ORIGINAL ARTICLE
Dichotomy between theory and practice in chest
radiography and its impact on students
Benard O. Botwe, MSc, Lawrence Arthur, MSc, Michael K. K. Tenkorang, BSc, &
Samuel Anim-Sampong, PhD
Department of Radiography, University of Ghana School of Biomedical and Allied Health Sciences, Korle Bu, Accra, Ghana
Keywords Abstract
Chest radiography, clinical rotation,
impact on students, theory–practice gap Introduction: It is important that theory is synchronous with clinical practices
that students engage in. Lack of congruence between theory and practice
Correspondence presents serious problems to students. This study was therefore conducted to
Benard O. Botwe, Department of determine if there was a theory–practice gap in chest radiography during
Radiography, University of Ghana School of clinical rotations, and any associated causes and effects on radiography
Biomedical and Allied Health Sciences, Korle students. Method: A descriptive survey design was used to conduct this study
Bu, Accra, Ghana. Tel: +233244029365;
from 2 February to 27 July 2014. A semi-structured questionnaire consisting of
E-mail: bebotwe@ug.edu.gh
open- and close-ended questions was used to purposively collect data from 26
Funding Information radiography students in Ghana who had completed theory lessons in chest
No funding information provided. radiography and had either completed or were undertaking clinical rotations in
chest radiography. Results: Twenty-five (96%) respondents indicated the
Received: 25 January 2015; Accepted: 12 presence of theory–practice gap in chest radiography during clinical rotations,
February 2016 where differences between theory and clinical practice were observed. Lack of
working materials 16 (62%), heavy workload 14 (54%), equipment breakdowns
J Med Radiat Sci 64 (2017) 146–151
14 (54%) and supervisory factors 11 (43%) were identified as the causes. Many
doi: 10.1002/jmrs.179 students (81%) experienced diverse adverse effects such as confusion 10 (38%),
poor performance during clinical examinations 6 (23%) and entire loss of
interest in the professional training 1 (4%) of this dichotomy. Conclusion:
Dichotomy between theory and practice found in chest radiography has diverse
adverse effects on students. Regular feedback on the quality of clinical practice
received by students should be encouraged to determine the existence of any
gaps between theory and practice in order to promote effective clinical rotation
programmes in radiography.
allowing students the experience of performing that task.3
Introduction
McCabe in Atanga et al.4 described clinical practice
In the health science professions, clinical or practical experience as the ‘heart’ of professional education as it
experience is necessary to develop knowledge and skills provides students with the opportunity for consolidating
acquired theoretically. For this reason, both theoretical knowledge, socialising into the professional role and
and clinical components of education are included in acquiring professional values.
health science educational programmes. In radiography, a Educational history suggests that, both theory and
curricula consisting of 50% theory and 50% practice is practice in the past have been delivered to students by
recommended.1 The purpose of the theoretical educators mostly at lecture halls and the institution’s
component is to provide students the opportunity to clinical laboratories or facilities. However, lack of
learn principles and concepts relevant for professional experience in clinical settings was often observed in
performance.2 The clinical practice on the other hand is health education programmes.5 This necessitated the
expected to allow students to understand the theoretical incorporation of clinical rotation in health care
reasoning that underlies the purpose of clinical task while programmes to provide students opportunities of direct
146 ª 2016 The Authors. Journal of Medical Radiation Sciences published by John Wiley & Sons Australia, Ltd on behalf of
Australian Society of Medical Imaging and Radiation Therapy and New Zealand Institute of Medical Radiation Technology.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License,
which permits use, distribution and reproduction in any medium, provided the original work is properly cited
and is not used for commercial purposes.
