AJHPE 397.indd Research October 2014, Vol.6, No. 2 AJHPE 143 Students’ perceptions of their education environment (EE) have an undeniable impact on their study behaviour and academic progress.[1] If the EE of a medical school is positively perceived, it not only promotes intellectual activities, but also cultivates friendliness, co-operation, academic advancement and a sense of well-being.[2] Therefore, the acknowledgement of the EE as a significant confounding factor for effective student learning and success[2] is fast becoming established.[3] In a medical school, the EE can be conceptualised as a social system comprising the learner, individuals who interact with the learner, intention of the interaction, setting in which the learner interacts with other individuals, and formal and informal rules that govern the interaction.[4] Clapham et al.[5] described the EE as consisting of the following three major components: (i) the physical environment; (ii) the emotional climate; and (iii) the intellectual climate. Factors such as the increasingly diverse student population in medical programmes and curricula innovation have triggered a heightened interest in evaluating the EE of medical schools.[6] In 2010, the Health Professions Council of South Africa (HPCSA) visited the University of the Free State (UFS), Bloemfontein, South Africa (SA), to re-accredit their medical programme. In contrast to the other seven medical schools in SA, which offer a six-year programme, the MB ChB degree at UFS comprises a five-year academic programme in three phases:[7] Phase I: Six months of six introductory modules. Phase II: Two preclinical years of basic medical science modules to establish the foundation for the clinical years. Phase III: Two-and-a-half clinical years during which the students apply their knowledge gained in Phases I and II to learn clinical medicine in the different clinical departments. In their report, the HPCSA accreditation panel raised concerns relating to the teaching platform at one of the training hospitals.[8] These concerns provoked further questions relating to the interaction of issues raised by the HPCSA and the perceived EE where students rotate during their clinical years (Phase III). Despite anecdotal feedback through informal conversations and quarterly discussions between the students’ class representatives and the MB ChB programme director, the EE, as perceived by Phase III medical students, has never been formally assessed on a departmental level. Therefore, our objective was to assess the perceived EE in the clinical departments among the fourth- and fifth-year UFS medical students. Differences in perceived EE scores between different demographic groups were also assessed. Methods The study was approved by the Ethics Committee of the Faculty of Health Sciences of the UFS (ECUFS 21/2012). Participants The target population was all fourth- and fifth-year UFS medical students in 2012 (n=124 and n=105, respectively). Those repeating their final year were excluded, as they did not rotate through all the departments involved Background. The education environment (EE) of a medical school plays a critical role in the learning of its students. The learner, other learners, teachers and the physical environment (campus and hospitals) influence the EE. In addition to recommendations of the Health Professions Council of South Africa (HPCSA) to revise the clinical training platform, staff and senior medical students occasionally experienced the EE in the clinical departments to be challenging. Objective. To assess the perceived EE in clinical departments at the University of the Free State, Bloemfontein, South Africa, among the 2012 fourth- and fifth-year medical students. Differences in perceived EE scores between different demographic groups were also assessed. Method. Only the departments where students rotated in both their fourth and fifth years (Obstetrics and Gynaecology, General Surgery, Paediatrics and Neonatology, Internal Medicine, and Psychiatry) were assessed. The Dundee Ready Education Environment Measure (DREEM) questionnaire was contextualised for each department and distributed among fourth- and fifth-year medical students. Questionnaires were self-administered and participation was voluntary. Differences among demographic groups and departments were assessed using the Mann-Whitney U-test and Kruskal- Wallis test (p<0.05). Results. The overall response rate was 87.7%. The overall median DREEM combined score for the departments was 137/200. Paediatrics and Neonatology was consistently