Nesredin Ahmed

Background and Aims: Telemedicine enhances healthcare access in resource-limited settings. In Ethiopia, despite its potential, implementation remains limited due to healthcare professionals' readiness. Therefore, this study aimed to assess the readiness of healthcare professionals for telemedicine implementation and its associated factors in public hospitals in the Harari region, Eastern Ethiopia, 2024. Method: An institution-based cross-sectional study was conducted from August 5-15, 2024, among randomly selected 383 health professionals at public hospitals in the Harari region. Data were collected using a structured, self-administered questionnaire assessing readiness, attitudes, digital competencies, and sociodemographic factors. The primary outcome was readiness for telemedicine implementation. Data were entered into EpiData version 4.6 and analyzed using STATA 17.0. Bivariate and multivariable logistic regression were used to identify factors associated with readiness. Results: Readiness to implement telemedicine was reported by 57.5% of health professionals (95% confidence interval (CI): 52.3-62.6). Having favorable attitude towards telemedicine (Adjusted odds ratio (AOR) = 2.61, 95% CI (11.63-4.15), computer skills (AOR = 4.07; 95% CI: 2.15-7.55), computer literacy (AOR = 3.00, 95%, CI (1.51-5.97), educational status (AOR = 4.84, 95% CI (1.31-17.79), work experience (AOR = 2.34, 95% CI (1.06-5.17) significantly associated with health professional's readiness for the implementation of telemedicine. Conclusion: More than half of the respondents demonstrated readiness for the implementation of telemedicine. Digital skills, educational level, work experience, and attitude largely determined readiness. These findings support targeted capacity-building interventions to enhance digital literacy and promote positive perceptions, thereby accelerating telemedicine adoption in Ethiopian healthcare settings.

Background: Pain assessment is a fundamental aspect of nursing care. Problems in applying pain assessment principles are more severe in low-income countries. This study aimed to assess pain assessment practice and associated factors among nurses working at the adult care unit at a public Hospital in West Hararghe Zone, Eastern Ethiopia, 2023. Methods: An institution-based cross-sectional study was conducted from July 15 to August 15, 2023, among 394 randomly selected nurses working in adult care units at public hospitals in West Hararghe Zone. A structured self-administered questionnaire and chart review were used for data collection. Pain assessment practice was evaluated using 8 "yes/no" questions, and total scores were computed. Nurses scoring ≥70% were categorized as having adequate practice, while those scoring below 70% were considered to have poor practice. Data was entered into EpiData version 3.1software and exported to the Statistical Package for Social Science (SPSS) version 26 for analysis. Bivariate and multivariable logistic regression were used to identify factors associated with pain assessment practice, with significance interpreted at p-value <0.05. Results: The overall self-reported pain assessment practice among study participants was found to be 63.5% (95% CI: 59.0% - 68.0%). Work experience of >5 years [AOR: 3.13 (95% CI: 1.21-8.14)], knowledge of pain assessment [AOR: 4.25 (95% CI: 2.51-7.18)], attitude towards pain assessment [AOR: 3.43 (95% CI: 2.05-5.72)], and having in-service training on pain assessment [AOR: 3.58 (95% CI: 1.05-12.23) were significantly associated with pain assessment practices. Conclusion: The study revealed that a moderate level of pain assessment practice was reported among participants, indicating room for improvement in clinical settings. Work experience, knowledge, positive attitudes toward pain assessment, and in-service training are significantly associated with pain assessment practice. These findings highlight the importance of enhancing healthcare workers' knowledge, attitudes, and training programs to improve pain assessment practices.

