Learning environment is defined as everything that happens in a classroom or department, faculty or university. (1) Learning environments refer to the various physical locations, contexts, and cultures in which students learn. The term encompasses the culture of a school or classroom and its key principles and characteristics, including how students interact and behave with each other, as well as the ways teachers can organize the educational setting to facilitate learning. Since the qualities and characteristics of the learning environment are determined by various factors, school policies, governance structures, and other features are also considered components of the "learning environment" (2).

Learning environment as the spirit of teaching and learning activities is the main determinant of developing motivation in students (3). It will play an important role in academic achievement, satisfaction and success. However, learning is a relatively permanent change in student behavior in three domains: knowledge, attitudes, and psychomotor aspects. (4)

In 1998, the World Federation for Medical Education highlighted the learning environment as a target for evaluating medical education programs. It is widely agreed among medical educators that the educational and clinical environment is an important influence on the attitudes, knowledge, skills, progress and behavior of medical students.(5-7)

 The foundation for improving patient health and safety begins with the competency of health care providers. Their education is fundamental to this health initiative. (8).

The study was a cross sectional study. The research used a short demographic questionnaire constructed to collect information such as gender, age group and three categories. Questionnaire was obtained from total 386 students after taking due consent. 94 Medical,164 paramedical and 124 dental students. Ethical approval was taken.

Data collection instrument

The Dundee Ready Educational Environment Measure (DREEM) questionnaire, a generic, highly reliable and diagnostic inventory, was used for collection of data. DREEM is a 50 items inventory, organized into 5 subscales. Students’ Perceptions of Learning (SPL)-12 items; maximum score is 48; Students’ Perceptions of Teachers (SPT)-11 items; maximum score is 44; Students’ Academic Self-Perceptions (SAP)-8 items; maximum score is 32; Students’ Perceptions of Atmosphere (SPA)-12 items; maximum score is 48; Students’ Social Self-Perceptions (SSP)-7 items; maximum score is 28. The 50-item DREEM has a maximum score of 200, indicating the ideal educational environment.

DREEM items were scored on 5-point likert scale as follows: 4 for Strongly Agree (SA), 3 for Agree (A), 2 for Uncertain (U) and 1 for Disagree (D) and 0 for Strongly Disagree (SD). However, 9 of the 50 items (number 4, 8, 9, 17, 25, 35, 39, 48 and 50) are negatively phrased statements and scored 0 for SA, 1 for A, 2 for U, 3 for D and 4 for SD.

The DREEM questionnaires were given to second year medical paramedical and dental students. The questionnaire was distributed to the students following a brief explanation of the objectives and data processing procedures. Informed consent was taken. Ethical approval for study was taken. The resulting scores for domains were interpreted using the guide proposed by McAleer and Roff [4] indicated that score of 0-50 was “very poor”, 51-100 was “plenty of problems”,101-150 was “More positive than negative”,151-200 was “Excellent’.

It was advised that score of 100 should be interpreted as being viewed with “Considerable ambivalence by students and as such needs to be improved”.

 Analysis

The DREEM items for the study sample were coded and analysed using Microsoft excel 2022( Microsoft Co., Redmond, WA, USA) and the Statistical Package for the Social Sciences (SPSS) program, version 20. Descriptive statistics were applied to get the total mean and the means of the five subscales (SPL, SPT, SASP, SPA and SSSP). Scores for categorized domains and each item were both expressed as Mean ± Standard Deviation (SD) and the maximum score percentages. A p-value < 0.05 was considered as significant.

The subscale scores were summed across the categories and the mean calculated for each subscale. The total DREEM score for each category was calculated by adding subscale score for all five domains.

The overall response rate was 95%. There was no missing data from any respondent.

Table 1 shows : Demographic details of 386 students i.e.  Percentage of gender distribution of male and female and age distribution of 16 yr-19 yr and 20yr-23yr. 51.1% females medical students and 64.3% female paramedical students and 72.6% of female dental students responded. The majority of students were in 20 yr-23yr age group.

