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Abstract
Objectives In response to a critical shortage of skilled workforce, Ethiopia has scaled up its health professional education (HPE) by increasing the number of training institutions and student enrolment capacity. However, strong evidence that shows how the HPE scale-up affected clinical placements is lacking. This study investigated the challenges and effects of the rapid HPE scale-up in clinical placements, and the adjustments made in response to the challenges.
Design A qualitative study using focus group discussions and constructivist grounded theory was conducted in July–August 2022.
Setting The teaching hospitals of six medical schools in Ethiopia.
Participants 53 purposefully selected participants (25 clinician-teachers and 28 intern students).
Measures Adequacy of skilled clinicians, student preparedness and learning environment were input measures. Quality of supervision, assessment, feedback and practice exposure are process measures. Clinical competence was an outcome measure.
Results We identified six themes: (1) class size and student motivation, (2) availability of skilled and motivated clinician-teachers, (3) learning environment and practice management, (4) clinical supervision and assessment, (5) extent of exposure, and (6) clinical competence. The HPE upscaling caused student overcrowding, resource shortages and unconducive learning environments. Concerns were reported on clinical supervision, assessment, feedback, role modelling and programme management. Clinician-teachers and students had low levels of motivation. Competitions for practice diminished learning collaboration. In response to the challenges, adjustments were made to strengthen clinical rotations, engage teaching methods and hire more clinician-teachers.
Conclusion The rapid HPE scale-up affected clinical placements, reducing student authentic practice and skill development. There is a need to optimise student enrolment, train clinicians as teachers and improve clinical learning resources. Interprofessional education can optimise student practice. Placement coordination facilitates supervision. Student practice should be expanded to primary healthcare settings.
- Clinical Reasoning
- MEDICAL EDUCATION & TRAINING
- Ethiopia
Data availability statement
Data are available upon reasonable request. With reasonable request, we can share relevant data on which the analysis, results, and conclusions reported in the study are based.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THE STUDY
This study showed the status of clinical placement of medical students in Ethiopia from the context, input, process and outcome aspects of a training programme.
In addition, exploring the views of students and clinicians-teachers from multiple schools of various characteristics (public, private, graduate-entry and direct-entry) and teaching hospitals enabled us to provide a comprehensive picture of clinical placements in the country.
The focus group discussion (FGD) guide was developed based on the national guideline for student clinical practice and in consultation with the health professional education experts, making the study contextually relevant, and ensuring the findings’ confirmability and replication.
While the FGD participants were selected purposefully, maximum care was taken to reduce selection bias. It is still possible that selection bias may be present. Therefore, caution must be taken when extrapolating the findings of this study to other healthcare settings or health training schools.
In this study, residents, health facility staff, patients and regulators were not part of the FGD participants who could otherwise have given additional perspectives.
Introduction
The global shortage of skilled health professionals has been a major constraint in achieving health development goals, including universal health coverage.1 Despite an increment in health workforce supply, the shortage is estimated to double and reach about 15 million in 2030.2 Resource-limited countries have been severely affected by the shortage, carrying nearly three-quarters of the global burden of disease while having an average physician density of 10 times lower compared with the high-income countries.3 4 The human resource crisis is threatening health equity at a local and global scale. For instance, the capacity of health systems to respond to the COVID-19 pandemic was challenged by physician shortages. And the shortage reciprocally exacerbated the pandemic.5 Addressing this crisis, therefore, requires an upscaling of health professional education (HPE) capacity.6
The gradual piecemeal HPE expansions have not fulfilled the workforce demands in several resource-limited countries. Therefore, a rapid scale-up in health workforce training capacity has been emphasised since 2000, leading to a manifold rise in the number of schools and student enrolments.7 Ethiopia increased the number of medical schools from 5 in 2005 to 43 in 2022.8 The existing medical schools enrolled three to four times more new students.9 The annual graduation outputs have increased 10-fold, reaching 1500–1600. The increased graduation capacity has contributed to the health system’s strategic goal of increasing physicians from 5624 in 2016 to 28 121 in 2025.10 11 The HPE expansion prioritised general practitioners (GPs) among other midlevel professionals to improve access to primary healthcare.
