Dundee Ready Education Environment Measure of Dentistry: Analysis of Dental Students' Perception about Educational Environment in College of Dentistry, Mustaqbal University.

INTRODUCTION: Evaluation of the educational environment is an important element which can be used to improve our curriculum. The aims and objectives of this cross-sectional study were to identify the student's perception about educational environment in College of Dentistry, Mustaqbal University. As the educational environment has a significant impact on the learning and academic performance of the students, the present study will help us identify areas of improvement and refining the dental curriculum.
MATERIALS AND METHODS: A total of 120 students of year 4, 5, 6, and interns, both male and female, responded to the Dundee Ready Education Environment Measure (DREEM) in the 1st month of the second semester, 2021. This scale measures the student's perceptions of the educational environment overall and for five domains: learning, teaching, academic self-perception, atmosphere, and social self-perception.
RESULTS: A total of 92 students responded and were generally positive about their learning environment, with a total DREEM score of 130.87 ± 32.73/200. The lowest score for Domain 5 (social self-perception) and the highest score for Domain 1 (student's perception of learning.) were noted.
CONCLUSION: Students' perception of educational environment of College of Dentistry, Mustaqbal University, was more positive than negative. This study provided a valuable insight of how students perceive their course and identified several weak areas that need to be worked upon, hence helping in improvement of the curriculum. Copyright:

INTRODUCTION

Dental education is regarded as a complex, challenging, and often a taxing pedagogical process.[1] Every year, thousands of students apply for admissions in dental schools throughout Saudi Arabia, but only a few can manage to enter due to the stringent admission criteria. Once in the program, students face a challenging science-based curriculum, the aim of which is to produce knowledgeable, well-learned, and self-directed learners possessing the appropriate skills, values, and high ethical/moral standards.[2] Moreover, students in dental schools interact with the variety of teaching/administrative staff, patients, and peers while performing the demanding educational and clinical tasks in a competitive and at times a belligerent learning environment.[3]

The learning environment is one of the main components in the evaluation of any dental education program, and there is a growing recognition of the importance of academic climate or setting, underpinning effective students' learning. Academic learning environment, also known as the “soul and spirit” of the school, is constituted of components such as physical environment, values, and instructional practices with which the learners interact. An educational environment that is not instrumental to learning reduces the learner's ability to acquire new knowledge and hinders their professional and social growth and contribution toward the community.[4] Many studies have shown that an educational environment affects students' achievements, happiness, motivation, and success.[5] As such, the students' perception of their learning environment is pivotal within the context of learning.[6]

A motivating study environment promotes deep self-regulated learning by stimulating various processes such as goal setting, metacognition, and self-assessment, all of which influence learning in many ways.[7] Students' perception of the environment within which they study has shown to have a significant impact on their behavior, motivation, academic achievements, and sense of well-being.[89] However, the input of dental students, the main stakeholders, has often been overlooked for decades.[1] Researchers have used various methods including quantitative surveys and qualitative focus groups to gain deep insight about perceptions of students about their learning environments.[10] To measure the undergraduate learning environment using a quantitative approach offers several advantages. It not only helps to assess the educational environment but also the subcomponents and highlights the problem areas.[6] Assessment of the environment of medical/dental education from the students' perspective measures the gross outcome of educational practices as well as general state of educational affairs in the curriculum.[4]

Dundee Ready Education Environment Measure (DREEM) is the most widely used quantitative instrument which measures the students' perception of the educational environment. DREEM has five subdomains: learning, teaching, academic self-perception (ASP), social self-perception, and atmosphere. It was originally developed by a Delphi panel of nearly 100 health profession educators from several countries who participated in various courses at the medical education center in Dundee between 1994 and 1996.[11] It was intended to be an international, generic instrument that is not culture specific. It is a reliable tool and data collected can be analyzed according to the variables.[8] Furthermore, it can be used as a diagnostic instrument to identify the areas of strength and weakness. Moreover, it can be used to compare various institutes and students at different stages of learning and even for undertaking gender comparisons. As a result, DREEM is used in many health specialties including nursing, dietetics, midwifery, pharmacy as well as in dentistry.[2] The results of the DREEM can be considered at three levels: individual items, subscales, and overall DREEM.[12]

The purpose of the current study was to understand how students perceive their environment and provide educators with strategies to improve school curriculum further enhancing the well-being of the students. Considering this, the present study was conducted to evaluate the students' perception of their educational environment using DREEM questionnaire for the College of Dentistry, Mustaqbal University.

