Analysis of Undergraduate Students ’ Perception of the Educational Environment of a Medical School in Zambia Provided a Framework for Strategic Planning

Aim: To propose a strategy for improvement of undergraduate students’ learning environment based on analysis of their perceptions. Methods: Medical, Pharmacy, and Physiotherapy undergraduate students participated in the study. The study used a quantitative descriptive design, based on the Dundee Ready Educational Environment Measure (DREEM) inventory. The University of South Africa and University of Zambia Ethics Committees provided ethical approval. Using stratified random sampling, participants were drawn from the Ridgeway Campus of the University. They responded to a demographic section and the 50 DREEM items. Data analysis included descriptive statistics on demographics, total and subscales DEEM scores, and mean scores on individual items. Cronbach’s alpha and confirmatory Original Research Article Ezeala and Moleki; BJMMR, 21(5): 1-9, 2017; Article no.BJMMR.33545 2 factor analysis provided reliability and validity indices of the dataset. Specific issues derived from individual items’ scores were used to propose a strategy. Results: Total participants were 488 including 239 from Medicine, 135 from Pharmacy, and 74 from Physiotherapy. Response rate was 95.5%. Mean total score was 119.3/200. Scores within subscales of perception of learning, perception of teachers, academic self-perception, perception of atmosphere, and social self-perception were 29.87/48, 26.29/44, 20.96/32, 27.26/48, and 14.86/14, respectively. Four strategic issues emerged from six items with mean scores below 2.0/4.0: lack of adequate social support for stressed students, substandard teaching and mentoring, unpleasant accommodation, and inadequate facilities. Strategic objectives were raised and strategic options recommended from literature. Conclusion: Strategic planning in medical and health professions education should consider learners’ concerns by analysing their learning environments.


INTRODUCTION
The management of higher education has become complex due to increasing competition and internationalization of educational programmes.This phenomenon is compounded by the greater stakeholders' expectation from institutions with respect to competencies of graduates and contributions to social development.Within medical education, this expectation is exemplified by the recent call for "social accountability" of medical schools [1].Medical education administrators need to deal with issues of resource scarcity, technological advancement, and the increasing expectations from the public [2].Strategic planning therefore requires relevant information in order to prioritize scarce resources.
The scanning of the operating environment during strategic planning often overlooks students' views and expectations.However, that students' perception of the learning environment determines their approach to learning and the outcomes of learning is now well known.Analysis of this perception is widely adopted in medical and health sciences education, as well as in other fields of education to compare effectiveness of contrasting educational strategies, different teaching sites in the same institution, diagnose institutional problems, for curriculum reform, among a host of other published applications [3].The Dundee Ready Educational Environment Measure (DREEM) is a popular tool for measuring learning environment quality in medical education [3].According to Stukalina [4], students' satisfaction is as an important factor in the strategic management of higher educational institutions.This paper therefore, explored the usefulness of undergraduate students' learning environments measurement in strategic planning in a medical school.The aims of the study were to determine students' perception of their learning environment (the educational climate) and to use the issues to propose strategies for improvement of the learning environment.It had no interest in comparing DREEM scores between programmes or levels of study.

