Posted on: Tue 14-05-2019

Theory and Practice in Nursing Profession: Bridging the Gap By Comr. Emmanuel Ejembi ANYEBE PhD, JP  (RN, RNE, RPN, FWACN) (08036422771; [email protected]) Department of Nursing Sciences, Faculty of Clinical Sciences, College of Health Sciences, University of Ilorin @ INTERNATIONAL NURSES WEEK, ABUJA Date: 8 May  2019

Protocols:

• Established protocols
• Organisers:
  • Applaud choice of topic.

Preamble

• From what I am given to share with us, it is concluded that GAPS exist between the theory and the practice of nursing, probably globally and specifically in Nigeria.
• So we all believe and so it is!
• However, before I attempt to address this topic, another obvious but often covert gap exists among us (nurses/midwives) that we must resolve (bridge) before we continue the discussion:
• That is:
  • A group of us nurses believe that practice standards are dropping because nursing has been over intellectualized (too much focus on certificate at the detriment of skills and values/attitudes)
  • Another group believes that nurses are too complacent when it comes to knowledge acquisition, so much so that our practice remains archaic and out-of-date.

• This year’s theme for International Nurses Week is

Nurses: A Voice to Lead: Health for All.

• My topic thus implies that in:

Bridging the Theory-Practice Gap in Health for All, Nurses are a Voice to Lead.

• Therefore, theory and practice of nursing must focus on harmonizing all the domains of Universal Health Coverage (Health for ALL).
  • Nursing practice is thus any actions taken by nurses to ensure such coverage.
• The Nursing Profession therefore includes all occupational areas the nurse/midwife practises:
  • Direct client care (clinical)
  • Education
  • Decision making (administrative and clinical)
  • Quality control and auditing
  • Policy formulation/informatics
  • Research

INTRODUCTION

• Theory-practice gap is not unique is not unique to the nursing profession: it is common in all practice professions.
• And in Nursing, the phenomenon is a universal issue, a global concern: it is established that nurses often do not follow their academic training in practice (Sharif and Masoumi, 2005).
• Nursing is the protection, promotion and optimization of health, prevention of illness and injury, and alleviation from suffering through the diagnosis and treatment of human response, for the individuals, families, and communities (ANA, 2012).

Focus of the Paper

• What are the key concepts of the discussion?
• What really is a gap? And the extent of it’s existence
• What causes gap in theory-practice dichotomy?
• How do gaps manifest
• What are the impacts/effects?
• What strategies can adopt to bridge the gaps?

Conceptual Clarifications: Definitions

• Theory:
  • The sum total of all the knowledge, skills and attitudes that are obtained from the classroom and empirical evidences obtained from research findings.
  •  Abstract ideas
  • Empirical facts/evidences
• Practice:
  • Action rather than idea;
  • a deliberately planned sequence of actions carried out by highly skilled individuals to clients (Usman, 1999);
  • the implementation or putting into action of all the knowledge, skills and attitudes learnt in the classroom setting;
  • the extent to which nurses are able to carry out procedures and nursing care as they are in the clinical area.
  • Practice provides the necessary experience necessary for the learner to develop knowledge, skill and values including the right attitudes.
  • It also serves a multipurpose role in the education of professionals.
• Gap:
  • An imbalance between theories learnt in the class and the practice in the clinical area.
  • The difference between the classroom teaching and the actual procedures/nursing care delivered in the clinical area.
  • “Matching of the textbook descriptions of clinical situations with the reality of practice in the nursing profession” (Scully, 2011, p. 93).
•  Clinical area:
  • Any environment where nursing care is rendered:  hospital setting, community, ambulances, etc. often, the practical setting is the real world.

RELATIONSHIP BETWEEN THEORY AND PRACTICE:

• Inter alia meant to:
  1. Provide basis for understanding the reality of nursing
  2. Enable the nurse to understand why an event happens, e.g. why a pressure sore develops faster in an unconscious elderly patient
  3. Organise nursing care AND Sets standards of practice
  4. Describe clinical problems to be considered
  5. Describe setting in which practice should occur
  6. Offer the nurse basis for making informed decisions
• Theory based practice will be able to describe, explain, predict and control nursing events and initiate preventive actions.
• Theory and practice are inseparable for the development of the profession and autonomic nursing practice.

