I S S U E S A N D IN N O V A T I O N S I N N U R S I N G E D U C A T I O N

The theory–practice gap: impact of professional–bureaucratic work

conflict on newly-qualified nurses
Jill Maben BA MSc PhD RN
Lecturer and Post-doctoral Fellow, Health Services Research Unit, Department of Public Health and Policy, London School of
Hygiene and Tropical Medicine, London, UK

Sue Latter BSc PhD RN PGDipHV

Reader in Nursing, School of Nursing and Midwifery, University of Southampton, Southampton, UK

Jill Macleod Clark BSc PhD RGN FRCN DBE

Professor, Deputy Dean of Faculty of Medicine, Health & Life Sciences; and Head of School of Nursing and Midwifery,
University of Southampton, Southampton, UK

Accepted for publication 28 November 2005

Correspondence:
Jill Maben,
Health Services Research Unit,
Department of Public Health and Policy,
London School of Hygiene
and Tropical Medicine,
Keppel Street,
London WC1E 7HT,
UK.
E-mail: jill.maben@lshtm.ac.uk
doi: 10.1111/j.1365-2648.2006.03939.x
MABEN J., LATTER S. & MACLEOD CLARK J. (2006) Journal of Advanced
Nursing 55(4), 465–477
The theory–practice gap: impact of professional–bureaucratic work conflict on
newly-qualified nurses
Aim. This paper reports the findings from a naturalistic enquiry undertaken in the
United Kingdom into the extent to which the ideals and values of the preregistration
nursing course are adopted by individual newly educated Registered Nurses.
Background. Research in several countries provides consistent evidence of the
existence of a theory–practice gap in nursing. Clear disparities have been demon-
strated between the best practice ideals and values that are taught and those actually
encountered in everyday practice. Nurse education ‘Project 2000’ reforms in the
United Kingdom were designed, in part, to address this issue. Few studies to date
have examined the impact of these reforms on newly qualified Registered Nurses’
ability to translate theory into practice.
Methods. A longitudinal study was carried out in three educational institutions in
the United Kingdom from 1997 to 2000. Final year nursing students (n ¼ 72) in
three colleges of nursing completed questionnaires to elicit views on their ideals and
values for practice. In-depth interviews with a purposive subsample of 26 partici-
pants (at 4–6 and 11–15 months postqualification) indicated the extent to which
these ideals and values were adopted in practice. Interviews were tape-recorded,
transcribed, and data were analysed using constant comparison and negative case
analysis.
Findings. Although new nurses emerged from their programmes with a strong set of
nursing values, a number of professional and organizational factors effectively
sabotaged implementation. Professional sabotage includes obeying covert rules, lack
of support and poor nursing role models. Organizational sabotage includes struc-
tural and organizational constraints such as time pressures, role constraints, staff
shortages and work overload.
Conclusion. The disparity between nursing as taught and as practised may have
profound implications for the future of the profession both in the United Kingdom
and internationally, in terms of morale, job satisfaction and retention. Measures to

