Perception of The Learning Environment Among Medical Students at Umm Al-Qura University, Makkah, Saudi Arabia

Introduction

The educational environment is one of the most crucial elements that improves students’ learning and develops educational programs; as the more suitable the learning environment is, the better the student’s wellbeing is, as well as the future identity of that student. Educational environment can be defined as the interaction of the students with the surroundings in the learning place, including students’ self-perception, general ambiance, academic self-perception, and social self-perception represented by their relationships with other people (peers, teachers) 1. Theories have offered support that the learning place affects a student’s academic achievement, performance, and future career markedly 2. However, most undergraduate and postgraduate teaching institutes have moved towards student-based learning. As adult learning theory supports the switch of many undergraduate and postgraduate programs to students being at the core of learning, student-centered learning needs a well-supported learning environment to ensure the safety and continuity of the educational process 1,3. Moreover, with the high prevalence of burnout, stress, anxiety, and depression among medical students and the inverse relationship between educational quality and stress and anxiety 2,4, the assessment of students’ satisfaction with and perception of their learning environment is an important indicator in most universities and institutions. Such assessments should be conducted periodically to improve students’ performance, enhance the quality of education, and evaluate the need for curricular change 5,6,7. Therefore, several medical schools, especially with the inclination toward reforming curricula and introducing new strategies in teaching, have decided to evaluate the learning environment 8,9.

Many tools are available to measure students’ learning environment. The Dundee Ready Educational Environment Measure (DREEM) is a global validated instrument which allows medical educators to evaluate the learning environment for students and interpret their responses 10. The DREEM tool has been widely used in various studies internationally, such as in the United Kingdom 7 and Thailand 9, as well as locally, such as in King Saud University Medical College 11, Oman 12, King Abdelaziz University Medical College 13, and Kuwait 14.

The Bachelor of Medicine and Bachelor of Surgery at Umm Al-Qura University (UQU) is a five-year educational program from the second to sixth academic years followed by a one-year internship. The classical curriculum provided a discipline-based education that was teacher-centered rather than student-centered. This curriculum consisted of educational blocks with the occasional addition of problem-based learning and challenge-based learning. In 2016, UQU reformed its curriculum to be a competency-based student-centered curriculum with interactive teaching methods and small-group discussions based on problem-based learning. This new curriculum integrates ethics and clinical skills education and links basic science material to clinical problems 15 to graduate a distinguished class of physicians that fulfil the criteria of the Saudi Medical Education Directives Framework 16.

As long as the curriculum is a part of the educational environment, any curricular change affects students’ perception of their learning environment 17. A 2002 study among medical students at UQU evaluated the environment of undergraduates using the DREEM score 18. However, the educational environment after the implementation of the new curriculum at UQU has not yet been evaluated. Therefore, this study aimed to assess students’ perception of the educational environment at the Medical College of UQU using the DREEM tool and compare the effect of curriculum change and the learning environment among medical undergraduates and interns.

Methods

This descriptive cross-sectional study was conducted between August 2020 and April 2021 at College of Medicine of UQU in Makkah, Kingdom of Saudi Arabia. The DREEM questionnaire was used to evaluate the educational environment of medical undergraduates and interns after taking consent. This study was approved by the biomedical ethics committee of College of Medicine, UQU, approval number (HAPO-02-K-012-2020-09-438).

The DREEM tool is a validated questionnaire of 50 items that consists of five subscales, as follows:

1. Students’ perception of learning, consisting of 12 items with a highest score of 48

1. Students’ perception of teachers, consisting of 11 items with a highest score of 44

1. Students’ academic self-perception, consisting of 8 items with a highest score of 32

1. Students’ perception of ambiance, consisting of 12 items with a highest score of 48

1. Students’ social self-perception, consisting of 7 items with a highest score of 28

The 50 items of the DREEM tool were shown to the participants, and they were asked to rate the statements offered using a 5-point Likert scale. The distribution of scores for each response was based on 4=strongly agree, 3=agree, 2=unsure, 1=disagree, and 0=strongly disagree, resulting in a maximum score of 200. For items 4, 8, 9, 17, 25, 35, 39, 48, and 50, reverse scoring was required. As a result, higher ratings reflect a more positive evaluation.