Effective clinical placement improves the outcomes of the HPE.12 During placement programmes, students have hands-on and authentic exposure to real patients.13 Firsthand lessons of being a physician will be learnt through applying medical knowledge, developing patient management capabilities, and professional identities.14 In Ethiopia, the medical education curriculum is provided in six academic years, including 1 year of internship. Starting from the third academic year, medical students undertake clinical placement in referral hospitals under the supervision of specialists and GPs. The primary healthcare settings, however, are not optimally used. During the HPE expansion, student practices in clinical sites are likely compromised, affecting students’ opportunity to see various patient problems. Undesirable effects of the HPE expansion in placement quality and student competence were reported in other contexts.15 16
There is a dearth of evidence showing the impact of the rapid HPE scale-up on clinician-educators, students, learning environment, training process, adequacy of exposure and learning outcomes. A better understanding of the impact can inform actions towards the quality of clinical placements and guide the health system’s preparations to train large classes in HPE. Therefore, this study aimed to investigate the challenges and effects of the rapid HPE scale-up on clinical placements, and adjustments made in response to the challenges.
Methods
Study design
We applied a constructivist grounded theory methodology to investigate the impact of the rapid HPE expansion in Ethiopia which has been happening since 2005 on student clinical placement.17 Using this methodology, we collected and analysed data in iterative processes in which each step informed our actions of the data collection and analysis in the next steps. Explicitly based on theories from the previous steps, this method helped us generate rich and new data in a flexible manner consistent with the local reality. We looked into training inputs (clinician-teachers, students and learning resources), processes (student supervision, assessment, feedback and placement management) and output (competence). We used qualitative data from focus group discussions (FGDs) with graduating medical students and clinician-teachers.
Study setting
We purposefully selected the teaching hospitals of 6 schools from those of 43 medical schools, considering the feasibility issues, namely, Debre Tabor University, Addis Ababa University, Hawassa University, Dilla University, Adama Hospital Medical College (AHMC) and Adama General Hospital Medical College (AGHMC). We used criteria to select the schools such as establishment ages, geographic locations in the country, ownership types and student entry schemes. The selection process ensured that various types, representatives of all medical schools in the country, were considered. In Ethiopia, medical schools implement nationally harmonised competence-based curricula. Of the teaching hospitals affiliated with the six schools, four were comprehensive specialised (tertiary care centres), and one was a general hospital (secondary care centre). AGHMC did not own a teaching hospital. Students at AGHMC used the facilities and learning materials of AHMC during clinical placement. Both hospital types had large catchment populations of 3.5–5 million and 1–1.5 million, respectively.18 The hospitals also served as clinical placement sites for residents and other health science students.