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J. Maben et al.
improve resources and reduce the professional–bureaucratic work conflict are dis-
cussed.
Keywords: longitudinal study, nursing, nursing students, staff shortages, theory–
practice gap, values, work overload
Introduction
Seminal works in the United Kingdom (UK) and United States
of America (USA) have examined the extent to which students
and qualified nurses are able to use ‘ideal’ best practice
theoretical accounts of nursing in the reality of everyday
practice, and provide important background and context to
the study reported here (Kramer 1974, Bendall 1976, Melia
1987). This so-called theory–practice gap appears to be a
global phenomenon and has been repeatedly debated within
nursing, with many pages of the Journal of Advanced Nursing
and other journals devoted to the issue (e.g. Rolfe 1998,
Upton 1999, Landers 2000, Larsen et al. 2002, Molassiotis &
Gibson 2003, Gallagher 2004, Higginson 2004, Stevenson
2005). The United Kingdom Central Council’s (UKCC)
‘Project 2000’ educational reforms (UKCC 1986) led to a
significant shift in nursing education in the UK and were, in
part, designed to address this problem. However, there is little
evidence as to how successful these have been. In this paper,
we examine the extent to which newly qualified Registered
Nurses emerging from ‘Project 2000’ programmes are able to
implement best practice theory and values learnt during their
education in the practice environment.
Background
Bendall (1976, p. 6) was one of the first in the UK to draw
attention to the fact that ‘what is taught in school is not
practised on the wards’ and vice versa. She examined the
relationship between traditionally trained students’ descrip-
tions on paper of how they would care for a patient (theory)
and actual observed behaviour (reality). Data collected via
questionnaire survey and observation of practice during 1972–
1973 revealed that in 84% of cases there was no correlation
between saying and doing. In other words, more than three-
quarters of nurses observed did not in reality undertake the
ideal care they had described on paper. Observation revealed
that nursing as practised was, in fact, task-centred and students
were rarely involved in anything approaching the total care of
individual patients (Bendall 1976).
Melia (1987) also identified differences between how
students wanted to practise and the reality of nursing in the
UK. She found pressure for students to be quick at the nursing
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tasks, not to ask questions, to have a tidy ward, to ‘pull their
weight’ and to ‘look busy’ even when the ward was quiet.
Students found this difficult, suggesting it prevented them
really talking to patients and giving good quality care. More
recently, a small-scale study examining whether student
nurses undertake manual handling in practice as they have
been taught theoretically found that students were socialized
into poor ward practice by other nurses (Swain et al. 2003).
In the USA, Kramer (1974) identified a disparity between
the idealized role conception, taught in nursing school, and
that found in the work situation, which she described as
‘reality shock’. The ideals and values promulgated in school
were professional and included notions of autonomy, indi-
vidualized and personalized care, as well as holistic analysis
of the work. The reality in practice was an impersonal
approach towards patients, and aspects of the work were
broken down into tasks and procedures. This reality has
recently been described as ‘utilitarian’ nursing in an Austra-
lian qualitative study, which identified that the completion of
tasks militated against new nurses transferring theoretical
knowledge of holistic care into the practice setting (Hender-
son 2002).
Similarly, new graduates in Canada felt caught between
caring effectively and caring efficiently, and also between the
ideals they had been taught in their undergraduate education
and the need to adapt to the institutionally modified practice
standards of the real world (Duchscher 2001), confirming
earlier work in the UK (Cahill 1996, Gray 1999). Boychuk
Duchscher and Cowin (2004) argue this tension leaves new
nurses marginalized and fosters feelings of isolation, vulner-
ability and uncertainty. A study of mental health nursing in
Norway (Hummelvoll & Severinsson 2001) also identified a
conflict between the professional and humanistic ideals of
psychiatric nursing and the ‘strenuous reality’ of practice
which promoted a medical model of care and treatment.
Professional or occupational socialization has been vari-
ously defined and much studied in nursing over more than
four decades (Oleson & Whittaker 1968, Kramer 1974,
Bucher & Stelling 1977, Melia 1987, Bradby 1990, Taylor
et al. 2001, Clouder 2003). Some definitions of professional
socialization often assume that a single set of values is held by
members of the profession (Cohen 1981), but the literature
reviewed above suggests that at least two differing value
Issues and innovations in nursing education
systems exist, in the form of a theory–practice gap. Nurse
education reforms in the UK (UKCC 1986) were designed in
part to address these differing value systems, yet it has been
suggested that the gap may have grown (Jasper 1996). The
research reported below sheds light on the contemporary UK
situation.
The study
Aims
The aims of the study were: to examine the extent to which
the ideals and values of the preregistration nursing course are
adopted by individual, newly educated Registered Nurses; the
extent to which they are able to implement them in practice,
and whether the so-called theory–practice gap outlined above
remains.
Design
A longitudinal study was carried out, using naturalistic
enquiry (Lincoln & Guba 1985) to follow a group of students
from the end of their Diploma of Higher Education (Dip HE)
adult nursing course into practice as staff nurses, and tracked
them for up to 15 months after qualification (in the UK, after
an initial Common Foundation Programme, lasting 12–
18 months, nursing students follow ‘Branch’ studies in one
of the following specialties: Adult, Child, Mental Health,
Learning Disability. On successful completion of this, they
are awarded the Dip HE).
Qualitative methods were employed, together with pur-
posive sampling, and many of the analytic techniques of
naturalistic enquiry (Lincoln & Guba 1985) informed the
data analysis. Questionnaires to identify baseline ideals and
values were used in Phase 1 with final year adult branch
nursing students (n ¼ 72) in three colleges of nursing.
In-depth interviews at Phase 2 (interview 1) (4–6 months
postqualification) and at Phase 3 (interview 2) (11–
15 months postqualification) determined the extent to which
ideals and values were adopted in practice by a purposive
subsample of 26 participants.
Participants
Three well-established urban colleges of nursing within
higher education (HE) institutions were selected. A prepi-
loted 24-item questionnaire was completed by Adult Branch
students (n ¼ 72) in the last week of their preregistration
diploma-level programme (equivalent to the first 2 years of
a Bachelor’s degree programme). Twenty-six participants

