2012 DREEM comes true - Students’ perceptions of educational environment in an Indian medical...

300 Journal of Postgraduate Medicine October 2013 Vol 59 Issue 4

Introduction

I n medical science as well as other sciences, outcome of research can be measured or quantified by objective

parameters while in the field of education such objective evidence is difficult to elucidate.[1] Research in the field of medical education can help to understand the learning process and the learning environment. The medical teachers can benefit immensely by such evidence in educational decision making processes.[1] In educational theories, teaching is about creating the environment for learning as well as dissemination of knowledge.[2] The accomplishment and contentment of

students depends upon their learning environment.[3] Learning environment research tries to assess the students’ perceptions of their environment and it can guide medical teachers to introspect, devise and incorporate the best teaching strategy for the betterment of the educational environment. Educational environment research assesses what is happening in a medical school.[3] It gives a complete and detailed account of the education process[4] the results of which can be used to enhance students’ satisfaction and achievement. Students’ perceptions of their environment has been shown to influence their behavior, progress and sense of well-being.[4,5] The educational environment, as perceived, has been termed as climate,[3] the measurement of which can help in a more meaningful understanding of the medical curriculum.[3] Students’ perceptions of their learning environment have been studied at multiple levels of the education system.[6] There are few studies in a developing country like ours focusing on medical education despite having a large number of medical schools (both government and private).

Several methods have been used to assess learning environment. Only the Dundee Ready Education Environment Measure

Associate Professor of Medicine, 1Principal and Professor of Medicine, JSS University, JSS Medical College and Hospital, Mysore, Karnataka, India

Address for correspondence: Dr. Kiran HS, E‑mail: drkiranhs@ rediffmail.com

Received : 02-08-2012Review completed : 29-09-2013Accepted : 30-09-2013

"DREEM" comes true - Students’ perceptions of educational environment in an Indian medical schoolKiran hs, Basavana Gowdappa h1

ABSTRACTBackground: The accomplishment and contentment of students depends upon their educational environment. Very few studies in India have looked at the impact of educational environment on students, there are few such studies in our country despite having a large number of medical schools. objective: This study was performed to assess the undergraduate students’ perceptions of medical education in general and educational environment in our medical school in particular. Materials and Methods: The Dundee Ready Education Environment Measure (DREEM), a validated inventory was distributed among undergraduate students in final Bachelor of Medicine and Bachelor of Surgery (MBBS) (2010‑2011) and students who were undergoing internship (2010‑2011) and various scores were calculated and the means were compared using Mann‑Whitney test. Results: The mean total DREEM score was found to be 121.5/200 for final MBBS students (n = 115) and 118.4/200 (n = 109) for the internship batch students. There was no statistically significant difference between the scores of the two batches. The overall DREEM score for our Medical School during the academic year 2010‑2011 (for the final MBBS and internship batch) was 120/200 (n = 224), which showed that the students’ perceptions were more positive. Conclusion: The study showed that the students' perception of the educational environment was positive. There was no statistically significant difference between the scores of the two batches (final MBBS and internship). This study helped us to introspect and identify remediable areas in the educational environment of our medical school and hence we could suggest some measures to modify them.

Key WoRds: Education environment, medical education research, perceptions, undergraduate medical education

Education Forum-Research article

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Kiran and Gowdappa: DREEM comes true

Journal of Postgraduate Medicine October 2013 Vol 59 Issue 4 301

(DREEM) inventory[7] is specific to the unique environment in medical education. It was developed by an international Delphi panel in Dundee, Scotland, UK. It is an universal, validated instrument, which provides medical teachers, a diagnostic aid to measure the overall state of affairs in the learning environment of their college.[7] It comprises of 50 items categorized under 5 domains [Table 1] with a total score of 200.[7]

Though DREEM has been widely used, it is not without criticism. Jakobsson et al.[8] have noted that a few items appear to have both low correlation and low factor loading. A few items are also subject to misinterpretation by the students and some items are not relevant in Swedish context according to Jakobsson et al.[8]

The objective of this study was to assess the undergraduate students’ perceptions of medical education in general and educational environment in our medical school in particular. Our medical school runs the Bachelor of Medicine and Bachelor of Surgery (MBBS) course in three phases (4 years and 6 months) plus a year of internship according to the guidelines and curricular framework given by the medical council of our country. We compared final MBBS and internship batches of students as they are exposed to the same environment.