Study participants
Our study had a focused aim which evolved during the data collection and analysis processes, requiring purposefully selected, knowledgeable and experienced FGD participants. A theoretical sampling approach was used in recruiting study participants in an iteration fashion where analysis of the first-round data will determine who to recruit next. In consultation with the deans of the medical schools, we selected the medical graduates and clinician-teachers for the earlier FGD rounds. Undergraduate medical students who completed their internship and are expected to graduate in 2022 and experienced clinician-teachers who had time and willingness were selected. Based on the codes and theories from the preliminary data analysis, we selected additional FGD participants for the subsequent FGD rounds. Guided by the concept of information power, we got theoretical saturation and had a total sample of 53 FGD participants.19
Data collection
In collaboration with the Ministry of Health (MOH), Ethiopian Medical Association (EMA) and medical schools, we developed a semistructured FGD guide based on the national clinical practice guideline that ensured the confirmability of the study findings.20 The FGD guide focused on the challenges and effects caused by the HPE scale-up on clinician-teachers, students, learning environment, supervision, assessment, feedback, practice exposure and clinical competence. It also focused on the adjustments made to address the challenges. Two experts from the National Medical Education Committee reviewed the FGD guide. Four data collectors (DD, FA, NAM, ZA) who were not staff of the six schools were recruited and trained on data collection procedures and tools, data quality assurance and ethical principles. The data collectors invited six participants from each school to each of the FGD sessions. We conducted separate FGDs for students and clinician-teachers. Students who completed the internship and clinician-teachers with at least 2 years of relevant work experience were included as they could provide valid and comprehensive assessments of clinical placement. Having interest and time to participate were also the inclusion criteria. Those clinician-teachers with less than 2 years of experience and those who were not full-time and had no interest were excluded. Medical students who did not complete their internship and had no interest were also excluded. The data collectors explained the study objectives and obtained informed consent from the FGD participants. Two data collectors (moderator and notetaker) facilitated each in-person FGD session by arranging the setting, introducing the sessions, asking questions, giving probes, encouraging participation, recording discussions, taking field notes and summarising sessions. Instructions and group norms were provided at the beginning to address concerns. To ensure confidentiality and conceal the identities of FGD participants, we de-identified the FGD data starting from the data collection period. The data were collected in Amharic, a local language to facilitate the free flow of ideas during the FGDs. To avoid distractions, the FGDs were held in quiet and private rooms. Data collectors used digital voice recorders and field notes. The study investigators supervised the data collection process. The data collection was conducted in July and August 2022 (online supplemental file 1).
Supplemental material
Data analysis
The de-identified FGDs were transcribed verbatim in Amharic and translated back into English to suit the data for analysis software. We applied interpretive translation to translate the transcripts. Maximum care was taken to preserve the meaning of words, sentences, meanings and cultural contexts during the translation process. Field notes were included in the transcripts. Transcription and translation were conducted on the same day to avoid the loss of details. We (DD, FA, ZA and NAM) did familiarise ourselves with the data by re-reading the transcripts and re-listening to the audio files. The translations were imported into NVivo V.12 (QSR International). To the best of our abilities, we could not get rigorous clinical placement studies in Ethiopia. Hence, an inductive thematic analysis was used to identify themes that allowed a better understanding of the data and flexibility during data analysis.21 Open coding was used where the data were broken into individual excerpts and continuously compared with other FGD participants’ excerpts. Similar and related excerpts were then grouped into codes which helped us to triangulate the data and check data credibility and dependability. A codebook with research questions, codes and code summaries was created. We ran queries to explore relationships and patterns of themes, sentiments and cases.22 Multiple codes were compared and the related ones were grouped into six categories (code summaries) through axial coding. Grounded theory memos were composed throughout the process by reflecting on our analytical thoughts.
Patient and public involvement
No patients or members of the public were involved in the research design, analysis and dissemination of the findings of this study. Deans, clinician-teachers and other experts of the HPE schools, MOH and EMA were engaged while interpreting and using the study findings.
Results
A total of nine FGDs were conducted with 53 study participants. Of these, five were held with 28 students (29% female), with a mean age of 25.3 years. About four to six students participated in each of the FGDs. The rest of the four FGDs were held with 25 clinician-teachers (12% female), with a mean age of 31.8 years. About five to eight clinician-teachers participated in each FGD. Clinician-teachers had an average work experience of 5.5 years (table 1).
Background characteristics of study participants
We identified six themes showing the challenges and effects of the rapid HPE upscaling on the inputs, processes and outcomes aspects of student clinical placement, and the congruent adjustments made. The themes included (1) class size and student motivation, (2) availability of skilled and motivated clinician-teachers, (3) learning environment and practice management in the clinical settings, (4) clinical supervision, (5) extent of practice exposure, and (6) clinical competence.
