Self Assessment of Dental students' Perception of Learning Environment in Croatia, India and Nepal.

AIM: The aim of this study was to assess dental students' perception of different learning environment in India, Nepal and Croatia.
METHODS: The study was conducted during a period of academic year 2016/17. A total of 849 dental students participated in the study. There were 188 respondents from Croatia, 373 from India, and 288 from Nepal. Non-responders were not followed up. The Dental Student Learning Environment Survey (DSLES) was used which consisted of 55 items subdivided into seven scales. The scales measured the following perceptions: Flexibility, 'Student-to-Student Interactions, Emotional Climate, Supportiveness, Meaningful Experience, Organization and Breadth of Interest. Statistical analysis of the data utilised the Kolmogorov Smirnov test. The Kruskal-Wallis "non-parametric ANOVA" was also used to test the differences between the countries. A post hoc analysis was performed using Ranks tables and the Median test.
RESULTS: The response rate was 26.9%. Significant differences between the countries were found for all DSLES variables (Kruskal-Wallis, p<0.01). The Median test also showed significant differences between the countries for all DSLES variables (p<0.01). The scales with the highest mean values were 'Student-to-student interactions' in India and Nepal, and the 'Emotional Climate' in Croatia.
CONCLUSIONS: Students in Croatia rated their school only with grades excellent and good, while their colleagues in India and Nepal were more critical. Despite the different settings in three countries, 'Flexibility' was identified as the area of weakness in all three educational systems.

Introduction

The direction of dental education and changes in dental schools' curricula emerged from research by dental practitioners, professional organizations and the academic community (). It has been recognized that dental students, as active participants in educational process, should be central to changes in dental curricula and learning environment improvements (, ). Undergraduate dental students are required to acquire specific competences and knowledge in the 4-6 years period of their training. This can be very stressful (), and creating positive and supportive learning environments is becoming an important goal for all the participants in the dental education process (). The experiences and opinions of dental students obtained using various surveys apprise dental curricula developments from the students' perspective. (). A number of instruments were developed to assess the students’ perceptions of their academic, educational, emotional, and social environment such as Learning Environment Questionnaire, Dundee Ready Education Environment Measure (DREEM), Clinical Learning Environment Inventory (CLEI), Anatomy Education Environment Measurement Inventory (AEEMI) and others (-). It was found that the students' perception predicts academic success at universities more than their prior achievements in secondary school (, ).

The development of the Medical School Learning Environment Survey (MSLES) by Marshall () enabled healthcare educators to gain insight into students' perceptions of their learning environment. MSLES contains 55 items subdivided into seven scales measuring students' perceptions of: 1) Flexibility - opportunities for faculty and students to modify the learning environment together; 2) Student-to-Student Interactions - social and academic; 3) Emotional Climate - the way in which students’ experiences influence their affective perceptions of learning environment; 4) Supportiveness - the extent of support provided to students by faculty; 5) Meaningful Experience - the degree to which structured learning activities are seen to be relevant to practical work; 6) Organization - the degree of cohesion of learning experiences within the curriculum; and 7) Breadth of Interest - the extent to which students are encouraged to develop extracurricular activities. MSLES was reported to be a reliable and internally consistent instrument for measuring the student perception of their learning environment compared with lecture based curricula and problem-based curricula (, ). With the attempt of gaining insight into dental students' perceptions of their education, MSLES was modified to fit the purpose, and DSLES (Dental Student Learning Environment Survey) was used to assess dental students’ perceptions (). The DSLES is virtually identical to the MSLES, but the words medicine and physician are replaced with dentistry and dentist. The reliability and internal consistency of DSLES was reported to be similar to MSLES ().

