COLLEGE OF HEALTH SCIENCE department of anesthesia

Research proposal

Name of investigators Mihret Tedla, Yared Woldu, Meklit Selomon,

Biruk Belay, and Sifen Israel

Name of advisor …..

Full title of the research project The poor competency of students in AAU anesthesia
department in practical skill and knowledge and the
contributing factors

Duration of project March 20 to May 20, 2022 G.C

Study Area Anesthesia department, AAU

Total cost of the project

Contact of investigators

September 2021

i
The poor competency of students in AAU anesthesia
department in practical skill and knowledge and the
contributing factors

ii
Summary

Background: Since Anesthesia practice is a risky and hard profession, the whole training
and education process should be under strict focus, follow-up, and assessment with
upholding the psychological makeup of the student. But there are different factors that
hinder the anesthesia training from developing the practical knowledge and skill of
students. So, identifying those factors will help to solve a lot of problems in the field.

Objective: To assess the magnitude of poor competency of anesthesia students in the

AAU anesthesia department and associated factors.
Methods: Institutional based cross sectional study design will be applied from March 22
to June 31, 2021. At department of anesthesia, Addis Ababa university, Ethiopia.
Quantitative data analysis will be used using SPSS version 26.

Work plan and budget:

Keywords: poor competency/anesthesia/practical knowledge/ skill/AAU

i
ACKNOWLEDGEMENT
First and foremost, praises and thanks to the God, the Almighty,
for His showers of blessings throughout our personal and academic life
and also completion of this proposal successfully.
We would like to express our deep and sincere gratitude to our
instructor assistant Professor and deputy head of anesthesia department
in AAU college of health, for giving us the opportunity to do this research
proposal and providing invaluable guidance and mentor throughout class
lectures.
Finally, we would like to thank all the people who have given us
support information, sources and materials for this work.

ii
 CONTENTS
Summary.....................................................................................................................................................i
Acknowledgement.......................................................................................................................................ii
List of Tables..............................................................................................................................................v
List of figures.............................................................................................................................................v
Acronyms...................................................................................................................................................vi
1. Introduction...........................................................................................................................................1
1.1 Background information...........................................................................................................1
1.2 Statement of the problem.............................................................................................................2
1.3 Justification of the study..............................................................................................................3
2. Literature review.....................................................................................................................................4
2.1 Conceptual Framework......................................................................................................................8
3. Objective of the study..............................................................................................................................9
3.1 General objective...............................................................................................................................9
3.2Specific objective...............................................................................................................................9
4. Methods of the study.............................................................................................................................10
4.1 Study design and period...................................................................................................................10
4.2 Study area........................................................................................................................................10
4.3 Population........................................................................................................................................10
4.3.1 Source population.....................................................................................................................10
4.3.2 Study population.......................................................................................................................10
4.4 Sample size and Sampling technique...............................................................................................10
4.4.1 Sample size determination........................................................................................................10
4.4.2Sampling technique...................................................................................................................11
4.5 Inclusion and exclusion criteria.......................................................................................................11
4.5.1 Inclusion criteria.......................................................................................................................11
4.5.2 Exclusion criteria......................................................................................................................11
4.6 Variable of the study........................................................................................................................11
4.6.1 Dependent variable...................................................................................................................11
4.6.1 Independent variable................................................................................................................11
4.7 Data collection, analysis and quality control...................................................................................11
4.7.1 Data collection procedure.........................................................................................................11
4.7.2 Data quality control..................................................................................................................12

iii
 4.7.3 Data analysis.............................................................................................................................12
4.7.4 Operational definition...............................................................................................................12
4.7.5 Ethical consideration.................................................................................................................13
4.4.6 Dissemination of the research...................................................................................................13
5. Work plan and budget............................................................................................................................14
5.1 Work plan........................................................................................................................................14
5.2 Budget.............................................................................................................................................15
References.................................................................................................................................................16
Annex 1: Consent form (English Version)................................................................................................18
Annex 2: Conset form (Amharic Version).................................................................................................19
Annex: Questionnaire................................................................................................................................20

iv
LIST OF TABLES
Table 1: work plan
Table 2: budget breakdown

v
ACRONYMS

AAU: Addis Ababa university

MOH: Ministry of health
WHO: World health organization

vi
1. INTRODUCTION

1.1 Background information

Competence is defined as the ability to complete a certain task in an appealing manner. This
term implies the ability to apply knowledge and experience to current situations as well as
recognizable tasks. It has been stated that the ultimate purpose of health professional
education. It includes knowledge and information utilization abilities, communication,
problem solving, and technical skills. Clinical ability is at the heart of any health-care system
and is critical for the progress of the health-care system (1,2)

