To examine the perception of educational environment among clinical year students in Thailand using Dundee ready education environment measure (DREEM) and identify factors associated with the DREEM scores.
A total of 2,467 fourth- to sixth-year students from 34 teaching hospitals nationwide responded to a Thai version of DREEM questionnaire. Data on each student’s sex, year of study, size of teaching hospitals and GPAX were collected. Mean total DREEM scores and subscales were calculated and then compared across groups using t-test and one-way ANOVA.
The overall student perception on educational environment was ‘more positive than negative,’ with the mean total DREEM score of 131.1 (SD=17.4). Similar findings were observed in all subscales. Mean total DREEM scores were lower in medium-size than small- and large-size teaching hospitals 129.9 (SD = 18.1), 131.9 (SD = 17.5) and 131.6 (SD=16.4) respectively (F (2,2422) =3.21, p=0.04). Sex and years of study was associated with certain DREEM subscales.
Clinical year medical students in Thailand were satisfied with their academic learning environment, with varying perceptions across different size of teaching hospitals. Repeat assessment of educational environment of medical schools over time is needed for monitoring changes after specific educational interventions being applied.
Educational environment consists of many factors such as physical environment (e.g., classroom and equipment), teachers, colleagues and other student support systems that can motivate the engagement of the learner.
Many tools have been developed for assessing student perception of educational environment. Most previous studies reported ‘more positive than negative’ learning environment.It is also suggested that perceived educational environment may be related to a number of factors such as student’s sex, study years and academic performance, and characteristics of medical schools.
The objective of the present study was to examine the perception of educational environment among clinical year medical students trained at 34 teaching hospitals across Thailand and to identify factors associated with overall educational environment scores and subscales.
This was a cross-sectional survey carried out by the Office of the Collaborative Project to Increase Production of Rural Doctors or CPIRD, with a primary aim to study the student perceived educational environment of teaching hospitals under the CPIRD project. Between July 2015 and April 2016, 2,878 fourth- to sixth-year medical students trained in different clinical clerkships in 34 teaching hospitals nationwide were asked to complete a questionnaire. A total of 2,467 students responded to the questionnaire (a response rate of 85.7%). No written informed consent was given by the participants as the survey was considered part of the quality improvement of these teaching hospitals. Before completing the questionnaire, the students were informed about the study objectives and procedures and reassured that research data would be treated anonymously. Ethical approval for the study was obtained from the Ethical Review Board of Chonburi Hospital.
Fourth- to sixth-year medical students were asked to complete a questionnaire, which included two parts: (i) educational environment using a Thai version of the DREEM questionnaire, and (ii) student’s characteristics including sex, year of study, grade point average (GPAX) and hospitals in which they were trained. The DREEM questionnaire is comprised of 50 five-point Likert scale questions on learning environment and atmosphere (0= strongly disagree, 1= disagree, 2= neither agree or disagree, 3= agree and 4= strongly agree), with a total score ranging from 0 to 200. Nine of the 50 items are negative statements. The questionnaire is divided into five subscales: (1) students’ perceptions of learning (SPL), (2) students’ perceptions of teachers (SPT), (3) students’ academic self-perception (SAP), (4) students’ perceptions of atmosphere (SPA), and (5) students’ social self-perception (SSP). Maximum scores for the above DREEM subscales are 48, 44, 32, 48 and 28, respectively. The questionnaire was reported to have high validity and reliability in student nurses (Cronbach’s alpha = 0.91).
