Students’ perceptions of educational environment in a medical school experiencing curricular transition in United Arab Emirates

Abstract

Background: Gulf Medical College, UAE, underwent a major curriculum change from a discipline-based to an organ-based integrated curriculum.

Aim: To compare students’ perception of the educational environment in the discipline-based curriculum with that in the integrated curriculum.

Methods: Data was collected from second-year students (Group 1) in the discipline-based curriculum and in the subsequent year from second year students in the integrated curriculum (Group 2). The instrument used was Dundee Ready Education Environment Measure (DREEM). Scores were compared using Wilcoxon Rank Sum test. Data from second, third and fourth year students in the discipline-based curriculum were used to determine the total DREEM score for the school.

Results: The total DREEM score was significantly higher (p < 0.001) for Group 2 (135/200) when compared to Group 1(116/200). Both groups unanimously perceived a positive educational environment. Although Group 2 showed significantly more satisfaction, they perceived an over-emphasis of factual learning and a problem of cheating. Total DREEM score for the school was 120/200.

Conclusion: This study shows that the organ system-based integrated curriculum is perceived to provide better educational environment than the discipline-based curriculum. However, areas like curriculum load and assessment strategies still require further fine tuning.

Introduction

Educational environment strongly influences the students’ learning experiences. A good educational environment is essential for effective learning (Genn 2001; Roff et al. 2001; Hutchinson 2003; Till 2004). Positive environment and positive learning outcomes go hand in hand.

Learning environment is primarily affected by the curriculum. “Curriculum's most significant manifestation and conceptualization is the environment, educational, and organizational which embraces everything that is happening in the medical school” (Genn 2001).

Gulf Medical College, Ajman, United Arab Emirates (UAE), offered a traditional discipline-based undergraduate curriculum for over 10 years. In-depth reviews of the existing curriculum revealed major weaknesses which undermined the effectiveness of the educational process. Also, the awareness of regional, local, and global changes in the health care delivery systems and guidelines from accreditation body (Ministry of Higher Education) highlighted a need for curricular change. Hence in 2007, a modular, organ-based integrated curriculum with elements of problem-based learning was introduced. The new curriculum emphasized a more student-centered approach to promote active learning among the students using less didactics and more interactive teaching/learning sessions like small group learning, computer aided learning, case-based learning and problem-based learning.

Although, there are many reports of studies measuring the educational environment in medical schools (Primparyon et al. 2000; Bassaw et al. 2003; Al-Hazimi et al. 2004; Mayya & Roff 2004; Zamzuri et al. 2004; Jiffry et al. 2005), we were unable to find any studies comparing the changes in the educational environment in the same medical school during an evolving curriculum. In our study, an attempt has been made to measure the students’ perceptions of the learning environment before and after the new curriculum was introduced in our medical school. A flexible curriculum can be constantly improved by identifying its weaknesses and strengths. The findings from this study will help in defining them so as to justify and improve our newly introduced curriculum.

Table

Practice points

Students’ perceptions of the educational environment are essential for curriculum assessment. DREEM questionnaire identified the weaknesses and strengths of newly introduced integrated curriculum. Satisfaction was significantly perceived with the curricular change as indicated by students’ perception of a positive learning environment. Reduction of core curriculum and introduction of new assessment strategies are areas of remedial interventions.

Objectives

1. To compare the students’ perceptions of the educational environment in the discipline-based curriculum with that in the newly introduced integrated curriculum at Gulf Medical College.

2. To measure the students’ perceptions of the educational environment at our school.

Materials and methods

Instrument

The 50-item Dundee Ready Education Environment Measure (DREEM) questionnaire was administered to students in Gulf Medical College.

The DREEM questionnaire has been found to have universal face validity (Primparyon et al. 2000; Bassaw et al. 2003; Al-Hazimi et al. 2004), cultural non-specificity (Roff et al. 1997; Roff 2005), and high reliability in a variety of settings (Mayya & Roff 2004; Riquelme et al. 2009).