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Theory–practice gap and professional–bureaucratic work
were purposively sampled from 49 participants who were
willing to take further part in the study. A range of practice
settings, ages and both genders was represented, together
with a range of responses to key questionnaire items.
Participants who were ‘information rich cases’ (Patton
1990) were also selected on the basis of their questionnaire
responses.
Data collection
Phase 1 comprised a 24-item, self-administered question-
naire, which used both open and closed items, and was
adapted from a questionnaire used previously in a nationwide
evaluation of Dip HE nursing students (Macleod Clark et al.
1996). Phases 2 and 3 comprised in-depth, audio-taped
interviews with a purposive sample of these students (n ¼ 26)
at between 4 and 6, and 11 and 15 months postqualification.
The interview commenced with an open question: how are
you finding life as a qualified nurse? This was followed by
prompts, such as ‘Compared to life as a student?’, ‘Is it as you
expected?’ and ‘What is different?’. Several questions referred
interviewees back to the questionnaire they had completed in
Phase 1. For example, they were invited to review their
responses to the question, ‘As a qualified nurse, what do you
anticipate will be your ‘ideals’ for practice? That is, if you
were able to choose how to practise, what would be the kind
of care you would want to give?’ They were then asked, ‘To
what extent are you able to give this care in practice?’, with a
follow-up question asking for ‘reflections on any barriers and
facilitating factors’. They were also asked to describe anyone
they considered to be a good role model, the kind of support
they had received in practice, and any enjoyable or not
enjoyable aspects of the job. Interviews were subsequently
transcribed prior to analysis.
Data collected between 1997 and 2000 therefore exist for
the same 26 participants across phases 1, 2 and 3, and
comparisons of individuals over time were possible, together
with comparisons between individuals. As outlined above, in
interviews 1 and 2, the ideals and values identified by each
individual participant in the Phase 1 questionnaire were
shared with the participant.
Rigour
Rigour, or reliability and validity, were addressed in all
phases of the research process and centred on sampling,
questionnaire development and rigorous analysis of the
interview data. Particular attention was given to criteria for
establishing trustworthiness and credibility of the data and
of the research process (Lincoln & Guba 1985). For
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example, ‘elite bias’, a threat to applicability (Sandelowski
1986), may be a particular problem in qualitative research,
as people who act as participants may be the most
articulate, accessible or high status members of the group.
Participants in this study were self-selecting, although the
whole cohort was given the opportunity to participate. To
guard against ‘elite bias’, the researcher established the
typicality or atypicality of participants’ responses, and
purposively sampled a range of responses to some of the
key questionnaire items.
Ethical considerations
The HE institution and health service Local Research Ethics
Committees for each centre approved the study. In all phases
of data collection, the prime concern was informed consent,
anonymity and confidentiality, the latter being re-confirmed,
and consent re-sought, at the beginning of each phase [Royal
College of Nursing (RCN) 1998]. Potential research partic-
ipants were given full information about the purpose of the
study, including how the data would be anonymized and
handled to maintain confidentiality, the research team and
the organization under whose auspices the work was being
carried out, and what would happen to the information once
the study had been completed.
Data analysis
Content analysis (Weber 1990) of the questionnaires was
undertaken to provide baseline data on senior student nurses’
ideals and values and to enable sampling for Phase 2 of the
main study.
All interviews were analysed using constant comparative
analysis based on the ‘unitizing’, ‘categorizing’ and ‘filling in
patterns’ (Glaser & Strauss 1967, Lincoln & Guba 1985), and
analysis was closely linked to the process of data collection.
Initially, thematic content analysis was undertaken at the end
of each interview to allow themes and issues to be developed
through that phase of data collection. More in-depth analysis
was undertaken at the end of interviews 1 and 2, and overall
comparative analysis undertaken on completion of data
collection to develop broader and more theoretically relevant
categories that reflected the longitudinal nature of the data.
Deviant case analysis was used to address alternative inter-
pretations of the data (Silverman 2000).
Findings: Phase 1
Findings from Phase 1 showed that the individual nurses in
this study emerged from the course with a coherent set of
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values and ideals, which largely reflected academic theories
and approaches currently promoted in nurse education.
Espoused baseline ideals
In Phase 1 questionnaires, students were asked, in an open
response question, to anticipate what would be their ‘ideals’
for practice as a qualified nurse. That is, if they were able to
choose how to practice, what would be the kind of care they
would want to give? There was great consistency across
responses, which fell into the three broad, somewhat over-
lapping categories of patient-centred holistic care, quality
care, and nursing knowledge and research-based care.
Patient-centred holistic care was the most frequently
identified with 25 respondents out of a total of 26 citing
this. Key features included an emphasis on psychological
care, ‘being with the patient’, and care that was organized
around the needs of the patient, with patients included in
their care, as opposed to care organized around the needs of
staff or the hospital.
Quality care embraced safety of care, as well as the need
for standards of care to be ‘good’ or ‘excellent’ and avoid
‘cutting corners’. The principles of non-judgemental and
unbiased care, facilitating people to cope, as well as ‘making
a difference’, were also deemed to be central to quality.
Responses related to nursing knowledge and research-
based care included the need for a continuing good
knowledge-base, and care based on research evidence and
theoretical underpinnings to ensure high standards. Know-
ledge of communication skills was frequently cited as
important.
Findings: Phases 2 and 3
Findings from Phases 2 and 3 of the study which are derived
from interviews with participants at 4–6 months (interview 1
– Phase 2 of the study) and 11–15 months (interview 2 –
Phase 3), reflect diplomates’ reports of the development of
their ideals and values, and the extent to which they could
implement them in practice. Their responses indicate that
putting ideals into practice was often hindered by processes
which are labelled here as organizational and professional
sabotage.
Quotations from interview transcripts in this section are
followed by an anonymized identifying code. The first number
of the participant ID number denotes one of the three different
research centres, i.e. school of nursing 1, 2 or 3. The
subsequent numbers denote consecutive participant numbers,
interview number, page number of interview transcript and
the type of ward/practice area.
Issues and innovations in nursing education
Development of ideals
Many aspects of the ideals identified by students at the end of
their diploma course were recognized as being clearly influ-
enced by the theoretical input at university. This supports the
notion that ideals and values can be taught. On the whole, the
students appreciated the way they had been ‘conditioned’ to
think, and felt that having ideals was important, guiding
practice and giving something to aspire to:
P: I do believe the college has conditioned you to think a certain way
(…)
R: And are you comfortable with that conditioning?
P: Yes, I am, because I believe in it and I understand it and I think they
are right. I wouldn’t be comfortable with it if I felt it wasn’t right.
[ID 231:Int 1:p9–10:Care of older people ward]
Participants also suggested that whilst ideals were useful to
provide structure and convey an ethos and goals, an
acknowledgement of the difficulties the new nurses might
face in putting these ideals into practice was called for:
It gives you something to aim for, and I think if you lost that you
would get bogged down and you would get too stuck in a rut of what
was happening…So I think it is healthy for them to be like that…they
should be idealistic but not so unrealistic.
[ID 366:Int 2:p52:Neonatal unit]
It’s OK for college to teach the proper way, they should do this, but
they should also tell you that it may not happen like this.
[ID 376:Int 1:p11:General surgical ward]
Reality of implementing ideals in practice
Participants were asked at interviews 1 and 2 whether they
still agreed with their original statements of ideals and values
and whether they were able to nurse in the way they had
described. They continued to value their ideals throughout
the study period, but most were not able to implement them.
They attributed this largely to the practice environment in
which they found themselves working (Maben 2003). The
interview data demonstrates that their ideals and values were
subjected to organizational and professional forces which
effectively sabotaged them. Organizational sabotage arose
from the pressures and constraints of the system and
professional sabotage resulted from the influence of individ-
ual colleagues and their approach to practice which, in turn,
was strongly influenced by organizational sabotage factors.
Components of organizational sabotage
Recently qualified nurses’ ideals were thwarted through
structural and organizational constraints beyond the control

