Internship Situation Analysis Survey Report

Internship Situation Analysis Survey Report Page 01
Makerere University College Of Health Sciences

Internship Situation Analysis Survey Report
By
Makerere University “Health Professions Education And Training For
Strengthening The Health System And Services In Uganda” Project
May 2022

CONTENTS
ACKNOWLEDGEMENT............................................................................................................................................... 4
ACRONYMS:..................................................................................................................................................................... 5
List of tables....................................................................................................................................................................... 6
List of figures..................................................................................................................................................................... 6
Foreword............................................................................................................................................................................. 8
Message from the HEPI-SHUU Principal Investigator......................................................................................... 9
Introduction..................................................................................................................................................................... 11
Methods:............................................................................................................................................................................ 12
Study design................................................................................................................................................................ 12
Study sites.................................................................................................................................................................... 12
Study population........................................................................................................................................................ 12
Sample size calculation for the quantitative survey:..................................................................................12
Sample size considerations for the qualitative survey:..............................................................................13
Survey instruments...................................................................................................................................................13
Data collection:.......................................................................................................................................................... 14
Pre-testing:.................................................................................................................................................................. 16
Data collection implementation:..........................................................................................................................16
Data Analysis:.............................................................................................................................................................. 17
Ethics:............................................................................................................................................................................ 17
A.1 Quantitative results:................................................................................................................................................18
A1a Descriptive information about the respondents..............................................................................................18
A.1b Stress levels, and stressors and finances..........................................................................................................19
A.1c Finances............................................................................................................................................................. 21
A.1d Time and workload...........................................................................................................................................23
A.1e Tasks and training..............................................................................................................................................24
A.1.j Perception of the supervision and the site......................................................................................................32
A.2. Model to predict perceived stress scores of the interns.....................................................................................34
Overall Conclusions and Recommendations:........................................................................................................45
Annex 1: Enumerators’ List.........................................................................................................................................47
Annex 2: Tasks and Competencies.....................................................................................................................................48
References........................................................................................................................................................................ 53
Citation:
Munabi IG., Mubuuke AG., Opoka R., Mukunya D., Kateete D., Nalugo-Mbalinda S., Ssentongo KG,. Kiguli
S., Internship Situation Analysis Survey Report. College of Health Sciences: Makerere University (Uganda);
2022 May. 56 p. Report No. 001
http://hdl.handle.net/10570/10424

ACKNOWLEDGEMENT
Research reported in this publication was supported by the Fogarty International Center of the National
Institutes of Health, U.S. Department of State’s Office of the U.S. Global AIDS Coordinator and Health
Diplomacy (S/GAC), and President’s Emergency Plan for AIDS Relief (PEPFAR) under Award Number
1R25TW011213. The content is solely the responsibility of the authors and does not necessarily represent
the official views of the National Institutes of Health.”

ACRONYMS:
HEPI-SHUU Health Professions Education and training for strengthening the health system and
services in Uganda
KIU Kampala International University
Pnfps Private Not for Profits
RAs Research Assistants
RRH Regional Referral Hospital
UCH Uganda Chartered HealthNet
UMDPC Uganda Medical Dental Practitioners Council

LIST OF TABLES
Table 1: Sample size estimation for the qualitative arm....................................................................................................13
Table 2: Qualitative arm issues covered in the guides......................................................................................................13
Table 3: Descriptive statistics of the participants in the quantitative arm.......................................................................18
Table 4: Summary of the scores from the perceived stress scores tool.........................................................................19
Table 5: Major stressors and ways of handling stress by the respondents......................................................................21
Table 6: Reported monthly expenditures in Uganda shillings..........................................................................................22
Table 7: Summary of the workload and time indicators...................................................................................................23
Table 8: Comparisons of time and workload by gender...................................................................................................23
Table 9: Scores for the work engagement questionnaire.................................................................................................26
Table 10: Scores from the work, effort, reward validated questionnaire.........................................................................28
Table 11: Perception of the internship site as a learning environment............................................................................30
Table 12: Covid-19 illness perception................................................................................................................................31
Table 13: Interns’ perceptions of supervision and the site...............................................................................................32
Table 14: Ratings on resources intense skills exposure and available resources for the interns...................................33
Table 15: Structural equation modeling estimated total effects.......................................................................................34
Table 16: Structural equation modeling indirect effects...................................................................................................35
Table 17: Summary of the key themes from the qualitative data.....................................................................................36
LIST OF FIGURES
Figure 1: Research assistants being trained on the data collection tools use.................................................................19
Figure 2: Research assistants interviewing intern doctors during pretesting..................................................................21
Figure 3: Perceived stress scores according to gender.....................................................................................................25
Figure 4: Reported monthly expenditure according to gender.......................................................................................27
Figure 5: self-reported rating of how well different tasks were performed before and during internship...................30
Figure 6: Multinomial Regression of self-assessment by region for each training phase................................................31
Figure 7: Work engagement domain scores by gender for the different regions in the country..................................33
Figure 8: Work effort reward imbalance by gender across the different parts of the country.....................................35
Figure 9: Domain scores of the internship site as a learning environment by gender...................................................36

INVESTIGATORS
Prof Kiguli Sarah Dr. Roy Mubuuke Dr. Ian Munabi, Dr. David Mukunya,
Gonzaga,
MBChB, MMed. MBChB, Msc. Anatomy, MBChB, M. Phil, PhD
Pediatrics & Child MSc, MSc. HPE, PhD, Msc. HPE, PhD is a is a Senior Lecturer,
Health, Faimer Fellow, Fellow-Bioethics, FAIMER Senior Lecturer in Faculty of Health
MHPE is a Professor Fellow is a Lecturer in the Department of Sciences, Busitema
in the Department of the Department of Human Anatomy, University (Co-
Paediatrics & Child Radiology, School of School of Biomedical investigator)
Health, School of Medicine, Makerere Sciences, Makerere
Medicine, Makerere University (Co- University (Co-
University (Principal investigator) investigator)
Investigator)
Dr. David Kateete, Dr. Scovia Nalugo Associate Prof Dr Katumba

Mbalinda, Robert Opika Ssentongo Gubala
B.Vet. Med, MSc, Ph.D. Opoka
is a Senior Lecturer BScN, MSc, Ph.D. is DDS MPH, MBA is
in the Department currently a Lecturer MBChB, MMed. a Registrar, Uganda
Medical Dental
of Immunology & in the Department Pediatrics & Child
Practitioners Council
Molecular Biology, of Nursing, School Health, Ph.D. is an (Co-investigator)
School of Biomedical of Health Sciences, associate Professor
Sciences, Makerere Makerere University in the Department of
University (Co- (Co-investigator) Paediatrics & Child
investigator) Health, School of
Medicine, Makerere
University (Co-
investigator)

FOREWORD
I am delighted to write the foreword for this report on the

current situation of the internship program in Uganda at a
time when the country is going through several unprecedented
challenges due to, among others, the ongoing COVID-19
pandemic. The internship program remains a core aspect of
Uganda’s pre-registration or licensure training for health
workers joining the health care system.The training is, in addition,
a critical quality control measure for the UMDPC in its efforts
to assure the public of quality health service provision. As such,
there are many expectations from the different stakeholders,
who include patients, health system managers and society, on
how well trained the interns are and whether they will have
the necessary competencies needed to address the health-
related challenges in the region.
The situational analysis undertaken by the team from the
Makerere HEPI-SHUU project is a welcome step in identifying
opportunities to strengthen the internship program in Uganda.
The study findings were presented to various stakeholders
within the UMDPC fraternity, who have all concurred with the
findings of the team. This is very important and supports the
UMDPC emphasis on evidence-based interventions to improve
all aspects of its activities and mandate to the people of Uganda.
As such, we welcome all support in such initiatives and offer
to mobilise all stakeholders, including the various government
agencies and institutions of higher learning to ensure that
the internship experience is one that is both world-class and
uniform for all interns participating in the program.
I would like to take this opportunity to thank the Federal
Government of the United States of America through its
National Institutes of Health for providing the support given
to Makerere University through the HEPI-SHUU project to
complete this exercise successfully. As we read this report,
let us all make an effort to address the recommendations
proposed as we strive to improve the internship experience
for all health workers.
Government of United States of America through its National
Institutes of Health for providing the support given to Makerere
University through the HEPI-SHUU project to successfully
complete this exercise. As we read this report, let us all make
Dr. Katumba effort to address the recommendations proposed as we strive
Ssentongo Gubala to improve the internship experience for all health workers.
Registrar, Uganda
Medical Dental
Practitioners Council

Message from the
HEPI-SHUU PRINCIPAL
INVESTIGATOR
As the Principal investigator for the HEPI-SHUU project and

a medical educator in Uganda, I am delighted to be associated
with this report on the current situation of the internship
program in Uganda. The internship program remains a core
aspect of Uganda’s pre-registration or licensure training for
health workers joining the health care system. The internship
training in Uganda relies heavily on the use of the apprentice
model to encourage work-based learning through an immersive
experience with guidance provided by a site supervisor. The
internship training is also a critical final quality control pre-
licensure step for health workers in Uganda. The situational
analysis that was undertaken as part of the Makerere HEPI-
SHUU project is a welcome step in the process of identifying
opportunities to strengthen the internship program in Uganda.
As medical educators, we are pleased to support the council
in its efforts to identify opportunities for evidence-based
interventions to improve health service provision in Uganda.
This is an effort of Makerere University to become an innovative
knowledge hub for the communities it serves within sub-Saharan
Africa. We hope that the findings and recommendations of this
report will support the UMDPC to ensure that the internship
experience is both world-class and uniform for all interns
participating in the program.
Government of the United States of America through its
National Institutes of Health for providing the support given
to Makerere University through the HEPI-SHUU project to
successfully complete this exercise.
Prof. Kiguli Sarah

HEPI-SHUU, Principal
Investigator
Makerere University
College of Health
Sciences

EXECUTIVE SUMMARY
Internship is a mandatory pre-registration training required for licensure of doctors in Uganda. During the
internship, medical workers acquire practical skills, attitudes and knowledge critical for them to work without
supervision. This is when they also acquire skills of working in inter-professional teams to deliver quality
health care services to the population. In addition, it is presumed that the internship experiences outside the
mainstream teaching hospitals prepare these interns for the real-life work experiences that they are likely
to encounter. However, the experiences of the interns and their perceived quality of internship in Uganda
have never been described. Knowledge of the experiences of interns and their perceived quality is crucial in
the design of interventions and formulation of policies aimed at improving internships and subsequently the
quality of health workers. Cognizant of the need to improve the internship experience in Uganda, Makerere
University College of Health Sciences (MakCHS) in collaboration with the Uganda Medical and Dental
Practitioners Council (UMDPC) under the auspices of the HEPI-NIH Project, conducted a comprehensive
study to tap into the experiences of interns while on duty in the various internship placement sites. The
primary focus of the study was to explore and assess the experiences of the interns and the perspectives
of their supervisors with the aim of identifying the strengths of the current internship program, challenges,
weaknesses, and gaps and suggestions for improvement.
This was a cross-sectional study that utilized both qualitative and quantitative approaches to capture feedback
from interns (2019 to 2020 cohort) about their experiences at the various internship sites in Uganda. A
total of 499 interns participated in the study. The interns were from 23 internship sites including regional
referral public hospitals, teaching hospitals and private hospitals that usually host interns from various parts
of Uganda. This wide inclusion of various hospitals in the country provided a 3600 rigorous analysis of the
experiences of interns, which generally reflects the picture for the whole country.
Analysis of the findings indicated that the interns generally liked the internship training and rated the internship
as a very good training period for them to master clinical skills. They generally reported having high levels
of work engagement with limited time for engaging in social activities. The supervisors generally reported
that the quality of interns is fair apart from occasional deficiencies in some clinical skills and other generic
skills such as communication, teamwork, leadership, and interpersonal skills. In addition, some interns had
a deficiency in clinical skills required for internship training. Despite this positive outlook, there are still
major gaps in the current internship program. It should be noted that in some cases, there was inadequate
equipment, supplies and materials to use during the internship training. The supervisors were not available or
provided inadequate support and the inadequate exposure to skills training opportunities, especially during
the surgical rotations. The interns also reported high levels of stress, though the quality of supervision and
mentorship while at the sites was a major moderator of their overall experience. The study overall revealed
a lack of standardization regarding the duration spent in each clinical rotation, internship supervision and
assessment of competence across the various sites. Overall, we strongly recommend the development of a
standardized internship program to guide both interns and supervisors at the various sites.

