Clinical teaching lies at the heart of medical education [1]. Clinical education is used in midwifery profession as a way to practice didactic information in hands on environment [2]. We get quality midwives when they get quality clinical education during their pre service training. The main goal of midwifery education is developing midwives who are critical thinkers, analytical, able to interpret scientific data for midwifery and nursing actions, solve problems and exercise independent clinical judgment in clinical settings [3]. Clinical excellence is a hall mark of midwifery [4]. An effective clinician is the ultimate goal of nursing education [5].

Clinical teachers are main pillar for facilitation of learning in the clinical area. The quality of learning in the clinical setting is greatly affected by clinical teachers. Many clinical educators think that the only role of the teacher is to be a reservoir of knowledge and skills that occasionally, and unpredictably, spills over its dam, letting information flow randomly down a canyon of learning [6] but not only knowledge but also teaching skill is additional role. Clinical teachers should realize that they assume multiple roles in their interactions with their students [6].

Supervision, teaching, evaluation and professional behaviors are roles of clinical teachers. The interaction of students with their clinical teachers facilitates or hinders learning in the clinical setting [7]. When the interaction is positive there is facilitation of learning but if the interaction is negative, learning in the clinical setting is hindered. The characteristics of clinical teachers play a key role in the development of professional nurses who ultimately provide quality services to all segments of population to attain maintain and recover optimal health [5,8].

Being role model, supervisor, interested in teaching learning and able to give value and respect to individuals are among what makes an excellent clinical teacher. Clinical teachers are effective when they motivate students to learn and to improve their clinical performance. Students’ perception about characteristics of clinical teachers varies among literatures.

The final goal of clinical learning is to be competent and skill full professional. The quality of clinical learning is hugely affected by clinical teachers’ characteristics. Effective clinical teachers are very crucial to produce effective professionals. Students cannot learn best in clinical setting unless their clinical teachers demonstrate effective clinical teacher’s characteristics. Promoting clinical education in midwifery fields requires continuous assessment of the current situations in clinical education and identifying effective factors from views of midwifery students [4].

It is imperative to describe characteristics of clinical teachers so as to facilitate clinical learning. A finding in Norway, showed that midwifery students in the clinical area: dot not get regular feedback, have poor relationship with the midwives who teach them and are asked questions which they do not master in front of clients [9]. In Ethiopia, only 32% of graduating midwifery students met the national standard of managing 20 or more births during training [10]. A study done in Ethiopia, Hawasa University, indicated that 77.1% of midwifery students were not clinically competent [11].

If the clinical teacher’s characteristics are not in line with the students need, students are not well trained. Clinically in competent students after graduation cannot give appropriate health services for clients, families, and community. But when clinical teachers demonstrate characteristics of effective clinical teachers, there is facilitation of learning resulting in competent professionals. To bring quality of clinical education, it is vital to explore the relationship between the clinical teachers’ characteristics and learning process. Identification of nurse students’ perception of effective clinical teacher’s characteristics is a spring board for modification and facilitation of effective clinical instruction [12]. This study aimed to assess clinical teacher’s characteristics and their influence on learning perceived by Midwifery students in Mekelle, Adigrat and Axum Universities, Tigray, Ethiopia, 2016.

The study was conducted at all public universities found in Tigray region: Mekelle University, Axum University and Adigrat University from January 2016 to June 2016 G.C. Tigray is one of the nine regions in Ethiopia. The capital city is Mekelle which is located 780 kilometer to the north of Addis Ababa, capital city of Ethiopia. It has a population of 5.1 million [13]. In Mekelle University, there are a total of 138 regular undergraduate midwifery students and 26 teachers (18 M.Sc and 8 B.Sc).

