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  • Published: 13 September 2021

Solutions to bridge the theory-practice gap in nursing education in the UAE: a qualitative study

  • Ahmad Saifan 1 ,
  • Briliya Devadas 2 ,
  • Fares Daradkeh 3 ,
  • Hadya Abdel-Fattah 3 ,
  • Mohannad Aljabery 4 &
  • Lintu Maria Michael 4  

BMC Medical Education volume  21 , Article number:  490 ( 2021 ) Cite this article

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The theoretical knowledge of nursing underpins the practice, while the practice environment determines the circumstances within which the theoretical knowledge is applied. The biggest challenge facing nursing as an academic field is the theory-practice gap, which is a universal issue in nursing . This study aimed to raise solutions to close the gap between theory and practice in nursing education through the eyes of nursing students in UAE.

A qualitative descriptive approach was followed; whereby 25 Emirati nursing students were interviewed.

Two main themes are discussed in this study: ‘Clinical Culture Creation’ and ‘Curriculum Content Reformation’. The students suggested to decreased the loud and stress on their clinical educators. They also suggested creating synchronization between what is taught in classrooms and labs and what is offered in the clinical training. Moreover, some of the students expected to have more benefit if they get their clinical training in health institutions owned by their college. On the other side, many of the participants suggested to move from the integration system to the block system. Another interesting suggestion includes having the same college staff to teach the theory and the clinical. The final suggestion includes decreasing the paper work during clinical training.


This study explored the solutions to bridge the theory-practice gap in nursing education in the UAE. The study has implications for nursing education and practice within the UAE and is imperative for graduating workplace ready professional nurses within the country.

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Theory and practice are the twin essential components of nursing education. The theoretical knowledge of nursing underpins the practice, while the practice environment determines the circumstances within which the theoretical knowledge is applied. Nursing is a scientific profession based on applied research, guided by evidence-based theory, and numerous concepts within the profession have focused on the art of nursing and theoretical sciences. However, the biggest challenge facing nursing as an academic field is the theory-practice gap, which is a universal issue in nursing and midwifery. It has been explained as a “distancing of theoretical knowledge from the actual doing of practice” [ 1 , 2 ], and it affects newly qualified registered nurses when they embark on clinical practice, as well as nursing students during clinical placements.

Though professional knowledge is introduced as theory in the classroom settings, it is within laboratory sessions that this knowledge is translated into practice in nursing education, and in clinical practice in hospital settings, these skills are transferred, to provide meaningful need-based care for patients. Thus, the theory-practice gap is most obvious in nursing education in laboratory sessions and clinical practice. This theory-practice gap is concerning as it primarily affects patient safety negatively, while concurrently contributing to an unsatisfactory clinical experience for the novice nursing student in the clinical environment.

Organizational culture and processes act as an important motor of the theory-practice gap, in addition to student and instructor factors in the teaching-learning environment. Several studies suggest that the reasons for the existence of the gap are multifactorial [ 3 ]. The frustrations and difficulties associated with the gap are experienced mainly by student nurses and newly qualified nurses, and can harm their socialization into the professional role, and subsequent professional development [ 4 , 5 , 6 , 7 ]. The reality shock is considered a major cause for low job satisfaction and high job attrition rates among newly qualified nurses [ 8 , 9 ]. The theory-practice gap has also been cited as a contributory factor in medication errors [ 10 , 11 ] and reduced physical assessment skills use among nurses [ 12 ]. The existence of the theory-practice gap can influence the quality of nursing care and patient outcomes.

Several studies highlight the theory-practice gap in nursing education worldwide and in the Middle East and North Africa (MENA) region [ 6 , 13 , 14 , 15 , 16 ]. Most reviewed studies in this field focused on searching for whether the gap is present or not, while some studies considered possible reasons for it. However, solutions to decrease this gap, and to link theory to practice, are rarely discussed and studied [ 14 , 17 , 18 ]. The role of nursing academics in linking theory to practice is crucial in closing the theory-practice gap [ 6 , 14 , 19 ], while the role of preceptor to assist the nursing students in developing clinical skills and integration into the culture of the clinical area cannot be emphasized more [ 20 ].

Several international studies from UK, Ireland, Turkey and the US have identified the importance of collaboration between nursing instructors, nurses, nursing school and hospital managements as one of the most suggested means of bridging the gap [ 14 , 15 , 20 , 21 ]. Several studies showed the importance of the availability of adequate number of well-trained academics and clinical preceptors. These studies identified other strategies to close the gap between theory and practice in nursing education such the presence of clear context-based curriculum and availability of standard clinical guidelines [ 6 , 14 , 18 ]. Eggertson [ 22 ], an expert Canadian nurse, stressed on the need for undergraduate nursing education that better equip nurses to assume leadership roles in inter-professional teams and support them in providing high-quality patient-centered care.

The nursing program, at the College of Health Sciences in the UAE, is a 4-year Baccalaureate degree program, having initial program accreditation from the Ministry of Higher Education for Scientific Research (MOHESR), and institutional accreditation from the UAE Commission of Advanced Accreditation (CAA). The current program study plan consists of 127 Credit hours; 98 credits of theory, 9 laboratory sessions and 27 clinical placement. Laboratory practice sessions are opportunities for students to practice hands-on clinical competencies and skills, albeit in a safe environment. Students in clinical placement are accompanied by clinical instructors with a ratio of eight to ten students assigned to one instructor. While in the clinical placement units, each student is paired with a nurse, as preceptor, who will demonstrate the nursing care provided to patients and provide opportunities for students to practice hands-on on real patients. At the end of the clinical placement, the clinical instructor will evaluate the students, with the preceptor feedback, based on competency checklists and the CAT (clinical assessment tool that students are already familiar with.

In the UAE, every year nursing student cohorts are graduated and start their professional careers in hospitals around the country and internationally. There is shortage in the number of nurses in the UAE and the surrounding countries such Sadi Arabia, Qatar and Oman. These countries require a large nursing taskforce and a ready to practice nursing graduates. This is a major concern for healthcare service managers, and highlights the need for immediate action to expedite the process of attracting and graduating ready to practice, local nurses that understand the local culture and context and remain in the system (23, 24). Therefore, it is essential that these nurses are well prepared upon graduation so they can handle the requirements of their new roles [ 23 , 24 ]. Reviewing the body of literature showed that suggestions and interventions to close the theory-practice gap in nursing education were rarely discussed worldwide. Moreover, there are no study to discuss this subject in the UAE.

It was thought that the best people to suggest solutions to close this gap are the nursing students who went through this experience. Finding solutions to the theory-practice gap before entry to practice may reduce the difficulties experienced by the graduating participants, and increase their ability to integrate their knowledge appropriately in the practice setting. The current paper aims to raise possible solutions to close the gap between theory and practice in nursing education through the eyes of nursing students currently studying and experiencing this phenomenon in nursing education in UAE.


This study aims to explore the strategies that could reduce the theory-practice gap in nursing education within the UAE context. This study used a descriptive qualitative approach to explore solutions to bridge the theory-practice gap in nursing education in the UAE. According to Glesne [ 25 ] (p. 4), “qualitative research methods are used to understand phenomena from the perspectives of those involved, to contextualize issues in their particular socio-cultural-political milieu, and sometimes to transform or change social conditions.” Face-to-face qualitative interviews are commonly used due to their usefulness and the fact that a great amount of information can be ascertained by simply questioning people in an interpersonal format. Qualitative research attempts to increase our understanding of why things are the way they are in our social world, and why people act in the ways they do [ 26 ]. The following research questions were initially used to explore the solutions to the theory-practice gap in the UAE.

Tell us about your first experience in training in clinical settings. How can you describe this experience?

Did you find differences between what you have been taught in classrooms and what you have faced in the clinical training? Please, explain …

How did your mentor’s support and understanding of what you learned in theory help you in practice?

How do you think we could bridge the theory-practice gap in nursing education?

Sample and sampling

Data for this study was collected from participants studying at a main College of Health Sciences in the UAE. This college has an accredited nursing program and have almost the biggest pool of nursing students and graduates in the country. Established in 2006, the College aims to meet the UAE’s growing need for skilled healthcare professionals. Being the first nursing college in the UAE to study participants’ experience in the clinical setting, the qualitative approach would help obtain rich and in-depth information. An interview schedule was developed based on the literature review, but an emergent design was used to enable the asking of probing and follow-up questions to explore emergent areas of interest [ 27 ].

Sampling is an essential step in the research process as it helps to inform the quality of interpretation made by the researchers that stem from the underlying results [ 28 ]. Purposive sampling technique was used to elicit participant views regarding the prevalence of theory-practice gap in nursing education in the UAE, from among the Nursing Program participants. The proposed participants for the study were selected based on specific criteria. They needed to be at the third-year level onwards as participants who had attended at least two or more clinical courses, because they would have a better understanding of the study topic under exploration and have had enough clinical practice to compare with the theoretical component. The College has branches in four emirates within the country, and participants were recruited from all four campuses. Bridging participants were excluded because of their prior work experience in hospitals, and the difficulty this could present to exploring the theory-practice gap specific to nursing education (as opposed to registered nurses’ practice).

A total of 25 participants expressed interest in sharing their views on the subject. As the College currently hosts only female participants within their population, 100% of the samples obtained were females. Both Emirati (local) participants and expat (non-national) participants were included in the study sample. According to Polit and Beck [ 27 ](p. 273), the “sample size in qualitative interviews is usually determined based on informational needs, and is approximately ten or until data saturation occurs”. Thus 25 participants in this study was more than sufficient to gain in-depth and rich data. Table  1 illustrates the demographic characteristics of the participants in this study.

Ethical considerations

Gerrish and Lacey [ 29 ] state that ethical implications should be addressed in every research stage, including protecting participants and researchers from harm, using voluntary participation, anonymity, and confidentiality, as well as informed consent. This study obtained ethical approval from the College Research Committee and College Institutional Review Board. All participants were given a participant information sheet and were made aware of their rights to withdraw from the study at any stage without giving a reason, and that this would not affect their educational progress or statutory rights. Anonymity was assured. All interviews obtained were audiotaped, and transcriptions were used for analysis purposes. All interviews were transcribed verbatim and were used only for this study. Participant confidentiality was maintained throughout. All methods were carried out in accordance with relevant guidelines and regulations.

Data collection procedure

After receiving ethical approval, invitation letters were sent via email to the nursing participants using their College email addresses, explaining the nature and scope of the study and participation expectations and rights, and inviting them to participate. Participants were asked to contact the research corresponding author if they wished to take part. Contact information for the corresponding author was added to the email and participants were given the chance to ask any questions or for any clarification before making their mind whether to participate or not. When they agreed to participate in the study and met the inclusion criteria, arrangements for interviews were made. Two expert interviewers did all interviews. These interviewers met with the primary author and discussed the interview guide. Each interviewer conducted two pilot interviews and shared the results with the primary author, then another meeting was arranged between the primary author and the interviewers. This meeting aimed to unify the interviewing method and to have similar interviewing questions and conditions. The reason to select two interviewers was to avoid social desirability and other forms of bias in the interviews, by avoiding interviews being conducted by participants’ teachers. In other words, the interviewers did interviews for participants out of their campuses, and they had never met them before.

Data analysis process

Computerized thematic analysis (NVIVo) was used to analyze the data that was generated by the interviews, similar to previous studies [ 30 , 31 ]. It was decided to assign Braun and Clarke [ 31 ] technique of thematic analysis to deduce emerging themes. They identified six phases of thematic analysis (Table  2 ), and these steps were undertaken in the study. Some sections of the interviews were in Arabic, which is the participants’ predominant native language. Transcribers fluent in Arabic assisted in the transcription and translation, and translations were checked for content accuracy and validity with the interviewers before analysis.

To build up the study themes, the researcher read the data repeatedly and highlighted common phrases to prepare the required codes. Interview extracts were highlighted and classified under possible codes. Participants’ phrases were highlighted with the same color to correspond to the codes, then the patterns among codes were identified to create the study sub-themes.

A total of 25 female full-time participants studying in the Bachelor of Nursing (BN) program at FCHS participated in the study. Their ages ranged from 21 to 23, and 17 participants were Emiratis, while 8 were expatriates. Eleven participants studied at the BN3 level, while the remaining 14 participants were at the BN4 level. Participants were distributed among the four FCHS campuses: Abu Dhabi ( n  = 5), Ajman ( n  = 8), Al Ain ( n  = 6), and Al Dhafra (n = 6). Nearly all the participants, directly or indirectly, made statements that reflected presence of a gap between what they have taught in the theory and what they have found in the clinical trainings. Many reasons were raised to explain the presence of this gap. Interestingly, most of the participants have raised some suggestions and solutions to close this gap directly after talking about these reasons. Therefore, it was important to focus on students’ suggestions and solutions to close the gap in nursing education in UAE. Four main themes are discussed in this study.

The students suggested decreasing the load and stress on their clinical educators. They also suggested creating synchronization between what is taught in classrooms and labs and what is offered in the clinical training. Moreover, some of the students expected to have more benefit if they get their clinical training in health institutions owned by their college. All these subcategories were collected under one major theme ‘Clinical Culture Creation’. On the other side, many of the participants suggested to move from the integration system (theory and clinical in the same time) to the block system (having the theory during the first half of the semester, and then having all the clinical trainings in the second half). Another interesting suggestion included having the same college staff to teach the theory and the clinical. This was expected to create more coordination between theory materials and clinical needs. Another suggestion was to decrease the paper work during clinical training. These suggestions have been grouped under another major theme ‘Curriculum Content Reformation’ (Table  3 ). Embedded within the above two themes, two other themes have also emerged – Learning by Reflection; and The instructors’ Approach. The themes have been elaborated below.