top-rated, whereas Obstetrics and Gynaecology consistently received the lowest rating in all domains and subscale analyses. There were few significant differences between the DREEM scores of demographic groups. Conclusion. The overall EE in the clinical departments was mostly positive, although concerns were raised regarding some departments. AJHPE 2014;6(2):143-149. DOI:10.7196/AJHPE.397 Assessment of the education environment of senior medical students at the University of the Free State, Bloemfontein, South Africa S Schoeman,1 MB ChB, MMed (UK); R Raphuthing,2 Medical student; S Phate,2 Medical student; L Khasoane,2 Medical student; C Ntsere,2 Medical student 1 Department of Internal Medicine, Medical Education Division, School of Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa 2 School of Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa Corresponding author: S Schoeman (schoemanfhs@ufs.ac.za) Research 144 October 2014, Vol.6, No. 2 AJHPE in the study. There were 111 male and 118 female students, of whom 105 and 124 received instruction and teaching in English and Afrikaans, respectively. Because of the UFS racial incident in 2008,[9] the students were asked to report their race to establish whether perceptions of racial discrimination existed in the EE of each department, yielding responses from 143 white and 86 black students. Data collection The Dundee Ready Education Environment Measure (DREEM) was used because of its suitability in health sciences education[11] and reliability for measuring the EE in undergraduate medical education settings.[6] The DREEM questionnaire is self-administered, and consists of 50 items scored on a Likert scale to derive a total score out of 200.[11] Five subscales assess the perceived EE relating to the students’ perceptions of teaching and learning (SPTL), the students’ perceptions of the teachers (SPT), the students’ academic self-perceptions (SASP), the students’ perceptions of the atmosphere (SPA), and the students’ social self-perceptions (SSSP).[11] Each of the 50 items was contextualised by inserting the names of the relevant department in each statement, e.g. ‘I find the experience at General Surgery disappointing’. Five separate DREEM questionnaires were administered for the departments of Internal Medicine, Obstetrics and Gynaecology, Paediatrics and Neonatology, Surgery and Psychiatry (Appendix 1). These departments were chosen because they hosted both the fourth- and fifth-year cohorts and the rotations through these departments add up to 81% and 75% of the total clinical rotation time of the fourth and fifth years, respectively.[7] Departments not hosting both the fourth- and fifth-year students were excluded to minimise recall bias and ensure that the reports on the perceived EE were current at the time of data collection. A pilot study was conducted using a group of three Afrikaans- and three English-speaking junior doctors who graduated from the UFS in the preceding academic year. To improve clarity and avoid ambiguity, minor contextual suggestions were incorporated into the questionnaire. To minimise the possible effect of translation errors, the DREEM questionnaire was administered in English only. The pilot study confirmed that the English language used in the DREEM questionnaire is basic enough for Afrikaans students to comprehend. Data were collected during meetings with the students, where the questionnaires were distributed and returned on completion. By completing the questionnaire, consent was given to participate in this study. Of a potential 1 145 questionnaires over the five departments, 1 037 were returned, of which 1 004 were complete and therefore valid for inclusion in the data analysis. The response rate ranged from 86% to 89% (mean 87.7%) across the five departments. Data analysis Completed questionnaires were analysed with Microsoft Excel and SPSS version 20. The Shapiro-Wilk test was used to test for normality and results were summarised using medians and percentiles. DREEM was calculated as a combined overall score across the five departments, and as individual scores for each department and each subset in each department. The Mann-Whitney U-test and Kruskal-Wallis test (p<0.05) were used to explore differences among demographic groups and departments. Table 1. Reliability statistics on the DREEM questionnaire data Completed DREEM questionnaires (per department – all students) n Cronbach’s α Standard error of measurement (/200) Internal Medicine 204 0.95 5.8 Obstetrics and Gynaecology 196 0.94 6.6 Paediatrics 202 0.93 5.0 