Experiences of clinical teaching-learning among medical and nursing graduates during internship and their supervisors in Tanzania

Abstract

Background
Health professions training in Tanzania has gradually adopted the competency-based curricula (CBC) approach that focuses on learners’ acquisition of competencies in knowledge skills and aptitude. Feedback from the graduates is crucial for improving CBC implementation and review to ensure that graduates acquire clinical competencies and thus improve patient care.

Objectives
To explore the teaching–learning experiences of medical and nursing graduates during their internship and their supervisors in three teaching hospitals.

Methods
Exploratory qualitative data from in-depth interviews and focus group discussions were analysed using a content analysis framework. Medical and nursing graduates who were in an internship program in three teaching hospitals in Tanzania were conveniently recruited based on their availability during the data collection period.

Results
The use of clinical logbooks, guidelines and protocols, bedside teaching, mentorship, and supervision were important for the acquisition of clinical competencies. Graduates demonstrated inadequate clinical competency including confidence, commitment, and professionalism because of a lack of clear clinical guidelines and protocols, inadequate bedside teaching including supervision by faculty and ineffective communication and feedback.

Conclusions
Clinical teaching–learning tools and approaches facilitate students’ acquisition of clinical competencies. However, inadequate use of guidelines and protocols, bedside teaching, clinical supervision and effective communication was observed. Use of these clinical teaching approaches should be emphasized for students’ clinical competency acquisition.

Full text

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Discover Education
Research
Experiences ofclinical teaching‑learning amongmedical andnursing
graduates duringinternship andtheir supervisors inTanzania
LilianTeddyMselle1· EdithA.M.Tarimo1· DoreenMloka2· DicksonAllyMkoka1· HarunaDika3·
RoseMjawaLaisser4· NathanaelSirili5· JudyMartin‑Holland6
Received: 17 June 2022 / Accepted: 18 October 2022
© The Author(s) 2022 OPEN
Abstract
Background Health professions training in Tanzania has gradually adopted the competency-based curricula (CBC)
approach that focuses on learners’ acquisition of competencies in knowledge skills and aptitude. Feedback from the
graduates is crucial for improving CBC implementation and review to ensure that graduates acquire clinical competen-
cies and thus improve patient care.
Objectives To explore the teaching–learning experiences of medical and nursing graduates during their internship and
their supervisors in three teaching hospitals.
Methods Exploratory qualitative data from in-depth interviews and focus group discussions were analysed using a con-
tent analysis framework. Medical and nursing graduates who were in an internship program in three teaching hospitals
in Tanzania were conveniently recruited based on their availability during the data collection period.
Results The use of clinical logbooks, guidelines and protocols, bedside teaching, mentorship, and supervision were
important for the acquisition of clinical competencies. Graduates demonstrated inadequate clinical competency includ-
ing condence, commitment, and professionalism because of a lack of clear clinical guidelines and protocols, inadequate
bedside teaching including supervision by faculty and ineective communication and feedback.
Conclusions Clinical teaching–learning tools and approaches facilitate students’ acquisition of clinical competencies.
However, inadequate use of guidelines and protocols, bedside teaching, clinical supervision and eective communica-
tion was observed. Use of these clinical teaching approaches should be emphasized for students’ clinical competency
acquisition.
Keywords Clinical teaching–learning experiences· Competencies· Medical and nursing graduates· Supervisors·
Tanzania
Abbreviations
CBC Competency-based curricula
CUHAS Catholic University of Health and Allied Sciences
KCMCUco Kilimanjaro Christian Medical University College
MUHAS The Muhimbili University of Health and Allied Sciences
* Lilian Teddy Mselle, nakutz@yahoo.com; lmselle@muhas.ac.tz | 1School ofNursing, Muhimbili University ofHealth andAllied Sciences,
DaresSalaam, Tanzania. 2School ofPharmacy, Muhimbili University ofHealth andAllied Sciences, DaresSalaam, Tanzania. 3Weill Bugando
School ofMedicine, Catholic University ofHealth andAllied Sciences, Mwanza, Tanzania. 4Archbishop Antony Mayala School ofNursing,
Catholic University ofHealth andAllied Sciences, Mwanza, Tanzania. 5School ofPublic Health andSocial Sciences, Muhimbili University
ofHealth andAllied Sciences, DaresSalaam, Tanzania. 6School ofNursing, Institute forGlobal Health Sciences, University ofCalifornia,
SanFranciscoSanFrancisco, CA, USA.