Relevant studies on the students’ motivation, performance and perception of their learning environment are associated with universities in the developed countries of Europe and North America (, -). The students’ perceptions using the DSLES instrument in one European country, Croatia (having recently joined the European Union after an economic transition) were compared with two Asian countries: India and Nepal. The three countries belong to different geographical, social and cultural backgrounds, and there are different finance models between the Universities included in the study (two state and one private). The colleges are representative of the national standards as they are accredited to their respective national councils. Currently, there is no student or staff exchange program between Croatia and the other two countries, but students from Nepal attend dental courses in India. The results gained from each country could be a baseline for further research, and evaluation of students’ perception of curricula changes and innovations in methods of teaching.

Generally, the competences expected to be acquired during studies do not differ significantly between the countries. However, there are differences in the respective educational systems, student/teacher ratios and the available educational resources (Table 1.) (, )

Table 1

The differences between Schools of Dental Medicine at which the research was conducted

	CROATIA	INDIA	NEPAL
Basic concept of the study	Lecture based study	Lecture based study	Lecture based study
Private or public institution	Public	Public	Private
Duration of the studies	6 years (12th semester is internship)	5 years (including 1 year of internship)	5 and half (including 1 year of internship)
Number of undergraduate students	645	974	256
Number of basic and medicine subject teachers	45	62	32
Number of dental subject teachers	147	89	24
Teacher-to-student ratio – basic-medical subjects	01:14.3	01:15.7	01:08
Teacher-to-student ratio – dental subjects	01:04.4	01:10.9	01:10.7
Percentage of lectures (classical ex catedra lectures and seminars)	2000/5100=39%	1590/5200 = 30.57%	Lectures (basic and clinical) = 3195/5887 = 54.3%
Percentage of preclinical practicals	1001/5100=19.63%	1540/5200= 29.61%	1040/5887 = 17.6%
Percentage of clinical practicals	2099/5100=41.56%	2070/5200=39.8%	1652/5887 = 28.1%
Financial costs for students (do they pay for textbooks and material for preclinical and clinical practicals)tuition fees	Students participate	Entirely by the students for textbooks and materials etc; tuition fees subsidized as they are government colleges	Entirely by the students
First contact with dental patient	3rd year (restorative dentistry under supervision)	3rd year (all clinical departments under supervision)	3rd year (all clinical departments under supervision)

The aim of this study was to assess dental students' perception of different learning environment in India, Nepal and Croatia.

Materials and methods

This study was approved by Ethical Committees at the School of Dental Medicine, Zagreb, Surendera Dental College & Research Institute, Sri Ganganagar, India, and People’s Dental College in Nepal.

In Croatia, students from three Schools of Dental Medicine at three Universities – Zagreb, Rijeka and Split, participated in the study. Dental studies at all three Schools that participated in this study follow the same curriculum. The research was also conducted at the School of Dental Medicine, Surendera Dental College & Research Institute, Sri Ganganagar, India and People's Dental College and Hospital, Tribhuwan University, Kathmandu, Nepal.

The study was conducted during a period of academic year 2016/17. An email containing the link to Dental School Learning Environment Survey (DSLES) was sent to all dental undergraduate (first to final year) students. The research and consent procedures were described in the e-mail. A total of 849 dental students responded. Of this group, there were 188 responses from Croatia, 373 from India, and 288 from Nepal. Only completed forms were considered for the analysis and non-responders were excluded.

The DSLES survey consisted of 55 questions, and was designed to take 10-15 minutes to complete. The questions were divided into seven groups based on the seven categories of student perceptions of their learning environment (as described in the Introduction). The survey was translated into the Croatian language and face validated before being distributed. Twenty students of the final year gave objections on some expressions in the test and three teachers of the Dental School including the Vice dean for the student affairs reviewed the questionnaire. The permission to use the DSLES survey in the research was obtained from the author of the questionnaire, Professor David L. Henzi.