Psychiatry 199 0.94 5.8 General Surgery 203 0.94 5.8 Total 1 004 0.96 6.2 DREEM = Dundee Ready Education Environment Measure. D R EE M s co re 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 Internal Medicine Obstetrics and Gynaecology Paediatrics Surgery Psychiatry Department Fig. 1. Overall DREEM scores for the departments. The dots represent outliers falling outside 1.5 times the interquartile ranges of the DREEM distributions (DREEM = Dundee Ready Education Environment Measure). Research October 2014, Vol.6, No. 2 AJHPE 145 Results The reliability analyses of the contextualised DREEM questionnaires are reported in Table 1. The overall median DREEM score across all departments, with the demographic variables included, was 137 (Fig. 1). This equates to a ‘more positive than negative’ interpretation according to the published interpretation guidelines for the DREEM questionnaire.[11] The students generally scored the perceived EE in Paediatrics and Neonatology the highest, with an overall median DREEM score of 153, while the department of Obstetrics and Gynaecology scored the lowest overall median DREEM score (106) (Fig. 1). Internal Medicine had a median DREEM score of 139, Surgery 131 and Psychiatry 145 (Fig. 1). When compared, all the departmental distributions were statistically different (p<0.01). The perceived EE was similar for males and females across all departments. Students’ perceptions of teaching and learning (SPTL). The median scores for this subscale ranged from 62% to 75%, equating to the top half of ‘A more positive approach’ (50 - 75%) result bracket.[11] Statistically significant differences in the SPTL distributions were noted when comparing individual departments (p<0.01), except between Psychiatry and Internal Medicine (p=0.054) and General Surgery and Psychiatry (p=0.169) (Table 2). Students’ perceptions of teachers (SPT). Four departments scored between 66% and 82%. This equates to a very positive result, ranging from ‘Moving in the right direction’ (51 - 75%) to ‘Model teachers’ (76 - 100%).[11] The only outlier of concern was noted in the Department of Obstetrics and Gynaecology, which scored significantly lower than the other four departments, with a median score of 51% and hinging on ‘In need of some retraining (26 - 50%)’.[11] Apart from this finding, statistically significant differences in the SPT distributions were noted in all departments (p<0.01), except between Internal Medicine and Psychiatry (p=0.302) (Table 2). Students’ academic self-perceptions (SASP). Scores ranged from 63% to 75%, equating to the top half of ‘Feeling more on the positive’ (51 - 75%) result bracket.[11] The departments of Paediatrics and Neonatology and Psychiatry scored equally. Besides this subscale being scored very positively overall, there were statistically significant differences in the SASP distributions among all departments (p<0.05), except between Paediatrics and Neonatology and Psychiatry (p=0.119) (Table 2). Students’ perceptions of atmosphere (SPA). All the departments scored in a range of 67 - 77%, except Obstetrics and Gynaecology, which received a disquieting score of 48%. This equates to four departments falling between the top half of ‘A more positive atmosphere’ (51 - 75%) to ‘A good feeling overall’ (76 - 100%) result brackets.[11] However, Obstetrics and Gynaecology was an outlier, falling in the disquieting ‘There are many issues that need changing’ result bracket.[11] Furthermore, there were statistically significant differences in the SPA distributions among all departments (p<0.001), except between Psychiatry and Paediatrics and Neonatology (p=0.207) and General Surgery and Internal Medicine (p=0.463) (Table 2). Students’ social self-perception (SSSP). In this subscale, the scores for four departments ranged from 58% to 71%, except for Obstetrics and Gynaecology, which was an outlier (42%). This equates to four departments falling in the ‘Not too bad’ (51 - 75%) result bracket.[11] However, Obstetrics and Gynaecology fell into the disquieting ‘Not a nice place’ result bracket.