Table:1 Demography of individuals participated in the study(n=386)

Table 2 shows: The total DREEM score of 117.14 was recorded. The paramedical students were found to be more satisfied with learning environment (indicated by their higher DREEM score) in comparison with medical and dental students Evaluating the sub-domains of perception, students had a more positive perception of learning (mean score: 24.77), their perception of course organizers moved in the right direction ( mean score: 29.26), their academic self-perception was more on the positive side (mean score: 21.51), they had a more positive perception of atmosphere (mean score: 27.59) and their social self-perception could be graded as not too bad (mean score: 15.62). P value of 0.04 was found statistically significant for social self-perception.

Table 2: Mean (SD) of subscales of DREEM score

^{P value <0.05 considered significance}   

 ^*Weak, ^** Statistically Significant

Table 3: Items of DREEM score   analysed in terms of means and standard deviation in medical, paramedical and dental students (n=386)

Table 3 shows that the subscale scores mentioned in  mean and  standard deviation (SD) for medical, paramedical, dental students is calculated. It shows that total DREEM score was 120.02 /200 for medical, 118.91/200 for paramedical, 116.01/200  for dental students. Score was least for dental students.

“Teaching is often stimulating” had mean score of 1.43 and 1.59,1.43 for medical paramedical and dental students respectively. “The teaching is sufficiently concerned to develop my competence” had mean score of 1.26, 1.27,1.35 for medical paramedical and dental students respectively. “The teaching is well-focused” had mean score of 2.72 and 2.7,2.7 for medical paramedical and dental students respectively. “I am clear about the learning objectives of the program” had mean score of 1.19 and 1.41, 1.32 for medical paramedical and dental students respectively. “The course organizers are knowledgeable " had mean score of 3.15 and 3.00,3.00 for medical paramedical and dental students respectively. “The teachers are authoritarian”

 had mean score of 2.39 and 2.28, 2.07 for medical paramedical and dental students respectively” “The teaching is too teacher-centered” had mean score of 2.23 and 2.45,2.23 for medical paramedical and dental students respectively. “The teachers are well prepared for their classes” had mean score of 2.96 and 2.75,2.89 for medical paramedical and dental students respectively. “My problem solving skills are being well developed here " had mean score of 2.66 and 2.67,2.44 for medical paramedical and dental students respectively. “I feel comfortable in class socially” had mean score of 2.74 and 2.82,2.56 for medical paramedical and dental students respectively. “My social life is good " had mean score of 2.66 and 2.71,2.44 for medical paramedical and dental students respectively. P value of 0.03, 0.61, 0.54 was calculated for mean of medical and paramedical and dental students. P value for medical students was found statistically significant.

Surveys by using qualitative and quantitative tools were done. Henzi and colleagues investigated dental school learning environment by dental version of medical student learning environment survey and provided information for dental teacher.(9) Dundee Ready Educational Environment Measure (DREEM) questionnaire.(10) is the most specific tool for investigation of the unique environment experienced by students on medical and healthcare-related courses. This instrument was developed by an international Delphi panel, and has been applied to a number of undergraduate courses for health professionals worldwide.(11)

Main purpose of medical education is to design the curriculum that enables medical students to become successful healer in future. Education environment is most important determining factor in successfull implementation of curriculum at medical institutes. In our study we aim to evaluate the perception of learning environment at our institute. The overall DREEM score was 117/200 which was within range of 101-150 which is suggestive of more positives as compared to negative perception(12)

Over all DREEM score 117/200 is lower as compared to previous study conducted by Rehana et al (13) but comparable to other studies from India 107/200, 114/200. (14-15) Study of Malaysia (16) and Nepal (17) reported mean score 125.3/200 and 129/200 respectively. DREEM scores from study conducted at Sri Lanka 108/200 and Trinidad are 109/200 are lower comparable to our study (18,19). Lowest score 89/200 has been reported from Saudi Arabia at the College of Medicine at King Saud University followed by 97/200 reported by a study of the Canadian Memorial Chiropractic College. This may probably be due to the workload of the students as compared to dental and paramedical students. (20,21)

