How do we bridge the gap between theory and practice in nursing?
To find out, we interviewed our healthcare leadership team on the causes, impact, and possible solutions from their perspective as experienced nurse leaders.
Nursing shortages get a lot of headlines, but challenges in the nursing workforce extend beyond just the numbers. Increased demand and strained resources are leading to burnout of the existing workforce. We know that to get more new nurses into the field, we need to increase capacity in nursing programs, but an influx of new graduates creates yet another strain on the very same resources who desperately need them. There's a gap between nursing education and clinical skills, often called the theory-practice gap or academic-practice gap, that must be bridged to ensure the practice readiness of new nurses and effectively support the needs of hospitals and health systems.
We sat down with our resident team of experienced nurse leaders, Colleen Sanders RN, FNP-BC, our Vice President of Healthcare, and Bethann Mendez DNP, APRN, CCNS, our Director of Healthcare Operations, to hear their perspective on the theory-practice gap, its root causes, its impact, and the possible solutions to efficiently transition new nurses to practice with meaningful academic-practice partnerships.
To start, why don't you each tell us a little bit about your background in nursing?
Beth: My background is in critical care and trauma nursing. I practiced for about 16 years at the bedside and then returned to school to get my MSN and licensure as a clinical nurse specialist. After a few years in the CNS role, I returned to school for my DNP in Clinical Leadership.
I served in several professional practice focused roles, including working on transition to practice and professional development. I ended my hospital career as an operational leader over a critical care division through the first year of the pandemic.
After achieving my doctoral degree, I began to explore academia. In addition to my full-time hospital-based roles, I had the opportunity to serve as adjunct faculty for both campus-based undergraduate BSN and ABSN programs, as well as online MSN leadership and quality programs.
You also have some experience hiring and orienting new and early-career nurses, correct? Can you tell us about that?
Beth: As a professional practice leader, I served in several positions, including unit and system-level roles responsible for onboarding new graduates and new-hire RNs. At the time, having new graduates in an ICU setting was unique and not well-supported, requiring a highly curated experience to ensure they were adequately prepared for practice.
In most of these roles, my team and I were eager to try and match the onboarding experience with what the new graduate or inexperienced nurses needed, attempting to provide gap closure courses and skill exercises that allowed them to transition to practice.
In my final hospital-based role as an operational leader, my perspective shifted from the front end of educating and preparing nurses, to the back end, being responsible for their clinical performance. Interviewing, hiring, resourcing, and retaining staff has a different set of challenges.
In that capacity, as the leader responsible for the outcomes of care, I found a new perspective on just how wide and deep the transition-to-practice gap can be.
Colleen: I started my nursing career in oncology at Memorial Sloan Kettering Cancer Center. It was the opposite of what I thought I would do with my nursing career, which was to be a NICU nurse with very small babies. I worked in the urgent care center, which was like the emergency room for cancer patients. I was there for several years while I worked on my family nurse practitioner degree.
When I finished my master's and had my FNP certification, I started looking for nurse practitioner jobs. I knew I wanted to leave New York, and I applied for some jobs back in DC. I got my BSN in DC at Georgetown, so I reached out to the faculty there, thinking I would be a part-time clinical instructor while I worked as a family nurse practitioner.
Is that how you made the transition into academics?
Colleen: Yes, once again, I did the opposite of what I'd planned when Georgetown asked me to work for them full-time because they were so in need of instructors. I took a full-time academic job and worked part-time as a nurse practitioner. I started my nurse practitioner clinical experience in Minute Clinic and worked there for a few years, and for almost 12 years now I've worked for a primary care practice as a part-time nurse practitioner. This has allowed me to occasionally work with nurse practitioner students and new NPs, and witness transition to practice firsthand.
On the academic side, I did didactic and clinical instruction for pre-licensure nursing, both traditional four-year programs and accelerated second-degree programs. In 2011 I got pulled into graduate faculty work at Georgetown as they launched their FNP program nationally. Georgetown's model was a distance program, but a faculty member visited the student once in their home state where they were doing clinical. And so I crisscrossed the country seeing students; I even went as far as Alaska! Eventually, in my last year at Georgetown, I ran the campus immersions for the FNP program, when all the online students came for hands-on, specific training related to the assessment, diagnosis, and management of patients.
