Perceptions of pharmacy clerkship students and clinical preceptors regarding preceptors’ teaching behaviors at Gondar University in Ethiopia

This study aimed to compare the perceptions of pharmacy clerkship students and clinical preceptors of preceptors' teaching behaviors at Gondar University. A cross-sectional study was conducted among pharmacy clerkship students and preceptors during June 2014 and December 2015. A 52-item structured questionnaire was self-administered to 126 students and 23 preceptors. The responses are presented using descriptive statistics. The Mann-Whitney U test was applied to test the significance of differences between students and preceptors. The response rate was 89.4% for students and 95.6% for preceptors. Statistically significant differences were observed in the responses regarding two of the five communication skills that were examined, six of the 26 clinical skills, and five of the 21 parameters involving feedback. The mean scores of preceptors (2.6/3) and students (1.9/3) regarding instructors' ability to answer questions were found to be significantly different (P= 0.01). Students and preceptors gave mean scores of 1.9 and 2.8, respectively, to a question regarding preceptors' application of appropriate up-to-date knowledge to individual patients (P= 0.00). Significant differences were also noted between students and instructors regarding the degree to which preceptors encouraged students to evaluate their own performance (P= 0.01). Discrepancies were noted between students and preceptors regarding preceptors' teaching behaviors. Preceptors rated their teaching behaviors more highly than students did. Short-term training is warranted for preceptors to improve some aspects of their teaching skills.

The School of Pharmacy at Gondar University was launch ed in 2003. Until 2008, it trained productoriented pharmacy students in a fouryear Bachelor of Science (BS) program. In 2009, Gondar University adopted a fiveyear clinical pharma cy program including four years of academic study and a one year clinical clerkship. In 2013, the first patientoriented phar macists graduated from the fiveyear curriculum. The novel structure of the program provided pharmacy students with an opportunity to make use of and refine recently acquired clini cal pharmacy knowledge and skills. The aggregate of percep tions reflecting the experiences of students and preceptors can be expressed in terms of the preceptors' ability to communi cate effectively with their students and patients, their indepth clinical knowledge, and their enthusiasm for giving students feedback [1,2]. At the Faculty of Pharmaceutical Sciences, Na resuan University, Thailand, differences were found in the perceptions of students and preceptors regarding instructors' teaching behaviors [1]. The present study aimed to compare the perceptions of pharmacy clerkship students and precep tors regarding preceptors' clinical skills and their methods of evaluating and providing feedback to students at Gondar Uni http://jeehp.org J Educ Eval Health Prof 2016; 13: 9 • http://dx.doi.org/10.3352/jeehp. 2016.13.9 versity between the 2014 and 2015 academic years by obtain ing data from two groups of graduating students.
This crosssectional study was conducted at the University of GondarSchool of Pharmacy in northwestern Ethiopia from June 2014 to December 2015. The first 65 responses were col lected among students who graduated in 2014 upon comple tion of their clinical rotations in June 2014. The next 48 re sponses were taken from students from the graduating class of 2015 in the same manner. All graduating students who had completed their clinical rotations were included. Twenty three clinical instructors who mentored these students were also in cluded as study subjects. A structured questionnaire contain ing 52 items was obtained by adding five more questions to a previous 47item instrument developed by Sonthisombat et al. [3]. The first five questions were used to assess preceptors' communication skills, while the next 26 questions were em ployed to evaluate preceptors' clinical practice and teaching, and the last 21 questions were designed to assess preceptors' provision of feedback and modes of evaluation. These items were directly administered to 23 preceptors and 126 clinical pharmacy clerkship students. A threepoint ordinal scale of measurement was applied to assess preceptors' skills and teach ing behavior, with a score of 1 indicating that a certain behav ior was not performed at all, a score of 2 indicating that the behavior in question was performed but inadequately, and a score of 3 indicating that the behavior in question was carried out well and satisfactorily. Participation in the survey was vol untary and anonymous. Two trained data collectors adminis tered the questionnaires to the students at their university res idences, while preceptors received the items directly from the principal investigator. The data collection period was one week for each group of students in June 2014 and December 2015. The data were analyzed with SPSS for Windows, version 20 (IBM Corp., Armonk, NY, USA). The level of significance was set at 0.05 and 95% levels of confidence were used to test the significance of the differences. The nonparametric MannWhit ney test was applied to test for statistically significant differ ences between the responses of preceptors and students. Ethi cal approval was obtained from the Research and Community Service Ethical Committee of the University of Gondar .

Study subjects
Of the 126 clerkship students (22 females and 104 males) who graduated during the 2014 and 2015 academic years, 89.4% responded to the questionnaire. A total of 23 precep tors, two of whom were female, taught, mentored, and evalu ated students during their clinical rotations. Twentytwo pre ceptors responded to the questionnaire. Two preceptors were assigned to emergency medicine, five to pediatrics, and five to internal medicine. The rest were assigned to surgery wards and ambulatory care (Table 1).

