Optimising the learning environment for undergraduate students in the Department of Family Medicine at Sefako Makgatho Health Sciences University Optimising the learning environment for undergraduate students in the Department of Family Medicine at Sefako Makgatho Health Sciences University I Govendera,b* and M De Villiersa aCentre for Health Professions Education, Stellenbosch University, South Africa bDepartment of Family Medicine, Sefako Makgatho Health Sciences University, Pretoria, South Africa *Corresponding author, email: indiran.govender@gmail.com Background: An important determinant of a medical student’s behaviour and performance is the department’s teaching and learning environment. Evaluation of such an environment can explore methods to improve educational curricula and optimise the academic learning environment. Aim: The aim is to evaluate the educational environment of undergraduate students in the Department of Family Medicine as perceived by students. Setting: This descriptive quantitative study was conducted with one group of final-year students (n = 41) enrolled in 2018, with a response rate of 93% (n = 39). Students were in different training sites at SMU. Methods: Data were collected using the Dundee Ready Educational Environmental Measure (DREEM) questionnaire. Total and mean scores for all questions were calculated. Results: The learning environment was given a mean score of 142/200 by the students. Individual subscales show that ‘academic self-perception’ was rated the highest (25/32), while ‘social self-perception’ had the lowest score (13/24). Positive perception aspects of the academic climate included: student competence and confidence; student participation in class; constructive criticism provided; empathy in medical profession; and friendships created. Areas for improvement included: provision of good support systems for students; social life improvement; course coordinators being less authoritarian and more approachable; student-centred curriculum with less emphasis on factual learning and factual recall. Conclusion: Students’ perceptions of their learning environment were more positive than negative. The areas of improvement will be used to draw lessons to optimise the curriculum and learning environment, improve administrative processes and develop student support mechanisms in order to improve students’ academic experience. Keywords: DREEM questionnaire, health professional education, learning environment, student centred, student satisfaction Introduction The term ‘learning environment’ commonly refers to the diverse physical locations, contexts and cultures in which students learn. It encompasses the culture of a university faculty, and its presid- ing ethos and characteristics, including how students interact and their relationships with one another as well as the ways in which teachers may organise an educational setting.1 Some educationists use it interchangeably with the term ‘institutional climate’.2 A vital driver for a student’s behaviour and perform- ance in health professions education institutions is the learning environment.3 Furthermore, it is widely agreed that the aca- demic learning environment influences the attitudes, knowl- edge, skills and academic progression of students.4 Assessing the educational environment correlates positively with determining student approaches to study, understanding of practice, desired educational outcomes and satisfaction with educational programmes.5,6 Undergraduate medical stu- dents’ perceptions of their educational environment have been studied at traditional and innovative medical schools. These studies have shown that students’ perceptions of the edu- cational environment can be a basis for implementing modifi- cations and thus optimising the educational environment. The educational environment influences how, why and what stu- dents learn.7 As a result of the recent imperatives towards enhanced quality assessment monitoring and the commitment of health professions education to student-centred teaching and learning, there is increased interest in the learning environment.7 Learning environment research for undergradu- ate medical students seeks to assess students’ perceptions of their environment and can guide medical and health sciences teachers to introspect, devise and incorporate the best teaching strategy.8 Student satisfaction is an important indicator of the quality of learning experiences and is usually related to several outcome variables.9 In this regard, researchers have been guided in their thinking by learning theories that stress the need and value of learning environments that provide engaging activities for students.4,10 The learning theories that apply particularly when assessing the learning environment include the social theories of learning, behavioural theories, self-determination theories, transformative learning theories and experiential learning.11 Although there are diverse determinants of how individual stu- dents view different aspects of a particular learning environ- ment, perceived rating measurements report their perceptions precisely.1 Previous research has shown that findings from edu- cational environmental investigations can be used effectively to implement and