-practice gap
has been extensively examined in the literature,
this seems to have had little influence in shaping
future educational developments.

making this explicit, it is not our aim to create

more anxiety and dissonance for practitioners; Research as the vehicle for closing
rather, it is to stimulate a debate to enhance devel- the theory-practice gap
opment of the discipline.The dilemmasand issues
discussed also hold the key to how the problems It is also apparent that there is little point generat-
identified can be resolved. Three fundamental ing evidence that is not going to be used. Dissemi-
questions seem to emerge: nation of findings and feeding them into powerful
institutions which are able to invoke change
0 What has nursing learned from its preoccupa- appear currently to be areas of major weakness for
tion with the issue? nursing and physiotherapy in the UK.
0 Is this debate necessary for the discipline of The preoccupation in nursing with the
physiotherapy? theory-practice gap has been accompanied by
0 Are there insights to be gleaned from the work strenuous efforts to generate a distinct body of
undertaken in nursing? theory, including the development of numerous
models of nursing. Physiotherapy has not fol-
lowed this course and, it has been argued, has an
A similar experience? impoverished theoretical base, lacking in models.
Comparisons between nursing and physiotherapy Roberts (1994) states: A gap in physiotherapists
reveal some interesting points. Both disciplines understanding of theoretical models is matched
have recently seen a move of its educational struc- by a gap in the professions understanding of its
ture into institutions of higher education and the own theoretical knowledge base. It is evident that
links with the workplace have been weakened. this lack of attention to theory is limiting the gen-
Also, students now have supernumerarystatus and eration of a coherent and rigorous knowledge
are no longer regarded as workers.As courses base which may inform more specific aspects of
have become more academic, the university-based patient care. For clinicians to be able to provide
tutors have become less practice-focusedand, con- evidence-based practice, research, education and
sequently, they may generate research questions practice need to be considered as complementary
that lack a clear practice orientation. This could components of one overarching entity, offering a
result in the expanding body of knowledge having seamless perspective on physiotherapy practice.
little to offer the practitioner. Nursing seems to The importance of this process is emphasised by
have identified this problem much sooner than Sackley (1994):Physiotherapistsare guardians of
physiotherapybut appears to have had little influ- a body of knowledge;it is fundamental to the exis-
ence in overturning the educational structure tence of the profession.
which is perpetuating the problem. Comparison Nurses have built their academic tradition on a
with the teaching profession shows how the variety of bases drawn from the social sciences.
 PHSIOTHERAPY THEORYAND PRACTICE 231

Physiotherapists, by contrast, have traditionally The policy process

adopted the biomedical model of investigation and
All of this suggests that both disciplines need to
have utilised basic scientific method. Examination
engage with the policy process in a more active
of the physiotherapeuticbody of evidence demon-
way. Although there are competing definitions
strates an incompleteness generated by a reliance
surrounding health policy (Ham, 1992), it is per-
on positivist approaches. Physiotherapistsare corn-
haps most usefully regarded as a cyclicalprocess in
ing to this via observationsof a theory-practice gap
which government statements of interest can be
and therefore the experience of nursing as a disci-
identified as starting points but that policies are
pline should be looked to and lessons learned. This
often adapted and distorted by interpretations,
is not to suggest that nursing has produced a neat
actions or inertia of lower-level actors (Allsop,
package of solutions;this is far from the case. How-
1995). If nursing and physiotherapycan intervene
ever, a thorough examination of the issues has cer-
and exert influence at these lower levels, some of
tainly occurred and those wishing to pursue these
the problems arising from the theory-practice gap
matters in physiotherapy could save a great deal of
may be offset.Antrobus and Brown (1997) feel this
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time by consulting this body of literature as a start-

ing point. The reason for characterisingthe theory-
practice gap as a series of opposites (Table 1) was to
highlight the different dimensions in a way that
could also act as a stimulusfor empirical study. Each
of the continua could serve as a starting point for
developing important research questions of value
to the profession. This would help offset the con-
duct of detailed but often esoteric work of ques
tionable relevance to the profession as a whole.
The intended outcome of this process, which will
take many years, is to reduce the gap between
theory and practice through the production of a
distinct and appropriate body of knowledge. Only
then can appropriate methods of dissemination of
this knowledge occur by undergraduate and con-
tinuous professional development routes. A
framework for this will include evidence-based
practice, facilitated by evidence-based education
and developed by evidence-based research.
There is a possibility that professional work
could become increasingly fragmented and
redistributed in the narrow pursuit of cost reduc-
tion and flexibility. Addressing the issues raised
through this brief review of the theory-practice
gap will also provide evidence that will effectively
challenge this short-sighted approach to the
organisation of patient care. Work in Nursing
Development Units, designed to study the contri-
bution nursing can make to patient care (Pearson,
Punton and Durant, 1992), has clearly demon-
strated that professionally led care is both of high
quality and cost-effective.It is vital that physiother-
apy marshals a similar body of evidence to support
its practice.
is essential and comment that, A new language is
therefore required which does not lose nursings
essentialvalue system,yet fits the context of power,
politics, targets and indicators, as part of a scien-
tific objective approach to health care.
This is one means of trying to influence policy
and ensure nursings voice is heard. Robinson
(1991) and Cox (1993) also believe that active
involvement in the policy process is necessary, but
that it must be imbuedwith professionalethics and
a compassionate concern for the best interests of
patients. This is more likely to be achieved if the
sound research base noted earlier is available,
which brings the argument full circle. Ifresearch is
undertaken which closes the theory-practice gap,
in both nursing and physiotherapy,the probability
is that it will also be instrumental in having a posi-
tive influence on the policy process, ultimately
improving patient care.
CONCLUSION
This paper has examined the phenomenon of the
theory-practice gap, focusing on its manifesta-
tions in nursing and physiotherapy. As
physiotherapeutic theoretical bases are still evolv-
ing, clinicians are currently unable to offer ade-
quate evidence-basedjustification of practice. It is
proposed, therefore, that physiotherapistsshould
examine the theory-practice gap more thor-
oughly to inform the direction of hrther research
and contribute to the developing body of
physiotherapeutic knowledge.The first step in this
process is to engage with the debate; once this
 232 AND PRACTICE
PHYSIOTHERAPYTHEORY
debate has been joined, a reduction of certain neg-
ative aspects of the theory-practice gap becomes a
realistic prospect. Consideration of the positive
effects of the gap, namely those of stimulating
questions driven by movement on either side of
the gap, as has been examined in nursing, is also
an issue worthy of further exploration. This is nec-
essary to subsequently generate those specific
questions which will make the research thrust of
the profession germane to its continued growth
and development. It is envisaged that encouraging
debate surrounding the theory-practice gap in
physiotherapy will produce a framework which
can ensure that professional growth and develop
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ment proceeds on both sides of the gap
symbiotically.
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