Materials and Methods

It was a cross-sectional study using the already validated DREEM inventory along with some additional questions for a comprehensive evaluation. Approval from the Institutional Ethics Committee of our medical school was obtained and written informed consent was taken from participants. The instrument (in a printed format) was distributed among undergraduate students in final MBBS (2010-2011) and students who were undergoing internship (2010-2011) after passing final MBBS exams. A covering letter highlighting the aims and objectives of the study, anonymous as well as optional status of the response and consent form was also attached to the questionnaire. The students were asked to read each item carefully, understand and to respond using a five-point Likert scale ranging from strongly agree, agree, unsure, disagree to strongly disagree. Items are in the form of statements relating to the student’s course environment (e.g., I am encouraged to participate in class), which are rated by 5-point Likert scale, where 4 = strongly agree, 3 = agree, 2 = unsure, 1 = disagree and 0 = strongly disagree. Nine items are worded negatively (e.g., the teachers ridicule the students) and were reverse scored by the researcher. Scoring was carried out in the questionnaire forms filled up by the students.

Each item was scored 0-4, with scores of 4, 3, 2, 1 and 0 assigned for strongly agree, agree, unsure, disagree and strongly disagree, respectively.

Negative items were scored in a reverse order so that high scores on these items indicate disagreement, i.e. a positive result.

In addition to the DREEM inventory, students were also asked to respond to some additional questions like: What are the

changes you would expect in medical education? Do you prefer blackboard with chalk or power point presentations with liquid crystal display (LCD) projector in lecture classes? Is it necessary to give more emphasis on medical research? Is it necessary to give more emphasis on medical ethics? Do you feel that teachers should be Role models or just teach their subjects? And Do you want to pursue post-graduation and if so, in which subject?

The data collected was entered in MS office excel software. Mean and standard deviation was calculated for all the items for both groups [Table 1]. Total scores for each domain and overall score was calculated for both the batches. The overall DREEM score out of 200 was calculated. The Means of the groups were compared with Mann-Whitney test using the statistical package for the social sciences (SPSS) version 16.0 software package for Microsoft Windows [Table 1]. P < 0.05 was considered as significant. Earlier studies,[9,10] have used the following as an approximate guide to interpret the overall scores: 0-50 (0-25%) = very poor; 51-100 (25.1-50%) = plenty of problems; 101-150 (50.1-75%) = more positive than negative; 151-200 (75.1-100%) = excellent. Reliability analysis was performed using SPSS software (n = 224 and no. of items = 50). Internal consistency was measured using Cronbach’s alpha. To identify lacunae within the learning environment in our school, items with a mean score below 2 were taken as remediable areas and items with a mean score of 3 and above were taken as positives. Items with a mean score between 2 and 3 were considered as areas of the learning environment that could be improved.

Eg: DREEM items Strongly agree Agree Unsure Disagree Strongly disagree

The teachers ridicule the students

√ 4

The teachers are authoritarian

√ 3

The teachers get angry in class

√ 1

The students irritate the teachers

√ 2

I am too tired to enjoy the course

√ 0

Eg: DREEM items Strongly agree Agree Unsure Disagree Strongly disagree

I am encouraged to participate in class

√ 1

The teaching is often stimulating

√ 3

The teaching is student centered

√ 4

The teaching helps to develop my competence

√ 0

The teaching is well focused

√ 2



Table 1: Mean (and SD) DREEM item scores for final MBBS and internship batch studentsDREEM item scores for final MBBS and internship batch of students (mean, SD and P value)

DREEM items Final MBBS Interns P value

PoL-(12 items with a maximum score of 48) Mean SD Mean SD

I am encouraged to participate in class 2.88 0.73 2.81 0.96 0.926

The teaching is often stimulating 2.64 0.75 2.50 0.89 0.268

The teaching is student centered 2.54 0.82 2.46 0.92 0.630

The teaching helps to develop my competence 2.63 0.78 2.50 0.96 0.472

The teaching is well focused 2.71 0.66 2.43 0.92 0.021

The teaching helps to develop my confidence 2.60 0.84 2.43 1.01 0.348

The teaching time is put to good use 2.63 0.91 2.53 0.93 0.215

The teaching over-emphasizes factual learning 1.53 0.82 1.69 0.93 0.160

I am clear about the learning objectives of the course 2.87 0.79 2.69 1.00 0.252

The teaching encourages me to be an active learner 2.63 0.84 2.45 1.05 0.274

Long-term learning is emphasized over short term learning 2.64 0.89 2.62 1.03 0.951