After I left Georgetown, I went to the Family Nurse Practitioner program at Marymount, a campus-based program, and helped slowly transition them online. At first, we were allowing students the option to just Zoom into the classroom for the week if they couldn't make it to campus, and then I was still running that program when they eventually went online during the pandemic.
During my time there, I also continued to teach in the BSN program, where I saw the challenges nursing students face today as they navigate operationalizing academic content in a clinical setting—whether real or simulated.
What is the theory-practice gap in nursing? Can you give us a brief explanation?
Colleen: It refers to the practice readiness of new nurse graduates, or rather, the gap in their knowledge and skill set that prevents them from being practice-ready without extensive onboarding and on-the-job training.
For some context, historically, nurses were trained with on-the-job training and, eventually, hospital-based training. There was a point where hospitals could even grant degrees or diplomas. But there was a movement to put a bachelor's degree behind nursing, so the pendulum swung from hospital-based training into academics. While that's great in many ways, a lot of faculty aren't actively practicing at the pre-licensure level. So coming from an academic side, you have a focus on theory, which is sometimes somewhat removed from what happens in actual clinical practice. Theory doesn't always perfectly translate into tangible, discrete items.
Traditionally we use clinical experiences to give students the opportunity to implement what they've learned in the classroom. But there's not always a great set of discrete objectives to guide them. Given that the time available for the clinicals is incredibly limited, they don't get the opportunity to understand the nuances. Clinicals don't extend the entire shift, and students don't assume all the responsibility, even under supervision, that they will have as a nurse on the floor.
Is there anything else, besides the limited clinical experiences, that leads to the practice gap?
Colleen: For accreditation, universities have to get community stakeholders to give input, often including nursing leadership from local hospitals. But even with that input, an academic-practice gap remains, and the hospitals still provide additional education to new graduates because they haven't been afforded the opportunity to implement or fully develop clinical judgment under the current educational models. They might know the theory and the didactic, but they don't have the psychometric skills to put it into practice.
Beth: To add to that, faculty have two pillars of responsibility. One is to be experts in education - how to educate, including pedagogy and appropriate delivery models. However, they also need expertise in the subject matter they're teaching. Maintaining these two distinct areas of expertise is difficult and time-consuming, so I think education often takes precedence. The clinical practice environment and evidence-based care change quickly, and the time and resources available to keep up are limited. The academic focus is theory-based, broad, and slower to change, while the actual practice environment changes at lightning speed.
Colleen: I also think that academics has changed a lot, even in the time since I started working in academics in 2008. In part, I think the learner has changed. Technology has made a significant impact on how people consume information and want to consume information. Both undergraduate and graduate students are accustomed to having information readily at their fingertips. Their thought is that they can find any information they need, and they only want the information they need to know and no more. But they have to understand the significance of how to apply that information, which is often a missing piece.
I always tell students that, in school, we can't prepare you for every possible clinical situation that you might experience in your career. The goal is to give you the skill set to problem-solve.
Beth: Students often have this misperception of what the environment will be like. They think it's more static than it is. Even when I was in nursing school in the early 90s, it was less dynamic than now. There was often one device and one way to interact with it—a complicated environment, to be sure, but one that could be broken down into manageable parts. Now the environments are overly complex, with multiple devices that all do the same thing and multiple ways to interact and apply each to patient care. This dynamic and ever-changing environment is harder to tease apart into smaller manageable components... teaching to the complexity of the practice environment is a new and overwhelming challenge.
Colleen: I agree that it used to be more static. And I think that's how students want it to be. They want everything to be very black and white when in reality, we live in a lot of gray.
Beth: Agreed, and learning and developing a comfort with ambiguity is essential. If the students aren't comfortable with ambiguity, it diminishes their resilience. And, of course, that feeds turnover.
What personal experiences have you had in dealing with the theory-practice gap in your career?
Colleen: In one of my early roles, I did some precepting for new nurses. I have a distinct memory of one of the nurses I was orienting struggling with medication calculation, and she said, "I don't understand math." I was like, but not understanding it is not an option. You have to sit with it, and you have to do some math work.
She got all the way through a nursing program and still was not confident in her own ability to do the medication calculations. Sometimes the practice gaps that must be bridged are very specific to an individual.
