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Nurse Education Today
journal homepage: www.elsevier.com/locate/nedt
The transfer of theoretical knowledge to clinical practice by
nursing students
and the difficulties they experience: A qualitative study
Ulviye Günaya,⁎ , Gülsen Kılınçb
a Department of Pediatric Nursing, The Faculty of Health
Sciences, Inonu University, Malatya 44280, Turkey
b Department of Psychiatric Nursing, Faculty of Health
Sciences, Inonu University, Malatya 44280, Turkey
A R T I C L E I N F O
Keywords:
Nursing students
Theoretical knowledge
Clinical practice
Difficulties
Experience
Transfer
Qualitative study
A B S T R A C T
Background: Nursing education contains both theoretical and
practical training processes. Clinical training is the
basis of nursing education. The quality of clinical training is

closely related to the quality of the clinical learning
environment.
Objectives: This study aimed to determine the transfer of
theoretical knowledge into clinical practice by nursing
students and the difficulties they experience during this process.
Methods: A qualitative research design was used in the study.
The study was conducted in 2015 with 30 nursing
students in a university located in the east of Turkey,
constituting three focus groups. The questions directed to
the students during the focus group interviews were as follows:
What do you think about your clinical training?
How do you evaluate yourself in the process of putting your
theoretical knowledge into clinical practice? What
kind of difficulties are you experiencing in clinical practices?
Results: The data were interpreted using the method of content
analysis. Most of the students reported that
theoretical information they received was excessive, their
ability to put most of this information into practice
was weak, and they lacked courage to touch patients for fear of
implementing procedures incorrectly. As a result
of the analysis of the data, five main themes were determined:
clinical training, guidance and communication,
hospital environment and expectations.
Conclusions: The results of this study showed that nursing
students found their clinical knowledge and skills
insufficient and usually failed to transfer their theoretical
knowledge into clinical practices. The study observed
that nursing students experienced various issues in clinical
practices. In order to fix these issues and achieve an
effective clinical training environment, collaboration should be
achieved among nursing instructors, nurses,
nursing school and hospital managements.
Additionally, the number of nursing educators should be
increased and training programs should be provided
regarding effective clinical training methods.

1. Introduction
Nursing education involves theoretical and practical educational
processes. Students are taught how to provide care for people in
dif-
ferent healthcare settings (Dinmohammadi et al., 2016), with
education
occurring in classrooms, laboratories and clinics. While the
classroom
environment provides students with largely theoretical
information, the
clinical environment provides opportunities to put theoretical
in-
formation into practice (Kelly, 2007).
Practical experience in health care settings is the foundation of
nursing education. The primary purpose of practical experience
is to
improve the students' professional knowledge and skills, but it
also
involves improvement of skills of research, critical thinking,
self-
esteem, independent decision-making, and effective
interpersonal
communication (Dinmohammadi et al., 2016; Elcigil and Sarı,
2007;
Papp et al., 2003). The quality of practical learning is closely
related to
the quality of the clinical learning environment (Dinmohammadi
et al.,
2016; Elcigil and Sarı, 2007). In the literature, it was found that
nursing
students' academic motivation increased as the quality of their
clinical