Clinical culture creation

Clinical training is a foundation of nursing practice and a salient feature in nursing literature. It is considered a basic block of nursing education, and this is exemplified in attempts to delineate and enrich the participants’ knowledge and skills throughout their program of study. All the participants have raised issues regarding the clinical training and they linked these issues with widening the gap between theory and practice in nursing education. The following discussion describe these issues under three subthemes.

Increase clinical loads on college clinical instructors

Participants revealed hesitation infrequently engaging with their instructors. Their reasons were related to the number of participants per group, the time designated to allow the participants to practice in each unit to understand all the nursing care required, and the clinical faculty instructor responsible for allocating more time to participants to bridge the gap between theory and the clinical training. As one of the participants reported:

“They are pressured, I have seen this in Aged Care clinical, Mr. X was very pressured, he had many groups, he tried his best to finish the requirements and to help us, and he did actually. However, if he was always available in the hospital, maybe we would have benefited more. the same thing I said earlier.” (P. 3, ADH Campus)

The students wanted to say that college clinical instructors should have more time to and fewer duties. This will facilitate their job and will enable them to spend more time with their students. They admitted the role of college clinical instructors to decrease the gap between theory and practice. Several students suggested assigning less number of students to each college clinical instructor. They explained that doing this will increase the time assigned to each student in the clinical practice and will allow the instructors to support their students.

“Oh … What I can say. They follow big number of students. They also have lots of paper work to finish. If the college assigned them to less number of students, they will be able to spend more time with us … They will be able to support us and to fill any gap in clinical education. I would suggest to assign each instructor to 3 or 4 students only.” (P15, AUH Campus)

Di-unification of competencies

According to the year of study, the competencies taught during the college lab sessions have to be twined with what the participants are exposed to during their clinical placement, in the clinical premises. Such similarity would provide participants with an increase in desire for clinical training and theoretical knowledge, and students will be more involved with patient care. According to their year of study, the competencies taught during the college lab sessions have to be twinned with what the participants are exposed to during their clinical placement in the clinical premises. Such similarity increases students’ desire for clinical training and learning theoretical knowledge, which consequently involves them more in patient care. Similarly, many participants mentioned that the same instructors supervising their clinical training is essential. Subsequently, the partnership between lab sessions and clinical instructors motivated the students in their clinical learning. Such a partnership approach has been emphasized in nursing literature for decades, and has continued to date [ 32 , 33 ]. As one participant remarked:

“My suggestion is to reduce the clerking on the clinical teaching as they have too many competencies to be completed in each clinical course, which is overwhelming, and diverts our focus … All of us would be preoccupied in completing these competences before the deadlines, and this will keep us away from doing hands-on procedures and engagement with patients. At the same time, having the same instructor who teaches us the theory and/ or the lab session supervising our clinical training would facilitate our clinical learning.” (P. 11, AJ Campus)

A few number of students provided practical solutions to the above problems. They suggested summarizing all the competencies requested from the students in the practice training. They suggested to share these competencies with all college academics and to explain them to the students before starting their clinical training. These students suggested adding more flexibility to implement these competencies. In other words, the students can take any opportunity to implement the available competency during their clinical training. This was expected to decrease the pressure on students and to give them more time to fulfill all the required competencies.

“Honestly, we do not have time for hands-on training. Each clinical course has different competencies, and we are requested to implement all of them during the semester. Sometimes, we keep waiting for one of the competencies for long time … We do not get the opportunity to implement all competencies during the semester. This add more pressure on us and make us anxious. If we have flexibility in implementing these competencies, this will ease our duty and will give us more chances to focus on the available competencies”. (P. 22, AA Campus)

Lack of own clinical facilities

There are some students explained that many medical-related education fields have clinical entities, facilitating feelings of belongingness, loyalty, and accountability. Such feelings facilitate and empower participants and clinical educators, who can ease the clinical training for both the clinical facilitators and participants during their placements. As one participant mentioned:

“The gap, first of all, is the hospital; if we had our own hospital it would be very nice; maybe we could have the labs in the hospital also. Maybe there would be patients who come to the hospital to take the treatment, but like, for less than other hospitals. Therefore, patients would come to our FCHS hospital because it is less costly.” (P. 6, ADH Campus)

This suggestion was not raised earlier in the literature. The students wanted to obtain all clinical training in one place owned by the college. This might be a difficult request, as the nursing curriculum includes several and different clinical courses such as medical-surgical, pediatric, maternity, mental health and community. It will be challenging to have all these courses in one place. The students might want to obtain their clinical training in more comfortable placements. This might be clear when one of the students described the clinical placements as a strange place for her. She explained that the preceptors were not familiar with the college curriculum and the objectives of their clinical courses. She indicated that there were no communication between their college clinical instructors and the preceptors in the clinical placements.

“The problem … No one know who we are and what we were requested to do. They did not have any idea about our curriculum. I think that there is a need for more communication between our college and the staff in the hospitals.” (P. 21, AJ Campus)

It should be indicated that only one student talked about the above barrier to link theory and practice. However, this might be shared by other students in the college and may influence negatively on the clinical training.

Curriculum content reformation

The second major them of the theory-practice gap concerned curriculum implementation in the classroom, which encompassed three sub-categories.

Need for adopting the block clinical rotation system

An area of reform revealed by participants related to the structure of the nursing programs’ teaching methodology. Participants felt that the nursing teaching plan could adopt the block model of clinical rotation rather than the integration model. This would help them complete and consolidate the theory of education first, improving their ability to translate their knowledge and abilities to the clinical practice through their clinical placement. Some participant views are shared below:

“I think we should finish the theory or clinical skills or laboratory skills; we should learn in the College first, and then we should start the clinical rotation. If we did not learn about the skills before and went to the clinical, it will be hard for us, because we do not know what it is and what to do. Therefore, if we already learned the skills in the laboratories then went to the clinical rotation, it would be easier for us and we will be familiar with the procedures done.” (P. 13, AA Campus)

One participant felt the need for clinical practice to inform the theoretical curriculum, contrary to the prevailing ethos of the curriculum and nursing education in general:

“Maybe we should focus on the clinical training or the clinical placement. We should link the clinical with the theory, not the theory with the clinical, because sometimes we cover a lot of things in the theory but it’s not relevant or current to the clinical practice.” (P. 20, AJ Campus)

It is important to indicate that the block system was adopted earlier in the college under study. The students used to finish the theory in the first half of the semester, and then they continue the clinical during the other half. The study plan was changed recently, and all the third and fourth year students went through a transitional stage of changing the study plan. The current study plan includes integration of theory and clinical. This means that the students study the theory and go to the clinical training every week during the semester.

Lack of congruence between theory and clinical training

Many participants related that teaching the theory of the subjects and clinical skills throughout the semester would improve their understanding of the course content. They reported that the educator would be better aware of the theory content covered and the clinical skills related, and would be able to merge these through the teaching and clinical training, as reflected in the following examples:

“I feel the one who is teaching should be the one with me in the clinical, because when it’s like this, I have a better experience in the clinical, but when it’s a different instructor, I feel like sometimes he becomes lost and I become lost.” (P. 13, AA Campus)
“So, when I reflect on my experiences in the clinical each semester, when it’s the same person who is teaching me, the experience is better. I get better experiences. I remember each day and what I do, but if I get a different instructor, I feel like he is lost and I am lost and I don’t get the same results as when it’s the same.” (P.24, AA Campus)

A few number of students suggested that college clinical instructors should have extensive clinical experience in the field of their specialty. They clarified that some college clinical instructors have excellent academic experiences and extensive theoretical knowledge about the courses they teach. However, they do not have good clinical experience or they never been in the clinical placements before. These instructors may have short experience or have not any experience as nurses in the field. These instructors were unable to support the students in the clinical training.

“I will tell you an example. One of our academics was amazing in the theory class, but she was not confident in the clinical. I think that she never worked as a nurse before. I noticed that she became stressful when she taught us in the clinical. It will be great if they keep her in theory and assign another instructor with more clinical experience.” (P. 1, ADH Campus)

Too much focus on workbook and clinical grades

The participants’ aim and focus during their clinical placement was primarily to complete the clinical workbook as a requirement for clinical assessments and grades, rather than acquiring skills and knowledge per se. This diverted their focus from clinical training and gaining skills due to the overriding objective of meeting their grade requirement for many participants. By focusing on filling the needed component of the workbook, time spent engaging with preceptors and being involved in clinical practice was limited within the course’s clinical component. Many students said they would prefer a unified way of teaching, combining theory/lab and clinical training, as such learning would facilitate their clinical training, minimize negative impressions from nurses, and enable more hands-on education, leading to motivation in student learning:

“Instructors usually give examples from their experiences while explaining concepts in the theory or the lab sessions, and such simulation will be very effective if they also continue teaching and supervising during the clinical placements.” (P.18, AUH Campus)
“Such unification between what we are taught in the College and what we are exposed to in the hospitals would make us feel that what we learn is what the nurses do in clinical practice, and make it easier for us to engage and involve with procedure and patients.” (P. 25, AA Campus)

Most of the students suggested decreasing the load on students in the clinical placement. They indicated that the heavy paper works shifted their focus and decreased their chances to improve their clinical skills. Some of these students went further to describe the clinical placement as similar to theory classes with only one difference, which was the place. One of the fourth year students said:

“They keep us always busy with paper works. I spend more time in writing and preparing in the clinical placement more that the theory classes. They have to give us more space to see real cases and to get more skills.” (P. 17, AUH Campus)

Learning by reflection

A lot of the student found it important to practice reflection in a clinical setting. Many students explained that reflection enhanced their learning through the retention of information. Reflection contributes to boosting students’ clinical skills as it helps in correcting mistakes and in feeling more confident when providing patient care. In addition, four students reported improvements in their analytic skills. For example, one participant noted that:

“Reflection provided me with the opportunity to evaluate my performance”. (P. 7, AJ Campus)

Some of the students preferred to interact with the clinical preceptors and the nurses during the clinical training. They thought that this would present them to the real world of nursing. They suggested to assign an hour at the end of each clinical training shift to discuss all what they have learned during the day with their college instructor.

“Instead of spending the time with our academics in the clinical placement, we can learn more about the real nursing world by the preceptors. We can discuss everything we have learned at the end of each clinical day.” (P. 11, AJ Campus)

The instructors’ approach

Many students regarded their instructors’ support as essential for reflection, especially when the instructors provided them with guidance and feedback on their performance. They highly valued instructors who were passionate, considerate and cooperative. The type of questions asked by their instructor guided them to look for information and helped to improve their analytic skills. One students explained that:

“Some instructors are very friendly and helpful. They are always keen to answer my questions, address my concerns, and acknowledge my work. These actions motivated me to improve my skills by reflecting on my experience.” (P. 14, AA Campus)

In summary, the findings of the current study have raised several interventions and suggestions to bridge the theory-practice gap in nursing education. Some of these interventions focused on improving the culture of clinical training, while other suggestions shed some light on revisiting the curriculum and make some changes to decrease the loads on students during clinical training. Finally, the findings showed the importance of having good reflection at the end of each clinical training day and providing support to the students by their college instructors.

The study has revealed some possible solutions to the theory-practice gap from the students’ perspectives. Within the clinical arena, participants revealed that the clinical instructor played a vital part in optimizing student-learning experiences. A similar finding was observed by Ahmed, Ahmed [ 34 ] among nursing participants in Egypt, where participants revealed that the quality of student-clinical teacher interaction could either facilitate or hinder participants’ learning experiences. Needham, McMurray [ 18 ] and McSharry and Lathlean [ 20 ] stressed that active collaboration between the clinical nursing instructor and the nursing preceptor facilitated student learning positively. In another qualitative study conducted among undergraduate students in Jordan, students voiced that they did not receive good support in the clinical area, with some explaining that their instructors were sometimes busy in other managerial issues, decreasing the time left teaching for students [ 16 ]. The disparity in ratio between instructor and students was also highlighted in a study by Shoghi, Sajadi [ 21 ], where it was revealed that nurse-to-nurse faculty/clinician ratio increased with large admissions, and consequently reduced the value and extent of learning experiences in the clinical environment.

Participants voiced discontent regarding the differences between procedures taught and those observed on clinical placements concerning the nursing competencies. In a recent paper by Billings [ 35 ] and Huston, Phillips [ 15 ], they stressed that at the curriculum level, faculty must consider the national nursing competencies as a curriculum thread and plan learning activities and clinical practice assignments to implement them within all courses. Tanriverdi, Ozyazicioglu [ 36 ] conducted a study in Turkey among the third- and fourth-year undergraduate nursing students and revealed that providing parallelism between the practicing field and the students’ needs was crucial to optimal learning. Their study also revealed that students preferred an integrated model of clinical practice, because it seemed to reduce the gap between the classroom and the clinical area. This was contrary to the findings that emerged from the current study, where students shared a preference for the block system of clinical rotation, on the basis that completion of the didactic content first would provide much-needed familiarity and confidence in their clinical practice.

There is a growing body of knowledge regarding the use of clinical simulation in nursing education to bridge the gap between theory and practice [ 2 , 13 , 37 ]. Proponents believe that a simulated environment helps students practice in a safe environment until competence is attained. Appropriate simulation activities would improve critical reasoning and self-reflection, and lead the way to more self-directed learning [ 38 ], which would foster better adjustments to the complex clinical environment and reduce the gap between theory and practice. A qualitative study by Brown [ 39 ] in the US using semi-structured interviews among graduating nursing students reaffirmed that high-fidelity simulation can reduce the theory-practice gap and ease the transition to independent clinical practice. None of the current study participants mentioned simulation training and its contributions towards bridging the theory-practice gap. This could be attributed to the fact that simulation training has only recently started gaining momentum. Meanwhile, the UAE currently offers a graduate nurse internship program to novice nurses in its government health care facilities [ 40 ], before their assimilation within the UAE health care workforce.