The DREEM questionnaire (Roff et al. 1997) has been used by a number of medical colleges to:

1. Assess the quality of learning environment as perceived by the students (Primparyon et al. 2000; Bassaw et al. 2003; Al-Hazimi et al. 2004; Mayya & Roff 2004; Zamzuri et al. 2004; Jiffry et al. 2005).

2. “Diagnose” the positive or negative aspects of individual institutions (Primparyon et al. 2000; Bassaw et al. 2003; Mayya & Roff 2004; Jiffry et al. 2005).

3. Identify the perceived weaknesses of a new curriculum (Till 2004).

4. Compare the educational environment in medical schools with discipline-based curriculum versus those with innovative curriculum (Al-Hazimi et al. 2004).

5. Ensure and maintain high quality educational environments when students of the same institution were placed at different teaching centers (Varma et al. 2005).

The DREEM inventory involves 50 items divided into five domains which are:

1. Students’ perceptions of learning (SPL) – 12 items; maximum score is 48.

2. Students’ perceptions of teachers (SPT) – 11 items; maximum score is 44.

3. Students’ academic self-perceptions (SAP) – 8 items; maximum score is 32.

4. Students’ perceptions of atmosphere (SPA) – 12 items; maximum score is 48.

5. Students’ social self-perceptions (SSP) – 7 items; maximum score is 28.

The total score for all domains is 200. Each item is scored from 0 to 4 with 4 = strongly agree, 3 = agree, 2 = unsure, 1 = disagree, and 0 = strongly disagree. Nine negative items are scored in reverse for analysis.

The DREEM questionnaire was first pilot tested on a small sample of our students. Following the pilot study, descriptive phrases were added to some items of the questionnaire for better understanding.

Sample

The questionnaire was administered to the student groups of Gulf Medical College on different occasions prior to a lecture class at the beginning of the academic year. Brief explanations of the objectives and the method of filling out the questionnaire were given. Voluntary participation was stressed upon. All students present in the class on the day of the survey took part in the study. The time taken for filling out the questionnaire was about 20 min.

DREEM questionnaire was answered anonymously by all the students of second year (n = 51) (Group 1), third year (n = 55), and fourth year (n = 40) in the discipline-based curriculum in September 2008. In the subsequent year, the questionnaire was administered to second year students in the integrated curriculum (n = 44) (Group 2).

The first years were not included in the study as they had recently joined the institution and were not in a position to comment on the educational environment. The final year students, on the other hand, were omitted from the study due to inability to contact all of them as they were in various clinical rotations.

The study was approved by the Ethics Review Committee of the institution.

Statistical analysis

Data was analyzed using the statistical package PASW-17. The mean Global scores, domain scores, and individual item scores were expressed as mean ± standard deviation (SD). Comparison of scores between groups was done using Wilcoxon rank sum test. The “p” value less than 0.05 was considered as statistically significant.

Results

The DREEM questionnaire was administered to a total of 190 students (response rate 83%). Of the 51 students in year 2 of discipline-based curriculum (Group 1), 49% were males and 51% females with a mean age of 20.3 years (SD = 1.9) and 19.4 years (SD = 1.4), respectively. Of the 44 students in year 2 of integrated curriculum (Group 2), 39% were males and 61% were females; their mean age being 20.6 (SD = 2.2) years and 19.5 (SD = 1.7) years, respectively. For this batch, the response rate for age was 93%. The two batches were homogeneous with respect to mean age and gender distribution. Data were also collected from third year and fourth year students in discipline-based curriculum.

The total DREEM scores for Groups 1 and 2 were 117/200 and 135/200, respectively. The total DREEM scores for third and fourth year students in discipline-based curriculum were found to be 121/200 and 123/200, respectively. The data from second, third, and fourth year students (n = 146) in the discipline-based curriculum were used to determine the total DREEM score for the school, which was 120/200.