BACKGROUND: The 2023 iteration of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) estimated prevalence, incidence, and health burden for 375 diseases and injuries, including 12 mental disorders. We assess past, current, and emerging trends in the prevalence and burden of mental disorders across sexes and age groups, for 21 regions, 204 countries and territories, and by Socio-demographic Index (SDI) quintile, from 1990 to 2023. METHODS: Mental disorders included in GBD 2023 were anxiety disorders, major depressive disorder, dysthymia, bipolar disorder, schizophrenia, autism spectrum disorders, conduct disorder, attention-deficit hyperactivity disorder, anorexia nervosa, bulimia nervosa, idiopathic developmental intellectual disability, and a residual category of other mental disorders. A literature review identified epidemiological data for each disorder. These were analysed via a Bayesian meta-regression to estimate prevalence by disorder, sex, age, location, and year. Disorder-specific prevalence was multiplied by disability weights representing the severity of health loss associated with each disorder to estimate years lived with disability (YLDs). Deaths due to anorexia nervosa were assessed with a Cause of Death Ensemble modelling strategy to estimate deaths by sex, age, location, and year, and then multiplied by the standard life expectancy at age of death to estimate years of life lost (YLLs). YLDs equalled disability-adjusted life-years (DALYs) for all mental disorders except anorexia nervosa (the only mental disorder considered as an underlying cause of death in GBD), for which DALYs represented the sum of YLDs and YLLs. We presented prevalence, deaths, YLDs, YLLs, and DALYs as counts, age-specific rates per 100 000 population, and age-standardised rates per 100 000 population. FINDINGS: We estimated 1·17 billion (95% uncertainty interval 1·06-1·31) prevalent cases of mental disorders globally in 2023, equivalent to an age-standardised prevalence rate of 14 210·7 cases (12 849·5-15 940·1) per 100 000 population. These estimates represented a 95·5% (75·0-121·2) increase in prevalent cases and 24·2% (11·4-41·4) increase in age-standardised prevalence rate between 1990 and 2023. All mental disorders showed increases in prevalent cases between 1990 and 2023, while notable increases were seen in age-standardised prevalence rates for anxiety disorders, major depressive disorder, dysthymia, anorexia nervosa, bulimia nervosa, schizophrenia, and conduct disorder. There were an estimated 171 million (127-228) DALYs due to mental disorders globally across sex and age in 2023, equivalent to an age-standardised DALY rate of 2070·5 DALYs (1519·1-2750·5) per 100 000 population. Mental disorders contributed to 6·1% (4·8-7·6) of all-cause DALYs in 2023, making them the fifth leading cause of global DALYs (up from 12th in 1990). DALYs were almost entirely composed of YLDs. Mental disorders were the leading cause of YLDs in 2023 (up from second in 1990), explaining 17·3% (14·8-20·6) of all-cause global YLDs. Leading causes of mental disorder DALYs were anxiety disorders (ranked 11th among the 304 diseases and injuries at Level 4 of the GBD cause hierarchy), major depressive disorder (15th), and schizophrenia (41st). Globally in 2023, mental disorder age-standardised DALY rates were higher among females (2239·6 [1643·7-3014·1] per 100 000) than among males (1900·2 [1399·8-2510·8] per 100 000), and peaked in the 15-19 years age group (2617·3 [1850·6-3696·8] per 100 000). All locations showed increased mental disorder DALY rates in 2023 compared with 1990, ranging across countries and territories from 1302·4 (952·7-1683·7) per 100 000 in Viet Nam to 3555·8 (2661·9-4715·0) per 100 000 in the Netherlands. Across SDI quintiles, DALY rates ranged from 1853·0 (1352·1-2469·3) per 100 000 for middle SDI to 2184·1 (1606·1-2890·3) per 100 000 for high SDI. INTERPRETATION: A significant health burden was imposed by mental disorders in all countries and territories in 2023, irrespective of the health resources available. In some instances, this burden has increased over time and is unevenly distributed across populations. Stronger surveillance systems, particularly in low-income and middle-income countries, are required. Additionally, we need more coordinated and inclusive policies to reduce the burden through early treatment and prevention, tailored to sex and age differences across locations. Responding to the mental health needs of our global population, especially those most vulnerable, is an obligation, not a choice. FUNDING: Gates Foundation, Queensland Health, and University of Queensland.