measure changes to the educational delivery and the physical environment.7,8 Many instruments are currently available to assess the learning environment of universities. Of all instruments available, the Dundee Ready Education Environment Measure (DREEM), South African Family Practice 2019; 61(4):136–143 https://doi.org/10.1080/20786190.2019.1613062 Open Access article distributed under the terms of the Creative Commons License [CC BY-NC 4.0] http://creativecommons.org/licenses/by-nc/4.0 S Afr Fam Pract ISSN 2078-6190 EISSN 2078-6204 © 2019 The Author(s) ARTICLE South African Family Practice is co-published by NISC (Pty) Ltd, Medpharm Publications, and Informa UK Limited (trading as the Taylor & Francis Group) mailto:indiran.govender@gmail.com http://crossmark.crossref.org/dialog/?doi=10.1080/20786190.2019.1613062&domain=pdf&date_stamp=2019-08-20 http://creativecommons.org/licenses/by-nc/4.0 Postgraduate Hospital Educational Environment Measure, Clini- cal Learning Environment and Supervision, and Dental Student Learning Environment Survey have been found to be the most suitable for undergraduate medicine, postgraduate medicine, nursing and dental education, respectively.12 The Manchester Clinical Placement Index (MCBI) is commonly used to assess per- ceptions of students placed in hospitals and measures two sub- scales, namely learning environment and training.12 The most widely used contemporary instrument to assess undergraduates in medical courses is the DREEM,9,10,13,14 which was developed by an international Delphi panel in Scotland.1 The DREEM ques- tionnaire has the highest reliability and validity scores in com- parison with other instruments measuring undergraduate medical students’ perceptions of the learning environment and clinical placements.8,9,12 It has been proposed as the stan- dard to be used for measuring undergraduate learning environ- ments.15 Because students of family medicine at SMU learn in community health care centres and not in hospitals, the eight- item Manchester Clinical Placement Index (MCBI), which was introduced in 2012 and tests for learning environment and train- ing only and not the five subscales that are the objectives for our study, the MCBI was not selected for this study.12 Furthermore, the DREEM tool has been used extensively in family medicine curriculum evaluations.14,16 The DREEM questionnaire was also used in a cross-sectional survey to assess clinical associate stu- dents’ perception of their learning environment at the University of the Witwatersrand.3 Sefako Makgatho Health Sciences University (SMU) was estab- lished as an independent health sciences university in 2015. The vision of SMU is to provide all-inclusive health sciences edu- cation and to employ educational approaches that include evi- dence-based methods for curriculum design, delivery and assessment of learning. The management structure of the uni- versity has also changed since 2016 with the appointment for the first time of a deputy vice-chancellor (DVC) for teaching and learning. There is a focus on, and commitment to, excellence in learning and teaching.17 On the other hand, students appear to be dissatisfied with the learning environment at SMU, according to reports presented by the academic planning and curriculum development com- mittee (APCDC) and memoranda submitted by students to the vice-chancellor during the student protest strikes on the campus during 2015, 2016 and 2018. Undergraduate students report that the academic environment at SMU is not conducive to learning, it is not based on their needs and is teacher-centred rather than student-centred.18 In the final year medical students spend six weeks in family medicine training. Of these, at least five weeks are spent in rural, community-based primary health care facilities. The stu- dents receive lectures at the central department for the first week and thereafter are taught at the various sites by family physicians. The Department of Family Medicine at SMU conducts almost all its teaching in the community using the problem-based model. From 2014 to 2017, the department achieved the award for the best clinical teaching department. Family Medicine is an emerging speciality in sub-Saharan Africa.19,20 There has been consensus nationally that this disci- pline is a core contributor to primary health care and critical to the achievement of equitable health outcomes for all. In order to accomplish this, training in family medicine must be community-based within the district health system with an ade- quate number of trained clinical personnel.21 Assessing commu- nity-based education as part of the curriculum is of vital importance as elaborated in the SPICES (student-centred; problem-based; integrated; community-based; elective; sys- tematic) model.22 Consequently, taking all these developments into consideration (change in the university’s structure and student dissatisfaction), the aim of this study was to investigate student perceptions of their learning environment in undergraduate family medicine teaching at SMU, in order to optimise the students’ learning environment experience. To reach this aim we had the following objective, namely to determine student perceptions of their learning activities, facilitators, academic