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THET Transforming Health Professions Education in Tanzania
FGD Focus Group Discussion
IDI In-depth Interviews
MD Medical Doctor
NUR Nursing
MNH Muhimbili National Hospital
BMC Bugando Medical Centre
KCMC Kilimanjaro Christian Medical Centre
1 Background
In the current competitive and globalised economy, employers and professional organisations call for higher edu-
cation institutions to produce graduates with relevant competencies and skills. Appealing to this situation, health
professions Universities in Tanzania are in a transition to adapt Competency-Based Curriculum (CBC) training that
focuses on student-centred rather than the traditional teacher-centred approaches. The Muhimbili University of
Health and Allied Sciences (MUHAS) as pioneers of using the CBC started implementing CBC learning and teaching
approaches in 2012, while other two Universities namely the Catholic University of Health and Allied Sciences (CUHAS)
and Kilimanjaro Christian Medical University College (KCMUCo) started using CBC approach in 2020/21 academic year.
Competence involves a combination of knowledge, skills, attitudes, values, and abilities that underpin effective
performance in the world of work. The CBC training focuses on learners’ ability to perform tasks [1]. It emphasises
clinical teaching as an essential facilitator of building clinical competence among learners. For the students to acquire
the required clinical competencies, the training environment should be authentic, well-equipped with adequate
support from faculty, supervisors and the clinical team. To ensure effective execution of CBC, medical and nursing
faculty were trained to understand and interpret the curriculum, equipped with facilitation skills, and practical tools
were developed to support implementation of CBC including assessment guides, practicum handbook and students’
logbooks. These measures ensured that at the end of clinical practice, learners can perform various clinical procedures
and act professionally in the actual work environment.
Studies in Tanzania [2, 3] and elsewhere [4–6] have reported that medical and nursing graduates had limited skills
in performing clinical procedures, making clinical interpretations, communicating effectively and conducting physical
examinations (PE). Inadequate PE was reported to significantly contribute to adverse patient events and enhanced
PE skills training should be considered as an important and viable approach to medical error reduction [5].Further,
significant gaps in the clinical performance among the newly graduates elsewhere raised concerns about models
of training [7]. For example, a study in Norway reported that graduates gave the highest self-assessment ratings for
the need for further training in medication effects and interactions [8], implying that clinical competencies were
not fully mastered during their training. Understanding constraints for inadequate skill acquisition among medical
and nursing students help in restructuring and creating an authentic clinical teaching environment necessary for
real hands-on clinical practice [9].
In low and middle-income countries including Tanzania, few studies have emphasised on graduates’ clinical competen-
cies as the product of clinical teaching with common modes of delivery used to impart clinical skills such as simulations,
role-plays, problem-based learning, clinical clerkship, hands-on and observation [10, 11]. Improved clinical teaching and
learning would ensure acquisition of clinical competencies among medical and nursing graduates and thus improved
patients’ care and outcomes.
In Tanzania, health professional graduates undergo a 1year internship to further reinforce their clinical skills prior to
being independent practitioners. During this period the graduates works under the supervision and guidance of clinical
supervisors and faculty [2]. This study aimed at describing the clinical teaching–learning experiences among medical
and nursing interns and their supervisors in Tanzania.

