Fundamental to the delivery of high-quality pre-registration (student) nurse training, is the importance of approved education institutions (AEIs), together with practice learning partners, working collaboratively to ensure the provision of effective clinical placements (Nursing and Midwifery Council [NMC], 2018a).
Central to this, is the ability of student nurses to develop the skills necessary to critically reflect on their clinical experiences and apply this learning to professional practice (NMC, 2018b).
In nursing, however, the omnipresent theory–practice gap continues to exist – a constant nursing problem experienced by all levels of nurses (Greenway et al, 2019), which remains predominantly visible in the clinical environment (Brown, 2019). And, with this discourse having raged on from as early as the 1980s, as evidenced by the work of Rafferty (1992), it seems likely that this debate will endure for some time.
The theory–practice gap, also known as the research–practice gap (Watkins, 2018) is best described as the missing link between evidence-based practice guidelines and the definitive quality of nursing practice (Labeau, 2019), which not only has the potential to reduce nurses motivation but also to lower the credibility of the profession (Ajani and Moez, 2011). Of particular concern is that it can lead to a decrease in the quality of patient care (Ajani and Moez, 2011).
Today, evidence-based practice is deemed to be a fundamental tenet of contemporary health care, the aim of which is to ensure the delivery of appropriate and effective care in a proficient manner (Jylhä et al, 2017). Disappointingly, however, there is widespread concern that new research is not being translated into practice in a constructive way (Westfall, 2007); with a gap of 17 years being widely quoted (Thirsk, 2018). The reasons for this are complex. A review of the literature by Mallion and Brooke (2016), for example, identified a plethora of barriers, including a lack of time and staff shortages, a substantial patient caseload and family commitments. Furthermore, the sheer volume of knowledge and information currently in circulation, argues Olson and Oudshoorn (2020), makes it almost impossible for health professionals to comb through and identify what is most meaningful in one's practice.
Bridging the gap
Despite the continued prevalence of the theory–practice gap (Aimei, 2015), there are a number of ways in which nurses and educationalists can work collaboratively to reduce this gap; one being the well-tested use of portfolios, through which nurses can record professional learning experiences; the emphasis being on professional development (Beckers et al, 2016). Furthermore, using portfolios has the capacity to enable students to become self-regulated learners (Beckers et al, 2016). Self-regulated learning being defined as a complex and multidimensional paradigm that refers to how learners achieve their coveted learning goals (Chen and Bonner, 2020) and refers to the self-directed processes and self-beliefs that enable learners to transform their cognitive abilities into academic performance (Zimmerman, 2008).
Characteristics of a self-regulated learner
Students with self-regulatory skills are characterised by proactive traits and self-motivating abilities and are predisposed towards taking responsibility for their own learning, which often sets them apart from their peers (Zumbrunn et al, 2011). Furthermore, self-regulated learners are more likely to be motivated and able to align their behaviours with their personally inspired goals. They are also more capable of identifying suitable strategies for their learning objectives and actively managing problems they may encounter (Sardareh et al, 2012). Central to this, however, is the need for students to be provided with opportunities that have the potential to advance their learning; an example of which is the ability to access high quality practice placements.
Practice placements
More than 10 years ago the World Health Organization (2009) declared that the future of nursing depends on the ability of the profession to adequately prepare large cohorts of nurses for first degree level practice. To do this successfully, however, requires nurse education to ‘give students a comprehensive knowledge base’ through which we can support the development of competent and skilful reflective practitioners, able to engage in critical clinical reasoning and effective decision-making (Birks et al, 2017: 17). Fundamental to this is the importance of students gaining ‘professional experience in the clinical environment’ (Birks et al, 2017: 23).
Disappointingly, however, such learning environments instead of being supportive, can often be fraught with uncertainty (Killam and Heerschap, 2013) as students grapple with their often transitory emotions and abilities to stay calm in stressful situations (Kaldal et al, 2018). Nonetheless, by receiving appropriate and effective high-quality support in high-quality placements, students are empowered to build confidence in their ability to overcome such challenges as they emerge (Andersen, 2016). In the UK, this level of support is being provided by practice supervisors and practice assessors in clinical practice, and in AEIs by academic assessors (NMC, 2018a).
Furthermore, research undertaken by Pedregosa et al, (2020: 12) highlights the significant benefits of clinicians and academic staff working collaboratively and includes a greater propensity to identify clinical problems, a ‘significant improvement in patient communication’, a positive attitude towards team working experience and ‘greater opportunities to practice clinical skills’. Practice placements can also support the development of practical skills that promote professional identity (Ewertsson et al, 2017).
‘Professional identity’ being defined as:
‘a sense of oneself, and in relationship with others, that is influenced by characteristics, norms, and values of the nursing discipline, resulting in an individual thinking, acting and feeling like a nurse’.