METHODS
To achieve the above aims, the study used a quantitative descriptive design applying the DREEM questionnaire.Undergraduate students of the Bachelor of Medicine and Surgery (years 3-7), Bachelor of Pharmacy (years 3-5), and Bachelor of Physiotherapy (years 2-5) participated in the study.Ethical approval for the study was granted by the Research Ethics Committee of the Department of Health Studies, University of South Africa (certificate number REC-012714-039), and subsequently, authority to proceed with the study was granted by the University of Zambia Biomedical Research Ethics Committee (UNZABREC, reference number IRB-00001131 of IORG-0000774).The Dean of the School of Medicine, University of Zambia gave written permission to carry out the study.Official permission to use the DREEM inventory was obtained from one of the tool's authors (S.McAleer).Aware of the effects of power differentials on data quality, none of the authors was involved in the teaching of these students prior to or at the time of the study, and they were not directly involved in data collection.Research assistants were used for all data collection.Sample sizes for each programme were calculated using margin of error of 5%, confidence level of 95%, students' total enrolment in the programme, and response distribution of 50%.For Medicine, total enrolment was 632, giving a sample size of 240, for Pharmacy, total enrolment of 220 gave sample size of 141, and for Physiotherapy, total enrolment of 105 gave sample size of 83.The total sample size for the three programmes was 464.The study used stratified random sampling (stratified according to programmes and year of study), and randomisation was achieved with the aid of an online randomiser (available at https://www.randomizer.org/).Each potential participant received an information sheet detailing the purpose of the study and the involvement of participants.
The DREEM was development by a team led by faculty at the University of Dundee through a Delphi process involving many stakeholders in medical education in 1997.It comprises 50 items including nine with negative statements.Each consenting student completed a demographic section of the questionnaire and then responded to the items in the DREEM inventory based on a 5 point Likert-like scale from strongly agree to strongly disagree.These were rated from 0 for 'strongly disagree' to 4 for 'strongly agree' (for items with positive statements).
Items with negative statements were rated the other way round, 4 for 'strongly disagree' to 0 for 'strongly agree.'The maximum achievable total score is 200 representing 'an ideal educational environment,' according to the rating guide.The cores were interpreted as follows: 0-50 'Very Poor,' 51-100 'Plenty of Problems,' 101-150 'More Positive than Negative,' and 151-200 'Excellent.' The factor structure of the DREEM also includes five subscales of 'perception of learning' (SPL) with 12 items, 'perception of teachers' (SPT) with 11 items, 'academic self-perception' (ASP) 8 items, 'perception of atmosphere' (SPA) 12 items, and 'social self-perception' (SSP) 7 items.Based on the DREEM developers' recommendation, the following guide was used for interpreting the subscale scores:

Social
Self-Perceptions (SSP): 0-7 'Miserable,' 8-14 'Not a nice place,' 15-21 'Not too bad,' 22-28 'Very good socially.' To ensure anonymity, participants' names or other identifying information were not collected, and access to the returned questionnaires was restricted to the principal investigator.Copies of the returned questionnaires were sorted into programmes and classes, and the responses rated as described above.All questionnaires were handled confidentially, in line with UNZABREC's guidelines.Data from the DREEM items and demographic section of the questionnaire were analysed with SPSS version 21 (IBM SPSS Statistics for Windows, Version 21.0 Armonk, NY: IBM Corp).Mean global DREEM scores and scores within subscales were determined.Mean scores for each of the 50 DREEM items were also determined and used to provide information on the specific issues in the learning environment.The study also performed a confirmatory factor analysis for data validity and Cronbach's alpha values for reliability.

Demographic Characteristics
Four hundred and seventy-one (471) questionnaires were distributed to participants from the selected programmes and 450 were returned corresponding to a response rate of 95.54%.Two (2) questionnaires were discarded, leaving 448 suitable for analysis.Of these, 239 (53.3%) were Medicine/Surgery students, 135 (30.2%)Pharmacy students, and 74 (16.5%) were Physiotherapy students.Table 1 describes the population and sampling frame.

DREEM Scores
The mean global DREEM score for the 448 participants was 119.30 (59.65%;SD = 21.24),indicating a "more positive than negative" perception.Table 2 presents the total and subscale DREEM scores with the Cronbach's alpha for the study participants.All the subscales were rated positively with the subscale of academic self-perception (ASP) most positively rated (65.5%), while the subscale of social selfperception (SSP) was the least positively rated (53%).
Individual item analysis showed that no item had a mean score greater than 3.5.The highest scoring item was number 10: "I am confident about passing this year," with a mean score of 3.33.Forty (40) items had mean scores between 2.0 and 3.0.Six (6) items had scores less than 2.0, indicating areas requiring improvement.These items were number 3 -"There is a good support system for students who get stressed," number 9 -"The teachers are authoritarian," number 25 -"The teaching over emphasizes factual learning," number 27 -"I am able to memorize all I need," number 42 -"The enjoyment outweighs the stress of studying," and 46 -"My accommodation is pleasant."Table 3 presents the six DREEM items with mean score below 2.0.
Cronbach's alpha for the total DREEM scores was 0.899, while values for the subscales varied between 0.406 and 0.769.Confirmatory factor analysis showed that the 5-factor structure initially proposed for the DREEM instrument accounted for 35% of the variance with maximum factor loadings between 0.213 and

