Students ’ perception of learning environment : A Base Line Study for identifying areas of concern at a Private Medical College , Bangladesh

Background: The importance of learning environment in teaching institution is increasingly being appreciated in terms of its effect on learning and outcome. Objective: The objective of this study was to explore students’ perception of learning environment for identifying measures to improve it of a private medical college, Bangladesh. Method: Two phase cross-sectional study combining quantitative and qualitative components was conducted among the students of a private medical college. In Phase I part the Dundee Ready Education Environment Measure (DREEM) inventory was used to obtain data for base line quantitative information on a total of 204 medical and final professional examinee students. Purposive sampling method was employed in this phase and the Item that scored >3 was categorised as highest and < 2 was categorised as lowest scored item. In Phase II part the highest and lowest score items were explored further by qualitative method of focus group discussions among teachers and students on two separate occasions. For focus group discussion a combination of 10 (clinical and preclinical) teachers and 10 students (2x5 =10) except the examinee batch were selected by convenience sampling method. The purpose and method of the focus group was clearly stated to the participants and a consent form was signed by one participant on behalf of the respective group. Results: The response rate was 100% in Phase I part of the study with a perceived global DREEM mean score was 120/200 (22.984) which indicated students’ positive perception towards the learning environment of ISMC. The global score for year 1, 2, 3, 4, 5 and examinee students were 133/200 (12.959); 134/200 (15.678); 127/200 (9.895); 112/200 (17.205); 67/200 (22.623) and 14/200 (22.984) respectively. The 1st year and 2nd year had highest global score whereas 5th year students had lowest score. The perceived Domains mean scores for Students Perception of Learning (SPoL) was 29.35/48 (8.189); Students Perception of Teacher (SPoT) 27.24/44 (5.195); Students Academic Self Perception (SASP) 18.69/32 (6.726); Students Perception of Atmosphere (SPoA) 28.09/48 (6.844) and Students Social Self Perception (SSSP) 14.65/28 (2.952) which indicated students’ positive perception in all five Domains of DREEM as well. Out of 50 items three scored >3 and 7 items scored <2 which were explored further by focus group discussions among teachers and students to know the underlying causes for such scores. many similar issues were identified by both the groups in focus group discussion. Conclusion: The combination of a quantitative and qualitative method revealed students’ positive perception and the strong and weak areas of the learning environment of ISMC. The findings were used in recommending remedial measure for creating an encouraging learning environment of ISMC which is one the main ingredient for effective learning.