THE GAPS: STATING THE PROBLEM CLEARLY

• However, many theories cannot be put into practice, creating a gap.
• The level of theory integration into practice is controversial.
• Several quantitative and qualitative studies provide compelling evidences both in Nigeria and elsewhere:
  • “I have learnt so many things in the class but there is not much chance to do these in the actual settings” (Sharif and Masoumi, 2005) (Iran)
  • “I noticed that many things which were taught in the class could not carried in the clinical area”   (Anyebe and Adamu, 2010) (Nigeria).
• A survey indicated the perceived level of gap among a convenient sample of 150 students.

Table 1: Rating of Theory-Practice Gap in Zaria
Source: Anyebe and Adamu (2010, Field work)

Gap	Frequency	Percentage %
No gap	13	8.7
Narrow	42	28.0
Wide	65	43.3
Very wide	30	20.0
Total	150	100

THEORY-PRACTICE GAPS: THE UNITS OF ANALSYIS (AS PERCEIVED REASONS)

• Themes or issues with five (5) categories were identified in the theory-practice gaps (as conceptual framework):
  1. Students/practitioner:
  2. Instructor/Manager
  3. Environment
  4. Culture
  5. Organisation process
• These reasons were classified into two themes: input and process (See Table 2 and Figure 1)

Table 2: Themes and subthemes

Fig. 1: Themes and Subthemes

CAUSES OF THEORY-PRACTICE GAPS IN NURSING

• Broadly, there are the following aetiologic issues in the theory-practice gaps:
  1. Lack of knowledge
  2. Lack of Skills
  3. Value Disorientation
  4. Poor Attitudes
  5. Structural or organizational issues
• These can be discussed as follows:

1. Lack of knowledge

– two types: “know that” and “know how”

• Memorization system in the nursing school (emphasis on passing examinations).
• Unappropriated clinical knowledge of instructions
• Imported theories and suitability
• Lack of local and culture-sensitive models
• Paucity of research in health care setting,
• Apprenticeship model and opportunities for continuous education.

Lack of incorporation of research into practice

2. Lack of Skills

• Anxiety/Transition shock by newly graduated nurses
• Domination of task-oriented work in the clinical settings
• Lack of current clinical practice among nurses and health educators
• Fear of making errors, thus limiting students’ development and willingness to experiment

3. Value Disorientation

• Shortage of philosophical insight about nursing.
• Transition shock and anxiety among learners/novices– new entrants see education as useless and then engage in the usual traditional routines as better choice (socialization into the “culture of practice environment” (leading cycle of routines).

4. Attitudinal Challenges

• Negative Attitudes of practitioners/learners
• Reverse clinical role modelling

5. Structural or organizational issues

• Poor communication/disconnect between theoretical units (schools, faculties) and practice units (wards, clinics)
• The school curriculum
• Ward setting (clinical situation). Inappropriate choice of settings account for many inappropriate theoretical application 9reilly and Oberman, 1999).
• Use of students as service providers
• Lack of mentoring,
• Poor/weak teacher and student relationship widen gap (Poor supervisory relationship (Aththiligoda, et al;, 2012)
• Gap between academia and Professional Bodies (NANNM and or the subspecialties)

A local study in a Teaching Hospital in northwest Nigeria, identified a mix of these factors as perceived by students in two nursing schools (Anyebe and Adamu, 2010).
Table 3: Factors Identified as Creating Gaps in Theory and Practice

Factors	Frequency	Percentage %
Insufficient instrument for practice	65	43.3
Lack of Clinical Teaching/Supervision	42	28.0
Inadequate time to practice ideal procedures	13	8.7
Human resource challenges	30	20.0
Total	150	100

PATHOPHYSIOLOGY OF THEORY-PRACTICE GAPS:

• The problem will ultimately be at two levels:
  1. Student clinical situation
  2. Practitioners’ clinical situation
• The processes leading to the development of gaps may be conceived as DISCONNECTS in:
  1. Interaction between teacher and learner occurs
  2. Interaction between clinical instructor
  3. Interaction between clinical practitioner
  4. Interaction between learner and client
  5. Interaction between learner and assessor
  6. Product produced
  7. Product circulated (employed)
  8. Manifestations

THE EFFECTS OF THE GAPS (MANIFESTATIONS)

“Theory without practice is sterile and practice without theory is blind. Research needs to be seen as mainstream and part of practice, not something outside of nursing.”