Recent growing evidence indicates that bridging the gap between theory and practice in nursing education is a shared responsibility between academic faculties, registered nurses, and student nurses [ 14 , 15 , 35 ]. There is an urgent need to take a systems view of the multifaceted issue in nursing education. Some other solutions from the literature include a dynamic understanding of the clinical setting, ongoing and timely collaboration with industry clinical partners, a systematic and regular review of the curriculum to ensure inclusion of essential competencies (with exclusion or updating of outdated practices), and incorporation of evidence-based teaching practices to prepare students for the realities of the clinical setting [ 35 ].

This study has helped gain awareness about students’ perspectives and concerns about the theory-practice gap in nursing education, and identified possible solutions to tackle the issue and reduce this gap. As a practice-oriented discipline, theory and practice cannot be separated in nursing. Raines [ 38 ] suggests using a K-W-L chart (Knowing; Want to know; Learnt) to encourage students to consider what they already know actively, and to prompt them to take active measures to enhance their knowledge and skills. As the body of knowledge grows in nursing education and practice, students need to be more self-directed and active learners to bridge the gap between theory and practice. This would lead to the students’ empowerment to develop personal connections to the learning experience, while taking ownership of their professional growth.

This study explored the solutions to bridge the theory-practice gap in nursing education in the UAE, from the perspective of the nursing students studying nursing within the country. Emerging categories related to the creation of a clinical culture and the reformation of the nursing curriculum. Future studies can explore solutions to the theory-practice gap among new nursing graduates practicing after their graduation, using mixed-methods approaches for data triangulation and improved rigor.


This study included homogenous group of female nursing students studying in one nursing college. Therefore, the findings of the current study may be transferable when we deal people with similar conditions. Additionally, it will be useful if there is a chance to study theory-practice gap from the perspectives of the newly graduated nurses. Finally, using a qualitative design limits the chance of generalizing the findings of the current study. It will be excellent to study this subject quantitatively.

Implications in practice

The study has implications for nursing education and practice within the UAE and is imperative for graduating workplace ready professional nurses within the country. The study presents solutions and suggestions to close the gaps in nursing education from the perspective of nursing students. This will be useful to nursing academics, nursing leaders and nursing preceptors by opening their eyes to the students’ needs during clinical training and the ways to bridge the gap between classrooms teaching and the clinical training.

Availability of data and materials

The data available in form of audiotape and transcripts. All data generated or analysed during this study are included in this article. All the data are saved in a secured computer. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Saifan, A., Devadas, B., Daradkeh, F. et al. Solutions to bridge the theory-practice gap in nursing education in the UAE: a qualitative study. BMC Med Educ 21 , 490 (2021). https://doi.org/10.1186/s12909-021-02919-x

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  • Theory-practice gaps
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case study bridging the gap between theory and practice

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Toward narrowing the theory–practice gap: characterizing evidence from in-service biology teachers’ questions asked during an academic course

  • Yael Furman Shaharabani 1 &
  • Anat Yarden   ORCID: orcid.org/0000-0002-3948-9400 2  

International Journal of STEM Education volume  6 , Article number:  21 ( 2019 ) Cite this article

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The gap between theory and teachers’ practice is a barrier to education improvement. There is therefore an ongoing need to understand teachers’ thinking and find new ways to meaningfully relate theory and practice in STEM education. The research explores, through teachers-as-learners’ questions, the connections made by experienced high-school biology teachers between theory and practice, their practical concerns, and the contribution of a supportive course pedagogy to these connections. The research included 31 experienced high-school biology teachers that participated in a special graduate program.

Applying a grounded theory approach, the analysis of the teachers’ questions, asked as a part of their course assignments, yielded four categories: theory, practice, practice and theory, practice vs. theory. We found that most of the biology teachers’ questions asked under a supportive pedagogical design, directed at mediating theory and practice, associated practice and theory. The teachers formed two types of connections between practice and theory in their questions. While asking questions associating practice and theory, the teachers mentioned practical aspects of their work. The types of connections between theory and practice are discussed, as well as the relevance to teacher education.


The opportunity to ask questions during assignments that are topic-specific and designed to combine practice and theory enabled teachers to think of both domains and try to better understand their association. The research results indicate that the questions asked by teachers-as-learners can serve a dual purpose: as a way to help teachers direct their thinking to the association between theory and practice, and as a tool to describe and understand teachers’ tacit thinking. This research also emphasizes the importance of supporting STEM teachers by developing courses and professional development programs that explicitly combine educational theory and practice.


Effective Science Technology Engineering and Mathematics (STEM) education requires teachers’ continued learning and development, including implementation of research-derived knowledge to their practice. Yet, many teachers relate to educational research and theories as irrelevant or far from their everyday lives, and thus the gap between theory and practice is an ongoing barrier to education improvement (De Corte, 2000 ; Nuthall, 2004 ). Teachers who valued both theory and practice during their pre-service studies were found to prefer practice once they entered into their teaching lives (Allen, 2009 ). Strategies such as action research or the use of case studies have been suggested to help teachers bridge the gap between theory and practice (van Driel, Beijaard, & Verloop, 2001 ), but there nevertheless remains an ongoing need to understand teachers’ thinking and find new ways to enable them to relate meaningfully theory and practice.

Questions are important markers of interest and thinking, and an intrinsic component of science and STEM education. Researchers have used questions to study various educational topics, for example, students’ conceptual change (Watts, Gould, & Alsop, 1997 ), teachers’ professional development (Watts, Alsop, Gould, & Walsh, 1997 ), and students’ interest in science (Baram-Tsabari & Yarden, 2009 ). Teachers’ questions in the classroom have been extensively examined, and the importance of certain types of questions in promoting students’ thinking has been acknowledged (Chin, 2007 ; van Zee & Minstrell, 1997 ). Questions raised by teachers during their own learning process, termed here teachers-as-learners’ questions, have the potential to serve as probes toward gaining a better understanding of the teachers’ thinking in general, and of their perspective on practice, theory, and the connections between them in particular. In this work, we suggest that the questions that teachers ask as learners under a supporting context can serve a dual purpose, as a way to help them direct their thinking to the relations between theory and practice and as a tool to describe and understand their tacit thinking.

The research explores, through teachers-as-learners’ questions, the connections made by experienced high-school biology teachers between theory and practice, their practical concerns, and the contribution of a supportive course pedagogy (discussing theory in relation to the teachers’ actual work and experience) to these connections. The research included 31 experienced high-school biology teachers that participated in a special graduate program (M.Sc). In this study, we use the term theory for all types of research-based knowledge, ranging from theories and models to specific frameworks and methods. This choice reflects the way in which teachers refer to research-based knowledge, as opposed to their experience-based knowledge.

Theory–practice gap

Kennedy ( 1997 ) summarized four reasons for the well-known lack of “usefulness of educational research” (p. 4): research is not persuasive enough; research is not relevant to practice; ideas from research are not accessible to teachers; educational systems lack the ability to change. A decade later, Broekkamp and van Hout-Wolters ( 2007 ) identified four basic and interrelated problems that contribute to the gap and demonstrate the same phenomenon: educational research yields only a few conclusive results; educational research yields only a few practical results; practitioners believe that educational research is not conclusive or practical; practitioners make little (appropriate) use of educational research. The combination of these problems seems to be holding back improvements in education, hence theoretical and practical solutions to bridge the theory–practice gap are at the heart of ongoing discussions (Korthagen, 2007 ).

Several potential paths to narrowing this gap hold some promise. One suggestion is to change research to better align with the needs of practice. This path calls for teachers and researchers to work together as collaborative partners in, for example, research schools that are infrastructures for connecting educational research with educational practice (Hinton & Fischer, 2008 ), or during professional development programs that enable the teachers to develop research based activities (e.g., Erdas Kartal et al., 2018 ). Another possible solution is to better communicate research results: “good communication with practitioners which means that the relevant outcomes are translated in such a way that they become palatable, accessible, and usable for the teachers” (De Corte, 2000 , p. 249).

Different means have been suggested to connect theory to practice during pre-service and in-service teachers’ education (Korthagen, 2007 ). For example, the use of cases was suggested as a powerful tool to bridge the gap between theory and practice: in an online forum, pre-service and in-service mathematics teachers were shown to connect the theory that they had read and studied in their university methods courses with the practice that they had critically watched in a video of a real classroom (Koc, Peker, & Osmanoglu, 2009 ). A different video case-based intervention at the pre-service level led to better connecting theory and practice, as revealed in pre-service teachers’ growing ability to base their analysis of classroom episodes on theories (Eilam & Poyas, 2009 ).

Korthagen, Loughran, and Russell ( 2006 ) suggested a seven-principle framework for teacher education to link theory and practice effectively, including an approach in which learning about teaching is enhanced through pre-service teacher research. Action research, or teachers’ research, is another method that may contribute to teachers’ development, including better association of theory and practice (Capobianco & Feldman, 2006 ; Halai, 2012 ; Roth, 2007 ). However, in many of the graduate-program courses for teachers, the performance of full-scale research is not feasible. Nevertheless, the course’s pedagogical design may contribute to narrowing the theory–practice gap. Many higher education courses are still using the traditional lecture-based transformative approach (Kober, 2015 ), although research supports a constructivist active-learning approach. For example, a meta-analysis of 225 STEM (science, technology, engineering, and mathematics) undergraduate studies found higher student achievements under active vs. traditional lecturing (Freeman et al., 2014 ). In the courses that were the context for this study, we employed a socio-constructivist approach, engaging the teachers in collaboratively analyzing and planning instruction in relation to educational theories that had been discussed, and in reflective thinking about their instruction. Reflection is considered a major contributor to teachers’ development (Bell & Gilbert, 1996 ; Schon, 1983 ).

Here, we suggest that teachers’ questions may serve as a valuable tool for understanding teachers’ thinking about the connections between educational theory and their practice, and as a way to narrow the theory–practice gap.

Questions as markers of interest and thinking

Questions have been established as markers of interest and thinking (Baram-Tsabari, Sethi, Bry, & Yarden, 2006 ). Questions can be viewed as expressions of the tacit subjects and issues that concern the person asking them, which are sometimes very different from what is generally expected. For instance, an analysis of questions asked by high-school biology students revealed that their interests are not aligned with the topics of the national curriculum in biology, because about half of their questions related to topics that were missing from the curriculum (Hagay & Baram-Tsabari, 2011 ).

It is generally agreed that questions are strongly connected to thinking and learning (Chin & Osborne, 2008 ; Dori & Herscovitz, 1999 ). As Chin and Osborne ( 2008 ) stated: “Questions from students indicate that they have been thinking about the ideas presented and have been trying to link them with other things they know” (p. 2). Teachers who participate in graduate programs are learners, and as such they ask questions that reflect their thinking. In this context, it is important to emphasize the difference between self-generated questions, which are questions that are asked freely without direction, and ordered questions, which are directed to a specific topic or issue by someone other than the person asking them (Gross, 2001 ). Self-generated questions are internally motivated (Gross, 2001 ) and therefore have the potential to reveal tacit interests and concerns (Biddulph, Symington, & Osborne, 1986 ). Hence, the teachers in this study were encouraged to generate questions during the course and in the different assignments.

There is a growing body of knowledge on students’ questions, revealing the importance of questions to learning and as data sources for different features related to learning. For example, a review of 26 intervention studies revealed that students’ level of comprehension of reading material increased after they were taught to ask questions (Rosenshine, Meisler, & Chapman, 1996 ). Analysis of questions sent to an ask-a-scientist site showed that students’ interest in science changes with age and gender, with girls favoring biological topics and asking less questions as they grow older (Baram-Tsabari et al., 2006 ). Students’ question-posing capability was suggested as an alternative evaluation method of secondary science learning, and it was found that the number and complexity of the students’ questions increased significantly after learning a unit that required coping with real-life problems and posing questions (Dori & Herscovitz, 1999 ).

Since questions are strongly related to thinking and learning, and are a basic tool of instruction, teachers’ questions in class have been investigated widely (Galloway & Mickelson, 1973 ). Teachers’ distinct ways of questioning have been related to helping students promote their thinking in science classes (Chin, 2007 ; Roth, 1996 ; van Zee & Minstrell, 1997 ; Yip, 2004 ). Questions can also potentially contribute to teachers’ reflection and change: students’ questions served as critical incidents that helped two science teachers change their thinking and classroom practice (Watts et al., 1997 ). In this study, we attempt to connect two distinct areas of research: the theory–practice gap and teachers’ questions. We focus on questions asked by teachers, as a window to the teachers’ thinking regarding possible connections between their practice and educational theory.

The first research objective of this study was to explore the contribution of a supportive course pedagogy to the connections made between theory and practice by the participating teachers. These connections were probed using the teachers-as-learners’ questions asked in the context of academic courses for biology teachers in a graduate program. The second objective was to characterize the connections made by the teachers between theory and practice and the practical aspects of their thinking during academic courses as expressed in their teachers-as-learners’ questions. Specifically, the following two research questions were addressed:

Did—and how did—a supportive course pedagogy contribute to the formation of connections between theory and practice by the teachers?

What types of connections did the teachers form between theory and practice, and what are the practical aspects of these connections?

Context and participants

The graduate program.

