Evaluating the learning environment for medical students is essential for improving their professional standards, knowledge, and skills. This mixed methods study explored medical students' perceptions about the learning environment at the College of Medicine, a well-known university in Saudi Arabia, King Saud University. This study is two-pronged, first, to quantitatively assess students’ perceptions of the COM-KSU learning environment and, second, to qualitatively explore their experience in the same medical school.
Our study yielded an overall average score of 81 out of 140 on the JHLES. Notably, there was no predefined threshold for a passing or positive score on this tool. Compared to the original study where the scale was first used and validated, the average score in our study was lower (107 vs 81, respectively) [9]. However, our results were consistent with those of other studies that were conducted in other medical schools in different countries, including Malaysia, India and Pakistan, ranging from 81.1 to 86 [10–12].
Two previously published studies in the same setting, COM-KSU (2008 and 2017), utilized the DREEM survey and revealed that medical students reported different average scores (89.9 out of 200 and 171.57 out of 250, respectively) [5, 6]. Compared to the current study utilizing the JHLES, we may compare the findings based on a significant correlation between the two measures that support the use of the JHLES in the assessment of the same construct [12]. This comparison yielded reassuring results that the perceptions of medical students are still positive, with variations in the domains of LE, as described below. The added value of the qualitative component of the current study elicits more depth in understanding LE in the COM-KSU.
Although there was no difference among male and female students in the DREEM overall average score in a previous study that was conducted at the same college in 2017, our study revealed a higher overall average score among males (83.4) than females (77.5). The lower recorded score among females might be explained by their tendency to have higher expectations of a learning environment that was not achieved as their counterpart expected [13, 14]. For explanations, male students had higher scores in different domains related to their relationships with the faculty and peers, including mentorship, peer support, and the academic climate. Nevertheless, both genders perceived a negative view where they expressed potential gender discrimination in the focus group interviews. Male students felt that they were treated differently than females, while their counterparts believed that males had more opportunities to build relationships with the faculty and gain more experience accordingly.
In terms of academic years, the domains and overall average scores decreased as the students progressed from the first year to their internships, with an exceptional decrease in the third year followed by the recovery of scores afterward. Nevertheless, students in the first year had higher average scores than interns, possibly due to the new environment and the support provided during their first year. Qualitative group interviews elaborated more on this variation, where medical students in the first year felt a sense of pride and honor upon being accepted in the COM-KSU. They believe that this was a validation of their social status.
Although the relationship between medical students’ feelings of pride in belonging to their college and the learning environment is complex and multifaceted [15], a positive and supportive learning environment that fosters a sense of belonging can enhance medical students’ feelings of pride and affiliation with their college [16, 17], which is evident among first-year medical students. In contrast, a negative learning environment that lacks support and inclusivity can detrimentally impact medical students’ feelings of pride and belonging [18]. Nevertheless, first-year students still experienced negative emotional effects that were not captured by the quantitative questionnaire due to the lack of professional identification they encountered when they moved from the preparatory year to medical school.
However, the decrease in the average score during the third year could be explained by engagement in clinical rotations and practical applications instead of merely learning basic science. This perception was explained during focus group interviews where students explained the third year as the most challenging due to the preparation for their actual medical practice. This included starting to see patients, taking medical history, and performing physical examinations. Interestingly, this result was consistent with other studies that were conducted in different medical schools, although different assessment tools were used, including MSLES, DREEM, and the same tool used in this study (i.e., JHLES) [3, 7, 11]. In contrast, other studies have shown that medical students feel more satisfied with clinical practice than with basic science during the first and second years [13, 19, 20]
This paradox might be explained by the difficulty students faced at the beginning of the clinical year, after which it decreased or diminished after they gained confidence in their practice under the supervision of well-trained faculty [9, 21, 22]. Hence, higher average scores in the following years could be explained by the maturity of the medical students and their ability to overcome early difficulties after they have more experience during clinical rotations. In the COM-KSU, medical students in their fifth year are prepared to experience life as physicians where they have pure clinical experience joining medical teams, attending rounds, clinics and doing procedures under the supervision of trained faculty and senior doctors. Hence, when mentoring was assessed among medical students, their perception reflected by the average score given to this domain increased as the number of academic years increased, with the highest score occurring during the internship. Mentorship plays an important role in the learning environment, as described in other studies [23–25]. The importance of the student‒faculty relationship and the enhancement of faculty influence on students are supported by the qualitative findings, which demonstrate that students' perceptions of faculty support vary, which is congruent with other studies [26–28]. However, a study revealed that the majority of faculty members are not prepared to provide the kind of support that has been shown to be most effective for students [29].