The DREEM survey was incorporated into an online survey distributed via the official email addresses of the medical undergraduates from the second to sixth years enrolled in the reformed curriculum and interns who had graduated during the 2019/2020 academic year enrolled in the old curriculum. It was composed of two sections. The first section included demographic data (gender, marital status, family income, living status, academic year, and GPA). The second section was the DREEM questionnaire.

The total number of eligible students and interns at UQU was 650, and all of them were contacted through their emails to participate in this study. Of them, 390 (30.95%) agreed to complete the questionnaire.

Statistical analysis

Statistical analysis was conducted using the Statistical Package for the Social Sciences (SPSS), Version 22 (IBM Corp., SPSS Inc., Chicago, IL). All the statistical analyses were carried out using two-tailed tests. A P value less than 0.05 was statistically significant. The scores for the different items of the DREEM subscales were calculated by summing their discrete items to find each subscale total score and the overall score. Due to differences in the number of the items in each subscale, the mean score percentage was calculated for standardization and comparability. Calculation of the score percentage was done by dividing the total score -1 by the maximum score for each domain. Descriptive analysis based on frequency and percent distribution was conducted for all the variables including students’ demographic data and GPA. Independent sample t-tests and one-way ANOVA with post-hoc multiple comparison tests were used to compare the mean scores among medical undergraduates and interns or among their personal characteristics.

The Biomedical Ethics Committee of the College of Medicine of UQU has approved this study. All participants provided informed consent and their confidentiality was ensured.

Results

A total of 390 of medical undergraduates and interns completed the questionnaire, representing a response rate of 30.95%. Of these, there were 347 medical undergraduates (response rate: 89%) and 43 interns (response rate: 11%). Most respondents were women, 229 (response rate: 58.7%), and 161 (response rate: 41.3%) were men (Table 1). The overall mean DREEM score for interns was 172±25, while that for medical undergraduates was 171±18; this difference was not significant (P=.974) (Figure 2) (Table 2). The mean score percentages per subscale among medical undergraduates and interns are shown in Figure 1. The highest mean score percentage of agreement was reported for “Students’ perception of teachers” (72.2%; interns 73.2% vs 72.1% medical undergraduates), followed by “Students’ academic self-perception” (71.3%; 69.9% vs. 71.5%), “Students’ perception of learning” (70.1%; 68.4% vs. 70.3%), “Students’ social self-perception” (66.1%; 67.7% vs. 65.9%), and “Students’ perception of ambiance” (63.4%; 64.2% vs. 63.3%), with no statistical significance in any of the five domains (P>.05) (Figure 1).

Figure 1. Mean DREEM scores per subscale among medical students and interns at UQU

Table 1. Demographic data of sampled students at UQU
Demographic data	No	%
Gender
Male	161	41.3%
Female	229	58.7%
Marital status
Single	376	96.4%
Married	13	3.3%
Divorced/ widow	1	.3%
Living status
Live with parents	368	94.6%
Away from parents	21	5.4%
Monthly income
< 5000 SR	41	10.6%
5000-10000 SR	98	25.3%
> 10000 SR	249	64.2%
Academic year
3rd Year	72	18.5%
4th Year	84	21.5%
5th Year	89	22.8%
6th Year	102	26.2%
Internship Year	43	11.0%
GPA
< 3	37	9.5%
> 3	353	90.5%

Figure 2. Overall mean DREEM scores per subscale among medical students and interns at UQU

Table 2. Distribution of overall education environment score according to students’ personal data
Factors	Overall score	P-value
Range	Mean	SD
Group				.974#
Students	117-230	171	18
Interns	71-233	172	25
Gender				.778#
Male	71-230	172	20
Female	117-233	171	17
Marital status				.791$
Single	71-233	172	19
Married	141-199	169	17
Divorced/ widow	179-179	179	0
Living status				.750#
Live with parents	71-233	171	19
Away from parents	139-202	173	17
Monthly income				.251$
< 5000 SR	117-217	169	21
5000-10000 SR	71-223	169	20
> 10000 SR	124-233	173	18
GPA				.303#
< 3	133-211	168	21
> 3	71-233	172	18