self-perceptions, learn- ing atmosphere and social self-perceptions. We sought to ident- ify any learning areas in the students’ perceptions of their learning environment that need to be addressed, explore trends in the learning environments at different site placements and, should deficiencies be found, make recommendations to the HOD on optimising the learning environment in under- graduate family medicine teaching at SMU. Methods Study design This was a cross-sectional, descriptive study using self-adminis- tered DREEM questionnaires. Study population There are six groups of final-year students annually with the total number of students per year being about 240. Students are placed in these groups by the School of Medicine in their first year of study where they remain for their entire study period at SMU. Students do not choose to which group they are allo- cated and there are no differences between the groups which, have on average 40 students per group. One group of students made up the sample. The health facilities where the students rotated included Phokeng Health Centre (two students), Tlhabane CHC (four stu- dents), Odi District Hospital (seven students), Job Shimankane Thabane Hospital (four students), Phedisong CHC (three stu- dents), Jubilee District Hospital (five students), Bapong CHC (three students), Swartruggens Hospital (six students), Soshan- guve CHC (four students) and Brits District Hospital (one student). Sample size Final-year family medicine students were surveyed at the end of their six-week family medicine block. There are six groups of stu- dents annually. The students in each group are randomly selected by the school of medicine from first year of study. One randomly selected group of students made up the sample. There are on average 40 students in each group. All the students in one group were approached to participate. Therefore a form of random sampling was used. The aims and objectives of this study were purely descriptive, aiming to measure perceptions of students around various topics, and not specifically to test any hypothesis; thus, a sample size calculation was not performed. Optimising the learning environment for undergraduate students 137 Data collection An independent third party distributed the questionnaires on the last day of the family medicine block. This was after their assessments when students felt less vulnerable. Data analysis Information from the questionnaires was captured onto a Micro- soft Excel spreadsheet (Microsoft Corp, Redmond, WA, USA) and exported to SPSS statistical software (version 25; IBM Corp, Armonk, NY, USA) for analysis. Scores for the domains were com- puted and summarised using appropriate measures of central tendency and dispersion. Trends in the results of student per- ceptions between the different training sites were explored using stratified analysis. The DREEM questionnaire has 50 items that assess five domains6 as can be seen in Table 1. There were nine negative items (items 4, 8, 9, 17, 25, 35, 39, 48 and 50), for which correction was made by reversing the scores; thus, after correction, higher scores indi- cate disagreement with that item. Items with a mean score of ≥ 3.5 are true positive points; those with a mean of ≤ 2 are problem areas; scores between these two limits indicate aspects of the environment that could be enhanced. The maximum global score for the questionnaire is 200, and the global score is interpreted as follows: 0–50 = very poor; 51– 100 = many problems; 101–150 = more positive than negative; 151–200 = excellent.6,19 Total percentage scores reflect the following: . agreement: calculated by adding responses of ‘strongly agree’ and ‘agree’; . uncertain: calculated by giving a percentage to all responses that indicated ‘uncertain’; . disagreement: calculated by adding responses of ‘strongly disagree’ and ‘disagree’. Ethical considerations Written informed consent was obtained from all participants. Ethical clearance was obtained from the Stellenbosch University Research and Ethics Committee (number S18/02/039). The Head of Family Medicine and Primary Health Care Department and the Acting Dean of the School of Medicine at SMU gave permission to conduct the study. Results A total of 39/42 (93%) students completed the questionnaire. There were 18 (46%) females and 21 (54%) male participants. The mean age of the students was 24.9 years (SD 2.6) and only two had other degrees (Biomedical Technology and BSc (Hons) Medical Microbiology). DREEM scores for all students The total mean score for the DREEM was 141/200. The lowest mean score was for ‘The teaching overemphasises factual learn- ing’ (1.23). Table 2 shows the percentage of students who either agree, disagree or are neutral regarding each statement. The best scores were as follows: . Students are encouraged to participate in teaching ses- sions (86% agreed). . Teaching helps to develop their competence (81% agreed). . Confidence (86% agreed). . Teachers practise a patient-centred approach (86% agreed). . Teachers give clear examples during teaching (82% agreed). . Students are confident of passing this year (almost 90%). . Students have learnt a lot about empathy in their pro- fession (96%). . Students’ problem-solving skills are being