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Procedia Social and Behavioral Sciences 15 (2011) 3927–3931

WCES-2011

Gap between knowledge and practice in nursing

Abstract

Nursing is considered as caring for a person in a variety of health related situations. This caring also involves teaching about
health and the prevention of illness; hence, nurses play a key role in promoting higher standards of health. To maintain a proper
balance between theory and practice, a nurse, has to be updated with current knowledge and practice in the field. This paper
addresses the issue of the gap between theory and practice in the nursing profession in the light of literature and makes some
recommendations accordingly to close the gap.
© 2011 Published by Elsevier Ltd. Open access under CC BY-NC-ND license.

Keywords: Knowledge gap, practice, nursing

1. Introduction

Education encompasses specific skills of teaching and learning, and also the imparting of knowledge, good
judgment, and wisdom. Education strives to close the gap between knowledge and practice, for the ultimate purpose
of increasing quality of care for the population served.

This paper addresses the issue of the gap between theory and practice in the nursing profession. It is important to
reflect on the terms theory, practice, and the gap between the two terms. Theory as defined by the dictionaries is a
set of statements or principles devised to explain a group of facts or phenomena, especially one that has been
repeatedly tested or is widely accepted and can be used to make predictions about natural phenomena. The term
practice is defined as the act or the process of doing something; performance or action. In definition these terms
appear to be at odds with each other but when considered in terms of professional setup they have to enable the
application of ‘applying the theory into practice’.

Nursing is considered as caring for a person in a variety of health related situations. This caring also involves
teaching about health and the prevention of illness; hence, nurses play a key role in promoting higher standards of
health. To maintain a proper balance between theory and practice, a nurse, has to be updated with current knowledge
and practice in the field.

If all the nurses are placed with competence in theory and practice forming the either ends of the continuum most
nurses are likely to find themselves at the either ends of the continuum. There is evidence to suggest that nurses who
are proficient in theory are able to write the best care plans, discuss pathophysiology, treatment rational, etc,

* Khairulnissa Ajani. Tel.:+92-21-34865409; fax: +92-21-34146880.

1877–0428 © 2011 Published by Elsevier Ltd. Open access under CC BY-NC-ND license.
doi:10.1016/j.sbspro.2011.04.396
3928 Khairulnissa Ajani and Salima Moez / Procedia Social and Behavioral Sciences 15 (2011) 3927–3931

however, they struggle with hands on practice. On the other hand, nurses who exhibit strong clinical practice skills
often find it difficult to rationalize the care in terms of theory. Their knowledge of Pathophysiology and
pharmacology needs to be strengthened.

This theory practice gap has been widely addressed in the literature issue has been given both positive and
negative meanings and justifications in the literature. It has consequences for the professional status and image of
nursing. It affects the perceptions and impressions to the patient and other members of the team about the nurse. It
also affects the evaluation that a nurse undertakes for the purpose of promotion and professional development.

This theory-practice gap has other influences on the nursing profession related to motivation and dignity of work.
If nurses are not well equipped theoretically, the image of nurses being doctors’ hand maidens is promoted. On the
other hand, if they do not exhibit proficient hands on skills, their credibility is questioned, leading to frustration and
de-motivation.
There are several factors responsible for promoting theory practice gap in nursing:
x The apprenticeship model
x Students being used as service providers
x Lack of current clinical practice amongst nurse educators
x Governmental support
x Support from the governing bodies in nursing
x Research in nursing
x Lack of opportunities for continuous education

The perceived problem of the knowledge and practice gap is built upon the assumption that theory can and must
be directly applied to nursing practice, otherwise it is irrelevant. The type of knowledge associated with practice
could be taught through theory and must be well represented in theoretical terms. Much has been written in other
countries regarding the theory practice gap in nursing which include the discrepancy between what is taught in the
classroom and how care is actually given in practice however almost nothing has been written in the context of
Pakistan.

2. Literature review:

The theory-practice gap is widely addressed in the international literature. Knowledge and practice issues have a
long-standing history in nurse education, and are a chronic source of controversy to which there is no easy or perfect
solution (Hewison, A & Wildman, S., 1996). This tension between theory and practice and research which can be
usefully exploited in teaching and research (Rafferty, Allcock, & Lathlean,1996).

