Medical Students’ Perception of the Educational Environment at College of Medicine: A Prospective Study with a Review of Literature

Dundee Ready Education Environment Measure (DREEM) inventory has been exhaustively used to evaluate the education environment (EE), especially in the health sector to identify the strengths and weaknesses of the program. This study was designed to investigate the medical students’ perceptions about the education environment (EE) of the College of Medicine (COM), Jeddah. This cross-sectional study was carried out on medical students and conducted between May and August 2020. A predesigned DREEM questionnaire written in English containing five subdomains was adopted to achieve the purpose of the study. A total of 220 students responded to the dispensed survey with a mean age of 21.97 (SD = 1.28). Male and female students represented 64.5% and 35.5% of the respondents, respectively, while most of them were in the fourth year of medical college (109, 49.5%), and the majority belonged to phase II (basic sciences) of the college (144, 65.4%). The overall total DREEM score for EE was 129.64 (SD = 31.81; 64.82%), and all the five subdomains of DREEM scored above 60% with the highest score by students’ academic self-perception (SASP) (21.22; 66.31%) and the lowest by students’ perception of learning (SPL) (30.16; 62.83%). Also, SASP2 was the highest scoring item with a mean of 3.13 (SD = 0.96), while SPA8 was the lowest with a mean score of 1.99 (SD = 1.38). We also compared our study with the available literature for contextual interpretations. The students’ assessment for EE of the medical program was positive; however, we identified a need for an improvement plan for six-weak scoring areas and one of the weak domains of DREEM i.e., students’ perception of teaching (SPT).


Introduction
In any educational institute around the world, the design, manner, and the way curriculum is implemented/imparted is regarded as the educational environment (EE) of the students. e overall learning environment not only plays an important role in students' learning and outcome but also affects their attitude, behavior, and academic progress [1][2][3][4][5][6].
With the advent of information technology, the teaching and learning environment within the universities has undergone drastic changes in the implementation of the curriculum, including the delivery of learning materials, the support of the location and tools, and assessment strategies.
is transformation from the mere physical spaces and traditional lecturing to the virtual and online methods of implementing curriculum has provided the most conducive educational environment the students can ever think of, where students better accommodate their distinctive learning needs, comprehend in a better way, and acquire the latest knowledge and skills that are necessarily essential for them to withstand the enormous competition in the medical market [5,7,8].
EE of any institution comprises of several controllable and conditioned factors which are known to influence the overall process of teaching and learning and modulates the learners' perspectives about the infrastructure, availability of facilities, teaching methodology, interpersonal relationships, cultural compliance of the university, and curriculum. It is a holistic climatic idea that encompasses three essential levels of the educational institution-the classroom, department, and the institution [9]. A well-suited EE is reported to enhance various competencies of the medicine students such as self-confidence, critical thinking, achievement, motivation, behavior, independence, and psychosocial wellbeing [10].
For the evaluation of any medical education program, the assessment of EE is considered as one of the major areas by the World Federation for Medical Education [11,12]. Dundee Ready Education Environment Measure (DREEM) inventory has been exhaustively used to evaluate EE, especially in the health sector in order to identify the strengths and weaknesses of the program, to develop the improvement plans to foster excellent quality of education, to compare students in different study years in college, to provide medical educators an inclusive view of the delivered curriculum, and to help in modifying the curriculum by comparing past and present one and in evaluating the efficacy of a university program in context to their peers [5,6,8,13,14].
In the Kingdom of Saudi Arabia, a change from the traditional curriculum to a PBL-based hybrid is going on.
is is to achieve better implementation of curriculum for effective and conducive teaching and learning environment. erefore, a gap exists in the literature for the perception of students about the PBL-based educational environment, for which only a few studies have been carried out. Hence, we designed the present study to investigate the medical students' perceptions about the education environment (EE) of the College of Medicine (COM), Jeddah. Furthermore, the study would help us to compare the students' perceptions according to the demographic characteristics enabling us to identify the strengths and weaknesses of the COM curriculum and to compare the scores with other medical colleges within or outside the kingdom. e investigation aimed to answer/know the following two questions.
(1) What is the perception of medical students towards the learning/teaching environment in COM, KSAU-HS in Jeddah campus? (2) Whether there is any difference between the perceptions of students according to the stages of medical education, i.e., the phase II (preclinical) and phase III (clinical stages) (3) What are the perceived strengths and weaknesses of our medicine program? (4) What is the medical students' perception towards five domains of the DREEM questionnaire? which are as follows: (a) Perception of learning (b) Perception of teachers (c) Academic self-perception (d) Perception of atmosphere (e) Social self-perception