• A disconnect between best evidences or research and practice (non-use of evidence-based practice);
• Transition shock and anxiety among learners/novices– new entrants see education as useless and then engage in the usual traditional routines as better choice (socialization into the “culture of practice environment” (leading cycle of routines).
• Incapacity of nurses
• Decreased quality of care
• Patient Dissatisfaction and prolonged period of hospitalisation and therefore increased cost of care and treatment:
• From the client perspective, I believe there are many people harmed and money wasted by not using the best interventions/practices.
•  Caregiver Dissatisfaction

BRIDGING THE THEORY-PRACTICE GAP IN NURSING PROFESSION

• Can the Gap Ever Be Closed?
  • Watkins (Jun 2018) distinguishes between bridging and closing the gap – Hence Applaud Choice Of Topic.
• The all-important question is, ‘can the theory-practice gap ever be closed’?
  • Cook (1991) argues that it can’t and that while the narrowing of the theory/practice gap may be a realistic goal, attempts to close it completely are doomed to failure.
• Therefore, the need to bridge the gap.
• But how do we bridge gaps to reduce negative impacts?

BRIDGING THE GAP: THE STRATEGIES

In bridging the gap,

• The first strategy is: “Agree on a consensus on the reason to bridge the gap.”
• This is a value or philosophical consensus which must focus on:
  • Setting the right rules
  • Having clear operational directions for various situations
  • Attaching clear meanings to events, terms and systems
• Academic-Clinician Collaboration: establish collaboration between academics and clinicians such collaborative research projects, integrating research into practice  Using clinical nursing professions
• Building a Research Culture and Improving Research Access (EBP)
• Clinical simulations: clinical teaching should be based on needs, equipping clinical skill lab
• Reflective Nursing (Critical Thinking)
• Curriculum Reform:
  • Basic/undergraduate and graduate remodeling
  • Internship in Nursing: opportunity provided if properly managed is theory-practice gap—losing or bridging model
  • Doctor of Nursing Practice vs PhD Nursing
  • Role models (both in faculty and clinical settings): the student/novice/junior colleague must be motivated to learn and reflect on practice
• Organisational approaches:
  • Improving Staffing situation
  • Staff continuous education
  • Internal Peer Review of lectures, demonstrations            and practice
  • A climate for learning -  freedom of learners to explore, question and dissent; allow teachers, preceptors, clinicians and students together examine failures and learn from them.
  • Link between Academia and NANNM/subspecialties to generate culturally sensitive models applicable to our diverse cultural heritage
• KAS (Knowledge, Attitude, and Skill) Strategy: (scenarios) updating knowledge of teachers and nurses, , better ways of engaging teachers and nurses
• Identifying four (4) things
  • Knowledge
  • Behaviours
  • Skills
  • Attitudes  (using the Model – next slide)

Fig.2: KAS (Knowledge, Attitude, and Skill) Strategy:

STAKEHOLDERS’ ROLES

• Student/Practitioner – deliberate desire to internalize learning and practice ideal procedures, processes and habits.
• Nurse Teacher – curriculum development and implementation to meet societal needs; role models.
  • Knowledgeable, skillful, competent and committed to clinical teaching.
• Clinical Nurse Preceptors/Mentors – clinical role models; to guide students to grow in competence and confidence is invaluable
• Clinical Nurse Practitioner – Support student development (highly influential in the development of the student nurse and midwife.
  • Prioritizing, putting theory into practice in context specific and workable ways, and implementing research
• The Institution:
  • Providing accurate evidence based teaching
  • Staffing levels,
  • Financial support and
  • A strong awareness of the importance of fitting within the context of the clinical setting.
• Patients/Clients:
  • Insistence of quality care through patient education;
  • Be ware of increased legal/right consciousness

