Perception of the learning environment by students in a new medical school in Saudi Arabia: Areas of concern Academic research paper on "Educational sciences"

Journal of Taibah University Medical Sciences (2012) 7(2), 69-75

Taibah University Journal of Taibah University Medical Sciences

www.jtaibahumedsc.net www.sciencedirect.com

Educational Study

Perception of the learning environment by students in a new medical school in Saudi Arabia: Areas of concern

Abdulaziz Fahad Al-Kabbaa, MD, Hashim Hassan Ahmad, MD *, Abdalla Abdelwahid Saeed, MD, Abdelshakour Mohammed Abdalla, MD and Ali Ahmed Mustafa, PhD

Faculty of Medicine, King Saud Bin Abdul Aziz University for Health Sciences, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia

Received 21 July 2012; revised 10 September 2012; accepted 15 September 2012

KEYWORDS

DREEM;

Learning environment;

Perception;

Riyadh

Abstract Objective: The learning environment affects the learning of medical students and their practice as physicians. The objective of the present study was to assess the perceptions of medical students towards the learning environment in a new a Medical School in Saudi Arabia.

Methods: This is a cross-sectional study, which used the self-administered validated Dundee Ready Education Environment (DREEM) questionnaire as a tool. The study was performed at the Faculty of Medicine, King Fahad Medical City, Riyadh, Saudi Arabia. The study population was all medical students enrolled in the academic year 2009/2010. The main outcome measure was the perception of students of the overall educational environment.

Results: The DREEM questionnaire, which consists of 50 items scored on a 0-4 Likert scale, was completed by 237 medical students (85% of total students). The mean total score was 111.5 out of a maximum of 200, indicating a relatively low satisfaction with the perceived environment. There were no individual areas of excellence (item scoring >3.5 points). Ten items scored consistently <50% indicating cause for concern. These included the long term atmosphere of learning, teaching methods, students' ability to concentrate and teachers' and students' attitudes.

Conclusions: This study identified areas of concern in the educational environment within this new medical college. Corrective measures need to be considered. Upon the implementation of those measures, the DREEM tool can be used to re-evaluate the environment.

© 2012 Taibah University. Production and hosting by Elsevier Ltd. All rights reserved.

* Corresponding author: Faculty of Medicine, King Saud Bin Abdul Aziz University for Health Sciences, King Fahad Medical City, P.O. Box 59046, 11525 Riyadh, Kingdom of Saudi Arabia.

E-mail address: hhahmad@kfmc.med.sa (H.H. Ahmad) Peer review under responsibility of Taibah University.

1658-3612 © 2012 Taibah University. Production and hosting by Elsevier Ltd. All rights reserved. http://dx.doi.Org/10.1016/j.jtumed.2012.11.001

Introduction

Students in medical schools interact with multi professional staff, patients, and peers. This can occur, often, under very challenging conditions due to the heavy workload, competition among peers and at times in a hostile environment [1-3]. The learning environment is one of the main components in the evaluation of any medical education program [4]. There is a growing recognition of the importance of the educational climate or environment in underpinning effective students' learning. Students' perception of the environment within which they study has been shown to have a significant impact on their behavior, academic progress and sense of well-being [5-9]. ''A motivating learning environment fosters deep self-directed learning in the students and subsequently good medical practice as physicians. Consequently, demotivating elements such as perceived bias, poor role models, information overload, teacher-centered or disorganized teaching need to be identified and eliminated'' [1].

Assessment of the environment of medical education measures the gross outcome of what is happening from the students' perspective, comprehensively [5]. It is an accepted way of assessing the nature of the educational practice of a given medical school. It also provides a holistic, comprehensive, systematic and detailed picture of the overall state of affairs in the education process [10]. Researchers have used different methods such as qualitative approaches or questionnaires in for assessing the educational climate [2,10-12]. The Dundee Ready Education Environment (DREEM) is the most widely used instrument [13]. It was originally developed between 1994 and 1996 by a Delphi panel of nearly 100 medical and health profession educators from several countries who participated in various courses of the Medical Education Centre in Dundee, Scotland. It is intended to be a universal and culture-free inventory. DREEM had been used in a multitude of studies in countries across all continents. These studies helped in identifying the strengths and weaknesses, within institutions as a predictor of students' performance [13-14].