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Theory–practice gap and professional–bureaucratic work
of individual nurses. Key factors were time pressures, role
constraints, staff shortages, work overload and a task-orien-
ted, as opposed to patient-oriented, approach to the organ-
ization of nursing work and care.
These factors had a significant impact on the nurses’ abilities
to care for patients in the way they desired and, indeed, had
been taught. Time pressures came from a number of sources,
including limited staffing and poor skill mix, high patient
turnover and the extra demands placed on them in their role as
newly qualified nurses. Time pressures limited care delivery, as
a nurse on a 28-bedded elderly medical care ward explained:
Time is a limiting factor. I mean there have been days when I haven’t
had time to write. Like I do an admission, I can’t write about twenty
problems that they come in with. I would write about three core
problems and then perhaps try and catch it up the next day…but time
is an incredible limiting factor.
[ID109:Int 1:p2:Care of older people ward]
This nurse also felt that the reality of practice prevented her
spending time with patients addressing psychological care.
Another nurse on a 16-bedded general surgical ward reflected
on the difficulties this posed:
We’ve got a lot of patients who need a lot of time that we can’t give
because we’re so busy, most of the time. I’d like to spend time with
patients, talk to them, but I can’t, I really can’t…I say, look, I’ll talk
to you, but I have to go…but then often they just go ‘Oh, it doesn’t
matter’, which isn’t good…Everywhere I’ve been you never have
time. Nurses don’t have time to care.
[ID108:Int 1:p14–16:General surgical ward]
At the first interview, many new nurses were still trying to ‘do
everything’ and this had implications for putting theory into
practice:
I feel quite sad that I’m not able to give my all to patient care all the
time. (…) I still want to give my ideal practice as well as doing all the
other hundreds and thousands of things that I have to do. So I do feel
quite drained when I come in from work, because I am trying to sit
down and talk with patients as well as get on with everything else I’ve
got to do. That will probably get less and less as I get more
experience…Something will have to go…I hope it’s my organisa-
tional skills, to be honest, because I’d rather not lose out on spending
time with the patients.
[ID364:Int 1:p23:Admissions ward]
By interview 2, being busy and having limited time put
pressure on the nurses and began to erode their compassion,
which was personally distressing:
When I’m really tired, I know I can feel myself, it’s awful, knowing
I’m different with the patients, but when you haven’t got time and
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J. Maben et al.
you’re really busy, I know I’m just impatient with them and I just feel
awful.
[ID230:Int 2:p18:Medical Oncology ward]
Being busy did not primarily refer to giving care, but
consisted of administrative tasks, dealing with enquires,
ward rounds, answering the telephone and administering
drugs. New nurses were often frustrated that such tasks
prevented them giving direct patient care.
Being ‘stretched to the limit’ through poor staffing levels
on the wards was also an aspect of organizational
sabotage. Staffing levels, the quality of staff, skill mix
and heavy workload go hand in hand, and were clearly
identified as very influential aspects of postqualification
experience:
I think staffing levels is quite a big one. There is nothing more
frustrating than when you end a shift and you know you haven’t
cared very well for patients…staffing levels prevent you from doing a
lot. As I say, you just run round doing the basic care. Very
basic…Like, even if you want to give someone a CD drug [controlled
drug e.g. morphine] then they have to wait twenty minutes in pain
while you run round trying to find someone that’s free, which is just
not on.
[ID370:Int 1:p48:Renal and general surgery ward]
Such organizational sabotage reflects the pressures and
constraints of the system and has inevitable impact on
established staff and their approach to practice.
Components of professional sabotage
Many of the ideals and aspirations of the diplomates could
not be put into practice because of the values and nursing
culture they encountered. This was enacted through ‘covert
rules’, and the behaviour of more experienced colleagues was
at times very different to the theoretical values and culture of
nursing espoused within their educational institutions.
However, it is not suggested that this sabotage was deliber-
ate. What does seem clear is that established members of the
nursing team had been influenced by the organizational
constraints identified above, and socialized into the needs of
the system at the expense of the needs of individuals. As a
result, their own ideals and values may have been sabotaged.
These established nurses then in turn socialized the new
recruits into the needs of the system through the covert rules
identified below.
Covert rules
The socialization messages conceptualized as ‘covert rules’
were readily identified in the first set of interviews, and were
