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Recontextualising professionalknowledge – newly qualified nurses andphysiciansJens‐Christian Smeby a & André Vågan a

a Oslo University College , Oslo, NorwayPublished online: 22 May 2008.

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Journal of Education and WorkVol. 21, No. 2, April 2008, 159–173

ISSN 1363-9080 print/ISSN 1469-9435 online© 2008 Taylor & FrancisDOI: 10.1080/13639080802018014http://www.informaworld.com

Recontextualising professional knowledge – newly qualified nursesand physicians1

Jens-Christian Smeby* and André Vågan

Oslo University College, Oslo, NorwayTaylor and FrancisCJEW_A_301967.sgm(Received 5 June 2007; final version received 30 January 2008)10.1080/13639080802018014Journal of Education and Work1363-9080 (print)/1469-9435 (online)Original Article2008Taylor & Francis2120000002008Jens-ChristianSmebyJens-Christian.Smeby@hio.no

This article examines the discrepancy between newly qualified nurses’ and physicians’assessment of acquired knowledge in education and their assessment of the knowledge demandsin occupational practice. Knowledge learned in educational institutions is traditionallyconceived as general and decontextualised with great potential for transmission transcendingdifferent contexts and situations. The gaps between knowledge learned in higher education andknowledge demands in professional practice are, however, not merely a failure in the deliveryof knowledge. It is argued that the concept of ‘boundary-crossing’ is an appropriate way ofreconceptualising the theory–practice gaps because it focuses on the challenges as well asconstructive processes graduates face in their first years in professional work. The empiricalmaterial is based upon questionnaires handed in by students in their final semester 2001 andthree years after graduation in 2004.

Keywords: boundary-crossing; theory–practice gap; newly qualified professionals; nursesand physicians

Introduction

Even though higher educational programmes are considered essential characteristics of profes-sional occupational groups (Freidson 2001), higher education is accused of being too academicand lacking relevance for professional practice. Research has documented reality stress,perceived knowledge lack and perceived lack of relevance and/or difficulties of translatingprofessional competence acquired in professional education into occupational practice amongnewly qualified professionals (Eraut 1994; Gerrish 2000; Hem 2002; Prince et al. 2005).

How to equip professionals with the sufficient and relevant forms of knowledge is achallenge theoretically as well as in practice. The central question is how to emphasise andorganise theory- and practice-based qualifications within professional education to bridge therecurrent theme of theory–practice gaps between education and work. Is the problem mainly thatknowledge emphasised in professional educational programmes lacks relevance for professionalpractice? Is the problem that the relationship between theory and practice is not emphasised oris the issue that the step from ‘knowing that’ and ‘knowing how’ (Ryle 1949) is a nexus first andforemost developed after years in professional work? From a situated perspective (Lave andWenger 1991; Wenger 1998) the traditional cognitive assumption that knowledge learned in thecontext of education simply can be transferred to the context of work is challenged. Thishowever, does not mean that the education has no qualifying function. The concept of ‘bound-ary-crossing’ (Engeström 2001; Guile and Young 2003) and ‘recontextualisation’ (van Oers

*Corresponding author. Email: jens-christian.smeby@hio.no.

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1998) may be appropriate to understand the challenges as well as constructive processes gradu-ates face when they, in their first years in professional work, have moved across boundaries intime and space (Saunders 2006).

The present article focuses on two professional groups: newly qualified physicians andnurses. There are significant similarities between the occupational practices of nurses and physi-cians: their general obligation is to treat patients for various types of diseases within the sameinstitutional contexts. We do not claim that their tasks are identical; there is a rather well-definedhierarchy and division of labour between these groups based on their respective professionalknowledge base. Nevertheless, compared to other professional groups, their tasks, professionalchallenges, ethical dilemmas as well as knowledge bases have many of the same characteristics.