MATERIALS AND METHODS

Ethical approval for the study was taken from the Ethical Committee at College of Dentistry, Mustaqbal University. Students were informed about the study in the classrooms and were offered a complete verbal explanation of the research methodology and how the data will be kept anonymous. Moreover, they were told that the participation in the study was voluntary and the study sought their actual opinion. The submission of the filled e-questionnaires was considered as implied consent.

Participants

DREEM questionnaire was distributed among students of the 4th, 5th, and 6th years and interns. Students who were perusing the basic sciences years, i.e., 1st, 2nd, and 3rd years of the dental program, were excluded as they were not attending the dental clinics. In this program, teaching and learning shifts from primarily lectures, tutorials, and practical skills development in preclinical years (years 1, 2, and 3), to the addition of patient-based and case-based learning through direct patient care in later clinical years (years 4, 5, and 6 and internship year). The data were collected between September 2020 and December 2020. The questionnaire was administered through Google Forms.

Study instrument

Students' perception of the learning environment was measured with the DREEM questionnaire, that is, a 50-item questionnaire using a five-point Likert scale (4 – strongly agree to 0 – strongly disagree). The cumulative DREEM score is 200. Nine of the question items (4, 8, 9, 17, 25, 35, 39, 48, and 50) were negative statements and had reverse scoring. Mean and standard deviation was calculated for each individual item.

DREEM inventory measures five subscales with their maximum scores as follow:[13]

Student's perception of learning (SPL): 12 items and maximum score is 48

Student's perception of teachers (POT): 11 items and maximum score is 44

Student's ASP: 8 items and maximum score is 32

Student's perception of atmosphere (POA): 12 items and maximum score is 48

Student's social self-perceptions (SSP): 7 items and maximum score is 28.

Students were anonymously asked to respond to all items based on their experience of previous years. Mean total scores for all subscales were interpreted according to the practical guide to using DREEM by McAleer and Roff,[10] as shown in Table 1.

Table 1

Guide for interpretation of Dundee Ready Education Environment Measure scores

Scores	Interpretation
Total DREEM score
0-50	Very poor
51-100	Plenty of problems
101-150	More positive than negative
151-200	Excellent
SPL
0-12	Very poor
13-24	Teaching is viewed negatively
25-36	A more positive approach
37-48	Teaching highly thought of
SPT
0-11	Abysmal
12-22	In need of some retraining
23-33	Moving in the right direction
34-44	Model teachers 3
SAP
0-8	Feeling of total failure
9-16	Many negative aspects
17-24	Feeling more on the positive side
25-32	Confident
SPA
0-12	A terrible environment
13-24	There are many issues that need to be changed
25-36	A more positive atmosphere
37-48	A good feeling overall
SSP
0-7	Miserable
8-14	Not a nice place
15-21	Not very bad
22-28	Very good socially

DREEM: Dundee Ready Education Environment Measure, SPL: Student’s perception of learning, POT: Student’s perception of teachers, ASP: Students academic self perception , POA:Student’s perception of atmosphere, SSP: Students social self perception

Statistical analysis

Statistics were tabulated using SPSS version 19, Karnataka, Bangalore. Mean scores for each item, subscale, and cumulative scale were calculated. Comparative analysis used independent sample t-test and one-way ANOVA test. Cumulative and domain-wise internal reliability was calculated by using Cronbach's alpha. The level of significance was set at <0.05. The relationship between the independent variables and overall DREEM score was determined by using Pearson correlation test.

RESULTS

A total of 91 students participated out of a possible 120 students giving a response rate of 75.8%. More participants were female (56%). The demographic details of the participants are depicted in Table 2.

