DUNDEE READY EDUCATION ENVIRONMENT MEASURE (DREEM) TOOL: PERCEPTION OF LEARNING ENVIRONMENT IN A MEDICAL COLLEGE OF INDIA

DUNDEE READY EDUCATION ENVIRONMENT MEASURE (DREEM) TOOL: PERCEPTION OF LEARNING ENVIRONMENT IN A MEDICAL COLLEGE OF INDIA

Monica Verma *, Abhishek Soni, Asha Kumari, Ashuma Sachdeva and Ramesh Verma

Department of Biochemistry, Pt BDS PGIMS, Rohtak, Haryana, India.

ABSTRACT: Background: In the present era of quality accreditation, considering the quality of medical education is also very important, especially in developing countries. The present study was planned to understand the current state of medical education and explore medical students’ perception of their learning environment so that problem areas can be identified both at the institutional and curriculum level. Methods: DREEM tool was circulated 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, and 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 an 'educational aspect that could be enhanced'. Out of five domains, students' perception of teachers scored the maximum (57.95 %) rating while students’ social self-perception scored the least (49.35 %). The relationship between students and domain is insignificant for teachers, academics, 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 the right direction. There is an urgent need for training and retraining of teachers and the DREEM scoring survey should be adopted in all medical colleges as an annual scoring system so that the level of medical education could be elevated.

Keywords: DREEM, Medical education, Learning, Teaching, Student-centered teaching, Mentor

INTRODUCTION: The learning environment in medical education is affected by many factors and plays a major role in the life of learners ¹. Most of the time it is measured at the institutional level and the perception of students is always ignored. But nowadays the scenario is changing with the introduction of competency-based medical education.

Measuring the learning environment indicates the quality of the educational environment expressing the efficiency of the 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 undergraduate curricula' educational environment, including medicine, dentistry, nursing, midwifery, anesthesiology, medical emergencies, paramedical sciences, and chiropractic learning environments ^{5 - 8}.

Since, our main target is to produce competent and well-educated Indian Medical Graduates. So, taking their opinion is also of 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 concern can be easily addressed. This will result in substantial amendments to 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:

Study Design: This is a prospective, descriptive, and cross-sectional study. The study was conducted at Pt B D Sharma, Post Graduate Institute of Medical Sciences (PGIMS) Rohtak in collaboration with Shaheed Hasan Khan Government Medical College, Mewat (SHKM). The MBBS undergraduate students studying at SHKM from 1^st, 2^nd, 3^rd, and 4^th year were included in the study after taking their due consent. Pre-validated DREEM inventory tool was used which is a well-proven certified and reliable tool and has been translated into various languages across the world ⁵.

The proforma of the original English-language version of the 50-item DREEM tool was used. A Google form was prepared and a link to the survey was forwarded to all the willing participants. The students were assured that participation in the study is completely voluntary and non-participation would not adversely affect their academics. Response to the questionnaire submitted by them was collected and analyzed. Reminders to complete the survey were also sent, as and when the need aroused.

Methodology: DREEM instrument was developed in Dundee, Scotland, UK by Delphi process ¹⁰. It is a generic, non-culturally specific, multi-dimensional questionnaire consisting of 50 questions divided into five domains – Students’ perceptions of learning/teaching (SPL; 12 items), Students’ perceptions of teachers (SPT; 11 items), Students’ academic self-perceptions (SASP; 8 items), Students’ perceptions of the atmosphere (SPA; 12 items) and Students’ social self-perceptions ⁵.

Each item was scored 0–4 on a five-point Likert scale (4 = strongly agree, 3 = agree, 2 = neutral, 1 = disagree, and 0 = strongly disagree). However, 9 out of the 50 items (Q 4, 8, 9, 17, 25, 35, 39, 48, and 50) were negative statements and were scored in a reverse manner (0 =strongly agree, 1 = agree, 2 = neutral, 3 = disagree and 4 = strongly disagree) so that, the higher the score, the more negative the feedback, or the more incorrect perception. Individual items were analyzed by calculating the mean score as it enables the identification of specific strengths and weaknesses within the educational environment.  The data which was adopted for interpretation of the overall score, domains score, and individual item mean scores are explained in Table 1 ^{11, 12}.

The data was compiled and analyzed using SPSS (v17; SPSS Inc., Chicago, IL, USA). Descriptive statistics were used to calculate mean, standard deviation, and minimum and maximum values. one-way analysis of variance (ANOVA) was calculated, and p< 0.05 was considered to be significant.