In Adigrat University, there are a total of 201 regular undergraduate midwifery students and 6 teachers (4 M.Sc and 2 B.Sc). In Axum University, regular undergraduate midwifery department, there are 174 students and 10 teachers (4 M.Sc and 6 B.Sc). Institution based; cross sectional study design was used. All 2^nd, 3^rd and 4^th year regular undergraduate Midwifery students in Mekelle, Aksum and Adigrat Universities were involved. Professional, personal and teaching ability characteristics were independent variables and learning facilitation as outcome variable. The sample size was calculated using single population proportion formula using the following assumptions, 95% Confidence Interval, 5% of precision and P=50% to get maximum statistical value. n=Z²p(1-p)/w², n=(1.96)20.5(1-0.5)/(0.05)2=385 study subjects. But the total population was less than 10, 000. Which was a total students (N)=513, so, we used correction formula methods.n_f=n/1+(n/N), n_f=385/1+(385/513)=230, by adding 10% non-response rate n_f=243 study subjects. But midwifery students those who had at least one clinical exposure were a total number of 286 students. Therefore, a total of 286 study participants were participated in this study.

Midwives who were 2^nd, 3^rd and 4^th year undergraduate regular students in all public universities of Tigray region, Ethiopia were included. The questioner is adopted from NCTEI developed by Mogan and Knox [14]. The NCTEI tool was found valid and reliable in reviewed literatures [14-21]. Reliability is the degree to which the questionnaire results stable and consistent results. The most widely used measure of reliability is internal consistency that is explained in terms of cronbach’s alpha coefficient. Its value ranges from 0 to 1. According to George and Mallery 2003, the rule of thumb for the value of cronbacch’s alpha is: >0.9=excellent, >0.8=good, >0.7=acceptable, >0.6=questionable, >0.5=poor, <0.5=poor [22-28].

The reliability of the tool in terms of internal consistency in this study at pretest has Cranach’s alpha of 0.916 for the learning facilitation on five likert scale that is excellent and 0.882 for characteristics in use on five likert scale which is good. It has 47 effective clinical teachers’ characteristics grouped into three categories which are midwifery competence, personal and teaching ability and. The questionnaire has two parts. Part 1 has socio-demographic characteristics of the respondents and part 2 has 47 characteristics of clinical teachers on five likert scale on frequency use of characteristics and learning facilitation. The five likert scale measurement for perceived learning facilitation was first developed by Marcia Kube [21]. The data was collected by six B.Sc midwives from February 26, to March 10, using the questioner that is structured and self-administered. Pre-test was done on 21 midwifery undergraduate regular students in Sheba University College to check for wording, clarity and the time need to answer the questionnaire. Participants filled the questioner in 10-15 minutes.

The questionnaire was developed in English language and it was not translated to local language because the official language for Ethiopian universities is/are English and the student are assigned to universities by Ministry of Education from the four corners of the nation. One day training was given for the data collectors and there was supervision by the supervisors. Data was entered using Epidata and the data was exported and analyzed using SPSS version 20. Socio demographic data are described by frequency and percentage. Characteristics are ranked computing their mean. To check for correlation between frequency use of characteristics and perceived influence on learning, Pearson product moment correlation was used. Pearson product moment correlation measures the strength of linear association between two variables. It is dented by r and its value ranges from -1 to 1. A value of 0 indicates the absence of relationship between the variables. A positive value indicates that as one variable increases the other variable also increases and negative value indicates that as the one variable increases the other variable decrease. Statistical significance was declared at P value <0.05.

The assumptions for Pearson are: both variables should be continuous, linear, no or minimum outliers, normally distributed and with homoscedasticity. Preliminary analyses were investigated to ensure no violation of the assumptions and the result showed that the data were found continuous variables, normally distributed, linear, minimum outliers, and with homoscedasticity. Mukaka explained that “based on Hinkle, Wiersma, and Jurs: 2003, the rule of thumb for strength of Pearson correlation is defined as follows: 0.90 to 1.00 (-0.90 to -1.00)=Very high positive (negative) correlation, 0.70 to 0.90 (-0.70 to -0.90)=High positive (negative) correlation, 0.50 to 0.70 (-0.50 to -0.70)=Moderate positive (negative) correlation, 0.30 to 0.50 (-0.30 to -0.50)=Low positive (negative) correlation and 00 to 0.30 (0.00 to -0.30)=negligible correlation” [29].

