Students Perceptions of the Educational Environment: A Cross-Sectional Study from a Moroccan Medical University

Introduction: The quality of the educational environment has frequently been identified

student can lead to increased satisfaction, achievement and success as a practitioner post-graduation [3,4]. A motivating learning environment fosters deep self-directed learning in the student and subsequently good medical practice in the physician. Consequently, demotivating elements such as perceived bias, poor role models, information overload, teacher centered, or disorganized teaching need to be identified and eliminated [5]. Therefore, the aim of this study is to evaluate students' perceptions, recorded on the DREEM inventory, of the overall education environment as well as specific aspects of this learning environment. A second aim of this study is to investigate whether the education environment or aspects of it are perceived more or less favorably for students of different year levels, age or gender.

Instrument
The Dundee Ready Education Environment Measure (DREEM) is a questionnaire developed by Roff et al. [2] to measure the educational environment in health professional education programs. The questionnaire was developed using a Delphi approach involving a range of professional health educators in different settings and countries. The DREEM contains 50 statements. Each statement is assessed using a 5-point Likert scale ranging from strongly agree to strongly disagree.
It is also divided into five subscales:

5.
Students' social self-perceptions (7 items, max score 28) The DREEM can be used to pinpoint more specific strengths and weaknesses. Items with mean scores≥3.5 are considered as highly positive points. Items with mean scores between 2 and 3 indicate aspects of the environment that could be improved. While items with a mean of 2 or less should be examined more closely as they indicate problem areas.

Subjects and settings
This cross-sectional study was conducted in the Faculty of Medicine and Pharmacy of Marrakech in January 2018. The questionnaire was distributed to clinical stage medical students (3 rd , 4 th , 5 th and 6 th years) in the University Hospital Mohammed VI of Marrakech, several sessions were organized within many hospital departments to explain the interest and purpose of the study. Then, the students, having accepted to participate in the survey, received the questionnaires to fill, while respecting their anonymity. These questionnaires, once completed, were given to the secretaries of each service. The students of the 7 th and the 8 th year received for their part the questionnaire directly within the faculty of Medicine and Pharmacy of Marrakech. Given the personal nature of certain questions in this survey, the questionnaire was also made available in electronic format in order to respect the privacy of students and to promote their sincerity.

Statistical analysis
The Data were analyzed using Excel 2010 and the statistical analyzes were performed by the ANOVA test. A P-value <0.05 served as the cut-off value for statistical significance.

Result
The response rate was 94.2% (total 358 out of 380 students). Among the 358 students, 120(33.52%) were male and 238(66.48%) were female. The mean age of participants was 22 ) eighth year students. 279(77.93%) students chose to study medicine, and 207(57.82%) wouldn't recommend medical studies to their friends. The mean DREEM total score was 86.5 (SD 29.194). Total DREEM scores ranged from 11 to 185. The descriptive statistics for each of the five DREEM subscales are presented in Table 1. The highest score was found in the subscale of students' perceptions of teachers (21.71/44(49.3%)), and the lowest score was found in the subscale of students' perceptions of learning (17.38/48 (36.2%)). Table 1 shows the individual item analysis of DREEM according to the five different subscales. 35 items scored less than two. Among them, 12 items were from the students' perceptions of learning subscale, four items were from the students' perceptions of teachers subscale, four items were from the students' academic self-perceptions subscale, 11 items were from the students' perceptions of atmosphere subscale and four items were from the students' social self-perceptions. The remaining 15 items scored between 2 and 3; there was no area of excellence (Item score ≥3.5). The lowest score was 0.57 for Item 3 "There is a good support system for students who get stressed". 1 I am encouraged to participate during teaching sessions 1,47 1,33 7 The teaching is often stimulating 1,23 1,21 13 The teaching is student-centered 1,32 1,18 16 The teaching helps to develop my competence 1,85 1,19 20 The teaching is well-focused 1,52 1,13 22 The teaching helps to develop my confidence 1,33 1,28 24 The teaching time is put to good use 1,3 1,29 25 The teaching over-emphasizes factual learning

Gender
Total DREEM score and sub-scale scores were derived for males and females separately; males consistently reported higher scores than female students across all disciplines Table 2. However, there was a significant difference only in two subscales, students' academic self-perception (p=0.04) and students' social self-perception (p=0.03). There were four individual items with statistically significant mean scores between male and female students Table 3. Male students' scores were significantly higher than male students' scores in three of the four items listed.