Study Settings.
is study is a descriptive type of research using a survey approach. e study was carried in between May and August 2020. All students were selected using the convenience sampling method. e study was approved by the Institutional Ethic and Research Board (IRB) of King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) and King Abdullah International Medical Research Center (KAIMRC).

Sample Size.
is study was carried out on the Medical Students of King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) and National Guard Health Affairs, Jeddah Campus, Saudi Arabia.
Sample size was calculated by using the Raosoft® software (website link: https://www.raosoft.com/samplesize. html). e required sample size was calculated at the 90% confidence level with an estimated 50% prevalence of awareness regarding euthanasia and a margin of error ±5%. With a total student population of 800 at College of Medicine (COM), Jeddah; the necessary sample size was calculated to be 203. However, the final sample size of 220 was deemed the best representation of the study population (to account for nonresponse rate). Following a clear instruction and mentioning the objectives of the study, an informed consent from all the participants was taken (first question on an online portal) for the implementation of a predesigned DREEM questionnaire.

Dundee Ready Education Environment Measure (DREEM).
e DREEM is a survey tool developed to quantitatively measure student's perceptions of their learning environment within a health profession educational setting and has been exhaustively used to collect evidence about the educational environment (EE) across the globe (Table 1). e DREEM survey consists of 50 items or statements, each of which is scored 0-4 on a 5-point Likert scale (0 � strongly disagree to 4 � strongly agree) [14]. However, there are nine negatively stated items (questions 4, 8, 9, 17, 25, 35, 39, 48, and 50) which are scored in reverse (0 � strongly agree to 4 � strongly disagree); thus, after correction, higher scores indicate disagreement with that item. e DREEM questionnaire was developed at the University of Dundee to assess five domains of EE [14,24] ( Table 2).
(1) Students' perceptions of learning (SPL) (12 items, maximum score 48) (2) Students' perceptions of faculty (SPT) (11 items, maximum score 44) (3) Students' academic self-perceptions (SASP) (8 items, maximum score 32) (4) Students' perceptions of atmosphere (SPA) (12 items, maximum score 48) and (5) Students' social self-perceptions (SSSP) (7 items, maximum score 28) Mean scores for individual items are calculated with a maximum score of 4.0 for each item. Items with a mean score of ≥3.5 are true positive points, and those with a mean of ≤2 are problem areas; scores in between these two limits indicate aspects of the environment that need to be enhanced. An overall or composite score is obtained by summing the mean score for each subscale, with a maximum possible score of 200, and the global scores are interpreted as follows: 0-50 � very poor; 51-100 � many problems; 101-150 � more positive than negative; 151-200 � excellent [5,6,14,24].

Data Collection and Statistical Analysis.
e data from the students were collected via an online survey using the Google Forms platform. e questionnaire was sent to all medical students via their official e-mail by the Students Affairs Departments of the College, Jeddah campus. e data collected were tabulated, and analysis was performed using IBM Statistic SPSS (SPSS Inc., Chicago, IL, USA) version 20.0. Descriptive analysis was employed to sum up the dataset; numerical variables were described using means and standard deviations (SD), and categorical variables were presented in frequencies and percentages. To test the influence of demographic characteristics on knowledge and attitude, chi-square or Fishers exact tests were applied wherever suitable, and p values were obtained for each test. P values less than 0.05 were accepted as statistically significant. e Independent t-test was applied for comparison between two means variables, which included sex, phase of the study, and type of secondary school. Analysis of variance (ANOVA) was used for comparison of more than two means, which included gender, education phase, and year of study. Multivariate logistic regression models were used to identify the factors related to education environment perception that differ between students.