Theme 1: class size and student motivation to learn
The first theme described the impact of rapid HPE upscaling on the class size, and the motivation of students to learn. In this regard, students and clinician-teachers emphasised that the upscaling caused student overcrowding at the teaching hospitals, leading to shortages of physical spaces, medical equipment and supplies. Clinician-teachers were also challenged to follow up with a large number of students. Competition for practice among students was also reported.
It is not easy to teach due to the number of students in the wards and clinics. Clinics are too narrow to accommodate students. [A 45–47-year-old female clinician-teacher]
Given there are few clinical procedures with limited BP apparatus, gloves, etc. … students even residents compete for practice opportunities. [A 26–28-year-old male student]
Students and clinician-teachers also claimed that student motivation was affected by shortages of materials, low follow-up from clinician-teachers, high level of competition and unpleasant relationships with hospital staff. In addition, the lack of jobs and low pay for young physicians were mentioned as demotivating factors.
… Decreased follow-up from seniors and the shortages of materials have affected my motivation. [A 24–26-year-old female student]
Our students are getting bored …. witnessing the life of physicians who find it difficult to pay house rent and raise their children with the current salaries. [A 35–37-year-old male clinician-teacher]
Theme 2: availability of skilled and motivated clinician-teachers
The second theme focused on the availability of skilled and motivated clinician-teachers to supervise numerous enrolled students. Students and clinician-teachers claimed that all schools supported and sponsored clinician-teachers’ training in various specialty fields to respond to the increased placement needs during the HPE upscaling. As a result, more specialist doctors were trained, hired and deployed to multiple clinical units in the teaching hospitals
…. Our students are lucky compared to how we trained in the past. For us, only a few seniors were available in major clinical areas. [A 43–45-year-old male clinician-teacher]
In most schools, the number of specialists and subspecialists has increased. This is a great asset for us. [A 25–27-year-old male student]
However, the students and clinician-teachers claimed that the clinician-teachers had gaps in teaching skills. Despite their experiences in medical care, they were not well trained in pedagogy. As a result, clinician-teachers had limitations in guiding student practice. The student practice was not always tailored to the curricular goals.
Being relatively inexperienced in teaching, the pedagogical aspect of the clinician-teachers is not good. [A 24–26-year-old male student]
… medical science is a wide field. Students should have been told what to focus on. Sometimes, students practice beyond their scope. [A 45–50-year-old female clinician-teacher]
In addition, the students and clinician-teachers had concerns about staff motivation and their overall performance due to the high work demands, challenges in the work environment, low salaries and limited incentives.
There is an imbalance between the workload and what is paid … We are not using our full potential to teach students. [A 44–46-year-old male clinician-teacher]
…there were issues with the punctuality and commitment of seniors. Some even send residents on their behalf, and some don’t come prepared. [A 35–37-year-old male student]
Theme 3: learning environment and practice management
This theme described the impact of HPE upscaling on the psychological readiness of students, the conduciveness of the hospital environment for learning, clinical task assignments and programme management related to planning, monitoring and addressing placement challenges. In this regard, the work relationships of the students with clinician-teachers and other staff were not usually smooth. Students were not always emotionally supported.
It is usually stressful and frightening for me. Some staff are harsh. We failed to learn humility, patience, and a caring attitude from the seniors. [A 25–27-year-old male student]
Due to the class size and busy schedule, we do not give our full attention to the students. [A 34–37-year-old clinician-teacher]
Students mentioned that too many tasks were assigned to the students during the internship period. Some tasks were not well defined. Some tasks were unrelated to the core competencies. There were no specific job descriptions for medical interns, leading to role conflicts with those of nurses and other staff. However, this claim was not supported by the clinician-teachers.
The significant parts of my assignment as an intern were just the roles of nurses and even porters. It consumes my time and energy. [A 24–26-year-old female student]
Although it is too much work, clinical tasks during placement sessions are important for student development. [A 47–49-year-old clinician-teacher]
The students and clinician-teachers claimed that the clinician-teachers did not always supervise students. And there were also occasions when seniors mismanaged students. In addition, the students were concerned that clinician-teachers were not monitored and held accountable for their absence and student mismanagement. On similar notes, clinician-teachers acknowledged suboptimal academic management at the hospitals.