Developing a Strategy for Improvement
The six items with scores below 2.0/4.0 were thematised into four strategic issues including inadequate social support system for the students, unsatisfactory teaching and mentoring methods, unpleasant accommodation, and inadequate physical facilities.Based on these, strategic objectives were raised for each issue.Through literature review, strategic options were identified for each objective, and targets were suggested for each (see Table 4).

DISCUSSION
A probably indicates that the students were barely satisfied with their learning environments, and some specific aspects needed to be improved.
Strategic planning begins with environmental scanning to determine the strengths and weaknesses of an organization's internal environment, and to define the opportunities and threats posed by the external environment [8].Quality assurance, which is a topical issue in health professions education, is built on good strategic management [9].Since the primary goal of healthcare educational institutions is to educate the most talented and most competent professionals that are able to secure the healthcare needs of their communities [8], understanding and addressing learners' needs through learning environment survey should be a vital component of strategic planning.This study has explored the learners' needs, and utilised the issues determined therefrom to propose a strategic plan for development.The study recognized six issues including lack of a good support system for students who get stressed, authoritarian attitude of the teachers, overemphasis on factual learning, inability to memorize, inability to cope with the stress of studying, and unpleasant accommodation.These issues are similar to reports from other studies, including reports by Odole et al. [10], Palmgren [11], and Riquelme et al. [12].
Following are discussions on the strategic issues.

Inadequate Social Support for Stressed Students
Education in the healthcare professions is associated with much stress, and dysfunctional stress could lead to significant morbidity [13].Students' coping strategies largely determine stress outcome, and in the light of this, training the students in engagement coping strategies might be a useful supportive approach for stress management.Other strategies recommended by this article include engagement of more counsellors in the students' centre, and training student-counsellors to enhance peer counselling and mentoring.

Overemphasis on Factual Learning
Anne Ditcher [16] and Caroline Kreber [17] noted that students' perception of heavy workload and inappropriate assessment methods correlate strongly with surface approaches to learning.Problem-based learning has been implemented in many medical schools as a means of reducing factual overemphasis and promote learning in context [18], but Berkson [19] argues that PBL may be subject to monotony and factual overload like other instructional methods.Prevailing reports of 'overemphasis on factual learning' from many studies on learning environments challenge the effectiveness of currently adopted measures.

Unpleasant Accommodation
Not many studies have reported unpleasant residential accommodation as an issue in medical schools.It is not clear what students perceived as unpleasant in their accommodation in this study, so this article recommends a study to understand what makes their accommodation 'unpleasant'.Amole [20] examined students' satisfaction in four Nigerian universities and concluded that the correlates of satisfaction are many and include social densities in the hostels, the kitchenette, bathroom, storage facilities, and configuration of the halls.

CONCLUSION
This study identified the issues within the learning environment of undergraduate medical and health sciences students using the DREEM questionnaire.It used the issues as the basis for proposing a strategy for improvement.Four strategic issues were identified, and evidencebased strategic options and targets were proposed.
The limitations of the study include its quantitative design.A mixed methods study incorporating a significant qualitative component could provide more in-depth exploration of the issues.Although the study focused on one medical school, the article recognises that strategic planning is an individual institution's affair.Notwithstanding, a nation-wide study could enhanced the generalizability of the findings.

CONSENT
Both authors declare that written informed consent was obtained from the participants for publication of this paper.

ETHICAL APPROVAL
As per international standard or university standard, written approval of Ethics committee has been collected and preserved by the authors.

COMPETING INTERESTS
Authors have declared that no competing interests exist.