[11] Similar to the SPA subscale, there were statistically significant differences in the SSSP distributions among all departments (p<0.001), Table 2. Median percentage subscale results per domain and department Department SPTL, % SPT, % SASP, % SPA, % SSSP, % Internal Medicine 71* 73* 72 67* 63* Obstetrics and Gynaecology 62 51† 63 48† 42† Paediatrics and Neonatology 75 82‡ 75* 77*‡ 71*‡ General Surgery 67* 66 69 69* 58* Psychiatry 69* 73* 75* 75* 71* SPTL = students’ perceptions of teaching and learning; SPT = students’ perceptions of teachers; SASP = students’ academic self- perceptions; SPA = students’ perceptions of atmosphere; SSSP = students’ social self-perception. *No statistical difference found in the subscale distribution analyses between individual departments. †Disquieting results. ‡Excellent results. Year 4th 5th p=0.003 D R EE M s co re 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 Internal Medicine Obstetrics and Gynaecology Paediatrics Surgery Psychiatry Department Fig. 2. DREEM scores of diff erent year groups for the departments. Th e dots represent outliers falling outside 1.5 times the interquartile ranges of the DREEM distributions (DREEM = Dundee Ready Education Environment Measure). ResearchResearch 146 October 2014, Vol.6, No. 2 AJHPE except between Psychiatry and Paediatrics and Neonatology (p=0.112) and General Surgery and Internal Medicine (p=0.51) (Table 2). Both the fourth and fifth years scored an overall median DREEM of 137 across all departments. Paediatrics and Neonatology attained the highest median DREEM scores for both the fourth (150) and fifth (159) years (Fig. 2). Obstetrics and Gynaecology achieved the lowest median scores for both the fourth (108) and fifth (105) years. The fifth-year students scored the perceived EE in the Department of Paediatrics and Neonatology significantly higher (p=0.003) than the fourth-year students (Fig. 2). In all the other departments the DREEM distributions of the fourth- and fifth-year students were the same. The students who received instruction and teaching in English scored the perceived EE in Internal Medicine significantly higher (p=0.004; median = 145) than those who received instruction and teaching in Afrikaans (median = 135) (Fig. 3). In the Department of General Surgery, the Afrikaans cohort scored the perceived EE higher (p<0.001; median = 137) compared with the English cohort (median = 124), while the perceived EEs were similar for both the English and Afrikaans cohorts in the other departments (Fig. 3). The younger students (20 - 24 age group) rated General Surgery significantly higher (p=0.042; median = 131) than the older students (>25 years group) (median = 127) (Fig. 4). However, there was no statistically significant difference noted in the EE rating in any of the four other departments (Fig. 4). At Internal Medicine, the black students rated the EE higher (p<0.001; median = 149) than the white students (median = 132) (Fig. 5). Similarly, at Obstetrics and Gynaecology, the black students rated the EE higher (p<0.001; median = 114) than the white students (median = 101). However, at General Surgery the opposite occurred, as the white students rated the EE higher (p<0.001; median = 135) than the black students (median = 120) (Fig. 5). There was no statistically significant difference noted in the other two departments. Discussion The overall DREEM score for the five clinical departments was 137. This value falls in the same range (101 - 150) as that in some other studies, such as Brown et al.[12] (137.3), Riquelme et al.[13] (127.5) and Demirören et al.[14] (117.63). This range means a ‘more positive than negative’ result.[11] It is, however, important to note that the DREEM interpretation brackets are rather wide (50 points) and a score of 101 or 149 has a similar interpretation, which is not ideal. Therefore, in our study the overall median DREEM score of 137 is actually firmly in the top half of its DREEM interpretation bracket and could possibly quite safely be interpreted as a ‘much more positive than negative’ EE. Interestingly, in general, both the fourth- and fifth-year medical students perceived the EE similarly, with a median DREEM of 137 for each year group. From the reliability analyses (Table 1) it was clear that the contextualised DREEM questionnaires were extremely reliable (Cronbach’s α >0.9 for all departments, together with a low standard error of mean (<7 DREEM marks)).[15] These findings also support the validity of the instrument used and compares favourably with the findings of other studies on Cronbach’s α of DREEM (0.93).[16] At departmental level, it was noted that the median DREEM scores for the departments ranged between 106 and 153. Therefore, in each department the students perceived the EE as ‘more positive than negative’.[11] Paediatrics and Neonatology achieved the highest DREEM score (153), which was in the ‘excellent’ range.[11] Obstetrics and Gynaecology, on the other hand, had the lowest DREEM score (106), yet it was within the ‘more positive than negative range’.