Emphasizing the importance of the issue (Rolfe, 2003), states that the theory- practice gap is felt most acutely by
student nurses. Student may find themselves torn between the demands of their tutor and the practicing nurses. They
are faced with real clinical situations in which they are unable to generalize from what they have learned in theory.
The discrepancy between nursing as it is taught in the classroom and nursing as it is practiced by students in the
clinical setting has long been a source of concern to teachers, practitioners, and learners worldwide. Despite
considerable efforts by the profession to bring about change, the basic problems identified in 1976, by Bendal,
continues to cause concern. (Bendal,1976) cautioned nurse educators about producing nurses who were
"increasingly proficient on paper and decreasingly proficient in practice. She had also cautioned that what nurses
were learning in theory was becoming increasingly divorced from what they were actually doing in practice.

If the theory-practice gap is not minimized, it can cause difficulties because the principles of practice established
in curricula are not well aligned with the principles operating in the workplace.

2
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This difference in philosophy can be problematic for a new graduate, which, in the extreme, may cause them to
leave the profession prematurely. To enable students to link theory and practice effectively, certain steps need to be
taken. Students need to be introduced to the debates surrounding the genesis and the generation of nursing
knowledge. They need to gain an appreciation of what counts as nursing knowledge at different points in time, and
the politics which drives the legitimization of nursing theory and practice. Such an approach will help nursing
students deal with reality shock and make sense of their experience as they confront the ambiguities, uncertainties,
and contradictions that characterize the stock-in-trade of professional life. Accordingly, the nurse educators should
constantly strive to ensure that theoretical content is designed to adequately prepare graduates and so avoid, or at
least minimize, 'reality shock' (Kramer, cited by Garbett, 2002).

Analyzing the issue in the light of the literature three versions of the problem can be highlighted. One is related to
the ‘practice’, which fails to live up to theory (Cook 1991, as cited in Allmark, 1999). This includes the discussion
on how to make nurses more research minded and get them into evidence based practice rather than performing the
skills in the ritualistic, robotic ways. The second version is where the theory is not relevant to the practice, and what
is taught in the idealistic environment of the classroom may not be applicable in the real practical situation. The last
version talks about the gap, which highlights a relational problem between the school of nursing and the hospital
area or the clinical placement. The critical question here is how to make theory more relevant to the practice so that
the gap between the two is minimized. (Scott, 1994 as cited in Allmark, 1995).

The irony of the debate lies in the fact that in nursing, which is a practice discipline, theory and practice cannot
be separated. Knowledge and practice cannot be separated, as both are very critical to any professions is its ability to
grow and change as the world changes. Another positive approach is also mentioned in (Rafferty, Allcock, &
Lathlean, 1996) state that the theory/practice gap can never be sealed entirely; they are by nature always in dynamic
tension, and this tension is essential for change to occur in clinical practice. This tension, seen from a positive point
of view can motivate nursing professionals to work on the issue, it also provides room for avoiding stagnancy in the
profession.

3. Recommendations

This now brings us to the point where some solutions should be highlighted. The literature has given a few
solutions, which includes the suggestion by (Brasell & Vallance, 2002), who state that a major challenge to the
nursing profession is to find ways of merging theory and practice in the delivery of nursing education and patient
care. One option for achieving this goal is for nurse educators to spend time in clinical practice; updating their
clinical skills and re-experiencing the realities of practice. Criteria for assessing both written work and performance
on practical placements should also incorporate evaluation of the degree to which the student has integrated
theoretical learning with practical experience. Many authors have suggested that integration will only be achieved if
the staff members responsible for classroom teaching are closely involved in clinical supervision of students
(Edwards, 2002).

Another recommendation is recruiting joint appointments from the area of practice. Also intermittent periods of
clinical update in practice and work role exchanges between educators and clinicians can be utilized by the
profession. This model of clinical practice/education exchange involving two people, one in clinical practice and the
other in education, who exchange jobs for a fixed period of time, is a relatively new concept. The aim of this model
is enhancing student learning and facilitating meaningful links between theory and practice for them. Hence, the
exchange occurs between the education institute and the service area where students are placed. Also, this model
enables the faculty has a responsibility to update themselves with the current changes in health care, through regular
faculty practices; and if faculty is clinically and theoretically competent then he/she would be able to produce
competent students, and in return, the community and country will benefit from the nursing services.

The curriculum team also needs to consider the potential influence of the hidden curriculum on the learning
process. Students should be prepared for the, inevitably, conflicting philosophies of nursing in the classroom and the
3930 Khairulnissa Ajani and Salima Moez / Procedia Social and Behavioral Sciences 15 (2011) 3927–3931

reality of the clinical environment. This may serve to reduce anxiety in students and help them work more
effectively with the discrepancies (Landers, 2002).