learning environment improved (Aktaş and Karabulut, 2016).
The
success of education in the clinical environment is influenced
by var-
ious factors. These are the instructors, students, healthcare
profes-
sionals employed at the clinic, and the physical environment
(Pollard
et al., 2007). When one or more of these factors are inadequate,
clinical
education may not be achieved at a desired level (Aktaş and
Karabulut,
2016). This situation may lead prospective nursing students to
https://doi.org/10.1016/j.nedt.2018.02.031
Received 18 May 2016; Received in revised form 6 February
2018; Accepted 26 February 2018
⁎ Corresponding author at: Inönü University, Faculty of Health
Sciences, Malatya 44280, Turkey.
E-mail addresses: [email protected] (U. Günay),
[email protected] (G. Kılınç).
Nurse Education Today 65 (2018) 81–86
0260-6917/ © 2018 Elsevier Ltd. All rights reserved.
T
http://www.sciencedirect.com/science/journal/02606917
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2.031&domain=pdf
experience inability and anxiety (Elliott, 2002; Hoel et al.,
2007).
Nurse training in Turkey started in 1921 with the establishment
of
six month “voluntary caregiver courses”. Literate daughters of
wealthy
families were accepted for these courses. Later, nursing schools
that
provided training on a high school level were opened (Ergöl,
2011).
Undergraduate level nurse education in Turkey began in 1955.
How-
ever, nurses were taught at the undergraduate level only in five
uni-
versities until 1994. Because of the scarcity of nurses in Turkey
during
this period, training was provided via 18-month courses
(Korkmaz,
2011). Despite these differences in nurse education in Turkey,
all nurses
who graduated from these schools or courses were given the
same title
of nurse. These nurses were granted the same authority and
responsi-
bilities. This situation negatively affected the process of
professionali-
zation of nurses (Ulusoy, 1998).
Today, nursing degrees are more widely available throughout
Turkey and the number of registered nurses has reached the
desired

level for the population. Presently, the number of schools
providing
education at the undergraduate level in Turkey is 96. The
education
process is designed to be at least four years with students
completing
4600 h of theoretical and practical experience (Ergöl, 2011;
Ulusoy,
1998). While nursing schools in Turkey are sufficient in terms
of
quantity, the quality of education is not at the desired level.
In Turkey, various problems are experienced in nurse education
both the school and the clinical environments. These may
include: lack
of sufficient number of highly qualified nursing instructors,
students'
inability to receive adequate guidance from educators, lack of
sufficient
support for students by clinical nurses, lack of suitable role
models,
negative approaches of healthcare personnel, communication
problems,
high numbers of nursing students, insufficient laboratory and
classroom
environments, and problems regarding clinical practices (Celik
and
Bayraktar, 2004; Elcigil and Sarı, 2007; Aydın and Argun,
2010; Kostak
et al., 2012; Karadağ et al., 2013).
It is unknown how nursing students can transfer theoretical
knowledge to practice in the clinical setting where they
experience
various problems. This issue needs to be examined in depth, as
well.

The results obtained from this study can contribute to increasing
the
quality of nursing education both in Turkey and in the world.
For this reason, this study was carried out with the aim of de-
termining the situations in which nursing students the
transferred of
theoretical knowledge to clinical practice and the difficulties
they ex-
perience.
2. Method
2.1. Study Design and Participants
The study was conducted with nursing students in a university
lo-
cated in the east of Turkey between May and June 2015. This
study was
conducted using a phenomenological method, using a qualitative
re-
search design. The purpose of phenomological interviews is to
obtain
detailed and multidimensional qualitative information regarding
par-
ticipant perspectives, knowledge, experiences, opinions,
feelings, atti-
tudes and habits about a specified topic (Corbin and Strauss,
1990;
Lawrence and Tar, 2013). This method was deemed appropriate
to
receive detailed information from nursing students about the
focus of
the study. Data were collected using the method of focus group
inter-
views. The study was conducted with 2nd (focus group 1), 3rd

(focus
group 2) and 4th (focus group 3) year nursing students. An an-
nouncement was made to all students about the study. A focus
group
was formed with 10 volunteering students from each year. A
total of
three focus group interviews were conducted with a total of 30
stu-
dents. Pre-interviews were conducted with 10 students one
month be-
fore the focus group interviews. The aim was to understand if
semi-
structured questions were sufficient to examine the subject. At
the end
of this process, incomprehensible phrases were revised in the
interview
form, and opinions and ideas related to the form were acquired
from
three experts in the field of nursing. The data from the
preliminary
interviews were not used because the corrections were made to
the
questions after the preliminary negotiations. In the subsequent
stage,
focus group interviews with the participants were carried out.
2.2. Ethical Considerations
The ethical approval was granted by the Scientific Research and
Publications Ethics Board of İnönü University, and the
institutional
permission was granted by the Faculty of Medical Sciences. The
struc-
ture, aim and procedures of the study were explained to the
students.