According to the perspectives of the sociology of professions, higher education is meant totrain professionals into a specific knowledge base and to socialise them into a professionalcommunity with a certain ethical codex. The educational programmes qualifying for nursingand medical practice are, however, very different. Medicine was established as a professionaleducation already within the first medieval universities. Its breakthrough as a modernacademic discipline first took place during the nineteenth century when scientific knowledgebegan to have a decisive influence on the profession and its medical practice: clinical researchstarted using scientific methods in investigating symptoms and underlying causal mechanismsbehind disease. The well-established scientific knowledge base is one of the reasons whymedicine has been considered as an ideal type in the sociology of professions and is a constitu-tive bulk in its professional education (Abbott 1988; Freidson 2001; Parsons 1968). Althoughcontinuous reforms to an increasing degree emphasise earlier clinical and more practical andrelational knowledge in the six-year-long professional education, medical education has manyof the same characteristics as other pure academic university programmes (Pauli, White, andMcWinney 2000).

Nursing education has a different origin. The establishment of nursing education from themid nineteenth century was greatly related to the development of modern medical practice; thephysicians needed professional assistance in their work. Three-year educational programmeswere established in the beginning of the last century. Physicians were responsible for thetheoretical part of the programmes and gave lectures in anatomy and physiology, while thepractical–technical part was the responsibility of a senior nursing officer. Nursing education hasbeen upgraded to higher education and nurses are to a great extent also responsible for theoreti-cal parts of the programmes (Fause and Micaelsen 2002). However, three and half years of thecurriculum still consists of practice in hospitals and other medical institutions.

This article examines different knowledge demands of newly qualified nurses and physiciansand the extent to which the professionals report to have acquired these during their initial educa-tion. Several categories have been developed to differentiate between types of knowledge (e.g.Becher and Trowler 2001; Bennett, Dunne, and Carré 1999; Eraut 1994; Squires 2005; Stark andLattuca 1996). As emphasised by Eraut (1994), and not becoming embroiled in definitionalissues, it may be appropriate to use the term ‘knowledge’ to address all aspects of knowledgeand skills relevant to professional work. Moreover, the question could be raised of the extent towhich different types of knowledge may be distinguished as separate and independent forms. Toavoid a narrow understanding of knowledge, it is nevertheless useful to distinguish betweendifferent aspects. To address the theory–practice gaps we distinguish between three aspectswhich are central in nursing and medical practice: codified, practical and relational knowledge.

While previous studies on nurses and physicians tended to focus on only one of these profes-sional groups, the present article stresses a comparative perspective. Comparisons of newlyqualified nurses and physicians facilitates examination of the extent to which curriculumcharacteristics as proportion of practice reduce the discrepancies between what is acquired in

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higher education and what is required in occupational practice, as well as indicating what typesor aspects of knowledge are best learned in higher education and what is best learned in occupa-tional practice. We do not claim that there should not be discrepancies between knowledgelearned in higher education and requirements in professional practice. However, it is reasonableto assume that nurses as well as physicians find the boundary-crossing from education to workchallenging and that such recontextualisation is experienced as a knowledge gap. Given theacademic characteristics of the medical curriculum we hypothesised that the challenges facingnewly qualified physicians are to a greater extent related to practical aspects of professionalknowledge, while newly qualified nurses who have gone through a much shorter and morepractical educational programme are more challenged when it comes to the codified aspects oftheir acquired professional knowledge.

Theory–practice gaps in nursing and medicine

Several studies of nursing and medical education have focused on the relation between theoret-ical and practical parts of education and the suggestions for improvement are many. It is reportedthat newly qualified nurses lack practical knowledge (Carlisle et al. 1999; Havn and Vedi 1997)and that they are inadequately prepared and ineffectually oriented to an oppressive workplaceculture (Duchscher and Cowin 2004). Moreover, it is claimed that they feel incompetentconcerning numerous aspects of knowledge (Alvsvåg and Førland 2004) and that nursingstudents gain an unclear conception of nursing as a subject, and whether nursing constitutes adiscipline on its own (Granum 2004).

To address theory–practice gaps in nursing, it is argued that theoretical themes must be madenear to experience and be integrated in reflection over practice (Field 2004), that practical andtheoretical learning potentials in particular practical situations should be emphasised to a greaterextent (Kyrkjebø, Mekki, and Hanestad 2002) and that a closer sequence of theory and practiceshould be developed (Corlett 2000). Others have suggested that nurse teachers’ practical skillsshould be increased, and that teachers should participate in students’ clinical practice to help thestudents to see relevant connections between classroom theory and practice (Gillespie andMcFetridge 2006; Landers 2000; Ramage 2002).