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2 Methods
2.1 Study design andsetting
This is an exploratory qualitative study [12] nested in the large project that focused on analysing the implementa-
tion of competency-based curricula for Medicine and Nursing programs offered at Muhimbili University of Health
and Allied Sciences (MUHAS). The large project, Transforming Health Education in Tanzania (THET) is a 5year effort
to use innovative educational strategies to transform health education, using Competency-Based Curriculum (CBC)
to produce health professionals who are competent to practice upon graduation. Competency-based Curriculum
approaches of teaching and learning focuses primarily in developing graduates’ skills than a theoretical concept [13].
In addition to the use of CBC and related educational strategies to produce competent health professionals, THET
also aims to support the development of junior faculty to become successful inter-professional researchers. Specifi-
cally, this study draws data from 3 teaching and referral hospitals of Muhimbili National Hospital in Dar es Salaam,
Bugando Medical Centre in Mwanza, and Kilimanjaro Christian Medical Centre in Kilimanjaro that form a Transform-
ing Health Professions Education in Tanzania (THET) consortium. Muhimbili University of Health and Allied Sciences
(MUHAS) is the first medical University in Tanzania which trains undergraduate and postgraduate students from
different countries. MUHAS was established in 1960s with 3 core functions of teaching, research and consultancy.
It started implementing CBC in 2012 in its various undergraduate and postgraduate programs including medicine
and nursing. This study considered MUHAS as a case study to input the harmonised generic CBC given MUHAS is a
pioneer for CBC implementation in medical Universities in the country [14]. The findings of the study are expected
to inform preparation of the harmonised CBC curricular for Nursing and Medicine programmes that would produce
competent graduates who would respond to national and international changes. These are changes in- the labour-
market dynamics, burden and patterns of the disease, political and economic orientations and community needs
and technology advances [15].
2.2 Participants anddata collection
The study involved two types of participants, graduates in nursing and medicine who were in the internship program
and clinical supervisors who guide medical and nursing students, as well as interns. The nursing and medical doc-
tor graduates were those who completed University between 2017 and 2018 and were in the internship program
at Muhimbili National Hospital (MHN), Bugando Hospital, and Kilimanjaro Christian Medical Centre (KCMC). Even
though the primary aim of the study was to explore information that would be used to input the development of the
national harmonised CBC template for nursing and medicine degree programs, it was deemed necessary to include
graduates from other medical universities that were not trained using CBC. The purpose of this was to holistically
identify core competency gaps in graduates to be able to develop relevant and sustainable curricula. Furthermore,
the study included clinical supervisors who guide medical students, nursing students and interns in the 3 teach-
ing hospitals. Participants were conveniently recruited based on their availability during the data collection period
[16]. Before the data were collected all participants were informed about the nature and procedures of the study
and voluntary nature of their participation. They were also informed that information they provided will be kept
confidential, only members of the research team would have access to the information. All participants provided
written consent to participate in the study and their conversions to be audio-recoded. The study did not necessitate
ethical clearance because it was conducted as part of quality improvement of nursing and medical training for the
Muhimbili University of Health and Allied Sciences under the THET project.
To explore the learning teaching experiences, two methods of data collection were used which are in-depth inter-
views (IDIs) and focus group discussions (FGDs). Fifteen (15) in-depth interviews were conducted with six nurses’
supervisors, six medical doctors’ supervisors and three with medical doctor graduates. Additionally, eight FGDs each
having between 6–10 participants were conducted, 5 groups were of nurses and 3 of medical doctors (see Table1).
As indicated in Table2, the interview guide consisted of four questions focusing on participants’ experiences
of teaching–learning clinical competencies. The guide was revised in the course of data collection to allow new
emerging experiences to be included for subsequent interviews. The discussions were moderated using a common
guide that had six questions aimed at exploring how the clinical teaching and learning facilitated acquisition of

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clinical competencies among Medical and Nursing graduates. Prior to the discussion, ground rules were set whereby
participants were asked to respect each other’s opinions and were informed that the discussion is confidential and
therefore they should not share information outside the group. They were also encouraged to actively participate
during the discussion. Interviews and discussions were conducted by the researchers in Kiswahili language after
working hours, within the hospital premises in an environment that was quiet and out of reach of other providers
and patients. Using FGD and IDI methods of data collection increased trustworthiness of the study findings [17].
Interviews and FGDs were conducted within the hospital settings for convenience reasons and lasted within 90min.
2.3 Data analysis
The qualitative content analysis approach [18] guided the analysis of data that was done manually. Recorded interviews
were transcription verbatim by the hired persons and two researchers reviewed the transcripts against audio-recorded
materials to ensure completeness of the transcription. Kiswahili transcripts were used for analysis. Transcripts were careful
read sentence by sentence to obtain a sense of the whole content as narrated by the participants. Phrases and sentences
related to experiences of clinical teaching learning were coded in the margin of the transcript sheets independently by
researchers. To ensure content validity and conformability, researchers reected, discussed the codes several times and
after they agreed to the codes [19], the codes were brought together into categories based on their similarities. ‘Member
checks’ [19] was done throughout the analysis process to increase credibility.
Table 1 Graduates and clinical
supervisors involved in the
study
Category In-depth inter-
views (IDIs) FGD discussions and participants Number of
participants
Bugando KCMC MHN
MUHAS nursing graduates 0 0 (0) 1 (6) 1 (7) 13
Non-MUHAS nursing graduates 0 1 (10) 1 (6) 1(6) 22
MUHAS-MD graduates 3 0 (0) 1 (6) 1 (8) 17
Non-MUHAS MD graduates 0 1 (6) 0 (0) 0 (0) 6
Clinical supervisors 12 0 (0) 0 (0) 0 (0) 0
Total 15 2 3 3 58
Table 2 The In-depth Interview and Focus Group Discussion Guides
A. In-depth interview guide for supervisors
1. What is your experience of supervising interns? (Probe: What common weaknesses do you observe? What areas of competence that
needs to be strengthening? Are there any dierences in terms of competences among interns from dierent institutions? Anyone in
particular?)
2. Upon recruitment, what were MUHAS graduates capable/ not capable of doing in their daily responsibilities? (Probe: To what extent do
they/don’t they meet your expectations?)
3. How can the training of MD/BScN in Tanzania could be improved? (Probe: What are the key issues to consider during the training of
these professionals?) How can the curricular be structured to ensure eective translation of theory into practice for the MD /BScN pro-
grams?
4. What are your recommendations for improving training at MUHAS for better health care provision? (Probe: new programs, knowledge,
skills, professionalism)
B. FGD guide for graduates
1. Please share your experience of training at MUHAS (Probe: teaching methods, teaching environment, students/teacher’s relationship,
competency (missing), content –integration, redundancy/overlap, success; barriers.)
2. Immediately after programme completion, what were you capable of doing? or not doing. (Probe: Did you feel inadequate in terms of
skills, knowledge, and attitude towards clients?)
3. What is your opinion regarding program structure in relation to acquisition of clinical competencies? (Probe: course content, sequence,
integration, duration of courses)
4. In what ways the training you undertook ensured translation of theory/skills into practice? (Probe: clinical/practical placement, clinical/
practical supervision/mentorship, professionalism)
5. What should be improved with regard to training at MUHAS to ensure eective translation of theory/skills into practice?
6. What is your opinion regarding the students’ assessment? (Probe: theory, clinical, practical)

