DREEM tool: Perception of learning environment through the eyes of medical students

Abstract

Background

In the present era of quality accreditation, considering quality of medical education is also very important, especially in developing countries. Since last few years there is massive increase in number of medical colleges in Haryana, India but is this affecting the standard of medical education too? So, the present study was planned to understand the current state of medical education and to explore the perception of medical students of their learning environment so that problem areas can be identified both at the institutional and curriculum level.

Methods

DREEM tool was circulate to all willing participants from first to final year MBBS students. data was collected and analyzed using recent SPSS software. Descriptive statistics were used to calculate mean, standard deviation, minimum and maximum values. one-way analysis of variance (ANOVA) was calculated, and p < 0.05 was considered to be significant.

Results

An overall score of 111.76 (55.88%) out of 200 was obtained indicating ‘more positive than negative’. The overall mean score was 2.21 ± 0.58, which is interpreted as ‘educational aspect that could be enhanced’. Out of five domains, students’ perception of teachers scored maximum (57.95%) rating while students’ social self-perception scored the least (49.35%). The relationship between students and domain is insignificant for teachers, academic, and sociality (p-value = 0.088, 0.290, and 0.30) but significant for learning and atmosphere (p-value = 0.039 and 0.018)

Conclusions

Overall institute is propagating in right direction but as per feedback obtained by students, it seems that there is decline in quality of medical education with increase in number of medical colleges. There is urgent need of training and retraining of teachers and DREEM scoring survey should be adopted in all medical colleges as annual scoring system so that level of medical education could be elevated.

Trial registration:

CTRI/2020/07/026665 [Registered on: 17/07/2020] - Trial Registered Prospectively

Introduction

The learning environment in medical education is affected by many factors and plays a major role in life of learners (1). Most of time it is measured at institutional level and perception of students is always ignored. But nowadays scenario is changing with introduction of competency based medical education. Measuring learning environment gives an indication of quality of educational environment expressing efficiency of educational program which in turn depends upon three components – physical environment, emotional and intellectual climates (2). As per guidelines of the World Federation for Medical Education (WFME), improving the learning environment has been recognized as one of the objectives of the assessment of medical education programs (3).

Worldwide many tools have been suggested for measurement of educational environment in health care professionals both at undergraduate and postgraduate levels like Dundee Ready Education Environment Measure (DREEM), Clinical Learning Environment Inventory (CLEI), Medical Education Environment Measure (MEEM), Postgraduate Hospital Educational Environment Measure (PHEEM), Surgical Theatre Educational Environment Measure (STEEM), Anesthetic Theatre Educational Environment Measure (ATEEM), etc. (4). Most widely used of all is DREEM. It is a widely accepted and globally validated instrument for assessing the educational environment for undergraduate curricula including medicine, dentistry, nursing, midwifery, anesthesiology, medical emergencies, paramedical sciences, and chiropractic learning environments (5) (6) (7) (8).

Since our main target is to produce competent and well educated Indian Medical Graduate. So, taking their opinion is also utmost important (9). Unintentionally neglected areas of students can be easily revealed by this anonymous feedback system by using the 50 item DREEM questionnaire and the areas of concerns can be easily addressed. This will result in substantial amendments in the learning environment and consequently, students’ performance. So, the present study was planned to explore the perception of medical students of their learning environment and to identify problem areas at the institutional and curriculum level.

Materials And Methods

Results

Only those questionnaire responses which were completed in all aspects were included in the study. Table 2, shows the number of students participated in the study. A total of 204 students (out of 480) submitted their feedback, of whom, maximum were male students, i.e., 156 (76.4%) males vs 48 (23.5%) females. The number of students in first, second, third and fourth year were 81, 75, 12 and 36 respectively. There was not much participation from third year students. Mean age of the entire cohort was 19.67 years. Mean age of first, second, third- and fourth-year students were 17.56, 18.76, 20.34 and 21.33 years respectively. No statistically significant difference was demonstrated between genders for the total DREEM score or subscale scores (p > 0.05).

Table 1, shows the interpretation of overall and domain scoring with number of students for each category along with individual scoring criteria. Table 3, shows the mean domain and overall scoring with interpretation. An overall score of 111.76 (55.88%) out of 200 was obtained, which when analyzed as per practical guide of McAleer and Roff (13) (5) indicated ‘more positive than negative’. The overall mean score was 2.21 ± 0.58, which is interpreted as ‘educational aspect that could be enhanced’. 63.2% students rated the education environment as more positive than negative. 27.9% thinks that there are plenty of problems in current education system while only 7.4% rated current education system as excellent.

Out of five domains, students’ perception of teachers scored maximum (57.95%) rating while students’ social self-perception scored the least (49.35%). 54.7% students had a positive perception of learning environment while 22.1% observed teaching negatively. 58.8% students believed that teachers are moving in the right direction but 27.9% perceived that they need some retraining. 51.5% students had positive feelings for self-academic perceptions but 39.7% dealt with negative side. Only 4.4% students are confident of passing the exams and are sure for their bright career. 63.2% felt more positive college learning atmosphere and 20.6% faced many issues which need changes in current system. 42.6% felt social self-perception as not too bad but equally comparable percentage of students (41.2%) felt that it is not a nice place which is overall the most problematic area of institute and to be looked by authorities immediately.

Table 4, shows year wise comparison of mean domain and overall score (using one-way ANOVA) with statistically significant differences. The relationship between students and domain is insignificant for teachers, academic, and sociality (p-value = 0.088, 0.290, and 0.30) but significant for learning and atmosphere (p-value = 0.039 and 0.018) Table 5, shows year wise comparison of average of domain score among students of all years. Table 6, shows average calculated for each item for all years accompanied by overall mean. Average with score ≥ 3 showed positive points and strength areas of educational environment. Average between 2 and 3 are problem areas which should be taken care of and items with average score ≤ 2 represented weaknesses of education environment of institute (Q-2, 8, 39, 27, 31, 3, 4, 14 and 28). Question no 6 (The teachers deliver research-led teaching) got the highest rating and question no 31 (I have learned a lot about the way scientific research is carried out) the least.