well developed (91%). . Students are able to ask any questions they wish to (96%). . The atmosphere is relaxed during lectures (91%). . Much of what they have learnt seems relevant to a career in health care (96%). The five subscales of the DREEM questionnaire The lowest minimum score for any domain was for the percep- tion of the course organiser, which was 4 (9%), indicating a very poor perception of the organiser (see Table 3). However, the Table 1: The DREEM questionnaire domains Domain Number of items Maximum score Students’ perception of learning 12 48 Students’ perception of teachers 11 44 Students’ academic self- perception 8 32 Students’ perception of atmosphere 12 48 Students’ social self-perception 7 28 Each item is rated on a five-point Likert scale from 0–4 where: Strongly disagree = 0 Disagree = 1 Unsure = 2 Agree = 3 Strongly agree = 4 The five subscales (domains) are as follows: Domain Representing item numbers Domain 1: Students’ perception of learning 1, 7, 3, 16, 20, 21, 24, 25, 38, 44, 47, 48 Domain 2: Students’ perception of course organisers 2, 6, 8, 9, 18, 29, 32, 37, 39, 40, 49 Domain 3: Students’ academic self-perception 5, 10, 22, 26, 27, 31, 41, 45 Domain 4: Students’ perceptions of atmosphere 11, 12, 17, 23, 30, 33, 34, 35, 36, 42, 43, 50 Domain 5: Students’ social self- perceptions 3, 4, 14, 15, 19, 28, 46 A guide to interpreting the subscales: Students’ perception of learning: 0–12 Very poor Teaching is viewed negatively A more positive perception Teaching highly thought of Students’ perception of course organisers: Very poor In need of some retraining Moving in the right direction Model course organisers Students’ academic self-perceptions: Feelings of total failure Many negative aspects Feeling more on the positive side Confident Students’ perception of atmosphere: A terrible environment There are many issues that need changing A more positive attitude A good feeling overall Students’ social self-perceptions: Miserable Not a nice place Not too bad Very good socially 138 South African Family Practice 2019; 61(4):136–143 mean score for this domain was 32 (72%) with a standard devi- ation (SD) of 8, which indicated that overall the course organiser was moving in the right direction. As regards the perception of learning subscale, the mean score was 34 (72% of the possible perfect score) indicating that stu- dents had a positive perception of learning. It is noteworthy that the minimum score was 17 and the standard deviation 6.9, indicating that there were students who viewed teaching negatively, although none perceived the teaching as very poor. The students perceived the atmosphere as positive (mean score 34 ± 7.3 SD; 71%). The minimum score was 20, indicating that the students perceived many issues in need of change. The mean score for the students’ academic self-perception was 25 ± 4.0 SD (77%), which indicates that their academic self-per- ception leaned towards the positive side. Their social self-per- ception was adequate with mean scores of 16.9 ± 4.1 SD (60.0%). These results are represented in Table 2. In total there were four problem areas (scores with a mean of ≤ 2). . Item 4: I am too tired to enjoy the course. . Item 9: The course organisers are authoritarian. . Item 25: The teaching overemphasises factual learning. . Item 28: I seldom feel lonely. One item (no. 10) detected a strength point in the educational climate: I am confident about passing this year. The subscale which scored highest was ‘academic self-percep- tion’ (25; 77%), which implies a feeling of academic self-confi- dence, followed by ‘learning’ (34/48), and course coordinator perception (32/44), which score 72% for each. When we use the DREEM scoring guide to interpret the results for these two subscales, the 34/48 for learning perception implies that the stu- dents have a positive perception of their learning. Similarly, the 32/44 for the course organisers implies that the students per- ceive the course organisers to be moving in the right direction to make the learning environment student-centred, although they feel that that there is room for improvement,9 indicating a more positive perception of their learning and a feeling that the course coordinator is moving in the right direction, respect- ively (see Table 2 for results of subscales). Categorisation of DREEM overall scores In total, 51% of the students felt that the family medicine train- ing environment was more positive than negative; 41% felt that it was excellent, while only 7.7% (= 3) of the students felt that the final-year family medicine programme has many problems (Figure 1). Comparison of male and female perceptions of the learning environment Male students seemed to perceive the learning environment more favourably than female students for all the subscale elements, although the difference was not statistically signifi- cant. The independent t-test indicated a p-value > 0.05 for all learning environments (Table 3). Health facility and learning environment Although the number of students training at the different facili- ties was small, it seems that the students were especially happy with Phokeng CHC and perceived its learning environment to be excellent (161/200) (Table 4). Table 2: Scores for the five subscales