Studies on newly qualified physicians entering clinical practice also show how they experi-ence a repertoire of shortcomings in knowledge, skills and general competencies (Prince et al.2005). They complain about difficulties in performing what is required of them both whenit comes to using codified knowledge, like specialist knowledge (Busari, Scherpbier, and Bush-uizen 1996; Burke et al. 1999), and practical knowledge, including various practical procedures(Prince et al. 2004). These competencies are inadequately obtained in professional education.The implementation of problem-based learning in medical education over the past 30 years maybe seen as a response to the increased dissatisfaction with ‘traditional’ curriculum that createdartificial divides between theory and practice. The aim of problem-based medical curricula is toprovide relevant learning contexts (realistic clinical problems) to foster problem-solving skillsand knowledge of basic and clinical sciences as well as skills for life-long learning. Reviewsindicate that the results are persuasive when it comes to issues such as student satisfaction,stimulating learning environment as well as interpersonal skills (Hill et al. 1998; Johnson andFinucane 2000). Nevertheless, findings concerning the relation between theoretical and practicalknowledge like retention of knowledge applied to clinical situations, the development of clinicalreasoning and skills in problems solving and improvement in learning motivation are conflictingand weak (Gaarder, Eide, and Falck 2000).

To summarise, the theory–practice gaps are widely referred to in the literature. The reasonscited for its existence, as well as initiatives to bridge the divide, are many. It is also pointed out

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that classroom theory can never resemble real situations (Landers 2000) and that the fact thateducation and work are significantly different learning contexts sheds light upon the theory–practice gaps (Gerrish 2000; Gillespie and McFetridge 2006). Moreover, the gaps may also beviewed positively as a means of developing students’ problems-solving skills (Corlett 2000).

Theoretical perspectives on learning

The interpretation of theory–practice gaps in professional education depends heavily on thetheoretical understanding of learning (Greeno, Collins, and Resnick 1996; Tuomi-Gröhn andEngeström 2003). In learning research it is often distinguished between a standard or individualcognitive perspective and a social situated perspective (Cobb and Bowers 1999; Hager 2004;Sfard 1998). Learning seen through a strictly cognitive lens emphasises the actors’ cognitiveabilities in thinking, problem solving and interpretation. A critical subject in this regard is thelearners’ ability to transfer what is internalised in one situation into another given the presuppo-sition of inner motivation and self-directed activity towards the issues at hand. The standardeducational discourses frame the perceived gaps of knowledge gained in education in terms oflack of relevance of educational programme or structure, insufficient engagement in schoolwork, lack of motivation or failure in obtaining and storing the knowledge supposed to belearned.

In a social situated perspective (Lave and Wenger 1991; Wenger 1998) the analytical unit isin social systems and the actors’ participation in social practice. In this perspective, learningtakes place as a process of socialisation that involves the learners’ steadily increasing parti-cipation in social practices. The focus is not on individual cognitive abilities and processes,on ‘learning as acquisition’, but on relations, interaction and communications between actors, on‘learning as participation’ (Felstead et al. 2005). The crucial point is that learning and profes-sional qualification cannot be understood without reference to the context in which they actwithin. Students in higher education and workers in workplaces are, in other words, participatorsin different communities of practice. A good example of this point is given in Laves’ (1988)analysis of school mathematics. Because mathematical activities in the classroom are organisedand structured differently than in everyday, maths pupils are often unable to transfer mathe-matical knowledge to ‘real-life’ situations.