It is essential, therefore, that students are given the opportunity to transition from student to registered nurse with as little distress as possible, although the last 12 months has clearly upset the applecart with students bearing some of the brunt of the COVID-19 pandemic and its disruptive forces as evidenced by the NMC emergency programme standards (NMC, 2021).
One way in which students can make sense of the often ‘swampy lowlands’ (Schön, 1983) of professional practice is to receive effective supervision by registered nurses, who are confident in their ability to support students to use portfolios as a means by which they are able to critically reflect on their experiences.
Considered an essential tenet of the clinical placement, therefore, is the provision of safe and effective supervision and the provision of quality feedback to ensure the maintenance of safe practice (Ossenberg et al, 2020). However, as a result of the dynamic and often chaotic workplace settings in which they find themselves, nursing students often struggle to meet the demanding theoretical and clinical practice elements required to be completed (Khishigdelger, 2016). Disappointingly, failure to identify these challenges can limit students' ability to learn effectively and grow professionally (Jamshidi et al, 2016).
Portfolio development, therefore, with its emphasis on critical reflection can be seen as an effective channel through which professional experiences can be explored (Fowler, 2020).
Portfolio development
Portfolios coupled with scaffolding opportunities can be an effective tool in helping students to plan and organise their learning, as well as to self-monitor and self-reflect on their learning (Bol and Garner, 2011). An earlier definition of scaffolding being described as:
‘a process that enables a child or novice to solve a problem, carry out a task, or achieve a goal which would be beyond his unassisted efforts. This scaffolding consists essentially of the adult “controlling” those elements of the task that are initially beyond the learner's capacity, thus permitting him to concentrate upon and complete only those elements that are within his range of competence’.
Further definitions have sought to build on this original work with scaffolds more recently defined as tools, strategies, or guides that support students to gain higher orders of understanding (Devolder et al, 2012).
With Caruana (2012) purporting the higher the stakes, the more scaffolding required; essentially: ‘the heavier the weight, the stronger the support’.
As portfolios are an essential element in pre-registration nurse training, it can easily be argued that these are indeed ‘heavy stakes’ and require a scaffolding approach to learning; the scaffolding only being removed as students take their rightful place as registered nurses; only to be rebuilt as they begin to develop professionally through NMC revalidation (NMC, 2015).
A significant sea-change is required if the nursing profession is to make significant inroads into bridging the theory–practice gap, with research undertaken identifying myriad opportunities to successfully do this (Shoghi et al, 2019); the emphasis being on the importance of cultivating positive attitudes and discussions with senior educationalists, and clinical directors, nurse directors and nurse educators … and perhaps it all begins with pre-registration nurse training.
Preparation for registration
The nursing profession continues to demonstrate its value in one of the most tumultuous episodes in global nursing history, having borne witness to the severe disruption caused by the COVID-19 pandemic.
Compounded by the significant shortage of nurses (Royal College of Nursing, 2019) and a population that is living longer, but requiring significant long-term care (World Health Organization, 2015), it appears beneficial to ensure that student nurses are not only appropriately prepared for registration but they are also well supported and nurtured as they advance their nursing knowledge and skills (Mills et al, 2020). Potentially, this can be achieved by providing clinical placement opportunities that not only provide excellent support for student nurses but also encourage deep levels of reflective practice, which in turn can help support portfolio development and ultimately translate evidence-based research outcomes into quality patient care. To do this successfully, however, requires a genuine commitment by all nurses to step up and support emerging generations of student nurses.
Conclusion
Today it is widely accepted that a combination of approaches is required if the nursing profession is to be successful in closing the theory–practice gap with these approaches being adapted to the needs and resources of the educational setting (Leeman et al, 2017).
Central to this is the ability of students to effectively manage the challenges they face. One way in which this can be effectively achieved is for students to become self-determined, self-reflective practitioners and self-regulated learners; a significant challenge. But one which could be considered essential in these challenging times.
Ultimately, however, the theory–practice gap cannot be closed without sustained and structured effort to make this a reality, but first it needs to be understood, and once understood, what has the potential to emerge is new and innovative ideas through which we can all act collaboratively, irrespective of role, to eradicate the spectre of the theory–practice gap; and to do this once and for all.
KEY POINTS
- Eliminating the omnipresent theory–practice gap requires a multi-dimensional approach, including a significant commitment from the current nursing workforce
- Self-regulated learners demonstrate high levels of motivation and a willingness to take responsibility for their own learning
- Portfolios combined with effective learning opportunities can enable students to become critically reflective practitioners, an essential attribute of a registered nurse
- Receiving a high level of support throughout training and qualification will ensure the next generation of nurses are able to effectively manage the increasing complexity of patient care
CPD reflective practice
- What is the theory–practice gap? Why is this an issue?
- What is a self-regulated learner?
- How can portfolios play a role in this?
- How could you help to close the theory–practice gap?