The teaching is too teacher centered 1.80 1.08 1.90 0.97 0.633

Total 30.10 29.01 0.497

PoT-(11 items with a maximum score of 44)

The teachers are knowledgeable 3.31 0.55 3.24 0.62 0.464

The teachers are patient with patients 2.91 0.70 2.62 0.90 0.023

The teachers ridicule the students 1.77 1.04 1.79 1.07 0.992

The teachers are authoritarian 1.27 0.83 1.49 1.01 0.103

The teachers have good communication skills with patients 3.05 0.63 2.78 0.91 0.028

The teachers are good at providing feedback to students 2.30 0.88 2.23 1.02 0.722

The teachers provide constructive criticism here 2.37 0.85 2.26 0.99 0.448

The teachers give clear examples 2.64 0.69 2.46 0.87 0.120

The teachers get angry in class 1.58 1.05 1.46 1.07 0.314

The teachers are well-prepared for their classes 2.78 0.70 2.52 0.95 0.073

The students irritate the teachers 2.23 1.09 1.75 1.26 0.003

Total 26.21 24.60 0.016

ASP-(8 items with a maximum score of 32)

Learning strategies which worked for me before continue to work for me now

2.20 1.12 2.05 1.09 0.236

I am confident about passing this year 2.85 0.84 2.99 0.82 0.168

I feel I am being well-prepared for my profession 2.53 0.83 2.40 0.93 0.268

Last year’s work has been a good preparation for this year’s work 2.48 0.93 2.40 1.01 0.494

I am able to memorize all I need 2.07 1.01 1.94 0.98 0.425

I have learned a lot about empathy in my profession 2.86 0.76 2.73 0.89 0.435

My problem-solving skills are being well developed here 2.52 0.85 2.45 0.99 0.796

Much of what I have to learn seems relevant to a career in healthcare 3.00 0.65 2.83 0.88 0.253

Total 20.51 19.79 0.531

PoA-(12 items with a maximum score of 48)

The atmosphere is relaxed during the ward teaching 2.42 1.02 2.30 1.10 0.497

The school is well timetabled 2.31 1.09 2.23 1.19 0.682

Cheating is a problem in this school 1.23 1.18 1.46 1.29 0.228

The atmosphere is relaxed during lectures 2.70 0.74 2.74 0.85 0.324

There are opportunities for me to develop my interpersonal skills 2.58 0.94 2.60 0.96 0.971

I feel comfortable in class socially 2.91 0.72 2.96 0.83 0.271

The atmosphere is relaxed during seminars/tutorials 2.50 1.16 2.45 1.06 0.548

I find the experience disappointing 2.19 1.07 2.43 1.06 0.065

I am able to concentrate well 2.52 0.82 2.59 0.94 0.373

The enjoyment outweighs the stress of the course 1.94 1.06 2.04 1.19 0.452

The atmosphere motivates me as a learner 2.67 0.77 2.48 1.03 0.294

I feel able to ask the questions I want 2.18 1.05 2.05 1.17 0.440



Results

A total of 260 questionnaire forms were distributed among the students of which 237 were filled and returned by the students and hence an overall response rate was 91.15%. 13 responses were discarded as invalid (Incomplete forms). Hence the total no. of responses analyzed were 224 (n = 224) (final MBBS – n = 115) (interns – n = 109).

The overall reliability coefficient alpha was 0.8792 rounded to 0.88, which exceeded the 0.7 threshold. Table 2 shows the DREEM domain scores for the final MBBS and internship batch students. For students’ PoL, students’ PoT, students’ ASP, students’ PoA and students’ SSP, the mean domain scores for final MBBS batch students were 30.1/48, 26.21/44, 20.51/32, 28.15/48 and 16.58/28 respectively while for the internship batch students, the scores were 29.01/48, 24.6/44, 19.79/32, 28.33/48 and 16.67/28 respectively. The mean total DREEM score was 121.5/200 for final MBBS students and 118.4/200 for the internship batch students [Table 1 and Figure 1]. There was no statistically significant difference between the scores of the two batches. The overall DREEM score for our medical school during the academic year 2010-2011 (for the final MBBS and internship batch) was 120/200 (n = 224) [Table 1 and Figure 1], which showed that students’ perceptions were more positive. Though not statistically significant, final MBBS batch students scored slightly more than the internship batch students in the first three domains, i.e., PoL, PoT and ASP, whereas internship batch students scored slightly more than the final MBBS batch students in the last two domains, i.e., PoA and SSP and the total DREEM domain score was found to be higher for final MBBS students. There was statistically significant difference between the two batches in the 2nd Domain, and in response to 6 items [Table 3].

