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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 13-May-2011, Vol 124 No 1334

Students’ and teachers’ perceptions of the clinical learning environment in years 4 and 5 at the University of Auckland
Ralph Pinnock, Boaz Shulruf, Susan J Hawken, Marcus A Henning, Rhys Jones
Abstract
Aim As the undergraduate medical curriculum is developed in response to an increasing number of students across multiple teaching sites, it is timely to review the clinical learning environment of medical students in the first two clinical years.
Method University of Auckland students in year 4 and 5 completed the Dundee Ready Educational Environment Measure (DREEM). Clinical Teachers completed a shorter questionnaire on their perceptions of the clinical learning environment.
Results The students perceive their clinical learning environment positively and their perceptions compare favourably with similar studies internationally. The DREEM is reliable for and practical to use in the New Zealand undergraduate clinical learning environment. Learning site, year of study, clinical team, gender, age, or ethnicity did not influence students’ perceptions of their learning environment. Clinical teachers view their teaching positively but there seem to be concerns over the amount of time they have available for teaching.
Conclusion Students are concerned about the amount of knowledge they need to acquire and the availability of support for students under stress as they enter and during the clinical years. Clinical teachers are concerned about the amount of time they have available for teaching.

The learning environment plays a critical role in how students learn and in the quality of the learning outcomes.1–3 The learning environment for medical students has been extensively investigated with a view to identifying strengths and weaknesses, to monitor change at times of curriculum reform, to compare learning environments across teaching sites and to compare staff and students’ perceptions.4–7
The learning environment of medical students in New Zealand is undergoing change. The way in which services are delivered is changing with an emphasis on shorter duration of admissions, increased patient acuity and greater use of ambulatory services. There is pressure on clinicians to increase patient outputs often at the expense of teaching.
In the next 5 years both the number of students and the sites in which they learn will increase. It is timely to review the clinical learning environment of medical students with the view to planning for the future.
The University of Auckland medical course consists of an initial 3 years in which students learn basic sciences around clinical examples followed by 3 years of clinical teaching. The sixth and final year of the course is a pre-intern year where students are encouraged to take on some of the roles of a first-year intern.8 A recent evaluation of this year suggests that it is more effective than pre-intern placements elsewhere.9 Our study surveyed the learning environment of students in their first 2 clinical years (years 4 and 5).
The Dundee Ready Medical Education Environment Measure (DREEM) has been validated in a number of undergraduate medical learning environments but has not been used in New Zealand or Australia.7,10–16 The DREEM provides a detailed quantitative view of students’ perceptions but to explore these views further we also added an open-ended question at the end of the DREEM and conducted focus groups.5 These results are reported elsewhere.17
Most studies of students’ perceptions of their learning environment have not considered the views of clinical teachers.7 This is surprising, given that change requires the understanding and support of teachers. Consequently, we felt it important to survey our teachers’ views using a brief questionnaire based on some of the themes in the DREEM.
We hypothesised that our students would consider the learning environment without consideration of the constraints and problems facing clinical teachers. In contrast, we expected the clinical teachers to be more aware of their limitations and be more focussed on time and resource needs.
Our aims were to:
  • Gather and compare feedback on the clinical learning environment from students in their early clinical training (years 4 and 5).
  • Assess whether age, gender, ethnicity, year of study, learning site, or clinical team influenced the students’ perceptions of their learning environment.
  • Compare some of the teachers’ perceptions of the learning environment with those of the students.

Methods

Study design

Students—After gaining informed consent all medical students in years 4 and 5 were invited to complete the DREEM at the end of the first 3 months of their clinical attachments in 2009. The questionnaire was anonymous and students had the option of not completing all or some of the questionnaire. Student ethnicity was identified by self report using the New Zealand Census Classification.18 The questionnaire took 7–8 minutes to complete.
The DREEM consists of 50 items each scoring 0–4 on a 5-point scale. Negative statements are recorded in reverse and high scores on these items indicate disagreement i.e. a positive result. The questionnaire generates an overall score and subscale scores. Acceptable ranges of scores have been suggested. Any individual item with a mean score less than 2.0 is viewed with concern.10 In the questionnaire the items are listed randomly so that the subscales are not apparent.
Clinical teachers—The clinical teachers completed a six item abbreviated questionnaire based on some of the DREEM factors. Although the DREEM has also been used to assess teachers’ perceptions of the learning environment we considered that asking teachers to complete a 50 item questionnaire would result in a very low response rate.