There are also a few studies that have confirmed higher overall mean DREEM scores. A Malaysian private nursing college (22) and a nursing school in China reported high mean DREEM scores of 134.42 and 131.26, respectively. (23) A series of UK learning environment studies recorded a high mean DREEM score of 142.91.35 Reasonably high mean DREEM scores were found in a study in the UK at different teaching hospital centers as 139.20. (24) and in seven major medical sciences courses at Monash University in Australia (137.3; 68.7%).(25) The results of these studies suggest that the nursing, midwifery, and paramedical schools of RUMS have achieved a more positive than negative status, which is just a level below the highest category of achievable scores is in accordance with our study.

According to adult learning theory teaching should be based on active learning principle in which learner actively participates in learning process (26). There is more emphasis on developing students' skill rather than just transfer of factual knowledge (27) as seen in our study. Several researches have proved that active learning techniques like small group discussion, case based learning, problem based learning are more effective mode of teaching as in our study(28).

According to principle of adult learning, teaching should be learner centered and role of teacher should be changed to facilitator instead of knowledge transmitter as seen in our study (29)

Paul Ikhodaro Idon etal( 30 )showed total mean score of 138.2 which is higher than our study. They also identified problem areas which centered on timetabling, emphasis on factual learning, boredom and stress. Formative assessment structure for students, attention to timetabling, improved administration, and systems to identify stressed students was also done as in our study.

Study conducted among medical students in Iran reported that students in basic medical sciences rated the educational environment more highly than students in the clinical course. The reason adjudged for this is that students at lower class are usually excited at gaining admission to medical school. (31)

Analysis of the subscale revealed that the highest score (71%) was recorded in students' perception of learning(SPL), followed by Students' Academic Self Perception (SASP) with a score of 66.3% while the lowest score (53.5%) was recorded in Students Perception of Atmosphere (SPA). This finding is in accordance with our study. This shows that teaching encourages students to be active learners, and to develop their confidence and competence. However, more attention is needed in the more deficient areas such as SPA to create a more conducive environment for learning.(32)

Considering  individual items in the DREEM questionnaire showed that there was poor support system for students that get stressed in their course of study. This has contributed to the low score for Student's Social Self Perception (SSSP) recorded in our study. The complaint by the students of lack of good support for stressed students was also a major factor in the low SSSP score as reported in a study conducted in Zambia(33)

The low score in SSSP at Ebonyi State University medical school is largely as a result of the teaching method and lack of support system for stressed students. Education in medical profession is [32] associated with much stress.(34)

The low score for Students' Perception of Atmosphere (SPA) recorded in this study is attributable to the fact that students perceived the environment as not being relaxed during lectures. Study conducted in India by James et al, is in keeping with this finding. This projects the stressful medical education schedule and therefore implies that suitable strategies have to be evolved to improve the immediate surroundings of students and provide a more relaxed and comfortable environment for learning.(35)

Students at the medical University have a somewhat positive perception of their educational environment, but their perception of atmosphere (SPA) and social selfperceptions (SSSP) are weak areas requiring further attention. Effective management of the observed shortcomings, especially with the introduction of student focused education, may lead to marked improvement in the perception of educational environment in the institution.

Use of the DREEM as a regular monitoring tool would permit timely interventions to remediate problematic areas, which translates into improved student perceptions of the educational experience. Continuous quality improvement and innovation are essential in a medical school .There is dire need of implementation of integrated curriculum. Faculty development programs and training courses should be initiated. There is need to shift the teaching learning strategy from teacher centered to student centered approach. Teaching strategy should be changed from large class lecture to small group problem based learning that will help to develop higher order skills. Our study has provided the base line data for further comparative study after implementing necessary changes in order to access the improvement.

ACKNOWLEDGEMENTS

We thank Santosh deemed to university for allowing us to conduct this study. We thank all members of anatomy department for their constant support.

CONFLICT OF INTEREST

There is no conflict of interest.

FUNDING

There is no funding from any agency.

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