More practical orientation, pre and para clinical subjects to be taught with clinical relevance and co-ordination among various departments in teaching interrelated topics were requested by the students. Seventy one percent preferred blackboard with

Table 1: Contd...DREEM item scores for final MBBS and internship batch of students (mean, SD and P value)

Total 28.15 28.33 0.567

SSP-(7 items with a maximum score of 28)

There is a good support system for students who get stressed 1.43 1.04 1.18 1.06 0.060

I am too tired to enjoy the course 2.07 1.12 2.04 1.20 0.909

I am rarely bored on this course 2.00 1.07 1.73 1.11 0.063

I have good friends in this school 3.09 0.81 3.21 0.99 0.030

My social life is good 3.00 0.74 3.23 0.78 0.007

I seldom feel lonely 2.42 1.06 2.56 1.14 0.246

My accommodation is pleasant 2.57 1.11 2.72 1.21 0.120

Total 16.58 16.67 0.683

Total 50 items with a maximum score of 200 121.55 14.94 118.40 21.03 0.493

DREEM score Final MBBS Interns

Total 50 items with a maximum score of 200 121.55 118.40 0.493

Grand total final DREEM score (2010-2011) 119.975 rounded to 120DREEM – Dundee Ready Education Environment Measure; SD – Standard deviation; MBBS – Bachelor of Medicine and Bachelor of Surgery; PoL – Perceptions of learning; PoT – Perceptions of teaching; ASP – Academic self-perception; PoA – Perceptions of atmosphere; SSP – Social self-perception

chalk whereas 29% preferred PowerPoint presentations with LCD projector. 65% felt it is necessary to give more emphasis on Medical Research while 35% felt it is not. 93% felt it is necessary to give more emphasis on Medical Ethics while 07% felt otherwise. 99% - an overwhelming majority felt that teachers should be role models and 87% wanted to do post-graduation in a clinical subject.

Discussion

This study is unique in the fact that the DREEM scores of final MBBS and internship batches of students were compared for the first time in our country, to the best of our knowledge while the previous studies have included pre and para clinical batches of students as well. We deliberately chose only these two groups for the simple reason that the pre and para clinical students are not exposed to clinical side as much as the final MBBS and internship batches of students. We felt that students need more clinical exposure to understand and respond properly to this instrument especially to the items like-The teachers are patient with patients, the teachers have good communication skills with patients, etc. The mean total DREEM score was 121.5/200 for final MBBS students and 118.4/200 for the internship batch students [Table 1 and Figure 1]. There was no statistically significant difference between the scores of the two batches. The Total DREEM score was high in this study, indicating that students’ perceptions of the learning environments were quite positive. The mean of 120/200 (60%) (n = 224) was within the range (101-150) said to indicate a more positive than negative perception of the environment.[9] As a percentage, mean scores ranged from 58% to 63% for each subscale [Figure 2]. Good Response rate of 91.15% indicated that students were interested in participating in this study. Three items scored more than 3 and hence can be taken as positives whereas seven items scored less than 2 and hence can be taken as remediable areas. This assessment goes a long way in setting up a feedback system in our institution wherein teachers can introspect. Various components of the curriculum are addressed by items under different domains of DREEM inventory. Hence



121.5 118.4 120

0102030405060708090

100110120130140150160170180190200

TOTAL DREEM SCORE

FINAL MBBS INTERNS OVERALL DREEM SCORE

Figure 1: Total DREEM scores

60% 58%63%

59% 59% 60%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PoL PoT ASP PoA SSP FINAL DREEMSCORE

Figure 2: Percentage contribution of DREEM domains

Table 2: Mean (and SD) DREEM domain scores for final MBBS and internship batch studentsDomain Final MBBS Interns Mean (%) P value

PoL 30.1/48 29.01/48 29.01/48 (60) 0.497

PoT 26.21/44 24.6/44 25.41/44 (58) 0.016

ASP 20.51/32 19.79/32 20.15/32 (63) 0.531

PoA 28.15/48 28.33/48 28.24/48 (59) 0.567

SSP 16.58/28 16.67/28 16.63/28 (59) 0.683

Total DREEM

item score

121.5/200 118.4/200 119.975 rounded to 120

0.493

Final DREEM score (2010-2011) (%)

120/200 (60)