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most powerful when first encountered. Analysis of the data
reveals four key messages, or ‘rules’ which have been
categorized as:
• Rule 1: ‘Hurried physical care prevails’
• Rule 2: ‘No shirking’
• Rule 3: ‘Don’t get involved with patients’
• Rule 4: ‘Fit in’ and don’t ‘rock the boat’
The ‘covert rules’ represent the content of the socialization
messages to the newly qualified nurses. Existing staff in
practice were the messengers who, although possibly uncons-
ciously, were indeed socializing the new nurses into a way of
practising at odds with their college-bred ideals and values.
The vision of nursing held by the new staff nurses and
reflected in their ideals, was not overtly denigrated or deemed
inappropriate by colleagues. The messages sent via covert
rules and expectations were more subtle than this.
Rule 1: ‘Hurried physical care prevails’
This rule was consistently identified and reveals the hidden
reality that physical care took precedence over psychological
care, and that speed and efficiency were highly valued. Visible
nursing work, such as making beds, giving hygiene care and
drug rounds was prioritized (perhaps through necessity) over
the ‘invisible’ work of holistic, psychological and quality
care:
It is very rushed, and you try to get everything done and people have
this idea of getting all the physical things done first…which I
appreciate are important things to be done but there’s also their
mental health that needs to be looked after, because if they aren’t
feeling well, you know…
[ID114:Int 1:p25:Orthopaedic ward]
Emphasis on physical care and speed often resulted in ‘talking
to patients’ not being seen as important or doing ‘real work’.
Talking to patients was judged undesirable in some areas:
Whenever I sat down to talk to patients, a nurse would come over
and ask me to do something or stand there going ‘ttt’ and I’d say, like,
‘Do you want me to do something?’ ‘No’. You know, it’s just that it
wasn’t acceptable to sit down and talk to patients.
[ID108:Int 1:p17:General surgery ward]
Speed has historically been associated with nursing work and
the ‘good’ nurse is the quick nurse (Clarke 1978, Melia
1987). In this study, there was also a culture of speed and
efficiency or, rather, speed or rush being equated with
efficiency:
All you want to do is get the wash out the way, in the morning, you
have got to get it out of the way…I was working on W ward the other
day, they are a lot more quiet down there, and I was just rushing
Issues and innovations in nursing education
around madly, when the girl I was working with said ‘What are you
doing, why are you rushing around, there’s not much to do!’ I said
‘Yes, but there might be, something might come up’. And I thought,
Oh my God, I’ve got into that role where I think something’s going to
happen (laughs). Rushing to get it all done now, then if anything
happens…
[ID239:Int 2:p11:Medical oncology ward]
There was a desire for all hygiene care, dressings, referrals
etc., to be completed during the early shift, and that it was a
sign of inefficiency to be handing over work to the late shift.
This was reinforced with praise and led to individuals
verbally accounting for their work as a list:
Yes, you were getting rewarded, people were saying well done for
getting everything done on the early.
[ID114:Int 2:p22:Orthopaedic ward]
You know, I’ve done all the washes, all the obs, all this, all that, all
the team rounds, two drug rounds, and by the next sort of eight hours
all you have got to do is a few wounds, something like that.
[ID114:Int 2:p24–5:Orthopaedic ward]
It appeared that a physical list, or the mental and verbal
‘ticking off’ of the activities, is one of the ways that newly
qualified nurses were socialized into the prioritization of
physical tasks, thus highlighting any lack of speed or
‘inefficiency’; if they did not tick everything off the list, there
was a sense of failure. Psychological care and support could
not be ‘tallied up’ so readily or accounted for in this way, and
was therefore ‘invisible work’ not recognized in this system
and therefore easily overlooked or abandoned.
Rule 2: ‘No shirking’
‘No shirking’ implied that ‘real’ nursing work is hard physical
work, and ‘good’ nurses undertake their fair share of this
work. They demonstrated ‘not shirking’ by prioritizing
physical tasks in favour of perceived ‘softer’ options, such as
talking to patients, and not delegating all of the hard physical
work to junior or unqualified staff.
The new nurses noted a hierarchy of nursing work on the
wards. Getting to grips with their role often meant they were
slower than their colleagues, and in an environment where
speed and hard work were valued, this often caused guilt:
I’m so slow at the moment. It takes up so much time. And I really feel
bad for the A grades, as well. And the students. I feel like I’m hiking
out of doing the work. (…) So that’s probably the worst bit.
[ID373:Int 1:p38:Medical and Cardiology ward]
Some participants felt that there was a lack of appreciation by
some staff (particularly unqualified staff) of the roles and
responsibilities of other members of the nursing team. There

