Bridging Theory and Practice: Challenges in Clinical Skill Application Among Radiology Technology Trainees in Ethiopia

Abstract

Background

The goal of clinical practice is to bridge the gap between theory and practice by preparing students to apply their classroom-based knowledge and skills to real patient situations. However, clinical practice faces many challenges based on the setting and infrastructure of the country's clinical learning environment. This qualitative study focused to explore the challenges faced by Medical Radiology technology students and instructors during clinical practice at Hawassa University.

Methods

A qualitative exploratory approach was conducted from June 15, 2022, to July 15, 2022. The participants consisted of 28 medical radiology technology students and 8 medical radiology technology instructors. The participants were selected using a purposive sampling technique, and data were collected using semi-structured open-ended questions. Focus group discussions and in-depth interviews were audio-recorded, and notes were also taken. The audio-recorded data were transcribed, translated, coded, categorized, and conceptualized into 4 major themes using thematic analysis and ATLAS ti.7.

Results

In the study, we conducted a thematic data analysis to identify 4 key themes that emerged from the data. The findings revealed that department-related factors, clinical learning environment factors, clinical supervision-related issues, and poor pedagogical approaches negatively impacted the clinical experiences of radiology technology trainees.

Conclusion

The study revealed significant challenges faced by radiology technology students during clinical practice in the study area. These included insufficient supervision, disorganized training, inadequate equipment, and overcrowded clinical settings. To enhance students’ clinical competence and future radiography skills, the curriculum and clinical training model should be revised to better integrate theory and practice. Establishing supportive clinical learning environments through improved supervision, structured protocols, adequate equipment, and reasonable patient loads is crucial for developing radiographers who can use radiology technology equipment safely and appropriately.

Keywords

barriers skill medical radiology technology clinical trainees environment

Introduction

According to the guidelines set forth by the American Society of Radiologic Technologists (ASRT) in 2023 and Ethiopian Nationally Harmonized Modular Curriculum for Medical Radiologic Technology, it is mandatory for radiology technology and radiation therapy specialists to possess the necessary educational preparedness and clinical proficiency before engaging in professional practice.^1,2 These standards emphasize that only professionals who have completed the appropriate education and training should be responsible for performing radiology technology and radiation therapy procedures. Additionally, individuals working in multiple modalities must meet the specific requirements for each modality they are responsible for.³

The clinical learning environment is a crucial part of the curriculum for radiology technology students. It serves as a platform for them to apply their knowledge and refine their skills through practical experience and evaluation. This hands-on experience is essential in helping students achieve proficiency and competency in their field.³

In radiology technology education, there are 2 fundamental components: theory and practical application. While theoretical knowledge is important, the practical component is equally indispensable. It allows students to gain real-world experience in radiology technology, develop their skills, and become familiar with standard protocols and responsibilities in the field of medical radiology technology.⁴

Clinical practice is an integral aspect of radiology technology and training.^5–11 It is a practical component of radiology technology where students gain supervised working experience in the clinical setting. During clinical placements, students apply the classroom theoretical knowledge to actual patient care scenarios.^7,12–14 Radiography students prior to completion of their program are expected to attain certain competencies to attain certification to practice. This makes clinical placement an essential aspect of radiology technology.^8,9. The goal of clinical practice is to bridge the gap between theory and practice by preparing students to apply their classroom-based knowledge and skills to real patient situations. By observing experienced preceptors, students gain valuable insights and practical experience, enabling them to integrate their theoretical understanding with the realities of radiology technology.¹⁵

Previous studies have focused on the importance of student learning in clinical practice, primarily examining the experiences of students from healthcare professions other than Medical Radiography education, such as nursing, during their clinical placements.^16,17 However, there is a lack of evidence regarding the challenges faced specifically by Medical Radiology technology students and instructors during their clinical practice, particularly in resource-limited countries like Ethiopia. Therefore, the purpose of this study was to address this research gap by exploring the challenges encountered by Medical Radiology technology students and instructors during their clinical practice.

Methods and Materials

Study area and period

This study was conducted at Hawassa University College of Medicine and Health Sciences in Hawassa City, Ethiopia, which is located 273 km south of Addis Ababa. The College offers both academic and community services through its specialized hospital as well as various academic schools and departments. The College consists of 34 programs, including 17 first-degree programs, 10 s-degree programs, 6 specialty programs, and 1 PhD program across 2 faculties – the Faculty of Health Sciences and the Faculty of Medicine.

The medical radiology technology department is an undergraduate program within the Faculty of Medicine. At the time of the study, the MRT department had 106 regular undergraduate students enrolled and 12 MRT instructors working in the department. Data were collected from June 15, 2022, to July 15, 2022.

Study design

A qualitative exploratory approach using the phenomenological method was employed.

Population

Medical radiology technology students who participated in 2 or more clinical practice experiences and clinical training at the affiliated hospital were included in this study while, the medical radiology technology students who were not willing to participate in the study were excluded and Medical Radiology technology instructors who were not exposed to clinical teaching experience sufficiently in a clinical learning environment at an affiliated hospital in Hawassa University were excluded.