BACKGROUND: Blood pressure regulation depends heavily on adherence to antihypertensive medication. Additionally, poor adherence to antihypertensive drugs leads to the development of hypertensive complications. However, little is knowen about the factors affecting antihypertensive medication adherance in Ethiopia, and no study has been conducted in the study settings. Therefore, this study aimed to assess antihypertensive medication adherence and associated factors among adult hypertensive patients in selected public hospitals in East Hararghe Zone, Eastern Ethiopia. METHODS: A facility-based quantitative cross-sectional study was conducted from August 20 to September 20, 2023, among 364 adult hypertensive patients on follow-up in selected public hospitals of eastern Ethiopia. A simple random sampling method was used to select the study participants. Data were collected through face-to-face interviews using a pretested structured questionnaire. Drug adherence status was assessed using Morisky Medication Adherence Scale-8. Data was analyzed using Epi-Data 3.1 and STATA 17.0, applying bivariate and multivariate logistic regression techniques. The association was declared using p < 0.05. RESULTS: The overall level of adherence to antihypertensive medications was 59.94% (95% CI: 54.65-65.06). Urban residence (AOR = 1.96; 95% CI: 1.21-3.18), college and higher education level (AOR = 3.41; 95% CI: 1.69-6.87), health insurance coverage user (AOR = 2.00; 95% CI: 1.11-3.59), having knowledge about hypertension (AOR = 1.75; 95% CI: 1.03-2.97), distance to health care facility less than 10 kilometers (AOR = 4.6; 95% CI: 1.97-10.73), having social support (AOR = 1.86; 95% CI: 1.13-3.08), and taking three and above medications (AOR = 0.28; 95% CI: 0.12-0.64) showed a statistically significant association with medication adherence. CONCLUSION: Adherence to antihypertensive medication was found to be low. This study identified place of residence, educational status, health insurance coverage, social support, knowledge of hypertension, distance from a health care facility, and number of medications as independent predictors of medication adherence. Therefore, improving accessibility of health care facilities, strengthening health insurance coverage, and providing health education about hypertension will improve antihypertensive medication adherence.

BACKGROUND: Cancer is a disease that occurs when abnormal cells grow uncontrollably, invade other cells, and spread to different parts of the body, leading to illness and, if left untreated, death. Patients with cancer are vulnerable to malnutrition as a result of the combined effects of the disease and its treatment. Malnutrition is a common problem among cancer patients. To design strategies and policies on health education, screening, and early intervention, a systematic review and meta-analysis are needed to highlight the burden of malnutrition among cancer patients in Ethiopia. METHODS: Electronic databases (SCOPUS, CINAHL, CAB Abstract, EMBASE, PubMed, and Web of Science), Google Scholar, and lists of references were used to search works of literature in Ethiopia. STATA version 17 was used for analysis, and the odds ratios of the outcome variable were determined using the random-effects model. Computing values assessed heterogeneity among the studies for I2 and P-values. Also, graphical diagnostic of small-study effect analysis was done using funnel plot to assess the publication bias. RESULTS: A total of ten studies were included with a total of 2,020 participants. This study revealed a pooled prevalence of malnutrition among cancer patients was 49.2% (95% CI: 35.5%, 63%). The subgroup analysis based on publication year revealed varying prevalence rates of malnutrition among cancer patients in Ethiopia. In 2020, a high prevalence of 86.5% (95% CI: 0.825, 0.904) was observed in Addis Ababa, the capital city. For the studies conducted in 2021, the prevalence ranged from 17.1 to 58.2% (95% CI: 0.053, 0.725). In 2022, the prevalence ranged from 48.1 to 56.7% (95% CI: 0.422, 0.54). Finally, in 2023, the prevalence ranged from 19.3 to 61.4% (95% CI: 0.048, 0.692). CONCLUSION: This meta-analysis revealed a high prevalence of malnutrition among cancer patients in Ethiopia. The findings underscore the need for systematic screening and effective nutritional interventions for individuals with cancer in Ethiopia. The study highlights the importance of a multidisciplinary approach involving healthcare professionals to optimize patient care and outcomes.

