How can we characterize medical simulation environment as a specific type of medical environment?

Background: In order to improve the quality of courses in simulation, it is necessary to get to know the educational environment. The objective of this study was to adapt the DREEM scale and to present a new questionnaire called QuESST, that allows to define medical simulation environment as a specific type of educational environment. Methods: The DREEM scale was translated and adapted into Polish conditions. A new tool – QuESST questionnaire was developed to complete the data with medical simulation environment aspects. Reliability, t-test, Component Analysis as well as correlation between the two methods were assessed in a sample of medical science students (N=312). Results: Statistical analysis presented a good reliability of the Polish translation of the DREEM scale (Cronbach’s Alpha = 0,95). The t-test for the DREEM questionnaire was stable and reliable relevant (t=-,584, p=,562). Significant strong correlation was reported with the DREEM and QuESST tool (r=0,559, p£ 0.001). Also, moderate and high correlations were found with the overall result of QuESST and the results of individual DREEM subscales. Conclusions: The QuESST scale may be considered helpful in determining the medical simulation environment conditions and can be used to supplement the DREEM scale to create an effective educational environment with medical simulation.


Background
Ensuring an effective educational environment has become an important aspect of planning high quality education service. When medical education is taken into consideration, the teaching process itself should meet specific requirements, including provision of an appropriate learning environment to optimize the learning process (1). With simulation methods introduced to enhance education of medical trainees in a setting resembling real clinical conditions, apart from general educational environment, identification of some special traits of an effective simulation environment should be given priority. Students' perception of this environment will be an important determinant affecting the effectiveness of the learning (2).
The purpose of our study was to adapt a method investigating general aspects of educational environment and to design a new tool, which would enable description of students' opinion about medical simulation environment. We assumed that there is a need for using two scales that would be complementary to successfully analyze the characteristics of an effective environment used to educate medical students.
For the basis of our study we have chosen to adapt the DREEM scale because it enables to examine the educational environment with high reliability, accuracy and can be used to collect data from medical students, nurses, dentists and other medical professionals. It can be used to compare medical schools in terms of existing conditions of the educational environment, as well as aspects of individual courses (22).
Since no other tool has been found that could be used to identify the characteristics of simulation environment allowing to recognize it as a specific setting of the learning process, a proprietary Questionnaire for Evaluation of Satisfaction with Simulation Training (QuESST) method was designed.
It describes distinct aspects that may influence organization of the educational environment, for example, the infrastructure and equipment, students' attitude towards simulation classes, students' opinions on the strengths and weaknesses of the simulation.
The paper presents mutual correlations between the overall result of the QuESST scale and the overall result along with the results of individual subscales of the DREEM tool. The efforts undertaken in this study to develop the QuESST tool should be continued to further strengthen the psychometric values of the tool.

ADAPTATION OF THE DREEM SCALE
The Educational Environment Assessment Method (DREEM) was designed by Roff and co-authors (22) as a tool to identify general aspects of the educational environment (20). The scale is not sensitive to cultural differences and can be widely used in medical and health care institutions. It consists of 50 4 items referring thematically to the educational environment, grouped in 5 subscales: Students' perception of the learning process II. Students' perception of teachers III. Self-perception in the academic environment IV.
The perception of the atmosphere by students V.

Self-perception in society
The DREEM scale enables to capture students' perception of learning, teachers, atmosphere as well as students' academic and social self-perception (3,4,(6)(7)(8). Although it is very attractive psychometrically, it does not address the conditions of medical simulation as specific teaching conditions.
The DREEM scale has a few other limitations. As some authors indicate (23), routine evaluation analyses may not have a good statistical background, which may lead to confusion and misinterpretation. Also obtained data may be difficult to interpret and compare when collected at different institutions due to the lack of a standardized way to analyze and report DREEM (20).
In the first stage of the adaptation process of the DREEM scale, the authors of the scale were asked for and approved the possibility to use and modify the tool. We obtained the original version of the questionnaire along with suggestions that proved useful for making necessary statistical calculations.
The scale was translated from the English language into Polish by two independent translators. After The first involved 50 people tested twice (test and retest); the second study was conducted after a one-month break. The results of the studies' analyses are presented in Table 2.

CONSTRUCTION OF THE QUESTIONNAIRE FOR EVALUATION OF SATISFACTION WITH SIMULATION TRAINING (QuESST)
The do not agree (2), and I completely disagree (1). In order to determine the reliability of the constructed QuESST method, the Alfa Cronbach's coefficient was calculated. In order to determine the internal 6 structure, the loads of particular items were analyzed using Component Analysis. Standardization of this method was calculated based on quartiles.