Sample size and sampling technique

The study was conducted at Hawassa University, College of Medicine and Health Science, Department of medical radiography education, Hawassa, and Southern Ethiopia. The study participants comprised 28 medical radiology technology (MRT) students in their third to fourth academic years, with 16 students participating in 2 focus group discussions (FGDs) and 12 students engaging in face-to-face in-depth interviews. The sample was diverse in terms of sex, academic year, and experience in a clinical learning environment to ensure comprehensive data collection.

For the FGDs, 2 groups were formed, 1 from third year MRT undergraduate students and the other from fourth year MRT undergraduate students, with 8 students in each group. The sample size for the face-to-face interviews was determined based on data saturation. In this study, data saturation refers to the point in the data collection process where enough information has been gathered that no new themes, insights, or information are emerging from additional interviews. Finally, a total of 12 MRT students from the third and fourth academic years were interviewed.⁸

A purposive sampling technique was used to select participants who could provide detailed insights into the challenges faced by MRT students and instructors during clinical practice. For the face-to-face interviews, students from the third and fourth academic years with significant clinical practice experience and who had not participated in the FGDs were purposefully selected. The interviews lasted approximately 30–45 min and were conducted until data saturation was reached. Maximum variation sampling was employed to capture a wide range of experiences and perspectives, including both male and female students from different academic years.

The FGDs were conducted in a quiet setting at a time convenient for the participants and lasted approximately 45–90 min. Instructors with extensive experience in the clinical teaching environment were purposefully selected for in-depth face-to-face interviews, which continued until data saturation was achieved, ensuring a comprehensive understanding of the challenges faced by MRT students and instructors during clinical practice at Hawassa University.

Data collection instrument and procedure

The interview was initiated with broad, open-ended semi-structured inquiries concerning the participants’ clinical experiences, followed by targeted questions based on their responses. Data acquisition involved multiple methodologies, including 2 focus group discussions (FGDs), individual interviews with audio recording, and field notes compiled by researchers. The data collection tool was derived from an extensive review of existing literature.^{1,2,5–14,18,19} Initially formulated in English, the semi-structured interview guide was subsequently rendered into Amharic and Afaan Oromo to facilitate comprehensive participant engagement.

Two focus group discussions were conducted to elucidate the challenges faced by Medical Radiology technology (MRT) students and instructors. Face-to-face in-depth interviews with MRT students and instructors were conducted individually and conveniently based on the participants’ willingness in the MRT Department, School of Medicine and Health Sciences, Hawassa University. Two well-trained moderators selected to conducted focus group discussions with the MRT students to achieve a more comprehensive understanding of this phenomenon. A group interview allows students to express their experiences and opinions regarding challenges faced by MRT students and instructors in a group setting, and in lieu of a researcher, group members are responsible for encouraging one another to speak.

Two BSc nurses, 2 MRT students, and 1 medical radiology technologist were recruited as data collectors, moderators, and supervisors, respectively, and underwent 2 days of training. Data collectors were recruited from the nursing department to mitigate power dynamics, influence, and bias in data collection concerning the challenges faced by MRT students and instructors.

Data quality control

To ensure the quality, consistency, and reliability of the data, appropriately designed data collection tools were used. Prior to conducting the actual data collection, the questionnaire was checked by pre-testing 6 MRT students and 2 MRT instructors from Negelle Arsi General Hospital and Medical College. Findings and experiences from the pre-test were utilized to modify and reshape the research data collection tools. Training was given to data collectors and supervisors about the research objectives, confidentiality of information, and extraction techniques before data collection. To enhance Scientific Rigor and Data Quality Assurance for qualitative studies, the following key strategies were followed:

Credibility

In this study, methods were proposed to enhance credibility through prolonged engagement, triangulation, and debriefing with peers.

Dependability

Reliability of the study in the data collection and analysis process. Accurate documentation, including all documents in the final report, avoiding spelling and grammatical errors that reduced the quality of work, and a detailed description of producers were included.

Conformability

The data were checked by independent researchers based on data accuracy, relevance, and meaning.

Transferability

Transferability was ensured by a detailed description of the study setting, thereby providing opportunities for other readers.

Confirm ability

The degree to which the results can be corroborated by other results should be well-reasoned, and the results of the study versus the researcher's bias checked. The reporting of this study conforms to, the principles outlined by Yardley and the Standards for Reporting Qualitative Research were adhered to as a guiding framework throughout the course of this study^20,21 file:///C:/Users/2974/Downloads/ISSM_COREQ_Checklist%20(1).pdf

Data processing and analysis

The generated data were then analyzed using a coding approach in thematic analysis through qualitative data analysis. This involved various stages, such as transcription, familiarization, code generation, theme searching, theme reviewing, theme definition and naming, and final report writing. The inductive coding system and ATLAS Ti.7 version software were utilized for this purpose.²²

Results

Sociodemographic characteristics of the participants

The study comprised a total of 28 MRT students and 8 instructors. The students selected for the study were in their third and fourth years of study. To gather relevant socio-demographic data, participants were requested to provide information on their age, sex, and year of clinical learning experience. In addition, all 8 instructors were individually interviewed for the study and all the instructors held the position of assistant lecturers, as indicated in (Table 1).

Table 1.

Socio-demographic characteristics of the participants at Hawassa University, 2022.