Recent theoretical debates have attempted to transcend the strictly cognitive and situatedpositions arguing that situated analysis neither sheds light on how individual understandingsare generalised beyond the specificity of their originating context, nor on how previous under-standings are brought into play in new situations (Carraher and Schliemann 2002; Cobb andBowers 1999; Eraut 2000; Sfard 1998; Tynjälä, Välimaa, and Sarja 2003). The concept ofboundary-crossing (Engeström 2001; Tuomi-Gröhn and Engeström 2003) may be a way toovercome the limitations in both these perspectives. When students develop and enter the roleof professional practitioner the ‘stuff’ of learning activity in higher education become ‘mediat-ing means’ at work (Le Maistsre and Paré 2004) and requires new learning where knowledgeundergoes various forms of transformation (Daley 2001). Knowledge has to be recontextual-ised. van Oers (1998) distinguishes between recontextualisation in a horizontal and a verticalsense. Horizontal recontextualisation takes places when one is doing something familiar in anew setting, for example when students been trained in giving injections on oranges and thenfor the first time are going to give injections on human beings. Recontexualising knowledge ina vertical meaning takes place when individuals or groups use problems occurring whileperforming tasks as a basis for developing new patterns of activity. An example can be whentheories on reason for variations in body temperature learned in an educational context are usedas a basis for making a diagnosis in a practical setting.

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The boundary-crossing perspective implies that the theory–practice gaps can never becompletely removed since the gaps are not merely a failure in the delivery of knowledge fromclassroom to clinical practice (Rafferty, Allock, and Lathean 1996). However, boundary-crossingis not just challenging and problematic. It also provides expanding and constructive learningprocesses (Engeström 2001; Guile and Young 2003). The relevance of such an understanding ofthe theory–practice gaps will be examined more closely in the discussion of our results.

Data and methodology

The data are drawn from the longitudinal Database for Studies of Recruitment and Qualificationsin the Professions (StudData) in Norway. The first wave of data that this article draws uponincluded several background variables as well as data on study efforts, their assessment ofvarious aspects of the educational programmes, satisfaction, gain and expectations for the future.The second wave focuses on their occupational carrier, knowledge demands in occupationalpractice, further development of professional knowledge as well as assessment of their profes-sional education. In this article data from both waves are used.

The present article is based on responses from two professional groups: nurses and physi-cians. The students answered a questionnaire when they were in their final semester in spring2001 and about three years after graduation in the spring of 2004. The response rate varied some-what between the educational programmes at the different institutions, but the lowest rate wasjust below 60%, which is considered acceptable. In the data set which is the basis for this article,138 (75%) physicians and 335 (64%) nurses answered the questionnaire in the first wave, 155(59%) physicians2 and 233 (54%) nurses answered in the second wave. Ninety-eight physiciansand 179 nurses responded in both waves.

The following indicators are used to examine the challenges physicians and nurses faceduring their first years in professional work:

● Newly qualified physicians’ and nurses’ assessment of the extent to which differentaspects of knowledge are demanded in their occupational practice.

● Newly qualified physicians’ and nurses’ assessment of the extent to which they haveacquired different aspects of knowledge during their professional education.

● Newly qualified physicians’ and nurses’ assessment of knowledge gaps in terms ofdiscrepancies between knowledge acquired in professional education and knowledgedemands in occupational practice.

Students assessed the extent to which various types of knowledge were necessary in theircurrent work on a scale of 1 (not at all) to 5 (to a great extent) and the extent to which they hadacquired the corresponding types of knowledge during their college education (also on a five-point scale). The assessment of knowledge demands as well as acquired knowledge duringeducation is from the second wave. It is reasonable to assume that the student assessed knowl-edge acquired during education in the context of job requirements. It is therefore interesting tofocus on the discrepancy between these variables. Knowledge gaps are simply computed bysubtracting the graduates’ assessment of knowledge acquired during education from knowledgedemands in professional practice. All results presented in the text are statistically significant(p< .05).

Regression analyses (OLS) have been conducted to examine the relationship between knowl-edge demands and knowledge acquired on individual level. We have chosen to use types ofknowledge acquired during education as dependent variables. There are two reasons why we donot use knowledge gaps as dependent variables: first, knowledge gaps are difficult to interpret in

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a regression model since the gaps are due to both knowledge demands and knowledge acquiredduring education. Secondly, using knowledge gaps as dependent variables makes it problematicto include characteristics of current job as an independent variable since aspects of knowledgedemands would then be included as an independent as well as dependent variable. The dependentvariables codified, practical and relational knowledge are indexes constructed on the bases of thevariables as specified in Figure 2.

