Tunisian DREEM: Nursing Students’ Perception of the Learning Environment ()
1. Introduction
Recently, the educational environment has gained a lot of interest among health professionals. The learning environment (LE), or climate, as it is also often referred to, englobes everything surrounding students in the learning space. It includes not only the physical location but also the social and psychological contexts [1] [2]. It was also described as the physical, social, and intellectual stimuli and forces that influence students’ learning outcomes [3]. Therefore, the learning environment can be considered as an interactive force between students, and teachers, in their learning and teaching activities, respectively.
In medical schools, many researchers focus on the learning environment to remediate the under-performance of their students. Because of their diversity, especially in personal motivations and emotions, the curriculum must provide a learning environment that supports all students so that they can deliver good quality health care for the best interest and safety of their patients [4] [5]. A high-quality learning environment is recognized as primary for health professions education. It influences knowledge, skills, and attitudes among future health providers [6].
Therefore, examining the climate in academic teaching in health care professional programs is very insightful. Since the program is student-centered, students’ perceptions of the educational settings are the keys to the improvement process of the institution. Students’ success and satisfaction are two indicators of the quality of the educational climate. Their assessment can guide schools and teachers to apply self-analysis and incorporate the best strategies to improve the learning environment [7].
To respond to new national and international requirements, the Tunisian nursing educational program has undergone a major reform, which started in 2006. The purpose is to align it with the Bologna process and to facilitate the recognition of Tunisian nursing diplomas by making the course content more visible. Furthermore, the student-centered teaching and learning approach [8] was the main objective of this reform.
The need for the evaluation of the educational environment is important for accreditation requirements, but above all, it is fundamental for each institution to highlight the strengths and weaknesses of its educational environment to make adequate changes in the curriculum to be more effective in ensuring the success and satisfaction of their students.
Therefore, this study aimed to assess the perceptions of nursing students concerning their educational environment at a Higher Institute of Nursing Sciences in Tunisia 10 years after the change. For this purpose, a variety of instruments have been developed to measure the educational environment at higher educational institutions [9] [10]. We chose the Dundee Ready Education Environment Measure (DREEM) instrument, which has proven high reliability for undergraduate health professionals [9] [11] [12] [13]. To the best of our knowledge, no previous research has used DREEM to assess the perceptions of nursing students regarding an educational environment at a nursing institute in Tunisia.
2. Methods
2.1. Study Design and Participants
The survey of the educational environment was conducted at a Higher Institute of Nursing Sciences in Tunisia. It is a descriptive cross-sectional survey conducted using a self-report scale.
All first-year, second-year, and third-year students without any specific pre-selection criteria were invited to participate in the study through posters at their institute. The questionnaires were distributed to 235 students and collected in a box placed at the institute’s main auditorium.
All students’ were enrolled at the beginning of the second semester, between 04 January and 25 February. The number of participants was calculated by using a “sample size calculator” based on a 95-percent confidence interval.
Before directly administering the questionnaire, the importance and potential impacts of this study were explained to the students. Completion of the inventory was undertaken voluntarily, and none of the information collected was identifiable, thereby maintaining data anonymity.
No ethical issues were encountered during this study.
2.2. Instrument of Measurement
The Dundee Ready Education Environment Measure (DREEM) is a valid tool for referring to deficient areas in the learning process. It was developed by an international Delphi panel of more than 80 international medical and health profession educators and validated in administration to students in health areas in a wide range of countries [14]. In this study, and to collect data, the DREEM was used in the French version with accepted validity and reliability.
The instrument has shown consistently high reliability in a variety of settings. Internal consistency coefficient Alpha of the DREEM instrument computed from present data was 0.81.
The DREEM questionnaire consists of 50 items; each is scored 0 - 4 on a five-point Likert scale (4 = strongly agree, 3 = agree, 2 = unsure, 1 = disagree, and 0 = strongly disagree). However, nine out of the 50 items (numbers 4, 8, 9, 17, 25, 35, 39, 48, and 50) were negative statements and had to be scored in a reverse manner.
For each item, a mean score of ≥3.5 is a true positive point. The item with a mean score of ≤2 should be examined more closely since this indicates a problem area. Items with a mean of 2 - 3 are aspects that could be enhanced.
The statements are also subdivided into five major domains or subscales treating different aspects of the educational environment. These five domains include the perception of learning, SPL (twelve items), perception of the teacher, SPT (eleven items), academic self-perception, SASP (eight items), perception of atmosphere, SPA (12 items), and social self-perception, SSSP (seven items). The base for the overall DREEM score is 200. DREEM overall scores were interpreted using the guide developed by McAleer and Roff, which defines a score of 0 - 50 as “very poor”, 51 - 100 as indicating “plenty of problems”, 101 - 150 as being “more positive than negative”, and 151 - 200 as “excellent” (Table 1).