Introduction
Academic interest in students' perceptions of health professional (medical, dental, nursing and other) learning environmenthas been increasing in recent years.The learning environment encompass student/ teacher interactions, teaching, and learning activity, good physical resources and students' psychosocial and emotional aspects that are experienced by students and other stakeholders in a learning institution.By addressing all these, an institute might be said to have a good learning environment [1][2][3][4][5][6][7][8] .The development of assessment inventories of learning environmentenables students' perceptions of their learning environment to be quantified and compared, either longitudinally or as a snapshot, and within a single health institution or between institutions and countries 9,10 .There are many study findings quoting the differences in students' perception about their learning environment based on gender differences, types of curriculum, years of study, entry requirements, ethnicity, across different courses of study, disciplines and academic results 1,3,[11][12][13][14][15][16][17][18] .The learning environment has been linked for many years to student achievement, satisfaction and success [19][20][21][22] .Consideration of the learning environment in an education institution, along the lines of continuous quality improvement and innovation is likely to further improve the learning outcomes of the school.Therefore, the learning environment is an important consideration for producing highly competent graduates and a good approach to and systematic design of the learning environment can lead to good outcomes for graduates 23 .The environment in a medical and allied health school is often competitive and at times even incompatible 24 .Students are influenced by both positive and negative role models, while working closely with teachers 25,26 .A learning environment study is one way to improve the quality of an education programme 22 .For the past two decades the DREEM is used to assess the key aspects involved in teaching and learning in medical and health professional schools 3 .Globally validated and reliable DREEM was developed by a world-wide panel of educational experts at the University of Dundee 19,27,28 and being used successfully in different setups and geographical locations. 3,13,29,30 . High internal consistency has been reported for the DREEM independently with Cronbach alpha levels of 0.92 and 0.93 31 .The inventory has been used for different purposes including: generating a profile of an institution's or course's strengths and weaknesses; making a comparative analysis within the institution or standardising between themselves and another institution; applying it as a predictor of student performance; and using it to obtain base line data for remedial action and as a diagnostic tool 1,2,20,32 .The data can be collected and analysed according to variables such as year of study, ethnicity, gender, age and course 1,3,7,8,10,20,23,27 .DREEM quantitative scores have further been explored by qualitative focus group discussion for many purposes including collecting baseline information for reinforcing the findings of the study,developing and suggesting remedial interventions or helping in pinpointing the actual problem 8,10,17,29,33,34 .The 50-item self-report inventory using a 5-point Likert scale, with scores reflecting a student's overall perception of the environment as well as their perceptions of five main aspects of theenvironment namely: their learning, the teachers, academic self-perception, atmosphere, and social self-perception. Itcan also indicate areas of strength and weakness by mean scores and also can pinpoint a particular problem by individual item analysis 27,35 .So the researchers decided to use DREEM for identifying the strengths and weaknesses of ISMC's learning environment.TheMedical Collegeis a non-profitable institution established in the year 1995 with the aim to produce highly competent graduates by introducing a sophisticated teaching and learning environment 36 .It has already been completed few cycles and students have already been graduated.It was thus important and timely for the college to know how the students are actually experiencing the learning environment of the College.The outcome of this study would assist the college to modify its learning environment for fostering the desirable approaches to learning that could enhance academic achievement and meaningful learning experiences forstudents.Identifying areas of concern from the medical students' perspective will also provide medical educators of Bangladesh with a road map that would be helpful for those responsible in producing efficient medical practitioners for the country.