The Rothschild-Weizmann Program for Excellence in Science Education was established to advance the academic and professional development of secondary science and mathematics teachers in Israel. The program’s goals are to empower science teachers and increase their motivation by providing them with unique opportunities to expand their knowledge and be involved in innovative professional activities. Realizing these goals is expected to trigger a significant increase in the level of science education in Israel. In the framework of this program, which consists of specially designed courses in Biology, Science Education, and Biology Education, experienced biology teachers are studying toward their M.Sc. degree (without thesis). The teachers participated in the program for two full days a week, and continued to teach in their schools for the rest of the week. Thus, enabling the teachers to implement new ideas and strategies they learned in the course of the program.


Thirty-one biology teachers who were participating in two courses: course A ( n  = 21) and course B ( n  = 10), were part of this study: 87% of the teachers were women; 13% were under the age of 30, half were between the ages of 31 and 40, and the rest were over 40 years of age; 70% had over 10 years of experience in teaching secondary-school biology (grades 7–12), with the majority teaching advanced biology levels (grades 10–12).

We refer to the participants of this study as “teachers,” although they are students in the described graduate program, in order to avoid misunderstandings when these teachers’ students are mentioned and also to emphasize that one of the requirements for participating in the program is to be an experienced practicing teacher.

The courses

Teachers’ questions were collected mainly from assignments submitted in two different biology education courses (courses A and B), and from one assignment submitted in a science education course (course C).

The course “Learning and teaching in biology 1” was held in the first semester of the 2009–2010 academic year. The 21 biology teachers (graduate students) attended 13 meetings of 1.5 h each, and participated in online discussions and assignments. The course was aimed to bridge aspects of the theoretical knowledge introduced in another course (“Introduction to science education”) and the biology teachers’ classroom practice: i.e., knowledge about the goals of biology teaching, students’ questions, means to promote students’ interest in biology, and modes of learning for understanding. The course was socio-constructivist in nature, and therefore structured as workshops, during which the teachers discussed their practice in relation to theory, engaged in group work to develop theory-based teaching units, and analyzed examples of their existing teaching materials. The teachers submitted three course assignments that focused on connecting theory and practice (Table  1 ). Each assignment was prepared in small groups and included a personal reflective section. They also read one paper about a topic that was not emphasized in the introductory course, and submitted a reading assignment. The personal section of all the assignments included a requirement to ask questions. The first author was the leading developer and instructor of this course.

The course “Introduction to biology education” was held in the first semester of the 2010–2011 academic year with ten biology teachers. The course had a similar rationale, structure, and assignment style as course A, except that this course also introduced the theoretical knowledge, since it was not accompanied by another introductory course. Theory was introduced via reading assignments and short lectures that were complemented with discussions and focused on relations to the teachers’ practical experience. To maintain the socio-constructivist nature of the course, each teacher chose one reading to present and discuss with the group, in addition to the regular course reading. The presenters were asked specifically to relate the papers’ content to their teaching experience. Relations to past experience and current practice were at the focus of all course assignments and discussions. Course B topics were biology understanding and misconceptions, central biological ideas, and inquiry teaching and learning, while “Learning for understanding” served as an organizing theme throughout the course (Table  2 ). The personal section of all the assignments included a requirement to ask questions. The authors were the developers and instructors of this course.

It is important to note that both courses fostered an atmosphere of sharing all participants’ practical knowledge and mutual contributions based on their rich teaching experience.

During the second semester of the 2010–2011 academic year, course B teachers studied a science education theoretical course (course C). This course was designed as a traditional lecture-based course and included ten reading assignments that were mostly unrelated to the teachers’ practice. Course C participants also included teachers of chemistry, physics, and mathematics participating in the graduate program. The questions asked by the biology teachers in one reading assignment of course C were collected.

Data collection

The participating teachers were invited to ask questions throughout courses A and B, both during the meetings and online. In each course, they were asked to submit three planning group assignments, each designed to enable the teachers to connect theory to practice and vice versa (see Tables  1 and 2 ). In the final part of each assignment, termed “a bird’s-eye view,” teachers were requested to respond individually. This part consisted of several reflective and meta-cognitive items, including one inviting the teachers to raise questions, without directing them to a specific topic or track. Thus, those questions were termed self-generated. In the reading assignments of courses A and B, the teachers were asked to specify the main ideas of each article, to describe their reservations and to raise questions, again with no specific direction. In the reading assignment of course C, the teachers were asked to read part of Vygotsky’s work (Vygotsky, 1978 ) and directed to ask questions about the “zone of proximal development.” The total number of questions collected was 310: 108 from the assignments of course A, 122 from the assignments of course B, and 80 from the assignment of course C.

Data analysis

This mixed methods research employed a grounded theory approach (Strauss & Corbin, 1994 ), hence the categories emerged from the data in the course of the data analysis.

During the first stage of this research, all of the questions posed by the teachers (teachers-as-learners’ questions) in the four assignments of course A ( n  = 108) were collected and read thoroughly and repeatedly. Initial categories regarding theory and practice were established, which were then refined by several cycles of analysis (following Patton, 2002 ). Although we were aware of individual differences between the participating teachers, we chose to analyze their questions as a cohort. This framework could be applied to most of the questions asked in the course A assignments; five questions addressed biological content rather than education or science education content and were therefore omitted.

Reliability was obtained using a blinded categorization of 15 questions by two other researchers. The initial agreement rate with each of the researchers was 74%. Following discussion, the final agreement rate was 93%.

The second stage of the research involved collection and analysis of new questions from the seven assignments of course B ( n  = 122) and from the single reading assignment of course C ( n  = 80) using the framework developed in the first stage (see Table  3 ). Two questions were omitted from this pool as they were articulated very generally and were not clear enough. Reliability was obtained using a blinded categorization of 13 questions by the two other researchers mentioned above. The agreement rate between raters was 85%. Two different comparisons were used for answering the first research question (see “Findings”). Due to the relatively small number of teachers participating in the courses and in the research, Wilcoxon non-parametric test was used for statistical analysis of the data for the first research question. The variables were the categories presented in Table  3 .

Two additional means of analysis, which revealed information about the content of the teachers’ thinking from the questions, were used in order to answer the second research question. Those means focused on the two categories of questions connecting teachers’ practice with the theory learned in the courses. One form of analysis revealed the types of connections that the teachers were thinking about while asking the “practice and theory” questions. Each question was analyzed to uncover the connection type. For example: How do I move to more guided and less structured inquiry ? was interpreted as the teacher asking about possible application of the theory (on levels of inquiry) to her practice. This type of question was labeled as “contribution.” All of the “practice and theory” questions were analyzed in this manner and then grouped into the two categories of connections emerging between practice and theory.

Another type of analysis focused on the practical aspects of the teachers’ questions categorized into the two categories: “practice and theory” and “practice vs. theory.” Since the theory was introduced during the course, it was informative to reveal the main aspects of practice being considered by the teachers while thinking about the connections to the theory they had just been exposed to. All of the questions of the “practice and theory” and “practice vs. theory” categories were read repeatedly and given an initial “practical aspect” description, which was then refined by several cycles of analysis to the final categories presented in the findings section.

As already noted, this research had two objectives. The first was to explore the contribution of a supportive course pedagogy to the connections formed by the teachers between theory and practice, using teachers-as-learners’ questions asked in the context of academic courses for experienced biology teachers. The second was to characterize the connections made by the teachers between theory and practice and the practical aspects of their thinking during academic courses as expressed in their teachers-as-learners’ questions. The findings are arranged according to these two objectives.

A supportive course pedagogy contributed to the formation of connections between theory and practice by the teachers

The teachers’ questions were analyzed according to the emergent framework presented in Table  3 . Our analysis yielded four distinct categories of teachers-as-learners’ questions: (i) practice , which focuses on acts and behaviors in class with no relation to theory; (ii) theory , which focuses solely on the theory, with no relation to practice; (iii) practice and theory , which attempts to connect theory with teachers’/students’ acts; and (iv) practice vs. theory , which attempts to confront the teachers’ practical knowledge with the educational theory learned. The “practice vs. theory” category is clearly a subcategory of the “practice and theory” category, but was treated as distinct due to an apparent difference in the various teachers’ standpoints: their attempts to know more or understand better (“practice and theory”) as opposed to expressing critical thinking about the theory (“practice vs. theory”).

Our findings concerning the first research question were based on these categories (Table  3 ) and include two sections: first, an inclusive comparison between the questions asked in courses A and B and course C’s assignment, then a specific analysis of types of connections with regard to assignment type and context.

Overall course pedagogy supported the formation of connections between theory and practices

The analysis of all teachers-as-learners’ questions according to the practice–theory framework (Table  3 ) produced a similar distribution in courses A and B (Fig.  1 ). Using Wilcoxon non-parametric test, there was no significant difference.

figure 1

Distribution of all teachers-as-learners’ questions asked in courses A (left) and B (right) according to the practice–theory framework (see Table  3 )

Since the teachers’ questions were collected in the context of two dissimilar courses, the fact that the various types of questions were similarly distributed is interesting, especially since the questions relating theory and practice (categories “practice and theory” and “practice vs. theory”) constituted more than 65% (course A) and 70% (course B) of their questions (Fig.  1 ).

The similarity in rationales and pedagogies of these two courses seems to matter. These results suggest that when the teachers learn in courses that focus on creating a learning atmosphere which mediates science education theory and everyday practice, they tend to focus their thinking on this relation, as reflected in their questions.

The importance of course pedagogy in forming connections between theory and practice can be demonstrated in the analysis of the questions asked by teachers who attended the theoretical science education course (course C). In a reading assignment handed out in course C, most (64%) of the 80 questions asked by the teachers were directed to theory, with no relation to practice. Thus, it seems that while the course framework and pedagogy supported engagement in the connections between theory and practice (courses A and B), the teachers not only directed most of their thinking to this association but addressed almost no questions to theory alone, and only minimally raised practical questions. In contrast, when the course framework and assignment focused solely on theory (course C), most of the teachers’ thinking was directed to theory, and not to the connections between theory and practice.

Reading assignments in a practical context supported the formation of positive connections between theory and practices

To examine whether the differences between the three planning assignments and the reading assignment (see “Methodology”) were expressed in the teachers’ questions, we grouped course A teachers’ questions according to assignment type (planning or reading), as presented in Fig.  2 . The overall distribution of the questions in the two types of assignments was quite similar: most of the questions (planning: 65%, reading: 73%) dealt with connections between theory and practice (categories “practice and theory” and “practice vs. theory”). Using Wilcoxon non-parametric test, there was no significant difference. Only a few questions dealt solely with theory and about a quarter of the questions addressed exclusively practice (Fig.  2 ).

figure 2

Distribution of teachers-as-learners’ questions regarding practice and theory in two types of assignments in course A (2009–2010)

Interestingly, the number of “practice and theory” questions asked in the context of the reading assignment was lower than that of questions asked in the context of the planning assignment ( p  < 0.05, Wilcoxon non-parametric). In contrast, the number of “practice and theory” questions asked in the context of the planning assignment was higher ( p  < 0.05, Wilcoxon non-parametric) compared to “practice vs. theory” (Fig.  2 ). Thus, when theory was presented in the form of an article (the reading assignment) prior to learning the subject, the teachers asked more “practice vs. theory” questions than during the planning assignment. These questions were critical in nature, implying that the teachers tended to notice the gap between the theories that they were reading about in the article and the practical knowledge originating from their everyday experience as biology teachers. When encouraged to narrow the gap between theory and practice by working collaboratively with their colleagues on the planning assignments, which required applying theory to practice, or by analyzing examples of their existing practical knowledge using theory, the teachers asked more “practice and theory” questions, thus indicating their need to better understand the connections between the two.

We planned the 2010–2011 course (course B) with these results in mind. Consequently, we incorporated three reading assignments in the three topics which were chosen as relevant to the teachers’ everyday practice and one pre-course reading assignment that was not specific to biology teaching (see “ Methods ”). The analysis of the questions asked in the two types of assignments (planning and reading) in course B is presented in Fig.  3 .

figure 3

Distribution of teachers-as-learners’ questions regarding practice and theory in two types of assignments in course B (2010–2011)

About half of the questions asked by the teachers who participated in course B were directed to connecting practice and theory. Using Wilcoxon non-parametric test, there were no significant differences between the two types of assignments, i.e., planning and reading. The teachers asked more questions confronting theory with practice in the reading assignments than in the three planning assignments, but less than those asked by the participants of course A (25% and 40%, respectively, see Fig.  2 ). This indicates that the incorporation of reading assignments in the context of teachers’ experience and everyday work may enable the teachers to think about the practice–theory connections more positively. They were more engaged in understanding the relevance and contribution of science education theory to their teaching and less in thinking of the differences between their practice and the learned theory. This interpretation is supported by the distinction between the first reading assignment, which was given as a pre-course assignment, and the other three reading assignments, which were given in a learning context emphasizing the connections between practice and theory. Fifty percent (12/24) of the questions asked in the pre-course reading assignment confronted theory with the teachers’ practice, whereas only 12% (5/43) of the questions confronted theory with practice in all three incorporated reading assignments. Moreover, most of the questions asked in the context of these three integrated reading assignments (53%) were classified in the “practice and theory” category.

To sum up, most of the teachers’ questions asked under a supportive pedagogical design were directed to the connection between practice and theory. In particular, incorporating reading assignments in a practical context supported teachers positively connecting their practice and theory.

Types of connections formed by teachers between theory and practice, and the practical aspects of these connections

The teachers who participated in this study were invited to ask questions during assignments that were designed to promote the connection between practice and theory. The teachers were mostly thinking of the possible contribution of the theory they learned to their practice while asking questions associating the two. While trying to connect or confront their practice with the theory learned in the course, the teachers raised questions regarding different aspects of their work. They were thinking about the ways in which they plan and teach in most cases, and about their students’ learning and diversity. They were also expressing the influence of the educational system on their work.