Consent was obtained from Mekelle University College of Health Sciences ethical clearance committee; the researcher asked consent to College of Health Sciences of Mekelle University, Adigrat University and Axum University to conduct this study at their respective midwifery department and approval to precede the study was explained by the health science college of the universities. The information is kept confidential and private through coding and leaving students alone to fill the questioner. Additional consent form was prepared for the questionnaire to participate in this study and with the right given for them to with draw at any time from the study.

A total of 286 students participated in this study. The response rate was 100%. Out of the 286 total participants, 127 (44.4%) were from Adigrat University and 82 (28.7%), and 77 (26.9%) were from Mekelle University and Axum University respectively.

Majority of the participants were male. Out of the 286 participants 178 (62.2%) were male while 108 (37.7%) were female. More participants were from third year 117 (40.9%), from second year 85 (29.7%), and from fourth year 84 (29.4%). The mean age of the participants was 21.63 years with a minimum 18 years and maximum 28 years old (Table 1).

Table 1: Describes the age, sex and year level of midwifery students at public universities, Tigray, Ethiopia, 2016.

The result for frequently used characteristics of the clinical teachers is explained as the following with their mean and standard deviation respectively.

Clinical teachers were self-confident (3.66, 1.268), answered carefully and precisely questions raised by students (3.57, 1.253), listened attentively (3.47, 1.224), encouraged active participation of students in discussion (3.47, 1.224) and quickly grasped what students were asking (3.39, 1.245) (Table 2).

Table 2: The frequently used characteristics of clinical teachers among midwifery students in descending order in public universities in Tigray, Ethiopia, 2016.

The first least character in use was found recognizes own limitations with mean and standard deviation (2.94, 1.258) followed by demonstrates clinical skill and judgment (2.95, 1.309), offers help when difficulties arise (2.96, 1.324), guides students development of clinical Skills (2.97, 1.285), and demonstrates clinical procedures and techniques (2.97, 1.333) (Table 3).

Table 3: The least 11 characteristics of clinical teachers in use in descending order among midwifery students at public universities, Tigray, Ethiopia, 2016.

The clinical teachers ‘characteristics in use in category were found as the following with their mean and standard deviation respectively in descending order: personality=mean 3.31 (0.11), interpersonal relations=3.28 (0.1), teaching ability=3.21 (0.18), evaluation=3.12 (0.08) and midwifery competency=3.11 (0.11).

The relationship between the frequency use of characteristics of clinical teachers and perceived learning facilitation was investigated using Pearson product moment correlation coefficient. Frequency use of characteristics of the clinical teachers were positively correlated to perceived learning facilitation at p=0.01 ranging from shows personal interest in students, r=0.619 to gears instruction to students level of readiness r=0.770. Among the items with high positive correlation were found as follows; gears instruction to students level of readiness r=0.77, answers carefully and precisely questions raised by students r=0.769, makes specific suggestions for improvement=0.756, questions students to elicit underlying reasoning r=0.754, and provides specific practice opportunity r=0.753. All the items had a moderate to high correlation. As the frequency of the characteristics increased so did too the facilitation of clinical learning (Table 4).

Table 4: Shows the correlation of frequency use of characteristics of clinical teachers and perceived learning facilitation among midwifery students at public universities, Tigray, Ethiopia, 2016.