Discussion

In the present era of Quality accreditation, checking the quality of educational environment is need of hour. Recently, National Medical commission has also shifted from the predominantly knowledge-based education system towards a competency-based medical education to create an Indian Medical Graduate, who is skilled, motivated and ready to meet the health care needs of the country (14). So, it is crucial to take feedback from students and watch over the quality of medical education, that we are providing to them, from their perspective. In present study, a score of 111.76 out of 200 is obtained which indicates more positive than negative. Although, it’s a good score indicating the progression of institute in right direction but also indicates some areas that require attention. If we compare the result with the range (101–150), it is towards lower side only. 27.9% students still think that there are plenty of problems in current education system which need to be looked after. Our DREEM score of 111.76 is very much similar to those obtained by some studies conducted at Indian medical colleges like by Gupta et al (118/200), Abraham et al (117/200) and Kiran et al (120/200)(15)(16) (17) but less than the scores obtained by Varma et al (139/200), Roff et al (130/200) and by Miles and Leinster (143/200) (5) (13) (18).

The students had a very positive perception of learning (SPL) and of their atmosphere (SPA) with statistically significant results of 57.29% and 57.12% score respectively. Among the four years, third year students gave highest rating for SPL domain. First and second year students felt a need of amendments but fourth year students are facing some challenges. Their main concerns are Q 7, 13, 22 ,24 and 48. Out of this most knotty area is teacher centered learning. Numerous studies have reported the same problem in other institutes too, whether of Indian origin or not (19) (20) (21) (22). Although competency-based medical education had been introduced by the institute but it seems that teachers are still wearing the traditional hats of factual learning. Our advice is to introduce more of students centered learning methods like cooperative learning, inductive learning, gamify learning, flipped classroom, etc. (23). As per majority of students, teachers of college are well knowledgeable, which is a very strong suit. But as per their feedbacks obtained, they are authoritarian too, get angry in class very often and not able to provide constructive criticism. In fact, fourth year students are interested in getting feedback of their teachers. It seems as institute is in need of training and retraining of teachers. A study done by Yilmaz, very well explains, how lack of training and fear of change from norm among teachers can affect learning a lot (24). There is need of replacement of role of teacher as a facilitator who can supervise their students and provide guidance. 21st century teaching is not about how the teacher teaches but how the students can imbibe their best (25).

Students from almost all years felt that they are not able to memorize and there is a lack of scientific research knowledge among them. Students perception of atmosphere declined in final year. Final year students had significant lower score than other students. Main tricky areas which need consideration are, ‘There are opportunities for me to develop my interpersonal skills’, ‘The atmosphere is relaxed during seminars/tutorials’, ‘I find the experience disappointing’, ‘I am able to concentrate well’ and ‘I feel able to ask the questions I want’. These all reflect lack of learner-centered teaching methods and lack of bonding between teacher and student. As defined by McCombs, the five fundamental domains of learner centered practices may prove beneficial in this condition. These domains include creating positive relationships and learning climate, adapting to class learning needs, facilitating the learning process, encouraging personal challenge and responsibility, and providing for individual and social learning needs (26).

The last domain, students’ social self-perception scored the least and suggested of “not a nice place”. Many of the negative perceptions in this domain centered on the lack of support system for students who get stressed and the course being boring and tiring. Also, there is a feeling of loneliness among students. Medical student mentoring program is a key to this glitch (27). Mentors play a different role than supervisor. This is a kind of informal relation which focuses on achieving specific goals. Positive mentoring could prove beneficial not only for personal and professional growth of students but can help them in research and academics too(28) (29). With increasing awareness of the potential value of mentoring, many medical colleges and even new competency-based medical education curriculum supports mentor mentee culture worldwide(30) (31).

The study had its share of certain limitations too. There is lack of full participation of students. In fact, input from third year students was the least. Also, the questionnaire is too long with 50 questions. It needs patience and dedication for students to fill the entire questionnaire. Although we tried to make it striking and eye-catching by integrating pictures with every question. Still, it could be one of the reasons for dearth. We have also decided to share the results of study with medical education unit of institute so that corrective actions can be taken. Indeed, medical colleges should conduct such kind of scoring surveys, at least annually, to improve the quality of medical education system.

Conclusion

The institute is propagating in right direction. Some arears need more attention. DREEM scoring could be helpful and should be adopted for annual scoring system so that level of medical education possibly be improved in Indian medical colleges.

Abbreviations

DREEM: Dundee Ready Education Environment Measure, PGIMS: Post Graduate Institute of Medical Sciences, SHKHM: Shaheed Hasan Khan Government Medical College, SPL: Students’ perceptions of learning/teaching, SPT: Students’ perceptions of teachers, SASP: Students’ academic self-perceptions, SPA: Students’ perceptions of atmosphere, SSSP: Students’ social self-perceptions.

Declarations

Ethics approval and consent to participate: Institutional Biomedical research ethics committee (BREC) approved the study via reference number BREC/20/125 dated 22/06/2022. Written informed consent from all participants was taken through google form and all methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication: not applicable

Availability of data and materials: The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests: The authors report no competing interests

Funding: None

Authors' contributions: MV, AS and RV planned the study. MV and AK collected the data. MV, AS and AS analyzed the data and formulated the results. All authors contributed to the literature review and discussion. All authors approved the final version of the manuscript.

Acknowledgements: The authors would like to acknowledge the contribution of all the MBBS students in completing the questionnaire.

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