Participants.
e demographic data of the participants are given in Table 3. A total of 220 students participated in this study. e mean age of the participants was 21.97 (SD � 1.28). Male and female students represented 64.5% and 35.5% of the respondents, respectively; while, 97.3% of respondents were single (214/220). Most of the participating students were in the fourth year of medical college (109, 49.5%), followed by the fifth year (49,22.3%), and most belonged to phase II (basic sciences) of the college (144, 65.4%). e overall total score for the student's perceptions of the educational environment was found to be 129.64 (SD � 31.81; 64.82%). Figure 1 shows the graphical representation of the overall DREEM scores versus the mean scores of the five subdomains. All of the five subdomains of DREEM scored above 60%, with the highest score by SASP (66.31%) and lowest by SPL (62.83%). Figure 2 shows the mean DREEM scores as per the demographic characteristics of the participants (Table 4).

Students' Perception of Learning (SPL).
In this subdomain constituting of 12 items (SPL1-12), a total score of 30.16 (SD � 8.95; 62.83%) was recorded (Table 4; Figure 1), however, when differentiated based upon the phases of education scores differed significantly (phase II � 28.97 vs. phase III � 32.42; p < 0.05). Only one item of this subdomain scored near to two, "SPL1-I am encouraged to participate in teaching sessions/class" which had a mean score of 2.01 (SD � 1.46); furthermore, out of 12 items, only three differed significantly (p < 0.05) in their phase-wise total scores, "SPL1-I am encouraged to participate in teaching sessions/ class," "SPL6-e teaching helps to develop my confidence," and "SPL12-e teaching is too teacher-centered" ( Table 5).

Students' Perception of Teachers (SPT).
In this subdomain constituting of 11 items (SPT1-11), a total score of 28.51 (SD � 7.77; 64.79%) was recorded (Table 4; Figure 1), and the scores based upon phases of education also differed significantly (phase II � 27.34 vs. phase III � 30.72; p < 0.05). Additionally, two items of this subdomain scored near to two, "SPT3-e teachers ridicule the students" with a mean score of 2.05 (SD � 1.35) and "SPT9-e teachers get angry in class" with a mean score of 2.03 (SD � 1.41), and one item had a high mean score of 3.08 (SD � 1.15), "SPT1-e teachers are knowledgeable" (Table 6). Also, out of 11 items, four differed significantly (p < 0.05) in their phase-wise total scores "SPT3-e teachers ridicule the students," "SPT6-e teachers are good at providing feedback to students," "SPT9e teachers get angry in class," and "SPT11-e students irritate the teachers" (Table 5). SPT11 mean scores also differed significantly in between gender (p < 0.05).

Students' Academic Self-Perception (SASP).
In this subdomain constituting of 8 items (SASP1-8), a total score of 21.22 (SD � 5.91; 66.31%) was recorded (Table 4; Figure 1),  year" scored with a mean of 3.13 (SD � 0.96), which made it the highest scoring item in this survey. However, also, out of eight items, three differed significantly (p < 0.05) in their phase-wise total scores "SASP3-I feel I am being well prepared for my profession," "SASP4-Last year's work has been a good preparation for this year's work," and "SASP5 I am able to memorize all I need" (Table 5).

Students' Perception of Atmosphere (SPA).
In this subdomain constituting of 12 items (SPA1-12), a total score of 31.35 (SD � 8.45; 65.31%) was recorded (Table 4; Figure 1), and the total scores based upon phases of education also differed significantly (phase II � 30.22 vs. phase III � 33.50; p < 0.05). However, one item of this subdomain scored below two, i.e., "SPA8-I find the experience disappointing" with a score of 1.99 (SD � 1.38), which is the lowest of all fifty items of DREEM. Additionally, in this domain, 50% of the items differed significantly (p < 0.05) in their phase-wise total scores (Tables 5 and 6).