B. O. Botwe et al. Theory–Practice Dichotomy in Chest Radiography
contact with patients and their relatives, hospital staff and practice gap and providing measures to curb it cannot be
hospital equipment.4,5 The clinical rotation component of overemphasised.
education is meant to provide students the opportunity In Ghana, clinical (third and fourth year) students of the
to integrate skills and knowledge from the classroom 4-year undergraduate radiography programme are assigned
setting into the clinical practice setting.6 It is also to offer to clinical rotations at imaging facilities 2–3 days a week to
students the ability to learn about the complex health observe and practice under the supervision of clinical
issues of patients, practice selected technical skills and tutors. However, the inadequate number of clinical tutors
develop communication skills in the clinical setting.7 renders this arrangement impracticable. Clinical
In addition, clinical rotations help students engage in the supervision is therefore mostly done by the radiographers
clinical environment, acquire new knowledge and skills in the assigned facilities. The complaints of some clinical
and participate alongside many health professionals and students about the dichotomy or existence of theory–
thereby learn how to work in a team. practice gap have however not been substantiated. This
Effective clinical rotations are essential for improving study therefore investigated the issue of theory–practice
competence and research-based education in radiography.7 gap in the most frequently performed procedure (chest
However, diverse challenges including theory–practice gap radiography) in some radiology facilities in Ghana.17
encountered by students during clinical rotations have
been reported.4,6,8 Theory–practice gap is the discrepancy
Method
between what is taught (theory) in the classroom and what
is actually practised clinically.9 It is considered detrimental A quantitative study design using a descriptive survey was
to radiography education and effective practice, and has used for this study. At the time of the study, 30
profound implications for the future of the profession.10 radiography students who had completed courses in chest
Duchscher and Cowin11 observed in the nursing profession radiography and had undertaken clinical rotations
that theory–practice gap leaves students and new nurses constituted the study’s sample size except four who either
marginalised, and fosters feelings of isolation, vulnerability took part in the pilot study or helped in the data collection.
and uncertainty. According to Lambert,12 the absence of A semi-structured, self-designed questionnaire
theory-based practice modelled for students may actually consisting of open- and close-ended questions was used for
result in ‘de-professionalisation’. Rolfe13 also indicated that data collection. The four-sectioned questionnaire, whose
qualified professionals have had some experience of this functionality was evaluated by two clinical tutors from the
so-called theory–practice gap, but argued that it is Radiography Department of the University of Ghana, was
probably felt most acutely by students. In particular, these developed to suit the aim of the study. A pilot study and
students often found themselves torn between the demands pre-testing analyses were also conducted to test the
of their tutors to implement or practice theory on one side, reliability and validity of the measuring instruments.
and pressure from practicing professionals to conform to Section A was designed to collect demographic data, while
the constraints of real life clinical situations on the other section B sought for information on patient preparation
side. Mantzorou14 also found that this gap often left for chest x-ray examinations. Section C was designed to
students in a state of confusion. collect data on technique and radiation protection
Identified causes of theory–practice gap during clinical practices in chest x-ray examinations, while section D
rotations include the supervisors’ and preceptors’ level of focused on supervision of clinical practice.
experience and competence.9 Besides discrepancy between The participants were recruited from the Radiography
theory and organisational protocol, heavy workload and Department between the periods of 2 February and 27
poor supervisee–supervisor relationship have all been July 2014. The responses to the open-ended questions
cited as causes of theory–practice gap.9 Other studies were categorised into major themes determined by the
have also found theory–practice gap to be associated with responses. The identified themes were counted and
lecturers’ changing role from ‘hands on’ supervision of organised quantitatively together with the closed-ended
students to focus on more research.15,16 The consequence responses. Statistical Package for Social Scientists (SPSS)
is that some practising professionals assume supervisory version 20 was used for data processing. Descriptive
roles with insufficient preparation, and are often unaware statistics were then used to describe the findings.
of the associated educational goals required of the clinical Ethical clearance and permission to use facilities were
supervisory roles.15,16 Lack of communication and obtained from the Ethical and Protocol Review
agreement between the educational institution and the Committee of the School of Biomedical and Allied Health
clinical supervisors involved in students’ learning is said Sciences and the Department of Radiography respectively.