				SEX
NO	PARTICIPANTS STATUS	AFFILIATION		MALE	FEMALE
1.	Students	Hawassa University comprehensive specialized hospital, radiology department	Year III	13	4
1.	Students		Year IV	5	6
2.	MRT instructors	Hawassa University MRT department		5	3

Challenges faced by medical radiology technology students and instructors during clinical practice

The study emphasizes the pivotal role of the practical environment in the Medical Radiation Therapy (MRT) profession. The practical setting serves as a platform for translating theoretical concepts into practical applications, enhancing clinical experience, and bridging the gap between classroom-based teachings and hands-on clinical experience. The majority of participants in the study recognized the significance of practical training in the MRT profession, emphasizing its importance in preparing students for their future careers.

Clinical practice is the place where the theoretical knowledge is transformed into practice or skill. We will associate real-life scenarios with real patients to develop social and decision-making skills. (ST13) – (Aged 28, male, third-year post-basic MRT students).

The findings revealed 4 main themes, each with its corresponding subthemes. The themes identified are as follows: department-related factors, clinical learning environment-related factors, factors related to clinical supervision, and issues with the curriculum and pedagogical approaches. These findings are visually represented in (Figure 1).

Figure 1.

Schematic diagram showing the main themes and subthemes related to the challenges medical radiology technology students and instructors faced during the clinical learning environment at Hawassa University, 2022.

Theme 1: Department-related factors

This main theme consisted of 3 subthemes: lack of awareness from the stakeholders, lack of budget, and structure of the MRT department.

Subtheme 1: Lack of awareness from the college dean and coordinator

Numerous participants in this study highlighted a prevailing issue of limited recognition and awareness concerning the MRT department among the college dean and higher officials. Moreover, a lack of effective communication and connection was observed between the students, instructors, and managers in relation to the MRT teaching and learning process. This lack of awareness on the part of college higher officials has resulted in a negative impact on the clinical learning environment for MRT students, and it has also hindered the motivation of MRT instructors to fully engage in teaching the students.

In my opinion, the major problem we encountered at clinical practice as MRT students is that I think the college does not know anything about the MRT students or the radiology service given by the MRT personnel. They didn’t give focus or recognition on our department. (Student (ST1)) – (Age 21, male, third-year student).

Hawassa University College Medicine and Health Science doesn’t give focus to MRT department instructors and the role of the radiology service we give to the patient as a whole. For example, there are no fulfilled facilities expected from the college; the MRT department office, class room, LCD, personal computer for instructors, and others to develop their careers. As the MRT instructors also don’t have a separate office to give advice or give some feedback to the students. Personally, this treatment affects my commitment and I don’t feel like I am important personnel for the college. (Instructor (In2)) – (Age 32, male, 5 years clinical learning experiences instructor).

In addition, as 1 student described the situation:

Does the MRT department have clear recognition among the stakeholders of the university and college? This is my first question. If it is known, why do not give the emphasis to this department's students and instructors? (ST7) – (21years, female, 3rd year student).

Subtheme 2 : Lack of budget

Through the focus group discussions and in-depth interviews, it became evident that a lack of financial resources was a prominent concern raised by all participants. The majority of individuals involved in the study expressed dissatisfaction with how the college treated MRT students and allocated funds for their clinical training and basic amenities, particularly when compared to other paramedical students. This disparity in resource allocation has led to a sense of dissatisfaction among the participants and has brought attention to the need for improved financial support for MRT students.

There is a budget problem for our department because there are no basic facilities like transportation service and incentives for technologists working in other hospitals to accept the students. These negatively affected the students’ ability to fully practice in the various imaging modalities and to get different experiences from other technologists. (In3) – (Age 29 years, male, 6 years clinical learning environment instructor)

The college doesn’t provide or arrange transportation, accommodation, and food service for students during clinical placement areas due to insufficient budget allocation. And also, the time given for clinical practice is short. The department and college want to cover the clinical learning environment within a short period. So I can’t say they are getting sufficient time and resources to be competent and proficient MRT professionals. (In6) – (Age 44, male, 8 years clinical learning experiences instructor)

Subtheme 3 : Structure of the department

During the focus group discussions and individual interviews, both instructors and students raised concerns about the departmental structure. One key issue highlighted was the absence of a designated individual responsible for coordinating the instructors and students within the department. The findings of this study have identified the department structure as a critical challenge in the clinical learning environment. At the study area, the MRT department recently merged with the radiology unit, and it is currently headed by a radiologist. However, this individual's lack of interest in MRT professions due to a conflict of interest between the 2 fields has created difficulties. As a result, the MRT department lacks the necessary authority to make decisions regarding students and other essential facilities required for clinical learning.

As the MRT department, there is no clearly set platform for the MRT students’ and instructors’ role. Recently, we have been unified under the Radiology and MRT unit, which is led by the radiologist (department head). So the radiologist doesn’t know anything about MRT students and instructors’ teaching and learning processes. Furthermore, there is no term for head position. Therefore, this structure affects the instructors’ motivation to teach the students. (In6) – (Age 44, male, 8 years clinical learning experiences instructor).

Theme 2: Clinical learning environment associated factors

The majority of respondents in the Focus Group Discussions (FGDs) and face-to-face in-depth interviews reported identifying factors related to the clinical learning environment. These factors were subsequently organized into a main theme, which comprised 6 subthemes: inadequate placement site, unsupportive environment, shortage of equipment, inconvenient placement site, limited hands-on training, absence of effective communication, and lack of suitable role models.