Beth: From a hiring perspective of new graduate nurses, I learned to interview for knowledge and attitude, assuming there would be a skill deficit at first. Because there was a gap and because I was blind to what they had completed during their university time, including the depth and breadth of their experience, I reinvented the wheel during orientation, paying for modules and putting them through classroom sessions - in addition to their precepted time. From my perspective, it was easier to ensure the gap was closed from my end than to make any assumptions that would leave them unprepared and unsafe at the end of orientation. As the leader responsible for outcomes, this ensured I could speak to their knowledge and its direct application to skill.
It sounds like a lot of time and resources went into getting them up to speed.
Beth: Right. A lengthy orientation, cost of modules, cost of paying people to teach, or develop and teach, the content – all were additive costs to the precepted orientation time at the bedside. It stretches the non-productive orientation window a great deal.
Colleen: What Beth just said touches on an issue with how we structure nursing education – it currently doesn't set them up to be immersed in a setting where they can fully develop the skills they need. For example, when I was taking students to clinical, I'd take them Tuesdays from 7:00 AM until 1:00 PM, and then I wouldn't see them until the next Tuesday at 7:00 AM. When it's one day a week, every week of the semester, you have these big gaps where they might be going home and thinking about what they need to do next, or what they should have done differently, or looking something up. But they don't have the opportunity to revisit that skill for another week, which just sets them up for regression. You can forget a lot in a week!
It's structured that way to allow them to apply the content throughout the semester, which does make sense. But unfortunately, I think that it adds to the challenges of getting them to feel confident and comfortable. Doing something once a week for 14 weeks versus going and spending several days immersed in it; I think that as learners, we need time to truly figure things out, and there's a different self-efficacy that comes with taking that time.
Do you think the structure of nursing education might need to change to mitigate the skills gap? Or is there more to it?
Colleen: I don't know if anyone has ever compared the effectiveness of schools that offer clinical courses in a shorter seven- or eight-week form, where students might be going into a clinical setting twice a week versus just once a week. Do they find that students acquire skills better because they have a quicker turnaround of being able to apply the knowledge? I don't know, but I think that could contribute.
I also think the gap exists because nursing schools focus on ensuring they've checked off a list of skills. Students get very hung up on exactly what steps they should follow, and they miss the clinical judgment piece.
What they need to know is, what are the critical elements to maintain patient safety and effectively implement the task or skill?
There's sometimes so much focus on the checklist versus true understanding and the ability to problem-solve based on the circumstances. And as we were saying earlier, the students tend to want to live in black and white, but everything is really gray.
Beth: Yes, it's really about the application of knowledge. The clinical experience, even if it's robust, is still singular in replication. The students might see something once during their clinicals, and even if it's a high-quality precepted experience with somebody who's intimately knowledgeable about the subject matter, it is still just a singular event. There's no scaffolding, no building on any competency because the intent is for it to be checked off the list.
Colleen: Many people can memorize a checklist, but can they identify why they're doing the items on the checklist? And what happens if one of those critical elements is missing or done incorrectly? It's not the checklist itself that's critical; it's the meat behind it.
Students also often go to multiple systems for rotations, creating a lot of excess noise. Instead of fundamentals, they're focused on questions like, where are things physically located? How do I log into this system? How do I find this in this EMR? Where are their policies? How do they do meds? There are so many details that generate noise when switching between systems that it can distract from the clinical judgment skills that should be paramount.
Beth: The shortened or fractured clinical experience time doesn't allow for that follow-up. In the clinical window, you might have given a medication that you spent time looking up and navigated "how" to deliver the med in that particular location. But then clinical ends, and you don't get to see the follow-up effects on the patient and evaluate whether it was appropriate, or take the post vital signs, or communicate with the ordering provider to allow for adjustments. You never have the opportunity to learn the importance of evaluating care decisions and revising care based on unmet outcomes. What an incomplete picture this creates.
Often these limitations are either because the experience time has run out or because you are part of a larger group and you're rushed to move on to something else. It's not set up for someone to say, "let's pause here or go back because you are going to want to see the effects of the medicine you just gave."
Colleen: Not to mention learning the complications of navigating America's healthcare system. You and the medical team have devised this great plan for the patient and sent them home. Three weeks later, they're back because they couldn't get their scripts - they couldn't afford them, or insurance didn't cover them. So much happens beyond just that minute you're in the room. If you can't see that over a longer trajectory, you miss out on a lot of essential things that nurses need to consider to care for patients and populations effectively.