Preceptors' communication skills
Nonparametric testing showed that a statistically significant difference was observed between preceptors and students re garding the instructors' ability to answer questions clearly and precisely (P = 0.01) regarding whether the instructors' voices were loud enough to be clearly understood (P= 0.02) ( Table 2).

Preceptors' clinical skills
Preceptors and students showed significant variation in six of the 26 items that assessed preceptors' clinical skills: posses  sion and demonstration of broad knowledge by preceptors (P = 0.01), preceptors' application of appropriate and upto date knowledge to individual patients (P = 0.00), demonstrat ing sensitivity to patient needs (P = 0.01), providing satisfacto ry care to patients (P= 0.02), mentoring (P= 0.02), and instruc tors' ability to capture the attention of learners while teaching (P = 0.04) ( Table 3).

Preceptors' feedback provision skills
Significantly different ratings were noted between students and instructors regarding the following five parameters: en couraging students to evaluate their own performance (P= 0.01), inviting comments and/or criticism of the preceptor's own ideas (P = 0.01), discussing students' strengths and limitations in clinical practice (P = 0.02), setting criteria for student per formance (P = 0.01), and grading students based on perfor mance and effort (P = 0.02) ( Table 4).
The above findings showed that the preceptors rated their performance more highly than students did in 11 of the 54 items. This finding is in contrast with those of the study con ducted by Sonthisombat et al., in which preceptors did not overrate their teaching behaviors in any of the items that eval uated preceptor communication skills [3]. Another study also reported no significant differences between teachers and stu dents in their attitudes toward communication skills [4]. Our findings may have been due to the recruitment of a small sam ple of preceptors in this study. This inconsistency may also have resulted from the longterm history of clinical pharmacy practice in the universities that were evaluated in those studies [3,4]. Students claimed strong reservations regarding whether in structors had broad knowledge suitable for the management of patients in clinical settings (P = 0.01). This may have been due to the fact that teaching materials are often introduced from other countries with limited consideration of local cir cumstances. It should also be realized that a greater focus on foreign information sources might not be relevant for acquir ing and applying appropriate and uptodate knowledge to in dividual patients (P = 0.00), which may have been why a dif ference was noted between students and preceptors in regard to this issue [5]. The new implementation of clinical pharma cy services results in exaggerated expectations from patients and students on one hand and frustrations from preceptors on the other [6]. Thus, students provided lower ratings than preceptors regarding instructors' sensitivity to patient needs, while preceptors provided higher rating than students regard ing their sensitivity (P = 0.01). Students believed that the ser vices were unsatisfactory for patients, whereas instructors tend ed to overrate their services (P = 0.02). This discrepancy may be due to the fact that preceptors do not work fulltime as pro viders of care. Encouraging students to take time to evaluate their own performance (P = 0.01) is important for increasing their efficiency. Preceptors try to accomplish this task through student consultation and by forming groups of one to five stu dents in which one student evaluates and makes suggestions about the performance of the other group members. Despite these efforts, students remained relatively unsatisfied with the instructors' ability to motivate students to evaluate their own performance. This may be due to the fact that such modes of instruction are still considered novel, and students' perceptions and attitudes towards group discussion need to change [7]. Students did not agree that the instructors graded them im partially (P = 0.02). The assessment of students during clerk ship is prone to subjectivity. However, preceptors tried to re duce this subjectivity by evaluating students based on case presentations, seminar presentations, pretests, portfolios, and oral and written examinations, so that students could prepare themselves to be evaluated using these parameters. However, students were not fully convinced of the value of this evalua tion system because they had experienced a direct shift from a long written examination to a more detailed mode of assess ment. Furthermore, they were required to cover a tremendous range of topics. Students felt less confident than preceptors about the preceptors' ability to comment on students' strengths and limitations in clinical practice (P = 0.02). This situation might create gaps between the extent of feedback that is pro vided and the degree to which it is implemented by students. Research has found that student ratings of preceptor perfor mance can be a reliable and valid indicator of effective teach ing. Some studies have also examined students' perceptions and found that student assessments were an effective means of voicing their opinions about teaching; nonetheless, students were not fully aware of the implications of their evaluations for university instructors [8].
We would like to identify further predictors for low ratings provided by students and recommend another study to ad dress the potential factors that may contribute to this dynam ic. The present study provides a comparison of students' and preceptors' perceptions of the instructors' teaching behavior. By doing so, it provides essential input for the improvement of pharmaceutical education because it is the first comparative study of this nature, to the best of our knowledge. In addition, this study provides directions for future research. However, this study was conducted in a single institution and the results might not be generalizable to other institutions in Ethiopia.
In conclusion, uneven ratings were observed between stu dents and preceptors regarding preceptors' teaching behavior. Preceptors rated their teaching behavior more highly than students did. Shortterm training is warranted for preceptors to overcome limitations in their teaching behavior. Special at tention should be paid on items for which a significant differ ence was observed between preceptors and students. In par ticular, preceptors should be trained in the implementation of service learning in clinical rotation sites and in mentorship in general. Preceptors should participate in workshops involving the development and implementation of new guidelines in order to obtain and demonstrate broad knowledge suitable for the management of patients in clinical settings.