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3 Results
As shown in Table3, three categories and eight subcategories emerged from the experiences of graduates and
supervisors on clinical teaching–learning. The emerged categories describe results of larger amount of text into
meaningful information reflecting participants’ experiences of clinical teaching and learning. The sub-categories
occurred as smaller textual meanings, and when grouped together formed a category. These experiences have been
supported by quotes from the interviews and discussions abbreviated as NUR for nurse and MD for medical doctor.
3.1 Clinical teaching andlearning
3.1.1 Tools forclinical teaching andlearning
Various approaches and strategies of clinical teaching were reported to be useful for ensuring that students acquire
necessary clinical competencies. These competencies include using simulated patients, bedside teaching, ward
rounds, and the use of clinical logbooks which identify competencies needed to be achieved by the students. Gradu-
ates acknowledged the usefulness of logbooks as an important tool to students’ acquisition of competencies during
the clinical practice:
I really appreciate the use of logbooks to guide clinical competencies to students. Previously when these logbooks
were not in practice, students chose what to learn/practice in the clinical placement... each student was doing what
he/she felt like doing!... But now there are logbooks with lots of skills one has to practice. This is very good. (FGD,
BScN MUHAS intern MNH)
During discussion the graduates also appreciated the use of guidelines and protocols that were available in the
clinical sites because they were able to use them as job aids in gaining skills and knowledge competencies.
“During clinical practice, it was emphasized that we use guidelines and protocols for patient management and
therefore each student was keen to use them. In that way we gained more knowledge and skills” (FGD, Non-MUHAS
graduates- MNH)
Additionally, the role of faculty was emphasized:
Actually, faculty ensures that we [students] are committed in the wards such that we did lots of clinical procedures
including dispensing medicine, taking samples from patients for investigation. We made sure that all procedures
listed in the logbook are practiced and they [faculty] were very serious about it. … so we had to go to the clinical
area even during the night to ensure that we practiced skills listed in the logbook. (IDI, MUHAS MD graduate, BMC)
However, other graduates expressed a lack of clear clinical guidelines to enhance practice during the internship.
The availability and use of clinical guidelines would guide time spent and required supervision.
We rotated for two weeks in Ophthalmology, there were no examinations. We just pass by and observe; we leave the
rotation. Therefore, it gives a picture that we are learning but no one judged our performance (FGD, Non-MUHAS
MD graduates, MNH)
During the clinical teaching, pre-service graduates, defined as those who were registered at the University directly
after secondary education, were disadvantaged because the clinical supervisors assumed they were as skilled as
Table 3 Experiences of
clinical teaching learning
among graduates and their
supervisors
No Categories Subcategories
1 Clinical teaching and learning Tools for clinical teaching and learning,Bedside
teaching, Mentorship and supervision
2 Reinforcing clinical competencies Communication and feedback, Being competent,
condent and committed, Divulging bad news
3 Demonstrating professionalism Abiding to professional dress code, Devotion to
work