Table 2

Demographics of dentistry students (n=91)

Variables	n (%)
Years of study
Interns	31 (34.1)
4th	20 (22.0)
5th	21 (23.1)
6th	19 (20.9)
Gender
Female	51 (56.0)
Male	40 (44.0)

Mean scores for individual DREEM items were calculated. Across all academic years, the whole sample was more positive than negative about their learning environment, with a cumulative mean DREEM score of 130.87 ± 32.73. The mean DREEM scores obtained by the sample in each subscale are shown in Table 3. SSP domain scored the lowest with a mean of 17.52 ± 5.09 (interpreted “as not very bad”), and the highest score was noted for SPL domain with a mean score of 32.52 ± 8.63 (interpreted as a more positive approach). SPT scored 27.38 ± 7.08, interpreted as “moving in the right direction;” ASP scored 21.95 ± 6.24, interpreted as “feeling more on the positive side;” and SPA scored 31.20 ± 8.18, interpreted as a more positive atmosphere.

Table 3

Mean scores for the total Dundee Ready Education Environment Measure and its subscales

DREEM subscale	Maximum score	Mean±SD	Cronbach’s α
SPL	48	32.8±8.63	0.932
SPT	44	27.38±7.08	0.942
ASP	32	21.95±6.24	0.937
SPA	48	31.2±8.18	0.929
SSSP	28	17.52±5.09	0.951
Total DREEM	200	130.87±32.73

DREEM: Dundee Ready Education Environment Measure, SPL: Student’s perception of learning, SPT: Student’s perception of teachers, SPA: Student’s perception of atmosphere, ASP: Academic self-perceptions, SSSP: Student’s Social self-perceptions, SD: Standard deviation

The overall mean scores as well as mean for all five domains across all the years were calculated. The highest mean score was noted for year 4 students (139.5 ± 37.91), whereas the lowest mean score (119.28 ± 18.39) was documented for year 5 [Table 4].

Table 4

Dentistry students’ perceptions of the learning environment in each year of study (n=91)

Domains	Years of study (mean±SD)				Overall	P
	Interns	4th	5th	6th
Total	129.61±41.34	139.5±37.91	119.28±18.39	136.68±32.73	130.87±32.73	0.199
Domain 1	32.32±10.72	35.0±9.8	28.92±4.93	35.52±4.65	32.52±8.63	0.056
Domain 2	27.80±8.95	28.9±8.22	25.19±3.90	27.52±4.50	27.38±7.08	0.389
Domain 3	21.19±7.58	23.6±6.90	20.19±4.50	23.42±4.40	21.95±6.24	0.207
Domain 4	30.35±10.19	33.8±9.57	29.71±5.06	31.52±5.01	31.20±8.18	0.386
Domain 5	17.93±5.85	18.2±5.37	15.23±3.63	18.68±4.38	17.52±5.09	0.122

SD: Standard deviation

In the individual item scores, it was found that none of the items scored ≥3.5 which indicates that no area was making a real positive impact. Six items showed a score of <2, indicating that there were problem areas and need to be monitored closely and regularly.

Analyzing the role of gender difference on students' perception of their educational environment, no significant difference was found between males and females [Table 5]. However, males had an overall higher mean perception as compared to the females across all years as well as higher mean perception score for all the five domains.