Table 3 illustrates mean DREEM scores for the individual items among medical undergraduates and interns at UQU. Considering “Students’ perception of teachers,” undergraduates had a significantly lower mean score for “Some teachers ridicule their students” than interns (3.2 vs. 3.69, respectively; P=.047). In addition, undergraduates had a significantly lower score than interns for “Some teachers get angry during teaching process” (3.2 vs. 3.7, respectively; P=.048). About “Students’ perception of ambiance”, undergraduates had a significantly lower mean score for “Cheating is a problem” than interns (2.4 vs. 3.3, respectively; P=.006). Further, they had a significantly higher mean score for “Opportunities to develop interpersonal skills is good” (3.7 vs. 3.3, respectively=.048). Considering “I find the overall experience disappointing,” undergraduates had a significantly lower score than interns (2.6 vs. 3, respectively; P=.049). As for “Students’ social self-perception,” undergraduates had a significantly lower mean score for “There is good support system for students who underwent stressful events” than interns (2.4 vs. 2.9, respectively; P=.050).

Table 3. Mean Dundee Ready Education Environment Measure scores for individual items among medical undergraduate students and interns at UQU.
Domain	Item	Group	P-value
Students	Interns
Mean	SD	Mean	SD
Perception of learning	Teachers in classrooms are understandable.	3.8	0.8	4.1	0.8	0.058
Teaching is often interactive.	3.6	0.9	3.3	0.9	0.052
Teaching is learner-centered.	3.6	0.9	3.4	0.9	0.059
Teaching helps to develop my competence.	3.8	0.9	3.9	1.1	0.635
Teaching is well focused.	3.5	0.9	3.6	0.8	0.669
I feel I am being well prepared for my profession.	3.4	1.0	3.3	1.0	0.664
Teaching time is put to good use.	3.4	0.9	3.3	0.8	0.647
Teaching overemphasizes student learning.	3.5	0.8	3.2	0.8	0.108
Learning objectives of the year is clear to me.	3.5	1.0	3.2	1.1	0.119
Teaching motivate me to be an active learner.	3.6	0.9	3.3	1.0	0.059
Long-term learning is emphasized over short-term learning.	3.6	0.7	3.4	0.9	0.119
Teaching is too teacher-centered.	2.8	0.9	3.0	0.8	0.110
Perception of teachers	Teachers have good knowledge	4.1	0.7	4.1	0.9	0.996
Teachers are patient with students.	3.7	0.9	3.6	0.9	0.547
Some teachers ridicule their students.	3.2	1.2	3.9	0.9	.047*
Some teachers are stern and controlling.	4.0	0.8	4.3	0.7	0.052
Teachers have good communication skills with students.	3.7	0.8	3.6	0.9	0.425
Teachers provide good feedback to students.	3.5	1.0	3.2	1.1	0.107
Teachers provide constructive criticism.	3.4	0.8	3.3	1.0	0.685
Teachers provide clear examples.	3.8	0.8	3.7	0.9	0.708
Some teachers get angry during teaching process.	3.2	1.1	3.7	0.9	.048*
Teachers are well prepared for the classes.	3.6	0.9	3.7	1.0	0.639
I feel free to ask the questions I want.	3.4	1.1	3.3	1.2	0.667
Academic self-perception	Learning techniques which worked for me before, keep to work for me now.	3.3	1.0	3.6	1.0	0.132
I am confident about passing this year.	4.0	0.9	4.3	0.8	0.174
Teaching helps to evolve my confidence.	3.6	0.9	3.4	1.0	0.627
Last year’s work was good preparation for this year’s work.	3.5	0.9	3.2	1.0	0.295
I have the ability to memorize all I need.	2.8	1.0	3.0	1.0	0.632
I have learned a lot about empathy in my profession.	3.8	0.9	3.5	1.1	0.207
My problem-solving skills are well developed.	3.6	0.8	3.5	0.8	0.706
Much of what I have to learn seems relevant to a career in healthcare.	3.9	0.8	3.5	0.9	0.051
Perception of ambiance	Ambiance is restful during ward teaching.	3.3	0.9	3.4	0.9	0.684
This college has well timetable.	3.0	1.1	3.0	1.1	1.000
Cheating is a problem.	2.4	1.2	3.3	1.3	.006*
Ambiance is restful during teaching.	3.5	0.8	3.4	1.0	0.684
Opportunities to develop interpersonal skills is good.	3.7	0.8	3.3	1.0	.048*
I feel comfortable socialize in teaching sessions.	3.4	0.9	3.3	1.0	0.637
Ambiance is restful during tutorials.	3.7	0.9	3.3	1.1	0.051
I find the overall experience disappointing.	2.6	1.0	3.0	1.0	.049*
My ability to concentrate is good.	3.5	1.0	3.5	0.9	0.999
The pleasure outweighs the stress of the year.	3.1	1.1	3.0	1.1	0.714
The ambiance motivates me as a learner.	3.3	1.1	3.3	1.1	1.000
The students irritate and annoy the teachers.	2.4	1.0	2.8	0.9	.049*
Social self-perception	I find good support system for students who get stressed.	2.4	1.1	2.9	1.2	.050*
I feel exhausting enjoy this academic year.	3.1	1.1	3.2	1.0	0.715
I am rarely bored in this year.	2.9	1.0	2.7	1.0	0.628
I have good friends in this college.	4.3	0.8	4.4	0.8	0.768
My social life is good.	3.6	1.1	3.7	1.1	0.821
I am rarely feel lonely.	3.1	1.1	3.2	1.0	0.706
My accommodation is delightful.	3.6	0.8	3.6	0.8	1.000