INTRODUCTION
According to the March 2021 Ministry of health Uganda Human Resource for Health Strategic Plan, it is
noted that despite the gains made in health workforce improvement in the past fifteen years between 2005
and 2020, the health workforce coverage remains inequitable and insufficient for achieving Universal Health
Coverage (UHC) and health goals. Over the last 12 years, there has been an overall increase in health
workforce numbers from about 45,000 in 2008 to about 118,236 in 2020. The current health workforce
density of 1.6 per 1,000 falls far short of the 4.45 per 1,000 population WHO threshold for progress towards
UHC. If 38% of the 74% of health workers are absent, then in reality, on average, only about 46% of the health
workers in employment are present at the health facility at any one time.
According to this plan, using projections based on the staffing standards of MoH, Uganda Health Labor
Market Analysis (2019), HRH Staff Audit Report (2018), and the planned health service changes in the HSDPII
(2020/21-2024/25) the total staff required to fill the staffing norms for both public and private sectors in
2020 is 118,521, and 128,286 in 2025. The total additional staff required to fill the staffing norms in 2020 for
both public and private sectors is 32,158.The total additional staff required to fill the staffing norms for both
private and public sectors in 2025 is 9,765.Therefore, the total new public and private sector staff required by
2025 are 41,923. The achievement of the HSDPII health workforce density target of 2.3 per 1000 population
by 2025 will require a total of 87,571 health workers. The public health staffing for the health professionals
will have to increase from 24,085 in 2020 to 101,540 in 2030 to achieve a health workforce density of 4.45
per 1000 population. The total number of new health workers to be recruited by the public health sector
over the next 10 years is 88,216, including an allowance for attrition at an average of about 4.8%.
The UMDPC is a key stakeholder in the implementation of this plan, whose main outcome is a well-
performing health workforce that is critical for the attainment of the Health Sector Development Plan II
goal “To accelerate movement towards UHC with focus on Primary Health Care (PHC) and improve
population health, safety and management by 2025,” and for effective contribution to the NDP III
Capital Development Program aimed “to increase the productivity of the population for increased
competitiveness and better quality of life for all”. It is recognized that the health workforce challenges
constitute a major impediment to meeting the current and future health needs of the people of Uganda. The
HRH Strategic Plan 2020-2030 aim to set the direction for the health sector and communicate the health
workforce goals and the actions needed to achieve those goals, building on the gains and lessons learned
from the HRH Strategic Plan 2005-2020. Specifically, HRH Strategic plan 2020-2030 provides a framework
for rationalization and coordination of HRH investments to enhance UHC capacity . It also provides a
framework for management and accountability for HRH, as well as benchmarks and targets for monitoring
the implementation of vital HRH programs for the realization of national health goals.
To inform the councils’ internship related activities in the above human resource for the health sector plan,
UMDPC partnered with Makerere University College of Health Sciences, HEPI-SHUU project, to conduct
a situational analysis of the current internship program. The goal of the situational analysis was to help
stakeholders understand the good aspects, challenges, costs, benefits, suggestions for improvement and other
aspects of doing internship in Uganda.This is especially important given the emphasis placed on strengthening
the internship training for the success of the above health sector plan.The study used qualitative and quantitative
methods of acquiring information through a series of friendly discussions with intern doctors, dentists, nurses
at a bachelor’s level, hospital directors or administrators, supervisors, patients, and caregivers. These friendly
discussions generated information that is useful in strengthening the internship training in the country. Strong
aspects of the program were identified, and we argue that these should be maintained. However, challenges
and suggestions for improvement were also identified that need to be addressed to further strengthen and
lead to a uniform internship experience for all.
The study was conducted in four regions of Uganda: Central, Eastern, Western and Northern, for a balanced
understanding of the situation across the country. Referral Hospitals and Private Not for Profit Hospitals
were sampled according to the list of internship deployment sites provided by the Registrar of the UMDPC.

METHODS:
Study design
This was a cross sectional survey that used both qualitative and quantitative methods to capture feedback
from interns (2019 to 2020 cohort) about their internship experience at various internship sites in Uganda.
Study sites
The sites visited in the survey included: Mbarara Regional Referral Hospital (RRH), Masaka RRH, Kitovu
Hospital, Mityana General Hospital, Kampala International University (KIU) teaching Hospital, Bushenyi,
Hoima RRH, Mubende RRH, Gulu RRH, Arua RRH, Lira RRH, Lacor Hospital, Bombo Military Hospital, Mengo
Hospital, Lubaga Hospital, Naguru Hospital, Nsambya Hospital, Mulago National Referral; Mulago, Kiruddu and
Kawempe, Jinja RRH, Soroti RRH, Mbale RRH, and Iganga Hospital.
Study population
The study population for both the qualitative and the quantitative arms of the study were the medical, dental
and nursing interns undergoing their mandatory one-year pre-licensure internship. Included in the survey
were the interns found at the sites at the time the survey team visited the selected internship training
hospitals. We excluded from the survey any interns that were unable to participate for reasons that included
non-cooperation of the hospital administration or at sites where there was an increased risk of exposure
to the COVID-19 virus. At the time of the survey, the interns remained with only 12 days to complete their
one year of hands-on internship training.The qualitative arm of the survey adopted a 360-degree approach to
explore the intern’s experience through purposively targeting the intern’s supervisors, a purposively selected
set of patient representatives, and a focus group discussion with the interns at each site. Efforts were made
to ensure that the interns did not take part in both the quantitative and qualitative arms of the study.
Sample size calculation for the quantitative survey:

Using an online sample size calculator (www.openepi.com) for sample sizes based on proportions for the
following assumptions: hypothesized proportion of observation in the study population 50%, precision 5%,
design effect of 1.5 for a finite population of 1500 interns, power of 0.95 and alpha 0.05 to give a sample
size of 459. This included a 10% allowance for non-response to give a final sample target sample size of 505
participants. A consecutive sampling strategy was used till the time for the survey had expired (12 days).
Sample size considerations for the qualitative survey:

As shown in table 1, the target sample size for the qualitative arm was restricted to the different study groups.
Table 1: Sample size estimation for the qualitative arm
KII-CHAIRPERSON AND SUPERVISORS AND

GROUP PATIENTS FGDS
ADMIN NURSES
Chairperson =1 Supervisors= 10 6 (each 6 – 8
Number Patients =12
Director/admin=5 Nurse in charge=6 interns max 48)
Supervisors per site = 2 Mulago = 4 (1

(1-med/1-surg) each discipline) Mulago =
2(surgical-1 med-1)
Distribution 1-per site (total 6) Nurses mulago = 2 Other site = 2
(1-med/1-surg) (8 total) Other sites each
1(total 4)
Nurses’ others=1 (Half female)

Survey instruments
The survey instrument, included in appendix 2, was divided into different sections corresponding to different
validated tools to capture data on the following items: descriptive information 1, feelings, thoughts and stress1-6,
cost of living, schedules, the content of their undergraduate training and skills acquired during internship7,
work and wellbeing8-14, work at the site15-22, working environment23, intent to remain in the profession24,
experience of being supervised24 and the experience of COVID-1925.
For the qualitative arm of the survey, the interview guides were designed to capture the following issues.
Table 2: Qualitative arm issues covered in the guides
SUPERVISORS
KII-CHAIRPERSON
GROUP AND NURSE IN PATIENTS FGDS
AND ADMIN
CHARGE
Deployment process:
Induction of interns Satisfaction with Quality: induction,
Quality: skills,
Issue 1 Choices of place, being treated by supervision, feedback,
comparisons
discipline interns attitude, evaluation
Finances(pay)
Welfare
Accommodation
communication Expectations and reality-gap
Issue 2 Meals welfare
(Patient consent): analysis
Leisure facilities
Duty rooms
Challenges: accommodation,
pay.
Quality of interns Handling
Attitude: work, Self-assessment of
Competency in both (explanation,
patient care… competency at beginning,
technical and non- safety) themselves
Issue 3 Competency end
technical and others,
Ability to learn Preparation for internship by
Ability to learn especially the
Teamwork medical school
Competency at end elderly/vulnerable
Opportunities to learn
Self-assessment
Numbers
Respect: for
Vis v resources, Their own training
the patient,
Issue 4 e.g., equipment, as supervisors, work environment
themselves,
infrastructure, patients’ assessment
colleagues…
supervision ability
Who do they pick

Difference
Challenges with the competencies (ethics,
Issue 5 Number between them and
program leadership, mentorship,
the others
procedural skills) from?
Issue 6 Covid-19 Covid-19

DATA COLLECTION:
Pre-internship training
Challenges of preparation (skills, culture
Issue 7 Supervision
supervision shock, knowledge, death,
ethics, communication)
There were four (4) major tasks during data collection:

1. Digitizing the paper form using Open Data Kit (ODK): One survey questionnaire was developed
electronically using ODK gather platform to be administered during the survey. This electronic tool
named: Intern_Situation_V5 was uploaded to the server. Details on how to access data on the server
were all provided to the designated personnel to handle data.
2. Device preparation and loading of forms: UCH installed the electronic data tools on 25 galaxy
tablets, and took part in the paper-based training of the questionnaire to note required changes which
were then incorporated into the electronic tool for upgrade.
3. Recruitment & User Training: The team comprised of 34 Enumerators who were degree holders
and have been conducting research activities for a minimum of three years. The enumerators were
identified and shortlisted by Uganda Chartered HealthNet.
Figure 1: Research assistants being trained on the data collection tools to use

It was a three-day training which was conducted at UCH offices from the 17th to 19th of September
2020. The training was conducted by Dr. Ian Munabi, Dr. Mworozi and Patrick Kibaya, who took
the enumerators through the key aspects of the project and the data collection tool. During the
entire training period, COVID-19 SOPs of sanitizing, wearing masks, and social distancing was strongly
adhered to.
OBJECTIVES OF THE TRAINING:

The training was aimed at equipping the research team (Enumerators) with the necessary skills to enable
them to undertake the Internship Situation Analysis assessment. The specific objectives were;
1. To train/orient the Enumerators on the Project, its objectives and intended outcomes
2. To train and orient the Enumerators on the methodology for undertaking the survey
3. To validate the data collection instrument on both papers and electronically using Samsung tablet
computers.
METHODOLOGY - CONDUCT OF THE TRAINING:

Throughout the entire training process, the trainers used a participatory and interactive approach to conduct
it. This enabled the enumerators to explicitly understand the objectives of the survey and the data collection
instruments.The qualitative team was trained independently from the quantitative team after the introduction
of the project and its objectives
ISSUES COVERED DURING THE TRAINING:

During the training, various issues were covered, including the following.
1. Objectives of the survey: the trainer ensured that the enumerators clearly understood why the survey
was being undertaken and what it intended to achieve.
2. Data collection tool: through a participatory approach, the trainer went through the data collection
instruments with enumerators and, by consensus, agreed on how to handle the different sections of
the questionnaire.
3. Assimilation: enumerators were paired in groups of two and conducted mock interviews to check
the flow of the questionnaire on tablet computers and familiarized themselves with the tool on tablet
computers.
4. Adherence to Ethical Standards: the enumerators were taken through the ethical standards to
be adhered to when conducting field work. More emphasis was put on seeking consent from the
respondents where the content of the consent form had to be read to respondents, and then after,
they could consent.
5. Target respondents: Enumerators were trained on the target respondents to interview as intern
doctors, pharmacists, and nurses at a bachelor’s degree level.
PRE-TESTING:
Pretesting of the tool was carried out on the 20th of September 2020 at Mulago National Referral hospital in
the Stanfield Children’s ward with six intern doctors. The team was divided up into a group of 5 to interview
one intern doctor following all the research protocols as per the training. This helped enumerators manage
expectations to be met in the field and also have a better understanding of the tool prior to the actual data
collection.
Figure 2: Research assistants interviewing intern doctors during pretesting
DATA COLLECTION IMPLEMENTATION:

Data collection activity was carried out for 12 days from 20th September 2020 to 1st October 2020.
A composition of 34 enumerators was divided up into five groups of five quantitative enumerators and two
qualitative enumerators to cover a sample size of 505 medical interns and 34 Key Informants plus six Focus
Group Discussions.
To be able to complete the survey within the specified number of 12 days, the five groups took different
routes according to the route directions of the sampled 24 hospitals as per the list provided by the registrar
UMDPC.
Courtesy calls to the administrations were mandatory as a way of observing entry point protocols to the
hospitals. During the courtesy calls, an introduction letter of the teams from the Registrar UMDPC was
presented, stamped and a copy given back to the team for presentation to the in charge of intern doctors.
Friendly interviews were conducted using electronic devices and paper tools to manage time since most of
the interviews started after 2: 00 pm.
DATA ANALYSIS:
Quantitative data: the data were entered in real time and exported as CSV file for further analysis in the R
statistical computing environment.The results that were reported using various descriptive statistics and odd
ratios have been summarized in tables and charts according to the different questionnaire sections. A value
of 0.05 was used as the cut off for significance for all statistical tests.
Qualitative: All interviews were audio-recorded with the consent of the research participants. Each interview
had a moderator one observer/note taker. The note taker summarized the major ideas that arose from the
interviews and discussions that were used to partly validate data after transcription of the audio clips. A
preliminary code book was created with broad categories. One of each of the different stakeholder group
transcripts was coded independently by two coders before coding the remaining transcripts. Differences in

coding were resolved by consensus. New codes were added to the code book as needed. NVivo software
will be used for data coding, deriving primary and secondary nodes. After all, transcripts were coded, the
investigators reviewed all codes to identify dominant themes. Representative verbatim comments were
selected for presentation.
ETHICS:
The study was a low-risk study involving anonymous data collection on various educational activities at the
different sites. This was part of the baseline evaluation for the HEPI-SSHU project that had received IRB
clearance from the school of medicine IRB (REC REF 2019-007). All participants gave their informed consent
to participate in the study and , received a total of 20,000 UGX compensation for their time in participating
in the survey.
RESULTS:
A.1 Quantitative results:
A1a Descriptive information about the respondents

One of the study sites declined to participate in this survey due to concerns about COVID-19. The survey
recruited 499 interns instead of the targeted 505. Table 1 provides a summary of the descriptive statistics of
the participants.
Table 3: Descriptive statistics of the participants in the quantitative arm
Variable Overall (N.499)
Age in Years
Mean (SD) 28.71 (5.23)
Range 22.00 - 57.00
Sex of the participant
Male 276 (55.3%)
Female 223 (44.7%)
Current marital status
Single 355 (71.1%)
Cohabiting 27 (5.4%)
Married 116 (23.2%)
Divorced 1 (0.2%)
Living with partner
Yes 84 (16.8%)
No 415 (83.2%)
Do you have Children or dependents
Yes 248 (49.7%)
No 251 (50.3%)
Housing Status
Living with parents 21 (4.2%)
Shared apartment with fellow interns 95 (19.0%)
Living in a hospital unit 170 (34.1%)
Living in a rental unit with a partner 35 (7.0%)
Living alone in a rented unit 150 (30.1%)
Stay in your own home 21 (4.2%)

Other 7 (1.4%)
For how long you have been at this site in

months
Mean (SD) 11.7 (1.3)

Range 1.0 - 17.0
Have all your rotations been at this
current internship site
Yes 390 (78.2%)
No 109 (21.8%)
In Table 3 it is important to note that only 170/499 (34.1%) of the interns were living in a hospital-owned
facility. Female interns were significantly more likely than male interns to be living with their parents (OR =
4.25 95% CI 1.57 to 14.77 p. value <0.01). There were significantly fewer female interns sharing apartments
with fellow interns (OR = 0.16, 95% CI 0.04 to 0.46, p. value <0.01), living in a hospital unit (OR = 0.12, 95%
CI 0.03 to 0.33, p. value <0.01), living in a rental unit with a partner (OR = 0.28, 95% CI 0.07 to 0.94, p. value
<0.05), and living alone in a rented unit (OR = 0.22, 95% CI 0.06 to 0.62, p. value <0.01) compared with
female interns living at home with their parents. For every unit increase in the age of the respondents, the
odds of having dependents significantly reduced by 26% (OR = 0.74, P-value <0.01). Compared with male
respondents, the female respondents were significantly less likely to have dependents or children (OR = 0.67,
P-value = 0.03). Participants who had not completed all their rotations at the interview site were less likely
to have children or dependents (OR = 0.84, 95% CI 0.55 to 1.28, p. value = 0.41).
A.1b Stress levels, and stressors and finances

Section B of the tool was derived from the validated perceived stress score tool version 10 (PSS-10) which
has six out of the ten items considered negative (B1, B2, B3, B6, B9, B10) and the remaining four as positive
(B4, B5, B7, B8), representing perceived helplessness and self-efficacy, respectively. Each item was rated on a
five-point Likert-type scale (0 = never to 4 = very often). Total scores are calculated after reversing positive
items’ scores and then summing up all scores. Total scores for PSS-10 range from 0 to 40. A higher score
indicates greater stress.
Table 4: Summary of the scores from the perceived stress scores tool
No. Question Mean (SD) Range
In the last month, how often have you been upset because of
B1 2.12 (1.11) 0.00 - 4.00
something that happened unexpectedly?
In the last month, how often have you felt that you were unable
B2 2.28 (1.16) 0.00 - 4.00
to control the important things in your life?
B3 In the last month, how often have you felt nervous and stressed? 1.66 (1.10) 0.00 - 4.00
In the last month, how often have you felt confident about your
B4 3.12 (0.97) 0.00 - 4.00
ability to handle your personal problems?
In the last month, how often have you felt that things were going
B5 2.67 (1.00) 0.00 - 4.00
your way?
In the last month, how often have you found that you could not
B6 2.31 (1.14) 0.00 - 4.00
cope with all the things that you had to do?
In the last month, how often have you been able to control
B7 2.85 (1.07) 0.00 - 4.00
irritations in your life?
In the last month, how often have you felt that you were on top
B8 2.37 (1.15) 0.00 - 4.00
of things?

In the last month, how often have you been angered because of
B9 1.94 (1.15) 0.00 - 4.00
things that were outside of your control?
In the last month, how often have you felt difficulties were piling
B10 2.35 (1.13) 0.00 - 4.00
up so high that you could not overcome them?
23.68
Total score on the PSS-10 tool 7.00 - 39.00
(5.93)
From Table 4, above, note the slightly above two scores for questions B1, B2, B6, and B10, point to struggles by
the interns to cope with being upset or problems. Overall, they do remain confident in their abilities to cope
(B4 and B3) and are not resorting to anger as a form of response. There were no significant differences in
the total score of the PSS-10 tool with regards to increasing age (0.10, p. value = 0.05), the respondent being
female (-0.91, p. value=0.09), having no dependents (0.38, p. value = 0.48) and having done the internship at
more than one site (-0.99, p. value = 0.12).
Figure 3: Perceived stress scores according to gender

On categorizing the perceived stress scores using the recommended cut off values of 0 to 13 for low stress,
14 to 26 for moderate stress and 27 to 40 for severe stress, we observed that most of the respondents were
moderately to severely stressed, as shown in the above figure 3.

Table 5: Major stressors and ways of handling stress by the respondents
Variables Median Max Min Mean SD
Stressors
Financial income as a major stressor 6 10 0 5.98 2.71
Workload as a major stressor 8 10 0 7.18 2.34
Unclear long-term career future as a major stressor 6 10 0 5.64 3.02
Supporting family as a major stressor 5 10 0 4.96 3.31
Job environment as a major stressor 5 10 0 5.03 2.75
Relationship with trainers or supervisors as a major stressor 5 10 0 4.56 3.28
Relationships with colleagues as a major stressor 2 10 0 3.91 3.82
Lack of a supervisor as a major stressor 3 10 0 3.72 3.38
Ways of handling stress

Handle stress by sitting Mesmerized in front of a television or
5 10 0 4.79 3.41
computer
handle stress by overeating 1 10 0 1.97 2.79
handle stress by Smoking and drinking 0 10 0 0.72 2.06
handle stress by Talk to colleagues 7 10 0 6.63 2.99
handle stress by Talk to family 7 10 0 6.74 3.04
handle stress by Self-mutilation 0 10 0 2.49 3.59
handle stress by Talk to trainers 3 10 0 3.82 3.26
handle stress by Stress management 7 10 0 6.57 2.99
In Table 5, note that the four stressors with the highest average scores were work, finances, unclear future and the
work environment. On the other hand, the highest scores of ways of handling stress were talking to family, talking to
colleagues and stress management.
A.1c Finances
Respondents were asked about their sources of income. On average, the reported monthly income for the
interns was on average 839,370.04 UGX (SD: 818,412.59 UGX).The range for total monthly cash inflows was
from 0 UGX to 14 million UGX per month. About half the respondents said they had other sources of cash
inflows ranging from family support to actual cash inflows ranging from 1 million UGX to 10 million UGX
per month. The rest said they had no other source of inflows. About 25% of the respondents said they had
work-related monetary allowances as additional incomes. Only 3/499 (0.6%) thought their monthly incomes
were more than adequate, 60/499 (12.02%) thought it was just enough to get through the month, and the rest
436/499 (87.37%) thought it was not enough to cover the monthly expenses.