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in-service staff, defined as those who had prior professional orientation at Diploma level. Thus, little attention was
paid to them during the clinical supervision. The graduates felt the need to have harmonized guidelines for both
pre and post-service.
We need to have a common teaching guide for all nursing students, regardless of whether they are in service or pre-service
(FGD, Non-MUHAS NUR graduates - KCMC)
3.1.2 Bedside teaching
Participants commended the use of bedside teaching and other clinical procedures to reinforce acquisition of clinical com-
petencies. They appreciated having opportunity to practice with real patients. The graduates felt the bedside teaching by
some faculty was inadequate and emphasized its use.
“The bedside teaching needs to be emphasized because it is less used. … students may choose an interesting case or procedure
with the guidance of the faculty and the faculty may have discussions with students at the bedside. These days we don’t have
these bedside teachings”. (FGD, MUHAS-NUR graduates- MNH)
Supervisors reported faculty tried their best level to teach students in the clinical area. However, commonly faculty spend
inadequate time with students and therefore the students were unable to competently demonstrate clinical skills.
3.1.3 Mentorship andsupervision
Clinical supervision and mentorship from experienced and competent personnel were essential to ensure that students
were constantly guided to acquire necessary clinical skills. The supervision and mentorship of nurse students’ clinical skills
are commonly done by faculty and designated clinical instructors who have been trained to assume instruction roles. How-
ever, participants reported that clinical supervision by faculty was limited. Consequently, graduates failed to gain expected
clinical skills and requested this training approach to be strengthened to enhance the acquisition of clinical competencies.
There is a need for the faculty to also make close supervision. When students are supervised closely and supported they will
denitely develop adequate clinical skills (IDI, NUR Supervisor 5—BMC)
Clinical supervision is commonly done by health care providers, employed by the hospital, who assist students in the
acquisition of clinical skills based on their needs. However, Supervisors thought there should be specic criteria set for one
to serve as a clinical supervisor.
Clinical instructors are mostly done by voluntary people. They work for a certain period, and they may work beyond regular
working hours depending on student needs…; we are there to help them [students]... we have to be careful on the selection
of clinical supervisors (IDI, NUR Supervisor 4 - KCMC)
The clinical supervisors expected the graduates to demonstrate competency in carrying out clinical procedures during
the internship. However, it was realized that graduates needed more support even during this time of clinical practice.
I expected the intern nurse to demonstrate clinical competency …but most of the time we have to show them how to do most
of the common nursing procedures. So if you leave them to work independently they may cause problems … they still need
a lot of support to carry out practical procedures. (IDI, NUR supervisor 6 - BMC)
However, the graduates lamented the implications of not having adequate clinical supervision during their training:
Yes, we faced challenges, sometimes we attended clinical practice because we were encouraged to see patients and write
notes on the patients’ les but faculty were not present to guide us. So as a student it puts you o because you clerk patients
without presenting and being guided by senior doctors (IDI - Non-MUHAS MD graduate X, KCMC)

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3.2 Reinforcing clinical competencies
3.2.1 Communication andfeedback skills
Communication in teaching and learning is pertinent for the acquisition of clinical skills. Nevertheless, participants
reported insufficient communication between faculty teaching the clinical courses and the clinical instructors to
assist students in the clinical area to master competencies.
In the absence of course, faculty to supervise students in clinical areas, students become unwilling to perform some
clinical procedures claiming that they were not taught such skills. (IDI, NUR Supervisor 2, MNH)
3.2.2 Being competent, confident, andcommitted
The supervisors thought that the majority of graduates were confident in theoretical knowledge, but failed to apply
the knowledge gained while taking care of patients:
Interns are well prepared theoretically, even when you ask them questions they correctly respond to them, but practi-
cally, no they still need help [pause]. The majority lack clinical skills as if they were never taught during training. (IDI,
NUR Supervisor 6- BMC)
Consistent with findings shared by supervisors, graduates acknowledge having very good theoretical knowledge
for clinical reasoning but fail to apply the concepts when performing various clinical procedures.
During training, I learned a lot of theories that build my confidence and reasoning when caring for patients. However,
sometimes I fail to apply the theoretical knowledge into clinical practice. We commonly used very limited time for
clinical exposure and there was no clinical mentorship (FGD, MUHAS NUR graduates—MNH).
As an intern I feel that I am still learning clinical skills because we had very limited time for clinical experience during
training, we had very few activities that could build psychomotor skills, therefore I am gaining a lot of confidence
working with patients now as an intern than during training. (FGD, MUHAS NUR graduate- MNH).
Graduates reported missing some important clinical competencies including theatre management, management
of complicated deliveries, and managing most surgical procedures. They were worried with their incapability of per-
forming various clinical procedures in case they were posted to work independently in remote places.
‘Imagine if I was posted in the Mpanda region [more remote rural setting with shortage of doctors] and assigned to
work in the theatre. … there would be a lot of expectations knowing that I am a graduate coming from the National
hospital. … the truth is, we never learned that competencies or practised in theatre (FGD, MUHAS NUR gradu-
ates—MNH)
I think we are missing surgical skills; we are a bit theoretical and we don’t get adequate time to practice surgical skills. The
placement is not favoured by MD students to conduct surgery. Surgical procedures are limited and there are residents [MD
on residential postgraduate programs] and therefore cases are limited for each student to practice before graduation
(FGD, MUHAS MD graduates—MNH).
3.2.3 Divulging bad news
Participants had the opinion that graduates had inadequate competency skills of divulging bad news. Graduates reported
that they did not know when, what and how to break the bad news to patients and their relatives despite the inclusion
of medical ethics compulsory course in the curriculum that was also aimed at teaching students how to eectively com-
municate bad news:
When I was in the fourth year, I had a 9 years child who had a fracture 10 days later on the day of examination the child
died. One of the residents was around, so he asked me “you are an MD 4, right? Yes. Have you ever tried to break the death
news to the relative? No.” then he told me “then this is your time you can try”. So it was very dicult for me to inform the
relatives about the death. This is because I had never done it. (FGD, Non-MUHAS MD graduate—KCMC)