Table 4 shows the satisfaction level among medical undergraduates and interns. Regarding “Students’ perception of learning,” 90.2% of undergraduates were satisfied compared with 88.4% of interns, followed by “Students’ perception of teachers” (97.7% vs. 94.8%). Satisfaction with “Students’ academic self-perception” was 86% and 88.8% for undergraduates and interns, respectively. Considering “Students’ perception of ambiance,” the proportions were 72.1% and 70.6%. Satisfaction with “Students’ social self-perception” was 90.7% and 82.4%. There was no statistical significance in any of the domains (P>.05).

Table 4. Satisfaction level regarding Education Environment per sub-scale among medical students and interns at UQU
Domain	Total	Group	P-value
Students	Interns
No	%	No	%	No	%
Perception of learning							.706
Unsatisfactory	39	10.0%	34	9.8%	5	11.6%
Satisfactory	351	90.0%	313	90.2%	38	88.4%
Perception of teachers							.411
Unsatisfactory	19	4.9%	18	5.2%	1	2.3%
Satisfactory	371	95.1%	329	94.8%	42	97.7%
Academic self-perception							.599
Unsatisfactory	45	11.5%	39	11.2%	6	14.0%
Satisfactory	345	88.5%	308	88.8%	37	86.0%
Perception of ambiance							.840
Unsatisfactory	114	29.2%	102	29.4%	12	27.9%
Satisfactory	276	70.8%	245	70.6%	31	72.1%
Social self-perception							.170
Unsatisfactory	65	16.7%	61	17.6%	4	9.3%
Satisfactory	325	83.3%	286	82.4%	39	90.7%

#: independent samples-t-test

$: One Way ANOVA

P: Independent t-test * P < 0.05 (significant)

P: exact probability test

Discussion

The educational environment is a valuable factor to assess academic success and assess curricular change using the DREEM scale that evaluates students’ perception of their learning environment 5,11. As far as we know, our study is the first to assess the educational environment between the old curriculum and new reformed curriculum using the DREEM tool among medical undergraduates and interns at UQU, Makkah, KSA. A similar study was carried out in Oman 12.

In our study, the learning environment was shown to be more positive than negative, with no statistical difference, as the mean overall DREEM score for interns was 172±25, while that of undergraduates was 171±18 (P=.974). This indicates a satisfactory environment. The overall DREEM score demonstrated in our study was similar to that reported by a study of King Saud University, Riyadh, KSA (171.57) 11, but higher than that reported by most medical schools in the Middle East, including King Abdulaziz University, Jeddah, KSA (102) 13, the University of Dammam, Dammam, KSA (106) 19, Kuwait University, Kuwait (108.7) 14, and Sana’a University, Yemen (100). A previous study in 2002 at UQU among medical undergraduates following the traditional curriculum had a lower DREEM score (107) than the present study 18. Similar results were reported by the College of Medicine at Gulf Medical University, Ajman, United Arab Emirates 17. This tremendous change in the DREEM score indicates an improvement in the educational environment and emphasizes the importance of curriculum reformation to enhance the learning environment of medical schools and support students through the faculty 12.