Background: Workplace violence remains a persistent health and occupational issue, but stakeholders often lack sufficient evidence to guide effective mitigation strategies. This review aims to ascertain the prevalence and determinants of workplace violence among healthcare providers in Ethiopia, where the issue is under-researched. Methods: The search included studies conducted in Ethiopia, regardless of publication year, that reported workplace violence among healthcare providers using PubMed, SCOPUS, Web of Sciences, EMBASE, CINHAL, Google Scholar, university repositories, and reference. After each author independently evaluated a study for inclusion, data was extracted, and disagreements were discussed and settled. A random-effects meta-analysis approach was used to evaluate the pooled prevalence, patterns, and determinants of workplace violence at 95% confidence intervals. Additionally, the I 2 and P -value were used to evaluate the heterogeneity. Meta-regression and subgroup analysis were used to assess the difference by study-level characteristics. Additionally, to evaluate the stability of pooled values to outliers and publication bias, sensitivity analysis and funnel plots were performed. Results: A total of 6986 participants from 17 eligible studies were included in this study. Of the participants, 56% (95% CI: 48%-63%) reported having experienced any form of workplace violence. Verbal abuse accounted for 57% (95% CI: 49-65%), sexual harassment for 56% (95% CI: 48-65%), physical violence for 55% (95% CI: 46-63%), and bullying/mobbing for 51% (95% CI: 40-62%), according to the participants’ reports of workplace violence. Working night hours (AOR: 1.57; 95% CI: 1.20-1.93), being female (AOR: 2.24; 95% CI: 1.07-3.41), being single (AOR: 4.58; 95% CI: 2.44-6.73), working in an emergency department (AOR: 3.87; 95% CI: 2.33-5.41), and consuming alcohol (AOR: 2.69; 95% CI: 1.10-4.28) were all associated with a higher risk of workplace violence. Egger’s test and the funnel plot revealed no publication bias, and sensitivity analysis demonstrated that the pooled odds ratios were stable. Conclusion: Given the comparatively high prevalence of workplace violence and its various types among healthcare providers, a multilevel intervention strategy was necessary to address and lessen its effects. In order to make the workplace safer and avoid negative consequences for health care providers as well as the larger healthcare system, this strategy should incorporate both individual-level strategies and targeted policies.

OBJECTIVE: The Human Papillomavirus (HPV) vaccine has offered a great promise to reduce the cervical cancer burden, yet its uptake remains limited, and the current evidence is mixed and inconclusive. This study aims to assess HPV vaccine uptake and its associated factors among adolescent school girls. DESIGN: A school-based cross-sectional study. SETTING: Schools in Harari regional state, Eastern Ethiopia. PARTICIPANTS: total of 416 female adolescent students, from 1 April 2024 to 30 April 2024. OUTCOME: Uptake of HPV vaccination. METHODS: A multi-stage sampling technique was used to select study participants. A structured interviewer-administered questionnaire was used for data collection. The collected data were entered into Epidata V.3.1 and analysed by using STATA V.17.0. A logistic regression model was used to assess the associations between dependent and independent variables. An adjusted OR with 95% CIs was used to declare a significant association. RESULT: Adolescent girls' uptake of the HPV vaccine was 49.26% (95% CI 42.65% to 56.59%) Being urban residents (AOR=2.59; 95% CI 1.61 to 4.18), having a government-employed mother (AOR=2.60; 95% CI 1.12 to 6.05), availability of health promotion in their vicinity (AOR=4.17; 95% CI 2.01 to 8.66), having a good knowledge of cervical cancer and HPV infection (AOR=1.64; 95% CI 1.05 to 2.57) were significantly associated with uptake of HPV vaccine CONCLUSION: Nearly half of the eligible in-school adolescent girls received the HPV vaccine. Being an urban resident, having a government-employed mother, the availability of health promotion in their vicinity, and having a good knowledge of cervical cancer and HPV infection were significantly associated with the uptake of HPV vaccination. Expanding health promotion and raising awareness of cervical cancer and HPV infection among rural adolescents could increase HPV vaccine uptake.

BACKGROUND: Chronic kidney disease (CKD) is common and ranks among the leading causes of mortality and morbidity. This analysis aimed to present global CKD estimates using the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 to inform evidence-based policies for CKD identification and treatment. METHODS: This analysis focused on adults aged 20 years and older over the period 1990 to 2023, from 204 countries and territories. Data sources used were published literature, vital registration systems, kidney failure treatment registries, and household surveys. Estimates of CKD burden, including deaths, incidence, prevalence, and disability-adjusted life-years (DALYs), were produced using a Cause of Death Ensemble model and a Bayesian meta-regression analytical tool. A comparative risk assessment approach estimated the proportion of cardiovascular deaths attributable to impaired kidney function and estimated risk factors for CKD. FINDINGS: Globally, in 2023, 788 million (95% uncertainty interval 743-843) people aged 20 years and older were estimated to have CKD, up from 378 million (354-407) in 1990. The global age-standardised prevalence of CKD in adults was 14·2% (13·4-15·2), a relative rise of 3·5% (2·7-4·1) from 1990. The region with the highest age-standardised prevalence was north Africa and the Middle East (18·0%; 16·9-19·4). Most people had stage 1-3 CKD, with a combined prevalence of 13·9% (13·1-15·0). In 2023, CKD was the ninth leading cause of death globally, accounting for 1·48 million (1·30-1·65) deaths, and the 12th leading cause of DALYs, with an age-standardised DALY rate of 769·2 (691·8-857·4) per 100 000. Impaired kidney function as a risk factor accounted for 11·5% (8·4-14·5) of cardiovascular deaths. High fasting plasma glucose, body-mass index, and systolic blood pressure were all leading risk factors for CKD DALYs. INTERPRETATION: CKD is a major global health issue, with rising prevalence and increasing importance as a cause of death and as a risk factor for cardiovascular death. A better understating of aetiology, appropriate screening, and implementation programmes are needed to translate advances in CKD treatment into improved patient outcomes. FUNDING: Gates Foundation, Wellcome, US National Kidney Foundation, and US National Institute of Diabetes and Digestive and Kidney Diseases.