Independent variables are students learning activities during college education in terms ofaverage hours spent on study per week including organised instruction as well as individualactivities, students’ study strategy and students’ assessment of whether employability wereemphasised in the educational programme. All these variables are from the first wave. While thefirst and the latter variables need no further explanation, study strategy is an index based on aseven-point scale from the following items:

● I try to have a critical attitude towards the content of the programme.● I prepare myself for classes.● Discuss with other students.● Discuss with teachers.● I am not limiting my coursework to what is obligatory.● I am not only concentrating on what is expected at exams.● I have participated in study groups organised by students.● I often read material in addition to the obligatory reading list.

To include variables on their current occupational practice, newly qualified nurses’ andphysicians’ assessment of the extent to which ‘job requires new knowledge and skills’ and ‘jobrequires a high level of skills’ (on a four-point scale) are used in the models based on dataform the second wave. Profession, gender and age are included as control variables. Age is acontinuous variable, while profession is a dummy variable based on physicians as referencegroup.

Results

In general, newly qualified nurses and physicians report relatively high demands in occupa-tional practice for all aspects of knowledge (Figure l). Comparing the professions, differencesbetween them are rather small. When it comes to codified knowledge, nurses report a some-what higher demand for planning and organisational knowledge than physicians, while physi-cians report a somewhat higher demand for professional specific knowledge. There are nodifferences between the occupational groups in the demands for general knowledge and insightinto rules and regulation. The patterns for practical and relational knowledge are more distinct:nurses report somewhat higher demands than physicians except that there are no significantdifferences between these groups in demands for ‘ability to work independently’ and ‘oralcommunicative skills’.Figure 1. Knowledge demands in occupational practice, physicians and nurses.

Knowledge acquired in professional education

In general, physicians report that they have acquired a somewhat higher level of knowledge inprofessional education (Figure 2). When it comes to the codified knowledge physicians report ahigher outcome in terms of ‘general’ and ‘specific knowledge’, while nurses report a higheroutcome in terms of ‘planning and organisational knowledge’. There are no differences betweenthese groups with respect to ‘insight into rules and regulations’. The patterns for practical

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knowledge are less contradictory. Physicians report a higher level of outcome in terms of ‘abil-ity to work under pressure’ and ‘ability to work independently’, while there is no differencewith respect to level of ‘practical skills’. There are no or only very minor differences betweenthe occupational groups concerning the various aspects of relational knowledge.Figure 2. Knowledge acquired in professional education, physicians and nurses.The characteristic of the profile among physicians is a relatively high level of acquiredknowledge in terms of ‘general’ and ‘specific knowledge’ and a relatively low level in terms of‘planning and organisational knowledge’. Nurses’ acquired knowledge profile is, on the otherhand, characterised by a relatively low level of practical knowledge in terms of ‘ability to workunder pressure’, and to some extent also a relatively low level of ‘ability to work independently’.

Knowledge gaps

To address the relationship between ‘knowledge demands’ and ‘knowledge acquired’ we havealso analysed the discrepancies between the two (Figure 3). These discrepancies are used as indi-cators on knowledge gaps. In this respect the indicator is a way to include the professionalcontexts, at least to some extent.Figure 3. Discrepancies between knowledge demands and knowledge acquired in professional education, physicians and nurses.First of all, none of the group report that they have acquired knowledge on a higher levelthan what is demanded in occupational work. However, nurses report knowledge gaps to a

Figure 1. Knowledge demands in occupational practice, physicians and nurses.

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greater extent than physicians. Insight into rules and regulations and ethical deliberation is theonly aspect of knowledge where physicians report greater gaps than nurses. Nurses reportgreatest gaps in terms of all aspects of practical knowledge, but especially ‘ability to workunder pressure’. It should also be recognised that they express a significant gap of ‘specificknowledge’.

Factors influencing knowledge acquired in professional education

Table 1 shows that students’ effort during education in terms of ‘time used for study activities’is the only variable that is significantly related to all three aspects of knowledge. The relationship,however, is very weak; an increase of 10 hours used for study per week only increases acquiredcodified knowledge by 0.09. The weak relationship is also confirmed by the low R2. Study strat-egy is only related to assessment of acquired practical knowledge. Students’ assessment of theextent to which ‘employability was emphasised in the educational programmes’ is significantlyrelated to the acquired practical and relational knowledge. Analyses show, rather surprisingly,

Figure 2. Knowledge acquired in professional education by physicians and nurses.