Table 5

Descriptive summary statistics and Cronbach’s α

Domains and variables	Mean±SD	P	Mean±SD	Cronbach’s α
Domain 1 (items=12)
Gender
Female (n=51)	31.33±8.77	0.065	32.8±8.63	0.932
Male (n=40)	34.67±8.19
Years of study
Interns (n=31)	32.32±10.73	0.056
4th (n=20)	35.00±9.81
5th (n=21)	28.95±4.93
6th (n=19)	35.53±4.66
Domain 2 (items=11)
Gender
Female (n=51)	26.53±7.25	0.191	27.38±7.08	0.942
Male (n=40)	28.47±6.79
Years of study
Interns (n=31)	27.81±8.95	0.389
4th (n=20)	28.90±8.22
5th (n=21)	25.19±3.91
6th (n=19)	27.53±4.50
Domain 3 (items=8)
Gender
Female (n=51)	21.57±6.52	0.507	21.95±6.24	0.937
Male (n=40)	22.45±5.92
Years of study
Interns (n=31)	21.19±7.58	0.207
4th (n=20)	23.60±6.91
5th (n=21)	20.19±4.50
6th (n=19)	23.42±4.05
Domain 4 (items=12)
Gender
Female (n=51)	30.25±8.30	0.209	31.2±8.18	0.929
Male (n=40)	32.43±7.98
Years of study
Interns (n=31)	30.35±10.20	0.386
4th (n=20)	33.80±9.57
5th (n=21)	29.71±5.06
6th (n=19)	31.53±5.02
Domain 5 (items=7)
Gender
Female (n=51)	16.94±5.27	0.212	17.52±5.09	0.951
Male (n=40)	18.27±4.83
Years of study
Interns (n=31)	17.94±5.85	0.122
4th (n=20)	18.20±5.38
5th (n=21)	15.24±3.63
6th (n=19)	18.68±4.38

SD: Standard deviation

The Pearson's correlation test showed the weak positive insignificant correlation of mean DECLEI score with gender and categories [Table 6].

Table 6

Pearson correlation

Variables	Pearson’s (r)	P
Gender	0.193	0.067
Years of study	0.043	0.686

DISCUSSION

Educational environment is believed to be a major component of educational curriculum.[4] There is evidence that the educational environment experienced by students has an impact on the satisfaction of the course of study, perceived well-being as well as academic achievements.[12] Accreditation is also one of the important goals of the institutes of higher education. Many studies have been carried out using this tool in medical, nursing, pharmacy as well as dental colleges across the globe.[14] The current study measured the SPL environment at the College of Dentistry, Mustaqbal University, Saudi Arabia.

The cumulative DREEM score indicates that an overall educational environment is conducive for the students' learning. The mean overall score of the current study is higher than some other studies conducted in various medical and dental schools across other regions of Saudi Arabia.[15161718] Al-Hazimi et al.[16] found DREEM scores of medical schools teaching traditional curriculum as 102/200 in King Abdulaziz University, 107/200 in Umm Al Qura University, and 100/200 in Sana's University Medical School, Republic of Yemen. A similar study at Medial School of King Saud University, Riyadh, showed that results had a score of 90/200, which is low as compared to our study.[11] Few studies conducted at dental schools, such as King Saud University and a dental training school in Malaysia,[1819] showed lower scores in comparison to our study. Difference of the educational systems and curricula may be the cause of these dissimilar findings. In our School of Dentistry, as in most of the dental schools across Middle East region, traditional curriculum is being followed, as defined by general medical council.[18]

The scores of our study were found to be lower than that of the medical school at Dundee University Medical School (139/200), which indicates that a curriculum with student-centered learning and more integrated learning approaches (problem-based learning [PBL] and task-based learning) scored higher as compared to those following traditional curriculum.[16]

However, a higher score of our study as compared to other traditional curriculums could be attributed to the process of curriculum shift toward integrated teaching and learning approaches. We are moving toward a hybrid problem-based curriculum, by conducting a greater number of tutorials (small group format) as compared to lectures and introducing PBL in our system. Our university has started faculty development workshops for capacity building according to framework of NCAAA (The National Center for Academic Accreditation and Evaluation)

Overall, comparatively strong infrastructure, experienced faculty, competent administration and leadership, as well as an environment that is student-friendly might have contributed to a score that is on a higher side as compared to other studies.

Although the overall score was better, we personally feel that there are certain areas of deficiencies and identifying these areas could help us to improve the Curriculum in future. Therefore, we analyzed the domain-wise score as well as individual item scores. ASP was perceived as the most positive of all domains which is consistent with other studies conducted in Australia,[2] King Saud University Dental School,[18] and medical schools across Jeddah, Makkah, and Sanaa.[16] This domain of ASP is very important as it calls attention toward the level of confidence of the students toward their academic progress. Many studies report that the career preferences have a strong influence on students' academic performance, motivation, and well-being.[20] Hence, the students who have dentistry as their preference for career would have better academic and social self-perception scores and higher intrinsic goal orientation and self-directedness,[2] although we did not include career domains in our study.