According to (Ward & Wright, 2004), after identifying a need to develop the knowledge and skill of health care
professionals in palliative care, a specialist team from a primary care trust set up a fast-track training programme.
This consisted of an academic module, a four-week secondment to palliative care settings and a project undertaken
in the workplace to bring about a change in practice. The programme proved successful in increasing the students'
skills and confidence and in changing practice in the workplace.

Goodfellow, (2004) has forwarded the suggestion that to build the research and practice gap it is imperative that
nursing students learn to use research as a basis for making clinical decisions. The author discusses how a journal
club was structured and designed to promote evidence-based practice, and to reduce several of the barriers in
utilizing research in the clinical setting.

Schools of Nursing can adapt the current models of teaching and learning which promote the self directed
approach and the problem-based learning approach. These modes of curriculum enhance critical thinking in the
students and make them more independent. The assessment criteria of the curriculum can also integrate case based
scenarios and practical example so that theory is tied up with the practice.

There is a need to consider continuing education and in-service education programs for nurses to enable them to
stay current with the changes in health care practices. Due to the advancement in technology there is more need that
change in nursing practice should initiate with change in the educational curriculum of the nursing programmes.
Thus, the nursing faculty should initiate change in the curriculum with a focus on changing and improving nursing
practice.

Rafferty, Allcock and Lathlean, (1996) have made very comprehensive recommendations under three headings,
which include reconstructing resources, reorganizing training, and reconstituting roles. Under reconstruction of
resources, it is suggested that clearer boundaries be defined between students and staff nurses and the nursing
assistants. The notion of ‘service is equal to education’ cannot be nurtured further. This means that students should
not be used as service providers; they have their own objectives to meet and studying to be done and, therefore, their
role has to be defined separately from the staff nurses. In re-organizing training it is suggested that the concept of
‘nuns becoming teachers’ have to be modified. Anyone and everyone cannot become a teacher. In order to provide
exemplary education, students have to be taught by qualified and specialized educators. The last point of
reconstructing roles talks about hiring joint appointees and academicians working as clinicians as well which has
been talked about earlier.

4. Conclusion

Thus, overall, it is quite evident that the gap does exist and has its strengths as well as areas that can be improved.
There are strategies available to overcome this issue, which focus on the revision of the curriculum and having a
liaison between the education and the practice areas. In the educational setting, as well as the clinical setting, the
leader and the follower will make the operational plan of this suggested model and connect it to the benefits, so that
the profession of nursing is benefited at large.

References

Allmark-P (1995). A classical view of the theory-practice gap in nursing. Journal of Advanced Nursing (1): 18-23.
Bendal, E. (2006) Learning for reality. Journal of Advanced Nursing. 53 (1): 3-9.
Bendall E. (1976). 30th anniversary commentary on Learning for reality. Journal of Advanced Nursing 1, 3–9
Brasell, B. R & Vallance, E. (2002). Clinical practice/education exchange: Bridging the theory-practice gap. Nursing-Praxis-in-New-Zealand
18(1): 17-26.
Edwards, S. (2002). Nursing knowledge: defining new boundaries. Nursing Standard;17(2):40-4
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Garbett, R. (2002).The qualities and skills of practice developers. Nursing Standard Aug 28-Sep 3; 16(50): 33-6.
Goodfellow, L. M. (2004). Can a journal club bridge the gap between research and practice? Nurse- Educator. 29(3): 107-10.
Hewison, A & Wildman, S. (1996). The theory-practice gap in nursing: a new dimension. Journal of Advanced Nursing Oct; 24(4): 754-61.
Landers, M. (2002). The theory/practice gap in nursing: the views of the students. All Ireland Journal of Nursing and Midwifery. Jan; 1(4): 142-7.
Rolfe, G. (1993). Closing the theory-practice gap: a model of nursing praxis. Journal of clinical Nursing 2 (3), 173-7.
Rafferty-AM; Allcock-N; Lathlean-J. (1996). The theory/practice "gap": taking issue with the issue. Journal of Advanced Nursing Apr; 23(4):
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Ward, C & Wright, M. (2004). Fast-track palliative care training to bridge the theory-practice gap Nursing-Times 23-29; 100(12): 38-40.