Furthermore, the meaningful engagement of students declines as the academic year progresses, as expressed by students’ responses to this domain in the JHLES. The qualitative approach elaborated more when students complained about the lack of support provided by the student council, which the COM-KSU perceived as the hub where medical students can engage and obtain the required support. From the students’ perspective, the student council was not able to provide effective support or bring about significant changes for students facing challenges related to their medical study needs. The qualitative study participants agreed with the findings of other local studies, highlighting the absence of a supportive environment for students in our local colleges [13, 30, 31]. On the other hand, the majority of students reflected positively on peer support, where they found it to have a positive impact on them. They identified college friends and colleagues as the main sources of support, which was congruent with other studies that explained the same attitude [32–34].
According to the students’ performance measured by their GPA, students with higher GPA had higher JHLES scores, both overall and domain average scores. High-achieving students tend to have more positive perceptions of the learning environment than do students with lower GPAs [11, 12, 21, 22, 35]. This could suggest a positive association between academic achievement and students’ perceptions of the educational setting [19, 20, 36–38]. However, students experienced positive consequences from high competition in the learning environment due to family and physician expectations that were captured during the focus group discussion. Similar results were found in another study that was conducted in the medical school of the University of Valladolid [39].
Inclusion and safety were negatively perceived in this study among medical students at all levels, regardless of their gender, academic year, or performance, which was reflected in their GPAs. This finding was consistent with other studies measuring the same domain average score of Cyberjaya University College of Medical Sciences (CUCMS), Nil Ratan Sircar Medical College (NRSMC), and College of Medicine and Sagore Dutta Hospital (CMSDH) [10, 12]; however, this finding was in contrast to that of PUGSOM [40]. A possible explanation might be related to the aforementioned reasons, which were associated with students’ perceptions of gender discrimination, stress in the first year due to the new environment and in the third year due to engagement in clinical practice, and their achievements, which elevated stress when they had lower GPAs. Previous studies have shown that the prevalence of stress is greater during the first three years of medical education, which is consistent with our findings [35].
In contrast, the physical space domain in our study received the highest score, where we believe that physical space has improved as a result of the college's 2018 expansion [41].
Strengths and Limitations
One key strength of this study is the employment of a comprehensive mixed methods approach to gain an understanding of how students perceive their learning environment. This approach collects numerical data, delves deeply into the students’ experiences and feelings, and provides valuable insights through the integration of findings from both approaches. Another strength of this study is the large number of participants from different academic years, which allows for a diverse range of perspectives from both new and experienced students.
Nevertheless, convenience sampling may not fully represent the student population and limits the generalizability of the findings. Additionally, focusing on one institution may not capture the experiences of students across different settings, cultures, or cities, potentially limiting the applicability of any recommendations to other medical colleges or regions. However, the large sample size, the diversity of data and the integration of results may enhance the transferability of the findings.
Recommendations for Educational Institutions
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Enhance faculty development: Address the issues of perceived neutrality and reported negative interactions with faculty by investing in faculty development programs. These programs should focus on improving communication skills and mentoring abilities and cultivating more supportive and encouraging faculty‒student relationships. Creating opportunities for regular feedback from students can also aid in faculty improvement.
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Cultivate Supportive Environments: Foster a less stressful academic climate by promoting a culture of mutual respect and collaboration within the institution. Encourage open dialog between students and faculty, where questions and concerns can be raised without judgment. Stress management and well-being programs should be implemented to help students cope with academic pressures.
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Revise Curriculum and Mentorship Programs: Address curriculum concerns by engaging students in the curriculum development process. Consider their suggestions for better organization, logical flow, and references. Additionally, structured mentorship programs that connect students with experienced doctors who can provide guidance, share experiences, and serve as positive role models should be established.
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Evaluate and Improve Support Services: Reevaluate the effectiveness of support services such as the students' council and academic support departments. These services are responsive to students' needs and have the authority to enact meaningful changes. Regularly solicit feedback from students to gauge the impact of these services.
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Promote Inclusivity and Gender Equity: Create initiatives to address perceptions of discrimination and gender bias within the learning environment. This may involve raising awareness, offering training on gender sensitivity, and implementing policies that promote inclusivity and equal opportunities for all students, regardless of gender.
Recommendations for Further Research:
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Longitudinal studies should be conducted to track the changes in students’ perceptions and experiences. This will help us identify emerging trends and understand the long-term effects of interventions and policy changes.
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This research can be expanded by including studies with medical schools or institutions to validate our findings and assess how applicable they are in diverse educational settings.
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The use of mixed methods research in the field of education should be further explored. Investigate approaches that combine qualitative and deductive methods to gain deeper insights into students’ educational experiences.
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Dive deeper into specific areas highlighted in this research, such as mentoring programs and concerns related to the curriculum. Explore ways to enhance mentoring effectiveness and develop strategies for improving the curriculum to create a learning environment.
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Interventions targeted at addressing identified areas should be implemented for improvement while thoroughly evaluating their impact. This will enable institutions to assess the effectiveness of these interventions based on data-driven decisions leading to the enhancement of education.