Responses to the survey questions were given using a four-point Likert scale: A=seldom, B=occasionally, C=more often than not, and D=very often. Additionally, answer E was offered when students did not have enough information to answer the question. Some questions were stated in the affirmative form, and some in the negative form. When statistically analysing the data, a mean score for each affirmative question was calculated by adding 1, 2, 3 or 4 points to A, B, C and D answers, respectively (). The score was reversed in questions that were negative formatted in such a fashion that positive ratings received higher scores. If the answer was E, the question was not included in calculating the mean score for the specific DSLES item.

Apart from the 55 DSLES items, additional demographic and self-assessment questions were added. They included the following choices: (i) graduate or postgraduate, (ii) year of study (-), (iii) self-estimated success during the studies (excellent, good, bad), (iv) self-estimated interest for the studies (excellent, good, bad), (v) appraisal of educational quality (excellent, good, bad), (vi) failing an exam during studies (yes/no).

The statistical analysis was carried out using SPSS ver. 17 software package (IBM, Armonk, NY, USA). The nature of answers provided for each question in DSLS was ordinal by applying the afore-mentioned scoring system. To confirm the normality of distribution of the data, the Kolmogorov Smirnov test was applied to the entire database, and to the database split by countries. The differences between countries were also tested using the Kruskal-Wallis “non-parametric ANOVA” because there were three schools included and the normality of distribution of the data had not been established. Post hoc analysis of the data was performed using the Median Test by Rank. For the additional questions (i-vi) the analysis was conducted using the Mann-Whitney test.

Focus groups and qualitative research was not chosen for this study because of culture differences between the countries. Since this was a pilot study, a quantitative method seemed more appropriate for the first step.

Results

The response rate was low at 26.9%. The total number of participants in Croatia was 188 (34 males and 154 females: 18.1% vs. 81.9%), in India 373 (161 males and 212 females: 43, 2% vs. 56,8%), and in Nepal 288 (79 males and 209 females: 27,4% vs. 72,6%). The gender response rates were in accordance with the student intake in the Schools in Croatia, but in India and Nepal gender response rates differed significantly (p>0.05)- in India there were more male respondents and in Nepal there were more female respondents.

The age of the students in Croatia ranged from 18 to 24 (22.54 ± 1.69 years) in India from 23 to 28 (25.30 ± 0.96), and in Nepal from 18 to 34 (22,88 ± 2.95).

The distribution was found not to be normal (p<0.05) for all DSLES subscales for all countries combined and for each country. When composite variables were tested they were similarly not normally distributed, such as: ‘Student to student interactions’ and ‘Emotional climate’ in the Croatia group; all variables in Nepal group and ‘Flexibility’ and ‘Student to student interactions’ in the India group.

The differences between the countries were found for all DSLES variables using the non-parametric Kruskal-Wallis test, with 𝟀2 values from 52.55 - 210.73, df=2 and p<0.01. The Median test also showed differences between the countries for all DSLES variables, 𝟀2 were from 46.35 - 171.54, df=2 and p<0.01. Scores are given in Table 2, and reverse score chart is represented in Figure 1.

Table 2

Scores for seven subscales of Dental School Learning Environment Survey (DSLES) used for the assessment of the learning environment in Croatia, India and Nepal, 2016.

DSLES subscales	Croatia (n=188)		India (n=373)		Nepal (n=88)
	Mean	Std. Deviation	Mean	Std. Deviation	Mean	Std. Deviation
Flexibility	2.2902	0.49057	1.877	0.57785	2.0229	0.47005
Student to student interactions	2.8376	0.49002	2.5448	0.39974	2.8015	0.47389
Emotional climate	3.0773	0.60728	2.222	0.55093	2.5024	0.53825
Supportiveness	2.82	0.58792	2.0453	0.57245	2.1965	0.55636
Meaningful experience	2.5723	0.59843	2.3199	0.44494	2.5989	0.4831
Organization	2.7799	0.54023	2.1422	0.49174	2.582	0.45882
Breadth of interest	2.5775	0.5149	2.2168	0.3685	2.325	0.45624

Figure 1

Reverse score chart - every rank was graded from 1-7 (with 7 being the highest rank and 1 the lowest of all rank values in Kruskal Wallis test), also average grades of each variable were transformed and presented in this chart in a same manner.