… seniors are feared as ‘God’. …They miss sessions in many instances. They can give a ‘C’ or ‘D’ grade, you couldn’t even ask why. This is an inherited culture… [A 35–37-year-old student]
The problems in clinical placement should have attracted the attention of school management. …sessions are missed. [A year 38–40-year-old male clinician-teacher]
Theme 4: clinical supervision
This theme described the impact of the rapid HPE expansion on placement strategies, teaching-learning methods, performance assessments and feedback. In this regard, the students and clinician-teachers commended the existing clinical rotations, attachment units, bedside teachings, morning sessions, duty assignments and other teaching methods that helped the schools to accommodate the large classes. However, there were challenges in supervising students closely and monitoring the clinical practice due to the large class sizes.
There are attachments in most clinical areas. … Good to have teaching rounds, bedside sessions, morning sessions, duty practice, and case-based discussions. [A 30–32-year-old male student]
Their number even makes it difficult to control who is attending a session. [A 45–47-year-old female paediatrician]
In addition, objective structured clinical examination (OSCE) and logbooks were introduced to build on the existing long-case, short-case and oral examinations. However, the clinician-teachers and students claimed that the schools failed to use the OSCE and logbooks consistently. The students in particular had negative views about the assessments and feedback. Large classes and low assessment skills of clinician-teachers were underlying issues. In addition, clinician-teachers and students believed that timely, specific and constructive feedback was not frequently provided.
Very sadly, assessment is full of bias, and subjectivity, and focuses on superficial things. For example, grading can be based on personal relationships and obedience to unrelated orders. [A 23–25-year-old male student]
Students should have been continuously assessed, mentored, and given feedback. …more is required in this regard. [A 39–41-year-old male clinician-teacher]
Theme 5: extent of practice exposure
This theme denoted the impact of upscaling on authentic and hands-on practice exposure to various patient problems. In this regard, those students and clinician-teachers practising in hospitals with no residency training and limited student groups had positive views about the extent of practice exposure. Given the hospitals are referral sites with a high catchment population, there were high caseloads and many case varieties that enabled the teaching hospitals to accommodate many students.
There are a lot of cases in this hospital. We are exposed to a variety of cases. We even see rare health conditions. [A 30–32-year-old male student]
… hospitals have high catchment areas. A lot of patients were referred to from different corners of the country. It is an opportunity for our students. [A 38–40-year-old male clinician-teacher]
However, students and clinician-teachers working in tertiary hospitals where residents and many student groups attached claimed they had no adequate practice opportunities, mainly to learn surgical and procedural skills. Opportunities to see and manage common infectious diseases were also limited. Student overcrowding, competition for practice with other groups and limited capacity of clinical units were reported as causes.
Not enough hands-on practice in clinical procedures and surgical cases. We only assisted residents. [A 25–27-year-old female student]
Due to the lack of proper training in critical procedures like lumbar puncture, chest tube insertion, Oro-tracheal intubation, manual vacuum aspiration … [A 45–48-year-old clinician teacher]
Theme 6: clinical competence
This theme described how well the students were prepared for independent clinical practice in terms of medical knowledge, skills and attitude. The students and clinician-teachers generally had a positive outlook on students’ competence in conducting basic clinical jobs: history taking, physical examination, interpreting investigations and managing patient problems.
I don’t think the graduating medical students will have difficulty treating patients. [A 45–47-year-old male clinician-teacher]
However, students from some medical schools did not concur with this claim since they were attached to tertiary hospitals where complicated cases were mostly managed. Medical students had limited opportunities to practise common health problems: TB, malaria and diarrhoeal diseases.