to have a serious problem in theory–practice gaps Research participants were informed that the study did
elsewhere.5 Therefore, investigating areas of theory– not present any risk. They also reserved the right to
ª 2016 The Authors. Journal of Medical Radiation Sciences published by John Wiley & Sons Australia, Ltd on behalf of 147
Australian Society of Medical Imaging and Radiation Therapy and New Zealand Institute of Medical Radiation Technology
Theory–Practice Dichotomy in Chest Radiography B. O. Botwe et al.
withdraw from the study at any point in time and were patients in lead skirts, thorough explanation of the
also asked to voluntarily sign a written informed consent procedure to patients before start and checking of last
form following detailed explanation of the study. Privacy, menstrual periods (LMPs) of female patients in their
anonymity and confidentiality of the information reproductive ages were ‘not often’ or ‘never’ done and
provided by the participants were safeguarded. These were observably high (42–69%).
were achieved by identifying respondents with codes and Table 3 shows that lack of working materials, heavy
using the data only for this study. Data were also locked workload and equipment break downs in addition to
with secured password and discarded afterwards. supervising factors constituted the major causes of
dichotomy between theory and practice.
Results
Attitude of clinical supervising
All 26 distributed questionnaires were completed and
radiographers towards students
submitted, constituting 100% return rate. The
demographic variables of the respondents are presented in The study results showed that the clinical supervisors
Table 1. The population consisted of more males 16 were either always (8%) or often (58%) friendly and
(62%) than females 10 (38%). Twenty-four years was the approachable, while the remaining 34% were considered
average age in this population. As presented in Table 1, as not always so. Twenty-three (88%) of the respondents
most of them had performed clinical rotations in 3–6 confirmed that supervisors allowed them to ask questions
imaging facilities. Twenty-one (81%) of them indicated on bothering issues during clinical rotations, while 2
chest radiography was always done in the imaging (8%) of the respondents stated no. However, 1 (4%) of
facilities, while the remaining 5 (19%) stated that this the respondents did not comment on the question, while
procedure was often done. Students were also invited another stated that the answers provided to their
during their clinical rotations to show how the procedure questions by their supervisors were always convincing.
was done taken into consideration radiation protection Fourteen (54%) of them stated that the answers were
measures as well as patient management techniques such often convincing, while 9 (34%) indicated that the
as patient preparation and radiographic technique. answers were not often convincing. Two (8%) refused to
The high-frequency responses in Table 2 recorded with comment on this subject. Additionally, 2 (8%)
respect to ‘always’ and ‘often’ suggest compliance with respondents affirmed that students were always allowed to
technique and some radiation protection practices in perform the procedure under supervision, while 16 (61%)
chest x-ray examination. However, reports on the use of and 8 (31%) confirmed that students were either often or
anatomical markers, regular and correct dressing of not often allowed respectively. This means majority of the
respondents were allowed to build clinical confidence as
Table 1. Demographics. they performed the procedures on their own. The
Age distribution responses of 25 (96%) of them confirmed differences
Age (years) n (%) between the theory and practice, while only 1 (4%) of the
18–27 21 (81%) respondents indicated the contrary. The effects of the
28–37 5 (19%)
differences on students are presented in Figure 1.
Total 26 (100%)
Gender distribution
Males 16 (62%) Discussion
Females 10 (38%)
Total 26 (100%) The traditional model of clinical supervision (direct
Educational level supervision) which involved the simultaneous presence of
Fourth year 15 (58%) teachers/lecturers and group of students in a clinical area
Third year 11 (42%)
for a specific amount of time has changed due to lack of
Total 26 (100%)
time on the part of the teachers/lecturers and the increased
Number of chest imaging facilities available
18
where students undertook clinical practice demand of research. Subsequently, the preceptor model,
1 2 (8%) otherwise referred to as the mentorship model in Britain,
2 1 (3%) was introduced.19 This model is meant to promote the
3 5 (19%) socialisation of students by involving them in one-to-one
4 8 (31%) relationships with clinical staff,20 with faculty members
5 8 (31%)
responsible for supervising the general student/preceptor
6 2 (8)
experience and ensuring that the course objectives are
Total 26 (100%)
met.21 This model is suggested to be more effective than
148 ª 2016 The Authors. Journal of Medical Radiation Sciences published by John Wiley & Sons Australia, Ltd on behalf of
Australian Society of Medical Imaging and Radiation Therapy and New Zealand Institute of Medical Radiation Technology
B. O. Botwe et al. Theory–Practice Dichotomy in Chest Radiography
Table 2. Students’ comments on patient preparation, radiography technique and radiation protection measures used during chest radiography in
clinical placement facilities.