The study was designed to explore the medical students' perceptions of: their learning environment; their academic climate; the teacher-student relationships; and the quality of their learning experience in different academic years.The baseline information was then be explored furtherfor identifyingthe areas of concern in learning environment of the college.Methodology A descriptive cross-sectional study was conducted at a Ibn SinaMedical College, Dhaka, Bangladesh in two phases comprising quantitative (Phase I) andqualitative (Phase II) components.With10% dropout rate, the estimated sample size should be 227 participants , , so we included all medical (n-171) and final professional examinee (n -33) students with a total of N -204 3 .In Phase I data was collected by guided self-administered DREEM inventory at face to face session after lecture class in different occasions for different years 27 .Students' profile was included as the first section in the DREEM inventory.As the medical students had good command in English we used English version of DREEM as a diagnostic tool 35 .Bangladesh's participation in DREEM's validation process was another reason to use the original English version.The students were briefed about the purpose and process of data collection and stressed anonymity.It was also made clear to them that the data would only be used for research purpose and the findings would be used collectively.The meaning of some educational terms and phrases such as "factual learning", "ridicule", and "authoritarian", of DREEM were explained before the students completed the questionnaire and the completed questionnaires were collected at the same session.Data was analysed byusingStatistical Package for Social Sciences (SPSS) version 20.Descriptive analysis was performed for demographic variables, the overall DREEM mean score for each item, each Domain and foroverall total mean score per year.The culture free DREEM is an instrument for measuring learning environment 1-8, 11, 15,19,23,24 .It gives a global score of 200for 50 items measuring five aspects of educational environment which includes students' perception of learning (SPoL), teacher (SPoT), Academic self-perception (SASP), atmosphere (SPoA) and social self-perception (SSSP) [27][28][29] .Each item is scored 0-4 on a 5-point Likert scale (4 -strongly agree, 3 -agree, 2-unsure, 1-disagree, and 0-strongly disagree): higher score indicates an agreement with the item whereas there are 9 negative items scored in a reverse manner (Items 4, 8, 9, 17, 25, 35, 39, 48, and 50); high scores on these indicate disagreement with the item.The guidelines for interpreting the overall DREEM score are 0-50 very poor; 51-100 many problems; 101-150 more positive than negative; and 151-200 excellent.To indicate the different areas of the learning environment, the DREEM items are grouped into five Domains with clear guidelines for interpretation of each Domain 27-29, 37.In Phase II of the project, two structured focus group discussions were conducted based on the information gathered in Phase I of the study.This phase aimed to explore in detail the highest>3 and lowest <2 scored items in Phase I of the study.Strengths of this focus group qualitative approach include inexpensive and quick method of information gathering, the ability to explore the participants' thoughts, experiences, and perceptions; values which are difficult to comprehend or express numerically only by quantitative research 12,38 .Two students from each year (year 1-5) except examinee students with a total of 10 students and 10 teachers (clinical and non-clinical) of different disciplines were selected by a convenience sampling for the Phase II part of the study.The discussion was informed by items that scored >3 and <2 in the DREEM questionnaire, items 1, 2 and 19 (positive/ strong areas) and (50, 27, 42, 3, 14, 28 and 46 (areas of concern) 3 .The discussions were conducted in two separateoccasions for two groups and in two different dates.The confidentiality of the discussion was ensured and the students and teachers were briefed about the purpose, methodology and data analysis part of this session.They were allowed to express their views, ideas, thoughts and suggestion about the identified issues.The researcher was the scribe and the course coordinator of MBBS programme was present as the observer for both sessions.He was also branded as external researcher to ensure the trustworthiness of the information gathered during the discussions.Both discussions were audio recorded with informed consent of the participants to enable the researcher to interpret the data during analysis.In analysis the discussion issues (recorded and documented), no noticeable inconsistency was found in the views of the participants in both groups.The analysis process considered word used, tone, content of discussion, frequency, extensiveness, intensity and specificity of the responses.Descriptive analysis of focus group discussion was done based on discussion guidelines and recorded discussion.Issues raised are prioritised based on the total number of comments made by respondents.Throughout the analysis process the external researcher acted as an audit trail to ensure the confirmability and for allowing others to assess the significance of the research reporting 39 .