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Theory–practice gap and professional–bureaucratic work
was also an implication that if staff were not giving physical
care, then they were somehow ‘shirking’ the work, and being
lazy:
I often noticed the health care assistants coming up and saying ‘oh
she hasn’t done anything this morning, she hasn’t done any
washing’…I’m conscious of how they feel. I think they probably
think I’m lazy on occasions.
[ID109:Int 1:p21–22:Care of older people ward]
Another way of reinforcing the message was at ‘handover’,
when those things not done were handed over to colleagues.
There was a sense of wanting to prove themselves competent
and efficient, to show that they were ‘not shirking’ and were
pulling their weight. Therefore, when any work was handed
over, it was with an implicit sense of apology:
We do end-of-bed walk-rounds after the main handover and we say
oh I’ve left you this and I’ve left you that and you do feel a bit guilty
because…there’s still this to do and that to do, you still feel like it’s
your job to do that in the mornings.
[ID114:Int 2:p21:Orthopaedic ward]
Rule 3: ‘Don’t get involved with patients’
There were several aspects to the third rule, including mes-
sages from some staff that it was both undesirable and
inadvisable to get involved with patients and that the new
staff nurses should ‘harden up’ and keep their distance. Thus,
holistic and psychological care was potentially thwarted.
Advocacy and going the ‘extra mile’ for patients also
reportedly met with resistance from colleagues, some of
whom suggested doing the minimum required.
Being involved with patients, empathizing and wanting to
individualize their care, was very much part of the study
participants’ nursing ideals and values. However, getting
involved with patients appeared to be seen as neither
professional nor desirable and was something they struggled
with:
I thought, you know, I’m meant to find out about their sexual needs,
their emotional needs, all of it. You’ve got to do a full admission, but
just don’t find anything out. You find anything out and you’re really
in for it…Anything that needs them to talk. If it means the patient
needs someone to talk to, of course we can’t do that because we can’t
come out from behind our uniform type thing.
[ID242:Int 1:p29:Care of older people ward]
Participants’ suggested that practice staff discouraged them
from becoming ‘too involved’ with patients and encouraged
them to keep a distance and to ‘harden’ themselves. This
was at odds with their ideals and values and was often
rejected:
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J. Maben et al.
People have said to me before now, ‘Oh, you’ve got to learn to try
and not take things home with you and you’ve got to harden yourself
as a nurse’. My reaction to that at the moment is that if I get that
hard, that’s the time when I know I’ve got to leave nursing. I don’t
want to become a hard nurse, even though people think it’s better for
me to cope.
[ID116:Int 1:p37:Urology ward]
I hope it never will happen. I think if ever I were to lose compassion, I
certainly feel I would give up nursing. If I lost compassion…maybe I
should go to work in the mortuary. (laughs).
[ID388:Int 2:p27:Medical oncology ward]
Rule 4: ‘Fit in’ and don’t ‘rock the boat’
The fourth rule underpinned many of the socialization mes-
sages of the newly qualified nurses’ nursing colleagues and
related to ‘fitting in’ and not ‘rocking the boat’. The new
nurses were aware of this, and were keen to keep quiet and
not rock the boat in the initial postqualifying period, which
prevented them from influencing and changing practice.
Research and theory were important to all the participants
and were key components of their nursing ideals. Some felt
actively discouraged from questioning things or showing any
initiative and felt colleagues were resistant to change:
I suppose that’s got to do with what other people expect of you as a D
Grade staff nurse, especially when you’re newly qualified…perhaps
you’re only allowed to have your own ideas and write teaching packs
and learn things and come to work and say to someone, ‘Did you
read this piece of research about such and such?’ when you’re an E
Grade. (Note: D grade is the minimum salary grade for a first level
Registered Nurse responsible for assessing, developing and imple-
menting care programmes without direct supervision. In addition to
these responsibilities, those at the higher E grade will either take
charge of a ward regularly, have an additional qualification in a
specialty, or be able to supervise and teach junior staff (RCN 2003).
[ID242:Int 1:p14:Care of older people ward]
Some nurses are not open-minded about adopting new things (…) it’s
really difficult to introduce new things because there is rejection, you
know from the nurses.
[ID101:Int 1:p15–16:General medical ward]
Role models as agents of socialization and providers of
support
If the covert rules were the messages, colleagues in practice
were the messengers, yet they were the only ones available to
help these newly qualified nurses. The adherence of estab-
lished staff to the ‘back stage’ realities (Goffman 1959) and
the covert rules meant that often they were not good role
models, and did not demonstrate how to implement their
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ideals and values in practice. Some participants drew a
distinction between good and bad role models:
Watching people talk to people about very sensitive things, it’s
almost like the role models that you’ve got, you really take them on
board and you try and be like them, and, you know, just the same,
you look at people and think, I really didn’t like the way they handled
that, that’s dreadful, I’m not going to do that.
[ID366:Int 2:p18:Neonatal unit]
From a management point of view, ward sisters and other
qualified nurses need newly qualified staff who can assume
responsibility and can ‘hit the ground running’ (Macleod
Clark et al. 1996), but this is at odds with the needs of newly
qualified nurses for support and continued learning. There
appeared to be a requirement for new nurses to do the work
required and not demand too much or add to existing staff’s
workload. In this study, the same phenomenon often made it
difficult to learn or get the required support:
Some people were saying to me ‘Right, you can do this, can’t you,
and you can do that?’ and I was saying ‘Well, actually, I can’t, I need
you to watch me’. And because they were in a hurry to do something
else, they’d say, oh, look, I’ll do this quickly, because obviously, I was
slower, so they’d end up doing it and I’d end up doing something else
for them.
[ID117:Int 1:p11:Care of older people ward]
Few recently qualified nurses in this study received good
support. However, for the small minority who did, it made a
huge impact on their confidence levels and thus on their
ability to cope with the demands of the job, to do it well and
to derive great satisfaction from their work. Those who
received good formal support, remained confident and very
committed to nursing, and their self-esteem remained high
throughout the period of the study:
I’m really well supported on the ward, I’ve got a really good mentor
and preceptorship programme…I had a good meeting with the sister,
and she went through everything with me – what was expected of me,
what was not going to be expected of me…they’re quite keen to not
give me too much responsibility too quickly, like being in charge…I
was given my preceptorship programme and my mentor, and we meet
up once a month, and go through everything.
[ID 364:Int 1:p3–4:Admissions ward]
Yet, even this minority still experienced major difficulties
with the conflict between their nursing ideals and the reality
of the practice environment, and most received no support in
this domain:
Well, it’s all right to have ideals and learn the right way because
otherwise you don’t know whether you’re doing it wrong but you
Issues and innovations in nursing education
Table 1 Comparison of professional and bureaucratic work structures in nursing
Professional work
Reliance on evidence and expertise to facilitate decision-making
Holistic whole task organization (e.g. primary nursing)
Individual qualified nurse undertakes all care for one patient
Power derived from expertise
Care individualized to meet individual needs
Evaluation of process rather than just output
‘Caring’ approach to patients wanting to go extra mile,
and be close to patients
Ethos of care which emphasizes psychological and holistic care,
where talking to patients is important
Autonomy as a professional practitioner
Innovation and new ideas welcomed
Adapted from Corwin (1960).
then realise how much pressure there is. You’ll have admission after
admission and you can’t do all the admissions properly…Unfortu-
nately I think it is a reality of nursing…I think you do need a support
system, like a supervisor. My hospital doesn’t have preceptorship set
up at all. I mean I did discuss it when I joined and they said ‘oh yes,
yes’ and I think I got two meetings, one in the first week and one after
three weeks and they’re the last meetings I had with my supervisor.
[ID109:Int 1:p3–4:Care of older people ward]
Very few recently qualified nurses encountered senior nursing
staff who led by example, and reinforced the messages of
patient-centred, or theory-driven and research-based care;
those who did were found mainly in isolated ‘good’ practice
environments (Maben 2003). For the majority, the messages
of the covert rules outlined above predominated, failing to
reinforce the professional expectations and messages from
college and, in many cases, sabotaging their ideals and
aspirations. A more ‘functional’ and bureaucratic vision of
nursing was therefore presented, which was at odds with
professional ideals. Table 1 illustrates the differences and
opposing principles between work conceptualized as profes-
sional and that conceptualized as bureaucratic. Professional–
bureaucratic (P–B) work conflict is discussed in more detail
below.
Discussion
Our findings confirm the continued existence of a gap
between theory and practice in nursing. Newly qualified
Registered Nurses emerged from their courses with a consis-
tent set of ‘high’ professional nursing ideals and values, which
were largely thwarted in practice. They were exposed to