3. Data Analysis
The DREEM items were coded and analyzed using the Statistical Package for the Social Sciences (SPSS) program, version 20. Descriptive statistics were applied to get the total mean and the means of the five subscales (SPL, SPT, SASP, SPA, and SSSP) (Table 1). The continuous variables were summarized as mean and standard deviation (SD). A single sample t-test and one-way analysis of variance with a post hoc Tukey-Kramer multiple comparisons test were used to identify the significant differences between subgroups. Probability values of less than 0.05 were considered statistically significant for all statistical tests.
4. Results
The questionnaire was completed by 200 students (200/245, a rate response of 81.6%); comprising 84 males (42%) and 116 females (58%). The mean age was 20.4 ± 1.2 years, with a range from 18 to 26. Thirty-five point five percent of students were in the first year, 40.5% were in the second year, and 25% were in the third year of education (Table 2).
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Table 1. 50-item questionnaire of the DREEM scores.
SPL: Students’ perception of learning; SPT: Students’ perception of teachers; SASP: Students’ academic self-perception; SPA: Students’ perception of atmosphere; SSSP: Students’ social self-perception.
The overall DREEM score for this study was 111.9/200. This score indicates that the learning environment in the institute is perceived by students as more positive than negative. The mean score of each domain with their interpretation is summarized in Table 3. Ten percent of the overall score in our population responds with “uncertain” or “don’t know”.
There was no significant difference between the genders in any of the educational environment subscales, nor the place of birth. A significant correlation was observed between age and the DREEM score (p = 0.03, r = −0.146), and the students’ perception of teaching (p = 0.001, r = −0.244).
A statistically significant difference in the students’ perception of the atmosphere regarding the current family living arrangement and funding (p = 0.03) with a higher mean score for those living with and supported by their families (26.4 ± 6.7 vs 24.4 ± 6).
Depending on their year of study, there is a significant difference in students’ appreciation of their learning environment. The overall mean DREEM scores were 121 ± 18.6 for the first year, 107 ± 21.5 for the second year, and 107.3 ± 18.6 for the third year of study. The DREEM score was significantly higher for the students in the first year of study (p < 0.001). Table 4 shows the overall scores of DREEM and the domains, with mean scores according to the year of study. In comparison between the three groups, the mean scores in overall domains show higher scores in the first year of study. The students’ perception of teaching was lower for the student of the second (p = 0.03) and the third years of study (p < 0.001). The students’ perception of the atmosphere was lower for the second year, with p < 0.001.
Table 5 summarizes the mean scores of each item. Regarding the “student’s perception of learning”, the item “The teaching over-emphasizes factual learning” has a lower score of 1.49, and “The teaching is well focused” has a higher score of 2.59. Concerning students’ perception of teaching and suitability of academic preparation for real-life, all items have a mean score of more than 2. The two outstanding items that scored the highest ranking with 2.74 points are “The teachers have good communication skills with patients” and “I feel I am being well prepared for my profession”.
In terms of students’ perception of the atmosphere, the item relating to the timetables has the worst score with 1.65.
For the domain of students’ social self-perception, the two items “There is a good support system for students who get stressed” and “I am rarely bored on this course” received a mean score of less than 2.
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Table 3. The DREEM domains with individual scores and interpretations.
SPL: Students’ perception of learning; SPT: Students’ perception of teachers; SASP: Students’ academic self-perception; SPA: Students’ perception of atmosphere; SSSP: Students’ social self-perception.
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Table 4. DREEM scores and domains, with mean scores by students’ year of study.
SPL: Students’ perception of learning; SPT: Students’ perception of teachers; SASP: Students’ academic self-perception; SPA: Students’ perception of atmosphere; SSSP: Students’ social self-perception.
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Table 5. Overall Score according to “DREEM” items.
SPL: Students’ perception of learning; SPT: Students’ perception of teachers; SASP: Students’ academic self-perception; SPA: Students’ perception of atmosphere; SSSP: Students’ social self-perception.
5. Discussion
The general students’ perception of the learning environment in the institute is positive. On the other hand, the students’ perception of teaching and of the atmosphere was lower.
In 2006, Tunisia, like many European countries, committed itself to reforming the nursing programs and curricula according to the Bologna process. The real conversion began a few years later after efforts to change the environment of institutions, the adoption of common educational programs, and the application of university rules for teaching, evaluation, and internships.
These reforms aim to offer the best health services to patients but also to be accredited by international instances [8]. The students’ perception of their educational environment, which is an important element of success in the learning process, was not evaluated. This study, to the best of our knowledge, is the first to evaluate the nursing learning environment in Tunisia.