Characteristic | N (%) |
---|---|
Year of study | |
Fourth-year | 885 (36) |
Fifth-year | 819 (33) |
Sixth-year | 763 (31) |
Female (gender) | 1,424 (58) |
GPAX | |
≤2.00 | 13 (0.6) |
2.01-2.50 | 117 (5.8) |
2.51-3.00 | 571 (28.4) |
3.01-3.50 | 956 (47.5) |
>3.50 | 357 (17.7) |
Size of teaching hospitals * | |
Small size | 713 (29.0) |
Medium size | 848 (34.4) |
Large size | 902 (36.6) |
Geographic region | |
Northern | 605 (24.9) |
Southern | 611 (25.1) |
North-eastern | 703 (29.0) |
Central and Eastern | 506 (21.0) |
*Teaching hospitals were divided into 3 groups by their size: 1. Large sized hospital teaching 120-180 medical students; 2. Medium sized hospital teaching 90-119 medical students; 3. Small sized hospital teaching fewer than 90 medical students
Characteristics of students and teaching hospitals (medical education centers) were summarized as number (percentage) and mean (SD) for categorical and continuous variables respectively. Average total DREEM scores and subscales were described. The average score for each DREEM item was also examined and ranked; therefore, areas for improvement could be identified. Independent t-test was used to compare the average total DREEM scores and subscales between male and female students, and one-way ANOVA was used to compare the scores across different years of study, sizes of medical, educational centers and geographic regions. The proportions of students perceiving their learning environment ‘excellent’ were compared across different size of medical education centers using chi-square test. A p-value of <0.05 was considered statistically significant.
The mean total DREEM score was 131.1 (SD=17.3) out of 200. The mean total scores in 34 teaching hospitals ranged from 119.7 (SD=20.4) to 139.7 (SD=14.0). Two thousand and seventy-two students (84%) rated a total score of 101-150, while 253 students (12%) rated a total score of 151-200 and 102 students (4%) reported a total score of below 101. The mean scores (SD) for SPL, SPT, SAP, SPA, SSP subscales were 31.4 (4.2), 30.7 (4.8), 21.4 (3.8), 29.8 (4.8) and 17.7 (3.6), respectively.
Considering each of 50 items of DREEM, eleven items averaged below 2.5, and nine items averaged more than 3.0 (
Item No | Items | Subscale | Mean score | SD | Median score | Min-Max score |
---|---|---|---|---|---|---|
2 | The course organizers are knowledgeable | SPT | 3.38 | 0.61 | 3 | 0-4 |
47 | Long term learning is emphasized over short-term learning | SPL | 3.32 | 0.67 | 3 | 0-4 |
15 | I have good friends in this course | SSP | 3.15 | 0.74 | 3 | 0-4 |
19 | My social life is good | SSP | 3.13 | 0.67 | 3 | 0-4 |
30 | There are opportunities for me to develop interpersonal skills | SPA | 3.11 | 0.63 | 3 | 0-4 |
31 | I have learned a lot about empathy in my profession | SAP | 3.02 | 0.71 | 3 | 0-4 |
18 | The course organizers appear to have effective communication skills with patients | SPT | 3.02 | 0.69 | 3 | 0-4 |
7 | The teaching is often stimulating | SPL | 3.01 | 0.69 | 3 | 0-4 |
40 | The course organizers are well prepared for their teaching sessions | SPT | 3.01 | 0.68 | 3 | 0-4 |
41 | My problem-solving skills are being well developed here | SAP | 2.48 | 0.72 | 2 | 0-4 |
36 | I am able to concentrate well | SPA | 2.47 | 0.78 | 3 | 0-4 |
12 | This course is well timetabled | SPA | 2.39 | 0.87 | 2 | 0-4 |
3 | There is a good support system for registrars who get stressed | SSP | 2.37 | 0.92 | 2 | 0-4 |
11 | The atmosphere is relaxed during consultation teaching | SPA | 2.33 | 0.92 | 2 | 0-4 |
48 | The teaching is too teacher centered | SPT | 2.28 | 0.91 | 2 | 0-4 |
4 | I am too tired to enjoy the course | SSP | 2.27 | 1.00 | 2 | 0-4 |
27 | I am able to memorize all I need | SAP | 2.27 | 0.83 | 2 | 0-4 |
14 | I am rarely bored on this course | SSP | 2.27 | 0.86 | 2 | 0-4 |
35 | I find the experience disappointing | SPA | 2.13 | 1.00 | 2 | 0-4 |
42 | The enjoyment outweighs the stress of the course | SPA | 2.06 | 0.90 | 2 | 0-4 |
There was no difference in overall perceived educational environment, as measured by total DREEM scores, across years of study (
Albeit no gender difference in overall perceived learning environment, female students seemed to perceive more positively about their teachers than male students (t = -2.54, p=0.011). However, male students had more positive academic self-perception than their female counterparts (t = 3.53, p<0.001).