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Theory–practice gap and professional–bureaucratic work
Bureaucratic work
Reliance on rules and protocols to facilitate decision-making
Part task organization (e.g. task allocation often in the
guise of team nursing)
Care for one patient fractured and distributed between
different grades of nurse
Power derived from position in hierarchy
Care standardized for all patients
Evaluation through output
Attitude often appears uncaring and staff advocate keeping
distance from patients
Ethos which emphasizes the physical tasks over psychological care,
which become an ‘add on’
Autonomy dependent upon position in hierarchy and position of
nursing to medicine in some areas
Innovation and change regarded with suspicion as challenges
old order and ‘rules’
professional and organizational sabotage, which left them to
make sense of this ‘gap’ with little support and few good role
models. These findings support earlier research (Kramer
1974, Bendall 1976, Fretwell 1982, Melia 1987, Duchscher
2001, Hummelvoll & Severinsson 2001, Henderson 2002),
and suggest that the theory–practice gap remains a feature of
nursing in the UK. This resonates with Bendall’s (1976, p. 9)
conclusions that ‘trainees are learning about an ideal state
which looks well on paper but is not put into practice’.
Recent reforms (UKCC 1986) attempted to address many of
Bendall’s concerns and suggestions but appear to have done
little to solve the theory practice gap, and may have
perpetuated or even increased it (Jasper 1996), or sharpened
it (Rafferty et al. 1996).
The theory–practice gap is described as a mismatch between
nursing as taught and nursing as practised (Gallagher 2004).
What counts as nursing knowledge is socially and historically
constructed and has been described more as a political than a
philosophical problem (Rafferty et al. 1996).
The pervasive and enduring nature of the theory–practice
divide may best be explained in terms of a P–B work conflict
(see Table 1), confirming earlier work in nursing on two
continents (Corwin & Taves 1962, Kramer 1974, Melia
1987) and, more recently, work in medicine in the USA and
UK (Kitchener et al. 2005). P–B work conflict is the conflict
between principles governing professional practice, such as
nursing and those used in employing institutions such as
hospitals. The conflict arises, it is argued, because each side
has differing and often opposing principles and norms which
govern behaviour. Representations of both profession and
bureaucracy are not permanent static structures; they are
473
J. Maben et al.
evolutionary in nature and are influenced by socio-economic
and political issues (Davies 1983). For example, recent
changes in health care in the developed world, such as the
introduction of managerialism (Exworthy & Halford 1999,
Traynor 1999, Tuohy 1999, McCloskey & Diers 2005)
together with nurse education reforms (UKCC 1986,1999),
have sharpened the tension between both sides of the P–B
work conflict, creating a more deeply segmented profession.
Thus, a greater gap may now exist between the ideals and
values taught and adopted by students during their education
and those evident in the practice settings where they work as
qualified nurses. The professional and organizational sabo-
tage described here represents the bureaucratic segment at
work.
Furthermore, we would argue that the P–B conflict thesis
relates not only to conflict between professional practice and
the bureaucratic structure within which it operates, but also
to conflicts within professional practice itself (P-P). There is
the professional mandate that emphasizes holistic individu-
alized care which, whilst not universally accepted, has gained
considerable credence (what we think we ought to be doing)
and what it is nurses actually do, which is often far removed
from this, as Bendall (1976) illustrated 30 years ago and our
findings have confirmed. Nurses are then faced with deciding
whether they should continue to strive for the professional
ideals and values of individualized holistic care by advocating
more resources, mandated nurse–patient ratios etc. when
evidence suggests this is not possible, or whether as Allen
(2004) suggests, they should modify their ideals and values
based on what nurses actually do in practice and work on
optimizing nursing care within a framework of what is
actually possible. Whatever the decision, we should not loose
sight of individual nurses struggling between opposing
systems, for to neglect and leave them unsupported will
contribute further to retention difficulties and the existing
global shortage of nurses.
As suggested, our findings support Bendall’s conclusions
that ‘trainees are experiencing reality with little help to make
any sense of it’ (Bendall 1976, p. 9), and while it has been
suggested that such a gap is inevitable (Rafferty et al. 1996),
the impact on individual nurses attempting to implement the
ideals and theory they have been taught in practice cannot be
ignored. Indeed, a recent study in Ireland identified high
levels of stress experienced by nursing students as a result of
the theory–practice conflict (Evans & Kelly 2004). In the
study reported here few good role models and little or no
support was identified. This resonates with earlier work
which describes disillusioned staff who were burnt out in a
short time and thinking of leaving the profession (Maben
2003), and confirms recent research with new graduates in
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Canada (Duchscher 2001, Boychuk Duchscher & Cowin
2004). Those researchers found that new nurses lacked
control, had low self-confidence, felt caught between focuss-
ing on their own needs and patients’ needs, and found the
entry into professional practice chaotic, unsupported and
painful (Boychuk Duchscher & Cowin 2004). Support and
supervision is vital to any new professional recruit (Maben &
Macleod Clark 1996, Dearmun 2000) and is crucial in
helping newly qualified staff make sense of the dichotomy
between their professional ideals and the often bureaucratic
reality. However, shortages of staff, poor skill mix and an
overstretched workforce inevitably contributed to the lack of
good role models and support.
There is evidence that nursing workload has intensified in
the past three decades. Increased patient throughput and
turnover, shorter patient stays in hospital, increasing use of
technology and increased acuity of illness means that
qualified nurses in the 1990s and beyond have a greatly
increased workload compared with their counterparts in the
1970s and 1980s (Office for National Statistics 2002a,
2002b, Garretson 2004). When rising public expectations
of health care (Dargie et al. 2000), the Department of Health
(DH) working time directive (DH 2004) and the increasing
emphasis on holistic, individualized and research-based care
are added to this, it is clear that much greater demands are
being made on nurses in an increasingly pressured environ-
ment. This has an inevitable impact on their ability to support
junior colleagues, provide ideal care and act as good role
models for newly qualified nurses. Far from attributing
blame, we suggest that existing nursing staff have had to
prioritize the needs of the many and the system as a whole
because of the organizational constraints identified in this
study. The needs of the individual were therefore often
overlooked.
Strong role models have been identified as crucial to the
positive socialization and development of nurses’ retention of
ideals and to minimizing the conflict between professional
ideals and bureaucratic practice (Kelman 1961, Kramer
1974, Bucher & Stelling 1977, Hamel 1990, Henderson
2002). Indeed, Bandura’s (1977) social learning theory
highlights the strengths of learning by role modelling and
observation of the work of others, and the importance of
seeing good practice in action. Negative role models have
been identified as adversely affecting and hindering learning
(Alain 1989, Calley 1990, Henderson 2002), with students
being ‘just as prone to accept models’ more ‘cynical’ goals as
their idealistic ones’ (Shuval & Adler 1980, p. 13). Too
many, or only negative role models, with little or no support,
serve to thwart implementation of the values and ideals of
new nurses. Strong role models are required who can display
Issues and innovations in nursing education
What is already known about this topic
• A ‘gap’ between theory and practice has previously been
identified in the nursing profession.
• Recent nursing education reforms in the United King-
dom were designed to reduce the extent of this gap, but
little research focuses on nursing since these educational
reforms or is based on longitudinal designs.
What this paper adds
• Professional and organizational factors effectively
sabotage ideals and values during the process of
socialization into the qualified nursing role.
• The concept of professional–bureaucratic work conflict
has potential as an explanatory model.
• High quality role models, mentorship and preceptorship
are key to the ability to translate theory into practice in
nursing.
and implement the professional ideals of newly qualified
nurses as well as support them with the ideal-real dichotomy
they encounter. These were rarely identified by our partici-
pants.
In reviewing a decade of nursing ethnographic research
Allen (2004) suggests the mismatch between the culture and
ideals of nursing and the structure and constraints of the
work setting is a chronic source of practitioner dissatisfac-
tion. The research reported here supports this, and it is
therefore imperative that the problems identified in this study
are addressed globally if we are to retain new nurses and
promote the delivery of high quality nursing care. Role
models, mentors and preceptors need to be nurtured and
supported in practice and must be facilitated in their
supervisory roles. It should be remembered that the large
number of student nurses currently requiring supervision and
support is increasing the burden on experienced staff, but this
does not mean that we can ignore the support needs of newly
qualified staff. There is a need for policy changes to improve
support for the latter, such as the introduction of a formal
1 year preceptorship programme, or probationary year, to
equate with foundation studies for new doctors [British
Medical Association (BMA) 2005]. There is also a case for
reassessing the numbers of student nurses allocated to each
placement area and the nursing skill mix required to support
them. Careful examination of the evidence from California
and Victoria, Australia in the use and implementation of
statutory nurse–patient ratios may also be useful. These states