Students' Social Self-Perceptions (SSSP).
In this subdomain constituting of 7 items (SSSP1-7), a total score of 18.39 (SD � 4.84; 64.28%) was recorded (Table 4; Figure 1), with no differences in between genders and phases of education. Also, one item of this subdomain scored above three, i.e., "SSSP4-I have good friends in this program/ course" with a score of 3.12 (SD � 1.00), which is the second highest scoring item in this study (Tables 5-7).       Table 6), in order of their decreasing scores, thus making the SASP the best performing subdomain and SPL as the worst (coupled with lowest scores � 62.83%) (Figure 1). e regression analysis also reflected that two (SPL and SPT) out of five domains of DREEM differ significantly (p < 0.001) in their scores when analyzed based upon the phases of education.

Discussion
e personal and professional development of medical students' is heavily influenced by EE, in which they spend their learning life. It effectively does affect the students'   Education Research International education, their satisfaction with the curriculum, program and course learning outcomes, and their respective professional development [70].
In the current study, we aimed to measure the overall educational environment (EE) in our College of Medicine and tried to analyze the factors such as gender and phase of education which could have an effect on the students' perception towards five domains of the DREEM questionnaire: (a) perception of learning, (b) perception of teachers, (c) academic self-perception, (d) perception of atmosphere, and (e) social self-perception [6,14].

Overall DREEM Scores.
As the overall DREEM score was found to be 129.64 (SD � 31.81; 64.82%), which is reflective that students in educational environment within the medicine program is more positive. Numerous studies carried out over the world using the DREEM survey have reported a wide range of overall scores, with the lowest score of 62 (out of 200) in an Australian study [68] to the highest of 149.47 in a report from Ireland [64]. In the Middle Eastern region, the range of overall DREEM scores varies between the lowest of 95.8 in an Iranian study [49] and highest of 130.75 in an Omani report [31]. Furthermore, male and female students had comparable scores with means of 129.9 and 129.1, respectively (Table 4, Figure 2), while phase II and phase III students had significantly different overall scores with means of 125.3 and 137.9, respectively ( Table 2). ese results are in concordance with the reported results, where it was suggested that senior year students (clinical) tend to score the learning environment higher than the fresher's (basic sciences) [4,8] because of the simple fact that seniors get transitioned to the clinical settings where they are acclimatized well to the specific learning environment.
In the Kingdom of Saudi Arabia, almost two dozen studies have been carried out in different colleges (medicine, nursing, and dental) on a varying sample size with overall DREEM scores ranging 89.9-143.9 (Table 1). e highest overall DREEM score of 143.9, in a sample of 100 nursing students of faculty of applied medical sciences, Umm Al-Qura University, has been reported by Sayed and El-Sayed [38]. Similarly, a score of 124.90 was reported by Imran et al. [44] in their study on undergraduate medical students on two campuses-Rabigh and Jeddah of King Abdulaziz University. While the lowest overall DREEM score of 89.9 was reported by Al-Ayed et al. [4] in their study on 500 medical students of King Saud University. e results of other important studies across the world are given in Table 1. For our own university, one study carried out on 242 nursing students reported a similar overall DREEM score of 129.70, reflecting the same perception towards EE and curriculum; however, the perception towards the subdomains and especially to each item of the survey differed uniquely. Only three DREEM items in our survey scored above three, i.e., SASP2, SSSP4, and SPT1 (Tables 5 and 6), while only one item scored below two, i.e., SPA8. Most of the items scored in the range of 2.20-3.13, which establishes the facts that the students perceived the curriculum and EE of the College of Medicine as positive. Table 6 provides the identified strong and weak areas of the program as identified by the DREEM score.

