INTRODUCTION

Health sciences schools and careers are currently contextualized within a global dimension known as the learning environment, an intangible multifactorial domain determined by curricular designs, teaching strategies and learning methodologies.(¹,²) Proper quality feedback, the social context and the role of models can also influence this atmosphere.(²) The main feature of this educational environment is its capacity to influence students’ behavior, their learning outcomes and their motivation and satisfaction about their own education.(³,⁴,⁵)

As medical education evolves, the students’ opinion on their own learning process is taken into account for curricular design.(⁶,⁷) In 1997, the DREEM (Dundee Ready Educational Environment Measure) was created at the Dundee University, in Scotland.(⁸) This 50-statement questionnaire constitutes a universal, not culturally-specific tool, with qualitative and quantitative methodologies, and allows the creation of an educational profile based on the following domains: learning, teacher, academic, atmosphere, and social perceptions.(⁹,¹⁰) Moreover, it has excellent psychometric properties,(¹¹,¹²) validity and internal reliability,(¹³) and it has been used in several countries from Europe, Asia, Africa and Latin America, and in several health science schools, like Medicine, Nursing and Dentistry.¹⁴,¹⁵,¹⁶) Regarding dentistry, its application has been reported in New Zealand, Germany, and India, while very little evidence seems to be available for Latin America.(¹⁵,¹⁷)

In Chile, the learning environment has been assessed in medical education but no studies have been published so far for dental schools in public universities..(⁴) It is therefore mandatory to assess this educational context, in order to make curricular changes and improvements and to boost the learning outcomes.(¹⁸)

The aim of the present study is to assess the learning environment in the new dentistry program at the Arturo Prat University, in northern Chile, using the DREEM questionnaire. The proposed hypotheses are: 1) the educational environment is perceived as favorable to learning and 2) there are no significant differences in perception between the basic, the pre-clinical and the clinical levels of the dentistry career.

MATERIALS AND METHODS

RESULTS

One hundred three of the 113 interviews were correctly answered and 8.9% of dropout was confirmed. Twenty-eight interviews corresponded to the basic level, fifty-one to the pre-clinical level, and twenty-four to the clinical level. The mean scores by level and domain are shown in Table 1, and the frequency distributions for qualitative rating in Figure 1.

Figure 1: Frequency (%) of distribution of qualitative rates by academic level 

In the basic level, the mean scores for all the domains are in the positive range, with 85.7% of participants grading the environment as ‘more positive than negative’ and 3.6% as ‘with many problems’. The global mean score is 131.78/200 points, corresponding to a ‘more positive than negative’ environment. In the pre-clinical level, all the domains except ‘social perception’ are in the positive range. In this item, the total mean score is 14.76/28 points, placing it in the limit between the negative and the positive range. The total mean score for this level is 120.80/200, qualifying as ‘a more positive than negative’ educational environment. In this level, 17.6% of participants rated the environment as ‘with many problems’ and a 78.4% as ‘more positive than negative’.

The results show a greater imparity in the clinical level. 54.2% of students rated the learning environment as ‘with many problems’ and 45.8% as ‘more positive than negative’. ‘Teacher perception’, ‘atmosphere perception’ and ‘social perception’ were rated in the negative range, with 22.04/44 points, 20.75/48 points and 14.08/28 points, respectively. The global mean score for the perception is 100.75/200 points, corresponding to a ‘more positive than negative’ environment, at the limit between negative and positive range.

The total mean score for all the three levels and five domains is 117.80/200 points, qualifying for a ‘more positive than negative’ global learning environment.