The Faculty of Medicine at King Fahad Medical City in Riyadh, the capital of Kingdom of Saudi Arabia, has a six-year curriculum which is almost totally problem-based for both male and female students. Few sessions are delivered as interactive lectures .The first batch of students graduated in 2010 .The College is reviewing the curriculum and this study is part of this reviewing process. Teaching at all levels in the country is conducted separately for male and female students by teachers of the same gender, respectively. The present study is the first, to the best of our knowledge, to report results from all undergraduate levels of a non-government-funded medical school in Saudi Arabia. There are perceived differences between government-funded and non-government-funded medical schools regarding the academic standard or calibre of the students, the social class, teaching and learning facilities in addition to tuition fees paid only by students in private colleges. This is because students who scored higher grades are given admission in government colleges whereas students with lower grades have to enrol in private medical schools in Saudi Arabia. Consequently the general impression is that students from private medical schools may have different attitudes and perception of their educational environment. As students' approaches to learning and the quality of their learning out-

comes are strongly influenced by students' perceptions of the educational environment [15], it is vital and appropriate to study these perceptions. The objective of this study is to assess:

(1) The educational environment as perceived by students using the DREEM inventory.

(2) The differences between students at different levels and between male and female students in relation to the total score and the scores of the 5 domains of the DREEM inventory.

(3) The areas of concern in the existing educational environment in order to suggest feasible and appropriate remedies.

Materials and Methods

A short demographic questionnaire was constructed to collect information on aspects such as the participant's gender, age group and enrollment level. Student's perception about educational environment was collected using DREEM inventory. DREEM has been widely used as a tool to gather information about the educational environment in many institutions .It consists of a 50 item inventory, consisting of 5 subscales.

(a) Students' Perceptions of Learning (SPL)-12 items; maximum score is 48;

(b) Students' Perceptions of Teachers (SPT)-11 items; maximum score is 44;

(c) Students' Academic Self-Perceptions (SASP)-8 items; maximum score is 32;

(d) Students' Perceptions of Atmosphere (SPA)-12 items; maximum score is 48;

(e) Students' Social Self-Perceptions (SSSP)-7 items; maximum score is 28.

The total score for all subscales is 200.

High internal consistency has been reported independently by Cronbach alpha with scores ranging from 89% to 91% [16,17]. Items are in the form of statements relating to the respondent's course environment (e.g., ''I am encouraged to participate in class''), which are rated via 4-point Likert scale, where 4 = strongly agree and 0 = strongly disagree. Nine items are worded negatively (e.g., ''Cheating is a problem in this school'') and are reversed scored by the researcher before tallying. Item scores count towards an overall environment score as well as one of five subscales or domains.

A pilot test was undertaken in order to assess whether the students have difficulties in understanding the questions. All queries of students regarding the meaning of the statements and how to fill in the answers were addressed before the actual study started. A validated Arabic version was made available to students if they faced difficulty in understanding any statement. The study was voluntary and self-administered. A covering letter was attached to the questionnaire indicating the purpose of the study, the anonymity of respondents, that the students have the option not to take part in the survey and that the results will be used only for the stated purposes of the study. All students enrolled in the college were included in the study and hence no sampling was used.

Statistical analysis

DREEM scores and demographic data were entered and analysed using Statistical Package for the Social Sciences (SPSS) Version 17.0. Means and standard deviations were calculated for DREEM total and subscale scores for the entire sample as well as for subgroups identified by the demographic data collected. For dichotomous variables (gender, level of enrolment) comparisons of total and subscale DREEM score means were carried out using a series of independent measures t-tests. For variables with more than two factors a series of one-way Analyses of Variance (ANOVAs) were used to compare all groups. The study outcome variables measured in a Likert scale of five points) but practically can be dealt with as continuous and they were quantified by using the mean and standard deviation. Column totals may vary due to missing data from certain variables.

The study population was all medical students enrolled in second semester of the academic year 2009/2010. The study was approved by King Fahad Medical City Internal Review Board (KFMC IRB) and by the Faculty of Medicine authorities.

Results

Of the 278 students enrolled in the college during the study period (second semester for academic year 2009/2010), 237 completed the questionnaire which corresponds to a response rate of about 85%. No significant differences were noted between responders and non-responders with regard to age, gender or class characteristics. The age of students ranged from 17 to 26 years with more than 45% aged 20-21 years and an overall mean of 20.3(±1.6) years (20.9 ±1.5 for males and 19.1 ± 1.0 for females). Male students were enrolled in all five class levels constituting 77% (173 students), while females were enrolled only in the first and second class levels constituting 23% (64 students) as shown in Table 1.