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3.3 Demonstrating professionalism
Participants expressed graduates lack of professionalism in different aspects of clinical practice including demonstrat-
ing professional dress code, respectful behaviour to seniors, and commitment and devotion for work.
3.3.1 Abiding toprofessional dress code
Supervisors reported that the clinical professionals’ dress code was still a problem to many students and graduates.
The problem of dress code was attributed to lack of seriousness among teachers and supervisors where some of
them do not bother to follow-up the issue of dressing:
Sometimes you don’t even understand, you can’t really say if this is a doctor, sometimes we send them back home for
them to dress properly. How can you come to the rounds like this on tights, somebody wears it for the ward-round,
you see. You ask yourself, was this person really trained, and was this person really mentored? So I think there is a
problem with mentorship. (IDI, MD Supervisor 1—MNH)
A student comes in the wards wearing a top and she knows that professionally it is not acceptable. You wonder how
she got off home. …. Some students are very bright and committed, but the way they dress is a problem.] (IDI, NUR
Supervisor 4—KCMC).
Graduates further reported that during their training, they commonly adhered to dress code on the days of clinical
examinations but not on other days:
Most of the time students dress very well during examinations you will see the student wearing a suit and a tie,
looking very smart. Other days we just dress casually and we are perceived by staff as not professionals. But during
basic sciences is when the foundation of professionalism is built therefore they should teach students how they are
supposed to dress (FGD, MUHAS MD graduates—KCMC).
Other graduates reported that mentors and supervisors had an influence on the dress code. They expected the
teachers to be the role model in dressing; however some supervisors were not good models while interacting with
patients.
You may find your mentor who you are working with and learning from…the way she responds to the patients! You
may be disappointed. (FGD, Non-MUHAS MD graduates—KCMC)
3.3.2 Devotion towork
It was also learned from the participants that individual graduates differed in their commitment and devotion for
work. While some of the graduates were devoted, committed to their work and performed clinical procedures without
being told, which indicated that they were competent, some needed to be taught and asked to carry out procedures.
In general, students should to be taught to be committed, because if you are committed you will need minimal super-
vision. I don’t know what the faculty will do to build a sense of commitment and accountability to students. I believe
with self-commitment the time that we spent in the clinical area would be enough to learn most clinical skills. (FGD,
MUHAS NUR graduates—KCMC)
The supervisors confirmed the lack of commitment among graduates:
There are individuals who are very committed to what they are doing and they seem to display that they are compe-
tent but some graduates do the work as if they were forced to join the profession”. (IDI, NUR Supervisor 2—MNH)
It was further reported that the commitment of graduates depended much on prior expectations that were some-
times not met hence low morale to work. The situation that affects their commitment and devotion to give quality
services to clients and patients:

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Faculty are doing a great job; however, the expectations of a bachelor’s degree graduate are shut down when they
start clinical rotations. When they realize that they have to perform bedside care, they become frustrated and their
morale goes down. Most think that their job is to administer drugs and do administrative work.” (IDI, NUR Supervi-
sor 3-KCMC)
During the discussion with medical doctors, it was shared that students were taught to cooperate with everyone they
work with within the clinical setting despite the level of education for the interest of patients.
4 Discussion
Our study demonstrated the importance of logbooks, guidelines, and protocols as tools during clinical practice. The
importance of bedside teaching and other clinical procedures to reinforce clinical competencies were also emphasised,
although bedside teaching was reported to be inadequately practised. The study has revealed that most faculty were not
available for clinical teaching and mentorship and when present, they spent inadequate time with students. Furthermore,
this study demonstrated that graduates had limited clinical competencies, lacked communication skills, and were not
committed to work. Lack of professionalism among new graduates was also observed.
The use of logbooks can inuence communication and regular feedback in dierent contexts. In this study, the fact
that graduates embraced the use of logbooks to guide the acquisition of clinical competencies during the practice is
worth noting. The use of logbooks may facilitate the timely acquisition of prescribed skills and regular feedback from
the supervisors. In Saudi Arabian University, despite poor-quality feedback, missing opportunities for feedback discus-
sion, and unfair marking, logbooks have been found to enhance students’ learning through the identication of areas of
weaknesses and reading in-depth about some topics [20]. Further, clinical decisions at the bedside and hospital opera-
tional rules are commonly inuenced by guidelines or protocols. These clinical guidelines are expected to provide clear
instructions on how one works with patients. During training, graduates were emphasized to make use of guidelines
and protocols to guide clinical practice. The guidelines (i.e. SoPs and Protocols) provide instructions on how to carry
out clinical procedures. For example, which diagnostic or screening tests to order, how to provide medical or surgical
services, how long patients should stay in the hospital, or other details of clinical practice [21].
Student-centred clinical teaching approaches and strategies such as bedside teaching, supervision and provision of
regular feedback and debrieng are key for students’ acquisition of clinical competencies [22, 23]. However, as reported
in this study and in other countries [24–26], bedside teaching and mentorship are inadequately used. The fact that gradu-
ates demanded supervision and mentorship from competent personnel implies that a partnership between trainees
and clinical supervisors needs to be strengthened. Students can benet from positive reinforcement of their eorts by
the supervisors when they work as partners [27, 28]. In the Tanzanian context, supervision of students from the clinical
instructors may signicantly improve the quality of clinical training because of the opportunity to focus on the needed
competencies as well as balancing the human resource eorts. In Poland, midwifery students acknowledge the role of the
mentoring that allows repeated performance of the same activities which improve their clinical skills [29]. In our study,
whereas the supervisors expected the graduates to eectively demonstrate skills when working with patients during
clinical placements, the graduates’ claims that clinical supervision was not commonly practised leading to inadequate
competency acquisition. Mentoring is becoming an innovative form of teaching clinical skills in medical education that
allow improvements in the quality of internships [29]. Faculty as mentors can sure trainees acquire the needed skills
before they graduate. Curriculum developers are expected to design curricula and teaching/learning models that pro-
mote self-learning supported by competent mentors to make sure newly graduates have necessary abilities to provide
high-quality and evidence-based care. Acquisition of new knowledge and practice skills however require collaborative
eort [27, 30], which can only be promoted by committed faculty, clinical supervisors and students.
The clinical competency in terms of knowledge, skill, attitude and ability for safe and eective practice without supervi-
sion is considered as the nal outcome in medical education. The subpar clinical competency of nursing graduates was also
reported in studies in Europe where nursing graduates’ abilities for undertaking clinical skills were rated low. More than
30% of graduates performed poorly or very poor [31]. Clinical teachers or Clinical Supervisors who implement bedside
teaching can signicantly improve graduates’ performance [32]. The ndings of this study indicate that these strategies
are inadequately used for teaching medical and nursing students in the health training institutions in Tanzania. In the USA,
all nursing students reported a signicant increase in their condence with performing the competencies associated with
generalist nursing practice in the high dose simulation clinical teaching model from the program midpoint and end of