Teachers’ questions were classified according to two different attributes: the types of connections formed by the teachers between practice and theory, and the practical aspects of questions connecting theory and practice.

Types of connections formed by teachers between practice and theory

A closer look at the contents of the questions classified in the “practice and theory” category revealed two main types of teachers’ approaches to the connections between practice and theory:

Contribution : How does theory contribute to the teachers’ practice or apply to their practice? This type of connection encompassed 77% of the “practice and theory” category.

For example: After reading a paper about students’ misconceptions regarding photosynthesis (Amir, 1993 ), Teacher K (course B) asked: “How can I deal with the knowledge I have acquired about misconceptions in class?” Following a planning assignment, Teacher Hn (course A) asked: “ Probably not every student can deal with every understanding performance—Should we match different understanding performances with different students?” In these examples, the teachers were clearly considering the potential contribution of the theory they had learned in the course to their teaching.

Some of the contribution questions (8%) dealt with application of the theory to a specific context of the teachers’ work. These questions could be generalized as follows: Can the theory be applied to all practical contexts or only to a particular context? For example, while involved in a planning assignment in the inquiry unit, Teacher Sh (course B) asked: “Can the students [low achievers] perform a less structured inquiry?”

Confirmation : Does the practice confirm the theory? This type of connection encompassed 23% of the “practice and theory” category.

For example: in her reflective section of a planning assignment following a unit about understanding and misconceptions, Teacher RB (course B) asked: “Do I teach toward remembering facts, without allowing to think deeply and creating a deep understanding of the topic?” The analysis of all of the questions that focused on the possible connections between practice and theory revealed that the teachers had attempted to connect their own practice to the theory they had just learned by asking mainly about the contribution and application of the theory to their practice in class. Thus, the confirmation category enabled revealing another way of thinking that is critical and reflective in nature. In the confirmation questions, the teachers focused on their students and ways of teaching, wondering about the match to the theory they had just learned.

Practical aspects of the questions relating theory with practice

The questions targeted at connecting practice and theory (categories “practice and theory” and “practice vs. theory”) naturally included some aspects of the teachers’ practice. Looking at these questions from the practical perspective revealed teachers’ main concerns in their everyday work. We identified six practical aspects in these questions which were classified into three categories: teaching , students , and the educational system .

Strategies (37%): Questions addressing ways, methods, and tools for instruction (including assessment). For example: “How can I upgrade the level of inquiry in my learning activities?” (Teacher RB, course B).

Planning (20%): Questions dealing with planning of a lesson, a subject, or an activity. For example: “How can I predict students’ misconceptions and plan my instruction accordingly?” (Teacher O, course B).

Learning (14%): Questions dealing with students’ understanding, motivation, and cooperation. For example: “Do students’ questions really reflect their level of interest in the topic?” (Teacher Y, course A).

Heterogeneous classes (5%): Questions considering differences between students. For example: “Is meta-cognitive thinking suitable to all students’ levels?” (Teacher O, course B).

The educational system

Limitations (18%): Questions considering the limitations of the system, such as limited time, curriculum, or the need to prepare the students for matriculation exams. For example: “How can we cover the needed curriculum while basing the instruction on students’ questions?” (Teacher S, course A).

National planning (6%): Questions dealing with the national science curriculum and the alignment between different levels of schooling. For example: “Do the curriculum developers take ‘learning for understanding’ into consideration?” (Teacher C, course B).

Classification of the teachers’ questions revealed the teachers’ main concerns in our program, and highlighted their complex world. They know, based on their experience, that teaching requires attention to numerous factors, and their questions reflect this knowledge. For example: when theory suggested developing teaching plans according to students’ questions (following Baram-Tsabari & Hagay, 2009 ), Teacher H (course A) asked about students’ personalities: “Does question-based teaching not damage the learning of shy students who are reluctant to ask questions?” The teacher was clearly associating the theory she had learned with her practical knowledge of students and their difficulties.

The framework developed here to analyze teachers-as-learners’ questions (Table  3 ) shed light on teachers’ thinking about theory–practice connections and on the importance of course pedagogy that supports discussion of theory in relation to the teachers’ work. Our findings indicated that most of the teachers’ questions asked under a supportive pedagogical design were directed to the connection between practice and theory. In particular, incorporating reading assignments in a practical context supported teachers’ positively associating their practice with the theory. In contrast, most of the teachers’ questions asked during a reading assignment in a theory-focused course were directed solely to theory. Furthermore, the practicing teachers formed two types of connections between practice and theory in their questions: they asked about the theory’s contribution to their practice and about possible confirmation of the theory by their practice. While asking questions associating practice and theory, the teachers mentioned practical aspects of their work: teaching strategies and planning, student learning and diversity, the educational system’s limitations, and national planning.

The supportive course pedagogy contributed to the formation of positive connections between theory and practice by the biology teachers. One of the major reasons for the theory–practice gap is the teachers’ stance on research as not being practical (Broekkamp & van Hout-Wolters, 2007 ; Kennedy, 1997 ). The teachers in our study were given the opportunity to discuss research in the context of their occupation and to work collaboratively on assignments connecting their practice and the theory they had learned. The collaborative work was intended to share their practical experience and deeper their analysis of their practice (Erdas Kartal et al., 2018 ; Roth et al., 2017 ). Their questions revealed that they were thinking about practical ways to use the theory in their work. This finding supports other studies showing that certain strategies, such as teachers’ research or the use of cases, can help teachers connect theory to their everyday work (van Driel et al., 2001 ).

In this study, we found that the opportunity to ask questions during assignments that are topic-specific and designed explicitly to combine practice and theory enables teachers to think of both domains and try to better understand their relation. We suggest that this type of activity contributes to the accessibility and usability of theory to science teachers, which is frequently claimed to be important for quality instruction (Broekkamp & van Hout-Wolters, 2007 ; Kennedy, 1997 ). As already noted, only a few of the teachers questions addressed only theory. This result shows that the teachers were not interested in theory alone, as suggested in previous research (Kennedy, 1997 ), thus highlighting teaching as a practical occupation. It appears that from a practitioner’s point of view, there is not much interest in theory as such, but rather in the ways in which theory is related to practice. Teachers usually regard research conclusions and theory as distant from their work, and there is therefore a continuing need to assist them in narrowing this gap in order to develop professionally and implement innovations in education. The emphasis given in both courses (courses A and B) on discussing theory in relation to the teachers’ actual work and personal experience was reflected in their questions about this association.

Furthermore, we found that the type of assignment is important, as is the context in which the reading assignments are given to the teachers. Assignments which were designed to connect practice and theory and readings that were introduced in relation to the teachers’ practice supported teachers’ thinking of the association between the two domains: the educational theory discussed in the course and their everyday practice. Hence, both the course pedagogy which encouraged association of practice and theory and the practical context of the assignments can be described as contributing to the teachers’ asking more questions directed at the practice–theory connection.

In our study, two types of connections between practice and theory were formed in the teachers’ questions: the contribution of theory to their practice and the possible confirmation of the theory by their practice. The teachers also related to the practical aspects of their work: teaching strategies and planning, student learning and diversity, the educational system’s limitations, and national planning. Analysis of question content indicated that an invitation to freely ask questions encourages teachers’ thinking about theory–practice associations. According to Chin ( 2004 , p. 107): “Self-questioning allows an internal dialogue with oneself, driving the mind to look for patterns and connections, establishing relationships with prior knowledge and building bridges to new perceptions.” While asking questions that connected teachers’ practice and the theory discussed in the courses, the teachers were mainly attempting to better understand the possible contribution of the theory to their practice or how to apply the theory to their instruction. This finding is not surprising, as teaching essentially involves various actions in class, meaning that most research results or theories are not useful to teachers until the relevant way of action is found and applied.

Teachers’ knowledge and practitioners’ wisdom are discussed in many works (e.g., Connelly & Clandinin, 1990 ; Shulman, 1987 ). Teachers’ concerns about the links between their complex world and educational theory were evident in the questions asked by the participants in this research. The questions content emphasized the teachers’ complex practical knowledge. They know, based on their experience, that teaching requires attention to numerous factors. While asking questions connecting practice and theory, the teachers were mainly thinking about strategies of instruction, but also about factors reflecting the realities of schools, such as limitations of the educational system or diversity of their students. These components of teachers’ knowledge (Shulman, 1987 ) seem to be important when teachers are considering a theory’s possible contribution to their work.

This study had some limitations. The questions analyzed in this research were collected within the context of our graduate program and courses, and the number of teachers participating in this research was low. Hence, the generalizability of our findings might be questioned. Along the same lines, the group of teachers participating in the graduate program probably does not represent the general population of biology teachers, since they were outstanding experienced teachers selected especially for the program. Nevertheless, we claim that the replication of almost similar results in two courses (A and B) with different topics and participants indicates a trend.

Shulman ( 2002 ) concluded that the field of research on teacher education “is in serious need of low-stakes, high-yield instrumentation to monitor the vital signs of teacher development in ways that can guide teacher educators, professional developers, and ultimately teachers themselves” (p. 252). The existing tools for narrowing the theory–practice gap, such as cases or teachers’ research (i.e., Korthagen, 2007 ), are demanding in terms of resources, whereas inviting the teachers to ask questions is very simple and can be incorporated into almost all types of assignments, activities or projects, in long- or short-term learning opportunities. The questions, once analyzed, may be the basis for varied activities, such as teachers’ discussions, or teachers’ teamwork, to provide solutions associating their practice with the theory. In addition, those questions may serve as indicators of the level of the in-service program theory–practice connection, and contribute to improve it. Teaching is a complex endeavor, and a single tool or method will almost certainly fail to capture its richness. We suggest the use of teachers’ questions to assist teachers in bridging the gap between their teaching practice and theory.

Sustaining teachers seems to be a major problem, and there is therefore a growing need to create spaces that will enable teacher development (Clandinin, 2010 ). In-service programs that focus on connecting STEM practice and theory and assisting the teachers’ thinking about the connections between the two worlds by inviting questions and reflection might serve as a space for teacher growth. Further research is needed to explore the connections between teachers’ thinking as manifested in their questions and their actual practice in the classroom.

This study presents a new framework to probe the ways in which teachers-as-learners view the connections between practice and theory, through their questions, a previously suggested powerful tool to encourage thinking (Chin & Osborne, 2008 ). Our findings suggest that self-generated questions (Gross, 2001 ) are an efficient instrument for teachers to consider various aspects of the connection between practice and theory. In addition, questions became a powerful “window” to the biology teachers’ thoughts and concerns. This research also emphasizes the importance of supporting STEM teachers by developing courses and professional development programs that explicitly combine educational theory and practice, since theory alone does not contribute enough to practitioners (Korthagen, 2007 ).

This research shows that under a supportive design, teachers can associate practice and theory in their questions, which in turn can serve as markers of their thinking. It seems that by addressing most of their questions to both practice and theory, the biology teachers in our research were demonstrating a desire to develop professionally by bringing these two different “worlds” closer together. Based on our study, we call for further investigation of teachers-as-learners’ questions as a means of reducing the theory–practice gap. As teacher educators and researchers of STEM education, it is our responsibility to provide new ways of connecting teachers’ practice and educational research and theory. Teachers-as-learners’ questions hold a promise to contribute to this highly important mission.


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YFS developed the academic courses, analyzed and interpreted the data, and was a major contributor in writing the manuscript, as part of her postdoctoral studies at the Feinberg Graduate School of the Weizmann Institute of Science under the supervision of AY. AY collaborated with YFS in the conceptualization of the study, in designing the analysis rubric, and in writing the manuscript. Both authors read and approved the final manuscript.

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Furman Shaharabani, Y., Yarden, A. Toward narrowing the theory–practice gap: characterizing evidence from in-service biology teachers’ questions asked during an academic course. IJ STEM Ed 6 , 21 (2019). https://doi.org/10.1186/s40594-019-0174-3

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Bridging the Gap between Theory, Practice, and Policy: A Decision-Making Process Based on Public Health Evidence Feasible in Multi-Stage Research on Biological Risk Factors in Poland

Anita gębska-kuczerowska.

1 Faculty of Medicine, Collegium Medicum, Cardinal Stefan Wyszyński University, Kazimierza Wóycickiego 1/3, 01-938 Warsaw, Poland

2 National Institute of Public Health, Chocimska 24, 00-791 Warsaw, Poland

Sudakshina Lahiri

3 Institute of Digital Healthcare, WMG, University of Warwick, Coventry CV4 7AL, UK; [email protected]

Robert Gajda

4 Gajda-Med Medical Center, Piotra Skargi 23/29, 06-100 Pułtusk, Poland; lp.demadjag@adjag

Stakeholder input into the decision-making process when developing public health programs and policies is crucial. This article presents an innovative approach, involving online participation with a wide group of stakeholders located in different geographic locations for policy consensus. The results of the project have been used to propose assumptions regarding a strategy for preventing blood-borne diseases in Poland. The research was conducted iteratively using a multi-stage qualitative methodology to explore risk assessment involving blood-borne infections. The final output of the study is a list of key problems/challenges and potential solutions associated with medical and nonmedical services that are connected to the breakage of tissue continuity. Qualitative research is rare in risk assessment, as priority is generally given to statistical data and endpoints. In addition to policy preparation for blood-borne illnesses, the methodology employed in the study can also be used to successfully explore other areas of public health.