Results:
A total of 204 students were responded to the questionnaire giving a response rate of 100%.Splitting by year the number of students over the first four years were fairly constant, examinee year students' number slightly lower and the 5th year much less in number.The majority (109, 53%) of respondents were within 20-22 years of age; (41,  20%)   37 the students of this college had positive perception across the board, but there is lot of scope for improvement in all five Domains (Table 3).The five Domains comparative mean scores in different years have shown a similar trend of overall mean score of DREEM (Figure 1, 2, 3, 4and 5) The students started the course with high and positive perceptions about this college's learning environment but gradually it started to decline.In all the domains the perception levelwas lowest in 5 th year but a sharp increase of perception level for examinee students.In Domain 1, 2 3, 4 the perception pattern is similar among the different year students except in Domain 5 there is a sharp fall of perception among 2 nd year student about their learning environment.Three items scored > 3 (item 1, 2 and 19) respectively (3.04, 3.24 and 3.17) in Domains 1, 2 and 5 (Table 4.A) indicated the most positive and strong areas of the learning environment of the college.There was no strong area in SASP and SPoA.Seven items scored< 2 out of which item 50 is a negative item means students agreed with the statement.4/7 items were from the Domain 5 which means the students of thecollege were having major problems in their social life.( The DREEM questionnaire has provided an overview of students' perception throughout the medical school and allowed areas of concern to be highlighted for remedial actions.The students of this college took part spontaneously in both phases of the study as marked by good response rate (100%) in Phase I part which is also reported in literatures 1,2,5 .The participants of both focus group discussions were also spontaneous and enthusiastic to express their thoughts, ideas and suggestions for remedial measures to improvetheir learning environment.In totality as per DREEM scoring scheme, This college was perceived by the students as having more positive than negative ( 120/200) towards their learning environment 27,40 .The score is similar with the reported global score of DREEM in other medical and allied healthschools around the globe ranging from very low 83 to more positive 149 9,11,12,14,[21][22][23][24][25][26][27][28][29][30][31][32][33][34][35] 42 and UniversitiSains Malaysia 120/200 1 , which may reflect that these institutions are fairly innovative in terms of providing a student-centred approach to education.Though in all five Domains the students had a positive perception about their learning environment (Table 3), many individual items scored between 2 -3 indicated that there is plenty of scope for improvement in all five Domains of learning environment of the (Table 4).The study findings are comparable with reported findings 7,26,29,23,34,7,43 .It is not definitivetosay that this overall score is due to participants' first time encounter with such a study which may have presented them with a dilemma, however since scores were not universally high it can be sensibly assumed this was not the case.The year wise mean perception score had shown a gradual declination from 1 st year to 4 th year, with a severe deterioration in 5 th year (67/200), interestingly the perception level sharply improved among the examinee students (Figure 1).The finding again indicated the scores were social desirability biasfree which means that the participants ' wish to please the researcher 44,, 45 .The students' started the programme with high expectations and positive perceptions which gradually eroded as they face the reality of medical education.The challenge and diverse teaching learning methods in clinical years , possiblelack of proper resources like number of patients, lack of proper hospital facility, academic staff and other physical facilities for clinical teachingmight played an important role in worsening thestudents' perception of their learning environment.The5 th year students had a negative impression reflected by overall mean score (67/200) and were extremely stressed may be due the overall pressure of final professional examination along with other difficulties in clinical teaching.The sharp rise of perception score ( 114/200)in examinee students probably be due to release of pressure of regular classes, clinical teaching and other learning experiences in 5 th year which is comparable with many reported literatures 5,46,47 .(Figure 1) The overall perception score of Domain SPoL was 30/48 indicative of positive perception.1of 12 items scored > 3 and the rest of the items scored within 2-3 which indicates that the students were quite satisfied with their learning.This suggests that the teaching is stimulating, well focused and helping the students in developing confidence and competence.
Though it has a discipline-based curriculum, still the students expressed their opinion in favour of student-cantered teaching which is also reflected by item 44: teaching encourages me to be an active learner.Domain 1 was perceived favourably in all aspects which is a great strength of this Medical in terms of students' learning and the findings are also consistent with reported findings 5,23,24 .
In SPoT, one item scored <2 and the 9 items scored within 2-3, indicating that the teaching and the teachers are well perceived by the students.Students perceived their teacher as knowledgeable (Item2: 3.24), had good communication skills (item 18: 2.81) and well prepared for the class (item 40 -2.80).Item 50score d <2 (students irritate the teachers) was explored by focus group discussion (Table 4).The opinion and feelings of the students should be taken into consideration to create apositive environment so that the students participated in teaching and learning activities.These findings are consistent with reported findings 5,7,23,24,34,48 .The students were confident and they perceived positively their academic performance as most of the items scored within 2-3 in SSAP.Many previous studies reported low score in different items of this Domain (24, 34) e.g.item 27: I am able to memorise all I need scored <2 which is also reported in many previous findings 3,23 .The findings of this Domain were interesting and not all items are consistent with reported findings as students did not report factual overload in their teaching and learning which is consistent with their opinion in Domain SPoL and SPoT.In Domain SPoA, no item scored > 3and 10 items scored within 2-3.Item 42 (The enjoyment outweighs the stress of the course) scored < 2. The reported score for the Item was very low for first year students (1.76) and for clinical year (1.62) in a reported study 5 .A study confirmed that psychological distress such as stress, anxiety, and burnout among students was consistently higher than the age-matched general population 49,50 .
The overall score of Domain 5-SSSP was 15/28 which means it has many negative aspects as per detail interpretation of DREEM Domains 37 .In this domain over half the items scored <2 which is a very concerning for the .All low-scored items were explored further to get more information of the problem.The individual item scores revealed,a deficiency or lack of support service for the students who get stressed and struggle with many issues related to personal and social life, teaching and learning.The knowledge regarding sources of support system if any in the school must be available to the students throughout their academic course.Importance of having proper support service for students is also highlighted in many literatures 51,52 .This Domain indicated that although the students' spiritual and social life is good (Item 19 -3.17) they are still stressed and lonely.Accommodation is a big concern for them and there is a lack ordeficit in support service as consistent with literature by Nahar et al, 2010 41 study in Bangladesh.Other study findings are not consistent with our study findings 3,53,54 .
The study can conclude that, the students of the college felt their teachers are knowledgeable, well focused, well prepared for their teaching and stimulate them to participate in teaching sessions.They also felt the teachers are good in communicating with them and their teaching helps them to become competent to be a good professional in the future.Students' perception towards their academic performance was quiet good as well.Also despite of the many problems in different areas of their learning environment they are confident enough to get through their examination and that was the excellent aspect of learning environment of this college.These findings are consistent with many previous findings 3,7,23,34,55 .

