"DREEM" comes true - Students' perceptions of educational environment in an Indian medical schoolHS Kiran1, Basavana H Gowdappa2
1 Associate Professor of Medicine, JSS University, JSS Medical College and Hospital, Mysore, Karnataka, India
2 Principal and Professor of Medicine, JSS University, JSS Medical College and Hospital, Mysore, Karnataka, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0022-3859.123159
Source of Support: None, Conflict of Interest: None
Background: 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.
Keywords: Education environment, medical education research, perceptions, undergraduate medical education
In 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.  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.  In educational theories, teaching is about creating the environment for learning as well as dissemination of knowledge.  The accomplishment and contentment of students depends upon their learning environment.  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.  It gives a complete and detailed account of the education process  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. , The educational environment, as perceived, has been termed as climate,  the measurement of which can help in a more meaningful understanding of the medical curriculum.  Students' perceptions of their learning environment have been studied at multiple levels of the education system.  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 (DREEM) inventory  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.  It comprises of 50 items categorized under 5 domains [Table 1] with a total score of 200. 
Though DREEM has been widely used, it is not without criticism. Jakobsson et al.  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. 
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.
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, , 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.
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 2 nd 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 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.
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.  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 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,  108/200,  130/200,  118/200,  139/200  respectively. The mean DREEM score for a medical school in India was reported earlier as 117/200  while in the present study it was 120/200.
In a review of the available instruments for measuring the educational environment, Soemantri et al.  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.  However, in a latest review on adoption and use of DREEM, Miles et al.  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.  Miles et al.  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.  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.  Notwithstanding the reservations about DREEM by Jakobsson et al.,  in the future, predictors of success at medical school may include perception of the educational environment vis a vis DREEM scores.  In the backdrop of absence of uniformity and clear guidelines, the said latest review article by Miles et al.  concludes with an emphasis on the urgent need of evidence-based guidelines for analysis and publication of DREEM data. 
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.
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.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]