Table 6: Reported monthly expenditures in Uganda shillings
Category Mean Std.Dev Min Median Max
Investment 239,090.91 134,373.65 30,000.00 200,000.00 500,000.00
Rent 242,664.42 127,003.24 200.00 250,000.00 1,200,000.00
Communication 75,086.09 52,650.03 5,000.00 50,000.00 350,000.00
Dependents 340,453.01 411,537.66 0.00 220,000.00 4,000,000.00
Basic Needs 224,325.91 157,572.09 3,000.00 200,000.00 1,500,000.00
Medical care 190,204.08 213,009.09 0.00 100,000.00 1,000,000.00
Leisure 132,020.41 89,475.44 26,000.00 100,000.00 500,000.00
Loans 322,500.00 165,037.87 150,000.00 292,500.00 600,000.00
Utilities 97,370.97 190,541.18 0.00 50,000.00 2,000,000.00
Others 193,432.46 421,064.56 0.00 150,000.00 8,000,000.00
In Table 6 summarizing the intern’s reported monthly expenses in Uganda shillings, we note that, on average,
the top three expense categories were: dependents, loans, and rent.
Figure 4: Reported monthly expenditure according to gender

Figure 4, shows a summary of the differences in reported monthly expenditure according to gender; note the
difference in the median reported expenditures for the two genders in each of the expenditure categories.
Female respondents spent more on loan repayments, dependents and items classified as others (donations,
contributions to functions, etc.). Overall, these differences in reported expenditure according to one’s gender
were not significant (Gender-Female mean difference = -15,944 UGX, t. value = -1.36, p. value = 0.18).

A.1d Time and workload
Table 7: Summary of the workload and time indicators
Question items N Median Max Min Mean SD
On a scale of 0 to 10, how busy is your typical day 490 9 10 0 8.82 1.54
How long is your on-call duty (Hours) 457 12 24 0 12.42 5.78
Number of days on call in a month 483 4 23 0 4.59 2.9
How long is your duration of break time per day

489 1 20 0 1.53 2.05
(Hours)
Monthly Number of inpatients usually attend to on
499 250 3,000 0 423.20 492.5
wards
The number of outpatients usually attend to per
499 250 3,000 0 429.60 523.9
month
On a scale of 0 to 10 how busy are your overtime
491 8 10 0 7.76 2.62
hours
Current overtime in working hours for weekdays 418 8 80 1 12.73 13.61
Total overtime working hours for weekends 330 6 48 0 10.77 10.59
Hours a week you spent on surgical emergencies 396 12 100 1 21.2 20.85
Hours a week you spent on caesarean sections

369 18 100 0 26.64 24.37
emergencies
Hours a week you spend on medical emergencies 453 16 100 0 25.89 23.85
Number of nights in a month that you are on duty 433 8 30 0 9.33 5.12
Please indicate your non-educational activities time 418 7 72 0 10.26 11.84
In the above Table 7, we note that on average, the interns will see 424 in patients and another 430 as
outpatients each month. On average, the scores for how busy a typical day were significantly higher than the
scores for the overtime hours for the same respondent (mean difference 1.06, 95% CI: 0.86 to 1.27, t = 10.14,
df = 485, p-value < 0.01, using the paired samples t-test)
Table 8: Comparisons of time and workload by gender
Question item a. OR 95% CI p value

Intercept 0.37 0.08 to 1.6 0.19
On a scale of 0 to 10 how busy is your typical day 1.06 0.9 to 1.24 0.51
How long is your on-call duty (Hours) 0.95 0.91 to 0.99 0.01
Number of days on call in a month 1.06 0.99 to 1.14 0.12
How long is your duration of break time per day (Hours) 0.9 0.78 to 1.01 0.11

Monthly Number of inpatients usually attend to on wards 1 1 to 1 0.04
The number of outpatients usually attend to per month 1 1 to 1 0.98
On a scale of 0 to 10 how busy are your overtime hours 1.04 0.95 to 1.15 0.39
Do you work overtime during on weekdays (No) 0.63 0.3 to 1.31 0.22
Do you work overtime over the weekends (No) 2.92 1.7 to 5.12 <0.01
Do you ever attend to surgical emergencies, excluding cesarean
1.06 0.56 to 2.01 0.86
sections (No)
Do you attend to caesarean sections emergencies (No) 0.93 0.51 to 1.69 0.81
Do you attend to medical emergencies (No) 1.65 0.71 to 3.86 0.24
Do you ever attend to night duties (No) 0.36 0.16 to 0.78 0.01
Do you ever have time for other non-educational activities (No) 1.78 1.02 to 3.13 0.04
In Table 8, showing the adjusted odds ratios for the different time and workload indicators, note that the male
respondents were significantly more likely to have: higher numbers of patients on the wards (p. value= 0.04),
indicating no for work overtime over the weekend (p. value <0.01), and have no time for other non-educational
activities compared to the female respondents. On the other hand, male respondents had significantly shorter
reported call duties (p. value = 0.01) and were less likely to indicate that they did not do night duties (p. value
= 0.01) compared to the female respondents keeping all other values constant for both cases.
A.1e Tasks and training

Figure 5: self-reported rating of how well different tasks were performed before and during internship
The above Figure 5 provides a summary of the interns reported proficiency on various clinical tasks from
their medical schools and later as part of the internship exposure. A full list of the tasks and competencies
that were rated is included as part of annex 2 in this report. In this figure it is important to note that overall,
there was no significant difference in the ratings of the tasks for the two phases of learning. In all cases, males
were more likely to give higher reported ratings than female respondents. This difference in ratings due to
sex was not significant.
Figure 6: Multinomial Regression of self-assessment by region for each training phase

Figure 6 Provides a summary of the regional differences in the ratings for the different tasks and competencies
for each one of the four regions in the country. It is important to note that for all four plots, the central region
is used as a reference as it had the highest number of participants in the study. For the skills and task plots,
enough is used as the reference group, while for the competencies fully developed is the reference group.
Looking at the plots for a2, the reported undergraduate training on work related competencies, we note
that interns doing an internship in the Eastern part of the country had a high risk of reporting that the prior
training led to partial or no development of work-related competencies keeping all other factors constant.
For internship exposure, it changed to interns working in the Northern and Western parts of the country.

A.1.f Work engagement
Table 9: Scores for the work engagement questionnaire
At my work I feel bursting with energy 499 4 6 0 3.66 1.88

I find the work that I do full of meaning and
499 6 6 0 5.42 1.16
purpose
Time flies when I’m working 499 6 6 0 5.11 1.50
At my job, I feel strong and vigorous 499 5 6 0 4.89 1.29
I am enthusiastic about my job 499 6 6 0 5.18 1.28

When I am working, I forget everything else
499 5 6 0 4.17 2.03
around me
My job inspires me 499 6 6 0 5.26 1.37
When I get up in the morning, I feel like going
499 5 6 0 4.83 1.51
to work
I feel happy when I am working intensely 499 5 6 0 4.38 1.86
I am proud of the work that I do 499 6 6 0 5.50 1.04
I am immersed in my work 499 6 6 0 5.13 1.24

I can continue working for very long periods
499 5 6 0 4.47 1.66
at a time
To me my job is challenging 499 4 6 0 3.77 1.90
I get carried away when I’m working 499 4 6 0 3.43 2.14
At my job, I am very resilient mentally 499 5 6 0 4.87 1.54
It is difficult to detach myself from my job 499 5 6 0 4.45 1.86
At my work, I always persevere even when

499 6 6 0 5.16 1.30
things do not go well
Table 9 shows a summary of the scores from the responses of the interns to questions from the validated
work engagement questionnaire. As can be seen from the column with the median and mean scores, almost
all the questions have a score greater than 3. The high scores for this tool and showing that the interns are
engaged with their work also rule out burnout. In this case, low scores would have implied that the interns
were burned out.This is especially important given that data collection happened at the end of the internship
training.

Figure 7:Work engagement domain scores by gender for the different regions in the country
In Figure 7, we further demonstrate the level of engagement with respect to the three domains of the
questionnaire: absorption, dedication and vigour. In this figure, it is important to note that there was no
significant difference in response according to sex for engagement and that for both sexes, dedication to
work was the highest scored domain. Also, looking at the four plots, there was no regional difference in the
pattern of work engagement across the country.

A.1.g Work effort reward perception
Table 10: Scores from the work, effort, reward validated questionnaire
I have constant time pressure due to a heavy workload 499 3 4 1 3.08 0.79
I have many interruptions and disturbances while performing

499 2 4 1 2.35 0.83
my job
Over the past year, my job has become more and more
499 3 4 1 3.09 0.77
demanding.
I receive the respect I deserve from my superior or a
499 3 4 1 2.94 0.85
respective relevant person.
My job promotion prospects to becoming a medical officer
499 2 4 1 2.06 0.93
are poor (Reversed)
I have experienced, or I expect to experience, an
499 3 4 1 2.5 0.86
undesirable change in my work environment (Reversed)
My job security is poor (Reversed) 499 3 4 1 2.63 0.96
Considering all my efforts and achievements, I receive the

499 3 4 1 2.77 0.86
respect and prestige I deserve at work
Considering all my efforts and achievements, my job
499 3 4 1 2.73 0.83
promotion prospects are adequate.
Considering all my efforts and achievements, my
499 1 4 1 1.57 0.86
salary-income is adequate.
I get easily overwhelmed by time pressures at work 499 3 4 1 2.72 0.8
As soon as I get up in the morning, I start thinking about

499 2 4 1 2.5 0.83
work problems.
When I get home, I can easily relax and ‘switch off’ work
499 3 4 1 2.7 0.84
(Reversed)
People close to me say I sacrifice too much for my job. 499 3 4 1 3.09 0.76
Work rarely lets me go it is still on my mind when I go to

499 3 4 1 2.74 0.83
bed.
If I postpone something that I was supposed to do today, I’ll
499 3 4 1 2.77 0.88
have trouble sleeping at night.
My department provides all the equipment supplies and
499 2 4 1 2.11 0.99
resources necessary for me to perform my duties
The Table above (Table 10) provides a summary of the intern’s scores for the questions from the validated
work reward effort questionnaire. In this table, it is important to note that the question with the lowest score
was the one that states, “Considering all my efforts and achievements, my salary-income is adequate”.

