Can the DREEM scale be adapted to the medical simulation environment?

The environment of medical simulation is a specific educational environment for teaching medicine. Medical universities are obliged to ensure appropriate conditions for conducting classes in medical simulation. In order to improve the quality of courses in simulation, it is necessary to get to know the educational environment and the medical simulation environment. It will be possible thanks to appropriately selected methods, which include important variables shaping these environments. The process of adapting the DREEM tool to Polish conditions and the construction stages of the QuESST tool were presented. The overall results of the QuESST and DREEM questionnaires correlated significantly. Also the overall result of QuESST correlated significantly with the results of individual DREEM scales.

2 Abstract Background The environment of medical simulation is a specific educational environment for teaching medicine. Medical universities are obliged to ensure appropriate conditions for conducting classes in medical simulation. In order to improve the quality of courses in simulation, it is necessary to get to know the educational environment and the medical simulation environment. It will be possible thanks to appropriately selected methods, which include important variables shaping these environments.

Methods
Among 312 medical students who had classes in medical simulation, the DREEM method (Roff et al.) and the QuESST method (Mamcarz et al.) were applied.

Results
The process of adapting the DREEM tool to Polish conditions and the construction stages of the QuESST tool were presented. The overall results of the QuESST and DREEM questionnaires correlated significantly. Also the overall result of QuESST correlated significantly with the results of individual DREEM scales.

Conclusions
The presented tools may be helpful in determining the educational conditions and conditions of medical simulation as a specific educational environment for teaching and learning medicine.

BACKGROUND
Developing an educational environment is essential for the overall learning process.
It is increasingly recognised as essential to meet the criteria for a high level of 3 medical education (1). The way a student perceives the educational environment in which he or she finds himself or herself may translate into behaviour in the future (2).
The use of simulation methods in the teaching of medicine is connected with the creation of a specific educational environment. The teaching process itself should meet specific requirements, including the provision of an appropriate learning environment to optimise the learning process (1). This applies to simulation methods, which are designed to create an environment as close as possible to the realities of the clinic. The perception of the educational environment by medical students and teachers is an important variable, which may shape to a large extent the effectiveness of the use of simulation methods (3).
The Educational Environment Assessment Method (DREEM) was designed by Roff and co-authors (4) as a tool to study the educational environment. It is not sensitive to cultural differences and can be widely used in medical and health care institutions.
Despite the undeniable advantages of the DREEM tool, it includes general aspects of the educational environment. In the ongoing research project, it was also important to consider the aspects of the simulation environment as a specific educational environment.
The simulation environment provides students with an opportunity to implement previously planned scenarios, perform specific procedures in safe and more predictable conditions. In addition to the many advantages associated with the use of medical simulation in medical teaching, it should undoubtedly be emphasized that the simulation environment is a reflection of the environmental conditions prevailing in the real world, for example in the clinic. The conditions created by a 4 simulation are an essential factor shaping and giving meaning to the whole educational process of the simulation. The potential of individual or team training in simulated conditions lies in the translation of proven educational methods into simulated conditions. These methods include reflexive learning and debriefing (5).
The medical simulation environment is designed to achieve specific goals in medical education. These objectives include enabling the student to have direct contact with the patient, acquire specific clinical skills, perform diagnostic procedures with the possibility of exercising and repeating procedures. The use of medical simulation in education improves the quality of this education, translating, among other things, into an increase in the level of students' knowledge, strengthening their internal motivation or belief in self-efficacy (6).
The use of the medical simulation environment in medical education is therefore a huge potential for a more complete implementation of the assumed educational goals and enabling the acquisition of specific clinical skills, which will then be used in the professional life of students.
In order to take into account the conditions of the simulation environment as specific conditions of the students' learning process, a proprietary Questionnaire for Evaluation of Satisfaction of Simulation Training (QuESST) method was designed. It enables to characterize the simulation environment as specific conditions for the acquisition of knowledge and skills. It describes, among others, such aspects of the learning process in the simulation environment as: premises conditions, students' attitude towards classes in simulation conditions, students' opinions on the strengths and weaknesses of the simulation. The DREEM tool described above is very attractive psychometrically, but does not refer to specific simulation conditions as teaching conditions. This tool was the main point of reference for the construction of a new tool, which focuses on educational conditions with particular emphasis on the conditions of medical simulation. Thanks to this work, it is possible to both generalize the aspects related to educational conditions, as well as to characterize specific aspects of the simulation conditions as an educational environment. The activities undertaken are the initial stage of work on the construction of the QuESST tool. It would be worthwhile, however, to undertake further actions aimed at strengthening the psychometric values of the tool.

