European Journal of Cardiovascular Medicine

‘Education is the most powerful weapon which you can use to change the world’ – was a famous quote given by Nelson Mandela.¹ Education is the harbinger of the modern era and is the basis for rational and logical thinking. It has brought in huge benefits for the people across every nook and corner of the globe.²

Educational environment refers to the diverse physical locations, contexts and cultures in which students learn. Students may learn in a wide variety of settings, such as outside-of-school locations and outdoor environments. The term also encompasses the culture of a school or class—its presiding ethos and characteristics, including how individuals interact with and treat one another—as well as the ways in which teachers may organize an educational setting to facilitate learning—e.g., by conducting classes in relevant natural ecosystems, grouping desks in specific ways, decorating the walls with learning materials, or utilizing audio, visual, and digital technologies.³

Medical students experience a variety of learning activities in their learning environment of the medical college. The environment is usually complex and unique;⁴ its most important determi­nant is the curriculum.⁵ The learning environment of a medical school is both a manifestation of the curriculum and a determinant of the behaviour of the medical school’s students and teachers.⁶

In the world of medical education where the learning environment is increasingly becoming student-centric from teacher centric⁷, assessment of the medical education environment and teaching patterns holds paramount importance. In Health Sciences Education a universal diagnostic inventory named DREEM (Dundee Ready Education Environment Measure) has been developed using a combination of qualitative and quantitative techniques to assess the educational environment by Roff et al and has been translated in many languages and used since 1997.⁸ It has become the most widely used instrument in medical education and has been used to measure perceptions in five different areas thus leading to identifying weaknesses in the curricula and proposing changes and also to compare different learning environments^9-13. Thus, assessment of the medical education environment holds prominence in lieu of the fact that medical educational environments have rarely been assessed in India all-the-more in Diamond Harbour and in a newly created tertiary care medical institution it becomes the need of the hour. Hence, the aim of the current study was to find out the perception about educational environment in community medicine among the 1^st, 2^nd, 3^rd and final year medical students of Diamond Harbour Government Medical College and to compare the perceptions of educational environment among the medical students between different years.

Design and settings:

The study is an observational cross-sectional study conducted in Diamond Harbour Government Medical College based on a questionnaire conducted for a duration of 1 month. The medical curriculum in this institute is traditional, discipline based and thus consists of 16 subjects taught in four years or nine semesters divided into preclinical, paraclinical and clinical subjects. The institute has an intake of 100 students annually.

Participants and sampling:

The study was conducted among the 1^st, 2^nd, 3^rd and final year MBBS (Bachelor of Medicine and Bachelor of Surgery) students. Total enumeration was used as a sampling technique and all the students who were present and consented to take part were considered in the study sample. Students from every year were approached (n=400) and finally a response was obtained from 264 students with a response rate of 66%.

Tools and instruments:

This study was performed using the DREEM questionnaire which has been standardised and validated across various settings in the world including India. The DUNDEE DREEM contains 50 items assessing five domains viz. students’ perception of learning (12 items), students’ perception of teachers (11 items), students’ academic self-perception (8 items), students’ perception of atmosphere (12 items) and students’ social self-perception (7 items). Each item is rated on a five-point Likert scale from 0-4 where 0=strongly disagree, 1=disagree, 2=neutral, 3=agree and 4=strongly agree. There are nine negative items (items 4,8,9,17,25,35,39,48 and 50) for which correction is done by reversing the scores, thus after reversal higher scores indicate disagreement with that item. Items with a mean score of ³3.5 are true positive points and those with a mean of £ 2 are problem areas, scores in between these two limits are areas of environment that could be enhanced. The maximum score is 200 and the global score is interpreted as follows: 0-50=very poor, 51-100=many problems, 101-150=more positive than negative, 151-200=excellent.

Data collection methods:

The students were approached in the scheduled lecture classes for Community Medicine. In the classes the aim and purpose of the study was explained to them. They were briefed about the DREEM questionnaire, its relevance, the meaning of the questions and the method of answering them. They were assured that the questionnaire would be kept anonymous and no identity of the students would be revealed. They were then handed a participant information sheet and a consent form. Those who gave consent were provided with the questionnaires. After giving due time, the filled-up questionnaires were taken back and the students were thanked for participation.

Data analysis:

The data was entered in Microsoft Excel and SPSS version 16 and the same software was used for analysis. The data was handled and stored in accordance with the tenets of the declaration of Helsinki (1964, amended in 2008). Descriptive analysis was first performed by finding out the frequencies and percentages for the items. Following this, the mean and standard deviation for each of the items was calculated. For each of the domains, the respective scores were evaluated by totalling of the score of each item in that domain. The scores were then assessed for different years and then compared between year cohorts and domains using one-way ANOVA and Tukey’s post-hoc tests.

DREEM questionnaire was administered to all the MBBS students. The response characteristics are represented in table 1. Response rate can be seen to be highest among the 1^st year students (97.9%) and lowest in the 2^nd year students (87.6%). The global DREEM score for all the students (n=264) out of a maximum possible score of 200 was 130.09 ± 20.36, which can be interpreted as a more positive score than a negative score. The DREEM scores were highest among the 1^st year students (135.70 ± 15.95), followed by 3^rd year (131.84 ± 22.55) and final year (127.54 ± 19.39) and were the lowest among 3^rd year students (120.14 ± 20.99). 

TABLE 1 – Distribution of students according to the presence in class and response percentage (n=264)

Table 2 represents the average scores for each DREEM item among all the students and the total domain scores for the items. It is evident that 35 items out of 50 have scores between 2 and 3. These 35 items can be focussed upon and could be enhanced in the medical education institutes. None of the items had a score of above 3.5 which is considered as an excellent score. 6 items have a score of below 2 which is worrying and needs to be worked upon.