Age
There was a significant difference between age and the global DREEM and 3 DREEM subscales scores, with students younger than 21 having more positive perceptions of their learning environment than older students Table 4. Statistically significant relationships were observed between age and 7 individual items Table 5.

Discussion
The high response rate (94.2%) obtained in our study was due to the brief introduction given to students about the aim of this study, which convince them that the results of such a study would lead to significant changes in their learning. The students also perceived it as an ideal opportunity to express their opinions.
The response rate in other similar studies ranged from 44.6% to 96.9%. This showed that our response rate was among the highest, indicating that our students were keen to participate in such study to improve their school. This response rate is comparable to that obtained in Canada (91%) [3] and in Australia (90%) [6]. On the other hand, the lowest response rate obtained in King Saud University (44.6%) was explained by students' fears of participation in their study and its impact on their exam results [7]. A study in Singapore reported that 79 (80.6%) of the 98 studies which reported DREEM scores showed total DREEM scores between 100 and 150, and only 3 studies reported excellent scores between 150 and 200 [8]. The global DREEM score of 86.5/200 indicated the existence of many significant problems in the educational environment. As far as we can verify, our study had the lowest score reported among published studies using the relatively recently validated DREEM inventory. The highest score was reported in Turkey and was of 156.91 [9]. This cry from students is, unfortunately, only too common to medical and many other healthcare programs due in no small part to the quantity and quality of information that has to be absorbed during the time of studies.
The local studies, that used DREEM, showed fairly similar results: 90.5/200 in the Faculty of Medicine and Pharmacy of Rabat [10] and 99.2/200 in the Faculty of Medicine and Pharmacy of Fes [11]. Internationally, overall DREEM scores reported were 89.9/200 in Saudi Arabia [7], 94.65/200 in South Korea [12], 108.5/200 in Brazil [13], 117.2/200 in Peru [14], 131.1/200 in Thailand [15] and 135.44/200 in Mexico [16]. Among the subscale scores, students' perception of learning was lowest in our study (36.2%). This is very close to the score of 38.3% reported by Andalib [17] and of 39.58% reported by Till [3], but lower than the score of 71.7% (34.42/48) [18] reported by Vaughan [6]; Table 8. The perception of learning atmosphere, which other studies showed to have significant impact on students' behavior, academic progress, and sense of well-being, scored low in the present study. The students appear unable to concentrate, memorize or enjoy the courses while the atmosphere is not relaxed during lectures or trainings. Many studies reported generally similar findings [7,19,20]. Medical students everywhere seem to share similar concerns as reported in studies that utilized the DREEM instrument [21,22]. It is interesting that most areas of concern are related to what is taught rather than how it is taught and allude to the curriculum content rather than its delivery. There were 35 items that scored below 2, which indicated problematic areas of the learning environment. Item 3 (There is a good support system for students who get stressed) had the lowest score (0.57) in the questionnaire. This item also scored the lowest in other studies [19,23]. A study in Greece [23] found 19 problem areas, another study in Germany [24][25][26] reported 18 items with scores below 2, while a study in Iran [27] objectified the existence of 22 problem areas.
In our study, no area of excellence (Score≥3.5) was reported, which is in agreement with many studies. [24,[28][29][30][31][32][33]. This study revealed significantly higher scores for males in ASP and SSP, for students younger than 22 years old for PoT, ASP and PoA and for These findings were concordant with the results reported in Saudi Arabia [19]. On the other hand, female students had a more positive perception of the atmosphere during classes, which coincides with the results obtained in Sri Lanka [41]. The perception of environment, in this study, varied between levels of enrolment. This result is in agreement with an English study that showed that perceptions of the educational environment, learning, teachers and of atmosphere were significantly superior for first year students over second year students [42]. However, a local study reported significantly higher scores in SSP for students in their fifth year of study than those in their fourth year [10]. This cry from students is, unfortunately, only too common to medical students and many other healthcare professions programs, due in no small part to the quantity and the quality of information that has to be absorbed during the time of studies.

Conclusion
The DREEM questionnaire has been useful in identifying the strengths and the major defects of the educational environment in our faculty. The problematic areas are clear indications of where the priorities for reform should take place at the study site. A larger study may need to be undertaken to verify the above results and conclusions, and more importance should be given to the students' perception of the learning environment, as it can be used to initiate change and improvement.