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that the extent to which the graduates report that their current ‘job requires new knowledge andskills’ is positively related to acquired relational knowledge while ‘job requires a high level ofskills’ is negatively related. The analyses confirm that nurses assess that they acquired practicalknowledge to a lesser extent than physicians (Figure 2). The relatively high R2 in the model exam-ining practical knowledge is, however, not first of all a result of differences between nurses andphysicians. Alternative estimations show that when ‘professional belonging’ is removed from themodel, R2 is only reduced to 0.133. The reason is first of all that an active study strategy has asignificant impact on acquired practical knowledge. Gender and age seem not to be related toknowledge acquired.

Discussion

Our analyses show that knowledge demands in occupational practice have very similar patternsamong nurses and physicians. The similarity does not indicate that nurses and physicians needsfor the different aspects of knowledge are equal – the respondents have not answered these ques-tions from a comparative perspective. Nevertheless, both of the groups report the knowledge

Figure 3. Discrepancies between knowledge demands and knowledge acquired in professional educationof physicians and nurses.

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demands to be rather high. Moreover, the knowledge demand profiles are almost the same forthe two groups and codified, practical and relational knowledge is assessed to be of about equalimportance in both of the occupational contexts.

The assumption that the differences in curriculum characteristics between nursing andmedical education have implications for their respective educational outcome is, however, onlypartly confirmed. Physicians report that they have acquired a somewhat higher level of generaland specific knowledge than nurses, but contrary to our assumption nurses acquired a somewhatlower level of practical knowledge in terms of ability to work under pressure and ability to workindependently. These patterns become even more significant when we look at the gaps betweenknowledge acquired in professional education and knowledge demands in occupational practice.

The results of our examination of newly qualified nurses and physicians show the relevanceand limitations of a cognitive as well as a situated perspective. On the one hand the significantgaps between knowledge acquired in education and knowledge demands in professional workseem reasonable from a situated perspective, and the lack of difference in knowledge gapsbetween nurses and physicians are difficult to understand from a strictly cognitive perspective.On the other hand, students’ study effort as well as their assessment of the extent to whichemployability was emphasised in the educational programmes seems to reduce the knowledgegaps since these variables are positively related to the nurses’ and physicians’ assessment ofknowledge acquired in education. This is more understandable from a cognitive rather than asituated perspective on learning.

As suggested in the introduction, however, the perspective of boundary-crossing may be anappropriate way to overcome the limitation of the cognitive as well as the situated perspectiveon learning. The significant gaps between knowledge acquired in education and requirements inoccupational practice among newly qualified nurses as well as physicians confirm the chal-lenges of boundary-crossing. The fact that physicians report somewhat smaller gaps than nurseswith respect to general and specialised knowledge illustrates the potential of such types ofknowledge. Given the high proportion of practice in nursing education it might seem strangethat nurses, to a much greater extent, report gaps of practical knowledge and especially with

Table 1. Relationships between knowledge acquired during college education and study efforts, knowledgerequirement in job and selected background variables (n = 216).

Codified knowledge Practical knowledge Relational knowledge

B SE B SE B SE

Constant 2.390 *** 0.400 2.415 *** 0.510 2.618 0.445Time used for studies 0.009 ** 0.003 0.008 * 0.004 0.002 *** 0.003Study strategy 0.063 0.041 0.116 * 0.053 0.062 0.046Education emphasised

employability0.043 0.022 0.058 * 0.028 0.081 *** 0.025

Job requires new knowledge and skills

0.029 0.077 −0.045 0.098 0.239 ** 0.085

Job requires a high level of skills

−0.010 0.064 −0.011 0.081 −0.143 * 0.071

Nurse 0.068 0.088 −0.464 *** 0.112 0.128 0.098Male −0.025 0.095 −0.006 0.120 0.004 0.105Age 0.003 0.007 0.006 0.009 −0.007 0.008R2 adj. 0.063 0.195 0.066

***p < .001; **p < .01; *p < .05.Note: Regression coefficients (B) and standard error (SE).

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respect to their ability to work under pressure. One reason may be that the study pressure ismuch harder in medical than nursing education and that physicians therefore have developed anability to work under pressure to a greater extent than nurses. Another reason might be thatphysicians have acquired a comprehensive body of codified knowledge during education whichhas been vertically recontextualised into practical contexts resulting in a higher ability to workunder pressure. In this way, comprehensive educational programmes might increase profes-sional confidence.