Students in Croatia in different years graded all DSLES subscales. However, the ‘Breadth of interest’ was significantly different (Kruskal-Wallis test, p<0.05). The differences were more expressed between the lower years (1st and 2nd) and the higher years, especially 6th year.

In India, the differences between the study years were significant for all the subscales except ‘Flexibility’ (𝟀2 =3, 52, df=2 p>0, 05). The grading for ‘Student-to-student interactions’ increased and grading for other subscales decreased as the study year progressed.

In Nepal, the grades were significantly different for all subscales (p<0,05) except for ‘Student-to-student interaction’ (𝟀2 =8,38, df=2 p>0,05). There was a noticeable decrease in ranks towards higher years for all significantly different variables.

In Croatia and Nepal, there were no statistically significant differences (p>0, 05) between the groups of students that differently assessed their overall success in grading DSLES subscales. However, no-one in Croatia appraised their overall success as “bad” (Figure 2.) There was a significant difference in DSLES subscales for Indian students (𝟀2 =17, 91 - 63.07, df=1 p<0, 01) relating to the self-assessed study success. The students who appraised their overall success as excellent had the lowest mean ranks, and students who considered their success as bad had the highest mean ranks for all variables except for variable II ‘Student to student interaction’ which showed the opposite distribution.

Figure 2

Students self-estimated overall success distributed by countries

‘Interest in the studies’ was distributed similarly as the self-assessment data (Figure 3.) In Croatia, there was a statistically significant difference for two subscales: Student to student interaction (𝟀2 =6,67 df=2 p<0,05) and Emotional climate (𝟀2 =3,95 df=1 p<0,05). Higher mean ranks were given by group of students who appraised their interest in studies as good. In India, the differences were statistically significant for all the subscales p<0.01, except for ‘Meaningful experience’ (𝟀2 =4, 03 df=2 p>0, 05). While the grades for subscale ‘Meaningful experience’ showed approximately equal distributions between the groups that appraised their experience as excellent, good or bad. The ‘Student–to student interactions’ subscale showed a decrease in the mean rank value ranging from excellent to bad, and other subscales showed the opposite. In Nepal, most of the subscales showed statistically significant difference (p<0.05) except ‘Flexibility’ and ‘Emotional climate’ subscales (𝟀2 =2, 54 and 4,55 df=2 p>0,05). For ‘Flexibility’ the distribution of mean ranks was uniform.

Figure 3

Students appraisal of their interest in the studies distributed by countries

Students in Croatia rated their school only with grades excellent and good, while their colleagues in India and Nepal were more critical (Figure 4.) In Croatia, the ratings for all subscales showed statistically significant differences between groups of students who rated their school as either excellent or good (𝟀2 =6, 49-40, 69 df=1 p<0, 01). The only exception was ‘Breadth of interests’ for which mean ranks did not differ much. For other subscales mean ranks were higher for group of students who marked their school as good. In India, ‘Flexibility’, ‘Student–to-student interactions’ and ‘Meaningful experience’ showed statistically significant differences (𝟀2 =8, 15-48, 97 df=2 p<0, 05). Mean ranks for these subscales decreased together with students’ ranking of their school. In Nepal significant difference was found for ‘Meaningful experience’ and ‘Organization’ (𝟀2 =12, 03 and 10, 19 df=2 p<0, 01). In both cases, same as in India, mean ranks decreased with students ranking of their school.