Low client satisfaction was reported in many health facilities, and inadequate skills among
health professionals were considered as a major factor [6]. Health systems cannot function
effectively without a sufficient number of skilled, motivated, and supported health workers
who display good work ethics at all times. (3)

Students’ competency is a global concern for all skill-based professions from accounting to
medical practice irrespective of the profession. There is an agreement that those who assess
practice are the gatekeepers of their profession; they and they alone determine whether the
practice they have observed is or is not up to the required standard. (4)

It is through experience in the clinical setting that students acquire the knowledge, skills, and
values essential to professional practice and become socialized into the profession. Clinical
experience is critically important to determine whether graduates can become competent
professional practitioners after completing their education. (2)

At the end of the training period, anesthesia students are expected to achieve the maximum
level of clinical competence after receiving necessary and adequate theoretical and practical
instructions. But previous researches show the level of competency of graduates and those
who are already on job is not up-to the required level.

A lot of questions occur about why this situation exists. Therefore, the purpose of this study
is to assess factors that contribute to the poor competency of anesthesia students at the
anesthesia department, Addis Ababa University, Ethiopia, throughout their academic level.

1
1.2 Statement of the problem
Anesthesia training in Ethiopia began in 1974 at Tikur Anbesa hospital by the ministry of
health (MOH) and the world health organization (WHO). Gradually it developed from a
diploma program to BSc and MSc; soon the Ph.D. program will begin. For those remarkable
changes and developments, the anesthesia department in AAU plays a great role.

The anesthesia education and training require strict follow-up, continuous guidance, and
evaluation. Since this profession is very risky, putting the patient between life and death in
good comfort, all students have to catch comprehensive knowledge, competent practical
skills, and vigilant attitude up to the standard. Having this as a goal, the anesthesia
department in AAU has received and trained a lot of anesthetists with good competency
while there are also incompetent and unconfident professionals.

Different researches were conducted on the performance of health professionals. For

example, the study conducted in 2013 GC on the performance of graduating students from
six public universities and colleges of Ethiopia shows that there is a varied percentage score
in practical skill and knowledge.
Students learning in AAU are supposed to have good opportunities and are expected to be
confident and competent. But, after some years back their competency has been decreasing.
This will affect the lives of students and also the patient gradually in the health care service
of the country.

Therefore, this study is intended to assess the magnitude of poor performance in both
undergraduate and master’s anesthesia students. As well as to identify factors contributing to
the decrement of their competence.

2
1.3 Justification of the study

Every field require good, competent and vigilant professionals. Aiming to achieve this goal
universities and colleges in our country have been training a lot of students in different
fields. Health science (specially anesthesia) is one of the critical field of studies which
require professionals who are competent enough practical skill and knowledge careful good
for patient and passionate.

Now a days health institutions (hospitals, clinics, health centers) are increasing in number
with advanced service and different health professionals, specialists and technicians. Along
with this the demand of our society for health service is also increasing. But not all
professionals have adequate knowledge and skill. There are also professionals working
without good understanding of the profession and what they do but has experienced routine
activities. This has a risk of endangering some one’s health and life.

Different studies were done on the competency of health professional and health student
graduates. But most are focusing on fields other than anesthesia. There are researches done
on the competence of anesthesia professionals and graduates. However most do not focus
from the root on students that has the chance to alleviate these problems

Doing this research will fill the evidence gap related to poor competency of anesthesia
students in their practical skill and knowledge and will provide a significant impact to
improve quality of education and training and in the long run improve quality of services. On
the other hand, it will be used as baseline for further research activities.

