HealthApril 16, 2019

Closing the education-practice gap

Diane M. Billings, Ed.D, RN, ANEF, FAAN, Chancellor's Professor Emeritus, Indiana University School of Nursing, Indianapolis, IN

The goal of nursing education is to prepare nurses for clinical practice, and schools of nursing are increasingly collaborating with their clinical partners to provide relevant education and a smooth transition to practice. However, recent evidence indicates several areas where there are gaps between nursing education and nursing practice that can be narrowed.

Two gaps require immediate attention: making clinical nursing judgments and implementing quality and safety education standards for nurses (QSEN). Nurse educators, and our colleagues in nursing service, must collaborate to close these gaps, as safe and patient-centered care depend on it.

When considering these gaps and how to close them, nurse educators must take a systems view. This includes understanding the clinical setting and collaborating with clinical partners, reviewing the curriculum to ensure inclusion of essential competencies, and, at the course level, using the full teaching-learning cycle and evidence-based teaching practices to prepare students for the realities of the clinical setting.

Making clinical judgments

Recent evidence indicates that only 23 percent of new graduates have entry-level competencies, and many of the errors related to patient safety are caused by ineffective clinical judgments. These gaps in the nursing practice of new graduates are caused by ineffective communication, the complexity of the clinical environment, lack of knowledge about patient care, and lack of experience in working with teams.

Interventions can be planned at all levels of the system to close this gap. In the clinical area, this could include using a dedicated educational unit for student clinical experiences, collaborating with nurses and professional development educators to create an environment that will help students (and staff nurses!) learn to be more deliberate in making clinical judgments, and initiating a transition program or residency to allow new graduates time to adjust to the demands of clinical practice.

Faculty also must evaluate the curriculum to ensure students are learning how to make clinical judgments. There are several models of clinical judgment, such as the information processing model used by National Council of State Boards of Nursing, the Nursing Process, or the Tanner Model of Clinical Judgment. 

These models emphasize the steps nurses must take to make appropriate clinical decisions.

At the course level, faculty must ensure that they are consistently using a nursing clinical judgment model throughout the teaching-learning process. This helps students to establish clear and high-level learning outcomes using active learning strategies, provides opportunities for students to practice and assess their attainment of the learning outcomes, and offers high-level evaluation strategies that measure students” ability to make nursing judgments.

Implementing quality and safety education for nurses

While QSEN competencies have been embedded in documents recommending essential competencies in the curriculum and accreditation standards in schools of nursing for several years, the QSEN competencies are just recently becoming established in Joint Commission and Magnet standards for clinical agencies. The gap of implementing QSEN in clinical practice may occur because of nurses” lack of knowledge about the competencies, or the fact that patient-safety culture is not well-established or may not be a part of the role of the staff nurse, but rather is the responsibility of a designated position or office.

A systems view reveals strategies that nurse educators can use to begin to close this gap.  For example, formalized service-education partnerships establish expectations for shared goals and offer access to clinical units that welcome the opportunity to host students and faculty and are willing to collaborate to improve practice.

Dedicated education units (DEUs) are an outgrowth of these relationships, as are joint-practice improvement projects that focus on developing evidence for practice, or the development of residency programs to promote transition to practice.

At the curriculum level, faculty must consider QSEN competencies as a curriculum thread and plan learning activities and clinical practice assignments to implement them within all courses. Within the courses, faculty can integrate the competencies in case studies, simulations, and other active learning strategies. Of concern is the need for informatics knowledge and abilities, and, because many schools do not have informatics courses or faculty with requisite expertise, faculty may need to seek access to modules or courses offered outside of the school.


Both schools of nursing and clinical agencies seek to ensure a safe environment in which high-quality and patient-centered care is the focus. A priority is to narrow and close gaps that contribute to patient errors, such as making ineffective and uninformed nursing clinical judgments, and establishing a culture in which the QSEN competencies are embedded in nursing practice.

Other gaps, such as the use of emerging technology, shortage of nurses and faculty, the emphasis on population health, and shifting roles and educational preparation required for nursing practice are also emerging. These gaps can be best managed when faculty and nurses in clinical practice collaborate for the benefit of the patients.


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