Midwifery clinical learning is a stepping stone to develop competent midwives. Clinical learning is affected by clinical teachers’ characteristics. This study was designed to assess perception of midwifery students towards characteristics of clinical teachers that facilitate clinical learning. In this study, the clinical teachers: Were selfconfident, answered carefully and precisely questions raised by students, listened attentively, encouraged active participation and discussion, quickly grasped what students are asking, explained clearly, stimulated students interest in the subject, were organized, showed personal interest in the subject and emphasized on what is important. When this study is compared with Knox and Mogan study on the top ten frequently used characteristics which are: is a good role model, enjoys teaching, demonstrates clinical skills and judgment, is well prepared for teaching, takes responsibility of own actions, is approachable, is self-confident, demonstrates enthusiasm, promotes student independence, and corrects students’ mistakes without belittling them. The only character in common is self-confidence. This difference could be due to difference in years that is 29 years gap. The other reason might be the difference in design that the students were asked to rate the characteristics of best clinical teacher while in the current study students were asked to rate not only to the best clinical teachers but averagely for all clinical teachers [18].

This study is congruent with the study in Greek that the clinical teachers were self-confident, able to listen attentively, and were organized [19]. Another study by Holes in USA stated that the clinical teachers’ characteristics with the highest frequency in use were found as follows in descending order: demonstrated strong clinical skills and judgment, was well prepared for teaching, enjoyed nursing, was selfconfident, and demonstrated breadth of knowledge in nursing [20]. The current study is in agreement with this study that the characteristic self-confidence is among the top four frequently used characteristics.

In the current study, there is total disagreement on the four mostly demonstrated characteristics as the study of Karen B, which was found in descending order: were responsible, had sense of humor, interested in students and listened attentively [22]. This disagreement could be because of the difference in economic and technological advancement and preparation of clinical teachers between America and Ethiopia. The current study showed that the most frequently used character was self-confidence which is the same with the finding of Marcia Kube [21]. In addition to that these two researches showed that the clinical teachers were organized and listened attentively. But compared the current study with a research done in Egypt in 2015, there is inconsistency with the frequently used characteristics except that of stimulates what is important that is first ranked but 10th in the current study [17]. The possible reasons for the discrepancy could be that the study was done only in one university which is Cairo University whereas the current study was done in three universities and Ethiopia and Egypt have different culture.

In the current study, the characteristics in use in category were found as follows in descending their mean order: personality=3.31, interpersonal relations=3.28, teaching ability=3.21, evaluation=3.12 and competency=3.11. This result is similar with the study done by Marcia Kub (2010) the two most frequently used characteristics in categories were personality and interpersonal relations and the least frequently used category was competence [21]. But there is difference with the study done in Egypt that the frequently used characteristics in category were as the following in descending order: teaching ability, evaluation, competence, inters personal relations and personality [17].

Positive linear relationship between frequency use of characteristics and perceived learning facilitation at p-value=0.01 was found. Among the items with high positive correlation were: gives instruction to students level of readiness r=0.77, answers carefully and precisely questions raised by students r=0.769, makes specific suggestions for improvement r=0.756, questions students to elicit underlying reasoning r=0.754 and provides specific practice opportunity r=0.753.The lowest was: shows personal interest in students r=0.619, r²=0.38 and the highest was: gears instruction to students level of readiness r=0.77, r²=0.59. As a result, increasing the frequency of the characteristics facilitated clinical learning. Kube found that among the items with high positive correlation were: demonstrates communication skill, reveals broad reading in the field, and good role model with r=(0.750, 0.762 and 0.762) respectively despite the other items were moderately, highly and positively correlated [21]. The current study is similar with this that all the items had positive and from moderate to high correlation. This is an indication that as the frequency use of clinical teachers’ characteristics increases, the learning facilitation in the clinical area increases too. It is an implication for the clinical teachers to increase their frequency of clinical teaching characteristics so as to foster clinical learning.

Students might have bias to assess their clinical teachers’ characteristics.

The clinical teachers were self-confident. They listened attentively and answered carefully and precisely questions raised by students but showed least activity at recognizing their own limitation, demonstrating clinical skill and judgment and offering special help when difficulties arise. But in relation to characteristics in category in use, clinical teachers were best at their personality and interpersonal relations but least at their professional competence and evaluation.

There was positive moderate to high relationship between the frequency use of characteristics and perceived learning facilitation. As the clinical teachers increased the frequency use of characteristics so did too facilitation of learning in the clinical area.