3
2. LITERATURE REVIEW
Cross sectional study was conducted in six regions in Ethiopia, where 92% of anesthetists
providing health care were found. Recently graduated anesthetists, who had been in
practice for 6 months to 5 years were included in the study.54 tasks were rated as being
highly critical task and 15 0f the tasks were not learned during pre -service education.
more than 10% of participants reported that they were unable to perform five of 54 these
highly critical task [CPR, patient management in ICU, evaluation of fitness for
anesthesia….]. Four of these tasks were also reported to be performed at a low frequency
and one of these tasks has been removed out of the scope of practice. Ideally, all highly
critical tasks should be covered in pre service education, ensuring that graduates can
proficiently perform the service on deployment.[1].[6]

Study conducted in 2013, assessed skills and knowledge of 122 graduating anesthesia
students at 6 public universities and collage. Higher education institution in the country
uses 60% as the cut-off score for competency exams- considering these as threshold to
judge students’ competence. The overall mean skills score across all OSCE stations was
61.5%. student competence varied across stations, with mean scores highest for spinal
anesthesia 79.5%, followed by neonatal resuscitation 74.4%, endotracheal intubation
72.8% and laryngeal mask airway insertion check 36.7% and preoperative screening
assessment 4.8%.[2][7]

In same study as above, less than 10 % of students believed that skills labs had adequate
staff and resources, but approximately half rated their instructors as effective 50.0% and
fair 48.4%. students rated the clinical practicum highest, but only 55.7% thought they had
received sufficient practical experience. RHSC students were significantly more likely
than university students to believe that preceptors were available at practicum sites. On
the top of this only 57.4% of graduates reported meeting the standard of performing
minimally 200 endotracheal intubations.{2}[8]

4
96 trainers from 9 public university and 17 regional health science collage in Ethiopia, were
selected for in depth interview to assess competency of graduating students. This study
highlighted that there is deficiency in learning environment limiting students from
developing core competency in anesthesia program and midwives’ program in Ethiopia.
Final evaluation showed that graduating anesthesia student scored 61% on an OSCE exam in
2016.perception of graduating student competency were largely based on observation.
internal assessment method, OSCE, to ensure competency before sending students to clinical
rotation. 83% of training programs said they had insufficient number of simulation
mannequins in skill labs. The other challenge was transportation problem to assign students
to institution where there is adequate case. And also, informants complained that regional
anesthesia was not covered in the curriculum.[3][9]

At Gonder and Bahirdar university cross sectional quantitative research was done to access
clinical competence among nursing students .regarding the learning and teaching process the
majority of the learning participants, 93.2% attended all theoretical classes ,80.3% attended
all demonstration classes and 92.3% attended all clinical practice.48.7% of the study
participants assumed them self as competent .and also in bivariate logistic regression
analysis , religion , job, social support, attendance , skill lab, were factors associated with
clinical competence.[4][10]

Full text definition for competencies were published in September 1999, followed by 10
years, three phase timeline for implementation. Outcome of these project along practice-
based learning and improvement shows that anesthesiology residents must be able to
investigate and evaluate their patient care practice, appraise and assimilate scientific
evidence and improve their patient care practice. and also indicated that mentorship and self
-reporting is good way of assessment. The other way to measure their competency is through
interpersonal and communication skill.in this case OSCE is the main weapon. However,
these is not proved and perhaps practice oral examination is considered as most potentially
useful to assess skill of communication. [5][11]

5
At hospital of sick children, university of Toronto, study was done about assessment of
procedural skills in anesthesia. Recently technology has advanced creating possibility of
standardized assessment of procedural skills. First being simulation center, which uses
virtual reality, simulate particular anatomical area. The success of outcome driven
simulation-based learning is potential to have a good impact on patients’ safety. The second
one is multiple station examination of procedural skills. OSACT were developed for the
purpose of assessing skill outside the OR. And it is almost similar to OSCI. Unfortunately,
OSACT is labor intensive and relatively expensive. For these reasons it is not used now a
day in anesthesia for assessment.[6][12]

In Dilla, institutional based study was done in 2016. Then finally they conclude that clinical
competency was 39%.the study shows that 95% CI of the student perceived them self as
clinically incompetent. These perceptions vary among different types of fields and year
study. Among different years students, competent student over clinical practice were
2(15.4%), 26(38.8%), 47(36.7%), and 30 (50.8%) from 2nd, 3rd, 4th and 5th year students
respectively. Whereas regarding their field of study 15(44.1%), 20(45.5%), 28(30.1%),
12(34.3%) and 30(49.2%) were competent over clinical practice from anesthesia, midwifery,
health officer, psychiatry and medicine fields of study, respectively.in the bivalent analysis,
instructor orientation, use of check list, giving of log book being related with clinical practice
competency at 5% level of significance (AOR=2.12, 95%CI =1.164-3.861). While in
multivariant analysis, receiving positive feedback from instructor consider themselves as
competent .and also student who have staff encouragement during practice were 2.6 times
more likely to perceive them self as competent than their counterparts
(AOR=2.608,95%CI=1.425-4.77) [7][13]