How significantly different is the skills gap or level of preparedness coming from various pre-licensure programs?
Colleen: Back in the 1960s, the American Nurses Association said BSN-prepared nurses have better outcomes and should be the gold standard. There have been studies since that have backed this up. For many reasons, nursing has never fully implemented that, so we continue to have diploma and associate degree nursing programs that don't lead to a BSN. The additional curriculum that's in a BSN program brings added value. And employers know that they're going to have better outcomes and that, in general, the capacity of the BSN-prepared individuals to grow and expand their role is going to be greater – usually, not in all cases.
Beth: In my experience, we see an even greater level of preparedness with second-degree nursing students, those coming through accelerated BSN programs. Their self-efficacy is greater; they chose to pivot to nursing. It's an intentional decision, so they take more ownership of learning and become better advocates for themselves. And, of course, there's some financial motivation, too, because they're potentially paying for the program themselves. I also believe that, even if they completed a four-year program and jumped right into a second-degree program, they have some life experience that helps with their learning. Adults are experiential learners, so the more experiences you have in life, the more you can relate what you're learning to those situations.
That's what the second-degree students that I worked with and looked to hire brought to the table - a little bit more maturity and intention coupled with some life experience that helped round them out as a person. Maybe it even made them a little more resilient.
Colleen: I would echo what Beth said from her clinical perspective with what I've seen in academics, having taught both traditional four-year BSN students and accelerated second-degree students. Second-degree students tend to be highly motivated and very intentional in their learning. They want to master it, and they really want to understand it. Whereas I think traditional undergraduates tend to be more like the average arc - you have a handful of people who are really good, a big group in the middle, and then a handful of people who struggle. Self-motivation seems more variable in that traditional undergraduate group. With second-degree students in particular, maturity and life experience make them excel a bit more at the softer skills, which are crucial to this profession.
What kind of impact does the skills gap have on the staff and the organization?
Beth: I think the effect of the gap on the new nurse is the potential for an environment of mistrust. Everything is built on a foundational level of trust - with their peers, their managers, their patients, and themselves. And when that isn't there, and they lack that confidence, as we discussed earlier, it feeds fear, ultimately damaging their professional resilience and desire to continue long-term. The gap makes them more fearful, feeling untrusted, not part of the culture, and not being embraced; they're afraid of making mistakes, and you can't learn when you're scared. And it's hard to grow when you're scared. When you have such a tricky start, it's going to impact your ability to stay resilient in the profession.
There were times when I didn't have enough nurses to take students. I only had enough inclined nurses who would precept to get my new employees onboarded. To ask someone to take on a student was just not an option.
No one had enough gas in their tanks to precept a student, even though we knew we couldn't get out of this shortage without it.
We couldn't actualize any resources for the student. There's this cyclical effect of burnout contributing to the burnout of existing experienced staff because of duplication of efforts. It is a continual cycle of demands with no breaks to ensure they have time to practice and care for themselves.
From an organizational perspective, the gap causes expense where there doesn't need to be. That duplication of effort by the preceptors who are trying to have time for students and onboarding new nurses is a strain on resources. That strain could be reduced with some transparency and a better understanding of where the students are when they come in.
Is anything currently being done to help close the gap?
Colleen: Health systems realize there is a gap that they have to bridge. A handful of health systems are trying to innovate - to get people more and better experience, more time to acclimate, and more support. I read a recent article where Yale New Haven Health offered an opportunity for nursing students to do additional clinical hours within their health system. It was an attempt to bridge the gap caused by the pandemic because of the shift to simulation versus actual direct patient care. And it showed that students wanted to continue to do these hours. So health systems know there's a problem, but not all of them have the capacity to design and implement solutions.
Another factor that plays into the gap is superficial collaborations between universities and systems. Usually, these are arrangements where the university says, 'give us placement spots, we'll send you students, and hopefully, they become your employees eventually.'
Very few, if any, universities and systems have been able to spend the time to create deep, meaningful academic-practice partnerships. There's a faculty shortage. There's a nursing shortage. There are hospital administrators giving everything they have just trying to keep things running. It'll take real, collaborative solutions to address the issues.
Beth: There are quite a few "on-paper" affiliations, but they aren't always meaningful.