Additionally, participants were also informed that their
participation in
the study was in a voluntary basis, and the information gathered
from
the interviews would be written down and used only for
scientific
purposes. Written consents were received from the students who
wanted to participate in the study.
2.3. Data Collection
In-depth and semi-structured interviews were used for data
collec-
tion. Participants were asked open-ended questions in the
interviews
(Corbin and Strauss, 1990). These were based on an interview
guide,
which was formulated based on a critical review of the
literature
(Table 1). Each focus group interview was recorded and
transcribed
verbatim. Each lasted an hour. The principal researcher
performed all
focus group interviews. The researcher refrained from using
judg-
mental, condoning and negatory statements and attitudes during
the
interviews. All of these interviews were carried out in a meeting
room
at the hospital.
2.4. Data Analysis
Data were analyzed using qualitative content analysis. Content
analysis is a research technique used to derive reproduceable
and valid

results regarding the content of data (Graneheim and Lundman,
2004).
Both researchers independently transcribed the audio recordings
gath-
ered as a result of the focus group interviews. They read and
reread
transcripts and coded the same, similar and different statements.
The
researchers gathered and compared their coding work. As a
result of
this comparison, it was seen that the coding work of both
researchers
was the same. In the next stage, the coded data were organized,
and the
main themes and sub-themes (Corbin and Strauss, 1990;
Graneheim
and Lundman, 2004) of the study were determined (Table 2).
3. Results
The mean age of 30 participants including sophomore, junior,
and
senior year nursing students was found to be 20.8 years. 55% of
parti-
cipants were female.
3.1. Clinical Training
Most of the participants reported that the theoretical
information
that they received in school was intensive; however, they could
not put
most of this information into practice, and their clinical practice
was
Table 1

The primary questions of the interviews were:
What do you think about your clinical training? Can you
explain?
How do you evaluate yourself in putting your theoretical
knowledge into clinical
practice?
How do you evaluate yourself in clinical practice? Can you
explain?
What kind of difficulties are you experiencing in clinical
practice?
What is your opinion on how to overcome these problems?
What do you think is the appropriate clinical setting? Can you
explain?
U. Günay, G. Kılınç Nurse Education Today 65 (2018) 81–86
82
not effective. As the students found their clinical knowledge
and skills
inadequate, they were afraid of providing care for and touching
pa-
tients. This section is discussed in two sub-themes as “clinical
knowl-
edge” and “clinical skills”.
3.1.1. Clinical Knowledge
The students found their clinical knowledge inadequate. They
re-
ceived extensive theoretical information at school. On the other
hand,

they were not able to put this information into practice:
We are inactive in the practice. We receive intensive theoretical
in-
formation but we cannot put it into practice.
(Focus group 1, Student 1)
Theoretical education and clinical practice are not taking place
in par-
allel; what is given in the lecture and what I observe in the
clinic are
always different from each other; therefore, I cannot maintain
control of
my patient completely.
One student gave a different answer to this question:
Our clinical practice training varies from course to course. For
example,
the instructor of a course taught us what we should absolutely
know
without overloading too much information. We put what we
learned into
our practices in clinic. I felt competent in that practice.
3.1.2. Clinical Skills
The students did not find their clinical skills sufficient. Thus,
they
did not trust themselves as they were afraid of incorrect care of
people,
they did not want to interact with them:

I am afraid of performing patient procedures incorrectly;
therefore, I
cannot touch patients too much.
Whatever the procedure may be, we are hesitant at first. We do
not want
to harm the patient. On the other hand, if we learned a practice
with the
instructor, we could do something when we visited the patient
later.
They tell us at school that “nursing is not only establishing
vascular
access or measuring vital signs.” We are receiving a
comprehensive care
training, but we never saw any practice other than vascular
access or
measuring vitals when we visited the clinic. I do not think I am
competent
in anything else as I have not carried out any practice other than
mea-
suring vitals.
3.2. Guidance
Students were not able to receive adequate guidance from
instructors in clinical applications. They wanted clinical
instructors to

be present during procedures and carry out the procedures
together.
Some clinical instructors were found to be strict and distant to
students.
So, the students were hesitant to ask questions:
Our instructors are knowledgeable, but they usually do not
spare time for
us. For example, doctors gather their students at the clinic and
provide
training. Our professors could also do the same thing. However,
they
constantly ask questions instead of teaching anything. We are
hesitant to
ask questions of some of our professors about things we do not
know,
because they might get angry with us.
(Focus group 2, student 10)
I think you cannot expect something back without giving
something back
beforehand. It is meaningless to ask in the first week of visiting
a totally
unfamiliar clinic whether I debriefed the patient or performed a
proce-
dure. They should first show the debriefing process, so the
student is able
to inform the patient. We cannot perform procedures without
seeing
anything.
(Focus group1, student 6)
A student in the 3rd year stated that they were able to receive
guidance from their instructors this term (year):

In previous applications, we used to see the actual instructor of
the course
only once, but since the beginning of this year, the main
instructor spends
time with us. They teach us and answer our questions. So, they
went
down to the level of the public. We like it when our instructor
spends time
with us, recognizes us and is interested in us. However, some
instructors
are usually too distant and indifferent.
3.3. Communication
Students experienced problems with some nurses and clinical
in-
structors. Nurses saw the students as insignificant and they did
not
cooperate. Similarly, so did some clinical instructors. The
students'
motivation was diminishing. Their courage to practice was
harmed and
they started to question their interest in the nursing profession.
This section consists of two sub-themes as “lack of
appreciation” and
“cooperation”.
3.3.1. Lack of Appreciation
Most nurses belittled the students, saw them as unnecessary
addi-
tions, ostracized them and ignored them:

Nurses do not consider us as their colleagues. They treat us as if
we
overcrowd their workplaces. If they appreciated us and
cooperated with
us, we would also love our profession. On the contrary, they are
keeping
us away from our profession.
We actually expect respect, because we show them respect.
Nurses see us
as a useless, ignorant and unnecessary bunch. If they
appreciated us, we
would like our profession and have high motivation.
Students experienced problems with some clinical instructors.
In
this case, their motivation decreased, and they felt insignificant:
At school, our instructors tell us “primum non nocere” (first, do
no
harm). We are saying to them, “first, do not belittle us”. They
should
appreciate us, not lower our motivation. They should not
interrogate us
like ‘how can you not know this?’ Instead, they should say “let
us do it
together”. This is our difference from students of medicine, we
are not
appreciated or encouraged.
(Focus group 2 student 5)

As some of our instructors have a very stern attitude, we cannot
ask
questions. When an instructor coming to the clinic is strict, it
gives an
Table 2
The results of the study were defined on the basis of these five
principal themes:
Main themes Sub-themes
Clinical training Clinical knowledge
Clinical skills
Guidance and communication Inadequacy in receiving clinical
guidance
Lack of appreciation
Cooperation
Clinical evaluation Expectations changing based on the
instructor
Injustice in clinical grading
Hospital environment Lack of resting environments
Hygiene problems
Expectations Instructors
Nurses
School and hospital management
83

image of “I am closed to communication”. I want my instructors
to be
both authoritative and gentle. Even if something is running
through my
mind a lot, I cannot ask a question to a professor who has a
stern atti-
tude. Instructors should be approachable. They should work as
nurses
before becoming academics.
3.3.2. Cooperation
While students complained about nurses not cooperating with
them,
nurses in intensive care units did give them the desired
attention. This
was because they were lacking in number in the intensive care
en-
vironment.
Some nurses cooperate with us. Some others treat us like as if
we are only
there to measure blood pressure and draw blood. They make us
do their
job to alleviate their work load. They use us.
Nurses do not embrace us and they do not treat us sincerely.
The do not
see us as colleagues, they do not cooperate.
A fourth-year student had a different opinion:

This attitude of nurses is caused by the high number of students.
For
example, when I went to the intensive care unit, there was a
nurse named
S. She taught us everything because we were just a few people.
She taught
us all procedures and said let us do it together. She encouraged
us. We
were also 4 people in the practice at the Newborn Intensive
Care Unit.
The nurses there also attended to us in person (one by one).
3.4. Clinical Evaluation
Some students complained about not being fairly evaluated by
some
clinical instructors. They did not want to fear attending visits in
clinical
practice or receiving bad grades:
Additionally, some assistants try to look for our mistakes
instead of
helping us close our gaps in knowledge. They ask questions
until we get a
negative score. They are satisfied when they give a negative
score. Or, in
another practice, they ask why we did something in that way,
and when
we say the main instructor wanted so, they say alright, if they
said so it is
correct. Despite the fact that they said the opposite 10 min
ago… They
behave inconsistently.
(Focus 1, student 10)

I do not believe our instructors know us. For example, ask them
who this
student is, what he is successful in, what she is interested in. I
do not
think you can get a response in any way. We are not seen as
individuals,
but considered as a group.
3.5. Environment
The clinic did not have a decent physical environment or a
resting
area. They were not given cards to open the doors for the clinic,
so they
had to wait outside for long times. They had no place to store
their
personal belongings. The sub-themes of this section are
discussed as
“resting environments” and “hygiene”.
3.5.1. Resting Environments
Students reported that they were physically and emotionally ex-
hausted because they had to work/stand for several hours during
the
clinical rotation and that they did not have an appropriate place
to take
a break:
We need a room to come in and sit down, have a rest after our
job is
done. As there is no such room, we wait either in the corridors
or next to
windows. Even if we are taking a break, we get tired and
exhausted
because we have to wait standing up.

When we are exhausted, we occasionally go to the room where
the nurses
take a break. However, no seats are left for them when we sit
down there.
They kick us out of the room.
(Focus group3, student 5)
A student had to wait outside the door of the clinic for a long
time:
Although we practice in this hospital, we are not able to enter
the hospital
because we do not have a card to open the door. This is a
problematic
issue. Even patient relatives are surprised about this. I think
relatives of
patients should be thinking like ‘even the hospital does not
embrace you,
does not see you as one of them, how can I trust you’.
3.5.2. Hygiene
Students left their personal belongings at insanitary areas. They
also
met their personal needs (toilet usage, etc.) in areas open to
everyone:
We should not be putting our belongings into a storage area or a
dirty
materials room, are our belongings not valuable? We have to

have our
coats in winter. We are forced to leave them in storage areas
and dirty
rooms…
We are not allowed to use the restrooms designated for
employees. We
use the restrooms downstairs used by the patients.
Nurses got angry with students because some materials were
spent
quickly in the clinic.
Last term, a head nurse get angry at us by saying the usage rates
of some
materials increased since the internships started. She said to us:
‘you will
not use the materials of the clinic from now on, you buy them
yourself
and bring them if you need’.
(Focusgroup2, student 7)
3.6. Expectations
In order to have an effective clinical education process, the
students
had some expectations from nurse educators, clinical nurses and
man-
agers. These requests could lead them to be active in clinical
education,
love their profession and feel appreciated.
The students expected nurses in the clinics to appreciate them,
to be
patient and cooperate with them. Similarly, students expected to

be
appreciated by their clinical instructors and expected their
instructors
to accompany them in the clinical area and play an active role
in
educating them, rather than being a supervisor:
“I want to receive help from them without fear.”
“I want to be seen as a nurse, not a student.”
We do not want to live in fear of a visit and be scared all day.
We want our instructors to understand us and be both tolerant
and
authoritative. They should help us in the clinic and show us the
practice.
We want a place where we can leave our coats and sit and relax
when necessary.
4. Discussion
This study showed that prospective nursing students had
problems
84

