Effective Clinical Teaching Practice and Associated Factors among Midwifery Educators in Public Universities of Ethiopia, 2019

Abstract Background: Despite the fact that effective clinical teaching realistically enhances learners to be competent, in Ethiopia only 31.6% of midwifery graduates passed the national standard of competence for graduation in 2013. Likewise, evidence is lacking on effective clinical teaching practice of midwifery educators in Ethiopia. As a result, this study aimed to assess effective clinical teaching practice and associated factors among midwifery educators in Public Universities of Ethiopia. Methods: Institution based cross-sectional study was conducted among midwifery educators in Ethiopia in April, 2019. A total of 424 educators were randomly selected to participate in this study. Data were collected through email then entered into Epi-data version 3.1 and transported to SPSS version 23 for analysis. The data presented using frequency, percentage and tables. Multivariable logistic regression analysis was done to identify associated factors of effective clinical teaching practice. The odds ratio at 95% confidence interval used to ascertain association. Statistical significance declared at P<0.05. Results: Only 178(47.3%) of participants had effective clinical teaching practice. Clinical teaching experience (AOR= 4.72; 95%CI=1.97, 11.29), training on higher diploma in teaching profession (AOR=2.78; 95%CI=1.61, 4.82), clinical teaching workshop (AOR=4; 95%CI=1.98, 8.05), students per clinical unit (AOR= 3.71; 95%CI= 1.66, 8.26), giving objectives of clinical learning for students (AOR= 4.74; 95%CI=2.43, 9.25), using performance based assessment tool (AOR =1.82; 95%CI=1.04, 3.16) and having good interest in clinical teaching (AOR=8.63; 95%CI=2.91, 25.56) were factors positively associated with effective clinical teaching practice. Conclusions: Less than half of midwifery educators of Ethiopian Public Universities had effective clinical teaching practice. The educators’ clinical teaching experience, training and adhering to clinical teaching standards were identified to affect effective clinical teaching positively.

Therefore, the educators should adhere to the standards for effective clinical teaching and receive trainings on effective teaching. Key words: Effective clinical teaching, associated factors, Midwifery educators, Ethiopia Background Midwifery is a profession concerned with provision of holistic care for women during maternal life, for newborn, and infants (1). Ability to perform midwifery competency in real situation can't be achieved through classroom learning alone (2). Thus, the preponderance of clinical experience in the training of midwifery students cannot be undervalued. It is noteworthy in guiding midwifery education process (3). To enable midwifery students acquire intended clinical experience, effective clinical teaching (ECT) is compulsory (4). But the quality and competence of midwifery graduate is affected by the excellence and capability of midwifery educators to teach effectively (5).
Midwifery educator has obligation to deliver ECT that optimally facilitate students' learning (6). These include consistently performing ECT attributes such as establishing rapport with learners, and maximizing the use of case-based learning opportunities (7), being knowledgeable, providing support, role modeling, being clinically competent, knowing how to teach and being communicative (6,8,9). ECT build students' clinical knowledge, skill, attitude, critical thinking, clinical judgment and decision making ability (4). Accordingly, ECT can lead to the fulfillment of the 5 th Ethiopian educational sector development plan for educational relevance and quality improvement in midwifery context. Which is to produce demand-driven and competent midwifery graduates (10).
Ethiopia is a developing country committed at expanding equitable access to quality tertiary education (10)(11)(12). But the graduation rate of students by first degree from university is as low as 79% partly due to low quality of instruction (10). Even among midwifery diploma and first degree graduates, only 31.6% passed the national standard (≥ 60%) of competence for graduation in 2013 after examined at the point of their graduation which leads to failure to satisfy country's demand for competent and qualified midwifery professional (13).
Related studies done previously were focused on describing how frequently each effective clinical teaching attributes were implemented by clinical educators (4,(14)(15)(16). In addition, none of these studies identified factors associated with effective clinical teaching practice (ECTP). However, the current study was aimed to identify factors associated with ECTP using regression analysis. Hence, the findings contribute new knowledge on ECTP among midwifery educators in public universities of Ethiopia. In addition, it helps midwifery educators to maximize ECTP and so does the competency of midwifery graduates that can satisfy the country's demand for competent midwifery professional. Moreover, it establishes baseline information for further study. Lastly, it serves as springboard for stakeholders to deal with the problem.

Study area, period and design
Institution based cross-sectional study was conducted in 30 Ethiopian Public Universities (EPU) in April, 2019.These universities were selected because they have at least Bachelor of Science degree in midwifery education regular program (BScMERP) and have started teaching clinical courses. In Ethiopia, there are 47 public universities distributed in all 11 regional states of the country. The 30 EPU with BScMERP had 807 midwifery educators of whom 584 of them are male. At the data collection period, 502 midwifery educators were active staffs while the rest 279 were learning their master's degree and 26 were learning their PhD degree.