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the program [33]. In addition, a recent study proposes One-Minute Preceptor and Bedside presentations being among
the techniques for improving clinical teaching [32]. The reported inadequate communication between faculty and clinical
instructors in the present study appears to hinder students’ acquisition of clinical competencies. Eective communication
can complement clinical teaching through the promotion of a secured learning environment. The senior Australian nursing
students suggested that the development of a positive relationship with the clinical teaching sta was crucial in generating
the ideal clinical environment [34].
Consistent with ndings reported elsewhere [35], this study has indicated that medical graduates did not demonstrate
professionalism. Professionalism is the belief system in which group members (professionals) declare to each other and
the public the shared competency standards and ethical values to uphold in their work and what the public and individual
patients can and should expect from such professionals. These values can be demonstrated in various ways including high
standards of ethics, ability to work in a team, showing compassion for others, responding appropriately to the emotional
response of patients and family members, demonstrating respect for others, demonstrating a calm, compassionate and
helpful manner toward those in need and being supportive to others. These values also integrate principles of ethics that
are commonly taught in most medical schools in the world including Tanzania. At MUHAS for example, professionalism is
one of the nine competency domains of the competency-based curriculum for MD and Nursing programs. Why were the
graduates unable to demonstrate professionalism?? How is professionalism taught, reinforced, demonstrated, and assessed
in medical education? Studies have reported the challenging nature of teaching professionalism, how it is understood and
taught [36, 37] and others [38] thought that professionalism was given low priority in medical school curriculum. In the lit-
erature, it has been reported that class-room based approaches to teaching professionalism are misaligned with the nature
of professional practice [39]. Professionalism is commonly taught theoretically and it appears dicult to assess practically.
There is a need for medical training institutions to focus more on the abilities of the students to demonstrate professionalism
throughout training and ensure that professionalism becomes a key criterion for qualication. Researchers have proposed
ways in which professionalism can be taught in medical education including persuasive communication, case vignettes, role
plays, simulations, videotape reviews, role modelling, mentoring, hidden curriculum, reective practice, eective communica-
tion, work-based groups, and use of experienced facilitators who could role model and build trust in the groups [36, 40–42]
4.1 Strength andlimitations
This is the rst qualitative study to be conducted in Tanzania describing experiences of clinical teaching and learning among
medical and nursing graduates and their clinical supervisors. The study uncovered where interventions are most needed
to improve curriculum implementation delity and ensure that graduates acquire clinical competencies to provide quality
health care. The ndings emphasize use of leaner-centred approaches in teaching and learning. The study was conducted
with rigour. The use of Kiswahili language during data collection and analysis allowed the participants to speak freely and
made the researchers to stay close to participants own native language in identifying the meaning units and codes. The
triangulation of multiple sources of data from nurses, medical doctors and supervisors, and from three University teaching
hospitals increased trustworthiness of the ndings which is important in qualitative research [17, 43]. Further, validation of
codes and categories was achieved through dialogue with members of the research team and continuous reection and
revision of codes ensured accurate t [43]. The direct quotes from participants description of their experience of clinical learn-
ing and teaching are presented to allow the reader to ascertain the dependability of the study ndings. Nevertheless, there
are some limitations to this current study, ndings of the study were limited to only graduates and supervisors in teaching
hospitals, it is likely that those found in other nonteaching hospitals may have dierent experiences. Data was collected by
health care professionals teaching in the University, it is likely this had inuenced participants’ answers by under reporting
their experiences of learning and teaching. However, their openness, instant and consistent responses to the questions
and probes during interviews left little doubt that participants provided accurate experiences of their clinical learning and
teaching. We believe that these ndings do broaden our understanding of clinical teaching learning and are relevant in many
other settings of sub-Saharan Africa with context similar to that of Tanzania.
5 Conclusion
We conclude that logbooks, guidelines, and protocols are important tools to students’ acquisition of competencies dur-
ing clinical practice. However, clear guidelines and protocols were not adequately used in some medical universities. The
study revealed inadequate use of bedside teaching by faculty despite its importance in reinforcing clinical competencies.

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1 3
A need for faculty to make close supervision and mentorship was also appealed. It is also concluded that graduates who
were trained in universities that were not using CBC, lacked sucient communication skills. The study also revealed that
the majority of graduates lacked clinical skills, competency, condence, and commitment to work. The study has also
demonstrated a lack of professionalism in dierent aspects of clinical practice including demonstrating professional
dress code, respectful behaviour to seniors, and commitment and devotion for work among graduates.
Acknowledgements The authors would like to thank and acknowledge all the nursing and medical graduates and their clinical supervisors
who participated in this study.
Author contributions LTM, EAMT, DM and NS developed the concept of the study and the design, also organized and collected data. LTM,
EAMT, DAM, DM and NS did the data analysis and interpretation. LTM drafted the paper which was critically reviewed ET, DAM, DM, NS, HD,
RML NS and JMH. All authors read and approved the nal manuscript.
Funding This work was supportedthrough the Transforming Health Professions Education in Tanzania(THET)consortium,under the Health
Education Partnership Initiative (HEPI)Project, funded bytheNIH through the Fogarty International Centre, Grant No. IR25TWO11227-01.
Data availability Audio recorded interviews and discussions will not be shared because participants did not consent for the original informa-
tion to be published. However, the analysed data that has not participants identiers can be shared upon request from the coordinator THET
project, Muhimbili University of Health and Allied Sciences, PO Box65,001, Dar es Salaam, Tanzania. Email: drsirili@gmail.com.
Declarations
Ethics approval and consent to participate This study was conducted as part of quality improvement of nursing and medical training for the
Muhimbili University of Health and Allied Sciences (MUHAS) under THET project and therefore the study did not require approval from the
research ethics committee. Permission to interview intern doctor and nurse graduates and supervisors was sought from authorities and
employers at the three Teaching hospitals. All participants provided informed consent after they were informed about the purpose of the
study, the rights and benets of their participation.
Consent for publication Not applicable.
Competing of interests The authors declare no conict of interest.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article
are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in
the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ b y/4. 0/.
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