Conclusion
The study identified positive learning environment of ISMC which is rewarding for the college in terms of the credibility of the programme.The lack of many excellent aspects may at present be considered as shortcomings, on the other hand it only means that there are lot of rooms for improvement and improvisation in the learning environment.The scores for the individual item from the first and in-depth exploration of second phase of the study gave clear indications of where the priorities for reform should be given.One of the main areas of concern was the support system for students who get stressed.The second main concern was not having a formal teacher training programme for the teachers.Based on thefindings, the recommendations were made for improving the learning environment situation.The findings of the study met the overall objectivesbut cannot be generalised, as it wasasnapshot study and limited to one private Medical College of Bangladesh.
A further study to include triangulation would strengthen this aspect.

Future direction and research ideas
The results obtained in this study could be used to guide strategic planning for remedial programmes.
For generalising the study findings, there should be a wide scale study in Bangladesh involving all private Medical Collegesand go beyond perception level.It could be a wise idea to conduct study by involvingboth private and public sector as echoed in literature aswell 56 .
Ethical issues -The study was approved by the local authority and ethically cleared by the Centre for Medical Education, Dundee University, UK.Acknowledgement -ThePrincipal of ISMC for approving and allowing us to conduct the research.
The students and teachers of the college for their spontaneous participation and support.

Conflict of interests:None
in the 17-19 age group and 54 (27%) in the 23 -25 age group.The male and female were (104, 51%) and (100, 49%) respectively (Table 1) The perceived global mean score of DREEM for ISMC was 120/200(SD 22.984)indicates students'positive perception towardsthe learning environment.The overall perception was fairly constant over the first three years i.e. 133/200, 134/200 and 127/200 in 1 st , 2 nd and 3 rd year respectively.The perception rate starts to decline in clinical years (4 th year 112/200), and in 5 th year it was extremely low (67/200).The perception rate sharply improves when students are about to leave the course (Examinee students) 114/200 (Table 2) As per interpretation guidelines for DREEM Domains

Table 4 .
B)The most positive ( Table4.A) and most problematic items (Table4.B) were further explored in focus group discussion to determine the underlying causes of high and low score.The views of the participants in different aspects in both group discussions were similar and there was no intra group conflict.The participants of both groups agreed and mentioned similar issues that need to be addressed in future for creating a positive learning environment for

Table 1 :
Demographic profile of the students

Table 2 :
Students' perceptions of year wise and global mean score of DREEM

Table 4 .
had no A: Items scored > 3 in different Domains