[11] Comparing this score with a DREEM score of 139 obtained in a study by Varma et al.,[17] which only looked at the EE of Obstetrics and Gynaecology at different training platforms, it can be seen that in both studies the EE was perceived as ‘more positive than negative’,[11] but it is disquieting that the UFS Department of Obstetrics and Gynaecology’s score was 33 points lower than that of the same department in the Varma et al. [17] study and 25 points lower than the fourth-ranked department in our study. The reasons for the difference are being further explored by UFS. Internal Medicine Obstetrics and Gynaecology Paediatrics Surgery Psychiatry Department D R EE M s co re 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 Afrikaans English p=0.004 p<0.001 Fig. 3. DREEM scores of groups with diff erent language of instruction for the departments. Th e dots represent outliers falling outside 1.5 times the interquartile ranges of the DREEM distributions (DREEM = Dundee Ready Education Environment Measure). Research October 2014, Vol.6, No. 2 AJHPE 147 Across most departments, the subscale analysis revealed positive to very positive results. Paediatrics and Neonatology was notably the top-performing department and achieved excellent scores in 4/5 subscales.[11] However, in contrast, Obstetrics and Gynaecology received some disquieting ratings in 3/5 subscales,[11] which included SPT, SPA and SSSP. Based on standard subscale interpretation,[11] students’ perceptions of Internal Medicine, Psychiatry and General Surgery were that teaching was helpful, relevant and useful and the teachers were moving in the right direction. The students were positive regarding their academic success and experienced the overall educational atmosphere as ‘more positive’. The SSSP, while rotating at these three departments, was positively rated. Based on the standard interpretation of subscales,[11] students at Obstetrics and Gynaecology indicated that teaching was helpful, relevant and useful and the teachers were bordering on the need for some retraining (in terms of influencing the EE). The students felt more positive regarding their academic success but thought that there was much that needed changing with regard to the education atmosphere. The SSSP was that it was ‘not a nice place’. It is therefore apparent that certain aspects of the EE at Obstetrics and Gynaecology are problematic and not conducive to the EE of the students. Based on the standard interpretation of sub- scales,[11] students at Paediatrics and Neonatology indicated that teaching was helpful, relevant and useful and the teachers were excellent. The students felt confident regarding their academic success and the overall educational atmosphere was very positive. The SSSP was not too bad (positive). Across all departments, fourth- and fifth-year students ranked the EE as ‘more positive than negative’,[11] with overall median DREEM scores of 137 for each year group. This was similar to that found in a UFS study (L M Moja, H Louw, G Joubert – unpublished data, 2007). These authors used the DREEM questionnaire to measure the EE of the entire Faculty of Health Sciences at UFS. From that study it was reported that the fourth- and fifth-year medical students had overall median DREEM scores of 125 and 125, respectively. This fell in the same DREEM result bracket as the current study, with the EE of the clinical years of the School of Medicine being ‘more positive than negative’.[11] Our study did however show an improvement of 12 points in the perceived EE in both year groups. Overall, the language of instruction made little impact on the EE perceptions of the students. The only statistically significant effect was at General Surgery, where the students in the Afrikaans classes ranked the EE higher than those in the English classes, and at Internal Medicine, where the students in the English classes ranked the EE higher than those in the Afrikaans classes. Interestingly, gender differences had no influence on how students perceived the EE in any of the clinical departments, which is a very positive finding. Generally, the age of the students made very little impact on their perceptions of the EE. The only statistically significant effect was noted at General Surgery, where the younger age group ranked the EE higher than the older age group. The race of the students made a statistically significant impact on their EE perceptions in a majority (3/5) of the departments. These were Internal Medicine and Obstetrics and Gynaecology, where black students rated the EE higher than white