After the 9 negatively stated items were reverse-scored the mean score of each of the 50 items according to the five sub-scales is shown in Table 2. Mean scores <2 out 4 points are shown in bold font. The overall mean score of all the 50 items was 111.5 out of 200 (2.23 points out of 4, 55.75 out of 100%). The highest score was for the statement ''teaching is sufficiently concerned to develop my confidence'' (2.78 out of 4) and the lowest was for the statement. ''The teachers ridicule the students'' (1.25 out of 4 points).

Table 3 shows the mean scores of the subscales. The highest score was for the subgroup of Academic Self Perception (ASP) with 2.34 points (about 59%) and the lowest was for Perception of Teacher (POT) with 2.09 points (about 52%). Junior classes scored significantly higher scores than senior classes for all subscales except POT. Females scored significantly higher scores for ASP than males. Students aged 20 and 21 years scored significantly higher scores for SSP than students who were younger or older than them. .Out of the 50 items included in the DREEM instrument, 10 items (20%) scored <2 points out of 4 (<50% of the possible score). The majority of these low scores (4 items) were in the POT group, 3 items were in POL, 2 items were in the POA, and only one item in SSP domain. The lowest score 1.25 points (31%) was for teachers ridiculing students, while the highest 1.94

Table 1: Gender distribution of students according to age and

class level.

Class level Males n (%) Females n (%) Total n (%)

First 38 (22.0) 35 (54.7) 73 (30.8)

Second 55 (31.8) 29 (45.3) 84 (35.5)

Third 26 (l5.o) 0(0) 26 (11.0)

Fourth 30 (17.3) 0 (0) 30 (12.7)

Fifth 24 (l3.9) 0 (0) 24 (10.1)

Age in years

17-19 23 (13.3%) 44 (68.8%) 67 (28.3%)

20-21 72 (41.6%) 20 (31.2%) 92 (38.1%)

22 + 78 (45.1%) 0 (0%) 78 (32.9%)

Total 173 (73.0) 64 (27.0) 237 (100)

points (48.50%) was for emphasizing short term duration of learning as shown in Table 4. Significantly lower scores were more among males, older students and senior class levels.

Discussion

Educational environment is one of the most important factors in determining the success of an effective curriculum and effective learning [2,4-6,8,18,19]. Hence assessing the educational environment is of vital importance. This study addressed students perception of their educational environment. The results showed a high response rate (85%) which may point to the keenness of the students in evaluating their college as they are fee-paying students and therefore anticipate their money's worth from their medical school. This response rate is much higher than the response rate of 59% recently reported by a study from Greece [20]. It is also much higher than the 50% response rate in College of Medicine, King Khalid University Hospital (KKUH) based elsewhere in Riyadh [21]. The authors attributed that to students' fear of being negatively affected by the authoritative atmosphere prevalent at that college [21] or because the students probably felt the survey is of no consequence and is a waste of effort [22].

The results of the present study showed an overall score of 2.23 points out of 4 (55.75% -111.5/200) which is within the range (101-150) said to indicate a ''more positive than negative'' perception of the learning environment [23-24]. This level is better than the 45.0% (89.9/200) of the mother college in the main university campus [21]. Other similar studies nationally and internationally reported overall scores ranging from 45% to 63.5% [14,21,22-26]. A few studies have yielded higher total DREEM scores than the present study, which may reflect that these institutions may be fairly innovative in terms of providing a student-centred approach to education [27-29]. No item received a mean score P3.5. A mean score P 3.5 indicates particularly positively-rated items. It is hoped that future assessment will show more items scoring more than 3.5 after corrective intervention is applied.

This study revealed significantly higher scores for females in ASP, for students aged 20-21 for SSP and for junior classes for all subscales except POT. Few studies reported no gender differences in the overall students' perception of their educational environment [9,21,30]. Some studies found a statistically significant difference between genders, with females in general, being more critical concerning the quality of teaching and gen-

Table 2: Mean scores of the five groups itemized.