Figure 4

Students rating of their school distributed by countries

In Croatia, most of the students failed at least one exam (Figure 5.). In India a very small percentage failed at least one exam, and in Nepal there was slightly larger percentage than in India. In Croatia, these two groups did not grade DSLES scales significantly differently, except the subscale ‘Organization’ (U=1404 p<0.05 mean rank YES 91.06, mean rank NO 118). In India, all the subscales were graded significantly differently (U was between 288 and 1776, p<0.01), with mean ranks always larger for the group which did not fail any exam, except for Student to student interaction. In Nepal only two subscales were graded significantly different: ‘Meaningful experience’ and ‘Organization’ (U=8301,5 and 7983 p<0,05). In both, mean ranks were higher in group which did not fail an exam. This study was conducted using a questionnaire only, as a sort of a pilot study of the students’ perception of their learning environment. Therefore, it did not include focus groups enquiries or student interviews.

Figure 5

Percentage of students who failed at least one exam during their schooling

Discussion

It could not be argued that academic climate is strongly influenced by the cultural circumstances. Contemporary global educational trend of encouraging student and staff exchange is especially emphasized in Europe through programmes supporting the free movement of students across EU (). Students from different countries found that international exchanges could enhance students’ knowledge and self‐awareness related to cultural competence (). This global trend brings students from different cultural backgrounds in interaction highlighting the importance of appreciating students’ needs and their perception of learning environment in order to facilitate their accommodation in a host country. Despite the current lack of exchange programme between Croatia as European country and India and Nepal as Asian countries, a comparison of the student perspective of learning environment could be a foundation for such future programme.

Despite the differences in the educational systems of the three countries (Table1.), dental students’ views regarding their education in Croatia, Nepal and India appear to be relatively convergent, as was noticed in previous studies ().

There was a difference in average grade distribution compared to ranks (Figure 1). The highest grades were given for subscale ‘Student to student interaction’, and the lowest for ‘Flexibility’; even though the rank grades gathered from Kruskal Wallis tests (rank by mean rank grade), that reflect what students think is important, they are differently distributed. In Croatia the highest rank impact and also grades are given to ‘Emotional climate’ which makes it the best graded and also the most important variable in this assessment. Students in India gave the highest importance to ‘Breadth of interest’, while graded it with the 3rd lowest grade. Students in Nepal value ‘Organization’ as a subscale of particular importance, and also graded it with the third lowest grade.

Although ‘Flexibility’ was graded with lowest grades in all three countries, its impact on students’ opinion is quite high (Grades by mean rank being 4 or above) which makes it worth considering while analyzing and developing the future curriculum.

The curricula are largely lecture based with strictly divided departmentalized areas. The curriculum is overly divided into compartments of syllabuses and catalogues of knowledge. Also, there are several redundant topics. For example the topics from the subject ‘Dental materials’ are taught at least twice, because every dental clinical subject includes the topics about dental materials. In fact, the reports of Institute of Medicine of the National Academy of Sciences and American Dental Education Association Commission, showing that dental curricula contained redundant and irrelevant content, did not reflect contemporary dental practice, and were lacking effective integration between the basic and clinical sciences (, , ).

Using the SWAT instrument Lanning et al. (15) analyzed students’ perceptions of a revised curriculum at the Virginia Commonwealth University School of Dentistry, and they recommended the following: the early patient care experiences should be maximized; learning expectations should be clearly set; course loads between semesters should be balanced; basic, social, and clinical sciences should be integrated (diverse faculty groups with various expertise come together to share information) (). In the curricula of the three countries from our study, there are some clearly notable deficiencies in the context of the above mentioned recommendations. Students experience patient care relatively early (3rd year of the study), but learning expectations at the clinic are not entirely consistent with their preclinical practicals. For example, preclinical courses of restorative dentistry are to a considerable degree based on Black’s principles, unlike the clinical practice where adhesive cavities are performed. Also, in Croatia, the students are not focused on clinical work and dental courses because they are preoccupied with learning for basic and medical exams- the courses that they have attended the previous semester. Learning expectations are more or less clearly set when it comes to theoretical knowledge, but when it comes to actual clinical competences; the expectations for a particular semester are not so clearly set i.e. stage that this study was carried out. Diverse faculty groups rarely come together to share information regarding students and studying. It is suggested that that working groups consisting of various specialties, students and graduates come together and to debate aspects of the curriculum, including more problem based learning, instead of lecture based delivery. It could be also accomplished through the structural, teacher supervised, forums available on faculty e-learning platform ().