in putting their theoretical knowledge into practice, they had
deficiency
of clinical knowledge and skills, and experienced several
problems in
the clinic. Most of the students reported that the theoretical
information
that they received in school was intensive; however, they could
not put
most of this information into practice and clinical practice was
in-
adequate. In literature found that nursing students could not
adequately
put their theoretical knowledge into practice and they faced
various
difficulties in clinical practices (Aydın and Argun, 2010; Chan
et al.,
2009; Dinmohammadi et al., 2016; Elcigil and Sarı, 2007). A
study
conducted to determine the difficulties faced by nursing
students in
practice found that almost half of the students faced difficulties
in
clinical practice, the most important of which was failure to put
the
theoretical information into clinical practice (Karadağ et al.,
2013). In a
study, students said that the clinical environment is more
different than
what is described in the classroom. They also indicated that
some
clinical skills they had learned in the skills laboratory are not
practiced
quite in the same way in the hospital (Elcigil and Sarı, 2007). In

this
study, students noted the reasons for this inability as fear of
dealing
with patients, inability to meet patient needs, fear of making
mistakes,
and anxiety in interacting with the nurses. They also expressed
that
they were not able to stay in the clinic environment for long
enough. In
a study conducted in Iran, prospective nurses reported the
clinical
knowledge deficit and inadequate preparation for entry into the
clinical
environment as the main origin of this anxiety (Dinmohammadi
et al.,
2016). In a similar study carried out in Sweden, it was found
that
nursing students hesitated to take part in procedures in clinical
practice
due to fear of making mistakes, uncertainty and dependence
(Lofmark
and Wikblad, 2001).
According to this study, nursing students noted that they did not
receive sufficient support from the clinical instructors. The
clinical
educators were a few in number and their expertise was
different in
clinics. The importance of clinical instructors to nursing
students in
their transfer of theoretical knowledge into practice is without
question.
Clinical educators could decrease stress and promote effective
learning
strategies (Killam and Heerschap, 2013). In literature, authors
stated

that students wanted clinical educators to be knowledge able
and
competent in their own fields (Kelly, 2007; Tuna, 2015). In an
article by
Kelly (2007), the most effective educators were described by
nursing
students as: approachable, supportive, helpful, empathetic and
en-
couraging. On the other hand, the least effective educators were
de-
scribed as non-supportive, unapproachable, intimidating and not
em-
pathetic to students' needs. Various studies in Turkey have
shown that
nursing students are not supported by clinical educators (Aydın
and
Argun, 2010; Bayar et al., 2009; Elcigil and Sarı, 2007;
Karadağ et al.,
2013). Among these, in Bayar et al.'s study (2009), 68.3% of the
stu-
dents reported that they were not supported by their educator,
and as a
result, they were afraid. Similarly, Iranian students stated that
they are
not sufficiently supported and guided by nurse educators and
particu-
larly staff nurses (Dinmohammadi et al., 2016).
Another element affecting the competency of nursing students
in the
clinics is the nurses working in the clinic. In this study,
students un-
derlined the fact that they were perceived as a useless crowd by
the
nurses and were not supported or encouraged. Students
experienced

communication problems with the nurses in the clinic. This
situation
not only lowered their motivation, but also made them feel un-
appreciated. Nurses are in the position to be role models for
nursing
students, behave in an informative manner and assist them to in
per-
forming procedures. Therefore, it is extremely important for
clinical
nurses to establish communication and cooperate with students
and
support them. In investigating the interactions of nurses and
students,
nurses were found not to play the role of educators and not to
provide
students with adequate support (Karadağ et al., 2013; Kostak et
al.,
2012; Serçekuş and Başkale, 2016). On the other hand, in a
study
conducted with 165 clinic nurses in Turkey, 77.6% of the nurses
stated
that they saw themselves as good role models for nursing
students
(Akyüz et al., 2007). Authors of other studies report …

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