The domains that scored lowest were for SSP. Social self-perception may be considered as a global indicator of overall well-being of the study and may be a marker of how educational environments such as long clinical hours, clinical schedule, and other factors influence the students' self-perception.[2] The relatively lower score in this domain may be an indication that curriculum revision is needed by incorporating the teaching methodologies that will ensure the more active involvement of students in the teaching–learning process, as well as creating supportive climate, and a strong social network of support for the students is recommended.[21]

In the individual item scores, the item that scored lowest was item number 8 “The teachers ridicule the students” which is consistent with other previous studies conducted.[1622] This could be attributed to currently administered dominated traditional curriculum where teachers are major partners in the learning transactions. Steps have already begun to improve staff approachability by conducting faculty development workshops and a strong and close professional relationship between staff and students by using techniques such as mentoring and advising.[19] A humanistic environment establishes a context for the development of interpersonal skills necessary for learning, caring for patients, and making meaningful contributions to the profession.[2324]

Most of the other items scored between 2 and 3 which indicate a scope of improvement in the educational environment. In similar studies done at Qassim University[22] and a University of Dammam in Saudi Arabia,[15] the highest score was given to item 15 which also scored highest in our study: “I have good friends in the department.” This indicates a friendly and a positive environment among students in the university.

Significant differences have been calculated between students' experiences at different stages of their learning. Year 4 and 6 students had a higher perception of their learning environment as compared to interns, but year 5 students had a mean perception, lowest of all the groups, contrary to many other studies.[215] Most of the DREEM studies conducted showed a trend of declining scores in all domains as we moved up to higher clinical levels.[151819] The deviation in our study could be attributed to the reason that they were working in a tougher situation of COVID-19 pandemic wherein the regulations for working in clinics changed drastically such as fewer appointments, stricter infection control protocols, and prior appointment bookings. Pandemic also resulted in the shift of curriculum to online instructional strategies which might have left students more stressed and still exploring their clinical environment. However, it could also be an indication of necessary curriculum modification related to their preclinical formative years and introduction to clinics at an early stage.

However, interns also had a lower mean perception as compared to year 4 and 6 which emphasizes the problems students face in the clinics that continue to stress them out. The patients they treat in clinics not only include the procedures and treatment but also includes a lot of paperwork. Along with the clinical skills, tracking down the patients, scheduling appointments according to their respective clinical schedules, needs to be mentioned.[18] Moving toward, a competency-based curriculum with comprehensive clinics could take the students out of such stressful clinical situation.

Gender did not have any significant effect on their perceptions. This might be due to separate male and female buildings, faculty, clinics as well as schedules. This is in agreement with many dental studies conducted in Saudi Arabia as well as India.[1825] However, few studies conducted in India[26] and a Nigerian school[27] recognized that gender differences with females have a better perception of their educational environment as compared to the males.

While this study can be used as a baseline for the students' perceptions and provided an insight into the educational environment of undergraduate students and can be used as a diagnostic information about the College of Dentistry, Mustaqbal University, an overall positive educational climate is suggested in this study with few areas that need to be improved, but further research and studies are needed to correlate each domain with the specific aspects of curriculum.

CONCLUSION

The learning environment as perceived by the students is one of the most central components influencing the accomplishment of a successful curriculum.[23] Overall, the sample of dental students rated that the learning environment in the School of Dentistry was more positive than negative. This study bestows a valuable insight into the educational climate of the institute and addresses specific concerns of students to make the learning set up more congenial for the students.

Consent for publication

Informed consent was taken from all participants. The manuscript has been read and approved by all the authors, the requirements for authorship as stated earlier in this document have been met, and each author believes that the manuscript represents honest work and authors alone are responsible for the content and writing of the paper.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.