2006 The Authors. Journal compilation
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Theory–practice gap and professional–bureaucratic work
report improved job satisfaction and nurse retention, with
nurses better able to nurse effectively (Garretson 2004).
Study limitations
As discussed previously, threats to the generalizability of the
research, such as a self-selecting sample, were dealt with by
establishing the typicality or atypicality of participants’
responses, and purposively sampling within the self-selecting
sample from a range of responses to some of the key
questionnaire items. The study relied on self-report data and
caution is needed in linking what participants reported to
their own actual clinical practice and that of other nursing
staff in clinical areas. However, the consistency of responses
and examples across different clinical areas provides support
for the validity of this data. We also acknowledge that the
length of time that has elapsed since data collection (1997–
2000) may be seen as a limitation. It is certainly too soon to
say whether more recent changes to nurse education in the
UK, such as the competency curriculum (UKCC 1999), may
exert an influence. Moreover, pressures on nursing workload
and changes in skill mix have continued to worsen (Garretson
2004, Healthcare Commission 2005). These pressures will
arguably heighten professional and bureaucratic work con-
flict.
Conclusion
The mismatch between nursing as taught and as practised
continues to be evident in the UK and elsewhere. This has
potentially profound implications for morale, job satisfaction
and retention. Measures need to be put in place to reduce P–B
work conflict. These may include: greater emphasis on
identifying high quality role models; providing mentors with
adequate support and supervision to enable fulfil the role, and
addressing resource and skill mix issues. The introduction of
provisional Registration processes and formal preceptorship
programmes for newly qualified nurses should also be
considered, together with close examination of the case for
introducing mandatory nurse–patient ratios for the nursing
workforce. The issue of an overstretched workforce must be
acknowledged. Failure to confront the issues highlighted in
this paper could have seriously deleterious consequences for
individuals and for the future health of the nursing profes-
sion.
Acknowledgements
We thank the nurses for sharing their experiences so readily
and the participating colleges of nursing and NHS trusts for
475
J. Maben et al.

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