Subtheme 1 : Insufficient placement site

The majority of participants in this study expressed that there were limited clinical placement sites available, which impacted their clinical learning experiences and perception of different imaging modalities working in both private and government hospitals. This was primarily attributed to budget constraints, as described by the department coordinator. Moreover, the inadequate ratio of students to clinical practice time further limited their exposure to clinical practice, with participants typically attending for only 2 or 3 days per week. The limited clinical placement opportunities provided by the program were deemed insufficient by participants, who noted that they lacked the necessary skills to work as MRT personnel. This was echoed by 1 instructor and 2 students who expressed similar sentiments.

In my opinion, we faced so many problems while we were attending the practical learning in Hawassa because we were only affiliated with other residents in the HUCSH for all imaging modalities, with lots of students in a confined room. In this case, we were not exposed to different placement areas and machines. (ST14 & In2)

Most hospitals do not accept MRT students to train on their machines because of patient privacy, comfort, and lack of incentives from the college. Therefore, all students were trained in our hospital for two or three days a week. This means we practiced for less than half the intended time. So due to the department and college's negligence, we didn’t get more practice areas and time. (ST2) – (21 years female 3rd year students)

Subtheme 2 : Unconducive environment

Participants in the study reported limited clinical placement sites, which impacted their clinical learning experiences and perception of different imaging modalities. This was due to budget constraints, as described by the department coordinator. The inadequate ratio of students to clinical practice time also limited their opportunities for effective learning. Participants attended clinical practice 2 or 3 days a week. The clinical placement did not provide them with sufficient skills for MRT personnel, as noted by an instructor and 2 students.

We faced so many problems during the clinical learning environment. There was inappropriate room construction and the drainage system passes through the CT scan and x-ray rooms. There is also unwanted noise coming from outside, which affects our attention during the clinical learning environment. (ST28) – (Age 21, male, three year clinical learning experiences, third year student)

For me, the clinical learning environment is not comfortable for clinical practice, and there is no clinical setup necessary for the students, no documents, a lack of sufficient skill labs and equipment, and a lack of competent staff. Generally, the institution doesn’t fulfill 30% of the requirements needed for clinical teaching. (In5) – (Age 27, female, 2years clinical learning environment instructor and working on X-ray)

Subtheme 3: Lack of equipment

It is imperative that learning resources and infrastructure are made available to participants. Moreover, the clinical learning environment is perceived to be enriching with ample opportunities for growth. However, despite the adequacy of conditions in the clinical learning environment, the majority of participants expressed that there was insufficient material, thereby hindering effective learning.

There were shortages of equipment during our clinical practice in all imaging modalities, specifically on X-ray and CT. For example, regarding radiation protection materials, there were no adequate or available radiation protection and supportive materials used for positioning of the patient in order to minimize radiation risk to the patient and attendant. Therefore, when it comes to real practice, you find that most of the equipment or accessories that you learned in class are not available in the hospital. (ST6) – (25 years old male 4th year student)

In addition, the 2 instructors’ perspectives were also supported as below.

…In my opinion, I think there was a shortage of ultrasound machines in the radiology department. Due to this, the students didn’t get the opportunity to perform ultrasound examinations very well. The radiologists also hurry to finish their work as much as possible because of the patient load. (In3) – (Age 29 years, male, 6 years clinical learning environment instructor)

There is a shortage of machines in our hospital. Currently, we are using only one X-ray machine. This X-ray machine is also not fully functioning. For example, standing up Bucky has not worked for a long time. For that matter, a PA erect chest x-ray was not performed. Therefore, it is difficult for me to teach students as well as give services to patients. (In5) – (Age 27, female, 2years clinical learning environment instructor and working on X-ray)

Subtheme 4: Inconvenient placement site

Participants formally expressed discontent with the high ratio of students to placement sites. There is a disparity between the number of students designated to a hospital or imaging center and the resources available to promote their clinical skill development. As 1 educator noted, this presents a significant hurdle in the teaching and acquisition of clinical proficiency.

The first and most difficult challenge we faced during the clinical learning environment was the disproportionality of the number of students and the capacity of the institution. For example, there is only one US machine in the hospital. On this US machine, there is a patient, staff (radiologist), and eight to ten MRT students. In addition, the resident students come from other departments. This makes the room overcrowded and then affects the students’ clinical learning experiences. (In7) – (Age 38, male, 8years clinical learning environment instructor)

Subtheme 5: Lack of hands-on practice

The majority of participants in this study were found to be deficient in hands-on experience during their clinical training in ultrasound and MRI. The absence of hands-on practice in these modalities was reported to have adversely affected the students’ acquisition of specialized imaging skills during their clinical placements, as documented below.