Supportiveness was the subscale that showed an interesting cross country difference. While this variable is very important for Croatian and Indian students it has been graded with a better grade in Croatia than in India, suggesting that although students find it to be equally important, their satisfaction with supportiveness is quite different. Perhaps this can partly be explained by a more favorable teacher/student ratio in Croatia, especially for dental subjects. In Nepal, that subscale was not considered as important, and was also not graded well on the overall scale. This difference might be explained by the fact the School in Nepal is a private institution. Also, the different learning style preferred in Asian and European culture is one of the factors that could influence student perception of their academic environment (, ). Despite certain heterogeneity of each studied population, there is traditional approach to knowledge acquiring in Eastern and Western civilization. The lack of supportiveness and faculty concern for the progress of undergraduate students has been recognized as an important source of stress among students, along with examination anxiety, limited leisure time, and adaptation to the clinical phase of their education (, , , ). Furthermore, supportiveness has been recognized and pointed out as one of four most important characteristics of a good clinical teacher, besides being competent and compassionate health care provider, effective supervisor and employing a varied and dynamic approach to teaching ().

Considering the stage of dental education (study year), several differences between the countries were noticed. Croatian students graded DSLES subscales with lower grades as they advanced in their studies but there was no difference for the ‘Breadth of interest’ subscale. In the case of Indian students, flexibility was graded uniformly low over the years. Other subscales received lower grades with the advancement of the studies, similarly as in Croatia, except Student-to-student interactions. Therefore, encouraging student-to-student interaction could contribute to the improvement of their educational process. In contrast to Indian students, their colleagues in Nepal value their interaction consistently in an equal manner over the course of their education.

There were some points connected to students’ self-estimated success which differed between different nations and could make the educational process more suited to different learning styles and different student populations. None of the Croatian students thought of their overall success was bad which is in great contrast to students from India and Nepal who seem to be more critical. In India, the students estimating their overall success as bad give higher grades to all subscales except ‘Student-to-student interaction’. This could mean that they feel that other colleagues may be impeding their educational development in a way that they are competitive and avoid sharing experiences regarding their learning and studies. Furthermore, Croatian students who appraise their interest in the studies as excellent gave lower grades to ‘Student-to-student interaction’ and ‘Emotional climate subscales’. It might be concluded that students who are less interested in the curriculum consider social aspects of their studies valuable. Conversely, in India, students who appraised their interest in the studies as excellent also graded their interaction with other students as very valuable. In Nepal, there was a correlation between high grading of DSLES subscales with the students’ high interest in the curriculum, which was quite different from with their counterparts in India and Croatia (Figure?). In addition, they do not relate their ‘Flexibility and Emotional climate’ to their interest in the studies. This might also be attributed to the fact that the College is private, and not public.

It was quite unexpected that students in Croatia, who rated their school as good and not excellent, gave higher grades to almost all subscales. In contrast, students in India and Nepal who ranked their schools better usually gave better grades. Moreover, it is obvious that variable ‘Meaningful experience’ in all three countries can be highly associated with the perception of the school’s quality including administration related factors, teaching methods and different kinds of student support (). The future research measuring faculty and staff perceptions of the learning environment could be used in further interpretation of these results. The survey follow up strategy is recording the changes in the curriculum and students' demographics during the next five years, and repeating the survey in a 5 year period in each country.

In conclusion, the findings of the current study showed a significant difference in dental students’ grading of various DSLES scales in Croatia, India and Nepal. It was observed that with lack of flexibility, supportiveness and lecture based curriculum, there is considerable amount of space for the improvement of learning environments in the three academic settings.