As this study presents the first consolidated evidence from a Tajik version of the DREEM questionnaire applied to measure the nursing learning environment, the reliability of the tool has been scrutinized [15]. Generally, it appears that the overall internal consistency of the Tajik version of the DREEM is high, while internal consistency measures of the five sub-scales are somewhat satisfactory, and Cronbach’s alpha value for students’ social self-perception is unsatisfactory. The low internal consistency of the social self-perception sub-scale could be caused by culture-specific variations in response format, as explained by Smith [25]. Further research is needed to explore this issue. In general, there is no consensus over the cut-off level of Cronbach’s alpha for satisfactory scale reliability [26] and it has often been argued that a level of 0.70 is acceptable as described by Nunnally [27]. Others report values higher than 0.50 as being sufficient as in the study by Wang, Zang and Shan [20] that used data from Chinese nursing students and reported alpha values of sub-scales ranging from 0.62 to 0.90, and an overall alpha of 0.95. By applying psychometric testing to the Singaporean version of the DREEM, O’Brien, Chan and Cho [28] reported values ranging from 0.65 to 0.84 for sub-scales (no report of overall consistency).
Results of our DREEM study show that Tajik nursing students at the two nursing colleges perceived their educational environment to be generally satisfactory. With an overall mean score of 133.4, the results of this study were comparable to those (133.5) of DREEM studies among nursing students in Chile [29], China (132.5) [20], and Indonesia (131.0) [10], and slightly higher than studies done in Malaysia (120.1) [30], Egypt (115.0) [31], or Iran (114.3) [32]. The results of the sub-scale measuring students’ academic self-perception scored relatively the highest across all five sub-scales which can be interpreted as students are “feeling more on the positive side” [23]. Three items scored particularly high: first, students felt very well prepared for their profession and, second, they perceived to have learnt a lot about empathy in their profession. Furthermore, students feel confident about passing exams, which might also indicate that exams are not very demanding or that there are flawed examination practices as discussed further below. The average score of the sub-scale on students’ perception of teachers is “moving in the right direction” [23]. Teachers were seen as being quite competent, prepared, and capable of having good interactions with patients. Thus, they were perceived favourably in terms of their technical competence, albeit it should be explained that most of the teachers are physicians rather than nurses themselves, and thus unable to offer a fully apt professional role model to their students. However, this sub-scale has the lowest relative score across the five sub-scales for all student groups. This can be attributed to the fact that students’ perception of teachers’ pedagogical skills was much less favourable and almost half of them stated that the teachers got angry in class and were irritated by students. In addition, about half of students were undecided or disagreed with the statement that teachers provided constructive criticism and about a quarter of them stated that teachers even ridiculed students. These findings highlight the vital need for faculty development programs to improve the teaching skills and ultimately support the learning process. In two items of the “Perception of learning” subscale, students specifically expressed their concerns about the learning process. About half of students thought that teaching over-emphasizes factual learning while more than half of all students perceived teaching to be too teacher-centred. These findings reflect the general teaching approach of the current educational system in Tajikistan. Indeed, most of the teachers themselves have limited nursing experience and are mostly anchored in medical science [33]. The faculty may also lack the skills to teach beyond knowledge recall and hence rather focus on the lower levels of the cognitive domain of Bloom’s taxonomy [34]. In fact, the ongoing reform has mainly focused on changing teaching plans rather than addressing broader aspects of the curriculum such as improving the teaching quality through efficient faculty development programs, and adopting effective pedagogical approaches that support competency based learning. Accordingly, continued efforts are needed to improve the learning process to make the curriculum and the methods of teaching more competency and clinical skills based and to build up a positive nurse role model.
With regard to the atmosphere perceived by students, cheating seems to be an important issue. While the item concerning cheating does not specify what type of cheating is meant, students’ comments at the end of the questionnaire might give an indication to what has driven the low score of this item. Some students commented that examination results were largely affected by students’ outer appearance and particularly by bribing teachers, rather than by students’ performance. This is a serious issue that warrants immediate remedial action to review the examination process and potential faculty involvement in any such flawed practices. Finally, about a quarter of students said that stress levels outweighed enjoyment of the course. Stress can affect memory, concentration, and motivation ultimately leading to decreased learning and academic performance [35]. Thus, it is essential that the learning environment is regularly checked for any potential causes of stress, while students suffering from high levels of stress receive the according support and counselling.
In comparing outcomes of fourth and second year students, this study finds that the average fourth-year family nursing student in Dushanbe generally perceived a more negative environment than the average second-year student. For example, Dushanbe fourth-year students had a significantly lower perception of learning, academic self-perception, and atmosphere when compared to their second- year counterparts. This result is comparable to many DREEM studies from other countries, where students from higher courses poorly perceived the educational environment compared to younger students (see Céron et al. [29] for a review). Some of the authors of those studies suggested that the perception gap is explained by over the years increasing psychological fatigue and the desire of older students to quickly leave their student life behind [29]. A more positive perception on the learning environment was found among students in Kulob as compared to students in Dushanbe for two out of five sub-scores. This result could be linked to differences in the teaching quality between the two nursing colleges. More research is required to identify the drivers of these geographical differences in the perceived learning environment to assure a more equal development of the medical education system in Tajikistan. There was no significant difference comparing the DREEM sub-scale scores across genders.
This study had limitations. As the study tool is not designed to directly observe the learning environment, we relied on self-reporting methods based on the perception of students which bears the risk to over- or understate the actual learning environment. With the DREEM being a standardized tool, we might have not accurately captured the range of factors that affect the learning environment in the Tajik nursing education. Furthermore, existing research shows that validity of the DREEM is not well supported. In order to control this risk, suitability of the DREEM inventory was statistically validated by testing for internal consistency.