Also, at Mettu university a cross sectional study was done in 2019, finally pointing that
nursing students were inadequate. Majority of the participants said that student staff
interaction was poor. The study revealed that three fourth of participants were incompetents.
in bivariate analysis age, year of study, clinical practice placement an staff student
interaction were significantly associated with students clinical practice competence at
6
p<0.025. However, in multivariate analysis found only year of study and clinical practice
placements were associated with practice competency.4th year nursing students were almost
5% more likely competent than third year students. And students who had conductive
clinical practice environment were 2.7 times more likely clinically competent than their
counterpart.[8][14]

7
3. OBJECTIVE OF THE STUDY

3.1 General objective

• To assess the magnitude of poor competency of anesthesia students in the AAU

anesthesia department and associated factors.

3.2Specific objective
 To determine the magnitude of poor competency of anesthesia students in the AAU
anesthesia department.
 To identify the contributing factors.

8
4. METHODS OF THE STUDY

4.1 STUDY DESIGN AND PERIOD

Institutional based, cross sectional study design, study design will be conducted from
February 22 to May 31, 2021.
4.2 STUDY AREA

The study will be conducted at anesthesia department in AAU, Ethiopia,

{
4.3 POPULATION

4.3.1 SOURCE POPULATION

All students studying anesthesia in AAU college of health science

4.3.2 Study population

BSc students from third year and above and all MSc students in the 2021/22 academic year.

4.4 SAMPLE SIZE AND SAMPLING TECHNIQUE

4.4.1 SAMPLE SIZE DETERMINATION
The sample size will be computed using a single population proportion formula. There is a
study conducted in Ethiopia on perceived clinical practice competency in Bahir Dar and
Gondar Universities with population proportion of 0.48(). So; we will use this value as
population proportion in our study.

The sample size is calculated using the formula of n=(z∝/2)2 p q/ ε2. where, n = is the desired
sample size; z = is standard normal distribution usually set as 1.96 (corresponds to 95%
confidence level); p = population proportion.

d = degree of accuracy desired (marginal error is 5% (0.05)); then the sample size is
calculated as follows:

n= (1.96)2× (0.48×0.52)/ (0.05)2

=383.56=384

4.4.2Sampling technique
9
Considering there is no patient characteristic difference we will include pediatric patients
within the data collection period.

4.5 Inclusion and exclusion criteria

4.5.1 Inclusion criteria
All MSc students and BSc students who start anesthesia clinical practice.

4.5.2 EXCLUSION CRITERIA

 Students that study fields other than anesthesia

 Students that do not begin clinical practice

 First and second year BSc students
 Refusal to participate in the study

4.6 VARIABLE OF THE STUDY

4.6.1 DEPENDENT VARIABLE
 Poor competency

4.6.1 INDEPENDENT VARIABLE

 Socio-demographic variables: Age, Gender, level of study, stay in the field,

substance use and type, residency,
 Student related factors: Students’ perception toward the clinical teaching
environment, attendance on all lectures, attendance on all clinical practice
 Department related factors: clinical instructor factor, clinical placement factor,
assessment method factor and
 staff–student interaction factor


4.7 Data collection, analysis and quality control

4.7.1 DATA COLLECTION PROCEDURE

10
Data will be collected at Sefere Selam campus and different practical areas at which MSc
students are assigned by volunteer BSc students. Data will be collected by disseminating the
pretested structured questionnaire for every study subject and let them to answer the
questions through by self-administered method

4.7.2 Data quality control

The questionnaires will be pre tested and Data collectors will train for 6 hrs. on the
objectives of the study, sampling procedure, checking the completeness of questionnaires.
Every single data will be supervised by the investigators after collection. Furthermore, data
will be checked during entry into the computer before analysis.