Also, the results from the regression analyses may be interpreted from the perspective ofrecontextualisation. We found a positive relationship between students’ study efforts and thenewly qualified professionals’ assessment of knowledge acquired in education, which indicatesthat this effort has been worthwhile with respect to knowledge acquired assessed in the contextof professional work. Moreover, there seem to be positive relationships between the extent towhich students report that employability was emphasised in their educational programme andtwo of the dependent variables. This indicates that students who understand the relevance ofwhat they learn in professional programmes in the end of their studies also have a greater poten-tial of recontextualising this knowledge into the context of work.

An active and critical study strategy is positively related to acquired practical knowledge.The lack of a significant relationship between study strategy and acquired codified and relationalknowledge contradicts the general conclusions in studies of student learning (Biggs 1993; Kuh,Pace, and Vesper 1997; Trigwell and Prosser 1991). Reframing the literature on the theory–prac-tice gaps in nursing and medical education, the main challenge for newly qualified professionalsis to establish a connection between classroom theory and professional practice (Gerrish 2000;Landers 2000; Ramage 2002). It seems reasonable that students reporting an active and criticalstudy strategy are more capable of resituating classroom theory vertically as well as horizontallyinto practical contexts than less active students.

The final result in the regression analyses is that students’ assessment of job requirements isonly significantly related to acquired relational knowledge and not to the other types of knowl-edge. The extent to which students report that ‘job requires new knowledge and skills’ ispositively related to acquired relational knowledge, while students’ assessment of whether ‘jobrequires a high level of skills’ is negatively related. These patterns seem somewhat contradictory.A possible interpretation may be that having to learn new knowledge and skills implies a possi-bility for vertical recontextualisation, while requirements of a high level of skills simplyincreases the challenges of the boundary-crossing between education and work. The reason whyjob requirements is only related to acquired relational knowledge and not the other types ofknowledge may be that it is more difficult to recontextualise horizontally the first, rather than thelatter, types of knowledge. Eraut (1994) emphasises that some aspects of knowledge may bestbe learned in higher educations, while others are best learned in occupational practice. Our resultsindicate that at least some aspects of relational knowledge are difficult to recontextualise andtherefore may best be learned in occupational practice.

Conclusions

The discrepancies between newly qualified nurses’ and physicians’ assessment of knowledgedemands in professional work and knowledge acquired in education are in accordance with thegaps discussed in the literature (Gerrish 2000; Landers 2000; Prince et al. 2004, 2005; Ramage2002). But as suggested in the introduction, the perspectives of boundary-crossing (Engeström2001; Guile and Young 2003) as well as the concepts of horizontal and vertical recontextualisation(van Oers 1998) are, in our opinion, more fruitful and relevant to understanding the challengesrelated to the transition between education and work. While some types of knowledge may rather

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directly be transferred into work contexts, others have to be recontextualised vertically as wellas horizontally. Our analysis raises important issues concerning these challenges.

First, our findings suggest that a high level of codified knowledge among medical studentsis also a resource with respect to practical challenges and, in particular, the ability to work underpressure. This corresponds with the argument emphasised in the introduction: theoretical knowl-edge has the potential for vertical recontextualisation. Moreover, from a somewhat differentperspective it has been emphasised that science and more abstract forms of knowledge play animportant role in the development of professionalism (Jensen and Lahn 2005; Smeby 2007). Basedon Karen Knorr Cetina’s concept of ‘wanting structure’ (Knorr Cetina 1997, 2001), they emphasisethe binding role of knowledge and the importance of encouraging students’ understanding thatall is not fixed, finished and complete. There are always new and unexplored possibilities. There-fore, strengthening nursing students’ knowledge in basic subjects (physiology, pharmacology,ethics and psychology) may increase their professional confidence and provide them with perspec-tives for understanding, reflecting and illuminating pressured situations at work. Rather thanhaving more practical training this may help nurses to act in a strained work environment

