Investigating Factors Affecting the Gap of Nursing Education and Practice from students and instructors’ viewpoints

Document Type : Original Article


1 Department of Educational Management, Payame Noor University of Mashhad, Mashhad, Iran

2 Department of Physiology, Birjand University of Medical Sciences, Birjand, Iran

3 Department of nursing, Faculty of Nursing and Midwifery, Birjand University of Medical Sciences, Qaen, Iran


The existence of a gap between theory and practice in nursing is a problem that is rooted in the history of nursing education, which means that there is a difference between what the student at the college and the behavior that appears in the clinic, and this discrepancy is of concern to community health educators. A coherent understanding of the learning and practice gap is a crucial step in dealing with this gap and thus promoting nursing and community health. This study aimed to determine the factors affecting the gap between education and practice from the three viewpoints of nurses in Shohada Medical Center and nursing students and trainers of the Faculty of Nursing and Midwifery of Qaen.
 This descriptive-analytic study was carried out at the Faculty of Nursing and Shohada Hospital in Qaen. The instrument was a researcher-made questionnaire, completed by a census sampling method, completed by 107 nurses and 16 instructors and 105 nursing students from the Faculty of Nursing and Midwifery of Qaen, and analyzed.
 The greatest impact on the gap between training and practice in terms of students, the use of experienced mentors, self-confidence, coaching support, and the greatest impact from the mentors' view, coach's conscience, motivation, weak mentor supervision, the use of experienced coaches, educational perspective Managers and most impact from nurses' perspective: self-esteem, experienced mentors, nurse motivation and nursing shortages. The results also showed that students had more faith in the training and practice gap than instructors and nurses.
 It seems that, given the gap between education and practice, managers of educational centers should take the necessary measures to reduce this gap in management, decision making and educational planning.


Main Subjects


In Iran, undergraduate nursing education is the basis for professional nurse education. The public nurses should examine and identify the health status, and coordinate the cares in different areas for the individual, family, and society. Nursing is a science and practice-based discipline, and clinical internships play a major role in the development of nursing skills in the psychomotor domain (1).

Clinical learning is an important part of the learning process in many medical sciences, including nursing, in which the students interact with the environment, and apply the learned concepts in practice (2,3).

Training in clinical settings provides students with opportunities to experience nursing in the real world and apply theoretical knowledge in practice (4,5). Any problem in this area will affect the efficiency and effectiveness of nursing education (6).

The gap between education and practice is widespread in the nursing profession (7). In the present era, the separation of theory and practice or the gap between education and clinical services is one of the most fundamental challenges and one of the most important issues related to nursing and the health system. That is, what is taught in the classroom is different from the services offered at the bedside (8).

The separation or gap between theoretical science and clinical care can be defined as a mismatch between what nursing students learn in the classroom and what they experience in a clinical setting (9).

As a practical profession, nursing requires training based on a theoretical framework that allows students to learn the clinical skills that are essential for the care of patients (10).

However, many studies confirm that today the knowledge provided in the classroom is different from the clinical care (11) and there is a relatively deep gap in the educational process of nursing and midwifery and the clinical performance of the students (12). According to Elahi (2014), studies in Iran suggest that theoretical training is not practical (11). Also, Azimi (12) has stated that existing clinical education does not provide the student with the ability to express clinical skills. Nursing leaders claim that there are a large number of nursing graduates who are theoretically competent but lack any clinical skills (11).

Although nursing theories have been studied for many decades and many theories have been developed in this regard, there is still a real gap between theory and clinical education (13).

As Bandal stated for the first time in 1976, "The educators teach people who are skilled on paper, rather than practice and what students learn in theory, is far from what they really do in practice." (9).

Rogers stated in 1986 that knowledge transfer from class to practical application is affected by three factors: teacher, student, and curriculum. Disruption in either of these cases could lead to a gap between theory and practice (14).

Researchers have concluded that methods for preparing nursing students for college-to-hospital transition have been unsuccessful. Also, one of the reasons that students' caregiving at the clinics is different from theoretical training is the emphasis on the acquisition of theoretical knowledge for postgraduate education. Given the age of the explosion of information, this vacuum is predicted to deepen each day. (8).

Nursing students understand the gap between theory and practice more than other groups. Because they are under the direction of the ideal and scientific training of the coaches. On the other hand, they are faced with routine practices of clinical nurses that are different from theoretical lessons (15). Current developments in the educational system suggest that higher education while considering the existing financial constraints, should maintain and improve its educational performance (13). The coherent understanding of the components and factors of the gap between teaching and practice is a vital step in dealing with it (7). Since nursing plays an important role in promoting health and standards of health, the gap between theory and practice has also the same impact. Nursing is a discipline that combines knowledge and practice. These two cannot be separated from each other and any change in nursing practice should be started by changing educational programs (16).