Students in the large- and small-sized teaching hospitals/ medical education centers perceived more positively about their educational environment than those in medium-sized hospitals (F (2,2422) = 3.21, p=0.04). Similar findings were observed for teacher (F (2,2455) = 12.93, p<0.001), atmosphere (F (2,2452) = 5.35, p=0.004) and social self-perception subscales (F (2,2453) = 3.53, p=0.029).
The proportion of students perceiving their learning environment ‘excellent’ was highest in small-sized hospitals/ medical education centers (12.1%, 9.9% and 9.7% for small-, medium- and large-sized hospitals respectively, (χ 2 (6, N=2425) = 16.08, p=0.010). There was no difference in perceived learning environment across geographical region.
This paper describes medical student’s perception of educational environment in 34 teaching hospitals nationwide using a Thai version of DREEM questionnaire. Overall, the medical students perceived more positively than negatively about their learning environment, although a small number of students felt dissatisfied. Students trained in teaching hospital of different sizes perceived differently about their learning environment, while student sex and year of study were associated with certain subscales of educational environment.
Similar to our findings, previous studies from Australia, Sweden and the United Kingdom reported that there were ‘more positive than negative’ student perceptions regarding learning environment and atmosphere as a whole, with a small proportion of students reporting ‘excellent’ or ‘poor’ learning environment.
subscales | Year of study | Gender | Size of teaching hospitals / MECs | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
Year 4 N=882 | Year 5 N=816 | Year 6 N=757 | F (df1,df2), p-value * | Male N=1042 | Female N=1416 | t (df), p-value * | Small N=710 | Medium N=846 | Large N=902 | F (df1,df2), p-value * | |
Mean(SD) | Mean(SD) | Mean(SD) | Mean(SD) | Mean(SD) | Mean(SD) | Mean(SD) | Mean(SD) | ||||
SPL | 31.3(4.5) | 31.3(4) | 31.5(3.9) | F ( 2,2455) =0.76, 0.469 | 31.3(4.5) | 31.5(3.9) | t ( 2456) =-0.97, 0.329 | 31.5(4.2) | 31.1(4.3) | 31.5(4.0) | F ( 2,2455) =0.19, 0.015 |
SPT | 31.0(5.0) | 31.0(4.7) | 30.0(4.7) | F ( 2,2455) = 13.14, <0.001 | 30.4(5.1) | 30.9(4.6) | t ( 2456) =-2.54, 0.011 | 31.3(5.0) | 30.1(4.9) | 30.7(4.6) | F ( 2,2455) =12.9, <0.001 |
SAP | 21.0(4.0) | 21.4(3.7) | 21.9(3.7) | F ( 2,2453) =8.60, <0.001 | 21.7(4.0) | 21.2(3.6) | t ( 2454) =3.53, <0.001 | 21.5(3.9) | 21.2(3.9) | 21.5(3.6) | F ( 2,2453) =1.50, 0.224 |
SPA | 29.3(4.8) | 30.0(5.0) | 30.0(4.0) | F ( 2,2452) =7.44, <0.001 | 29.7(5.0) | 29.9(4.6) | t ( 2453) =-0.74, 0.457 | 30.0(4.8) | 29.3(4.9) | 30(4.6) | F ( 2,2452) =5.35, 0.004 |
SSP | 17.5(3.6) | 17.7(3.6) | 18.0(3.3) | F ( 2,2453) = 3.91, 0.020 | 17.7(3.7) | 17.8(3.5) | t ( 2454) =-1.01, 0.312 | 17.4(3.7) | 17.9(3.6) | 17.8(3.4) | F ( 2,2453) =3.53, 0.029 |
Total score | 130.3(18) | 131.4(17.2) | 131.5(16.6) | F ( 2,2422) = 1.23, 0.292 | 130.8(18.6) | 131.3(16.3) | t ( 2423) =-0.73, 0.464 | 131.9(17.5) | 129.8(18) | 131.6(16) | F ( 2,2422) =3.21, 0.040 |
*p-values for comparison across two and three groups using t-test and ANOVA respectively SPL: students’ perceptions of learning; SPT: students’ perceptions of teachers; SAP: students’ academic self-perception; SPA: students’ perceptions of atmosphere; SSP: students’ social self-perception
Although this does not imply absolute advantages of Thailand’s medical schools over those in the two countries, it suggests that overall learning environment in teaching hospitals in Thailand relatively meet most students’ expectations. It also suggests that educational environment and atmosphere were fairly consistent across 34 teaching hospitals of Thailand.