Background: Spinal pain is a prevalent occupational health issue, particularly among bank workers who often experience prolonged sitting and poor ergonomic conditions. Despite the increasing occupational-related burden of spinal pain, data specific to bank workers in study setting, remains limited. Objective: This study aimed to determine the prevalence of spinal pain and its associated factors among bank workers in Harar, Eastern Ethiopia. Methods: An institution-based cross-sectional study was conducted among 322 bank workers from July 20 to August 20, 2023. Participants were selected using a simple random sampling technique to ensure unbiased representation. The standardized Nordic Musculoskeletal survey was interviewer-administered for data collection. Data were entered in EpiData version 3.1 and exported to STATA version 17.0 for analysis. Descriptive statistics, including frequencies and percentages, were applied to calculate the proportion. Bivariate and multivariable binary logistic regression was conducted to identify factors associated with spinal pain, with an alpha level of 0.05 defining statistical significance. Adjusted odds ratios with their 95% confidence intervals were used to assess the strength and direction of associations. Results: The study found that lower back pain (45.4%), neck pain (37.14%), and upper back pain (34.92%) were the most frequently reported spinal complaints among bank employees in the past 12 months. Neck pain was associated with female gender, job stress, and high workload. Lower back pain showed association with alcohol consumption, longer duration of service, managerial roles, and workload intensity. Upper back pain was associated with being in a managerial position. Conclusion: The study highlights a high burden of spinal pain among bank workers, with distinct associations across neck, upper back, and lower back regions. Ergonomic strain, occupational stress, behaviors, and job roles significantly contributed to pain. These findings underscore the need for targeted workplace interventions that address both physical and psychosocial risk factors to enhance employee wellbeing in banking environments.

Background: Preoperative anxiety is commonly characterized as a feeling of tension, apprehension, nervousness, distressing fear, and emotional discomfort preceding surgery. Different studies across the countries indicated an inconsistent prevalence of preoperative anxiety and its associated factors. Therefore, this study aimed to determine the pooled prevalence of preoperative anxiety and associated factors among surgical patients in Ethiopia. Methods: In this study, all observational study designs conducted in Ethiopia were included while studies that did not report our main outcome of interest or did not meet the quality criteria by Joanna Briggs Institute (JBI) critical appraisal techniques were excluded. Electronic databases (PubMed, SCOPUS, Web of Science Core Collection, CAB Abstract, EMBASE, and CINHAL (EBSCO)), Google Scholar, and lists of references were used to search works of literature in Ethiopia. STATA version 17 was used for analysis, and the odds ratios of the outcome variable were determined using the random-effects model. Computing values assessed heterogeneity among the studies for I 2 and P-values. Also, sensitivity analysis and funnel plot were done to assess the stability of pooled values to outliers and publication bias respectively. Results: A total of 10 studies were included with a total of 3054 participants. The pooled prevalence of preoperative anxiety among surgical patients in Ethiopia was 60% (95% CI: 55-66, P &lt; .001, I 2 = 90.00%). The overall prevalence among non-obstetric patients was 59% (95% CI: 53-66) while among obstetric 66% (95% CI: 62-69). Fear of complication (AOR = 2.32, 95% CI: 1.23, 3.41, P = .62, I 2 = 0.00%), postoperative pain (AOR = 1.92, 95% CI: 1.29, 2.56, P = .37, I 2 = 0.00%), and fear of death (AOR = 2.27, 95% CI: 1.53, 3.00, P = .70, I 2 = 0.00%) were significantly associated with preoperative anxiety. Conclusion: This study revealed a high pooled prevalence of preoperative anxiety among surgical patients in Ethiopia. The findings showed that fear of complication, postoperative pain, and fear of death were significantly associated with preoperative anxiety. This implies that a multidisciplinary approach involving various healthcare professionals is essential to optimize patient care and outcomes by addressing postoperative pain through pain management, counselling on fear of death, and complications to reduce the level of preoperative anxiety.