The mean scores among the three levels and arranged by domain and statement are shown in table 2. For the ‘learning perception’ domain, the highest mean values were obtained in questions 1 and 16, related to learning and motivation, whereas the lowest scores (less than 2 points) were in the items 25 and 48, related to the learning focus. In the ‘teacher perception’ domain, only statement 2 obtained a high score (over 3 points), concerning teachers’ knowledge. The lower mean score was found in question 9, related to the authoritarianism of teachers. No score was below 2 points (qualitatively negative). In relation to the ‘atmosphere domain’, no statement scored over 3 points. All items scored between 2 and 3 points, except for items 12, 17, and 42, in relation to schedule management, coping phenomenon and stress, respectively. In the ‘social perception’ domain, only item 15 ‘I have good friends’ scored over 3 points, and questions 3, 4 and 14 have scores below 2 points, regarding student support systems, burnout and motivation, respectively.

The statistical comparison by domain and among levels is shown in table 3. For the ‘learning perception’ domain, statistical significant differences were found for the three study levels, with a decreasing tendency from the basic to the clinical level. For ‘teacher perception’, ‘academic perception’, and ‘atmosphere perception’, no significant differences were observed between the basic and the pre-clinical level, but between the clinical level and the other two levels, also with a decreasing tendency. When comparing the scores from the ‘social perception’ domain, no significant differences were found among levels.

The comparison of the global mean scores did not show statistical significant differences between the basic (131.78/200) and the pre-clinical level (120.80/200). Both groups differ statistically from the clinical level, showing a similar decreasing trend towards the clinical academic course (100.87/200).

DISCUSSION

The learning environment is now considered essential in the health sciences curricula, mostly because of its several influencing factors and its impact on students’ learning outcomes.(¹⁴) In the present study-the first one conducted in a dentistry program in a public institution in Chile, which had a 90.1% of participation-, the students’ perception of the learning environment was assessed by applying the DREEM questionnaire. The results demonstrate that the overall perception of this educational atmosphere is more positive than negative, hence favoring learning. This confirms our first hypothesis. When analyzing the overall score by level and qualitative significance, a constant and significant decrease is observed from the basic to the clinical level, when students usually face new and more complex academic challenges-and thus the second hypothesis is not validated.

The results corresponding to the clinical level show a greater impact on the students’ psychosocial conditions. This is evidenced from the questionnaire statements on the atmosphere and social perceptions domains regarding stress. Several psychosocial and academic factors have been described in the literature and have been correlated with a lower positive perception at the clinical level: a) the first real contact with patients; b) the perception of a higher degree of courses difficulty; c) the fear of not achieving the minimum requirements of each program; d) the varying degrees of criticism and authoritarianism, and e) the lack of proper feedback.(¹⁹,²⁰,²¹,²²) In the present study, we also observed a lower qualitative perception of the student support system, which plays a key role in the perception of the learning environment and stress. The need for an adequate support system available in all institutions has already been discussed in the literature.(²³,²⁴) In general terms, these strategies seek to develop resilience and the professional vocation, as well as the acquisition of learning strategies and tools based on a personal approach, through multidisciplinary mentoring networks. (²⁵) The results and the available evidence suggest that it is essential to develop an adequate support system for the clinical level in particular. However, some strengths can be highlighted, such as how teachers’ knowledge can help improve self confidence in students. This is reflected in the present study as a higher perception of teacher and academic environment, which are the domains that scored the highest qualitative values.

There is high variability among the mean scores for each statement of the five domains. This shows the complex interaction of the psychosocial factors and how the perception of each domain can be influenced by each factor. Even though DREEM has been described as a not culturally-specific tool, and as an instrument of universal use and application, one must be especially cautious when comparing results with dental schools among countries, mostly because of the heterogeneity of the social profiles worldwide. Comparisons should be taken as a reference and not as an absolute contrast.(¹⁵,¹⁶,¹⁷,²³)

CONCLUSIONS

The learning environment is positively perceived by students of the Arturo Prat University. However, when analyzing by DREEM domains, some significant differences can be found between academic levels, and some domains seem to be negatively perceived. There is a tendency to a lower perception from the basic to the clinical level, mostly due to psychosocial factors. It is necessary to enhance student support systems in order to compensate this drawback and to promote better learning.