4.7.3 DATA ANALYSIS

Data will be will be entered and analyzed by using statistical software SPSS version 20.
Model fitness will be checked. The association between the dependent and independent
variable will be using Binary Logistic Regression. For variable with p-value < 0.2 on binary
logistic regression will be entered to multiple regression. Results will be presented in graphs
and table.

4.7.4 Operational definition

Competency: are once ability of the student to integrate the skills, knowledge and attitudes
during in clinical practice
Clinical practice: is a complex and dynamic process in which students gain experience and
transform theoretical knowledge into practice in the clinical setting
Good clinical instructor: those instructors who fulfill at least 50% good clinical instructor
activities.
Conducive clinical practice environment: is a hospital or health center which the wards, the
staff, and the cases are incorporated at least 50% of conducive environmental factors.
A measurable assessment method is an assessment method that includes at least 50% of a
good assessment method.

11
 4.7.5 Ethical consideration
Ethical clearance will be obtained from the Institutional Review Board (IRB) of the College
of health science, Addis Ababa University. After explanation of aim and benefit of the study
written and verbally informed consent will be obtained from each study participant and their
confidentiality will be guaranteed throughout the study. Any personal identification of study
participants will not be recorded.

4.4.6 DISSEMINATION OF THE RESEARCH

The final result of research will be submitted to anesthesia department of AAU, peer
reviewed journal for publication and annual meeting of The Ethiopian Association of
Anesthetist (EAA) lastly it will be submitted to the repository of Addis Ababa University.

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5. WORK PLAN AND BUDGET
5.1 Work plan
Table 1 A Gantt chart is used to shows work plan

Activity Responsible Time out line

person
September October March April 2022 May 2022
2021 2021 2022

Topic Investigator
selection &advisor

Development Investigator
of proposal
Submission Investigator
of proposal to
advisor

Data Selected
collection Data
Collector
Data analysis Investigator
and report

Submission Investigator
of final
research
document

5.2 Budget
13
Table 2 Budge break down
No Item Amount Price
Birr Cent
1 Paper
2 Photo copy &
Printing
3 Flash Disk

4 Pen

5 Binding

6 Logistics

7 Cost for data

collector

Total price

14
REFERENCES

[1]. Reilly M, Oerman H, clinical teaching in nursing education; journal of nursing

education; 2OO7; 40(8):347353.
[2]. Federal Ministry of Health; Health sector strategic plan. Planning Programming,
Addis Ababa; 2004-2005; 20-30
[3] American Nurses Association (ANA); Continuing Competence: Nursing’s Agenda
for the 21st Century; Washington, DC: ANA; 2000
[4] Whiteford G. Autonomy, accountability, and professional practice. N Z J Occup
Ther. 2007;54(1):11–14.
[5] Sharon kibwana , Mihereteab Teshome , Leulayehu akalu education , practice and
competency gaps of anesthetists in ethiopia ; task analysis , journal of perianesthesia
nursing , 2017 p429-434
[6]. Sharon Kibwana, Damtew Woldemariam,Awoke Misganaw, Miheretab Teshome,
Preparing the health workforce in Ethiopia: A cross-sectional study of competence of
anesthesia graduating students , education for health,2016 p 3-5
[7] Sharon kibwana, Rachel haws, Adrienne kols ,nurse education today, trainers
perception of the learning environment and student competency ,Elsevier journal ,
2017 p6-8.
[8]. Berhanu boru bifftu, berihun assefa dachew,bewket tadesse tiruneh, perceived
clinical competence among undergraduate nursing students in the university of gonger
and bahirdar university , northwest ethiopia , hindawi publition coopration 2016 p3
[9]. John E. tetzlaff, M.D, assessment of competency in anesthesiology, 2007;106: p
816-819.
[10]. M.D. Bould,N .A. Crabtree and V .N. naik , assessment of procedural skills in
anesthesia , british journal of anesthesia , 2009, p479-478.
[11]. Tinsae Shemelise TesfayZ, Wagaye Alemu and Tadesse Mekonen, perceived
clinical practice competency and associated factors among undergraduate students of
medicine and health science collage in Dilla university, advances in medical education
and practice 2020, p134

15
[12] bonsa amsalu, tadele fekadu, ayelign mengesha , ebissa bayana, clinical practice
competence of mettu university nursing students, advances in medical education and
practice 2019,p794-795.