There is a gap in our medical knowledge of common infectious diseases. We are usually trained and assessed on complicated cases like diabetes mellitus, cancer, stroke, congested heart failure … [A 24–26-year-old male student]
To ensure quality training, there are efforts to expand placement sites to health centers, and primary hospitals… it was not fully successful due to logistical challenges
Concerns about procedural skills to conduct minor surgeries, obstetrics tasks, medical procedures and other cases were consistently reported due to the shortage of authentic practice, guidance and manuals.
Some students even struggle to insert IV cannulations, let alone do chest tube insertion, lumbar puncture, and manual vacuum aspiration. [A 24–26-year-old female student]
In addition, issues were reported in students’ communication and collaboration skills. As a result, communication and collaboration with patients, fellow students, clinician-teachers and other health workers were not up to expectations.
Communication of students with faculty was dominated by fear and uncertainty. Work relationships with nurses, midwives, and other health workers were not usually positive. [A 38–40-year-old female paediatrician]
Discussion
With the critical health workforce shortage in several resource-limited countries, expanding the capacity of HPE is necessary though it is challenging. Noteworthy to mention, its effectiveness depends on the attention paid to the training quality.23 We described and summarised the challenges and effects in clinical placements resulting from the rapid expansion of undergraduate medical education and the adjustments made by the schools in six themes: students, clinician-teachers, learning environment and practice management, clinical supervision, practice exposure and clinical competence. Our study can inform the HPE policies and actions in three ways. First, it can guide the planning, preparations and responses to the HPE scale-up efforts. Second, it provides additional perspectives on curricular design, implementation and evaluation amidst training expansion. Finally, it expands the knowledge base on how upscaling affects HPE quality.
The undergraduate medical education programmes are expected to produce competent GPs who provide unspecialised medical care mainly in primary care settings. Quality clinical placement is a vital element of the medical curriculum for developing essential competence.24 In this study, we found out that the rapid HPE scale-up affected the quality of clinical placements due to inadequate school preparations.25 26 Shortages of learning resources, overcrowding of clinical sites and unsuitable clinical environments were evident, diminishing authentic practice and subsequent skills development among students.27–29 Though adept supervisors are critical for achieving student learning outcomes,30–32 the teaching skills of clinician-teachers were inadequate. Supervisory supports to students from clinicians such as role-modelling, skill assessments and feedback provision were also compromised, which were otherwise vital in aligning clinical placement with the curricular goals.33–35 On the contrary, it is well documented that supervised patient encounters are necessary for students to get relevant, adequate and authentic exposure.36 In addition, the clinical placements were too much situated in the tertiary referral hospitals while the primary care settings and general hospitals were the main deployment sites of GPs, igniting a question: did the clinical placements have an optimal alignment with the GPs’ future roles?37 Expanding the placement sites to primary care settings may enable students to practice common health problems and infectious diseases adequately. The number of primary healthcare settings in the country was also a missed opportunity for bettering student practice amidst a greater placement demand.
A high level of motivation in a complex learning environment determines the commitment of educators and students towards educational goals. It stimulates the cognitive learning process and performance among students and clinicians.38 In our study, the clinician-teachers had no optimal motivation level26 due to the high workload, inadequate compensation, unsuitable learning environments and concerns in academic management.39 40 The clinician-teachers were not very good at punctuality, teamwork and communication, which might be due to their low level of motivation, negating soft skill development among the students.41 42 Similar challenges could also lower the motivation of students. With such prevalent motivational issues, we cannot stop asking questions about how committed clinician-teachers were to do rigorous student coaching, assessment and role modelling responsibilities. How well did students study the course materials? In addition, the overcrowding in placement sites could also usher in unhelpful student competitions for hands-on practice and even with residents, affecting their motivation, psychological safety, collaboration and skills learning.43 The residents might have coached the undergraduate students, had there been better programme coordination. To that end, improving performance management, clinical environment, job assignment and incentive packages requires attention.