1. Introduction

The urgent need to bridge the gap between science, practice, and policy in public health has accelerated in recent years [ 1 , 2 , 3 , 4 , 5 ]. Often, policymakers’ decisions are a result of their goodwill and knowledge, along with social and economic pressures. It would be optimal to make decisions based on scientific circumstances and facts; however, in practice, this is not always feasible. An additional barrier to a conscious approach to policy-related decision-making in the field of healthcare is that the effects of actions are shifted in time, whereas cost considerations exist at very early, though critical, stages, such as preliminary analyses of information and strategy preparation. Therefore, convincing arguments, informed by theory and practice on the part of researchers, are needed in order to persuade legislators to make decisions—the effects of which are, at times, visible only after their tenure ends. Innovative program proposal requires a thorough analysis of each of the stages of its development, such that the obtained portrayal of a problem and the proposed process of change can be implemented. Indeed, strategies to implement evidence-based practices at a healthcare system level have been recently explored in terms of facilitators and barriers to the implementation process [ 6 ].

Information is a crucial element in decision-making [ 7 , 8 , 9 ]. When program proposals are prepared, attention should be paid to the element of participation by actively seeking inputs from those concerned with an analytical decision-making process through social consultancy to ensure that wider expectations have been taken into consideration. Therefore, as an argument to the critics of evidence-based public health, the intention of the current authors is to present a method that can potentially reduce the gap between science and policy-making through a systematic approach to problem-solving.

Many researchers and legislators believe that it is necessary to involve stakeholders into the decision-making process when developing programs and policies [ 10 , 11 ]. Likewise, a preliminary definition of the rules regarding the directions of reasonable decisions, related to the current knowledge about clinical sciences and public health, has also taken on tremendous importance [ 12 , 13 , 14 , 15 ]. In this regard, a recent review by Mathieson and colleagues uncovered a number of factors that serve as either barriers or facilitators to the use of theory and evidence when planning, guiding, and evaluating the implementation of policies and innovations [ 6 ]. The authors found that successful implementation results not only from a well-prepared plan (i.e., the what), but also from information on the process (i.e., the who, how) from previously obtained knowledge about barriers and facilitators. According to the authors, perceived barriers to implementation may result from fear of introducing innovations, which may initially seem destabilizing (for example, organizational restructuring that might be construed as either decentralization or centralization). Another barrier reported was an impaired organizational system, involving issues of hierarchy, leadership, management, and the flow of data and information. Equally important, they caution against proposing innovations without prior organizational preparation (i.e., infrastructure, people) as this might end up as a “falsestart” [ 6 ].

The objective of this article is to present a methodology for a multi-stage analysis process using a qualitative framework to prepare assumptions for a public health program strategy with wider inputs to gain policymakers’ support, especially with regard to prioritizing the goals of the program. The specific focus chosen was prevention of blood-borne illnesses. While medical progress has made it possible to diagnose and cure most blood-borne diseases, however, some of these conditions are not completely understood at present, making prevention especially important, including due to the economic costs involved [ 16 , 17 , 18 ].

The prevention of BBIs and related complications refer to a wide range and scope of activities in public health. In accordance with the epidemiological approach, it is important to take actions related to decreasing the number of infections in the population, reducing the chance and risk of transmission of infections, as well as harm reduction after exposure to the pathogen. In practice, the reduction in the number of sources of infection in the population concerns pathogens’ diagnosis, such as the detection of new cases and their effective treatment, increasing awareness of the risks and limiting new infections, and the microbiological safety of medical products and devices. Reduced chances of infections are a result of safe health behavior and preventative practices. Yet another component of prevention is awareness-building through health education, and increasing current understanding of threats and risks. Knowledge on potential sources of infection and elimination of threats, such as labeling and processing of infectious material and sharp equipment, is also of great importance. The reduction of the risk of infection transmission are can be achieved through the use of microbiologically safe equipment, along with compliance with procedures and regular epidemiological supervision aimed at ensuring the quality and safety of high-risk services. It is equally important to update the list of sources and routes of infection by monitoring high-risk areas. Harm reduction post-pathogen exposure is associated with active prevention (vaccination, such as HBV) and an efficient system for the registration of all cases of exposure and their immediate and effective treatment [ 19 , 20 ].

2. Materials and Methods

The current research was proceeded by a pilot study [ 21 , 22 ] which included 16 regional epidemiology consultants representing all voivodeships, that is, health administrative regions, at the national level in Poland. Approval for the research was received from the Research Board (steering committee of the Project KIK 35) of the National Institute of Public Health (NIPH). The Institute was established almost a century ago as the National Institute of Hygiene with disease prevention as one its key goals. The study protocol ensured voluntary participation and anonymity of all participants. Informed consent was obtained before the study from all participants.

The study was conducted in three stages, as illustrated in Figure 1 . These stages helped with the identification of the problem, process, and proposed solutions, as well as task prioritization.

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Project scheme—research project stages.

2.1. Sample

Stakeholders were defined as individuals who had a substantial role in advancing the development of a blood-borne infection (BBI) prevention program. Stakeholder opinions were obtained from a broad group of experts and practitioners located throughout the country. A total of 111 participants, representing all 16 Polish health administrative regions, took part in the study. Three groups of experts were invited to participate: practitioners; employees of supervising authorities (administrative supervision) at the regional level; policy-makers; and opinion leaders, that is, decision-makers, at the national level. The study was carried out in the form of a two-panel internet forum discussion (quasi-FGI), and a focus group (FGI).

The first two groups participated via forums that were conducted using IDEABLOG ® from Kantar Mill Word Brown, London, UK (first three days as individual input and the remaining two days as common forum), an independent online interviewing platform, whereas the third group of stakeholders, that is, experts and administrative supervisors, provided inputs through in-person focus group interviews (FGI). The use of an online platform was deemed important as it provided participants with a degree of flexibility to express their views and at a pace that was manageable with their individual schedules. The participation through an independent interviewing company and the anonymity of experts helped to reduce the risk of biases in the views expressed.

Participants in Stage 1 comprised of management staff and practitioners, specifically epidemiologists, experts, and service providers whose daily work was associated with the risk of BBIs, both exposure to the risk and risk generation. The perspective of an authority that oversaw the observance of regulations regarding the minimization of risks, that is, the Sanitary Inspectorate, was also obtained at this stage. Participants were invited using a list prepared by the NIPH. The official invitation contained a presentation of the research project, its objectives, and a request to participate in the study. Due to the novel nature of the vehicle of their participation, that is, online forums, it was important to over-recruit in order to ensure a suitable response rate. To date, little is known about adequate response rates involving online forums. However, studies involving focus groups suggest a minimum of five participants as acceptable and this benchmark served as a guide for Stage 1. Hence, for this stage, 80 individuals were contacted, of which 42 agreed to take part in the first online forum (Forum 1) [ 23 ].

For Stage 2, representatives of supervising agencies, such as state administration authorities, medical center managers, experts from academic centers, and specialists and experts from the field of public health were contacted. Of the 125 people invited to participate, 41 took part in the study and formed the cohort for the second online forum, that is, Forum 2. The rationale for conducting the aforesaid fora was underpinned by the need to obtain information, both from the level of service implementation (Stage 1) as well as the management level (Stage 2). The main reason for refusal to participate in the study at each stage was an excessive number of other obligations, which participants indicated would have made it difficult for them to be completely involved in the project.

Lastly, Stage 3 consisted of one set of FGI. Generally, FGIs are a qualitative method used to discuss particular themes with a group of invited participants in an open atmosphere with proposed scenarios [ 24 , 25 ]. In total, 11 opinion leaders and administrative supervisors were invited, all of whom participated in the study. Table 1 provides a detailed outline of participants.

Profile of interviewees and knowledge supporters.

1 An individual breakdown is not provided to protect participant anonymity.

2.2. Data Collection

In-depth views and opinions were obtained focusing on two key areas: (1) The problem of reducing the risk of infections in services and procedures connected with abrasion and damage of tissues; and (2) risks associated with the spread of infections and protection of patients, staff, and clients. The exploratory nature of the study lent well to a qualitative research framework, as it allowed for understanding of the decisions made by participants regarding a particular policy stance and factors underpinning the decision-making [ 26 , 27 ]. Table 2 depicts the topic guide that was used with each of the three groups of stakeholders to collect the necessary data.

Topic guide used with specific participant groups.

1 The topics were discussed in the open forum and users could see each other’s statements, but all usernames were pseudonymized. 2 Blood-borne infections.

Informed consent was obtained from all groups of participants prior to the actual proceedings. There was a note-taker, and independent observers supervised the online quasi-FGIs and FGI.

The first stage of this research project (i.e., online Forum 1) was carried out between 18 July and 20 August 2016. Throughout the forum, the invited epidemiologists and experts were given two topics every day, on which they were asked for their views and opinions. On each topic, the necessity to support answers with evidence was emphasized; for example, from practice, figures, statistical data, along with particular examples reflecting problems and good practice. The presented information was verified by participants through their own publications, practice case descriptions, and synthetic expert opinion. These elements constituted the quantifiable information or source data (SD) provided by the participants. The first three days involved conducting the individual interviews. The last two days consisted of a joint discussion about the information that was collected until then. During the joint discussion, each participant only had access to general statements, but not the SD.

The data collected were verified through the SD, and these constituted an extensive collection of research material that was arranged in a strengths, weaknesses, opportunities, and threats (SWOT) analysis which was then used for the subsequent second stage. The SWOT analysis allowed for organization of the first-stage data in a detailed report, based on suggestions that were made by participants during the joint discussion. The forum and associated discussion covered all aspects of BBI risk analysis. The information obtained was available for review by all participants in the final stage of the study (FGI). At the same time, all items were assessed by strengths or weaknesses, as well as how participants saw opportunities and limitations from their professional perspective.

Information for Stage 2 was gathered via the online Forum 2 and also conducted as a quasi-FGI between 5 September and 7 November 2016. In a similar methodology as Stage 1, participants received one topic per day for five days, and were asked to express their views and opinions regarding the topics. Figures and data collected and verified (from Stages 1 and 2) constituted the basis for the subsequent analysis. During the second forum, the first-stage data were consulted while also obtaining new data. The key output from Stage 2 was a list of 33 proposed solutions or postulates, which participants were asked to categorize based on groupings that they viewed as appropriate. This led to categorizing the postulates into the following topics: management, legislation, education, and financing, which is compatible with the administrative structure of healthcare management. Proposals for the 33 postulates formed the basis of discussion for the third stage of the project. As part of preparation for the FGI, the 33 proposed solutions from Stage 2 were further reviewed by research staff and reclassified into four categories: legislative, educational, organizational, and financial. These were emailed to the FGI invitees prior to the meeting so that they could adequately prepare for the discussion.

Finally, the in-person FGI that summed up the first and second stages of this study was completed on 30 November 2016 at the NIPH in Warsaw. The meeting was attended by opinion leaders and policy-makers who represented patients’ interests, service providers, public payers, the Agency for Health Technology Assessment and Tarification, and the Ministry of Health. The focus group lasted for about 90 min. Welcoming comments and presentation of the project details were followed by a general discussion on the subject of prophylaxis and prevention of BBIs. Next, a list of priorities, selected during the previous two stages of the study was introduced, along with a discussion exploring approximate timelines that would be needed to achieve any chosen priorities. Such an arrangement was aimed at redirecting specific tasks to the listed areas of national policy and administration. Participants were encouraged to freely discuss all topics that came up during the proceedings. The proceedings were overseen by a moderator whose role was to create conditions favorable for discussion.

At the FGI, participants were asked to prioritize the 33 proposed solutions. Then, they assigned priority in terms of time and urgency of implementation, according to the principle of the highest scoring. Rough rank ordering was used for the prioritization process. For example, one task could get a maximum of three points. In this way, the postulates were assigned a rank. In the first group of the most important priorities (i.e., high number of credits 11–18), four postulates were included. In the second group of moderate priorities (4–7 credits), there were seven postulates. Finally, in the third group of low importance (1–3 credits), 15 postulates were included and seven were rejected. In addition, under prioritization of tasks, similar to the earlier stages, the adopted topic areas were classified into legislation, education, organization, and finance, which are recognized areas from the policy perspective and arrangement of administration. The final outcome of this study was the rank-ordered 33 postulates (see Amendment).

2.3. Data Analysis: Quality and Verification

A broad thematic approach was applied to the gathered data. Research staff simultaneously reviewed all evidence and SD and proceedings of the two online forums and the FGI (as well as the tracks of interviews). The proposed data-ordering at Stages 1 and 2 according to the SWOT analysis method and division according to the proposed criteria were carried out jointly by the respondents and experts from their professional perspective. The research team met to discuss the broad themes that arose from the proceedings, and refined these to arrive at the postulates and their categorization under the four areas, that is, legislation, education, organization, and finance.

Stage 1: Discussions from this stage led to the identification of the following risk factors for BBIs by the participating epidemiologists—namely, HBC, HCV, and HIV. The risk factors and pathways of BBI dissemination were recognized in accordance with scientific evidence. In the context of this study, the BBI population risk was categorized by participants and based on statistics and indicators (incidence, prevalence, medical treatment of BBIs, and associated complications of BBIs). Additionally, the risks to professionals and providers were also identified, particularly involving procedure types and injuries during procedures, as well as waste disposal of therapeutic materials. For example, it was identified that nurses were more at risk of exposure to BBI-related adverse events, and that most of these events were caused by self-injuries, such as injections and cleaning of devices. Moreover, the importance of keeping an audit of occupational risk factors related to the afore mentioned factors was also discussed, as was medical tracking.

Exposure to hepatitis infections . Experts also identified a level of awareness of BBIs among professionals in different service sectors, with a related high risk of BBI. Participants emphasized that staff must follow both proper procedures related to handling BBI pathogens, and also follow preventative measures. Moreover, outsourcing of cleaning equipment and devices was also seen as a risk of spreading BBIs. Staff should also be mindful that procedures for preventing BBIs are followed according to best-practice protocol. Based on the above discussions, the epidemiologists concluded that there was a rather stable situation in Poland in selected diseases from the group of BBIs ( Supplementary Materials ). The results on the risks of BBI analyses were grouped into areas indicating the strengths and weaknesses of risk management and the opportunities and threats leading to the SWOT analysis which formed the input to Stage 2.