The mean domain scores obtained by Groups 1 and 2 are shown in Table 1. The interpretation of each domain was done as suggested by Roff et al. (1997). Both the groups perceived “a more positive approach” for their learning “moving in the right direction” for their teachers; “feeling more on the positive side” for their academic self perception; “a more positive atmosphere” for their atmosphere and “not too bad” for their social self-perceptions. However, the mean domain scores for Group 2 were significantly more as compared to Group 1.

Table 1.  Mean ± SD DREEM domain scores (% of maximum score) for Groups 1 and 2

Domain	Group 1	Group 2	p-value
SPL	29.57 ± 5.80 (61.6%)	33.36 ± 5.21 (69.5%)	<0.005
SPT	26.14 ± 3.99 (59%)	29.98 ± 5.08 (68%)	<0.001
SAP	19.29 ± 4.77 (60%)	22.41 ± 4.13 (70%)	<0.005
SPA	26.08 ± 6.00 (54%)	31.45 ± 7.17 (65.5%)	<0.001
SSP	15.43 ± 3.57 (55%)	18.20 ± 4.66 (65%)	<0.005
Total DREEM score for the group	116.5 ± 18.7 (58%)	135.4 ± 22.1 (67%)	<0.001

Group 1 identified “perception of learning” as the domain with highest mean score, whereas Group 2 gave highest scores to the domains “perception of learning”, and “academic self-perceptions”. Both groups gave low mean scores to the domains “perceptions of atmosphere” and “social self-perceptions.”

On analysis of the mean scores of individual items, mean scores 3 and above were considered as areas of strength; mean scores between 2 and 3 were considered as areas that could be improved and mean scores of 2 and below were areas of weaknesses.

Group 1 gave the highest score for the item “the teachers are knowledgeable”. Group 2 also supported this by ranking this second. Group 1 felt that “the teachers ridicule the students” and so this item had the least score. Group 2 gave low scores to items stating “the teaching over-emphasizes factual learning” and “cheating is a problem in this school” (Tables 2 and 3).

Table 2.  Mean (SD) DREEM item scores with significant differences between second year students in discipline-based curriculum and second year students in integrated curriculum

Domain	Serial no.	Item	Discipline-based curriculum	Integrated curriculum	p-value
SPL	7	The teaching is often stimulating (interesting)	2.24 (1.088)	2.91 (0.802)	<0.001
	13	The teaching is “student centered”	2.2 (0.825)	2.91 (0.709)	<0.001
	24	The teaching time is put to good use	2.45 (1.045)	2.91 (0.709)	<0.05
	25	The teaching overemphasizes factual learning (a method of learning which concentrates on memorizing information)	2.45 (0.966)	1.77 (1.159)	<0.01
	44	The teaching encourages me to be an active learner	2.31 (1.068)	2.89 (0.722)	<0.005
	47	Long-term learning is given importance over short term learning	2.35 (1.055)	2.77 (0.937)	<0.05
SPT	6	The teachers are patient with the hospital patients	2.04 (0.564)	3 (0.747)	<0.001
	8	The teachers ridicule (make fun of) the students	1.47 (1.206)	2.86 (1.091)	<0.001
	18	The teachers have good communication skills with hospital patients	2.06 (0.645)	2.91 (0.884)	<0.001
	50	The students irritate the teachers	2.75 (1.23)	2.32 (1.095)	<0.05
SAP	22	The teaching is sufficiently concerned to develop my confidence	2.43 (0.944)	3 (0.482)	<0.001
	26	Last year work has been a good preparation for this year's work	2.25 (1.163)	3.07 (0.695)	<0.001
	31	In my profession, I have learned a lot about empathy (ability to understand somebody's feelings/difficulties)	2.47 (1.222)	3.05 (0.888)	<0.01
	41	My problem-solving skills are being well developed here (ability to solve medical problems)	2.45 (1.006)	2.89 (0.754)	<0.05
	45	Much of what I have to learn seems relevant (having some sensible or logical connection) to a career in medicine	2.59 (0.963)	3.11 (0.579)	<0.01
SPA	11	The atmosphere is relaxed during the hospital ward teaching	1.92 (0.523)	2.77 (0.912)	<0.001
	23	The atmosphere is relaxed during lectures	2.24 (1.159)	2.7 (0.93)	<0.05
	30	There are opportunities for me to develop interpersonal skills (skills involving relationships between people)	2.14 (1.149)	2.68 (0.983)	<0.01
	34	The atmosphere is relaxed during seminars/tutorials	2.39 (1.168)	3.02 (0.849)	<0.01
	35	I find the experience (of studying here) disappointing	1.78 (1.119)	2.3 (1.231)	<0.05
	36	I am able to concentrate well	2.14 (1.096)	2.66 (1.077)	<0.01
	43	The atmosphere motivates (encourages) me as a learner	1.78 (1.064)	2.68 (0.909)	<0.001
SSP	3	There is a good support system (help) for students who get stressed	1.67 (1.089)	2.14 (1.112)	<0.05
	15	I have good friends in this school	2.9 (1.1)	3.36 (0.81)	<0.05
	46	My accommodation is pleasant	1.65 (1.426)	2.91 (1.235)	<0.001