The gap between the theory and practice has negative effects on students as well; they are unable to adapt themselves to conditions due to the conflicts between faculty expectations and the realities of the workplace. Therefore, they will be afflicted with mental and physical problems including feeling disability, depression, anxiety, and insecurity due to lack of efficiency in the workplace and ultimately leaving the profession (9).

The most important issue is that the existence of the gap between theoretical education and clinical care can endanger the health of patients. Identifying the factors affecting it and recognizing the weaknesses and strengths in this area can improve the nursing profession (13).

Given the aforementioned reasons, frequent observations of writers and other educators, and the student's own admission to a difference (gap) between what is said in the classes (training) and what is done in the patient's bedside (practice), this study was conducted. It aimed to identify the reasons why the teachings are not applicable and what solutions can be found to reduce this gap.

The aim of this study was to determine the factors affecting the gap between education and practice from three perspectives of nurses in Shohada Medical Research & Training Center and nursing students and educators of the Faculty of Nursing and Midwifery of Qaen in the first semester of 2017.

The data was collected using a researcher-made questionnaire consisting of a demographic section and a specific section related to factors affecting the gap between education and practice based on the Likert scale. Data analysis was done with SPSS version 22.


 This is a descriptive-analytic study that investigates the factors affecting the gap between education and practice from the viewpoint of nursing students of faculty and instructors and nursing staff of Shohada Medical Research & Training Center.

Sampling was done by census method and 107 nurses, 105 nursing students and 16 instructors participated in the study.

Inclusion criteria:

For students: They must agree to participate in the study. They must be a Nursing student at the Faculty of Nursing and Midwifery of Qaen in the first semester 2017.  At least one semester of internship at Shohada Medical Research & Training Center.

For staff: They must agree to participate in the study. They must be a member of the medical staff of Shohada hospital.

For educators: They must agree to participate in the study. They must be selected as trainee instructors.

The data was collected using a researcher-made questionnaire consisting of a demographic section and a specific section related to the factors affecting the gap between education and practice.

 A specific section was developed based on the Likert scale. For content validity, questionnaires were presented to ten professors of Qaen Faculty of Nursing, and their views were applied. Furthermore, the validity of the questionnaire was confirmed by exploratory factor analysis after the distribution and gathering and entering of data.

To test the reliability of the tool, the retest method was used and (r = 0.85) was determined which was acceptable. Then, for analyzing the data using SPSS version 22, first Kolmogorov Spironov test was performed to determine the normality of the whole questions, which was normal and ANOVA and t-test were used. Then, for measuring the relationship between demographic variables and questions, Kolmogorov-Smirnov test was performed for each question. Because it was abnormal, Kruskal-Wallis and Mann-Whitney U tests were used for analysis.


The findings showed that all of the students believed there was a significant gap between nursing education and practice and nursing students felt the most gaps. Table1 shows these results.


Table 1. The extent of education and practice gap from the viewpoint of the three groups of nurses, students, and nursing educators

Mean (SD)



109.46 (10±13)



146.12 (16±79)







The highest effects on the gap between training and practice as mentioned by students according to table 2 were as follows: self-esteem (88%), coaching support (85%), use of experienced trainers (84%), equipment shortage (82%), And the least impact were the comprehensive theory before internship (66%), imitating the higher-level students (70%), the encouragement and punishment of superiors (71%), and the patient’s level of knowledge (72 percent)


Table 2. The most effective factors on the gap between teaching and practice from the students' point of view

Number (percentage)

Most effective factors

92.4 (88%)

Self Confidence


Supporting the coaches

88.2 (84%)

Use experienced coaches


Lack of equipment




Based on the view of nurses, the factors which have the highest greatest impact on the educational gap and practice according to table 3 are respectively: confidence (89%), experienced educators (88%), nurse motivation (87%), lack of nurse (86%), interest in Training (85%), head nurse support (84%), untimely non-payments (84%). The least impact was related to accreditation (61%) and health promotion plan (64%).

Table 3. The most effective factors on the gap between teaching and practice from nurses 'viewpoints


Frequency (percentage)

Most effective factors

95.23 (89%)

Self Confidence

94.16 (88%)

Using experienced coaches

93.09 (87%)

Nurse motivation

92.02 (86%)

Nurse shortage

90.95 (85%)

Interest in teaching

89.88 (84%)

Support from the head nurse

89.88 (84%)

Lack of timely payments



The factors which have the highest impact on training and practice gap based on educators according to table (4), are respectively: educator’s work ethics (91%), Motivation (91%), weakness of coach supervision (87%), lack of use of experienced coaches (86%), educational viewpoints of managers (86%), and the factors which had the least impact was related to health promotion plan (53%) and patient’s accreditation (61%).