In ultrasound clinical practice, there is no one who shows us how to scan an ultrasound examination on the patient and follow it during the clinical learning area. We just get to the department for observation only during ultrasound clinical practice. (ST3) – (24 years old, 4th year, male and he has 3 years clinical learning experiences)

Ultrasound practice was the most difficult and worst clinical practice for me because we didn’t get what we were expecting. We didn't even touch an ultrasound probe during our clinical practice. Almost the whole time, we were working as porters (for calling patient names only) in the hospital and standing at the corner for observation. To tell you the truth, I touched an ultrasound probe/machine for the first time while they were asking me for clinical evaluation. (ST5) – (21years, female, 4th year student)

On the MRI machine literally, they informed us not to touch the machine. We don’t have freedom to use or touch the MRI machine. But for their evaluation purposes, they were expecting us to perform the MRI examination on the real patient without showing anything. (ST1) – (21 years male 3rd year students)

Subtheme 6: Lack of effective communication

The majority of study participants reported a lack of effective communication between instructors, students, and radiologist working in the clinical learning environment. Even though there was no communication observed between the patient and the radiologist and the instructors working in the clinical learning environment. As 1 student described below,

On MRT department instructors working in the clinical learning environment, they didn’t apply patient preparation, communication, and patient care, including the radiation protection mechanism. Literally there is no patient communication, care, radiation protection, or patient preparation during all clinical practice (X-ray, CT, and MRI). Even they didn’t ask the name of the patient. (ST7) – (21years, female, 3rd year student)

In addition, as 1 student and 1 instructor were supported below,

…Radiologists are compelled to respond to theoretical or practical questions that students raise to have a better understanding of concepts and skills. The responses obtained from some radiologists are unsatisfied, which may be due to the attitude they have towards us. This is not your scope. You just have to take an X-ray. In addition, they are not interested and don’t encourage students to perform skills; they are resistive and have discouraging verbal and facial expressions, which doesn’t allow one to get closer to them. (ST14) & (In4)

Subtheme 7 : Lack of role model at the clinical learning environment

This subtheme emerged from most participants in this study due to a lack of effective communication with the patient and a lack of compassionate and respectful care. In addition, the participants also reported unsupportive and unprofessional staff behaviors like disrespecting students, lack of cooperation, and lack of commitment from the technologists and radiologist working in the clinical learning environment. As 1 student pointed out below.

Some radiologists and technologists do not communicate with patients before and during the examination; they do not explain what they are doing for the patient. They hide behind the protocol or the ultrasound machine when they are inquiring or writing reports. This indicates that they do not want to raise questions from the patient or the students. They undermine us and they are totally arrogant towards us as well as the patients. (ST7) – (21years, female, 3rd year student)

Theme 3: Clinical supervision-related problems

The primary theme identified in this study encompassed 4 subthemes: scarcity of clinical coordinators, absence of orientation, dearth of motivation, and inadequate clinical evaluation and feedback mechanism.

Subtheme 1 : Lack of clinical coordinator

“The lack of a clinical coordinator was identified as a significant challenge by all participant of the student focus group and in-depth interviews. It was reported by all participants that they were dissatisfied with the supervision provided by the MRT instructors. Furthermore, many students expressed that they were unaware of the evaluation criteria and how they would be approached in the clinical learning environment. One student reported, ‘I didn't know what to expect in terms of how I would be evaluated and how I should be approaching the clinical environment.’” “Generally, there was no clinical coordinator follow up and no instructors who were interested in teaching us and forcing us to read. In addition, the radiologists were not willing (cooperative and interested) to teach us about ultrasound clinical practice.” (ST5) – (21years, female, 4th year student)

The instructor's perspective is supported below.

There is a problem with clinical supervision. For example, there is no one who follows and instructs the students during clinical practice. The department also failed to assign an instructor to the clinical learning area to follow and coordinate the students, so no one knows whether or not the students are actually attending the hospital. (In2) – (Age 32, male, 5 years clinical learning experiences instructor)

Subtheme 2: Lack of orientation

This subtheme emerged from the in-depth interviews of all participants as the major challenge of the clinical learning environment.

There is no orientation given by the department before the clinical practice and instructions come from the instructors on the way we are going to perform our clinical learning area. We don't even have enough information about equipment or protocols used in the hospital. (ST13) – (Aged 28, male, third year post-basic MRT students)

Subtheme 3: Lack of motivation/commitment

On the instructors’ side, there is no commitment to teach us very well and they just come only to take the assessment. So it's better if the instructors smoothly communicate with us in order to gain knowledge and skills expected from us to help the patient. This could be due to they are being busy with their personal business. I'm telling you the truth, the instructors don't invest the time allotted to us to guide us in the practical area; instead, they seek and run personal businesses. (ST7) – (21 years female 3rd year student)

Subtheme 4: Inappropriate clinical evaluation and feedback mechanism

The vast majority of participants in this study recognized that the most significant clinical evaluation challenge was the absence of a thorough and suitable evaluation instrument for evaluating students. This deficiency in objective and clinical evaluation tools, which measure the students’ clinical competencies and learning process, causes instructors to rely on subjective judgment, resulting in bias. As 1 student articulated,

There is no clearly set assessment method for our final oral exam at the end of the clinical practice and there is no fairness while they are giving us feedback, even though we stayed for 3 months in the hospital for ultrasound practice. But the evaluation was made at the end by an oral exam out of 60%. This is not important to attend in clinical practice. Generally, there is no guideline or protocol to evaluate students in a clinical learning environment. (ST27) – (Age 21, male, three year clinical learning experiences, and fourth year student)

The department doesn’t follow the students and assign the instructors. There is no clinical assessment method. If there is an assessment, the evaluation will be taken without any guidelines, objectives, or protocols for clinical learning assessment of the students. All students were assessed by one instructor, who is the department coordinator. (In5) – (Age 27, female, 2years clinical learning environment instructor and working on X-ray)

Theme 4: Poor pedagogical approaches

The majority of participants from the focus group discussions (FGDs) and in-depth interviews identified the challenges of the clinical learning environment as the main theme. Six subthemes emerged: the discrepancy between theory and practice, the absence of protocols or guidelines, the lack of manpower, the inadequate amount of time allocated for clinical practice, the lack of skill labs and demonstrations prior to clinical practice, and the inappropriate programming of clinical practice.