Colleen: When I was at Marymount, the Virginia Hospital Center, which was right down the road, called and said, 'we need you to teach evidence-based practice content for our nurse residency program.' Not that their nursing leadership didn't know it, but they just didn't have the bandwidth to teach it. So our faculty went over and taught it. But that was only one part of the residency. There wasn't further conversation around what else they needed help with or how else we could make it easier.
It was complicated because the hospital had students from other schools in their new grad cohort in addition to the Marymount students. So even if you solve the problem with one school, not all of your new nurses will come from that one school. And while it seems like there should be an even playing field, there isn't really. Every student coming out of one program is in a slightly different spot, and then every program is slightly different even though they all map to the same accreditation standards.
Beth: There's also the question of how much effort will be invested in a surface-level partnership or affiliation. When resources are scarce, and people are stretched, how much they care can be diminished. How much time and energy do you invest in students who are ultimately not your people? You're not going to take ownership or responsibility. Of course, there are some really great people out there who care a whole lot. Beyond those few people who go the extra mile no matter what, most people are thinking, how much time and energy do I have, and who needs it? And for a student I may never see again, I'm going to expend the least amount of my precious energy reserve and get them through this rotation.
But if you can build an in-depth partnership, you can work on helping them to understand why it's important to invest their time and energy. Because at some point, they're going to be standing next to them in the unit, and they're going to be their team member. It's different from thinking they'll never see this person again. It changes the calculation of how invested they are.
This is a complex challenge, but in an ideal world, how would you fix it?
Colleen: I'd provide a way for health systems or hospitals to know where they need to pick up on the professional development of the new nurse they just hired. Ideally, through strategic academic-practice partnerships, working at a deeper level to generate opportunities for students to acquire the professional knowledge and skills they need in a meaningful way that will better prepare them for the time after graduation.
We also have to figure out where we can reduce redundancies.
I recently watched a vignette of a video about a nurse residency program, and one of the participants said, 'well, it's a lot of stuff that was taught in nursing school.' We shouldn't have to reteach.
There are certain things from a risk management liability standpoint that you do need to observe a person doing, but you should be able to quickly do those things based on what someone should have learned and demonstrated in school. Making that transition more seamless and less redundant could significantly impact new nurses feeling more confident in their skills as they see those connections between academics and practice.
Beth: I think it's critical that we change our focus from the output, or maybe it's about changing our alignment on the output. The hospital has regulatory bodies, and there are certain metrics and quality standards that they're trying to achieve. The university has a different set of standards that they're trying to accomplish in a student's academic preparation. We need to find the point of commonality, changing the focus from these disparate goals to something congruent. Is it student focus? Is it practice-readiness focus? Whatever it is, acknowledging that yes, one has to answer to the Joint Commission, one has to answer for NCLEX success rates, but in the end, we all answer to the patients we serve. Patient care has fallen in the gap. How do we achieve alignment to create a new focus on translating education to practice?
Colleen: There's a concept for assessing competence called Entrustable Professional Activities (EPAs). EPAs are a framework for defining and measuring activities a professional must be able to do to carry out their role competently. If universities and health systems could agree on the essential EPAs an RN needs to enter practice and establish ways to track an individual's progress, they could be better aligned on those mutual goals.
The academic side tends to be very theory-based and abstract. Hospitals are more focused on whether you have a specific skill - and of course, clinical judgment skills, which are imperative but difficult to measure. But while we may be speaking different languages around the theories and the competencies, the actionable things overlap.
There is an opportunity to find a common vernacular that will foster alignment to bridge the academic-practice gap.
Beth: It's a complex problem to solve, given the current healthcare landscape. Hospitals are treading water to fill nursing staffing needs. Nursing programs have faculty shortages and are struggling to find enough clinical placement sites. The solution is going to have to come from meaningful, in-depth partnerships.
Colleen: Collaborative academic-practice partnerships have the best chances of bridging the gap - partnerships that leverage innovation. There is a vested interest in generating solutions on both sides; the challenge is bringing together the right resources and support to uncover the common ground between academics and clinical practice. The benefits to new nurses feeling supported and empowered will likely have a long-term impact not only on their careers but also on patient care and quality outcomes.
Keypath is committed to making an impact on the theory-practice skills gap in nursing by building meaningful academic-practice partnerships that bridge the gap between hospitals, universities, and students and provide sustainable solutions to nursing workforce challenges.