students, compared with General Surgery, where white students rated the EE higher than black students. In conclusion, the majority of clinical departments included in this study should be encouraged to continue with their good work to foster the positive EE for senior medical students. Furthermore, feedback regarding the outcome of this study was given to the medical school and the relevant departments and positive steps have been initiated to conduct further research (individual DREEM item analysis and some focus group discussions) into the areas where improvement in the EE is needed. Limitations of this study included the following: • Only five clinical departments were included. It would have been useful to have included all the departments in phase III of the curriculum. • Only fourth- and fifth-year students partici pated in the study. It would have been useful to have D R EE M s co re 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 Internal Medicine Obstetrics and Gynaecology Paediatrics Surgery Psychiatry Years 20 - 24 ≥ 25 Department p=0.042 Fig. 4. DREEM scores of diff erent age groups for the departments. Th e dots represent outliers falling outside 1.5 times the interquartile ranges of the DREEM distributions (DREEM = Dundee Ready Education Environment Measure). ResearchResearch 148 October 2014, Vol.6, No. 2 AJHPE included students in Semester 6 (third year), as they are part of phase III of the curriculum. However, due to limited time and resources, the scope of the study had to be restricted. References 1. Soemantri D, Herrera C, Riquelme A. Measuring the EE in health professions studies: A systematic review. Med Teach 2010;32:947-952. [http://dx.doi.org/10.3109/01421591003686229] 2. Abraham R, Ramnarayan K, Vinod P, Torke S. Students’ perceptions of learning environment in an Indian medical school. BMC Med Educ 2008;8(20):1-5. [http://dx.doi.org/10.1186/1472-6920-8-20] 3. Dunne F, McAleer S, Roff S. Assessment of the undergraduate medical education environment in a large UK medical school. Educ Health 2006;65(2):149-158. 4. American Medical Association. Initiative to Transform Medical Education: Strategies for Transforming the Medical Education Learning Environment. Chicago, IL: American Medical Association, 2008. 5. Clapham M, Wall D, Batchelor A. EE in intensive care medicine use of Postgraduate Hospital EE Measure (PHEEM). Med Teach 2007;29:184-191. 6. Miles S, Swift L, Leinster SJ. Th e Dundee Ready Education Environment Measure (DREEM): A review of its adoption and use. Med Teach 2012;34:620-634.[http://dx.doi.org/10.3109/0142159X.2012.668625] 7. University of the Free State (UFS). Yearbook of the School of Medicine. Bloemfontein: UFS, 2012. 8. Health Professions Council of South Africa (HPCSA). Accreditation of Undergraduate Medical Education and Training at the UFS. Pretoria: HPCSA, 2010. 9. Matlala C. Th e Free State Four – race and racism in the press. Media monitoring Africa Resources – Media Analysis, 19 May 2008. http:// www.mediamonitoringafrica.org/index.php/resources/entry/the_ freestate_four_race_and_racism_in_the_press/ (accessed 28 February 2012). 10. Roff S, McAleer S, Harden R, et al. Development and validation of the Dundee Ready Education Environment Measure (DREEM). Med Teach 1997;19(4):295-299. 11. McAleer S, Roff S. A practical Guide to using the Dundee Ready Education Environment Measure (DREEM). AMEE Guide 2001;23:29-33. 12. Brown T, Williams B, Lynch M. Th e Australian DREEM: Evaluating student perceptions of academic learning environments within eight health science courses. Int J Med Educ 2011;2:94-101. 13. Riquelme A, Oporto M, Oporto J, et al. Measuring students’ perceptions of the educational climate of the new curriculum at the Pontifi cia Universidad Católica de Chile: Performance of the Spanish translation of the Dundee Ready Education Environment Measure (DREEM). Educ Health 2009;22(1):1-11. 14. Demirören M, Palaoglu Ö, Kemahli S, Özyurda F, Ayhan IH. Perceptions of students in different phases of medical education of EE: Ankara University Faculty of Medicine. Med Educ 2008;13(8):1-7. 15. Tavakol M, Dennick R. Making sense of Cronbach’s alpha. Int J Med Educ 201; 2:53-55. [http://dx.doi.org/10.5116/ijme.4dfb .8dfd] 16. De Oliveira Filho GR, Vieira JE, Schonhorst L. Psychometric properties of the Dundee Ready EE Measure (DREEM) applied to medical residents. Med Teach 2005;27(4):343-347. 