of the DREEM questionnaire Score Learning perceptions (max. 48) Course organiser perceptions (max. 44) Academic self- perceptions (max. 32) Atmosphere perception (max. 48) Social self- perceptions (max. 28) Overall score (max. 200) Mean 34 (72%) 32 (72%) 25 (77%) 34 (71%) 17 (60%) 142 (71%) Standard deviation 6.9 8.0 4.0 7.3 4.1 26.7 Minimum 17 (35%) 4 (9%) 16 (50%) 20 (42%) 8 (29%) 83 Maximum 44 (92%) 44 (100%) 31 (97%) 48 (100%) 26 (93%) 183 Percentiles 25 30.00 29.00 22.00 28.00 14.00 123.00 50 34.00 31.00 25.00 33.00 17.00 139.00 75 39.00 36.00 28.00 39.00 20.00 164.00 Table 3: Comparison of male and female perceptions of the learning environment Learning environment domains Sex Male Female Mean SD Mean SD t-test Learning perception 34.6 (72.1%) 7.3 34.0 (70.8%) 6.6 0.620 Organiser perception 32.6 (74.1%) 6.5 30.3 (68.9%) 9.6 0.217 Academic perception 25.0 (78.1%) 4.3 23.9 (74.7%) 3.7 0.845 Atmosphere perception 34.7 (72.3%) 6.6 33.6 (70.0%) 8.2 0.845 Social self-perception 17.2 (61.4%) 3.9 16.6 (59.3%) 4.4 0.556 Overall scores 144.1 25.2 138.4 28.7 – Optimising the learning environment for undergraduate students 139 It is emphasised that the DREEM score is not related to the quality of clinical care rendered at the individual facilities; it is a reflection of students’ perceptions of their learning environment. Discussion The DREEM evaluation of the final-year family medicine stu- dents’ perception of their learning environment had a total mean score of 141/200, which indicates a more positive than negative perception of their environment. These family medi- cine students perceived their learning environment to be slightly better than those reported by students at other medical schools in India (123/200)10 and Nigeria (118/200).23 Medical students from Sri Lanka (108/200)12 and Iran (100/ 200)24 perceived their learning environment to be poorer than that of SMU. The differences could be attributed to the fact that our total DREEM score was based on a single group of stu- dents, while other studies administered the DREEM question- naire either to a large number of undergraduate students in different years of enrolment,25 to all students in medical schools,20 or conducted comparative cross-sectional studies in a number of medical schools.15 Other single-cohort studies in medical schools in the United Kingdom (139/200)10 and Nepal (130/200)24 also perceived their learning environment to be more positive than negative. Valuable insights and recommen- dations were drawn from surveys of family medicine students at universities similar to SMU, in Egypt and Saudi Arabia where research designs were used.19,26 In these studies, students’ major concerns were that the curriculum was not student- centred and the quality of teaching was poor.19,26 Our scores are higher than those of several studies conducted in other family medicine departments of middle-income countries, e.g. King Abdul Aziz University (102.0),27 King Khalid University (112.95),28 and Qassim University (112.0).29 Our mean score of 141/200 and the score of 2.90 for the students’ perception of whether they consider teaching to be student-centred indicates the dominance of student-centred methods of teaching.29 The total DREEM score was slightly higher for males compared with females; however, with the small sample, we could not con- clude whether the difference was statistically significant. Although there have been studies reporting on gender differ- ence in the perception of the DREEM total and subscale scores at other medical universities,30,31 the reported effect of gender is inconsistent; this could be a topic for further investigation in a larger sample size.32,33 One important application of the DREEM instrument is the analysis of the individual items. This directly shows the strengthsand weak- nesses of different aspects of the educational environment. The majorityofitems inthedomainoflearningscored2.9ormore,indi- cating few problems. Our results showed one weak learning domain issue that should receive attention and this was the lowestitemfortheentireDREEMquestionnaire:1.23for ‘Theteach- ing overemphasises factual learning’. This learning encourages more superficial learning and remembering facts rather than a deeper learning with understanding and application of knowl- edge. This finding is consistent with that of Arzuman et al.33 Perhaps, in the short time they spend in this course, lecturers provide facts on clinical conditions and the current guidelines on managing common clinical conditions, which may be perceived as an excess of factual knowledge that students are expected to remember and recall for their written assessments. The students may have referred to the class-based teaching (which includes factual learning) and not clinical teaching which focuses on real patients (hands-on/practical learning). Further exploration of this aspect through a qualitative research design may provide a clearer picture of what the students are actually referring to. Nega- tive perceptions of the learning subscale were reported in Spain where they were attributed to the use of traditional methods of teaching (lecturer standing in front of the class and talking).34 On the other hand, item number 47 (‘Long-term learning is