• Professional Associations
  • Sensitization (as being done, applaud NANNM);
  • Link with academia;
  • Challenges sub-specialties to come with NANNM definitions of nursing, treatment protocols, white papers on prevailing health issues;
  • Pursue placement for nurse policy makers and implementers in the hierarchy
  • Among others which participants at interactive and communiqué brainstorming

Barriers to Bridging the Gap: Perceived and Real

As identified by (Armstrong 2009)

• Nurses did not feel they had authority to implement research findings.
• There was insufficient time on the job to implement new ideas and/or to read research articles.
• Hierarchy of health care system would not allow and/or cooperate with implementations.
• Statistical analyses were not understandable.
• Facilities were inadequate for implementation.
• Other staff were not supportive of implementation.
• Lack o linkages: practice/academia; association/academia
• KAVS issues and other aetiologic factors
• Among others

Some Nigerian Experiences
(KAVS Conceptual Model)

• Attitude more than knowledge responsible for the widening gap…..
• Or can we say that knowledge of nurses is dropping? Or the knowledge base is atrophying? No.
• Attitude! Attitude!!  Attitude!!! All the way

Selected situations

• Scenario 1: MVA (all materials available, nurses trained, but procedure wrongly carried out)
• Scenario 2: Vital signs (chatting without assessment)
• Scenario 3: Case Study on Birthing Position and Perineal Trauma: African Experience Paperback – by Faith Diorgu (see next slide)
• Scenario 3:  Case Study on Birthing Position and Perineal Trauma: African Experience Paperback – by Faith Diorgu

”Cumulative evidence supports the use of upright positions during labour and childbirth, which has benefits for both mothers and babies.

Despite good evidence to support upright birthing positions and the restrictive use of episiotomy, birthing in some part of Africa continues to use the lithotomy/semi-recumbent birthing position and episiotomies.

These practices may reflect challenges in adopting and supporting evidence-based practices.

Hence, it became important that research be undertaken to explore mothers’, midwives’ and obstetricians’ perceptions and experiences of birthing positions and perineal trauma with this research question:

What are the perceptions and experiences of mothers, midwives and obstetricians regarding birthing positions and perineal trauma?”

Your answers please

SUMMARY

• Theory-practice gaps are yawningly wide, due to:
  • Individual factors such as anxiety, insufficient knowledge and inadequate self-confidence affect clinical education negatively.
  • Organisational/Environmental factors: Insufficient equipment, students being treated as workers, inadequate time to perform procedure, the actual ward situation and demonstration room, poor interpersonal relationship and communication with hospital staff, poor staff attitudes towards student/novice learning, insufficient clinical supervision, and leadership style
  • Professional Factors: such as collaboration challenges and curricular issues.
• In Bridging the Gap, we need (among many other things):
  • Enhance collaborative work in the clinical environment and school;
  • Increase facilities;
  • Treat students as adult learners;
  • Implement modern teaching methodologies;
  • Conduct continuous revision and upgrading of the curriculum
  • Conduct further studies to identify problematic areas and overcome the theory practice gap in nursing profession.
  • Nurses MUST a Voice to Lead IN  BRIDGING HEALTH CARE GAPS

CONCLUSION

• Despite these barriers and scenarios, there is strong hope.
• The difference between a successful person and others is usually not a lack of knowledge, skills and strength but rather in a lack of will… (anonymous).
• The responsibility to bridge the gap must however be shared by educators/academic, practitioners, professional bodies, and other stakeholders.
• After all, the effects of the gaps are widespread: individual patients, caregivers/professional and society at large.
• With the strong hope, continuous education and skill acquisition as well as the attitudinal revolution anticipated, the gaps between the ideal (theory) and real (practice) should and will  experience a Julius Berger-type of Bridging.

I thank you immensely for giving me opportunity to share my thoughts with esteemed Nigeria Nurses and Midwives:

HAPPY NURSES WEEK

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