Students' Perception of Learning (SPL).
A total score of 30.16 (out of 48; 62.83%) for this subdomain (Figure 1; Tables 2, 4, and 5) is interpreted as a more positive approach acquired by our program in educational pedagogy; however, this score is the lowest among five subdomains of DREEM and also differed significantly in between phase II and phase III students (p < 0.006). e items which scored less in this domain pertained to lack of encouragement in participating in class, teacher-centric teaching, poor use of teaching time, and lack of opportunities for confidence building (scores range 2.01-2.49). Same concerns have been reported by other institutions as well [2,5,8,16,21,51], in which it was reported that students viewed the institutional learning as teacher-centric. Al-Hazimi et al. [71] in their sentinel study had reported that mean DREEM scores for the learning and teaching domains from the innovative (hybrid) programs were significantly higher than the scores from the traditional programs. However, since our program utilized a hybrid curriculum combining traditional lectures with innovative teaching techniques such as problem-based learning (PBL), team-based learning (TBL), flipped classroom, and mini-CeX, onus lies on the medical educationist to improve upon the learning environment. e focus should be directed so as to make teaching and learning more student-centric, so as they are encouraged to attend classes proactively in addition to cultivating an environment where students feel selfconfident as well [5,6,8,16,24,72].

Students' Perception of Teachers (SPT).
In this subdomain, a total score of 28.51 (out of 44; 64.79%) was recorded ( Figure 1; Tables 2, 4, and 5), which is interpreted as the teachers moving in the right direction in their pedagogical skills when delivering their sessions of the curriculum in the program. Furthermore, phase II and phase III students had significantly different scores with means of 27.34 and 30.72, respectively (Table 5). One item of this domain pertaining to the teachers' knowledge has a mean score of 3.08, which is a positive reflecting point of our program, which was in congruence with other positive reports as well [8,16,21,36,55]. e items which scored less in this domain pertained to the authoritarianism, anger, and ridicule issues with teachers and students irritating their teachers (scores range 2.03-2.43). Al-Naggar et al. [55] had also reported that two areas of low scores being the teachers being angry in class and students irritating their teachers, and so did other studies as well [16,36]. e low scores of this item do suggest that teachers in our program are still inclined towards the traditional authoritarian styles of teaching which identifies a dire need for a well-developed orientation program for faculty. Orienting faculty with specific faculty enhancement activities helps them in developing essential skills, positive attitude, and empathy towards students, which plays a pivotal role in the learning process (WFME, 2005) [6,12,69,70,72]. Additionally, faculty needs to be encouraged to emphasize self-directed learning which is the essence of hybrid curriculum (with PBL and TBL), whereby they need to act as facilitators for the acquisition of necessary knowledge, skills, and attitudes for lifelong learning [12,16]. Additionally, harsh criticism and ridicule combined with the negative feedback is one of the most discouraging things teachers can do for their students, reflecting it negatively on their self-confidence [5,16,36,72]. (SASP). For this subdomain of DREEM, a total score of 21.22 (SD � 5.91; 66.31%) was recorded (Figure 1; Tables 2, 4, and 5), which is the best of all domains, thereby, reflecting the facts that students were feeling positive for their overall academic performance ( Table 2). e overall score of 21.22 in our study is higher than reported by many other studies [4,21,36,47] but was in congruence with another Saudi study [8], but lesser than reported by an Omani study [31]. Also, phase II and phase III students had significantly different scores with means of 20.49 and 22.60, respectively (Table 5). One item of this domain pertaining to being confident about passing examinations has a mean score of 3.13, which is the highest score for any item of the DREEM survey in this study. is can be regarded as the strength of our medical program that despite the heavy academic workload, the hybrid curriculum has succeeded in instilling confidence in the student to cope well in EE.