empha- sised over short-term’) is perceived more positively. It is worth noting that durable knowledge is one of the primary goals of medical education.35 The highest individual scores in this section indicate that teach- ing helps to develop the students’ competence (3.38) and con- fidence (3.26), which are important traits needed for their Figure 1: Categorisation of DREEM overall scores. Table 4: Health facility and learning environment Health facility No. of students per site % DREEM overall score for each facility Phokeng Health Centre 2 5.1 Mean 161.0 SD 31.1 Tlhabane CHC 4 10.3 Mean 148.3 SD 36.9 Odi District Hospital 7 17.9 Mean 147.2 SD 29.1 JST 4 10.3 Mean 145.3 SD 25.6 Phedisong CHC 3 7.7 Mean 139.3 SD 25.7 Jubilee District Hospital 5 12.8 Mean 139.2 SD 38.5 Bapong CHC 3 7.7 Mean 137.3 SD 32.3 Swartruggens Hospital 6 15.3 Mean 135.7 SD 20.7 Soshanguve CHC 4 10.3 Mean 136.8 SD 25.6 Brits District Hospital 1 2.6 Mean 135.0 SD 140 South African Family Practice 2019; 61(4):136–143 future professional career. Students also believed that they were encouraged to participate in class (3.36), which is an indication of an open and interactive learning atmosphere. Contrary to our findings, medical students in Malaysia rated class partici- pation at 1.88, which indicated their teaching does not provide enough experiences and participation in class in order to help them develop and grow their confidence.33 The other concerns that could be improved upon are that teach- ing is perceived to be teacher-centred and the course does not really allow the student to be an active learner. This also ties in with their perception that the teaching could be more stimulat- ing. These areas need to be enhanced as the family medicine curriculum strives to focus on student-centred and problem- based learning. In the curriculum greater emphasis should be placed on the promotion of student-centred learning. This may involve training the clinical trainers and has already begun as part of the European Union Project nationally.36 In terms of quality of teaching (course organiser perceptions), educators in the family medicine programme are perceived as moving in the right direction. The best traits of teachers, as per- ceived by students, include being knowledgeable (3.46), espous- ing a patient-centred approach to consulting (3.36) and giving students clear examples (3.21). This finding is similar to that of the study by Arzuman et al.,33 which indicated that teachers had good communication skills. The students also recognised that their teachers are well prepared for their teaching sessions (3.18). This is encouraging for the family medicine programme, as the findings of a study conducted by Aghamolaei et al.37 were that teachers were not knowledgeable, not prepared for their lectures and did not provide constructive feedback. However, students in our study also considered that there was some room for improvement as far as constructive criticism is concerned and the course organisers are perceived as being too authoritarian (1.69). This area must be explored further through interviews with the students for a better understanding, and then measures implemented to ensure that course organ- isers are more approachable and student-centred. In contrast to studies conducted in other medical schools, which found that academic self-perceptions were rated low,25,38 in our study this was rated highest. Students strongly believed and were confident that they would pass (3.51), they had learnt a lot about empathy in their profession (3.44), and much of what they had learnt seemed relevant to a career in health care (3.01). They also perceived that their problem-solving skills were being well developed (3.03), which is an important objective of the family medicine programme indicating that the learning environment contributes to the fulfilment of the course objectives. This good positive perception of the academic environment at the family medicine department indicates that the academic curriculum is transparent, relevant and student- centred. Moreover, the students’ perceptions were proved accu- rate when they all passed the course. The findings of our study differ from those of Hamid et al.39 who found that ‘academic self-perception’ had a low score of 20/32. Our study reveals a more positive feeling among the students with regard to their academic environment. All students rated their learning atmosphere in the category of ‘a more positive attitude’ with a mean score of 34/48 (71%). The best perceived aspect of the learning atmosphere is that stu- dents felt there were opportunities available to them to develop their interpersonal skills and were able to ask questions as they desired, which potentially enhanced their communi- cation skills. The atmosphere was relaxed during teaching, thereby promoting teacher–student interaction and sharing of scientific and conceptual knowledge. Other studies also found that the overall learning atmosphere for the students was per- ceived as positive and relaxed and that this promoted learning.34 In the social domain, the stress of studying medicine out- weighed the joy during the course and the perception was that the atmosphere to motivate students as learners could be improved upon. The