Stage 2: Initially, participants in this stage were invited to present their experiences and knowledge regarding information collected from Stage 1. Additionally, they were also asked to weigh in on program management concerns regarding BBI within their localities and issues of policy overseeing BBI in the context of infectious diseases generally. Participants also indicated the area of activity for the policy to resolve the presented BBI issues from Stage 1. The main output from this stage was the formulation of the 33 postulates which were assigned to the following areas: management, legislation, education, and financing.

Stage 3: The key output from this stage was the rank ordering of the 33 postulates from the perspectives of feasibility and public health program capacity.

4. Discussion

Taking a “bottom-up” data collection approach to the presented methodology, we selected epidemiological diagnosis and risk analysis evidence from the perspective of service providers, and then a decision-making process analysis. The next step entailed a presentation of both the problems and their management, and finally, rank ordering of the collected findings.

Due to the practical nature of the current research, a qualitative method that enabled the collection of different opinions, evidence, and postulates from a wide group of stakeholders was selected. This approach is in line with the new method of managing public health proposals, as qualitative methods provide participants with a space for free expression of thoughts, while also being evidence-based [ 28 ]. The techniques and web tools employed in qualitative research also provided a space for discussion and exchange of opinions, such as time for consultations, locating evidence, and protecting anonymity. In turn, this allowed for the obtaining of responses from participants, reflecting not only the direction of their views (e.g., what they find to be positive or negative), but also their substantiation (e.g., explanations for their thoughts), supported by examples and evidence. Therefore, the application of free-discussion techniques, such as the use of an online platform, was necessary.

Unlike standard interview techniques, the online platform enabled a flexible reaction to participants’ responses and the expansion of resultant information. In the field of public health, qualitative techniques comprise an additional, valuable source of information that enables the rationalization of a decision-making process by providing an opportunity to take a broader view of the problem, and includes other stakeholders in the interpretation and decision-making process [ 29 , 30 , 31 , 32 , 33 ]. To that end, the use of the online platform IDEABLOG ® turned out to be a useful tool in the context of this study.

The evaluation of the reliability and quality of data analyses is usually based on quantitative approaches. For example, known methodologies, such as GRADE and AGREE, are largely related to the implementation of results from other studies into policy [ 34 , 35 , 36 , 37 ]. In the analysis of data, especially in relation to the assessment of efficacy and safety of treatment, these studies are of indisputable importance. Relatively less importance has been attached to qualitative studies, which also require different methodologies and indications for their application.

The methodology of the multi-stage process of research and analysis as presented in this article involved epidemiology experts who helped with the identification of BBI risk factors and risk analysis underpinned by evidence through their repository of things such as statistical data, research results, expert opinions, case studies, and publications, which were a condition for participating in the first and second stages. The project included a sequence of diagnoses of the situation, results from the first stage and diagnosis of decision-making processes ensuing from the second stage, and a discussion on a coherent catalogue of the developed data of the first and second stages, which then led to results of the third stage. References to practical links between theory and practice were emphasized both at the stage of problem diagnosis and at that of programs/procedures. Such an approach is in step with the opinions of many other researchers, and includes both the creation of recommendations and their updating based on data [ 33 , 34 , 35 , 36 , 37 ].

The present analysis, divided into status diagnoses (Stages 1 and 2) and decision-making processes (Stage 3) was an attempt to systemize information about the extent of the risks associated with BBI and the essential stages of analysis for the preparation of further stages (i.e., proposed solutions). This is consistent with a methodological “mixed research approach” represented by other researchers in public health and healthcare policy [ 38 , 39 , 40 , 41 , 42 ]. Through its use of qualitative inquiry, the current study aimed to understand the extent to which the identified problems and opinions are common among the group of participating experts. However, respondents were asked for their opinions and to provide supporting evidence in the form of statistical data and other sources.

First, the study collected qualitative data and figures and diagnosed the status of knowledge (practical and theoretical) and the functioning of the system of services with regard to a problem researched. The web tool, IDEABLOG ® , was especially helpful to widening participation, as study participants were located in different parts of the country. In the final stage, the collected data on the diagnosis of the system and assessment of the scale of the risk of BBIs was systematized, and priorities were identified through rank ordering.

In terms of public health evidence, the results of this research, in the form of extensive reports from each research stage, were submitted to the Hepatitis C-virus Project Board (KIK35) to propose a new strategy for a policy of BBI prevention. These reports were also presented to all stakeholders as a source of information on the issue of blood-borne diseases in Poland. The selection of solutions resulted from substantive reasons, that is, the intention to collect possibly the most extensive material about the foundations and the actions taken by various institutions in the context of the prevention of BBIs, as well as organizational and technical reasons, since the target groups presented all health regions in Poland and people with different professional backgrounds and responsibilities.. The dissemination of the findings of the analysis to the stakeholders resulted in a greater degree of awareness and legislative changes; for example, of a greater sanitary regime in non-medical services and educational changes related to the inclusion of a range of issues in vocational education programs. To that end, some results were incorporated into policies and programs by the Ministry of Health, the Chief Sanitary Inspectorate, National Training Centre for Nurses and Midwives, and National Institute of Public Health.

Particularly in this study, the discussions focused on biological risk factors, but the methodology employed in our research might be useful to explore other risk factors. In the first stage, the risk of infection in services was assessed. In the second stage, infection risk issues related to processes and procedures were examined. In the third stage, decision-makers were asked to prioritize the lessons learned in the previous stages. Economic realities and the dynamics of changes in the field of epidemiology, as well as pressure from patients, clients, and service providers who are aware of the risk, provide the possibility of numerous decisions. This increases the obligation of experts to prepare recommendations for public health programs and policies considering broader insights around the particular problem.

This study also had certain limitations. The detailed analysis did not consider current regulations or organizational and financing structures; instead, it only indirectly referred to the opinions of experts and the information provided by them related to these elements. Moreover, some of the invited experts were unable to participate due to their professional duties, while others felt that there might be a possibility of political pressure.

Nevertheless, the findings of the present study provide directions for further research. In the future, the current authors will verify the extent to which the present results contributed to improvements in the field, for example, health conditions related to BBIs and whether the presented method of priority selection will find support. Statistical data on health risks allows for assessment of health implications, while the applied methodology also allowed for diagnosis of the processes leading to these effects. A limitation of the qualitative method is that it is not possible to quantify directly the risk, which has made it possible to look at the infection problem from a different perspective. However, the choice of the presented method was dictated by the necessity of the chosen objective. Acknowledging the limitations, the study recommended a method wherein experts were asked to support their views and decisions with analysis of hard data and research results from their own repository.

5. Conclusions

Evidence-based public health is routine. There is also an ongoing need to seek methods for evaluating the effects and processes of action taken in public health management. A standard sentinel system and epidemiological research provide strong statistical evidence and are the basis for rational decision-making. Improvement of the quality of statistical data and the need to broaden knowledge with new and better diagnostic tools inspire the search for better qualitative and quantitative methods in public health. This is particularly important in areas of public health in which there are similar risks and different approaches in terms of prevention, as well as different regulatory responsibilities.

This study examined some of the aforesaid principles through the lens of the challenges involving the problem of blood-borne diseases from the perspectives of medical and non-medical services, particularly to see how stakeholders approached issues of prevention surrounding BBIs in the services sector.

The methodology can be useful for the development of a strategy for the prevention of BBIs, but also for other risk factors. The methodology applied and the results obtained also inspired changes in education programs for employees in both the medical and non-medical service sectors in the prevention of BBIs. This allowed for the consolidation of various professional and social environments in order to reach a common consensus regarding the development of an infection risk-reduction program.

The report from the three-stage analysis was presented for decision-makers at various levels of management (in the medical and non-medical service sectors). As an outcome of the study, a proposal for a health policy prevention strategy for BBIs was then prepared with input from the research. The policy included extension of education programs based on analysis and educational material in direct e-learning. Additionally, specialized training programs for nurses were amended, indicating the need to modify the training programs for other professional groups.


We thank the sponsors of the research for their financial support. The authors thank persons from Kantar Mill Word Brown for their professional cooperation in this research, especially Magdalena Stec, experienced interviewer and facilitator, for her extraordinary merit-based support. We sincerely thank our invited experts and specialists for their availability, time, and contributions. We thank the Public Health and Epidemiology Consultants for their support. One of the authors wishes to acknowledge support of the Digital Lifecycle Management Group, WMG, at the University of Warwick, UK, in discussing the formal analysis.

Supplementary Materials

The following are available online at http://www.aaem.pl/Author-Anita-G%C4%99bska-Kuczerowska/147403 .

Author Contributions

Conceptualization, A.G.-K. and methodology, A.G.-K.; validation, A.G.-K., S.L. and R.G.; formal analysis, A.G.-K.; investigation, A.G.-K.; resources, A.G.-K.; data curation, A.G.-K.; writing—original draft preparation, A.G.-K., S.L., R.G.; writing—review and editing, A.G.-K., S.L., R.G.; visualization, A.G.-K.; supervision, A.G.-K., S.L.; project administration, A.G.-K.; funding acquisition, A.G.-K., R.G. All authors have read and agree to the published version of the manuscript.

The Study was supported by a Swiss Contribution and Ministry of Health grant (KIK35). The tasks under that project were assigned to an outsourcing company (financed) to avoid conflict of interests. The founders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The outsourced independent research agency performed research according to project protocol (presented methodology). At each stage, research workers monitored the course of anonymous interviews and discussion moderation, restructuring it depending on the necessity to focus discussion on particular problems.

Conflicts of Interest

The authors declare that they have no competing interests.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Bridging the Gap Between Theory, Research and Practice: The Role of...: Volume 12

Table of contents, table of contents, list of contributors.

The case for child development laboratory programs has never been more pressing than it is at this time. The three-part mission of facilitating and supporting teaching, research, and outreach activities has guided the activities of child development laboratory programs since their inception. Although these programs continue to be important players in the child development and early childhood education arenas, many are being asked to provide justification for their continued existence. In recent years campuses have reconsidered, reconceptualized, and restructured the ways in which these laboratory programs fit within the agendas and missions of the universities where they are located, the local communities surrounding the universities, and the child development and early childhood education professions in general.


When Brent McBride and Nancy Barbour approached me with a proposal for an Advances in Early Education and Day Care theme volume on child development laboratory schools, I was eager to pursue the topic with them. This Advances series has always been dedicated serving as a forum to furthering the knowledge base on all aspects of early education, broadly defined. The disciplinary roots of the field are necessarily interdisciplinary, reflecting the range of disciplines that are relevant to us, including sociology, psychology, policy studies, curriculum studies, history, and related fields. A fair amount of our existing knowledge base was generated in campus laboratory programs, which were designed to be interdisciplinary, as Barbour shows us in her chapter in this volume. At the same time, I am aware of some of the turmoil and transformation that has shaken campus child development programs over the past two decades ( Keyes, 1991 ); venerable programs have closed, converted from nursery schools to child care, altered to reflect communities beyond the ivory tower of campus, or asked to do things that they had never done in the past. What might a special volume on campus laboratory programs for children tell us about the state of knowledge, and the state of the field of early childhood education and care?


History helps us to better understand current practices, struggles, and potential solutions. This chapter provides a look back at the long, rich history of child development laboratory programs in the U.S. over almost 80 years. In particular, it explores the original vision of those involved in the early days of “child study” and the evolution over time of a sample of three child development laboratory programs. The struggles of today’s child development laboratory programs in the areas of funding, collaboration, research, training, and service are not unique to our times. Many of these same issues have plagued child development laboratory programs in the past. The historical perspectives were developed using a range of data sources: some period pieces (primary sources), some historical accounts, oral history interviews, and records of activity at various sites, with the intention of developing the historical foundation of the child development laboratory program in order to understand better the challenges we face today.


The University of South Carolina’s child development lab school faced extinction because of campus renewal projects and shifting priorities. Shrinking state budgets ended subsidies for small-scale programs at the same time the university was privatizing non-essential services. It became apparent that we needed to forge new partnerships and explore innovative funding strategies if the center was to continue providing quality childcare on our research university campus. Our five-year-long struggle has culminated with the creation of a unique public/private partnership linking the management expertise and investment capital of a for-profit childcare provider with the resources and professional knowledge at the state’s flagship university. After the framework for the public/private partnership had been created the state’s Department of Health and Human Services and Educational Television joined to create a center of excellence that will be a demonstration site for the entire early childhood community. We believe the partnership we have created is a sustainable solution to the campus childcare dilemma, one that will keep quality childcare and related research and teaching on our campus. The partnership we have created can serve as a sustainable model for other programs faced with shrinking budgets, eroding support, and threats to their existence.


This chapter describes the transition of a nursery school to a laboratory school. Dissatisfaction on the part of populations involved with the nursery school led to an extensive self-study, the results of which indicated several forms of discontinuity. The program was restructured through initiating structural changes and articulating missions congruent with those of traditional laboratory schools. Actions specific to educating and training students, conducting scientific inquiry and research, and implementing best practice and educational innovation also were taken in order to address the new missions and achieve higher levels of continuity. Throughout the chapter the difficulty and necessity of linking theory and research with practice and innovation are highlighted.


Child development lab schools have long played a significant role in contributing to our understanding of child development and new and innovative educational practice. In this chapter, we argue that lab schools need to be continually reinvented and reconstructed to meet changing societal and institutional demands. As models for the early childhood community, lab schools should be on the leading edge of what theory and research informs us are best practices in early childhood education and child development. Here we tell the story of the Virginia Tech Child Development Lab School’s efforts to reconsider and reconstruct our philosophical approach, practices, and policies and move closer to bridging theory and practice as a family-centered, teacher-inquiry based, community of learners. It demonstrates a paradigmatic shift in thinking about children, families, early childhood teacher education, and the role of lab schools in general.