Ethics

The study was approved by The University of Auckland Human Participant Ethics Committee.

Statistical analysis

Descriptive statistics were used to describe the students’ demographics, for comparison between the scores in this study and others in the literature and for comparison of the clinical teachers’ responses with the student DREEM measures.
A set of analyses were conducted including:
  • Comparisons of the students’ perceptions across years 4 and 5 to check for difference and homogeneity.
  • Evaluation of the students’ perceptions in relation to year of study, clinical team, site, age, gender and ethnicity.
  • Comparison of the teachers’ response between those who had taught for more and those who had taught for less than 10 years.
The student t-test was used to compare the means and standard deviations of the DREEM individual and subscale scores. The supervisors' responses were analysed using the same method.

Results

Participants

276 of 344 (80.2%) of medical students responded. The response rate was slightly higher from year 4 students (83.7%) than from the year 5 (76.2%). The other demographic details are shown in Table 1.
Table 1. Participant details
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In addition, 136 of the 197 (69%) clinical teachers completed a short questionnaire.

DREEM perceptions of the two students groups (years 4 and 5)

The results of the student perceptions to the questions in the DREEM questionnaire are shown in Table 2 (at http://www.nzma.org.nz/journal/124-1334/4658/Table.pdf). The results suggest that 10–items (4, 5, 14, 24, 27, 31, 38, 44, 48, and 50) are different (p<0.05). However it is acknowledge that type I or II error (false positive or negative) may be in effect for many of these differences. Nonetheless, the differences between the two groups on items 24, 27, and 44 are very large (p<0.0001) which minimises this error. In all these three items year 5 students rated their responses higher indicating that year 5 students had more workable learning strategies, were more prepared, and felt more supported than their year 4 counterparts.

Internal consistency check of the DREEM

The overall internal consistency Cronbach alpha was 0.93.

Evaluation of DREEM perceptions in relation to clinical team, site, age, gender or ethnicity

In terms of factors influencing perceptions there was no significant differences when individual items or subgroup scores were compared by clinical team, site, age, gender or ethnicity (data not shown).

Comparison of mean scores of the DREEM subscales with the literature

The findings below indicate that the students in this study are similar to other students being surveyed on four of the five factors. However, students in this group rated the items higher than the other students groups in relation to the factor ‘Perception of learning’. See Table 3.
Table 3. Comparison of mean scores of the DREEM subscales with the literature
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Table 4. Clinical teachers' responses
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Comparison between the clinical teachers abbreviated DREEM and the student DREEM measures

The clinical teacher’s responses are detailed in Table 4. The clinical teachers items yielded a Cronbach alpha of 0.80 indicating good reliability. However, there were no differences in responses between teachers of year 4 and year 5 year students and between teachers who had taught for less or more than 10 years (p>0.01 data not shown).

