Students' perceptions of learning environment in an Indian medical school

Background Learning environment in any medical school is found to be important in determining students' academic success. This study was undertaken to compare the perceptions of first year and clinical phase students regarding the learning environment at Melaka Manipal Medical College (MMMC) (Manipal Campus) and also to identify the gender wise differences in their perceptions. Methods In the present study, the Dundee Ready Education Environment Measure (DREEM) inventory was used. DREEM was originally developed at Dundee and has been validated as a universal diagnostic inventory for assessing the quality of educational environment. In the present study, DREEM was administered to undergraduate medical students of first year (n = 118) and clinical phase (n = 108) and the scores were compared using a nonparametric test. Results Among the two batches, first year students were found to be more satisfied with the learning environment at MMMC (as indicated by their higher DREEM score) compared to the clinical batch students. Gender wise, there was not much difference in the students' perceptions. Conclusion The present study revealed that both groups of students perceived the learning environment positively. Nevertheless, the study also revealed problematic areas of learning environment in our medical school which enabled us to adopt some remedial measures.


Background
There is an increasing interest and concern regarding the role of learning environment in undergraduate medical education in the recent years. Educational environment is one of the most important factors determining the success of an effective curriculum [1]. The quality of educational environment has been identified to be crucial for effective learning. Curriculum's most significant manifestation and conceptualization is the environment, educational and organizational which embraces everything that is happening in the medical school [2].
In the present study, Dundee Ready Education Environment Measure (DREEM) identified students' perceptions of the elements operating in the educational environment at Melaka Manipal Medical College (MMMC) (Manipal Campus). MMMC offers the Bachelor of Medicine and Bachelor of Surgery (MBBS) program which is a twinning program with Malaysia. The program runs in two phases, Phase 1 Phase 11. Students undergo Phase 1 training in Manipal, India and it comprises first year (Phase 1, Stage 1), second year (Phase 1, Stage 2) and six months of clinical training. Phase 11 component comprises clinical subjects which are taught in Malaysia. About 98% of the students are from Malaysia while the remainder are from different parts of the world.
The objectives of the present study were as follows: 1) To compare the quality of the educational environment as perceived by the first year and clinical batch students so that remedial measures could be taken to enhance students' learning experiences.
2) To identify whether there is any gender difference in the students' perceptions in first year and clinical phase.

Methods
DREEM has been widely used as a tool to gather information about the educational environment in many institutions [3][4][5]. It was originally developed at Dundee and has been validated as a universal diagnostic inventory for assessing the quality of educational environment of different institutions [5].
The total score for all subscales is 200.
The DREEM questionnaire was administered to students of MMMC (n = 226) in July 2006. They consisted of 118 and108 students in the first year and clinical phase respectively. The questionnaire was administered at the end of year to both the student groups on different occasions after a lecture class. In advance to administration of the questionnaire, the class was addressed regarding the purpose and process of collecting data, stressing the anonymity of the participants and the fact that the data could not be tracked to individual participants. Meanings of some of the terms such as 'course organizers' and 'registrars' were explained to the students prior to the administration of DREEM. It was also explained that the data would be used for quality assurance as well as for research purpose and their co-operation was requested. Students completed the questionnaire anonymously. As 7 students in first year and 8 students in the clinical phase did not mention their gender in the response sheet, we could only study the gender wise difference in the perceptions between 56 male and 55 female students in first year and 58 male and 42 female students in the clinical batch. Each DREEM item was scored 0 to 4 with scores of 4,3,2,1 and 0 assigned for strongly agree, agree, uncertain, disagree and strongly disagree, respectively. Reverse scoring was used for the negative items (9 items).
To pinpoint more specific strengths and weaknesses within the learning environment at MMMC, items with a mean score of 3 and above were taken as positive points and items with a mean score of 2 and below were taken as problem areas. Items with a mean score between 2 and 3 were considered as aspects of the learning environment that could be enhanced. By means of the statistical package SPSS, Mann-Whitney test was used for all the comparisons. Table 1 shows the DREEM domain scores for the first year and clinical batch students. For Students' Perceptions of Learning, Students' Perceptions of Teachers, Students' Academic Self-Perception, Students' Perceptions of Atmosphere and Students' Social Self Perceptions, the mean domain scores for first year students were 29/48, 26/44, 19/32, 28/48 and 16/28 respectively. While for the

Discussion
Students were interested in completing the inventory as evidenced by the good response rate. The overall mean DREEM score for our medical school was found to be 117/200 (n = 226), indicating that, students' perceptions were more positive. The DREEM global scores for medical schools in Srilanka, Nepal, Nigeria and UK were reported as 108/200 [3], 130/200, 118/200 [6], and 139/200 [7] respectively. The mean DREEM score for a medical school in India was reported as 107.44/200 [4]. In our sample, the score for all the five domains of DREEM indicated a more positive perception both by the first year and clinical batch of students.
While taking the individual items into consideration, out of the 11 items for which the first year students scored less than 2, 5 items were negative items and belonged to the domains Students' Perceptions of Learning (25,48), Students' Perceptions of Teachers (8,9) & Students' Social Self Perceptions (4). First year students felt to a greater extent that the course over-emphasizes factual learning and is too teacher centred, compared to the clinical batch students. In the first year, students learn anatomy, physiology and biochemistry in an integrated manner. The number of independent learning sessions were less in first year compared to the clinical batch. Further, students have repeated summative assessments in first year. As the students progress to the second year and later to the clinical phase, they spent more time learning independently. Students felt that the course is stressful (item 4). The rating was more by the clinical batch students as their schedule demanded more time. Students felt that teachers were very strict and sarcastic (items 8,9). Three items (2,15,40) were rated positively by the first year students. They felt that the course organizers are knowledgeable and well prepared for class. Clinical batch students felt that the teaching and learning strategies which worked for them during the preclinical phase continued to work for them and also the learning environment at MMMC seemed to make them more confident with respect to their perception regarding passing the course.
13 items (Table 3) were found to have significant difference (p < 0.01) between the two batches of students. 10 items (from all domains) (items 1,2,7,11,15,20,21,29,33,49) were rated higher by the first year students. They felt to greater extent that teaching was stimulating enough  for them to participate during teaching sessions. They also felt that teachers are knowledgeable, well focused and also prompt in providing feedback to the students. Clinical batch students felt that they were prepared well for clinical training. They also felt that the teachers communicated effectively with the patients.
Gender wise, the overall DREEM score did not show much difference in the two groups. Mayya SS reported low total DREEM score for female academic under-achievers compared to their male counterparts in a study conducted at an Indian medical school [4]. In a study reported by Hettie Till [8], the mean DREEM scores were lower for female students compared to the males.
Considering all the above observations, we arrived at the following assumptions: Students at Melaka Manipal Medical College (Manipal Campus) felt that: 1) The course organizers are knowledgeable and well prepared for classes; but they are strict.
2) Teaching is teacher centred, and overemphasizes factual learning.
Remedial measures taken 1) Implementation of Problem Based Learning (PBL) sessions and Short-term Student Research Project which were intended to make the students independent learners.
2) Implementation of Personal and Professional Development (PPD) sessions and less number of summative examinations to reduce stress.

Conclusion
The present study revealed that both groups of students perceived the learning environment positively. Nevertheless, the study also revealed problematic areas of learning environment in our medical school (as the mean score of most of the items were between 2 and 3) which enabled us to adopt some remedial measures. As the learning environment affects student motivation and achievement, it is important to get feedback from the students on how they are experiencing their learning environment.