TABLE 2 – Average individual item scores and total domain scores of DREEMS items

*Negatively scored item, low score indicates agreement

Table 3 shows the comparison of mean DREEM domain scores between the different MBBS years by using ANOVA and post-hoc tests. When year wise domain scores were considered, the 2^nd year students (29.4 ± 0.15) differed significantly from both the 3^rd years (33 ± 0.32) and 1^st years (34.9 ± 0.47) for the perception of learning. Students’ academic self-perception also had a significant difference with final year students varying from both 3^rd and 1^st years. Also, the 2^nd and 1^st year students differed significantly in their perception of academics. The atmosphere was perceived differently by the 1^st and 3^rd year students than the 2^nd year students.

TABLE 3 – Comparison of means of DREEM domains among the different years using ANOVA and Tukey’s post-hoc test

^#Tukey’s post-hoc test

*Significant at p<0.05

This study was done to find out the perception of medical students about the educational environment in a newly formed tertiary care teaching institute. Diamond Harbour Government Medical College is a new medical college along with 5 other institutes in various regions of the state of West Bengal created with an aim for providing topmost tertiary care to the rural population in South 24 Parganas district which covers vast scathes of Sundarbans area, and also to produce supreme doctors with an aspiration for knowledge. DREEM was used as it is reported to be culturally non-specific and reliable for health professions^13,14,15. The global score of the students in this institute was 130/200 which suggested a more positive than negative environment, a fact that provides some encouragement. An item with a score of greater than 3.5 out of 4 is considered a positive aspect in the curriculum¹⁶. There are 9 items with a score greater than 3 which is quite positive but none greater than 3.5. Majority of the scores were between 2 and 3 which was a very satiating fact for the teachers and showed that we are in the right direction.

In the first domain none of the items were given a score of greater than 3. Thus, students’ perception of learning was very average but satisfactory. Many institutions globally report similar concerns^{4, 13, 14, 17, 18, 19, 20}; these difficulties are not insurmountable and should be addressed. The current pattern of learning is a factual based learning with inclusion of both formative and summative assessments for evaluation of the students.²⁰ This pattern can be done away with a more problem-based approach which goes a long way to alleviate the teacher centric teaching. This approach can be taken up by forming a medical education unit in the institute. The literature suggests that such a change might provide students with stimulating opportunities for learning, thereby building confidence as well.²⁰

Considering the students’ perception of teachers most of the items scored more than 2. Thus, the fact may be quite encouraging for the teachers as well as this also may remind teachers that students respect is important while learning and they may be mentored in a more loving way rather than getting angry and ridiculing them.^4,21,22 Excessive criticism and absence of any feedback is considered to be discouraging and damaging to students’ learning process and damage their self-confidence.²³

Students’ academic self-perception was highly rated by the students as there were no items getting a score of less than 2. They were confident about passing the exams and developing empathy in their profession. Majority of the studies on the contrary have reported a curriculum overload whether it is traditional or innovative, suggesting low scores in this domain.^4,17,18,24. The first and the third years reported the maximum scores significantly different from the second and final years probably because first year students are highly confident and energetic about their performance and the third-year students have the least syllabus to cover so academic overload is minimum.

Students considered the timetable appropriate for the course and rated it very highly. Thus, there was also a significant difference in perception of atmosphere among the candidates of the first, second and the third year with second year students having an overall low score. There may be a difference between the students having a clinical exposure as highlighted in other studies¹³. The clinical teaching in India may be rich in knowledge and providing a good exposure but it degenerates as the load in public tertiary care hospital becomes unbearable with the focus shifting from more clinical teaching to a patient care and students getting devoid of time. A review of the teaching is thus necessary for improving student experiences in clinical learning.

The students have made some good friends in this course and they reveal that they have a good support system but they have rated that they get bored during the course. This is in contrary to some studies which show that the problem shown by the students is mainly of poor support system^13,17,18,22. The boredom may be a result of some external factors for the institute which is location, availability of alternative modes of recreation and transport. Curriculum planners may thus consider ways to make the curriculum less bulky and more innovative, engaging and meaningful with outings and excursions in between to alleviate the boredom in students¹⁴.

Albeit a first study for a new institution, this study was not devoid of limitations. This study used a preset, prevalidated questionnaire with fixed choices with deterred the advantages of open-ended questions and other options which may have occurred from the students. A qualitative study could also have provided more insight into the topic with more information coming out from the respondents. Also, comparison between different streams could have made the study more robust and thus added to the information we already have. The response rate was only 66% which was due to the low attendance. Thus, many students were missed who could have given a valuable input to the study. This could have been avoided if the students would have been pre-informed about the study and its importance and the time of administration of the questionnaire.

The second-year students seemed to have the lowest score among all the students which suggest that a smooth transition is required from pre to para-clinical subjects and to clinical teaching in the wards. Thus, to conclude in a newly constituted institute, the students gave quite a positive overall response to the education environment however improvements are required across all the domains. The greatest difficulty was with students’ perception of learning with second year students having the most problems. Also, this study acts as an eye-opener and tells us not be complacent, to build up a systematic, structured curriculum and teaching environment for the students, and to develop mentoring abilities par-excellence, so that they move out from the boundaries of the institute and carve out a niche in the society for themselves and for the institute. 

The DUNDEE DREEM instrument is a validated and accepted questionnaire for assessment of student perceptions and the same tool was used to judge the insights into community medicine by the undergraduate students in a newly formed medical college and their differences in perception. The overall response was quite encouraging and enforces us in our pursuit to promote academic excellence and provide a supportive learning atmosphere in community medicine.

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