Response, n (%)
Activity Always Often Not often Never
Is the procedure explained thoroughly to patients before start? – 6 (23%) 15 (58%) 5 (19%)
Are the LMPs of female patients inquired of? – 2 (8%) 12 (46%) 12 (46%)
Are the right patient positioning and tube orientations used when needed? 2 (8%) 24 (92%) – –
Are the right examination instructions given? – 20 (77%) 6 (23%) –
Are the right FFDs used? 1 (44%) 25 (96%) – –
Are high kVp techniques and appropriate use of grid for general chest radiograph used? 8 (31%) 18 (69%) – –
Are high kVp techniques and appropriate use of grid for bedside chest radiograph used? 8 (31%) 18 (69%) – –
Are the right exposure factor combinations used? 4 (15%) 22 (85%) – –
Are anatomical markers used? 4 (15%) 6 (23%) 15 (58%) 1 (4%)
Are patients often and correctly dressed in x-ray lead skirts as taught? – 2 (8%) 18 (69%) 6 (23%)
Are adequate collimation used during chest radiography? 11 (42%) 10 (39%) 4 (15%) 1 (4%)
Are the people that stay with and assist patients during the exposure also protected? 5 (19%) 16 (62%) 5 (19%) –
LMP, last menstrual period; FFD, film focus distance; kVp, kilovoltage.
Table 3. Causes of theory–practice gap. students either observed practiced or practiced under
Reason provided by respondents n (%) clinical supervision at clinical placement facilities.
Theoretically and ethically, it is a professional
Some supervising radiographers do not know 3 (12%) requirement that imaging procedures are explained to
the learning needs of the students patients as part of patients’ preparation for chest
Some supervising radiographers indicated that 6 (23%)
radiography, and enquiries made about the pregnancy
this is how we have been doing it.
Heavy workload 14 (54%) status of female patients in their reproductive age to avoid
Equipment break downs 14 (54%) unnecessary exposure to any foetus. On the contrary, our
Lack of working materials, e.g., anatomical 16 (62%) study revealed a ‘non-often’ compliance as reported by
maker and lead skirts 58% of the students who testified of absence of pre-
Lack of awareness of educational objectives 2 (8%) examination explanations of imaging procedures. The fact
that only 8% of the participants testified that the LMP of
Some respondents gave more than one responses.
female patients was often inquired is consistent with the
the traditional model in increasing a student’s knowledge observations by Bushong22 and Compeau and Fleitz,23 of
base.19 In this study setting, the later model where possible and unnecessary radiological exposure of many
radiographers in the clinical facilities supervise students foetuses. Aside the risks associated with this practice to
with the support of the clinical tutors is practiced. patients, the frequent and repeated observation of clinical
Chest radiography is taught at the first and second lapses by the students may have the tendency of instilling in
years of the 4-year radiography programme in Ghana, them wrong approaches to clinical practice.
while clinical practice rotation is done in the third and The study further established that the majority of the
fourth years. Therefore, in order to determine the clinical students observed and also often practised chest
existence of a gap between theory and practice, the group radiography without the use of anatomical markers and
of students consisting of 15 fourth-year students (58%) lead skirts. This is contrary to the reports of Whitley et al.24
and 11 third-year students (42%) were queried on what and Compeau and Fleitz,23 and thus constitutes a non-
has been taught and what is practiced in all the clinical compliance of the fundamental tenets of chest imaging.