Among a variety of instruments, the DREEM is the most commonly used worldwide in the evaluation of undergraduate learning environments. It allows highlighting, by each item, the strengths and weaknesses of the educational climate. It is widely used in health sciences for LE evaluation [6] [15] [16] [17] [18].
In our study, the response rate of our students was more than 80%, which reflects the interest that they have in the subject. The overall DREEM score for this study was 111.9/200. This score indicates that the learning environment at an Institute of Nursing Sciences is perceived by students as “more positive than negative”. Bakhshialiabadet et al. related that in several studies, the overall scores range between “101 and 150”. The best score was observed in nursing schools in the UK (score 142.91) [19], China (score 131.26) [20], and Malaysia (score 134.42) [21]. These scores reflect the institutions’ strategy-based student-centered educational programs while conventional curricula scores were less than 120/120. By comparing these three countries, the difference in terms of material, and probably human resources, explains the degree of satisfaction in each country. Indeed, despite the efforts made over ten years, our institute still lacks sufficient material resources, as well as teachers and supervisors.
The DREEM score also shows a difference between the years of study, with a much better score in the first year. Indeed, in the current study, DREEM scores in all domains in year 1 were higher, with a mean score of 121 ± 18.6, compared to years 2 and 3, with a mean score of 107.1 ± 20.4. This finding is similar to that of many studies [13] [22] [23] conducted in various nursing colleges. This positive perception among the new students may be explained by the motivation they feel when they first enter nursing school. However, in the following years, the students’ perception becomes more critical because they become more self-confident in addition to the lack of support, the stress, and the desire to leave school. These reasons may also explain the negative and weak correlation (p = 0.03, r = −0.146) we found between age and the DREEM scores. The difference between groups may also reflect the differences in their degree of experience in both the institution and the curriculum. There were no significant differences between other socio-demographic variables and learning perceptions.
According to the practical guide of McAleer and Roff [24], the evaluation of each of the five domains of DREEM in our population shows that the perception of learning “is moving in the right direction” and that “there is a more positive perception” for the perception of teaching and the academic atmosphere’s perception.
The evaluation of the students’ responses showed that their “perception of learning” was the highest subscale in the number of items that scored less than 2. These items were: item 13 (mean 1.66 ± 1.17), item 24 (mean 1.59 ± 1.37), item 25 (mean 1.49 ± 1.18), and item 48 (mean 1.95 ± 1.95). The students perceived their learning climate as more centered on teachers with factual learning [7] [25].
The structural changes in learning strategies have often provoked thought and dialogue among students and teachers. In fact, in 2011, the institute adopted the learning by clinical reasoning technique with the continuous support of students during their internships. The success of this technique depends on the adequacy of the teacher-student ratio, which was—and still is—not the case in this under-staffed institute; therefore, the overall satisfaction rate was not high.
These findings focus on the need to develop a focus group to understand and identify possible deficiencies. This is how we can initiate change in the curriculum and enhance the student-centered approach.
On the other hand, “the student social self-perception” revealed a negative perception, expressed by DREEM as “not a nice place”. This domain was scored negatively despite a good social life and the presence of friends. The item “There is a good support system for students who get stressed” recorded the lowest value with a mean score of 1.2 ± 1.2, and no difference was observed between the different years of study. The main causes are overloaded programs and the lack of sports or leisure activities—even though the staff and faculty constantly encourage students to participate in cultural and extra-curricular activities. This reflects the need for an efficient support system for all students. More attention must be given to the students’ social environment [15] [26] [27].
Furthermore, no item received a mean score ≥3. Nine items received a mean score between two and three. Five items [15] [18] [19] [20] and [21] were related to the teaching perception. The students appreciate the good relationship with teachers who explain and give good examples without criticism. These items are aspects of the educational environment that could be enhanced.
6. Conclusions
In conclusion, our study, which is the first in Tunisia, tried to highlight some issues related to the educational environment in a nursing school. The general students’ perception of the learning environment is more positive, but many shortcomings should be addressed. The two urgent axes of improvement should enhance; the learning curricula and the social support in the institution.
However, the study was not free from limitations. The first one is that it involved nursing students from a single institution, with a non-random sample, so we cannot extend its findings to other nursing schools. The second one is that the study data were collected using a self-report questionnaire that offers a subjective assessment of the learning environment with a bias of understanding and interpretation. There is a need to use more than one instrument or a qualitative tool, such as focus groups, to further explore the concept of the educational environment.
Further studies in other nursing schools are required to confirm the relationship between educational strategies and the learning environment.