ADAPTATION OF THE DREEM SCALE
The DREEM questionnaire, constructed by Roff and co-authors (4) 13.
Conducting pilot studies to determine the psychometric properties of the adapted DREEM scales. The pilot study involved 50 people tested twice (test and retest) -the second study was conducted after a one-month break. The results of the conducted analyses are presented in Table 1. In order to determine the reliability of the constructed QuESST method, the reliability coefficient of Alfa Cronbach was calculated. The reliability of the scale for 20 items was α=0.865. In order to determine the internal structure, the loads of 8 particular items were analysed by using Component Analysis. 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 2). The four claims that were removed from the method did not meet this criterion. Therefore, the method was re-examined for reliability. The Alpha Cronbach value after deletion of the four entries is α=0,91.
The paper also presents the mutual correlations between the overall result of the QuESST scale and the overall result and individual scales results of the DREEM tool. Table 3 shows the correlations between the overall score of the QuESST and the overall score and the individual scales of the DREEM tool. Undoubtedly, a strong point of organizing the learning process in a simulation environment is the possibility of implementing specific content while maintaining patient safety. The student has the ability to undertake activities and procedures in a repetitive manner, without exposing the potential patient to risk. At the same time, the simulation environment is a reflection of the conditions that will most likely be found in the work environment in the future. This translates into the process of using the acquired knowledge and skills. Healthcare professions require not only technical skills or knowledge of specific medical procedures. It also requires future physicians and nurses to have non-technical skills, make decisions, work in a team, communicate with patients of different ages and needs (11).
Classes conducted by students in simulated conditions provide an opportunity to practice and acquire these skills which are necessary for future work.
Despite the benefits of using medical simulation in teaching, it also has its limitations. Bokken et al. (2008)  Since 2013, Poland has introduced a process of medical education that includes medical simulation, educational profile is largely focused on practical aspects, the standardization of the educational process is taken into account. Hence, our goal was to construct tools that would cover the aspects related to the simulation environment, with particular emphasis on medical simulation.

LIMITATIONS AND FURTHER DIRECTIONS
In this article we described a stage of initial work on adaptation and construction of tools. In the next stages it will be necessary to introduce the adapted DREEM scale into a wider simulation environment, taking into account several medical simulation centers in Poland.
Due to the fact that medical simulation was included in the process of medical education in Poland, it was necessary to make an attempt at constructing a tool for testing the simulation environment as a specific educational environment. Despite the fact that the DREEM tool is well standardized, is used in many countries and appears in the literature, it does not directly address specific simulation conditions. This tool clearly refers to 5 dimensions related to the educational environment, but does not refer to specific simulation conditions that make up the process of medical education in Poland. However, 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.

abbreviations DREEM The Educational Environment Assessment Method
QuESST Questionnaire for Evaluation of Satisfaction of 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 patient for the publication of this case report.

AVAILABILITY OF DATA AND MATERIALS
The datasets during and/or analysed during the current study available from the corresponding author on reasonable request.  Perception of the learning process ,544 *** Perception of teachers ,433 *** Self-perception in the academic environment ,420 *** Perception of the atmosphere ,544 ***