Discussion

The high response rate suggests that our results reflect the views of students in their first two clinical years of training. The response rate and time taken to complete the questionnaire show that the DREEM is practical to use in New Zealand. The lower response rate from the clinical teachers can be explained by pressure of access and time required to complete this questionnaire.
The assessment of the DREEM’s internal consistency exceeds the range reported in the literature (Cronbach alpha 0.84–0.90) and suggests that the DREEM is reliable for use in New Zealand.5,15
The students have identified a number of items with means of more than 2.8 and these can regarded as strengths. Students perceive that they are encouraged to be active learners and that their teaching is both stimulating and practical (items 1, 2, 4, 10, 31 and 43). Their teachers are regarded as knowledgeable and as good role models (items 13, 14 and 17). They feel relaxed in their clinical learning environment and able to ask questions (items 32, 35, 37, 38 and 43).
Three items (items 18, 28 and 44) have consistently been identified in other studies as areas of concern (mean scores of less than 2.0).5,14–16 Two of these items were also identified as such in our study.
Though the students’ perceptions that they are unable to memorise all that is needed (item 28) could be due to the fact that no guidance is given in prioritising learning, it has also been suggested as reflecting an excessive volume of material to be learned. It has been shown that such perceptions are correlated with a risk of surface learning and in the long term less retention of knowledge.5
Students in year 4 perceived that there was inadequate support for stressed students (item 44). For students in year 5 this was a less of a concern perhaps indicating that by the time students reach year 5 they have identified how to access support when they need it. Year 4 students need to be informed when they start their course how to access support should they become stressed. Posters could be placed in student areas to remind them of the availability of support services during the year.
Our students did not perceive lack of teacher feedback (item 18 mean 2.18) as a significant concern. However the mean for this item is relatively low and because feedback is such a powerful educational intervention this needs further consideration.21 In contrast the teachers indicate that they perceive that feedback is given regularly (mean 2.7). For any change to be effective this difference in views needs to be acknowledged.
For three items there were differences in mean scores between years 4 and years 5 (items 24, 27 and 44). Two of these relate to transition between years (item 24 and 27). This suggests that students in their year 4 require more assistance in transitioning between the preclinical and the clinical years of study. To address this, focus groups should be conducted to explore what support students would find beneficial as they transition from the preclinical to the clinical years.
The fact that the students’ perceptions were not influenced by the clinical team or the site in which they were learning has been suggested as indicating that the curriculum is delivered consistently across different learning sites.6 However lack of consistency in teaching and assessment across our teaching sites was identified as a significant concern in answers to the open-ended questions which we have reported elsewhere. 17 This suggests that when using the DREEM it is important to include open-ended questions to offer students the opportunity to comment on aspects of the learning environment not specifically covered in the DREEM.
The desire for fewer lectures, more bedside teaching and more clinical exposure in the early years of training were also identified in the answers to the open-ended questions.17 These concerns would also not have been apparent if we had not added open-ended questions to the DREEM.
Gender differences have been reported in other studies with female students perceiving the learning environment as less supportive than their male counterparts.4,10,13 This is not the case with our students.
Our mean subscale scores compare favourably with results published from other institutions.7,11–16
The teachers’ confidence in their ability to teach is supported by the views of their students. The mean score of the subscale, students’ perceptions of their teachers was the second highest of all subscales. The teachers perceptions of the time they have available for teaching scored the lowest mean and this should be explored further.
There are two limitations to this study. Firstly, the teachers’ low response rate does not permit generalisation of our findings to all teachers at our school. Secondly the DREEM does not give any information on the reasons for the perceptions of students and teachers perceptions and these are important to make effective changes.
This study has provided some guidance on what needs to be addressed as our curriculum is developed to meet the needs of an increasing number of students. Further assessments of the learning environment will be needed once changes have been introduced to see whether they have been effective.

Conclusion

The DREEM is a reliable and practical tool for assessing the undergraduate clinical learning environment in New Zealand.
The learning environment of year 4 and 5 medical students at the University of Auckland is perceived positively by students irrespective of year of study, learning site, clinical team, ethnicity, age or gender.
Our students’ perspectives compares favourably with studies internationally.
Students are concerned about the amount of knowledge they need to acquire and the availability of support for students under stress as they enter, and during, the clinical years. Clinical teachers are concerned about the amount of time they have available for teaching. Further research needs to address these areas of concern.
Competing interests: None.
Author information: Ralph Pinnock, Paediatrician and Senior Lecturer, Department of Paediatrics: Child and Youth Health, Starship Children’s Hospital, Auckland; Boaz Shulruf, Senior Lecturer, Centre for Medical and Health Sciences Education, Faculty of Medical and Health Sciences, University of Auckland; Susan J Hawken, Senior Lecturer, Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland; Marcus A Henning, Senior Lecturer, Centre for Medical and Health Sciences Education, Faculty of Medical and Health Sciences, University of Auckland; Rhys Jones, Senior Lecturer, Te Kupenga Hauora Māori Faculty of Medical and Health Sciences, University of Auckland
Acknowledgements: We thank the students and teachers who contributed to this study.
Correspondence: Dr Ralph Pinnock, Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Park Road, Auckland 1023, New Zealand. Fax: +64 (0)9 3078977; email: ralphp@adhb.govt.nz
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