Table 3.  Mean (SD) DREEM item scores without significant differences between second year students in discipline-based curriculum and second year students in integrated curriculum

Domain	Serial no.	Item	Discipline-based curriculum	Integrated curriculum
SPL	1	I am encouraged to participate in class	2.82 (0.713)	3.07 (0.695)
	16	The teaching is sufficiently concerned to develop my competence (the ability to do something well)	2.67 (0.952)	2.95 (0.645)
	20	The teaching is well focused (concentrated well on topic being taught)	2.76 (1.031)	2.91 (0.563)
	38	I am clear about the learning objectives (goals) of the course	2.45 (1.222)	2.68 (0.829)
	48	The teaching is too “teacher-centered”	2.43 (0.964)	2.59 (0.897)
SPT	2	The teachers are knowledgeable	3.31 (0.648)	3.16 (0.68)
	9	The teachers are authoritarian (strict)	2.22 (1.064)	2.34 (0.888)
	29	The teachers are good at providing feedback to students (comments in the form of opinions about students performance)	1.88 (1.211)	2.2 (0.978)
	32	The teachers provide constructive criticism (carefully considered, helpful opinion of what is wrong about somebody)	2.43 (1.118)	2.75 (0.781)
	37	The teachers give clear examples	2.65 (0.89)	2.89 (0.538)
	39	The teachers get angry in class	2.43 (1.204)	2.66 (1.077)
	40	The teachers are well prepared for their classes	2.9 (0.964)	2.89 (0.689)
SAP	5	Learning strategies (methods) which worked for me before continue to work for me now	2.31 (0.905)	2.52 (0.902)
	10	I am confident about my passing this year	2.86 (0.825)	3.02 (0.792)
	21	I feel I am being well prepared for my profession	2.47 (0.833)	2.66 (0.834)
	27	I am able to memorize all I need	1.88 (1.107)	2.09 (1.053)
SPA	12	The timetable of this school is appropriate (is correct)	2.08 (1.339)	2.48 (1.045)
	17	Cheating is a problem in this school	2.31 (1.14)	1.98 (1.303)
	33	I feel comfortable in class socially	2.73 (0.981)	3 (0.863)
	42	The enjoyment (of studying medicine) outweighs the stress of studying medicine	2.1 (1.237)	2.3 (1.231)
	49	I feel able to ask the questions I want	2.47 (1.172)	2.89 (0.813)
SSP	4	I am too tired to enjoy this course (MBBS)	2.1 (1.153)	2.14 (1.212)
	14	I am rarely bored in this course (MBBS)	2.04 (1.248)	2.09 (1.309)
	19	My social (personal) life is good	2.67 (1.16)	2.98 (1.023)
	28	I very rarely feel lonely (I don’t feel lonely)	2.41 (1.314)	2.59 (1.3)

For Group 1, there were 8 items (16%) indicating the areas of weaknesses; 1 item in the positive area (2%) and the remaining items were in the areas that could be improved (82%). The domains “perceptions of atmosphere” and “social self-perceptions” had maximum items in the areas of weaknesses.