facilities during their clinical rotations. Normally, The employment of right examination instructions,
monthly placement is done for each clinical facility every film focus distance, collimation, exposure factors, patient
semester, and as observed (Table 1) all the respondents positioning and tube orientation when needed, high kVp
had been to at least a chest radiography facility. technique and appropriate use of grid for general and
The results of our study revealed a dichotomy between bedside chest radiography as often observed by the
theory and practice in chest radiography, a procedure students during clinical rotations (Table 2) are good
performed in most clinical placement facilities in clinical practices and agreeable with the literature.22–24
Ghana.17 In particular, the study showed some differences However, the fact that the aforementioned good practices
between theory presented in lecture halls and what were not always executed by the students and the clinical
ª 2016 The Authors. Journal of Medical Radiation Sciences published by John Wiley & Sons Australia, Ltd on behalf of 149
Australian Society of Medical Imaging and Radiation Therapy and New Zealand Institute of Medical Radiation Technology
Theory–Practice Dichotomy in Chest Radiography B. O. Botwe et al.
40%
35%
30%
25%
20%
38%
15%
23%
10%
15%
5%
8%
4% 4% 4%
0%
Confusion Poor Confusion + Errors in Unable to Confusion + No effect
performance poor pracce pracce loss of interest
in praccal performance theory in the programme
exams in praccal exams
Effects of the dichotomy on students
Figure 1. The impact of the theory–practice differences on students.
radiographers (supervisors) during clinical rotations was based on the norm ‘this is how we have been doing it’
presents worrying concerns as the lack of congruence at their work places and expected the students to do same
between theory and practice presents serious problems to against standard practice, which is a concern. In addition,
students and evidence-based health care.5 few students reported that some supervising radiographers
Duchscher and Cowin11 observed in the nursing neither knew the learning needs of the students nor saw the
profession that such theory–practice gaps left students responsibility to let students practice theory (Table 3). This
marginalised and fostered feelings of isolation, may indicate an educational structural fault. Lewin27 has
vulnerability and uncertainty. In this study (Fig. 1), poor suggested that learning in the clinical setting is intrinsically
performance in clinical practice and examinations, inability complex because patient needs take precedence over
to practice the theory, confusion and loss of interest in the student’s learning needs and sometimes this can
course were identified as major negative impacts of the compromise students’ learning. Therefore, the academic
theory–practice gap experienced by radiography students institution has to ensure that those who train their
during clinical practice. These observations are consistent students during clinical rotations know about their
with the literature where other studies have indicated students learning needs.
confusion and ‘de-professionalisation’ as some outcomes Meanwhile, the evidence suggests that most of
of the theory–practice gap.14,15,25 supervising radiographers were friendly and approachable,
The main challenges drawn in this study as the causes of allowed students to ask questions and their responses
theory–practice gaps were lack of working materials in the were often convincing to students. In addition, they often
clinical facilities such as anatomical makers, lead skirts and allowed students to practice on their own under
constant equipment breakdowns (Table 3). These factors supervision. This is essential for students as Atanga et al.4
caused the radiographers to use other compromised means found that students felt confident and developed
of practice contrary to what had been taught to the competence when given opportunities to practice on their
students. Heavy workload was also an added challenge own under friendly and welcoming supervision
which prevented the appropriate steps to be followed environments. These positive attributes demonstrated by
during chest radiography, and consequently induced a the supervising radiographers need to be upheld by
theory–practice gap. This is agreeable with the reports of clinical preceptors in general to enhance students’
Lambert and Glacken16 and Hall-Lord et al.26 that learning during clinical placements or rotations.
unavailability of some working materials and heavy
workload in the nursing environment were causes of Conclusion
theory–practice gap. Notwithstanding, other factors which
were not related to equipment and working materials The study found dichotomy between theory and practice
contributed to dichotomy between theory and practice. It in chest radiography in clinical facilities where students
was observed that the practice of some (23%) practitioners undertook their clinical rotations in Ghana. This
150 ª 2016 The Authors. Journal of Medical Radiation Sciences published by John Wiley & Sons Australia, Ltd on behalf of
Australian Society of Medical Imaging and Radiation Therapy and New Zealand Institute of Medical Radiation Technology
Frequency (%)
B. O. Botwe et al. Theory–Practice Dichotomy in Chest Radiography
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The authors declare no conflict of interest.
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