Subtheme 1 : Gap between theory and practice

MRT students and instructors were requested to provide their insights regarding their experiences and challenges encountered during the clinical learning environment through Focused Group Discussions (FGDs) and face-to-face in-depth interviews. The findings revealed a substantial discrepancy between the theoretical knowledge acquired in the classroom and the practical application in clinical practice.

There is a gap between theory and practice. For example, in theory, we learned about tube angulation in the skull radiographic examination in order to clearly visualize all parts of the skull. However, we found that technologists do not apply this technique. (ST18)

We have learnt so many things in the class, but there is not much more chance to do them in actual settings.

To speak frankly, what we have learned in theory and what is being practiced in the clinical learning environment are totally different. For example, on patient care, theoretically we learned a lot about how to have good patient care and infection prevention. But practically, there is nothing at all. No one is applying patient care and communication. In particular, they were using one glove for all patients that came for radiographic examinations. (ST7) – (21 years female 3rd year student)

On special radiographic procedures, theoretically we learnt in detail about special radiographic examinations and fluoroscopy machines. But practically, we didn’t observe any special radiographic procedures or even see any fluoroscopic machines in the hospital. There is no special radiographic examination. Therefore, our skill in this special radiographic procedure is highly compromised. (ST17)

There is a huge gap between what we have learned in the class and what we observed during our clinical learning experience. For example, in the theory we learned in the class room, there are some exposure techniques that could be applied in order to protect both the patient and staff from unnecessary radiation. However, we found that technologists do not apply this technique. (ST5) – (21years, female, 4th year student)

Subtheme 2 : Lack of human resources (insufficient educators)

A significant proportion of participants in the focus group discussions and in-depth interviews expressed dissatisfaction with the qualifications and expertise of the MSc MRT instructors. The prevailing sentiment among students and instructors was that the majority of instructors lacked adequate clinical experience in ultrasound, a solid foundation in theoretical knowledge, and the necessary practical skills. This deficiency in higher education is believed to be the root cause of these shortcomings.

I can't see myself as a lecturer (assistant lecturer) because I teach BSc students with BSc. I can’t fulfill the academic criteria of the university. So we lack some knowledge and skills to teach the students. This affects my motivation and discourages the students’ learning environment. Generally, there are no MSc MRT instructors in our department. (In6) – (Age 44, male, 8 years clinical learning experiences instructor)

Subtheme 3 : Lack of objectives/protocol/guidelines

The majority of participants in the study declared that there are no established objectives, protocols, or guidelines in clinical practice. Furthermore, there are no morning sessions, weekly presentations, or seminars that foster clinical learning environments for students. Consequently, the lack of these teaching guidelines impairs students’ ability to develop proficient skills.

Subtheme 4: Time allocated for clinical practice

The restriction on clinical training hours and the scarcity of opportunities to engage in related theoretical classes, exams, and regulations pose a significant challenge to students seeking to acquire skills in a clinical learning setting.

The time given for clinical practice was short and not organized. In addition, they were wasting our time on unnecessary courses like global trends and economics. (ST2) – (21 years female third year students)

Other problems we faced during clinical practice were time constraints or tightness of the time given for the clinical practice as well as the fact that there is also a theory class simultaneously. (In7) – (Age 38, male, 8years clinical learning environment instructor)

Subtheme 5 : Lack of skill lab and demonstration prior to clinical practice

Most students in the focus group discussions and in-depth interviews identified the lack of a skills lab and demonstration prior to clinical practice as a problem in their clinical practice.

Another problem with our department is not having a skills lab and demonstration before and during clinical practice in order to be more skillful. (ST1) – (Age 21, male, third year student)

Subtheme 6 : Unsuitable programming of the clinical practice and course sequences

The majority of participants in this study, as gleaned from Focus Group Discussions (FGDs) and in-depth interviews, perceived that unsuitable clinical practice schedules and inappropriate theoretical course sequences negatively impacted their clinical learning environment.

There is a problem with the schedule of the clinical practice and theoretical course sequences. For example, we are taking the CT and MRI practices before the radiological pathology courses. But radiological pathology is essential and a pre-requisite for CT, MRI, and US. In addition, there is a parallel theory to the course during clinical practice. It's better to adjust the theoretical course sequences like equipment, radiological physics, and imaging to be given before the positioning and procedure courses. (ST9) – (27 years, male, third year post-basic student)

Discussion

The research findings, derived from focus group discussions and in-depth interviews, suggest that the MRT students and instructors in the study area experience difficulties in their clinical practice that are related to department-specific factors, the clinical learning environment, clinical supervision, and poor pedagogical approaches.

Theme 1: Department-related factors

It has been ascertained by the MRT students and instructors that the department-related factor is the principal cause of inadequate clinical skill acquisition among MRT students during their clinical learning experience. Consequently, 3 subthemes have come to light: a lack of awareness on the part of stakeholders, a lack of financial resources, and a lack of organizational structure within the department.