Student’s perceptions on learning environment and atmosphere provide valuable information for curriculum development and improvement of medical schools. The DREEM questionnaire and similar other tools were designed to describe several aspects of learning environment ranging from teachers, atmosphere, supporting facilities to student’s academic self-perception. Therefore, they can be used to identify strengths and limitations of medical schools, which may form key parts of the framework for improvement of medical schools themselves and to benchmark with other medical schools. As shown in our study, teachers appeared to be one of the key strengths of Thailand’s CPIRD teaching hospitals. This might be because CPIRD particularly have continuously improved its teacher-to-student ratio and faculty development. On the other hand, it seemed that atmosphere and social self-perceptions were among the crucial areas for improvement. To address these issues, a number of interventions may be implemented, such as stress management program, and social and academic support for medical students to develop self-resilience. In addition, student support and guidance such as effective mental health program and advising/ mentoring program may also be beneficial.
Student perceptions on educational environment and atmosphere may change over years of study as the result of interaction between student experience and varying challenges over time. In the present study, although overall perceptions on learning environment were consistent across years of study, students’ academic and social self-perceptions and perception of atmosphere were increasingly positive when they advanced to a more senior year. This is in contrast with many previous studies which showed the decreasing trend of DREEM scores over years of study.
Gender inequality in perceptions of educational environment has been consistently reported. Similar to previous several studies,
Size of medical schools may have influence on educational environment, with some evidence suggesting favorable learning environment in small-sized medical schools. Similar to the previous studies in Australia and Canada,
CPIRD is a good demonstration that using existing health services as training facilities helps enhance student’s experience in community-oriented competencies and interprofessional skill.
Our study has some limitations. First, as the DREEM questionnaire is a tool to assess the perception of undergrad students concerning general learning environment, it might not reflect the whole and true picture of clinical teaching environment and climate. A more clinical-specific tool may be needed. Additionally, as this survey was carried out at a certain period of the year when students were on different clerkship rotations, the results might have been different if the study had been done at the different time of academic year. Furthermore, although the DREEM questionnaire has been validated in Thai student nurses, using this tool in students in different majors and faculties may have altered the results. As this survey was conducted solely in the teaching hospitals under a special CPIRD project, it may not represent the educational environment of all medical schools in Thailand.
Perception of learning environment in clinical year students under Thailand’s CPIRD project was more positive than negative, with differences in many aspects of learning environment between sexes, years of study and size of teaching hospitals. Key areas for improvement of Thailand’s medical schools included stress management, social and academic support systems. Repeat assessment of educational environment of medical schools or departments over time is needed for monitoring changes after specific educational interventions being applied. A tool more specific to clinical year teaching may be needed.
We gratefully acknowledge contributions of 34 Medical Education Centers under the CPIRD project.
The authors declare that they have no conflict of interest.