RESULTS: Only those questionnaire responses which were completed in all aspects were included in the study. Table 1, shows the number of students who participated in the study. A total of 204 students (out of 480) submitted their feedback, of whom, the maximum were male students, i.e., 156 (76.4%) males vs 48 (23.5%) females. The number of students in the first, second, third and fourth years was 81, 75, 12 and 36 respectively. There was not much participation from third-year students. The mean age of the entire cohort was 19.67 years. The 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: NUMBER OF STUDENTS WHO PARTICIPATED IN THE STUDY WITH A GENDER DISTRIBUTION

Table 2, shows the interpretation of overall and domain scoring with the 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 the practical guide of McAleer and Roff ^{5, 13} indicated ‘more positive than negative’. The overall mean score was 2.21±0.58, which is interpreted as an 'educational aspect that could be enhanced’. 63.2% of students rated the education environment as more positive than negative. 27.9% think that there are plenty of problems in the current education system while only 7.4% rated the current education system as excellent.

TABLE 2: DREEM INTERPRETATION SCORING ALONG WITH NUMBER OF STUDENTS IN EACH CATEGORY

TABLE 3: OVERALL PERCEPTION OF THE EDUCATIONAL ENVIRONMENT AND DOMAINS OF THE DREEM QUESTIONNAIRE

Out of five domains, students’ perception of teachers scored the maximum (57.95%) rating while students’ social self-perception scored the least (49.35%). 54.7 % of students had a positive perception of the learning environment while 22.1% observed teaching negatively. 58.8% of students believed that teachers are moving in the right direction but 27.9% perceived that they need some retraining. 51.5% of students had positive feelings about self-academic perceptions but 39.7% dealt with the negative side. Only 4.4% of students are confident of passing the exams and are sure of their bright careers. 63.2% felt a more positive college learning atmosphere and 20.6% faced many issues which need changes in the current system. 42.6% felt social self-perception was not too bad but an equally comparable percentage of students (41.2%) felt that it is not a nice place which is overall the most problematic area of the institute and to be looked at 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, academics, 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 the average calculated for each item for all years accompanied by the overall mean. An average score ≥ 3 showed positive points and strength areas of the educational environment. Average between 2 and 3 are problem areas that should be taken care of and items with an average score ≤ 2 represented weaknesses of the education environment of the 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.

TABLE 4: YEAR-WISE COMPARISON OF OVERALL SCORES AND DOMAINS SCORES OF THE DREEM QUESTIONNAIRE

TABLE 5: YEAR-WISE COMPARISON OF THE AVERAGE DOMAIN SCORE AMONG STUDENTS OF ALL YEARS

TABLE 6: OVERALL AND YEAR-WISE AVERAGE SCORES OF INDIVIDUAL ITEMS OF THE DREEM QUESTIONNAIRE

*Items with negative statements. Items with a mean score below 2 were taken as problem areas needing remediable action. Items with a mean score of 3 and above were considered positives. Items with a mean score between 2 and 3 were considered as aspects that could be possibly enhanced.

DISCUSSION: In the present era of Quality accreditation, checking the quality of the educational environment is a need of the hour. Recently, the 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 the 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 the institute in the right direction but also indicates some areas that require attention. If we compare the result with the range (101-150), it is towards the lower side only. 27.9% of students still think that there are plenty of problems in the 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 – 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% scores respectively. Among the four years, third-year students gave the highest rating for the SPL domain. First and second-year students felt a need for 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 - 22}. Although competency-based medical education had been introduced by the institute 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, gamified learning, flipped classroom, etc ²³. As per the majority of students, teachers of the college are well knowledgeable, which is a very strong suit. But as per their feedback obtained, they are authoritarian too, get angry in class very often, and are not able to provide constructive criticism. Fourth-year students are interested in getting feedback from their teachers. It seems as if the institute needs training and retraining of teachers. A study done by Yilmaz, very well explains, how lack of training and fear of change from the norm among teachers can affect learning a lot²⁴.  There is a need for a replacement for the role of a teacher as a facilitator who can supervise their students and provide guidance. 21^st 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' perceptions of atmosphere declined in the final year. Final-year students had significantly lower scores than other students. The 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 a lack of learner-centered teaching methods and a 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.

In the last domain, students’ social self-perception scored the least and suggested "not a nice place". Many of the negative perceptions in this domain centered on the lack of a 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 key to this glitch ²⁷.

Mentors play different roles than supervisors. This is a kind of informal relationship which focuses on achieving specific goals. Positive mentoring could prove beneficial not only for the personal and professional growth of students but can help them in research and academics tool ^{28, 29}. With increasing awareness of the potential value of mentoring, many medical colleges and even new competency-based medical education curriculum support mentor-mentee culture worldwide ^{30, 31}.

The study had its share of certain limitations too. There is a lack of full participation of students. 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 out 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 the dearth. We have also decided to share the results of the study with the medical education unit of the 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 the medical education system.

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

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

Funding: None

CONFLICTS OF INTERESTS: The authors report no competing interests

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    How to cite this article:

    Verma M, Soni A, Kumari A, Sachdeva A and Verma R: Dundee ready education environment measure (dreem) tool: perception of learning environment in a medical college of India. Int J Pharm Sci & Res 2024; 15(1): 137-44. doi: 10.13040/IJPSR.0975-8232.15(1).137-44.

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