A significant proportion of participants in this study have indicated that the MRT department is undersupplied in terms of recognition from stakeholders and an adequate setup, which is impeded by bureaucratic constraints and a lack of allocated budget. This finding is consistent with a study carried out in Rwanda, which underscores the crucial role of organizational support and infrastructure in the development of proficient radiographers.⁴

The study's findings unequivocally highlighted the department structure as a significant hindrance to the clinical learning environment. Specifically, the MRT department at Hawassa University, which was recently merged with the radiology unit, lacks authority due to the department head's lack of interest in MRT professions. This conflict of interest undermines the department's ability to make decisions regarding students and basic facilities necessary for clinical learning. This deficiency in the department structure negatively impacted the clinical placement experience of students.

Theme 2: Clinical learning environment associated factors

The clinical environment, characterized by an interconnected array of factors within the clinical setting, exerts a significant impact on the learning experience of students.²³ Clinical learning is a multifaceted and context-dependent process that is influenced by both activity and cultural factors, as well as the broader societal and organizational milieu in which it takes place.²⁴ The clinical learning environment (CLE) exerts a significant influence on the educational development of students. It embraces all aspects that a student encounters, including equipment, clinical supervisors, clinical staff, and patients.^25,26 Through the focus group discussions and face-to-face in-depth interviews, the participants identified that the clinical learning environment-related challenges were the primary factors affecting the teaching and learning process of the Medical Radiologic Technology (MRT) students and instructors. The lack of sufficient placement sites, unsupportive environment, inadequate hands-on training, poor communication, and the absence of adequate role models were among the key challenges highlighted by the participants. Furthermore, the absence of necessary equipment and facilities resulted in wasted time and delays in patient diagnosis, and the educational environment was uncomfortable for the students. Radiologists and technologists also expressed dissatisfaction with the inadequacy of the physical space to accommodate the large number of students in the department. A study conducted at Addis Ababa University and other similar settings has also revealed that a high student-to-placement site ratio presents a significant inconvenience. There exists a disparity between the number of students assigned to a hospital or imaging center and the available resources to support their learning.¹⁸

It has been demonstrated by studies conducted in Kenya and Ethiopia that the suitability of the placement environment is contingent upon various factors, including the availability of resources and the departmental culture, as well as the quality of relationships between the academic and clinical departments. The quality of social interactions within the clinical department is of utmost importance for the enhancement of student learning in the clinical learning environment.^19,²⁴ On the contrary, the results of this study indicate that there is no existing partnership between the academic department (MRT) and clinical colleagues to support student learning during their clinical placements. Furthermore, the investigation exposed a significant communication issue between academic and clinical colleagues due to the conflicting interests between them.

A systematic review conducted in Iran reported that a conducive CLE is supported by a good departmental atmosphere and relationships. Students feel confident and motivated to learn in an environment where they are respected, supported, and regarded as part of a team.²⁵ In contrast, our findings indicate that there is a problem with the conducive environment to support and respect MRT students’ clinical learning due to the lack of motivation from the radiologist and the instructors’ insufficient knowledge and skills toward clinical learning experiences.

Theme 3: Clinical supervision-related problems

In the realm of clinical supervision in MRT clinical training, the majority of study participants highlighted significant challenges. These challenges can be categorized into 4 subthemes: lack of a clinical coordinator, inadequate orientation prior to clinical practice, lack of motivation, and ineffective clinical evaluation and feedback. As teachers, it is crucial for us to provide MRT students with the necessary training and support before they enter clinical settings and help them embrace their roles as professionals. However, both our study and previous research indicate that MRT instructors and other health science educators, such as nurses, lack the efficiency, expertise, and abilities required to effectively train students in this area.²⁷ Furthermore, survey participants expressed concerns about instructors’ lack of enthusiasm in teaching students, inadequate orientation prior to clinical practice, and the absence of clear assessment tools for evaluating clinical learning. Many students in our study reported that MRT instructors only appeared during clinical practice to collect evaluations, suggesting that they were preoccupied with personal matters.

In a study conducted in Iran, it was highlighted that effective treatment and communication with students are crucial aspects for nursing teachers to serve as role models for their students.²⁸ Unfortunately, in our study, poor support and ineffective communication from instructors in the clinical learning setting led to vulnerable students with reduced confidence in their work and a lack of enthusiasm to learn. Students also expressed dissatisfaction with being abandoned during clinical practice and inadequate monitoring and follow-up from their instructors.

Similar to our findings, a study conducted in Malawi revealed that the lack of support in clinical teaching and supervision significantly impacts students’ clinical learning experiences. Students highly value familiarity, acceptance, trust, support, respect, and recognition of their contributions to patient care in the clinical setting.²⁹ The study further emphasized that support from lecturers and tutors during clinical practice helps alleviate fears and anxieties, provides guidance and encouragement, and enables students to acquire the necessary knowledge, skills, and attitudes to deliver high-quality patient care.²⁹ The significance of clinical supervision discovered in our investigation aligns with findings from studies conducted in Iran and other countries.³⁰