Figure 8:Work effort reward imbalance by gender across the different parts of the country
Figure 8 provides a summary of the tool’s scores according to the tool’s domains according to the sex of the
respondent. In this figure note, the following: (1) the domain related to the prospects of job promotion had
the lowest effort reward imbalance scores suggesting that the interns had high hopes of moving to the next
level once complete with the internship assignment. (2) Female respondents were more job secure than their
male counterparts. (3) for the other domains, the effort the interns were putting in was greater than the
rewards leading to a high imbalance equally for both sexes. It is important to note that, as with the previous
figure, there were no significant differences in the patterns of perceived effort rewards imbalance according
to gender across the different parts of the country.
A.1.h Perception of the internship site as a learning environment
Table 11: Perception of the internship site as a learning environment
The training at the site helps to develop my confidence 499 2 3 0 2.35 0.66
I feel I am being well prepared for my profession 499 2 3 0 2.37 0.66
The internship supervisors are knowledgeable 499 3 3 0 2.45 0.65
The training at the sites encourages me to be an active learner 499 2 3 0 2.35 0.66
The supervisors have good communication skills with interns 499 2 3 0 2.06 0.81

The supervisors give clear examples 499 2 3 0 2.15 0.76
My problem-solving skills are being well developed here 499 2 3 0 2.29 0.63
Much of what I have to learn seems relevant to a career in

499 2 3 0 2.43 0.57
healthcare
I am able to concentrate well 499 2 3 0 2.27 0.61
The atmosphere motivates me as a learner 499 2 3 0 2.04 0.74
There is a good support system for interns who get stressed 499 1 3 0 1.11 0.92
My social life is good 499 2 3 0 1.77 0.88
The above Table 11 provides a summary of the intern’s responses to the questions related to the site as a
learning environment. In this table, note that the question related to the supervisor’s knowledge received the
highest score. On the other hand, the one related to support systems for interns has the lowest score.
Figure 9: Domain scores of the internship site as a learning environment by gender

Figure 9 shows a summary of the domain scores for the internship site as a learning environment by gender. In
this figure, note that the scores for the domain “perception of atmosphere” had the lowest overall scores.This
supports the previously observed low score for the support systems that make the workplace environment
hostile for these new recruits to the profession. Of interest in this figure is the observation that the male
respondents had a higher perception of the trainers than the female respondents overall. This may call for
further investigation as part of a follow up study. All the other domains had relatively high scores of similar
ranges for both sexes.

A.1.i Covid-19
Table 12: Covid-19 illness perception
Covid-19 has affected my work life 499 7 10 0 6.88 2.68
Covid-19 has affected my social life 499 8 10 0 7.7 2.35
how long will Covid-19 continue 499 9 10 0 8.01 2.2
How much control do you feel you have over your getting
499 5 10 0 5.29 3.03
Covid-19
How helpful would the available treatments be to you if you got
499 5 10 0 5.51 2.76
Covid-19
How much would the experience of covid-19 symptoms affect
499 6 10 0 5.86 2.81
you
How concerned are you about Covid-19 499 10 10 0 8.33 2.27
How well do you feel you understand Covid-19 499 8 10 0 7.56 2.16
How much does Covid-19 affect you emotionally 499 7 10 0 6.29 3.02
How well did your undergraduate training prepare you for

499 4 10 0 3.77 3.61
Covid-19
How well prepared is this internship site for delivering Covid-19
499 6 10 0 5.63 3.14
related patient care
Table 12 has a summary of the illness perception towards the ongoing covid-19 pandemic. Most of the interns
had a good understanding of COVID-19. COVID-19 has severely affected their social, emotional and work
life. In this table, note the low scores for preparedness of the hospitals and undergraduate training for the
COVID-19 pandemic. At the time of the survey, it was safe to posit that the level of COVID-19 pre- and in-
service preparedness is even lower among the non-degree holding health workers. With the possibility of a
third COVID-19 wave in the country, there is an urgent need to strengthen frontline health worker’s infection
prevention and control pre- and in-service training. This is especially important given the reports that the
current strains now adversely affect the previously spared young age groups.

A.1.j Perception of the supervision and the site
Table 13: Interns’ perceptions of supervision and the site
Questions N Median Max Min Mean SD
The buildings grounds and layout of this health facility are

1 499 3 4 1 2.49 0.93
adequate for me to perform my work duties.
My current internship site provides me with access to basic

2 499 3 4 1 2.79 0.95
social amenities including clean toilets running water electricity
I feel encouraged by my supervisor to offer suggestions and

3 499 3 4 1 2.99 0.85
improvements
I would recommend this health facility to other interns as a good

4 499 3 4 1 3.1 0.81
place for internship
5 How do you feel about leaving the medical profession 499 4 5 1 3.77 1.04
How important is it to you personally that you spend the rest of

6 your life or career as a health professional rather than in another 499 4 5 1 3.86 1.27
profession?
Concerning internship supervisors’ standards of work-cuts
7 corners must be followed up or reminded to ensure that all is in 499 1 1 0 0.88 0.32
order (reversed)
Concerning internship supervisors’ standards of work-can be
8 counted on to perform supervisory activities without reminders 499 0 1 0 0.44 0.5
(reversed)
Concerning internship supervisors’ standards of work-in

9 addition to supervisory activities goes out of the way to identify 499 0 1 0 0.42 0.49
opportunities or tasks of benefit to me as a health professional
Concerning internship supervisors use of time and resources-

Even with daily routine work, does not select the most
10 499 1 1 0 0.92 0.27
important work to do first and make poor use of time and
resources to get the job done
Concerning the internship supervisor’s use of time and

resources-Usually can select the most important job to do
11 499 0 1 0 0.46 0.5
first and makes use of time and resources to get the job done
(reversed)
Concerning internship supervisor’s use of time and resources-

Even when overloaded with work models, how to select the
12 499 0 1 0 0.47 0.5
most important job first and make the best use of time and
resources to get the job done (reversed)

Concerning internship supervisors modelling continued
13 professional development-Overall has not done anything to 499 1 1 0 0.89 0.32
encourage my continued professional learning and development
Concerning internship supervisors modelling continued

professional development-Identifies knowledge gaps and asks for
14 499 1 1 0 0.53 0.5
feedback on what I learned only in relation to clinical work of
the rotation
Concerning internship supervisors modeling continued

15 professional development-Identified and encouraged in depth 499 0 1 0 0.4 0.49
research to address knowledge gaps using the latest literature.
Concerning internship supervisors: I have published some of

the interesting things that we identified with my internship
supervisor, who has motivated me to learn in-depth using the
16 499 0 1 0 0.17 0.38
latest available information from the internet. I have also been
encouraged to share what I have learned through presentations
to others
How would you rate this health facility as a place to do an

17 499 8 10 1 7.27 2.02
internship on a scale of 1 to 10
The above Table 13 provides a summary of the intern’s perception of the site and supervision at the site.
Note that the items were drawn from different scales ranging from Yes (1) and No (0) items, with the rest
representing Likert scales of different ranges. It is also important to note that where the items have been
labelled as reversed, it means that the order has been changed from Yes (1) and No (0) items to No (1) and
Yes (0) in the case of question 7. Questions 8 through to 16 looks at various aspects of the internship sites
supervisor’s role. It is important to note that most of these questions were given an average score by the
respondents, with a few exceptions.
A.1.k Perceptions of the available resources at the site
The next table (Table 14) provides a summary of the respondents’ ratings of (i) their exposure to resource-
intense skills and (ii) the actual availability of resources at the site.The resource-intense related skills that have
been selected include doing diagnostic procedures like the lumbar puncture, surgical emergencies, X-rays,
ECGs, and laboratory investigations. For each of the selected resource-intense skills, it was assumed that both
the equipment and human resource to ensure the success of the exposure were available. Overall, exposure
to ECGs was the only skill that more than 10% of the interns indicated they did not receive enough exposure
to during the internship. Most respondents thought that the sites had exposure to resource-related skills
though most of them said the departments did not provide them with adequate equipment, supplies and
resources necessary for me to perform their duties.

Table 14: Ratings on resources, intense skills exposure, and available resources for the interns
Number of responses (percentage)
Resources, intense skills exposure Not enough Adequate Very adequate
1 Diagnostic procedures 43 (8.6%) 133 (26.7%) 323 (64.7%)
2 Interpret X-rays 70 (14.0%) 176 (35.3%) 253 (50.7%)
3 Interpret ECGs 150 (30.1%) 187 (37.5%) 162 (32.5%)
4 Lab investigations 49 (9.8%) 146 (29.3%) 304 (60.9%)
5 Interpret lab investigation results 19 (3.8%) 149 (29.9%) 331 (66.3%)
6 Deal with surgical emergencies 53 (10.6%) 182 (36.5%) 264 (52.9%)
Ratings on resources Strongly disagree Disagree Agree Strongly agree
My department provides all the

7 equipment supplies and resources 164 (32.9%) 170 (34.1%) 109 (21.8%) 56 (11.2%)
necessary for me to perform my duties
The buildings grounds and layout of this

8 health facility are for me to perform my 86 (17.2%) 149 (29.9%) 197 (39.5%) 67 (13.4%)
work duties.
My current internship site provides me
with access to basic social amenities
9 64 (12.8%) 97 (19.4%) 216 (43.3%) 122 (24.4%)
including clean toilets running water and
electricity

A.2. Model to predict perceived stress scores of the interns
The next two tables’ summarise the results of a structural equation model exploring the effect of each of
the observations from the above tools on predicting the interns perceived stress scores. The structural
equation model used the non-parametric partial least squares approach to generate the observed effects
based on a bootstrapping re-sampling routine. The items in bold represent those paths that were significant
in a model capturing the different pieces of data collected by the survey on the internship experience.
The significant paths represent the areas of emphasis or points for potential interventions to improve the
internship experience. Some of these are highlighted in the text that follows table 15.
Table 15: Structural equation modelling estimated total effects
To ~ from paths Estimate Std. error t-stat. p-value 95% bootstrap CI
covid ~ supervision 0.3995 0.0604 6.6194 0.0000 0.2910 to 0.5276
covid ~ intern 0.2971 0.0569 5.2173 0.0000 0.2011 to 0.4271
dreem ~ supervision 0.8555 0.0261 32.8055 0.0000 0.8027 to 0.9045
dreem ~ intern -0.0216 0.0462 -0.4688 0.6392 -0.1202 to 0.0602
time ~ intern 0.0505 0.1530 0.3303 0.7412 -0.2421 to 0.3128
engagement ~ supervision 0.3921 0.0492 7.9761 0.0000 0.3043 to 0.4964
engagement ~ intern 0.1534 0.0474 3.2354 0.0012 0.0718 to 0.2572
engagement ~ covid 0.1734 0.0817 2.1216 0.0339 0.0139 to 0.3339
engagement ~ dreem 0.0269 0.1385 0.1941 0.8461 -0.2618 to 0.2797
effort_reward ~ supervision 0.7247 0.0559 12.9711 0.0000 0.6188 to 0.8357
effort_reward ~ intern 0.1211 0.0625 1.9392 0.0525 0.0090 to 0.2554
effort_reward ~ covid 0.2590 0.0945 2.7408 0.0061 0.0716 to 0.4368
effort_reward ~ dreem 0.1766 0.1490 1.1852 0.2359 -0.1689 to 0.4136
effort_reward ~ time 0.2024 0.0694 2.9173 0.0035 0.1001 to 0.3592
effort_reward ~ engagement 0.0630 0.0605 1.0414 0.2977 -0.0568 to 0.1786
pss ~ supervision 0.2784 0.0647 4.3008 0.0000 0.1836 to 0.4391
pss ~ intern 0.1815 0.0727 2.4966 0.0125 0.0731 to 0.3546
pss ~ covid 0.1214 0.1215 0.9995 0.3176 -0.1093 to 0.3640
pss ~ dreem 0.1686 0.1991 0.8471 0.3969 -0.2532 to 0.5267
pss ~ time -0.0982 0.1840 -0.5337 0.5935 -0.3283 to 0.2928
pss ~ engagement 0.2344 0.0908 2.5817 0.0098 0.0382 to 0.3945
pss ~ effort_reward 0.5885 0.2609 2.2552 0.0241 0.2391 to 1.2379