17. Varma R, Tyagi E, Gupta JK. Determining the quality of educational climate across multiple undergraduate teaching sites using the DREEM inventory. BMC Med Educ 2005;5(8):1-4. [http://dx.doi. org/10.5455/2320-6012.ijrms20131113] p<0.001 D R EE M s co re 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 Internal Medicine Obstetrics and Gynaecology Paediatrics Surgery Psychiatry Department Race Black White p<0.001p<0.001 Fig. 5. DREEM scores of diff erent races for the departments. Th e dots represent outliers falling outside 1.5 times the interquartile ranges of the DREEM distributions (DREEM = Dundee Ready Education Environment Measure). Appendix 1. Contextualised Dundee Ready Education Environment Measure (DREEM) questionnaire, School of Medicine, University of the Free State, Bloemfontein, South Africa: The education environment perceptions of senior medical students at the Department of Internal Medicine (example) Statements Strongly agree (4) Agree (3) Unsure (2) Disagree (1) Strongly disagree (0) 1. I am encouraged to participate in Internal Medicine lectures 2. The lecturers in Internal Medicine are knowledgeable 3. There is a good support system in Internal Medicine for students who become stressed 4. I am too tired to enjoy Internal Medicine 5. Learning strategies which worked for me before continue to work for me now at Internal Medicine 6. The teachers at Internal Medicine are patient with patients 7. The teaching at Internal Medicine is often stimulating 8. The teachers at Internal Medicine ridicule (humiliate) the students (Afrikaans = verkleineer) continued... Research October 2014, Vol.6, No. 2 AJHPE 149 Appendix 1 (continued). Contextualised Dundee Ready Education Environment Measure (DREEM) questionnaire, School of Medicine, University of the Free State, Bloemfontein, South Africa: The education environment perceptions of senior medical students at the Department of Internal Medicine (example) Statements Strongly agree (4) Agree (3) Unsure (2) Disagree (1) Strongly disagree (0) 9. The teachers at Internal Medicine are authoritarian (bossy) 10. I am confident about passing Internal Medicine 11. The atmosphere at Internal Medicine is relaxed during ward teaching 12. Internal Medicine is well time-tabled 13. The teaching at Internal Medicine is student-centred 14. I am rarely bored at Internal Medicine 15. I have good friends who rotate with me at Internal Medicine 16. The teaching at Internal Medicine helps to develop my competence 17. Cheating is a problem at Internal Medicine 18. The Internal Medicine teachers have good communication skills with patients 19. My social life is good while rotating at Internal Medicine 20. The teaching at Internal Medicine is well-focused 21. I feel Internal Medicine is preparing me well for my profession 22. The teaching at Internal Medicine helps to develop my confidence 23. The atmosphere is relaxed during Internal Medicine lectures 24. The teaching time at Internal Medicine is put to good use 25. The teaching at Internal Medicine over-emphasises factual learning 26. Last year’s work has been a good preparation for this year’s work in Internal Medicine 27. I am able to memorise all I need to in Internal Medicine 28. I seldom feel lonely at Internal Medicine 29. The teachers at Internal Medicine are good at providing feedback to students 30. There are opportunities for me to develop interpersonal skills at Internal Medicine 31. Internal Medicine has taught me a lot about empathy in my profession 32. The teachers at Internal Medicine provide constructive criticism 33. I feel comfortable socially at Internal Medicine 34. Internal Medicine seminars/tutorials have a relaxed atmosphere 35. I find the experience at Internal Medicine disappointing 36. I am able to concentrate well at Internal Medicine 37. The Internal Medicine teachers give clear examples 38. I am clear about the learning objectives at Internal Medicine 39. The Internal Medicine teachers get angry during teaching sessions 40. The Internal Medicine lecturers are well prepared 41. My problem-solving skills are being well developed at Internal Medicine 42. The enjoyment at Internal Medicine outweighs the stress 43. The atmosphere at Internal Medicine motivates me as a learner 44. The teaching at Internal Medicine encourages me to be an active learner 45. Much of what I have to learn in Internal Medicine seems relevant to a career in medicine 46. Overall, my rotation at Internal Medicine was pleasant 47. Long-term learning at Internal Medicine is emphasised over short-term learning 48. The teaching at Internal Medicine is too teacher-centred 49. I feel able to ask the questions I want to at Internal Medicine 50. The students irritate the Internal Medicine teachers