Materials and Methods

Study design and setting

This institutional-based explanatory sequential cross-sectional study was designed using quantitative and qualitative approaches, and conducted from June 1 to August 30, 2024, in selected public and private higher education institutions in the west and southwest Shewa Zones, Oromia, Ethiopia. The study followed an explanatory sequential mixed-method design, where quantitative data were collected and analyzed first, before conducting qualitative data collection to explain and elaborate on the quantitative findings.

Study population

The quantitative population consisted of all undergraduate nursing interns enrolled in the selected institutions during the study period. The qualitative population included nursing instructors actively engaged in theoretical and/or clinical nursing teaching.

Sample size and sampling procedure

The quantitative sample size was 422 students, which was determined using a single population proportion formula with an assumption of 50%, 95% confidence level, and 10% non-response rate. Participants were selected using proportional allocation across institutions, followed by simple random sampling.

For the qualitative component, 16 nursing instructors were selected using purposive sampling based on their teaching experience and involvement in both theoretical and clinical instruction. Data collection was continued until saturation, which was defined as the point at which no new themes emerged.

Data collection tools and procedures

Quantitative data were collected using a structured, self-administered questionnaire adapted from a previously validated instrument used in a study conducted at the University of Lahore, Lahore, Pakistan.12 The tool was contextualized to the Ethiopian setting and pretested prior to actual data collection to ensure its clarity, validity, and reliability.

Qualitative data were collected using a semi-structured in-depth interview guide developed based on study objectives and relevant literature. The guide explored perceptions of the theory–practice gap, institutional factors, and instructor-related challenges affecting integration of theory and practice. Interviews were conducted face-to-face in private rooms within the institutions to ensure confidentiality and minimize interruptions. All interviews were conducted by the principal investigator, audio-recorded with consent, and supplemented with field notes.

Timing between data collection phases

Quantitative data collection and preliminary analysis were completed first. Qualitative data collection was then conducted to further explore and explain key findings from the quantitative phase. This sequential timing facilitated the integration of results during interpretation to enhance our understanding of the theory–practice gap.

Variables

The dependent variable was the theory–practice teaching gap. The independent variables included student-related factors (age, sex, clinical placement area, and motivation), instructor-related factors (communication between theoretical and clinical instructors, teaching experience, and continuity of teaching), and organizational factors (availability of learning resources, supervision, institutional support, and type of hospital), where these variables were selected based on evidence from previous studies.

Data analysis

Quantitative data were entered into EpiData and analyzed using SPSS version 26 (IBM, Armonk, NY, USA). Descriptive statistics such as frequencies, percentages, means, and standard deviations were used. Binary logistic regression analysis was performed to identify factors associated with the theory–practice gap. Variables with p-values <0.05 were considered statistically significant.

The internal consistency of the questionnaire was assessed using Cronbach's alpha, which yielded a value of 0.83, indicating good reliability.

Qualitative data were analyzed using thematic analysis. Audio-recorded interviews were transcribed verbatim, followed by coding, categorization, and development of themes and subthemes.

Trustworthiness and quality assurance

For the quantitative component, data quality was ensured through pretesting, training data collectors, and close supervision. Reliability was confirmed using Cronbach's alpha.

For the qualitative component, credibility was ensured through member checking and prolonged engagement. Dependability and confirmability were maintained through systematic documentation of the coding and analysis procedures.

Data integration and triangulation

The quantitative and qualitative findings were integrated during the interpretation stage using triangulation. Quantitative data provided the magnitude of the theory–practice gap and associated factors, and the qualitative findings helped to explain and contextualize these results. Convergence and complementarity between data sets were assessed to strengthen validity and provide a comprehensive understanding of the results.