However Group 2 showed a more positive perception as only 2 items had a mean score of 2 or less (4%); 11 items had a mean score above 3 (22%) and the rest were in the areas that could be improved (74%). The items in the areas of weaknesses were in the domains of “perception of learning” and “perceptions of atmosphere” (Figure 1).

Figure 1. Mean item scores for Groups 1 and 2.

Discussion

“Curriculum generates and establishes environment” (Genn 2001). Any curricular change will definitely result in a change of educational environment. Based on this principle, we anticipated that there would be a positive change in the learning environment of our institution due to a shift to a more student-centered curriculum. The DREEM questionnaire was administered to assess the change (if any) in the educational environment as perceived by our students following the curricular change.

We had an acceptable response rate of 83%. The total DREEM mean score of our students (120/200) is higher than the scores found for medical schools in Nigeria 118/200 (Roff et al. 2001); Trinidad 110/200 (Bassaw et al. 2003); India 107/200 (Mayya & Roff 2004); Saudi Arabia 102/200, 107/200; Yemen 100/200 (Al-Hazimi et al. 2004); and SriLanka 108/200 (Jiffry et al. 2005) but is lower than schools in Bahrain 127/200; UAE 125/200 (Al-Qahtani 1999); Nepal 130/200 (Roff et al. 2001); UK 139/200 (Varma et al. 2005); and Dundee 139/200 (Al-Hazimi et al. 2004). Similar to that observed in a few other studies (Al-Hazimi et al. 2004; Varma et al. 2005; Riquelme et al. 2009), Group 2, in a more student-centered curriculum, has a significantly higher DREEM score (135/200) than Group 1 (117/200), in the traditional curriculum.

Group 2 were the first batch of students to experience the newly restructured curriculum. Therefore, data from this group should give an immediate feedback about the strengths and the weaknesses of the changed learning environment and so the new curriculum may be judged from this point of view.

The results of this study show that Group 2 has a significantly more positive perception of the educational environment than Group 1. These findings are reassuring for the curriculum planners as the higher scores can be attributed to the positive curriculum change which has taken place.

On analysis of the domains, higher mean scores in the domains “perception of learning” and “academic self perception” seen in Group 2 reflects a positive response to the student-centered curriculum emphasizing long-term learning and problem-solving skills. On the contrary, low scores in domains “social self-perceptions” and “perceptions of atmosphere” reveal the inappropriate timetable, the stress of studying medicine, tiredness of students, and tediousness of the course. These are the areas of weaknesses which have to be studied in detail for rectification.

The individual item analyses identified the teachers’ medical knowledge and competence as the strength of our college, while the over-emphasis on factual learning and cheating are areas necessitating intervention. Both these areas of weaknesses have also been identified by other institutions (Bassaw et al. 2003; Jiffry et al. 2005; Riquelme et al. 2009), suggesting that these are common issues of concern.

The fact that there is scope for improvement in areas like appropriateness of the timetable of the school, stress of studying medicine, weariness of students and inability to memorize, reinforces the belief that still there is curriculum overload. Significant endeavors have been made to develop the students’ confidence; prepare them for the next level, instill empathy in them; motivate them and create a more relaxed atmosphere for learning. The significant difference observed for item 41 (my problem-solving skills are being well developed here) can be attributed to the elements of problem-based learning incorporated in the new curriculum. The relevance of learning to a career in medicine (item 45) has also been enhanced. This is critically important as the relevance to learning is intimately linked to motivation and retention of learning (Hutchinson 2003).