Background: Community-based health insurance is a voluntary scheme where community members pool resources to cover healthcare costs. Assessing beneficiary satisfaction with chronic disease management is crucial for the program’s long-term viability. Therefore, this study aimed to assess determinants of satisfaction with community-based health insurance among beneficiaries with chronic diseases in selected public hospitals in the Hararghe Zones of Eastern Ethiopia. Methods: An institution-based cross-sectional study was conducted among randomly selected 416 chronic disease beneficiaries of community-based health insurance from 30 July to 30 August 2023. Data were collected through a pre-tested and structured face-to-face interview questionnaire. The data were entered into Epi-Data 3.1 and then exported to STATA 17.0 for analysis. Bivariate and multivariate logistic regression analyses were performed to identify determinants of satisfaction with community-based health insurance. Significance was set at a p-value &lt; 0.05. Results: The mean age of the study participants was 48.10 ± 15.8 years. The study revealed that 55.1% (95% CI: 50.2%–59.8%) of beneficiaries with chronic diseases were satisfied with community-based health insurance. Beneficiaries aged over 55 years (AOR = 0.27; 95% CI: 0.08–0.91), experiencing delayed community-based health insurance opening times (AOR = 0.35; 95% CI: 0.17–0.73), preferring hospitals for future services (AOR = 4.13; 95% CI: 1.14–14.85), shorter waiting times (&lt;60 min) (AOR = 8.8; 95% CI: 4.39–17.72), availability of drugs (AOR = 2.67; 95% CI: 1.30–5.45), availability of laboratory services (AOR = 5.5; 95% CI: 2.83–10.84), and knowledge of community-based health insurance benefit packages (AOR = 2.8; 95% CI: 1.47–5.43) were significant determinants associated with satisfaction to the community-based health insurance service. Conclusion: About half of the community-based health insurance beneficiaries with chronic diseases were satisfied, indicating that a considerable number of them were dissatisfied with the services. The age of the participants, office opening time, waiting times, laboratory services, pharmacy services, and knowledge of community-based health insurance benefit packages were significant determinants of satisfaction with community-based health insurance schemes. Therefore, the government and other stakeholders need to enhance service quality, increase awareness, and address both supply and demand-side factors. These key strategies can lead to higher satisfaction with and ensure the sustainability of community-based health insurance schemes.

Introduction One of the global strategic direction and policy priorities in 2021 through 2025 is preservice education of nurses. Even though, quality education is the foundation to produce competent health workers, ensuring the competence of the health professionals is as imperative as maximizing their number. This study aims to fill the literature gap among nursing students in public universities. Objectives The purpose of this study is to assess the prevalence of clinical practice competence and its associated factors among graduating BSc nursing students in public universities from July 15 to August 15, 2022. Methods An institutional-based cross-sectional study was carried out in randomly selected public universities in eastern Ethiopia. A total of 143 students were systematically selected to fill out the questionnaire through multistage sampling. Frequency, mean, and standard deviations of independent variables and proportion of clinical practice competence were analyzed using descriptive statistics. AOR with a p-value of &lt;.05 was used to declare a significant association. Results The study found that 69 (53.1%) of study participants were clinically competent. Students with good clinical instructors [AOR: 3.79, 95%CI: 1.56–9.21], learning in a conducive clinical setting [AOR: 3.59, 95%CI: 1.26–10.23] and assessed using measurable methods [AOR: 3.77, 95%CI: 1.53–9.30] were significantly associated. Conclusion In this study, almost one in two of the students was clinically incompetent. Respective stakeholders could enhance students’ competence by monitoring and evaluating students during clinical practice, creating favorable learning settings, and developing comprehensive assessment methods.