16
ANNEX 1: CONSENT FORM (ENGLISH VERSION)

ADDIS ABABA UNIVERSITY COLLEGE OF HEALTH SCIENCES

DEPARTMENT OF ANESTHESIA

I_____________________________ one of the members of study team for assessment of

incidence and associated factors with postoperative pain among pediatric patients following
abdominal surgery. This study will improve the quality of pediatric surgical and anesthetic
and will fill the information gap that exist in our hospital. This study will not cause any harm
to your child.
I_______________________________ give my consent to my child to participate in this
medical study or research. As long as me and mychild identity is kept secret and my
autonomy is guaranteed. I also agree to allow observers, technical representatives and
participants in the operating room.

Signatures
My signature below means that:
• I have read and understand this consent form.
• I have been given all the information I asked for about the medical study undergone.
• All my questions were answered.
• I agree to everything explained above.
Parent’s Signature: _______________
Date signed_____________________

17
ANNEX 2: CONSET FORM (AMHARIC VERSION)
እኔ_____________________እባላለሁ የዚህ ጥናት አባል ነኝ፡፡ እርስዎም ፈቃደኛ ከሆኑ በዚህ ጥናት እንዲሳተፉ
ተመርጠዋል፡፡ ጥናቱ በትክክል አላማውን እንዲመታ የእርሶዎን ድጋፋና ተሳትፎ ጉልህ ሚና አለው፡፡ በዚህ ጥናት ወቅት
የማንኛውም ግለሰብ ስም አይመዘገብም እንዲሁም ሀሳቡ ብቻውን ይፋ እንዲዎጣ አይደረግም፡፡ ሙሉበሙሉ በሚስጥር
የተጠበቀ ነው፡፡ በጥናቱ የመሳተፍም ሆነ አለመሳተፍ ሙሉ መብት አለዎት፡፡ ነገር ግን በዚህ ጥናት በመሳተፍዎ
የሚገኘው መረጃ ውጤትን በማጠናከር አሁን ከሚሰራበት ዘዴ ጋር ማገናዘብና ለወደፊትም አቅጣጫዎችን ለማስቀመጥ
ይጠቅማል፡፡ ግልፅ የሆነምላሽንና ከልብ የመነጨ ተሳትፎዎን እንዲሰጡኝ በአክብሮት እጠይቃላሁ፡፡
ለመሳተፍ ፈቃደኛ ነዎት?
ሀ/ አዎ: ፊርማ__________________ (ጥናቱ መቀጠል ይቻላል)
ለ/ አይደለሁም(ጥናቱ ይቁም)
ጥናቱ የሚካሄድበት ቀን፡__________
የጠያቂው ስምና ፊርማ:_____________
በጥናቱ ዙሪያ ለበለጠ መረጃ ተማራማሪዉን በሚከተለው አደራሻ መጠየቅ ይችላሉ፡፡

18
 ANNEX: QUESTIONNAIRE

Socio Age
Gender Male
demographic
Female
Level of study Undergraduate Third year
Fourth year
Postgraduate First year
Second year
Substance use Yes Chat
Alcohol
Cigarette
other
No
Residency Dormitory
Home
Other: -----------------------------
Student related Student’s perception towards Good
Moderate
factor the anesthesia
Not well
Attendance on all lectures Yes
No
Attendance on all clinical Yes
No
practice

Department Clinical instructor factor Frequency they come Always

related factor to clinical practice area Sometimes

Never

Assist on clinical Yes

practice
No

19
 Create good Yes
environment for practice
No
Yes
Staff monitor students
No
Placement factor Conducive environment
Not conducive environment
Assessment method Oriented
Not oriented
Availability of skill lab after Easily available
theoretical class difficult but available
Not available

Student’s Preoperative Very confident

skill assessment Confident
Less confident
General Preparation Very confident
anesthesia Confident
Less confident
Induction Very confident
Confident
Less confident
Intubation Very confident
20
 Confident
Less confident
Extubation Very confident
Confident
Less confident
Bag mask Very confident
ventilation Confident
Less confident
Others
Regional Spinal Very confident
anesthesia anesthesia Confident
Less confident
Epidural Very confident
anesthesia Confident
Less confident
Peripheral Very confident
nerve block Confident
Less confident

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