students could have perceived the course to be too stressful for them to enjoy; it included being away from family and friends for the family medicine clinical rotation. The course was perceived to be relatively well timetabled. This result was different from other studies in which students did not consider their course to be well timetabled and this caused stress for them.39,40 Although the students had different social environments at their clinical placements, their overall ‘social self-perception’ received the lowest scores of all the domains. Students perceived their social environment as ‘not too bad’. This subscale reflects that students expect the educational environment to be creative and less stressful. There is an indirect relationship between stress and the academic performance of students. Students reporting higher stress levels perceive a lack of self-confi- dence.9,41 The social self-esteem domain was scored the lowest by both male and female students. The item asking about friends (3.28) was similar to perceptions of students at other universities.36,42 The presence of friendly relationships between students reflects a healthy support structure. Problem-based learning encourages interaction between the students and this has been shown to build friendly relation- ships.42 The item ‘I am too tired to enjoy this course’ had a low score (1.33) while the feeling of loneliness scored 1.96. This indicates a lack of supportive strategies for stressed stu- dents. Unfortunately, this situation prevails at many other uni- versities.25,42 It has been reported that the top stressors for undergraduate students are perceived lack of social support, depression and concerns regarding the completion of clinical work.43 It is recommended that SMU offer support and teach students how to manage and cope with the various stressful situations they encounter, whether academic, social or financial. The pres- ence of positive and friendly relationships among students is essential as a coping mechanism to minimise the effects of stress generated by the study load. On this point, it was unclear as to whether the students were referring to social, aca- demic or personal support systems. In order to improve the social aspect and ensure that apart from the academic aspect of teaching and learning family medicine students also enjoy their social life, we need to further explore this aspect and take measures accordingly as this will impact on their experi- ence of working in clinical settings away from home. Concerning the perception of learning, it was noted that the high mean score of 34 indicated a positive perception of the educational environment. Academic self-perception showed a positive score (32). This is mainly concerned with the students’ views of their academic abilities and skills, as well as their expected duties, as one of the most important factors affecting the academic success of the students is their learning skills.26 Students’ academic Optimising the learning environment for undergraduate students 141 achievement requires the use of appropriate learning methods. Taking into consideration individual items to detect strengths and weaknesses, it was noted that students felt that teachers do not ridicule them, cheating is not a problem and they do not find the course disappointing.37,42 Concerning the eight negative statements, the students were in full agreement that the university programme organisers are authoritarian. These negative perceptions of the course organ- isers could be addressed with the interviews suggested pre- viously and may lead to a greater awareness of what the students mean and how this can be improved. As regards social perceptions, they mentioned that they do not consider the atmosphere to be socially comfortable. These results empha- sise the role of the staff who are responsible for doing their tasks efficiently, who should be patient with their students, show tol- erance towards them and bear in mind students’ expectations.39,44 Conclusion The results of this study showed that, overall, the educational environment was rated more positive than negative. Concerning the individual items, the perception of the social environment was the most defective domain while problems in the learning environment had a higher DREEM score among males. Greater efforts are needed to manage the negative items, which include the negative perception of teaching, the stressful environment and the lack of supportive strategies for stressed students. This study is a brief descriptive study conducted with a group of final-year students. Despite the sample size, the study tried to evaluate the overall educational climate of the innovative approach to family medicine at SMU. Results from this study demonstrate that the course was perceived as a positive learn- ing environment, contributing to the course objectives. This study highlighted strengths and weaknesses in the programme that could guide course organisers in modifying the course. Limitations Considering the nature of the course, which combines class- room-based learning with hospital/clinic-based teaching, DREEM does have some limitations in this context. Terms such as ‘course organiser’, ‘teachers’, ‘atmosphere’ and ‘learning/ teaching’ present ambiguity in terms of whether the students perceived these as referring to a classroom- or hospital-based learning environment. Another study with a larger sample size and data that are sup- ported by qualitative data from in-depth interviews that specifi- cally address the weak areas identified in this study would provide more information for the course organisers to enable them to optimise the finer details of the educational environment. The number of students at various training sites could influence the total scores for the sites. More students per site would lead to more observations per site, and the weighting of the obser- vations could be influenced either positively or negatively. Acknowledgements – The authors would like to thank all the stu- dents who voluntarily participated in this study and Mr Stevens Kgoebane for text-editing the document. Disclosure statement – No potential conflict of interest was reported by the authors. References 1. Al-Rukban MO, Khalil MS, Al-Zalabani A. Learning environment in medical schools adopting different educational strategies. Educ Res Rev. 2010;5(3):126–9. 2. 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Received: 23-01-2019 Accepted: 26-04-2019 Optimising the learning environment for undergraduate students 143 Abstract Introduction Methods Study design Study population Sample size Data collection Data analysis Ethical considerations Results DREEM scores for all students The five subscales of the DREEM questionnaire Categorisation of DREEM overall scores Comparison of male and female perceptions of the learning environment Health facility and learning environment Discussion Conclusion Limitations Acknowledgements Disclosure statement References << /ASCII85EncodePages false /AllowTransparency false /AutoPositionEPSFiles false /AutoRotatePages /PageByPage /Binding /Left /CalGrayProfile () /CalRGBProfile (Adobe RGB \0501998\051) /CalCMYKProfile (U.S. Web Coated \050SWOP\051 v2) /sRGBProfile (sRGB IEC61966-2.1) /CannotEmbedFontPolicy /Error /CompatibilityLevel 1.3 /CompressObjects /Off /CompressPages true /ConvertImagesToIndexed true /PassThroughJPEGImages false /CreateJobTicket false /DefaultRenderingIntent /Default /DetectBlends true /DetectCurves 0.1000 /ColorConversionStrategy /sRGB /DoThumbnails true /EmbedAllFonts true /EmbedOpenType false /ParseICCProfilesInComments true /EmbedJobOptions true /DSCReportingLevel 0 /EmitDSCWarnings false /EndPage -1 /ImageMemory 524288 /LockDistillerParams true /MaxSubsetPct 100 /Optimize true /OPM 1 /ParseDSCComments false /ParseDSCCommentsForDocInfo true /PreserveCopyPage true /PreserveDICMYKValues true /PreserveEPSInfo false /PreserveFlatness true /PreserveHalftoneInfo false /PreserveOPIComments false /PreserveOverprintSettings false /StartPage 1 /SubsetFonts true /TransferFunctionInfo /Remove /UCRandBGInfo /Remove /UsePrologue false /ColorSettingsFile () /AlwaysEmbed [ true ] /NeverEmbed [ true ] /AntiAliasColorImages false /CropColorImages true /ColorImageMinResolution 150 /ColorImageMinResolutionPolicy /OK /DownsampleColorImages true /ColorImageDownsampleType /Bicubic /ColorImageResolution 300 /ColorImageDepth -1 /ColorImageMinDownsampleDepth 1 /ColorImageDownsampleThreshold 1.50000 /EncodeColorImages true /ColorImageFilter /DCTEncode /AutoFilterColorImages false /ColorImageAutoFilterStrategy /JPEG /ColorACSImageDict << /QFactor 0.90 /HSamples [2 1 1 2] /VSamples [2 1 1 2] >> /ColorImageDict << /QFactor 0.40 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /JPEG2000ColorACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 15 >> /JPEG2000ColorImageDict << /TileWidth 256 /TileHeight 256 /Quality 15 >> /AntiAliasGrayImages false /CropGrayImages true /GrayImageMinResolution 150 /GrayImageMinResolutionPolicy /OK /DownsampleGrayImages true /GrayImageDownsampleType /Bicubic /GrayImageResolution 300 /GrayImageDepth -1 /GrayImageMinDownsampleDepth 2 /GrayImageDownsampleThreshold 1.50000 /EncodeGrayImages true /GrayImageFilter /DCTEncode /AutoFilterGrayImages false /GrayImageAutoFilterStrategy /JPEG /GrayACSImageDict << /QFactor 0.90 /HSamples [2 1 1 2] /VSamples [2 1 1 2] >> /GrayImageDict << /QFactor 0.40 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /JPEG2000GrayACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 15 >> /JPEG2000GrayImageDict << /TileWidth 256 /TileHeight 256 /Quality 15 >> /AntiAliasMonoImages false /CropMonoImages true /MonoImageMinResolution 1200 /MonoImageMinResolutionPolicy /OK /DownsampleMonoImages true /MonoImageDownsampleType /Average /MonoImageResolution 300 /MonoImageDepth -1 /MonoImageDownsampleThreshold 1.50000 /EncodeMonoImages true /MonoImageFilter /CCITTFaxEncode /MonoImageDict << /K -1 >> /AllowPSXObjects true /CheckCompliance [ /None ] /PDFX1aCheck false /PDFX3Check false /PDFXCompliantPDFOnly false /PDFXNoTrimBoxError true /PDFXTrimBoxToMediaBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXSetBleedBoxToMediaBox true /PDFXBleedBoxToTrimBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXOutputIntentProfile (None) /PDFXOutputConditionIdentifier () /PDFXOutputCondition () /PDFXRegistryName () /PDFXTrapped /False /Description << /ENU () >> >> setdistillerparams << /HWResolution [600 600] /PageSize [595.245 841.846] >> setpagedevice