Results
The value of the Alfa Cronbach's coefficient for the original DREEM questionnaire is α = 0,91 (22), while the value of the Alfa Cronbach's coefficient for the Polish translation of DREEM questionnaire is α = 0,95, which indicates a good reliability of the translation. The value of the t-test (test-retest) for the DREEM questionnaire shows no statistical significance, which means that the result is internally relevant ( Table 2).
The above psychometric values confirm the adaptation of the questionnaire according to the research methodology.
In order to determine the reliability of the constructed QuESST method, the Alfa Cronbach's coefficient was calculated. The reliability of the scale for 20 items was α = 0.865. The Component Analysis was conducted to determine the internal structure. It was assumed that the items would be included in the structure of the method if the value of the load was above or equal to 0.30 (Table 3).
There were four items removed, as they did not meet this criterion. For this reason, the method was re-examined for reliability. The Alpha Cronbach value after deletion of the four items was α = 0,91.
The correlations between the overall score of the QuESST questionnaire, the overall score and the scores of individual subscales of the DREEM tool are presented in Table 4.
The results indicate that obtained correlations are at the level of significance equal to p ≤ 0.001.
The overall score of the QuESST questionnaire correlates moderately with the following DREEM Proper design and construction of the educational environment seems to be important from the perspective of optimization of the learning and teaching process. It is a kind of basis for the development of conditions in which learning will be organized using simulation methods (1,30,31) especially in medical faculties, where students often have to face real-life situations in a hospital or clinic. Using the DREEM tool seems to be essential for proper assessment of the educational environment. Additionally, it was necessary to construct another appropriate tool in order to capture 9 specific conditions of simulation environment as an educational environment. The QuESST questionnaire proved to effectively identify distinct aspects related to educational process using medical simulation. Only a proper design of this process allows realization of the teaching content and successful achievement of the assumed educational goals.
Notwithstanding the effects of the QuESST tool designed in our study, it is recommended that further work on strengthening its construction and psychometric values is undertaken.

Conclusions
The presented work shows the DREEM adaptation procedure for Polish conditions and the construction of the QuESST questionnaire that embraces the conditions of medical simulation as a specific educational environment. The DREEM tool is a well-standardized method and the actions undertaken in this work were aimed at testing this method in the simulation environment in Poland.
Poland is a country of 38 million people, where many doctors and specialists receive high-level medical education and then migrate to other countries to pursue their professional careers. Since 2012, steps have been taken at the national level to improve the system of medical education.
Implementation of new standards required simultaneous development and improvement of both conceptual and practical issues related to teaching medicine. Many procedures needed to be supplemented in different medical education areas (32). The educational profile of medical studies has been largely focused on practical aspects and standardization of the teaching and learning process.
A well-organized general educational environment is the first step for specific organization of education in simulated conditions. For this reason, our goal was to prepare tools that would help to investigate educational environment, with particular emphasis on simulation environment, and identify the aspects, which make it an effective learning and teaching site.
The DREEM scale is a well standardized tool, used in many countries and is referred to in subject related literature. It clearly refers to 5 dimensions related to the educational environment, however, does not address the specific simulation conditions; so widely-used in contemporary medical education. Nevertheless, the DREEM questionnaire was the basis for us to undertake work related to the construction of a specific QuESST tool. Thanks to the reference to the DREEM questionnaire, this QuESST has a good external relevance and seems to meet the needs that emerged in response to legislative changes in medical education in Poland. In our opinion, these two scales are complementary to successfully analyze the characteristics of an effective environment used to educate medical students. The study constitutes the basis for further development of learning conditions using simulation methods (1,30,31).

Limitations And Further Directions
In this article we described the stage of initial work on adaptation and construction of tools. In the next stages it will be necessary to introduce the Polish translation of DREEM scale into a wider simulation environment, taking into account several medical simulation centers in Poland as well as strengthening the construction and psychometric values of the QuESST questionnaire.

Abbreviations DREEM The Educational Environment Assessment Method
QuESST Questionnaire for Evaluation of Satisfaction with Simulation Training

This study was approved by the Medical University in Lublin
Respondents were informed that participation in the study is considered as granting consent to the study Written informed consent was obtained from the students for publication of this survey.

AVAILABILITY OF DATA AND MATERIALS
The datasets during and/or analyzed during the current study are available from the corresponding author on reasonable request.

COMPETING INTERESTS
The authors declare that they have no competing interests

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

AUTHORS' CONTRIBUTIONS
KT have made substantial contributions to the conception and designing the work; PM contributed to the analysis of the data; IM contributed in the interpretation of the data and preparation the introduction; AT substantively revised the work   Table 3. Items factorial load