The following were the significant paths for the large and moderate effects in order of presentation from the
above table of total effects:
1. Supervision had a moderate effect on the intern’s perception of the covid-19
2. Supervision had a large effect on the intern’s perception of the internship site as a learning environment
3. Supervision had a moderate effect on the intern’s work engagement
4. Supervision had a moderate effect on the perceived stress scores
5. Supervision had a large effect on perceived effort reward imbalance
6. The intern factors (accommodation, dependents, etc.) had a moderate effect on work engagement
7. The covid-19 illness perception had a moderate effect on work engagement
8. The covid-19 illness perception had a moderate effect on effort reward imbalance
9. Time and workload had a moderate effect on the effort reward imbalance
10. The work engagement scores had a moderate effect on the perceived stress score
11. The effort reward imbalance had a large effect on the perceived stress scores
From the above observations, we note that the first five observations related to supervision of the interns had
large to moderate effects on various aspects of the internship experience.This implies that any changes to the
supervision experience have the potential to impact the interns overall experience of the internship training
exposure positively or negatively. Beyond the above listed direct effects, it is also important to note that
there were also indirect effects of supervision on the other modelled aspects of the internship experience.
In table 16, we note that supervision again had a moderate and significant indirect effect on the perception
of effort and reward (effect 0.27) and a large significant indirect effect on the perceived stress scores (effect
0.53). From this data, we argue that a focus on making modifications to the current supervision of the interns
has the potential to positively impact many aspects of the internship experience quickly. Modifications to the
supervision of interns fall within the medical council’s mandate that is already mandated by law to supervise
the internship training program. The other aspects of the program, like pay or accommodation or workload,
may require additional policy interventions that the council can spearhead to eventually strengthen the
overall impact of the program and promote the uniformity of the training experience for all interns.
Table 16: Structural equation modelling indirect effects

Indirect
To ~ from path Estimate Std. error t-stat. p-value 95% bootstrap CI
effect
engagement ~ supervision 0.0923 0.1288 0.7165 0.4737 -0.1717 to 0.3368
engagement ~ intern 0.0509 0.0284 1.7965 0.0724 0.0027 to 0.1143

effort_reward ~
0.2734 0.1528 1.7899 0.0735 - 0.0722 to 0.5277
supervision
effort_reward ~ intern 0.0898 0.0484 1.8562 0.0634 0.0078 to 0.1969
effort_reward ~ covid 0.0109 0.0123 0.8871 0.3750 -0.0117 to 0.0379
effort_reward ~ dreem 0.0017 0.0121 0.1404 0.8883 -0.0227 to 0.0288
pss ~ supervision 0.5286 0.2868 1.8432 0.0653 0.0952 to 1.1772
pss ~ intern 0.0699 0.0756 0.9249 0.3550 -0.0508 to 0.2366
pss ~ covid 0.1866 0.1080 1.7278 0.0840 0.0505 to 0.4649
pss ~ dreem 0.1092 0.1276 0.8562 0.3919 -0.1346 to 0.3645
pss ~ time 0.1191 0.0922 1.2912 0.1966 0.0385 to 0.3409
pss ~ engagement 0.0370 0.0480 0.7718 0.4402 -0.0383 to 0.1498

B. Summary of the Key Qualitative Findings
In addition to the quantitative survey, we also collected qualitative data to gain more understanding of the
experiences of interns at the training sites. We interviewed administrators and supervisors at the sites to
further provide more insight and meaning into what the interns were reporting hence coming up with
robust data triangulated across a variety of responses. Thematic analysis was employed to attach meaning
and interpret the qualitative responses from the participants. We used an interpretive inductive approach in
which raw data was read several times to familiarize ourselves with it. Subsequently, the raw data was re-read
to identify common responses that were labelled as codes. These were also related to each other to identify
common patterns that formed the categories, and eventually, the categorized data was also related to each
other to come up with aggregated over-arching themes which have been used to report the findings thus the
reported themes naturally emerged from the data.
Three over-arching themes emerged, namely: 1) positive experiences, 2) challenges, and 3) suggestions for
improvement. These are summarized in Table 1, along with key issues that relate to each theme. Thereafter,
each theme has been further deconstructed along with key representative field quotations to contextualize
each theme.
Table 17: Summary of the key themes from the qualitative data
Theme Key issues
• Good mentorship
• Deep learning of clinical skills
• Supervisors are available at any time and
Theme A: Positive experiences
willing to teach
• Teamwork
• Inter-professional collaboration to assist
patients
• Variety of clinical cases/patients to learn
from
• Supportive administration
• Expectations met in bigger hospitals with
more specialists
• Expectations are not met in some hospitals
with fewer specialists
• Interns had adequate theoretical knowledge
• Interns well-grounded in medical ethics
• Quality of interns is generally fair
• Junior medical schools tend to send more
committed interns when compared to the
more traditional medical schools

• Limited practice in some disciplines,
Theme B: Challenges especially Surgery
• Limited periods of rotation in different
clinical disciplines
• Inadequate welfare of interns
• Acquisition of loans to bridge the gap
• Poor remuneration of interns
• Deficiencies in some clinical skills despite
having enough theoretical knowledge
• Limited generic skills in some interns such
as communication, interpersonal skills,
leadership, problem-solving
• Increased workload of interns at the sites
• Limited time for social activities at the
internship sites
• Poor induction when interns have just
reported
• Lack of standardization in assessment,
supervision and giving feedback to interns
across the sites
• COVID-19 related challenges such as
inadequate PPE and learning IPC measures
Theme C: Suggestions for • Standardize the internship supervision

improvement process
• Standardize assessment of interns across
sites
• Formative feedback should be part of the
process and not waiting at the end to give a
summative evaluation
• Improve the induction process of interns
• Recruit more specialists into the al referral
hospitals to supervise the interns
• Need to improve quality of training
especially in clinical skills beyond the pre-
internship or post-internship exam. These
are still summative and more formative
assessments should instead be created.
• Numbers of interns are too many, and they
need to be reduced
• Improve on the welfare of interns e.g.,
accommodation, feeding at sites
• Social activities should be part of the
internship program
• Improve coordination of the internship
program right from ministry up to the
sites. The communication channels seem
inadequate.
• Remuneration of interns still needs to
improve

Theme A: Positive Experiences:
This theme relates to the positive internship experiences that swept through the responses. Overall, the
internship seemed to have very positive experiences, especially in learning and acquiring clinical skills.
• Good mentorship from supervisors and specialists: The mentorship was good; specialists and
supervisors were available most of the time to give knowledge and clinical skills.The students seemed
to have appreciated the clinical learning environment and reported having obtained deep learning of
the clinical skills and mentorship from the supervisors.
``…the strength of our supervisors because our supervisors are so friendly and approachable, you can reach them at any time,
be it morning, be it daytime, be it at nighttime, they are always there. We always learnt a lot of clinical skills at the sites and the
supervisors were willing to teach. So, our supervisors are always available such that whenever we want them, we can always find
them, yah that’s the strengths``.
• Ability to engage in teamwork and inter-professional collaboration:There were opportunities to work

in teams and also meet other people from various universities. This appeared to be a very good
learning experience especially that it promoted inter-professional collaboration.
`Òne of our strengths has been teamwork, so most of our colleagues ensure that we work as a team, and we provide the patients’
needs, and they are always catered for within the specific time and in the right way…. working at times with nurses and pharmacists
on the same ward provided us an opportunity to understand each other`s role``.
• Lots of learning experiences and holistic growth: Interns had opportunities to learn from many
patients. The experience seemed to provide a variety of clinical cases from the many patients that the
interns interacted with.
``We are allowed to touch every patient and learn from them be it a private setting or the general one and the feedback is also
very good once you make a mistake, and if anything is wrong, we are always informed and corrected normally``.
• Administration and supervisors supportive: The hospital administration and supervisors were generally
supportive across the internship sites. Most of the responses pointed out the fact that despite the
challenges, the administrations of the various hospitals were supportive of the interns during their
placements.
``The hospital administration was very supportive, and even our colleagues in other hospitals said that despite the many problems,
the administrations were supportive``.
• Expectations were met with consultants available: In some of the sites, the expectations were met.
This was particularly noted from responses from Mbarara teaching hospital, which perhaps has a
number of SHOs and specialists. The other internship sites did not report overwhelming satisfaction
with meeting expectations.
``My expectations were met, I expected to come out a competent and skilled doctor, I am confident which ever patient comes my
way, I will be able to handle. So, I think as I expected, I got my expectations``.
``Some of my expectations were met…. however, the hospital lacks enough specialists to supervise us, and we would have benefited
more if there were enough specialists…. may be our friends in bigger hospitals like Mulago and Mbarara that have many consultants
and masters’ students may be more satisfied than us``.
• Pre-internship preparation: This sub-theme swept through most of the responses from supervisors
and administrators. They reported that most of the medical schools seemed to have prepared the
students for internship, but there were some gaps in some of the clinical skills. Students had more of
theory than clinical skills.
`À number of the interns had adequate theoretical knowledge, but they were lacking in some of the clinical skills, and this may be,
was due to inadequate preparation during their training. May be medical schools should reduce on numbers of students admitted
so that they can have few whom they can properly train to grasp the skills``.
• Medical ethics and generic skills: Some of the students were well prepared in generic skills such as
teamwork, communication, ethics, professionalism and interpersonal skills. These are key skills that

health workers would need, and we encourage all medical schools to put some emphasis on these
skills as well.We particularly noted that they were well grounded in medical ethics which they applied
during clinical situations.
``The interns well prepared with issues of medical ethics. We also encourage trainers to emphasize skills such as professionalism,
communication, teamwork and leadership because all these are needed during their internship period``.
• Quality of interns: The supervisors and administrators reported that the quality of interns seems to
be fair and acceptable generally. However, they reported that junior medical schools tend to send
more committed intern doctors.
`Òn quality, they are fair, I have noticed that junior Universities, that are new, tend to send us committed doctors than the traditional
ones depending on how they are mentored and supervised in their universities and are more focused in terms of patient care``.
Overall, the internship program has very key positive aspects, as pointed out by the interns and supervisors.
For example, the observation that the interns received good mentorship and were engaged by the supervisors
and specialists who were available to them is a very strong finding as it helps us to know that supervisors
are at the sites to assist the interns. In addition, the fact that interns reported being able to work in inter-
professional teams collaboratively is also a strong experience of the internship program. The good grounding
in medical ethics is also a positive outcome to note. A key observation is that junior medical schools tend
to send more committed internsthan the old traditional medical schools. This is not surprising as the newer
medical schools tend to put in more effort to make a mark in the field. However, it also calls for all medical
schools to ensure that they produce committed health workers who will serve the community. In addition,
the observation by supervisors that a number of the interns had adequate theoretical knowledge but were
lacking in some of the clinical skills, and this may be due to inadequate preparation during their training,
should be addressed.
Theme B: Challenges:
This theme speaks to the key challenges identified with the internship activity from the responses of the
various participants. Although the internship was generally good and provided good learning experiences,
there were some challenges identified. The following were key that swept through most of the responses:
• Limited hands on in some clinical disciplines: The interns reported some limited hands-on practice
with some clinical disciplines and most particularly the surgical disciplines. More interrogation of data
points to perhaps large student numbers and limited time as many students cannot be accommodated
in theatres. This limited surgery was reported from almost every internship site.
`Ìn the area of surgery, it needs some improvement, there is little hands on, as opposed to the expectations, most of them under
surgery, have done little, may be little…``
``Surgery needs improvement as we did not learn much. We are many and we cannot all be in theater at the same time and the
internship period in surgery is also limited.This limits our learning in that particular discipline…``
• Welfare: The welfare of interns needs improvement e.g., accommodation, lunch, transport, no lunch
allowance, sharing small rooms in town, government allowance delays. It was also shocking to note
from many responses that a number of interns actually acquire loans to cater for their welfare:
``The government allowance is pea nuts and comes late. A number of us actually get loans from various sources to bridge the
gap……it is so stressing…``
`Às we speak now the site has about 70 intern doctors, though three have left, we are currently 67, about 35 have accommodation,
pharmacists and Nurses sleep outside. We are lucky the hospital administration gives us lunch, but half of the intern doctors don’t
have access to lunch and accommodation. ``
• Challenges of rotations in different disciplines: There is unequal time given for rotations at the sites
leaving interns with limited skills in some areas. They do not get to participate in some procedures
due to unbalanced rotation time.