Items N Minimum Maximum Mean Std. deviation

A - Perception of Learning (PoL)

I am encouraged to participate in class 237 0 4 2.75 1.009

The teaching is sufficiently concerned to develop my confidence 234 0 4 2.78 .963

The teaching encourages me to be an active learner 229 0 4 2.08 1.189

The teaching is well focused 232 0 4 2.52 1.032

The teaching is sufficiently concerned to develop my competence 234 0 4 2.33 1.044

I am clear about the learning objectives of the course 236 0 4 2.22 1.269

The teaching is often stimulating 235 0 4 2.32 1.048

The teaching time is put to good use 232 0 4 1.78 1.037

The teaching is student-centred 237 0 4 2.24 1.077

Long term learning is emphasized over the short term 226 0 4 1.94 1.200

The teaching is too teacher-centred 238 0 4 1.66 1.078

The teaching over-emphasized factual learning 232 0 4 1.88 1.047

B - Perception of Teacher (PoT)

The teachers are good at providing feedback to students 234 0 4 2.68 .862

The teachers have good communication skills with patients 230 0 4 2.27 .969

The teachers are knowledgeable 232 0 4 2.25 1.043

The teachers give clear examples 233 0 4 2.43 0.963

The teachers are well prepared for their classes 230 0 4 2.27 1.177

The teachers provide constructive criticism here 227 0 4 2.10 1.320

The teachers ridicule the students 230 0 4 1.25 1.009

The teachers get angry in class 235 0 4 1.41 .880

The teachers are authoritarian 238 0 4 1.43 1.161

The teachers are patient with patients 237 0 4 2.67 1.026

The students irritate the teachers 235 0 4 1.43 .955

C - Academic Self-Perception (ASP)

I am able to memorize all I need 234 0 4 2.45 .989

Much of what I have to learn seems relevant to a career in medicine 234 0 4 2.44 1.134

I feel I am being well prepared for my profession 233 0 4 2.01 1.265

Last year's work has been a good preparation for this year's work* 234 0 4 2.34 1.082

My problem-solving skills are being well developed here 236 0 4 2.29 1.211

I am confident about passing this year 234 0 4 2.48 1.028

I have learned a lot about empathy in my profession 237 0 4 2.59 1.060

Learning strategies which worked for me before continue to work for me now 232 0 4 2.31 1.147

D - Perception of Atmosphere (POA)

The atmosphere is relaxed during lectures 232 0 4 1.93 1.055

I feel able to ask the questions I want 235 0 4 2.21 1.176

I feel comfortable in the class socially 234 0 4 2.31 1.143

There are opportunities for me to develop interpersonal skills 235 0 4 2.29 1.155

The atmosphere is relaxed during seminars/tutorials 230 0 4 2.46 1.013

The enjoyment outweighs the stress of studying medicine 233 0 4 2.53 .991

The atmosphere motivates me as a learner 233 0 33 2.47 2.299

I am able to concentrate well 234 0 4 1.49 1.069

The atmosphere is relaxed during the ward teaching 232 0 4 2.28 1.004

This school is well timetabled 234 0 4 2.29 1.132

I find the experience disappointing 229 0 4 2.07 1.067

Cheating is a problem in this school 233 0 4 2.47 1.034

E- Social Self Perception (SSP)

I have good friends in the school 233 0 4 2.08 1.188

There is a good support system for students who get stressed 232 0 4 2.61 1.160

I am too tired to enjoy this course 233 0 4 1.41 1.051

I am rarely bored on this course 235 0 4 2.75 1.045

My accommodation is pleasant 235 0 4 2.42 1.002

My social life is good 231 0 4 2.27 1.099

I seldom feel lonely 230 0 4 2.43 1.126

Overall 237 0 4 2.23 0.309

eral climate of the school [11,31]. Others, however, reported that gender is not associated with a consistent pattern of per-that mean total score for males were less than females [4] which ception of educational environment although there is a long-is in agreement with the present study. In general it appears standing evidence that males and females typically exhibit dif-

Table 3: Mean scores of subscales out 4 points according to class

level, gender and age.

Class level/subscales POL POT ASP POA SSP

First Mean 2.23 2.02 2.37 2.32 2.38

Std. deviation .311 .291 .527 .418 .418

Second Mean 2.44 2.11 2.42 2.27 2.28

Std. deviation .470 .288 .622 .583 .486

Third Mean 2.33 2.20 2.38 2.18 2.37

Std. deviation .671 .360 .483 .378 .455

Fourth Mean 2.10 2.14 2.19 2.05 2.14

Std. deviation .353 .445 .543 .418 .587

Fifth Mean 2.01 2.09 2.14 2.00 2.06

Std. deviation .615 .304 .535 .306 .430

P value 0.001 0.223 0.025 0.031 <0.001

Gender

Male Mean 2.28 2.11 2.27 2.20 2.26

Std. deviation 0.506 0.343 0.428 0.429 0.311

Female Mean 2.28 2.03 2.36 2.35 2.26

Std. deviation 0.344 0.265 0.564 0.359 0.307

P value 0.994 0.125 0.007 0.129 0.545

Age (yr)