The study conducted at Addis Ababa University further supports the notion that instructors’ supervisory role in assisting students is critical for facilitating their learning, establishing effective communication with the department, and preventing unnecessary conflicts between students and departmental technicians. Moreover, students believe that increased involvement of instructors in the evaluation process will enhance their practicum experience.³¹ Additionally, our study identified flaws in the clinical learning evaluation and feedback processes, which reduced students’ motivation to learn in the clinical setting. An Iranian study indicated that nursing students expressed dissatisfaction with their clinical assessments and evaluations, as they believed the nursing personnel conducting these assessments lacked knowledge and experience in providing feedback.²³

Theme 4: Poor pedagogical approaches

This study showed that there are big differences between what students learn in class and what they do in real life. This made students feel anxious and confused. But we know that learning happens when students can apply what they learned in class to real radiography work. The idea of connecting theory and practice is really important for training future professionals.¹⁹ Previous research indicates the big gap between classroom learning and clinical training is caused by how the courses are designed.³² Our findings focus on suggestions from the participants to improve clinical experience and skills. This includes having skill labs and demos before clinical practice, having the same professors who teach theory also supervise clinical placements right after teaching the concepts, and fixing the course schedule to allow more time for clinical practice.

A study at Addis Ababa University also found students wanted equal time across different imaging methods to build confidence. And they wanted to practice clinical skills in a lab before going to clinical sites. This study also showed not having enough instructors in the clinical setting creates a theory-practice gap and hurts students’ clinical competence.^18,31 To build clinical skills, universities must design curricula with proper training in skills labs AND clinical sites. Clinical instructors should teach at both places to connect theory and practice.

Finally, the study found poor clinical programming and unstructured theory lessons hurt the clinical learning experience. An Indian study also revealed too many written assignments block clinical learning.³³ The clinical environment is crucial for radiography training. But effectively planning and executing MRT education has many challenges. It requires careful coordination and integration of educational goals across the technology's diverse clinical applications.

Strength and limitations of the study

The strength of this study lies in its qualitative approach, which allowed for a deep exploration of the experiences of MRT students and instructors in the clinical learning environment. This was achieved through the implementation of various data-gathering strategies and reaching data saturation, which enabled a comprehensive understanding of the subject matter.

However, it is important to acknowledge the limitations of the study. Firstly, the research focuses solely on the experiences of MRT students and instructors and does not include stakeholders who may have valuable insights. Furthermore, the study was conducted in a single setting, which restricts the generalizability of the findings. It is important to exercise caution when applying these findings to other contexts, as different settings may present unique factors and challenges. Additionally, conducting similar studies in diverse settings and contexts will help validate and expand upon the findings of this study, ensuring their relevance and applicability in a broader context.

Conclusions

The study conducted at the study area identified several challenges faced by students during their clinical practice, including department-related, clinical learning environment, clinical supervision-related, and curriculum and documentation-related factors. Participants emphasized the need for better resources for medical radiology technology education and patient radiology services. They also reported difficulties such as equipment shortages, inadequate clinical placements, and poor communication with staff. Furthermore, concerns were raised about the implementation of the curriculum and related documents, including a lack of connection between theory and practice, inadequate instructor knowledge, and a disorganized course sequence with limited clinical practice time. To address these challenges, the medical radiology technology department should appoint a clinical coordinator to improve the clinical learning environment and select appropriate clinical placement sites. Collaboration between the Ethiopian Radiographers and Radiology Technologists Association, the Ministry of Health, and the Ministry of Education is crucial to improve the implementation of the MRT curriculum and the clinical learning environment. By addressing these issues, the quality of clinical practice for students can be significantly improved.

Footnotes

Abbreviations

Acknowledgments

The authors would like to acknowledge the Institute of Health at Bule Hora University for their support in conducting this research. We are grateful for the suggestions and comments received from various individuals, which have contributed to the development of this study.

A special word of thanks goes to the dedicated data collectors who provided compassionate support and assistance throughout the entire data collection process. Their commitment and effort are greatly appreciated. The collaboration and contributions of all these individuals have been invaluable in the successful completion of this research.

Authors’ Contributions

AE, AA, YM, TU, and AA conceived the idea and designed the study, led data analysis and interpretation, developed the first draft of the manuscript, and made all revisions based on coauthor comments and suggestions. AE, AA, YM, TU, and AA critically revised the manuscript for important intellectual content and ensured the requirements of submission of the manuscript were met. AE, AA, YM, TU, and AA contributed toward the analysis and data interpretation, as well as revision and editing of the manuscript. All authors read and agreed to the final version of the manuscript for publication.

Availability of Data and Materials

All necessary information was included in the manuscript.

Consent for Publication

Not applicable

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics Approval and Consent to Participate

The Institutional Research Ethics Review Committee of Bule Hora University (IRERC) through this ref. no. (BHU/IOH/080112) granted ethical approval for this study through (BHU/RPD/934/14). Prior to the research, participants were fully informed about the objectives and purpose of the study. Informed consent was obtained from each participant through a written signature. It was made clear to the participants that they had the right to withdraw from the study at any time or choose not to answer any questions. Additionally, participants were assured that all data collected would be treated with strict confidentiality, using codes instead of personal identifiers. Furthermore, the research procedures followed the ethical guidelines outlined in the Helsinki Declaration of the World Medical Association. These guidelines ensure the protection of participants’ rights and well-being throughout the research process. By adhering to these ethical standards, the study aimed to conduct research in an ethical and responsible manner, safeguarding the rights and privacy of the participant's involved.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Alo Edin

Yenuse Molla

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