This chapter describes how a college of education sponsored child development laboratory school responded to P-12 school reform movement efforts, particularly related to the establishment of professional development schools for the preparation of teachers. In its efforts to create a diverse learning community where all constituents (teachers, preservice teachers, and parents) are engaged in collaborative inquiry, the school sought inspiration from other sources, most notably the Reggio Emilia approach to early childhood education. In both the professional development school standards and the principles of the Reggio Emilia approach, emphasis is given to learning to teach within practice, teachers as researchers, making teaching and learning visible and egalitarian roles in carrying out the work of the school.


This chapter focuses on the importance of collaboration between university laboratory schools and community partners. The why, what, and how of collaboration within higher education contexts are reviewed, with a focus on the steps required for successful collaboration. The University of Rhode Island Child Development Centers’ collaborative efforts are used to illustrate potential ways collaboration can occur through statewide professional development activities, relationships with state and local public school systems, and relationships with various community groups and agencies. The conclusion is that through collaboration, lab schools can enhance their potential to fulfill their three-part mission of teaching, research, and service, and can strengthen the interconnections among the missions, bridging the gap between theory, research, and practice.


Child development laboratory programs relying heavily on department and university funding can face unique economic challenges due to the constant shifts in academic resources. Many programs have faced elimination during times of financial crisis at their institutions. The purpose of this chapter is to present a variety of creative financing strategies for child development lab schools to address these economic challenges. The focus is on strategies that bring financial stability to programs and lessen the reliance on university funds for viability. It is equally important for lab schools to be highly integrated with the mission of their institution to prevent funding dilemmas. For many administrators this means addressing the research, teaching and service missions of their programs. A case study of one child development laboratory school faced with elimination will also be presented.


Although child development laboratory programs share a common history and a commitment to a three-part mission of teaching, research, and outreach, they vary in the ways their programs are structured. At the same time, lab schools are being confronted by new challenges that have put many of these programs at-risk for cutbacks in support and/or closure. The diversity that can be found in the structure of lab schools has made it difficult for these programs to collaborate on ways to address the challenges they face on a daily basis. The purpose of this chapter is to present findings from a national survey of lab schools, with a goal of identifying common issues and challenges being faced by programs regardless of their structure. Results are used to identify critical issues lab schools must address in order to continue playing an important role in bridging theory, research, and practice in the field of early childhood education.

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ICU Management & Practice, ICU Volume 11 - Issue 1 - Spring 2011

Bridging the gap between theory and practice.

case study bridging the gap between theory and practice

Publication and distribution of guidelines alone insufficiently succeed in changing practice. This theory-practice gap is, at least partly, responsible for suboptimal patient care and potential patient harm. This paper reviews the most elementary conditions to enhance successful implementation of evidence-based guidelines in daily practice. 


For centuries, man has tried to find ways to improve practice. High-quality research was found to be key. In the 1980s, the evidencebased medicine movement emerged and has firmly developed in the following decades. The emphasis was on integrating "best practice care derived from well-conducted research" taking into account the preferences of the patient, experiences of the caregiver, and ethical considerations. Since that time, vast investments in healthcare research have been made. Yet, in recent years, it has become clear that the bottleneck that exists is not due to the provision of guidelines, but rather in their implementation. This paper discusses the troublesome theory-practice gap, which is often responsible for inferior patient care. The guidelines to prevent respiratory infections are used by means of an example. Respiratory infections carry a highly relevant clinical and economic burden. Successful implementation of prevention guidelines should be of particular concern for those involved in ICU management. The recommendations provided below are nevertheless also valid for all circumstances in which implementation proves to be a hurdle.

The Theory-Practice Gap in the Prevention of Ventilator-Associated Pneumonia (VAP)

Several studies indicate that evidence-based guidelines to prevent VAP are poorly adopted. Self-reported non-adherence rates to evidence based guidelines among ICU physicians and nurses demonstrated to be 37% and 22%, respectively (Rello et al. 2002; Ricart et al. 2003). In a multicentre survey among respiratory therapists and ICU nurses, the average reported adherence to ineffective and equivocal interventions was about 70% (Kaynar et al. 2007). In spite of this, there is growing evidence that an increase in adherence to evidence-based guidelines goes along with a decrease of VAP rates (Bird et al. 2010; Zaydfudim et al. 2009). Yet, the simple publication of prevention guidelines does not guarantee adherence. It seems that a more pro-active approach of implementation is needed to achieve favorable adherence rates.

Reasons for Non-Compliance with Guidelines

Self-reported reasons for non-compliance include inadequate resources, high costs, patient discomfort, and disagreement with the interpretation of clinical trial results (Rello et al. 2002; Ricart et al. 2003). According to a systematic review, the most frequently identified obstacles are a lack of awareness of the problem, lack of familiarity with the guideline, non-agreement with the recommendations, poor self-efficacy, inability to overcome the inertia of previous practice, and presence of external barriers to perform recommendations (Cabana et al. 1999). Yet, these results are not generalisable because barriers in one setting may not be present in another.

How to Bridge the Theory-Practice Gap?

Luckily, a number of facilitators to guideline implementation have been identified and should be considered. These refer to features of the guideline (scientific basis, logical and attractive presentation); the target group (level of knowledge, skills and attitudes, working practices); the social context (actual operating culture, views of opinion leaders), and the organisational context (organisational aspects, staffing levels). A duly considered implementation programme includes the following elements: First, one should identify and measure the problem. This will increase awareness of the issue and convince non-believers that there is actually a problem.

Second, an action plan must be defined. This includes the selection of action points by all stakeholders: policymakers, patients and public, professional organisations and educational bodies, healthcare providers, and purchasers (Haines & Jones, 1994). It can be recommended to invite an opinion leader to support the programme.

As a third step, objectives must be defined. These should be realistic, clear and limited in order not to demotivate.

Fourth, consensus should be reached among the team members about the action plan and the way to achieve these objectives. It is important that this is negotiated prior to the implementation phase. Without consensus, the programme is a priori doomed to fail, if not on short term, definitely on the long term.

The fifth rule is to implement the programme in a multifaceted approach. Doing so will avoid a bulldozer effect which will evoke resistance. This method succeeds in enhancing awareness and behaviour towards the problem (Bouadma et al. 2010; Gross et al. 2001). 

Finally, the process as well as the outcome must be monitored. Monitoring the process is done by measuring the compliance rate with local recommendations. The outcome is monitored by measuring the occurrence rate of the event to be prevented. Feedback of these data to the personnel is of key importance. Even when objectives are not achieved, feedback should be as positive as possible. If necessary, the programme must be adapted or the objectives redefined.

Knowledge as a "Conditio Sine Qua Non" to Improve Adherence

How can we expect healthcare workers to adhere with guidelines if they lack knowledge or deeper insights in the rationale of prevention measures? Targeted education is key to increasing awareness of the problem and the necessary knowledge to tackle it. Knowledge does not guarantee adherence, but it is highly important to realise that a lack of knowledge, per definition, impedes adherence. Certainly achieving long-term effects without a solid knowledge base seems to be an impossible goal. Several studies demonstrated that knowledge among European ICU nurses concerning infection prevention guidelines is poor (Labeau et al. 2010). As a response to these disappointing findings an interactive webbased 'crash course' in infection prevention is developed ( www.evidenceproject.org ). The interactive course design might be helpful to more easily adopt and maintain knowledge about infection prevention in the ICU. To which extent this learning module is effective, is currently a matter of study.

The theory-practice gap is highly relevant as it endangers patient safety. High adherence rates to guidelines are difficult to achieve. Implementation programs should be well thought-out and should take into account features of the target group, the social and organisational context. Investments in knowledge are of key importance, not only to help healthcare workers understand the rationale of the guidelines, but also because they positively affect their awareness and attitude.

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Bird, D., Zambuto, A., O'Donnell, C., Silva, J., Korn, C., Burke, R., et al. (2010). Adherence to ventilator- associated pneumonia bundle and incidence of ventilator- associated pneumonia in the surgical intensive care unit. Arch Surg, 145(5), 465-470. Bouadma, L., Mourvillier, B., Deiler, V., Derennes, N., Le Corre, B., Lolom, I., et al. (2010). Changes in knowledge, beliefs, and perceptions throughout a multifaceted behavioral programme aimed at preventing ventilator-associated pneumonia. Intensive Care Med, 36(8), 1341-1347. Cabana, M. D., Rand, C. S., Powe, N. R., Wu, A. W., Wilson, M. H., Abboud, P. A., et al. (1999). Why don't physicians follow clinical practice guidelines? A framework for improvement. Jama, 282(15), 1458-1465. Gross, P. A., Greenfield, S., Cretin, S., Ferguson, J., Grimshaw, J., Grol, R., et al. (2001). Optimal methods for guideline implementation: conclusions from Leeds Castle meeting. Med Care, 39(8 Suppl 2), II85-92. Kaynar, A. M., Mathew, J. J., Hudlin, M. M., Gingras, D. J., Ritz, R. H., Jackson, M. R., et al. (2007). Attitudes of respiratory therapists and nurses about measures to prevent ventilatorassociated pneumonia: a multicenter, cross-sectional survey study. Respir Care, 52(12), 1687-1694. Labeau, S., Vandijck, D., Rello, J., Adam, S., Rosa, A., Wenisch, C., et al. (2008). Evidence-based guidelines for the prevention of ventilator-associated pneumonia: results of a knowledge test among European intensive care nurses. J Hosp Infect, 70(2), 180-185. Labeau, S. O., Witdouck, S. S., Vandijck, D. M., Claes, B., Rello, J., Vandewoude, K. H., et al. (2010). Nurses' knowledge of evidence-based guidelines for the prevention of surgical site infection. Worldviews Evid Based Nurs, 7(1), 16-24. Rello, J., Lorente, C., Bodi, M., Diaz, E., Ricart, M., & Kollef, M. H. (2002). Why do physicians not follow evidence-based guidelines for preventing ventilator- associated pneumonia?: A survey based on the opinions of an international panel of intensivists. Chest, 122(2), 656-661. Zaydfudim, V., Dossett, L. A., Starmer, J. M., Arbogast, P. G., Feurer, I. D., Ray, W. A., et al. (2009). Implementation of a real-time compliance dashboard to help reduce SICU ventilatorassociated pneumonia with the ventilator bundle. Arch Surg, 144(7), 656-662.

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Ensuring Quality in Professional Education Volume I pp 53–72 Cite as

Simulating: Bridging the Gap Between Practice and Theory in Higher Professional Education

  • Yngve Nordkvelle 4 ,
  • Odd Rune Stalheim 4 ,
  • Trine Fossland 5 ,
  • Thomas de Lange 6 ,
  • Anne Line Wittek 6 &
  • Monika Bærøe Nerland 6  
  • First Online: 12 January 2019

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3 Citations

This chapter draws on three case studies of higher education courses conducted as part of the larger research project Quality of Norwegian Higher Education: Pathways, Practices and Performances. These cases had important elements of simulation in their curriculum as part of their nursing, law and management studies. We look more closely into how simulations are designed and used in these courses. The overall questions are: How are simulations used in these teaching practices, and in what ways do they serve to bridge the gap between theory and practice? Nursing education use sophisticated manikins, manipulated by specially trained nurses who interact with nursing students through, predominantly digital technologies as well as tactile hardware. They pose challenges to the students who try to develop mastery of procedures and handle the uncertainties that follow a “true” nursing situation. The management education course used a role play developed in-house with the purpose of training students to perform interviews and selecting candidates for hiring. The setup for simulation in law studies was to establish a stage for a trial court room, with students filling the roles of prosecutors and defenders and members of the audience. We discuss how the cases display risks and promises for the use of simulations in teaching practices in higher education, especially where potentials for knowledge integration are concerned.

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The project is financed by the Research Council of Norway (2014–2017) and is led from the research institute NIFU in collaboration with the Department of Education, University of Oslo. More information about the methodology and findings from the case studies is available in Nerland and Prøitz ( 2018 ).

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Nordkvelle, Y., Stalheim, O.R., Fossland, T., de Lange, T., Wittek, A.L., Nerland, M.B. (2019). Simulating: Bridging the Gap Between Practice and Theory in Higher Professional Education. In: Trimmer, K., Newman, T., Padró, F. (eds) Ensuring Quality in Professional Education Volume I. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-030-01096-6_3

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    The gap between theory and practice is a central problem in teacher education (Barends 2022; Gravett & Ramsaroop 2015; Korthagen 2011). The purpose of this article is to explore how the ...

  22. Strategies for bridging the theory-practice gap from the perspective of

    Consequently the theory-practice gap is a consistent nursing problem experienced by experienced and newly qualified nurses and students (Greenway et al. 2019), best summarized as the gap between the theories practitioners claim underlie their practice, and the implicit theories embedded within their practice, of which they may not be aware.

  23. The Gap between Theory and Practice: Problems and Possibilities

    The Gap between Theory and Practice: Problems and Possibilities Y. Hatasa Published 2013 Education, Linguistics This paper treats the classic problem of the gap between theory and practice in the field of second and foreign language education.

  24. The Power of Preaching and Deliberative Dialogue to Catalyze ...

    This article explores different ways that preachers and congregations have used the sermon-dialogue-sermon process to address social issues in their churches and engage their local community. I begin with a brief review of the homiletic theory behind the emergence of dialogical preaching, including the ways I have integrated this theory into my own method of the sermon-dialogue-sermon (SDS ...