17-19 Mean 2.23 2.03 2.31 2.38 2.20

Std. deviation 0.351 0.264 0.435 0.455 0.263

20-21 Mean 2.33 2.10 2.22 2.33 2.32

22 + Mean 2.14 2.10 2.07 2.15 2.07

Std. deviation 0.538 0.317 0.393 0.494 0.325

P value 0.129 0.439 0.074 0.129 0.002

Overall Mean 2.28 2.09 2.34 2.22 2.28

Std. deviation 0.464 0.321 0.565 0.478 0.479

ferent learning styles [30]. The perception of environment, in this study, varied between levels of enrolment. This result is in agreement with other studies which showed that perceptions of teachers and of atmosphere were significantly superior for second year students over fourth year students [32].

There are several areas of concern where students gave poor rating. Of the 50 items, 10 items scored <2 out of 4 points. Out of these 4 items (40%) pertained to the area of POT which was the lowest among all areas. The student felt that the teachers were strict, and at times sarcastic about the students' shortcomings. Moreover, teaching was teacher-centred and overemphasizing factual knowledge. This is in agreement with some studies [31] but contradicting other local and international studies [4,6,22]. Differences in student's perception are

not unexpected. Such results call for further comprehensive studies to detail in-depth specific areas of concerns.

The POA learning atmosphere which other studies showed to have significant impact on students' behaviour, academic progress and sense of well-being, scored low in the present study. This suggests that more investigations are needed before a corrective intervention is instituted. The students appear not able to concentrate, memorize or enjoy the courses while the atmosphere is relax during lectures. Many studies reported generally similar findings [6,21,22]. Medical students everywhere seem to share similar concerns as reported in studies that utilized the DREEM instrument [33-35]. It is interesting that most areas of concern are related to what is taught rather than how it is taught and allude to the curriculum content rather than its delivery. This needs corrective intervention in our setting, since we are adopting a Problem-Based Learning (PBL) system which calls for more student-centred and student self-directed learning (SDL). We need to support the teaching staff to be more oriented towards PBL, improve their sense of responsibility by training. Furthermore, recognizing their needs and implementing programmes for motivating and rewarding, the teaching staff becomes a necessity [26]. We suggest that this area be emphasized in our continuous professional development (CPD) programme.

The nature of self-reporting questionnaires imposed some limitations to the conclusions of this study. The validity and accuracy of students' perceptions of their learning and the learning environment may be questionable. This study was totally quantitative in nature and a qualitative component would have, further, strengthened the study.

Conclusion

This study indicated widespread and major defects in the educational environment in our school which is in agreement with previous studies. There is a need for the creation of a supportive environment to facilitate learning; to design and implement interventions in order to improve the learning environment if we are to realize effective and successful learning. Inviting experts to help formulate strategies and design corrective plans of action to further improve learning is a right step. Further research is needed to comparing our findings with other nongovernment and government institutions in order to assess the educational environment prevailing in medical colleges in the region.

Table 4: Items with scores <50% (<2 points out of 4 points) in descending order.

Question Score P value age P value gender P value class

Long term learning is emphasized over short term learning 1.94 0.001 0.562 0.003

The atmosphere is relaxed during lectures 1.93 0.268 0.244 0.15

The teaching overemphasizes factual leaning 1.88 0.001 0.001 0.001

The teaching is too teacher cantered 1.66 0.326 0.163 0.234

I am able to concentrate well 1.49 0.014 0.001 0.002

The teachers are authoritarian 1.43 0.033 0.001 0.157

The students irritate the teachers 1.43 0.018 0.001 0.001

I am too tired to enjoy the course 1.41 0.001 0.00 0.001

The teachers get angry in class 1.41 0.191 0.001 0.107

The teacher ridicule the students 1.25 0.001 0.001 0.001

Competing interests

The authors declare no competing interests of any kind. No funding was received from any source for this study.

Authors' contributions

A.F.K. helped design the study questionnaire and helped performed the same; H.H.A. conceived the idea, collected and collated the data; A.A.S. assisted in recruiting and conduct of the study; A.M.A. assisted in the conduct of the study; A.A.M. assisted in the conduct of the study as corrected the final manuscript. All authors read and approved the final manuscript.

Acknowledgements

The authors are grateful to Dr. Jaffar Ali of the Research and Scientific Publications Center for his assistance in reviewing the manuscript. The participation of the students is highly appreciated.

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