This study found no difference in the mean overall DREEM score among men and women, similar to the findings of other studies 7,11. However, some studies have found a higher total DREEM score for men than women 18,20. This is likely because of the equality among both genders the educational environment at UQU provides, as all students share the same educational environment and follow the same study guides.

All five DREEM subscales showed a positive perception of medical undergraduates and interns. Further, the mean score for the “perception of teachers” subscale was the highest followed by “academic self-perception,” whereas the lowest mean score was for “perception of ambiance” and “social self-perception,” similar to that observed in a previous study 21. Therefore, we suggest that a committee could be formed to evaluate the quality of academic classrooms, and a student support unit be provided to improve the learning ambiance at the university.

Three items scored a mean higher than 4: “Teachers have good knowledge,” “I feel confident about passing this year,” and “I have good friends at this college.” A similar result was reported at King Saud University, Riyadh, KSA 11. By contrast, the item “There is a good support system for students who get stressed” was found to have a low mean score for both medical undergraduates and interns. This finding for item 3 was similar to those of several studies 13,22, but contrary to others 5,18,21 that reported a high score for the support system. Consequently, we need to establish a well-mentored support system to help students cope stressful situations and support them with their physical, social, and academic difficulties. The item “Cheating is a problem” scored a mean of 2.4 for undergraduates and 3.3 for interns (P<.05), which illustrated that cheating is a problem at our school. Our result for cheating coincided with those from the studies at King Saud University, Riyadh, KSA 11 and the Gulf Medical College, Ajman, United Arab Emirates 21, but is the opposite to those observed in Nigeria and Nepal 20. Moreover, the item “Opportunities to develop interpersonal skills is good” scored a mean of 3.7 for undergraduates and 3.3 for interns (P<.05). This finding reflects the role of the reformed curriculum that enhances interpersonal communication skills through the implementation of a professional development module that starts from the second academic year and continues until the sixth year 23.

Conclusion

The overall perception of medical undergraduates and interns of their educational environment at UQU was perceived to be more positive, which indicates the progression in the learning environment from 2002 to 2020. In addition, the study reported a positive score in all five domains by undergraduates and interns, with three items that scored a mean score of more than 4.0. The areas of weakness should be addressed to improve and develop the educational environment at our university to raise student performance, and hence graduate qualified physicians.

Limitation

The findings of our study are limited by the low response rate of the participants, which could be attributed to the length of the DREEM tool. Thus, to adequately assess all aspects of the educational environment, it could be an option to use other instruments such as Medical Instructional Quality, Measuring the School Learning Environment Survey, and Learning Environment Questionnaire 24.

List of abbreviation

EE = Educational environment.

DREEM = The Dundee Ready Education Environment Measure.

UQU = Umm Al-Qura University.

KSA = Kingdom of Saudi Arabia

PBL = Problem Based Learning.

GPA = Grade Point Average.

SPoL = Students’ perceptions of learning.

SPoT = Students’ perceptions of teachers.

SASP = Students’ academic self-perceptions.

SPoA = Students’ perceptions of ambiance.

SSSP = Students’ social self-perceptions.

P-value = Predictive value.

MedIQ = Medical Instructional Quality.

MSLES = Instructional Quality Measuring the School Learning Environment Survey.

LEQ = Learning Environment Questionnaire.

Declarations

Ethical approval and consent to participate

This study was ethically approved by the Scientific Research Ethics Committee of College of Medicine of UQU, Makkah, KSA. Informed consent was obtained from all participants and their confidentiality was assured. All methods were carried out in accordance with relevant guidelines and regulation.

Consent for publication

Not applicable.

Availability of data and materials

The datasets analyzed during the current study are available on this manuscript.

Competing interest

The authors declare that they have no competing interest.

Funding statement

The authors received no specific funding for this research.

Authors’ contributions

GK was a major contributor in the writing of the introduction and discussion parts. GK and SA did the SurveyMonkey form. SA and SF worked on the statistical analysis and result representation. MuA was a major contributor in the writing of methods and abstract parts. GK and EB did the citation and helped in conclusion part. MaA and JM helped in revising the data language of the manuscript. All authors contributed in the manuscript and approved it. All authors participated in the literature review and proposal writing.

Acknowledgements

Not applicable.

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