Table 4. The most effective factors on training and practice gaps from coaches' point of view


Frequency (percentage)

Most effective factors

14.56 (91%)

Educator’s work ethics

14.56 (91%)


13.92 (87%)

Weak supervisor supervision

13.76 (86%)

Lack of experienced coaches

13.76 (86%)

Educational view of managers



Additionally, in measuring the relationship between demographic variables and the factors affecting the educational and practical gap, the following items were significant:

The relationship between gender and factors affecting the educational and practice gap in students in the lack of using experienced educators was significant. The relationship between gender and factors affecting nursing education and practice gap was significant in cases such as gap, lack of supervision of the head nurse, lack of distinction between good and bad performance, and lack of educational viewpoints of managers. Also, in examining the relationship between age of nurses and factors affecting educational gap, the role of time, self-confidence, educator's teaching style, staff support by colleagues and weakness of head nursing supervisor were significant.

Results of the study showed that the most effective factor in the gap between the training and practice among students and nurses is the self-confidence factor and work ethics in educators. These findings were similar to Mehrabian et al’s study (13). They considered the role of nurse's self-confidence and his support by the head nurse as factors influencing the adaptation of theoretical knowledge and clinical care. The results were also consistent with the study of Khodayi et al. (9) and Kerman Saravi (16). According to Khodayi et al. (9), the most important strategy to reduce the gap between theory and practice is to use qualified instructors. He defined qualified as having the power to integrate theoretical knowledge and clinical practice. In his qualitative study, Kerman Saravi (16) emphasized the instructor’s role in promoting the educational system. He stated that the improper teaching method of educators is one of the most important barriers to theoretical and clinical education.

In order to illustrate the educators' viewpoints, the research results were found consistent with the results of Joe Carlot (17) and Khodayi et al. (9). Joe Carlot (17) stated in his research that all of the interviewees felt that there was a gap between the theory and practice and the lack of clinical facilities, the lack of cooperation between clinical centers and educational institutions, and the role of mentor as factors influencing the gap between theory and practice. However, these results were different from those of Mohammad Ali Hosseini et al. (16) because he concluded in a review study that there should be a gap between theory and practice, because if this gap does not exist then it can no longer be called theory, and it is in fact practice (18).

 The results of the present study and similar studies all refer to one essential point which is the gap between theory and practice in nursing. Although the factors affecting this gap from the point of view of students, nurses and nursing educators are different in some cases, they all have a common point, and this is the existence of this gap between theory and practice.

 It seems that factors that have a significant and effective role in this educational gap have not been seriously considered in nursing, including the lack of self-confidence that had the highest percentage both from the point of view of students and the personnel. Self-confidence is defined as the individual's confidence in his or her ability and competence, in which case arrangements must be made, and nursing educators should try to update their nursing knowledge first and, on the other hand, by using mixed methods instead of traditional methods and timely use of educational theories Instructional such as social cognitive theory attempt to increase self-confidence, self-efficacy, and motivation of students. In order to have such effective and useful training, it is necessary to have experienced and knowledgeable trainers who, in addition to having a strong academic resume and complete familiarity with the principles of management, in particular, the control and monitoring aspects, have a proper clinical performance as well. These things should be taken into consideration when hiring instructors.

On the other hand, the results of this study and other studies indicate that the lack of facilities and equipment are also factors that influence this educational gap. The therapeutic techniques are process-oriented. In other words, it is a step-by-step and regular process. It is clear that the absence of a device and equipment will disrupt this process; therefore, there must be a balance between the available facilities and what the student learns at the center of clinical skills in the college. It should be kept in mind that the lack of facilities is not merely equipment, in most cases, the shortage of manpower is an effective factor that results in the gap between education and practice. Failure to observe the standard nurse distribution of the patient in the educational centers and the assigning the written and office work to the nurses, in addition to nursing care, has also led to the increasing deepening of the gap.


It seems that changing the views of health managers is essential and they should strengthen their educational outlook and, by eliminating deficiencies, attracting qualified trainers, increasing monitoring and control, take a step to reduce the gap between education and practice. In order to improve nursing profession and society health, students must be trained to have high knowledge and self-confidence in their future career, and instead of using traditional and non-scientific routines and inappropriate methods in departments, use scientific principles in for taking care of the patients and in this regard, they must be supported by their managers.

It should be noted that the limitations in this study were that it was conducted at a faculty and a training center. Apparently, if it was done simultaneously in several faculties and hospitals, we would have achieved wider results.