PoL – Perceptions of learning; PoT – Perceptions of teaching; ASP – Academic self-perception; PoA – Perceptions of atmosphere; SSP – Social self-perception; DREEM – Dundee ready education environment measure; SD – Standard deviation; MBBS – Bachelor of medicine and bachelor of surgery

Table 3: DREEM items where significant differences (P<0.05) were observed between the batches of studyDREEM items Final MBBS Interns P value

Mean SD Mean SD

The teaching is well focused 2.71 0.66 2.43 0.92 0.021

The teachers are patient with patients

2.91 0.70 2.62 0.90 0.023

The teachers have good communication skills with patients

3.05 0.63 2.78 0.91 0.028

The students irritate the teachers

2.23 1.09 1.75 1.26 0.003

I have good friends in this school 3.09 0.81 3.21 0.99 0.030

My social life is good 3.00 0.74 3.23 0.78 0.007MBBS – Bachelor of medicine and bachelor of surgery; DREEM – Dundee ready education environment measure; SD – Standard deviation

DREEM can be helpful in curricular evaluation as well as curricular modification.

Considering these scores, in our medical school, we can presume that the teachers are knowledgeable but are authoritarian, often get angry in the class and ridicule the students; the teaching over-emphasizes factual learning and is teacher centered; Support system for students who get stressed is not adequate.

Based on this study, we suggest the need to create a congenial environment wherein teaching-learning process becomes a joy rather than a stress for both students and teachers, creation of good support systems for handling stresses, to break away from the traditional mindset and create a student centered environment wherein teaching - learning process is based on encouragement, to develop problem solving and critical thinking abilities among students; more practical orientation instead of only factual learning, to introduce problem based learning sessions, to enhance co-ordination among various departments in teaching interrelated topics; pre and para clinical topics to be taught with emphasis on their clinical relevance and to give more emphasis on medical ethics and medical research.

The DREEM scores for medical schools in Iran, Srilanka, Nepal, Nigeria, UK, were reported as 99.6/200,[11] 108/200,[12] 130/200,[13] 118/200,[13] 139/200[14] respectively. The mean DREEM score for a medical school in India was reported earlier as 117/200[15] while in the present study it was 120/200.

In a review of the available instruments for measuring the educational environment, Soemantri et al.[16] concluded that DREEM is a good instrument for measuring the educational environment in undergraduate medical institutions and highlighted the need for an analysis of the educational environment to be an integral part of an institution’s good educational practice.[16] However, in a latest review on adoption and use of DREEM, Miles et al.[17] demonstrate that there is hardly any uniformity or unanimity in analysis (including the statistical methods used) and publication of DREEM data, thus making the comparison between institutions difficult.[17] Miles et al.[17] recommend that the means have to be reported for each item to enable useful comparisons of DREEM data between institutions (which has been already implemented thoroughly in our study). Going further, they observe that the review by Soemantri et al.[16] may enhance the use of DREEM and publication of the data and may encourage the consistency in analysis and publishing, so that the DREEM is utilized universally cutting across the barriers of nationalities and institutions.[17] Notwithstanding the reservations about DREEM by Jakobsson et al.,[8] in the future, predictors of success at medical school may include perception of the educational



environment vis a vis DREEM scores.[17] In the backdrop of absence of uniformity and clear guidelines, the said latest review article by Miles et al.[17] concludes with an emphasis on the urgent need of evidence-based guidelines for analysis and publication of DREEM data.[17]

Evaluation of the quality of the educational program is an integral part of any institution’s good educational practice. The accomplishment and contentment of students depends on their positive learning environment. Technology has grown at a mindboggling pace and has invaded every sphere of life including education and learning. Student has evolved as a center around which the medical education technology revolves. Evolution of medical teachers is apt as a natural corollary. It is imperative for the medical teachers to introspect and infuse an element of objectivity into medical education. DREEM in its current format may not be completely appropriate for clinical/bedside teaching as it appears to concentrate more on classroom teaching and therein lies a wider room for improvisation in DREEM so that it covers all aspects of medical education, equally and unambiguously. An indigenous version or adaptations to suit our set up are also desirable.

Acknowledgments

The authors acknowledge students who kindly completed the DREEM inventory and this study is dedicated to all the students and teachers, JSSMC and JSS University. The authors gratefully acknowledge Mr. Lancy D’Souza for statistical consultancy.

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how to cite this article: Kiran HS, BH. "DREEM" comes true - Students' perceptions of educational environment in an Indian medical school. J Postgrad Med 2013;59:300-5.

source of support: Nil, Conflict of Interest: None declared.

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