The implication of the rapid HPE scale-up on the feature landscape of practice
To ensure access to essential health services, Ethiopia has expanded primary hospitals in rural and remote communities that require many qualified GPs, among other midlevel professionals. The HPE scale-up has created the opportunity to deploy more GPs to rural areas, addressing the physician shortages and maldistribution.44 45 However, the graduating medical students had deficiencies in essential skills, particularly in surgical, procedural, communication and collaboration skills, and lacked the required level of motivation.46 47 Unless the new-to-be doctors were prepared well with the essential skills and motivation, having more GPs would have a limited impact on the quality of medical care, patient safety and population health. Therefore, schools should strengthen interprofessional education to improve students’ collaboration, team building and communication skills.48 49 Strengthening interprofessional education during placement programmes can optimise the use of learning resources and experienced faculty. There is also a need to design prudent decisions in staff deployment, development and clinical rotation.
Strengths and weaknesses
Our study assessed the quality of clinical placement from contexts, inputs, processes and outcomes aspects of a training programme. Exploring the views of medical students and clinicians-teachers from multiple medical schools and teaching hospitals of various characteristics (public, private, graduate-entry and direct-entry) enabled us to generate comprehensive findings. However, residents, health facility staff, patients and regulators were not engaged in our study. These people could have otherwise given additional perspectives. The FGD guide was developed based on the national clinical practice guideline and in consultation with the HPE experts, making this research more contextually relevant. The tool development process also helped us to ensure the result confirmability and replication. While the FGD participants were selected purposefully, maximum care was taken to reduce selection bias. It is still possible that selection bias may be present. Therefore, caution must be taken when extrapolating the findings of this study to other healthcare settings or teaching schools.
Conclusion
The rapid scale-up in HPE capacity challenged student clinical placements in various aspects. It affected the motivation of clinician-teachers and students. It reduced authentic practice exposure to students, affecting clinical skill development. There is a need to optimise student enrolment considering placement capacity, train clinicians as teachers and improve clinical learning resources. Strengthening interprofessional education can optimise resource use and student learning during placement programmes. Placement coordination and scheduling can reduce competition and facilitate clinical supervision, assessment and monitoring. The placement needs to expand to primary healthcare settings. Research studies are required to assess the impact on other aspects of student competence and the economic implications of the training scale-up.
Data availability statement
Data are available upon reasonable request. With reasonable request, we can share relevant data on which the analysis, results, and conclusions reported in the study are based.
Ethics statements
Patient consent for publication
Ethics approval
Ethical approval was obtained from the Ethiopian Public Health Association institutional review board (IRB). We also obtained ethical approval from the Johns Hopkins Bloomberg School of Public Health institutional review board with IRB number 21116. The MOH provided permission letters to conduct the study. We also communicated with medical schools to facilitate data collection. Data collectors met with deans and department heads of the target institutions to explain the purpose of the study and data collection processes. Data collectors obtained written consent from each study participant before commencing data collection. Data on study participants’ names and other personal identifiers were not collected. The datasets were stored in a password-protected secure place.
References
Footnotes
X @ddejene
Contributors DD contributed to the conceptualisation, protocol development, study planning, data collection and statistical analysis, results interpretation, write-up and manuscript development. FA contributed to the protocol development, data collection and analysis, result interpretation and manuscript development. TY contributed to the study conceptualisation, protocol development, result interpretation and manuscript review. SM contributed to the study planning, data collection and manuscript review. ZA contributed to the data collection and analysis and manuscript review. NAM contributed to the data collection, analysis and manuscript review. JS contributed to protocol development, result interpretation and manuscript review. MV contributed to protocol development, result interpretation and manuscript review. DD is the guarantor in the statements of authors’ contributions.
Funding Jhpiego-Ethiopia, under its Health Workforce Improvement Program, received a donation from USAID, contract/agreement number 72066320CA00008, which provided the financial resources for the study.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.