Students' Perception of Atmosphere (SPA).
A total score of 31.35 (SD � 8.45; 65.31%) was recorded for this subdomain ( Figure 1; Tables 2, 4, and 5), and the total scores based upon phases of education also differed significantly (phase II � 30.22 vs. phase III � 33.50), making it a second best scoring in this study. e scores range for all items were 2.13-2.92, except one related to experience in college being disappointing which had a score of 1.99 (lowest). ese scores were comparably higher than reported by other studies [5,8,16,21,28]. e high scores of this domain indicate that students have a positive perception of the learning atmosphere in the College of Medicine, which is important as it affects all aspects of the curriculum [72]. e student positively perceived the items related to the program as being well managed, having less problem of cheating, being comfortable socially, and have developed good interpersonal skills. However, we need to look into their experience part holistically so as to improve it further to suit their taste.

Students' Social Self-Perceptions (SSSP).
In this subdomain, a total score of 18.39 (SD � 4.84; 64.28%) was recorded ( Figure 1; Tables 2, 4, and 5), with no differences in perception based on gender or phases of education, which was a not too bad perception for this subdomain (Table 2). One item related to friendship scored 3.12, which is the second highest scoring item in this study (Tables 5 and 6). e students reported that they were happy with their friends, their social life, not feeling lonely, and a good support system for students in college. ese scores were comparably higher than reported by other studies [5,8,16,21,28]. Our program has a dedicated and robust academic counseling and mentoring program in place, which provides much-needed counseling and guidance to the students throughout their journey in this college to reduce stress and develop coping techniques.

DREEM Domain Comparisons.
Additionally, we also identified the six-strong and six-weak points in this program (based on their scores) ( Table 6). e weak areas are more pertaining to the teachers and their attitudes in the program. So, there is a need for intervention with well-developed strategic actions to improve them in a five-year plan. We do recommend some suggestions such as making attending lectures nonobligatory, evaluating teacher's skills at the end of each session/semester, peer review of teacher's lecturing, obligatory faculty enhancement training/workshops for all teachers, accepting negative feedback from students, and providing grooming training to all teachers to serve as empathetic mentors.

Limitations of the Study.
Although the DREEM questionnaire is one of the best-designed tools to evaluate an EE within any setting, it is not free from all bias like study sample, sample size, study design, and its application itself. Since our study is a cross-sectional study, one of the limitations was that participants of this study varied between gender and phases of education. Second, DREEM items are close-ended and hence cannot capture all the information which a qualitative interview can. Furthermore, the study was carried out during the COVID-19 pandemic via online portal which might affect the overall DREEM and domain scores towards lower quartiles.

Conclusion
In this study the medical student assessed EE of the medical program, using the DREEM tool, towards a more positive side. However, we did identify a need for improvement in one of the five subdomains of DREEM, i.e., SPT. e perceptions of preclinical students and clinical students about EE differ significantly for four of the five domains of the DREEM questionnaire. One of the strengths of our college was that the overall total DREEM score for EE rated by students came out 129.64 (SD � 31.81; 64.82%), with all five subdomains scoring above 60% and only one of the weak domains of DREEM, i.e., SPT. e domain needs continuous monitoring to analyze various confounding factors which might have affected the perception and also proactive mitigation for future reassessment. In addition, we did find the weak areas within our EE by six low scoring items (≤2.15) of DREEM, i.e., SPL12, SPT3, SSSP3, SPT9, SPL1, and SPA8. All of these need an actionable intervention by the academic affairs department for their improvement, with well-developed strategic actions to improve them in a five-year plan, in order to make EE within the college more conducive for teaching and learning.

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Data Availability e data used to support this study are included within the article and are available from the corresponding author upon request.

Ethical Approval
A proper ethical approval as per Helsinki protocol was taken prior to carrying out this study via Institutional Research Board. is study was approved by the Institutional Review Board of King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) and King Abdullah International Medical Research Center (KAIMRC), a research wing of KSAU-HS, Jeddah (reference no. RJ19/137/J; dated: 13/11/ 2019).

Consent
A due informed consent was taken from every participant.

Conflicts of Interest
e authors declare that they have no conflicts of interest.