Though we have significantly achieved a more student-centered teaching atmosphere, the teachers have not been able to successfully let go of their traditional role as indicated by the scores of item 9 (the teachers are authoritarian). There is also room for improvement with regard to feedback and constructive criticism by the teachers.

There is a significant positive change in the support system for stressed students (item 3). This may be attributed to the recently introduced student support system with certain members of staff giving personal academic support to the students (preceptor support). Apparently, this is not sufficient as indicated by the scores being less than three for both items 3 and 28. Moreover, the process of curriculum change is often stressful for both students and faculty (Roff et al. 1997; McAleer et al. 1998) which may also contribute to the students “perceptions”.

The interventions to improve our evolving curriculum have to be taken up not only by the curriculum planners but also by the administrators. There should be a substantial reduction of the core curriculum, introduction of study guides and curriculum maps and the encouragement of peer to peer learning (Davis & Harden 2003). It is a well-known fact that assessment drives learning. Hence the assessment system should be improved to assess not just factual recall but also higher cognitive levels. Formative assessment should play a more dominant role and students self assessment should also be considered. Portfolios can be introduced in order to minimize the stress due to summative assessment. Existing educational facilities like the clinical skills center have to be developed and other facilities need to be introduced like integrated learning areas (Davis & Harden 2003).

To circumvent the problem of cheating, the establishment of “an institutional culture of integrity” is a necessity. This will require clarity of institutional regulations, more active participation by the students, interactive teaching of medical ethics with exposure to anticipated ethical situations faced by students themselves and the introduction of new strategies in assessment (Glick 2001; Bassaw et al. 2003).

The emphasis on collegiate, cooperative staff–student relationships; student-centered, competency-based education must be sustained (Genn 2001). The encouragement of student evaluations of teaching should be continued. Attention should also be paid to areas which have been highlighted as not having significant improvements. Reorganization of the timetable; well-communicated explicit learning objectives and adequate preparation for their profession is the need of the hour. The powerful effect of effective feedback on learning is well recognized and so, our continuous Faculty Development programs should reacquaint the faculty members with effective feedback techniques (Norcini 2010). The introduction of a “Stressful Experience report form” can be considered to enhance the student support system. This would allow the students an opportunity to report any distressing incidents and seek support (Whittle et al. 2007). Qualitative analysis using focus groups and open-ended questions can assist in providing additional insights into the results obtained from our study (Whittle et al. 2007).

Our study gives us baseline data about the students’ perceptions of the educational environment in the new curriculum. Consequently, it may be too premature to come to more concrete conclusions. We aim to monitor changes within the same cohort (Group 2) by longitudinal studies. Moreover, comparative analyses between future students of the integrated curricula and this group are also in the pipeline. These may overcome the limitations of this study to some extent. Other aspects which have been ignored are the correlation of perceptions of learning environment with the academic performance and the prediction of academic achievers and under achievers with the use of the DREEM questionnaire. We also advocate the use of additional (qualitative) studies to circumvent the limitations of this questionnaire-based data (Seabrook 2004a).

Conclusion

Positive perceptions of environment are intimately linked with the end points of learning outcomes like student behavior, achievement, satisfaction, and success (Genn 2001). Moreover, continuous curriculum assessment is integral for a sustainable positive learning environment. The DREEM questionnaire has helped in identifying the strengths and weaknesses of the new curriculum. Our students in the integrated curriculum perceived significantly more satisfaction with the curricular change which has reinforced our justification in undertaking this tremendous step. However, curriculum overload and cheating continue to remain as areas of concern. Consequently, substantial reductions of the core curriculum and introduction of new strategies in assessment have emerged as the main areas of remedial interventions for the improvement of the new curriculum and the learning environment in Gulf Medical College.

Acknowledgement

The authors would like to thank Dr Gita Ashok Raj, Dr Elsheba Mathew and Dr Rizwana B Sheikh for their suggestions in editing this article.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.