`` Let’s say you are rotating one month in surgery, the whole month cleaning wounds, because sometimes you spend five months
without getting any patient, how about you who is here for one month? if the time for rotation was balanced, it would be better, the
person has a chance to learn, much as there is a supervisor but what you learn in surgery, if it is a child, the knowledge you acquire
from a child is different from when a patient is an adult….``
`Ìt would be better to be three months and if government is able to make it six months, of course for us we are exiting but if there
is an agreement of six months per rotation and government is facilitating, let it be``
• Poor remuneration of intern doctors: Allowance from government is inadequate to cater for needs
if they have to pay for accommodation, buy food etc. Some interns have families as well and they get
loans to cater for their needs.
`Ì think the other thing not going well is the current remuneration is very poor compared to the current standards. I t is not a secret
that as an intern doctor, you cannot easily get accommodation, it should be scaled up…``
``The 750.000 shs given out and an intern gets 300,000shs for accommodation, and transport, no houses nearby and have to go
across, so the remuneration is poor.Then another thing, some of us have families, after spending on accommodation and transport,
there is nothing to send home and the option is to get loans which also stress us``.
• Increased workload with fewer interns and little time for social activities. The workload is much
compared to number of interns who do most of the work leaving them with limited time to engage
in other social activities which are crucial.
``The work rotation, you have to be on call, the next day you have to be on work, no weekend, no social life.The time I have been to
Mbarara, the interns are few compared to the workload in the facility.The only time you are a bit free is when you are on leave for
a week, but otherwise it is only work, work, work and work``.
Training in medical school partially prepared me for internship and a lot needs to be improved.
`` No, me in the medical school where I studied from, it was largely theoretical learning to know what you find on ward, I think
because of large numbers though there was fundamental knowledge and personal skills``.
• Poor induction of interns: Most of the interns were just thrown into the fire without proper induction
at the sites. This seemed to create challenges for them to integrate into the hospital systems. This
observation was a common denominator across the internship sites.
`` The induction was not okay to me. The way they introduced us because at first we expected to see everyone and get introduced
to everyone, but at that time some important people were missing and during the process, some of the things such as the dos and
don’ts were not told to us but we discovered by ourselves yet we had done some mistakes of going through, so I don’t think that it
was really enough time for induction``.
• Assessment, feedback and supervision: There seems to be no standardized way of supervision,

assessment and delivering feedback during internship. Each site seems to be following their own
criteria which is not even sometimes written. There were limited opportunities for instant corrective
formative feedback to interns which they yearned for to be able to improve.
``We do assess the interns, but we devised our means at the hospital how to do it…. may be the council can come up some form
of standardization so that we are on the same page across the various sites…``
``Some consultants just wait to fail you at the end when nothing much can be done. I think internship is for us to learn skills and
it is better if I have made a mistake the consultant should correct me immediately so that I learn how to do it the correct way. ``
• COVID-19 related challenges: At the time of the internship evaluation, there was the pandemic
of COVID-19 and responses from participants reflected challenges with COVID-19 from the
administrators, supervisors and students. Most of the issues related to ill-preparation regarding
infection prevention and control, large numbers of interns at the sites as well as limited PPE for the
interns.

``COVID-19 came with its challenges, and as supervisors of interns, it was too challenging for us. For example, the hospital cannot
keep on buying PPE for all the interns, so they had to buy some of these things themselves because we need them to be protected
in the hospital. ``
``The hospital budget is inadequate and if someone expects us to buy gloves, masks, sanitizers for all the many interns, it becomes
a challenge. ``
`Às interns, we faced a challenge with the COVID situation because we had to buy some of the required items like gloves and masks
ourselves. In addition, we had to learn the prevention measures as this was a new disease``
The major issue sweeping through this theme is a lack of standardization in supervision, rotation times in
the various disciplines, and assessment and evaluation of clinical competence across all the internship sites.
From this study, each internship site seems to haveits own way of engaging the interns and evaluating them.
This, unfortunately, compromises the eventual quality. Developing some form of standard guidelines for the
supervisors is key in mitigating this.
Theme C: Suggestions for improvement:

This last theme relates to the key suggestions that were pointed to improve the overall internship experience.
• Quality of supervision needs to be improved with supervisors available when interns need them.
Also, the supervision process should follow certain guidelines so that interns across several hospitals
receive the same quality of supervision.
`Ì would suggest that Supervision should be standardized that an intern in Mbarara and another one say in Masaka, will follow
the same standards and meet the same standards by the time they finish their internship and would be judged using the same tool
not personal judgment``.
• Creation of a standardized tool for assessment of intern performance.There should be a standardized

way of assessing the performance of interns.
`Ì would suggest that there has to be a standard used to assess the tool. Some of our friends have been victimized on nonsensible
personal grudges, the tool should guide the supervisor on guidance to determine that this one has failed, this one has passed but
not personal judgment to say this one is good, this one is bad therefore has failed``.
`` May be for emphasis and clarification, the tool exists but it is on an individual basis. In some departments, it is not being used
and applied. So, in some departments if you had a minor issue with your supervisor even if it is a small thing, will wait for you during
the assessment to pin you ``.
• Formative assessment and feedback: Create a mechanism for formative assessment with incorporation
of constructive feedback from interns throughout the internship period and not to wait at the end of
the internship to just provide a summative evaluation. Even then, the assessment should not be done
by an individual so as to avoid any biases.
``…. not one individual should assess but at least two or three should sit and assess……at least if I have failed, let it be continuous
but not at the end of internship and you tell me that I have failed. And even when I have failed, tell me where I performed well and
where I did not perform well so that next time I can improve, if I am reporting late, you caution me so that I can improve``.
``…about the assessment, no, for me I have never received feedback from the surgical ward. Although I know I have passed but I
don’t know how I was assessed and now it has been 6 months since that assessment. So, I don’t know, all you do you wait for the
ministry to publish the list``.
• Need for interns to undergo some induction when posted to the sites before being taken straight
into the wards.
`Ìntern Committee needs to sensitize the intern on what to expect in the internship training field.There is a human resource gap``.
• More specialists should be recruited into all referral hospitals where interns work for adequate
supervision.
`Òne of the things I would recommend is that the Ministry needs to recruit more specialists for different facilities for proper
mentorship of the interns. For Mbarara hospital, we have specialists who are always available, they can teach…. if possible, all al
referral hospitals should be teaching hospitals because it is the theoretical part such that interns can learn hands on from those
specialists``.
• Need to strengthen the quality of training before students graduate rather than a pre-internship exam.
The pre-internship exam is still summative in nature and more emphasis should be placed on more
formative evaluations during training so that students are corrected before they reach summative
evaluations.
`Ì think pre- internship exam or post internship exam is not a qualitative approach. Maybe they can set an exam for all finalist
medical students other than those exams or another general exam from say second year to third year, this will be a more qualitative
approach than the pre-or post-internship exams``.
• Number of interns is too much. Need to reduce on the current number of students admitted into
medical schools so as to reduce the congestion of interns who graduate. The interns are too many
and many of them get limited time to learn the skills.
``Ministry of Education admitting many students, they allow them to enter the medical school they should agree on a general
approach, to regulate at the entry, when admitting them to the medical school not when they are finalizing at the end. There is no
way you can regulate at the end``.
• Interns need to be given to engaging in social activities during internship so that they come out
as holistic individuals. The workload should factor in time for interns to participate in other social
activities while doing internship
• Improve coordination of internship program right from Ministry up to the internship sites. Even at
the sites themselves, there seems to be no proper coordination of interns. There should be a small
committee at the hospital that deals with issues of interns. For example, there is a disjointed flow of
information right from the ministry.
``The other issue in addition to structures is flow of information from top is lacking. Like today 21st sept., it is almost a week to close
the internship program but have not got feedback as to when they are winding up to the internship program, but as a Coordinator
have not heard from top whether they continue or stop, in fact I was preparing to assess them today``.
This theme generally re-enforces what has been described earlier, the urgent need to standardize the internship
program in terms of supervision guidelines, assessment, evaluation and feedback delivery during the internship.
This might also address issues of uncoordinated induction programs and the disjointed coordination of the
whole internship exercise. Protected time should also be availed to the interns to engage in social activities
while at the placement sites. Lastly, the need to improve the quality of undergraduate medical training was
identified so that doctors have some key clinical and other skills before internship training. The need to
reduce the number of students in medical schools was one way to achieve this.
In summary, the qualitative data supplemented the quantitative findings. Of particular importance is the issue
of standardization of the coordination, supervision, assessment, evaluation and delivery of feedback during
internship training.

OVERALL CONCLUSIONS
Introduction:
The over-arching goal of this study was to assess the experiences of interns at their respective training sites in Uganda
as well as gather views of some of their supervisors at those sites with the aim of identifying strengths that can be
maintained and improved as well as challenges that need to be addressed. A variety of hospitals that host interns across
the whole country were involved, as earlier described. Thus, the findings in this study generally reflect the overall
picture of the country.
Key Conclusions:
• The interns generally reported a positive experience in terms of learning and having supervisors and
specialists available to them while at the sites. However, the quality of supervision and assessment
of their competence was variable across the sites and were thus major moderators of their overall
experience.
• There were high scores of stresses observed, most likely due to high levels of work engagement
reported and having limited time to engage in social activities during the internship period.
• There is a lack of standardization in terms of supervision, assessment and evaluation of intern
competence, delivery of feedback, duration of rotations in the various disciplines and coordination of
the internship program. Each site seems to be doing it their own way, which would compromise the
quality of interns trained.
• The supervisors generally reported that the quality of interns was acceptable. However, interns from
relatively young medical schools seem to be more committed than those from the more established
medical schools.
• Overall the medical training seemed to have prepared the students for internship fairly well in terms
of theoretical knowledge, medical ethics, expected clinical skills and some key generic competencies
such as communication and teamwork. However, in some areas, the interns seemed to lack a connection
between knowledge and clinical skills, as reported by the supervisors. In addition, several interns
lacked key generic competencies or soft skills to navigate through their routine work experiences.
Inadequate quality of training in medical schools needs to be improved so that all interns have the
appropriate clinical skills before the commencement of the internship.
Inadequate hands-on practice in surgical areas.
Inadequate materials and equipment to use.
• The COVID-19 pandemic exposed ill-preparation of the interns in terms of emergency infection
control measures.