 The authors thank the professors and the staffs of the faculty of Nursing and Midwifery of Shohada Medical Research & Training Center for their sincere cooperation.

Financial support: This research was registered at Payame Noor University of Mashhad (No. 41774). Therefore, the authors appreciate the university's research assistants.

Conflict of interest: The authors state that there is no conflict of interest.


Kambiz Rokhzadi MZ, Mahmoudi S, Abdolmaleki MR, Salehnejad Gh. A study on the accessibility of nursing students to clinical internship learning objectives. Research in medical education 2015; 7(2):  37-44. [In Persian].
2.         Pourghane P, Hosseini MA. The role of clinical nurses on nursing students' learning in the hospital environment. Journal of medical education development in Zanjan 2010; 3(4): 7-11. [In Persian].
3.         Tanumand A, Abdullah Zadeh F, Niknam F. The study of environmental barriers in clinical education from the viewpoint of students and instructors. Journal of education development in Jondishapour 2014; 5(2): 106-13. [In Persian].
4.         Mohammadzadeh A, Ramezani Badr F, Amini K, Musaeefar M. Factors affecting clinical learning of nursing students: A qualitative study. Journal of development of medical education in Zanjan 2011; 4: 20-30. [In Persian].
5.         Alaei S, Kahui M. Study of nursing students' information needs in clinical education of emergency departments. Koomesh 2010; 11(3): 155-61. [In Persian].
6.         Nazari R, Beheshti Z, Arzani A, Haji Hosseini F, Saatsaz S, Bijani A. Stressors in Clinical Education of Nursing Students of Amol Nursing Midwifery Faculty. Journal of Babol University of Medical Sciences 2007; 9: 45-50. [In Persian].
7.         Hatlevik IK. Reflective skills and theoretical knowledge as key factors in bridging the gap between theory and practice in initial nursing education. J Adv Nurs 2012; 68(4): 868-77.
8.         Zayghami R, Saadatjoo A, Khorasani P, Afshani S, Ganjeiy S, Jafarian H, et al. Drafting a national document on reducing the breakdown of theory and practice in nursing in Iran. Journal of nursing education 2014; 3(2): 68-75. [In Persian].
9.         Khodayi A, Mansourian M, Ganje'i S, Asgari H. A study on the strategies for reducing the gaps between theoretical knowledge and clinical practice from the perspective of nursing students in Tabriz University of Medical Sciences. Research in medical education 2016; 8(2):  49-59. [In Persian].
10.       Razi M, Rajabpour M, Poursmaeil Z, Chamanzari H, Sharafi S. Evaluation of coordination of theoretical education with clinical education of nursing students from the perspective of the teachers of Mashhad Nursing and Midwifery Faculty. Quarterly journal of the Student Research Committee of Research Vice-Chancellor of Mashhad University of Medical Sciences 2016; 19: 33-40. [In Persian].
11.       Ellahi N, Alhani F, Ahmadi F. Professional participation: Explaining nurses' experience in facing the clinical distance between theoretical and clinical education. Nursing education 2014; 3(1): 21-31. [In Persian].
12.       Azimi N, Bagheri R, Mousavi P, Bakhshandeh Bavarsad M, Honarjoo M. (2016). Study of the problems of clinical education and providing solutions to improve its quality from the viewpoints of midwifery students. Journal of research in medical education 2016; 8(4): 43- 51. [In Persian].
13.       Majidi SA, Mehrabian F, Asgharnia M, Safarmohammadi H, Kazemnejad E. Effective factors on adaptation of theoretical education and practical nursing care. Research in medical education 2015; 7(2): 12-20.  [In Persian].
14.       Rolf G. Closing the theory-practice gap: A new paradigm for nursing. Butterworth-Heinemann:  Elsevier; 2002: 127.
15.       Khairulnissa Ajani S, Moez I. Gap between knowledge and practice in nursing. USA: Elsevier; 2011: 3927-31.
16.       Kerman Saravi F, Navidian A, Imani M. Understanding nursing students about the quality of clinical and theoretical education: a qualitative study. Journal of the Center for Research and Development of Medical Education in Yazd 2016; 7(4): 28-4. [In Persian].
17.       Corlett J. The perceptions of nurse teachers, student nurses and preceptors of the theory-practice gap in nurse education. Nurs Educ Today 2000; 20(6): 499-505
18.       Hosseini MA, Sepahvand MJ, Mohammadi Shahbolaghi F, Nisea F, Bagheri Noparest K. The gap between theory and practice in nursing: being or not. Nursing education 2016; 5(1): 23-9. [In Persian].