A second issue we raise in the analysis underlines the importance of being trained in recon-textualising knowledge. Students reporting that employability was emphasised in their educationprogramme seem to be more equipped to recontextualise their educational knowledge in realpractical contexts both in a vertical and a horizontal sense. Training in recontextualising theoret-ical medical knowledge of medications, learned in lectures and books, for treatment in practicalcontexts is an example of training for vertical recontextualisation. Executing procedures andskills rehearsed in nurse educational laboratories in real situations is an example of horizontalrecontextualisation. Newly qualified nurses who have undergone sufficient ‘lab-learning’ areprobably better prepared when performing similar activities in new real-life situations wheretime pressure and concerned patients are often a part. Moreover, we found that students reportinghaving an active and critical study strategy are more likely to be able to resituate acquiredpractical knowledge into real practical contexts both vertically and horizontally. An example ofthe latter could be students who develop critical attitudes towards subject matters. By expandingtheir coursework, moving beyond what is obligatory and expected from reading lists studentsdevelop an understanding and an ability to reflect on practical problem solving that is not limitedto the simple ‘know how’ of practical procedures. Students developing interrogative and criticalattitudes as integral parts of their practical training and their professional practical knowledgemight experience horizontal recontextualising as less problematic. Hence educationalprogrammes that promote and stimulate students into developing active and reflexive attitudestowards subject matters, and focus on the relevance of what is learned for practical problemsolving, probably lessen the burden for newly qualified professional.

Third, some aspects of knowledge are more difficult to recontextualise horizontally thanothers. Such knowledge is probably best learned and developed in professional practice. Ourresults suggest that this is particularly the case with respect to relational knowledge. Learning toco-operate, communicate and the ability to make ethical deliberations are important parts ofpractical and practice-based training in relational knowledge for medical students and nursingstudents. However, recontextualising these skills into work contexts as a newly qualified physi-cian or nurse with a professional responsibility constitute challenges that may be too difficult tocreate realistically in an educational context. Preparing for ‘real life in clinical settings’ (Baxterand Rideout 2006) has therefore to be developed in professional practice. While medical studentscarry out a preliminary internship under professional guidance and supervision of a senior physi-cian, this is not the case for nurses, at least not in Norway. It is reported that one of the obstaclesfor further development of professional knowledge among nurses is the lack of dialogue andreflection on work experiences, amongst other things, due to the time-pressure amongst employ-

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ees (Bjørk 1999). The challenges of horizontal, but also vertical reconceptualisation, illustratethe importance of workplace learning among newly qualified professionals.

Our analyses of boundary-crossing among newly qualified nurses and physicians is howevertentative. Further studies are needed. First of all our quantitative data are composed of rathersimple indicators on knowledge demands and knowledge acquired. Moreover, even though thereare important similarities, there are also important differences between nurses’ and physicians’professional tasks. It would, therefore, be interesting to examine more closely how variousaspects of knowledge learned in higher education are recontextualised horizontally as well asvertically in various situations and contexts. Qualitative studies will be especially relevant toimprove our understanding of the characteristics of such complex processes. The challenges ofboundary-crossing should also be studied by focusing on other professional groups.

Notes1. Authors contributed equally to the article.2. The reason why the response rate is lower among physicians in Wave 2 even though the number of

respondents is higher than in Wave 1 is that more physicians were included in Wave 2 than in Wave 1.

Notes on contributorsJens-Christian Smeby is a professor at the Centre for the Studies of Professions at Oslo UniversityCollege. He is educated as a sociologist with special interests in higher education, professional knowledgeand learning, and the relationship between theory and practice. Smeby’s publications have appeared injournals including Higher Education, Research in Higher Education, Research Policy and Studies inHigher Education.

André Vågan is a PhD fellow at Centre for the Studies of Professions at Oslo University College. Heobtained his master’s degree in social anthropology. Vågan’s PhD project is on ‘physicians-in-the-making– the development of professional identity among medical students’.

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