Study population and sampling procedures
The study population was all midwifery educators who were working in 30 EPU which have BScMERP. Midwifery educators recruited as regular academic staff in the 30 EPU for position of graduate assistant II and above and who taught at least 1 clinical course within this (2018/2019) and/or last (2017/2018) academic year were eligible for this study.
Midwifery educators who were learning their master's degree or PhD were excluded from this study since they are on education hence their response could probably be the result of the education they are learning but may not be what they actually practice during their clinical teaching. On the other hand, since they might be busy on their study, the concern they give for such extra responsibility may be low and may not provide their response.
The sample size was calculated using single population proportion formula (n = (z α/2) 2 p(1-p) /d 2 ) with the assumption of (50%) proportion of ECTP, 95% confidence level, 5% level of precision and 10% of non-response rate resulting 424 sample size. Simple random sampling technique was used to select study participants. The sample size was proportionally allocated for the 30 EPU using the sampling frame taken from the midwifery department of respective universities.
Data collection tool, procedures and quality assurance Data collection tool was semi-structured questionnaire partially developed incorporating both locally relevant factors those were not studied previously and factors identified by different studies conducted elsewhere (17)(18)(19)(20). In addition, it was partially adopted from clinical teachers effectiveness inventory tool developed by Mogan & Knox and cited in Marcia (14).The questionnaire was developed in English and did not translated to local language as respondents were university midwifery educators and they were considered as they understand English as it is the official working language at university level in the country. Pretest was done on 43(10%) of the sample size among nurse educators of Jimma University before the actual study. The purpose of the pretest was to test validity and reliability of the questionnaire and to check the wording, logic and order of the questions.
Finally, the questionnaire was found valid and reliable with Cronbach alpha coefficient 0.88 which shows good internal consistency and modification was made concerning the syntax of the questionnaire accordingly.
ECTP was defined as practicing qualities that enable clinical educators to teach effectively. These qualities include being knowledgeable, clinically competent, skillful in clinical teaching and evaluation of clinical learning of students, interpersonal relationships with students, and personal characteristics of clinical educator those facilitate clinical learning of students. ECTP was measured using 47 items that describe qualities that enable clinical educators to teach effectively using 1-5 points. Sum of the score was used to classify the status of ECTP of respondents using 75% as cut point as EPU use it as criteria for effective teaching. As an example the legislation of Jimma University was referenced (21). As a result, respondents those had sum of score ≥ 188(75%) were considered as having ECTP and those had sum of score < 188(75%) were considered as having not ECTP.
Data were collected through email. To assure quality of data, pretested, valid and reliable questionnaire was used to collect data. Objective of the study was clarified for participants and confidentiality of their response was assured to encourage them to provide their genuine response. Questionnaires with unfilled and/or inconsistent part were sent back to respective respondents and made to be corrected and sent back again for the principal investigator.

Data processing and analysis
The collected data were checked for completeness, coded and entered into Epi-data version 3.1 and exported to SPSS version 23 for data processing and analysis. Data cleaning was performed using frequencies, sorting, and listing to see missed values and outliers and then correction was made accordingly. Descriptive statistics such as frequency and percentages were used to describe the study participants. Multivariable logistic regression analysis was done to identify associated factors of ECTP. Odds ratio with 95% confidence interval was estimated to measure the strength of association between independent and outcome variable. Variables that have p-value of < 0.2 at bivariate analysis were included in multivariable logistic regression to control possible confounding factors. Statistical tests at p-value of <0.05 were considered as cut off point to determine statistical significance. Forward stepwise likelihood ratio method of analysis was used to develop final model due to large number of independent variables that did not allow to use the enter method. Multicollinearity was tested using variance inflation factor (VIF) and it was indicating absence of significant co-linearity (all less than ten). Hosmer and Lemeshow model fitness chi-square test was 6.569 and p-value was non-significant Around four-fifth 298(79.3%) of respondents were male. While the median age was 30 with interquartile range (the first and third quartiles) was 27 and 32 years, respectively (Table   1).
In-service training status of respondents

Strengths And Limitation
This study was conducted at national level using large sample size and probability sampling method to minimize selection bias and to ensure its generalizability. To minimize information bias pretested, valid and reliable questionnaire was used to collect data.
Study participants were also limited using exclusion criteria to those who were on clinical practice at data collection period to reduce recall bias. Similarly, the objective of the study was clearly described for study participants and confidentiality of their response were assured to enable participants to be free of fear of social desirability bias and to encourage them to provide their genuine response. In addition, data quality was maintained throughout and appropriate statistical analysis method was used with strong model goodness of fit test. However, it was not without limitation. It was better to support the finding of this study by data collected by observational method to further strengthen the validity of the findings. Declarations KA designed the study, prepared the proposal, obtained funding and data, analyzed and interpreted the data and prepared this manuscript. SWG and ABB had provided guidance to the corresponding author throughout the course of the study, reviewed the paper from beginning to end and approved the manuscript for publication.