RECOMMENDATIONS:
Based on key findings from the study across the internship sites that were involved, we thus recommend the
following:
• Developing and implementing standardized practices for the internship program in Uganda.This should
involve emphasis on standardizing guidelines for the supervisors at the sites, standardizing assessment
and evaluation of competence and standardizing feedback delivery as a form of formative assessment
during the internship training.
• Improving the induction process of the interns when they report to the sites. Some of them were not
inducted at all. Guidelines should be developed on how induction can be implemented to enable the
interns to fit in the system.
• Improving supply of materials, and equipment to use during internship training.
• There is a need to design interventions to reduce stress levels during the internship. Despite the high
volumes of work, there should be protected time for the interns to engage in social activities.
• Adopting a mentorship model where interns are not only taught while at the sites but are also
mentored to acquire skills beyond knowledge and clinical skills. For example, skills such as leadership,
time management, effective communication, teamwork, and interpersonal skills can be acquired
through a mentorship model.
• A mechanism should be put in place to ensure that interns do have adequate time to rotate in the
various clinical disciplines especially surgical disciplines. This will prevent a situation where interns
experience limited learning in some of the disciplines when compared to other.
• Need to improve the quality of training in medical schools so that graduates have the prerequisite
clinical schools for internship training.
• Medical schools need to emphasise preparing interns through proper infection measures before they
leave medical schools, as COVID-19 has taught us.
• As an oversight body, the UMDPC needs to develop an inspection structure to periodically make
support supervision visits to the internship sites to ensure that all guidelines for quality internship
training are fully implemented.

Annex 1: Enumerators’ List
DISTRICT NAME
1 Kato Christopher
2 Patrick Joshua Kibedi
KABALE
3 Robert Rutaburwa
4 Babirye Fatina

5 Martin Kabenge

Qualitative, RA 6 Innocent Atuhairwe

7 Muyanja Brian

1 Kiyimba Tonny
ARUA
2 Mulinde Peter

3 Namuyombya Thiatra

4 Charlie Wagholi

5 Katamba Samuel
Qualitative, RA 6 Atukwase Ronald

7 Serwadda Goerge
1 Musiime Richard
MBALE
2 Matte Daniel

3 Kayemba Sylivia

4 Martha Kobusingye

5 Aino Mugisha Donald
Qualitative, RA 6 Brenda Lemuze

7 Florence Nanvuma
MULAGO 1 Kizza Christine

2 Raziya Khan

3 Marvin Mpereirwe

4 Ivan Baingana
5 Sharon Aidah
6 Osinia Doreen
Qualitative, RA
7 Namutebi Susan
1 Nanyanzi Rose
2 Nkiizi Dorcus
NSAMBYA 3 Martin Muwonge
4 Namaganda Druscillah
5 Kwesiga Milton
Qualitative, RA 6 Nabunya Annet

Annex 2:Tasks and Competencies
Task and Competencies Count
Not enough 17
Adequate 167
Taking histories
Very well 315
#Total 499
Not enough 20
Adequate 201
Do physical examination
Very well 278
#Total 499
Not enough 28
Adequate 243
To manage patients
Very well 228
#Total 499
Not enough 76
Adequate 229
Do diagnostic procedures
Very well 194
#Total 499
Not enough 65
Adequate 261
To evaluate data
Very well 173
#Total 499
Not enough 121
Adequate 264
To interpret X-rays
Very well 114
#Total 499

Not enough 220
Adequate 221
To interpret ECGs
Very well 58
#Total 499
Not enough 64
Adequate 239
Do lab investigations
Very well 196
#Total 499
Not enough 39
Adequate 253
Interpret lab investigation results
Very well 207
#Total 499
Not enough 47
Adequate 238
To deal with emergencies
Very well 214
#Total 499
Not enough 79
Adequate 256
To manage agitated/confused patients
Very well 164
#Total 499
Not enough 85
Adequate 266
To manage elderly patients
Very well 148
#Total 499

Not enough 87
Adequate 255
To withdraw treatment
Very well 157
#Total 499
Not enough 87
Adequate 253
Using sedatives
Very well 159
#Total 499
Not enough 13
Adequate 172
Infection control
Very well 314
#Total 499
Not enough 21
Adequate 213
Prescribe antibiotics
Very well 265
#Total 499
Not enough 31
Adequate 216
Write prescriptions
Very well 252
#Total 499
Not enough 51
Adequate 167
Write discharge notes
Very well 281
#Total 499

Not enough 66
Adequate 184
Write referral notes
Very well 249
#Total 499
Not enough 105
Adequate 219
Cope with stress
Very well 175
#Total 499
Not enough 32
Adequate 229
Prioritize
Very well 238
#Total 499
Not enough 13
Adequate 194
Manage time
Very well 292
#Total 499
Not enough 3
Adequate 144
Listening
Very well 352
#Total 499
Not enough 5
Adequate 133
Communicating with patients
Very well 361
#Total 499

Not enough 24
Adequate 210
Assess patients’ knowledge of disease and prognosis
Very well 265
#Total 499
Not enough 24
Adequate 217
Giving information sensitively
Very well 258
#Total 499
Not enough 78
Adequate 235
Breaking bad news
Very well 186
#Total 499
Not enough 63
Adequate 272
Dealing with difficult questions
Very well 164
#Total 499
Not enough 30
Adequate 243
Imparting appropriate amounts of information to patients
Very well 226
#Total 499
Not enough 34
Adequate 249
Eliciting and responding to patients’ fears
Very well 216
#Total 499

Not enough 30
Adequate 211
Communicating with patients’ relatives
Very well 258
#Total 499
Not enough 12
Adequate 167
Communicating with professional colleagues
Very well 320
#Total 499
Not enough 39
Adequate 195
Empowering patients to exercise autonomy
Very well 265
#Total 499
Not enough 10
Adequate 181
Appreciate skills and contributions of other healthcare workers
Very well 308
#Total 499
Not enough 3
Adequate 139
Understand concept of teamwork
Very well 357
#Total 499
Not enough 42
Adequate 200
Ability to chair team meetings
Very well 257
#Total 499

Not enough 29
Adequate 235
Strategies which facilitate teamwork
Very well 235
#Total 499
Not enough 26
Adequate 239
Agree priorities with patients
Very well 234
#Total 499
Not enough 28
Adequate 183
To discuss treatment with patients
Very well 288
#Total 499
Not enough 54
Adequate 226
Not withhold information from patient at request of third party
Very well 219
#Total 499
Not enough 24
Adequate 204
Fulfil patients’ needs for information about treatment
Very well 271
#Total 499
Not enough 128
Adequate 194
Understand issues which surround euthanasia
Very well 177
#Total 499

Not enough 87
Adequate 229
Supporting a bereaved person
Very well 183
#Total 499
Not enough 91
Adequate 244
Preparing family for bereavement
Very well 164
#Total 499
Not enough 67
Adequate 248
Recognizing & supporting a colleague who is bereaved
Very well 184
#Total 499
Not enough 60
Adequate 250
Recognize and respond to stress in self or others
Very well 189
#Total 499
Not enough 59
Adequate 266
Recognize the sources of personal opinions and belief systems
and the danger of projecting these feelings onto others
Very well 174
#Total 499
Not enough 88
Adequate 248
Cope with guilt in self and others due to deficiencies in care
Very well 163
#Total 499

Not enough 81
Adequate 209
Recognize the danger of trivializing-denying personal needs by
always putting patients first
Very well 209
#Total 499

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Internship Situation Analysis Survey Report Page 01

Makerere University College Of Health Sciences

Internship Situation Analysis Survey Report Page 02

Internship Situation Analysis Survey Report Page 03

Internship Situation Analysis Survey Report Page 04

KIU Kampala International University

Pnfps Private Not for Profits

RAs Research Assistants

RRH Regional Referral Hospital

UCH Uganda Chartered HealthNet

UMDPC Uganda Medical Dental Practitioners Council

Internship Situation Analysis Survey Report Page 05

Table 2: Qualitative arm issues covered in the guides......................................................................................................13

Table 3: Descriptive statistics of the participants in the quantitative arm.......................................................................18

Table 5: Major stressors and ways of handling stress by the respondents......................................................................21

Table 6: Reported monthly expenditures in Uganda shillings..........................................................................................22

Table 7: Summary of the workload and time indicators...................................................................................................23

Table 8: Comparisons of time and workload by gender...................................................................................................23

Table 9: Scores for the work engagement questionnaire.................................................................................................26

Table 11: Perception of the internship site as a learning environment............................................................................30

Table 12: Covid-19 illness perception................................................................................................................................31

Table 13: Interns’ perceptions of supervision and the site...............................................................................................32

Table 15: Structural equation modeling estimated total effects.......................................................................................34

Table 16: Structural equation modeling indirect effects...................................................................................................35

Figure 2: Research assistants interviewing intern doctors during pretesting..................................................................21

Figure 3: Perceived stress scores according to gender.....................................................................................................25

Figure 4: Reported monthly expenditure according to gender.......................................................................................27

Figure 6: Multinomial Regression of self-assessment by region for each training phase................................................31

Figure 9: Domain scores of the internship site as a learning environment by gender...................................................36

Internship Situation Analysis Survey Report Page 06

Dr. David Kateete, Dr. Scovia Nalugo Associate Prof Dr Katumba

Internship Situation Analysis Survey Report Page 07

I am delighted to write the foreword for this report on the

Internship Situation Analysis Survey Report Page 08

As the Principal investigator for the HEPI-SHUU project and

Prof. Kiguli Sarah

Internship Situation Analysis Survey Report Page 09

Internship Situation Analysis Survey Report Page 010

Internship Situation Analysis Survey Report Page 011

Sample size calculation for the quantitative survey:

Sample size considerations for the qualitative survey:

KII-CHAIRPERSON AND SUPERVISORS AND

Supervisors per site = 2 Mulago = 4 (1

Internship Situation Analysis Survey Report Page 012

Who do they pick

Issue 6 Covid-19 Covid-19

Internship Situation Analysis Survey Report Page 013

There were four (4) major tasks during data collection:

Internship Situation Analysis Survey Report Page 014

OBJECTIVES OF THE TRAINING:

METHODOLOGY - CONDUCT OF THE TRAINING:

ISSUES COVERED DURING THE TRAINING:

DATA COLLECTION IMPLEMENTATION:

Internship Situation Analysis Survey Report Page 016

A.1 Quantitative results:

A1a Descriptive information about the respondents

Internship Situation Analysis Survey Report Page 017

For how long you have been at this site in

Mean (SD) 11.7 (1.3)

A.1b Stress levels, and stressors and finances

No. Question Mean (SD) Range

Internship Situation Analysis Survey Report Page 018

Figure 3: Perceived stress scores according to gender

Internship Situation Analysis Survey Report Page 019