Faculty and Students ’ Perceptions of Student Experiences in a Medical School Undergoing Curricular Transition in the United Arab Emirates

OBJECTIVES
In 2008, the Gulf Medical College in the United Arab Emirates underwent a curricular change from a discipline-based to an organ-system-based integrated curriculum. In this context, this study aimed to compare the faculty and students' perceptions of the student experiences with the new curriculum.


METHODS
Data were collected from faculty and second-year students in the integrated curriculum using the Dundee Ready Education Environment Measure (DREEM). Data collected were transferred to Predictive Analytics Software, Version 18. Global and domain scores were assessed with the Wilcoxon Rank-Sum Test. Percentage agreement, disagreement and uncertainty were assessed by the z-test for proportion.


RESULTS
There were no significant differences between the total DREEM scores of faculty (139/200) and students (135/200). The faculty perceived that the students were experiencing significantly more positive learning as indicated by the domain score of "Students' Perceptions of Learning". Proportions of agreement between faculty and students showed that more faculty members than students perceived the need for increased feedback to students and a greater emphasis on long term learning.


CONCLUSION
The study showed that the faculty and students had similar perceptions about the student experiences in the integrated curriculum. Areas necessitating remedial measures were the need for faculty to learn constructive feedback techniques and an emphasis on long term learning in the new curriculum.

2][3] A conducive educational environment will result in positive learning outcomes. 1The connection between the learning environment and the curriculum is robust.The "curriculum's most significant manifestation and conceptualization is the environment, educational and organizational, which embraces everything that is happening in the medical school". 1 Following in-depth reviews in 2008 of the existing curriculum at the Gulf Medical College, in Ajman, United Arab Emirates (UAE), which revealed major weaknesses, a major curricular change was introduced from a traditional disciplinebased curriculum to a modular, organ-systembased integrated curriculum with elements of problem-based learning (PBL).The new curriculum accentuates student-centered learning with more interactive teaching/learning sessions such as small group learning, computer-aided learning, case-based learning and PBL.The language of instruction remains English as in the previous curriculum.The first year involves an introduction to medical sciences beginning with courses like Cells, Molecules and Genes and then moving on to more in-depth courses such as Tissues and Organs; Embryogenesis and Life Cycle; Metabolism and Nutrition, and Internal and External Environment.Courses like Language and Communication Skills and Psychosocial Sciences introduce the students to various aspects of the delicate doctor-patient relationship.The next two years are dedicated to the integrated study of organ systems.The final two years are the clinical clerkship phase which is followed by a one-year compulsory rotating internship.
Students' perceptions of the educational environment have been explored in depth, [4][5][6][7] but the same attention has not been paid to teachers' perceptions.Faculty perceptions of the educational environment will have a strong bearing on the learning environment of the students. 1As the learning environment is an important determinant of the behaviour of both students and teachers, a comparative study of the perceptions of the teaching faculty and the students will enable the development of guidelines to improve the quality of the educational environment in any institution.Such a study would also help ascertain whether the faculty perceptions of student experiences in the new integrated curriculum actually align with those of the students.Subsequently, these findings will probably reveal the strengths and weaknesses of a newly introduced curriculum with the findings contributing to the ultimate aim of refining it.
The aim of this study was to compare the faculty members' and students' perceptions of the student experiences after one year of study in the newly introduced organ-system based integrated curriculum at the Gulf Medical College, Ajman, UAE.

Methods
5][6][7] This questionnaire has identified the perceived weaknesses of a new curriculum 3 and has been used to compare the educational environment in two different curricula. 7,9In a UK medical school, a modified version of the DREEM inventory 10 was used to compare the perceptions of teachers and students.

Constructive feedback techniques and more emphasis on long-term learning were areas identified as requiring remedial intervention.
Application to the patient care 1.The insights gained from this study into student and faculty perceptions of student experiences should help in the design of better curricular strategies to maximise the learning of future physicians.It should ultimately improve the quality of health care which they will subsequently deliver.
The DREEM Questionnaire was pilot tested on a sample of our students and faculty.Following the pilot study, descriptive phrases were added to some items of the questionnaire for better understanding.As the DREEM Questionnaire was originally developed to give only the students' perceptions of the educational environment.The faculty DREEM Questionnaire was modified in our study to assess the perceptions of the faculty about the student experiences in our institution.(I feel comfortable in class socially was modified to The students feel comfortable in class socially).
The questionnaire was administered to 44 second year students in the integrated curriculum at the Gulf Medical College at the beginning of the 2009 academic year.Brief explanations of the objectives and the method of filling out the questionnaire were given.
The 28 faculty members of the Gulf Medical College, teaching in the integrated curriculum of the Bachelor of Medicine, Bachelor of Surgery (MBBS) programme, were given details of the objectives.They were informed that their perceptions should be about the students' experiences in the previous academic year.They were encouraged to answer items regarding students' personal views of the environment (e.g.students have good friends in this school), or which were outside the context in which the staff dealt with the students (e.g.teachers are patient with the hospital patients) as "unsure".
Voluntary participation was stressed for both the sample groups.The DREEM questionnaire was answered anonymously by both students and faculty.The study was approved by the Ethics Review Committee of the institution.
Data were analysed using the statistical package Predictive Analytics Software (Version 18, IBM, Illinois, Chicago, USA).The mean global scores and domain scores were expressed as mean ± standard deviation (SD).The comparison of scores was done using the Wilcoxon Rank-Sum Test.A P value of less than 0.05 was considered statistically significant.We also analysed the domain scores based on the interpretation suggested by Mc Aleer and Roff. 11s there were items in the DREEM questionnaire on the personal views of the students, we anticipated a large number of "unsure" responses by the faculty." Hence, to weed out the actual differences between the student and faculty responses, the responses to each individual item of the questionnaire were classified into three categories: ' Agreement' (strongly agree/agree), 'Disagreement' (strongly disagree/disagree) and 'Unsure' (unsure); they were compared using the z-test for proportion with a significance level of 0.05.

Results
The response rate for the faculty was 93% and all students present in the class on the day of the survey responded (93% of all second year students).The characteristics of the sample are given in Table 1.The total DREEM scores for the faculty and the students Perceptions of Teachers in the range 23-33 revealed that both the groups perceived "moving in the right direction" for the teachers; scores between 17-24 for Students' Academic Self-Perceptions showed "feeling more on the positive side" for the academic self-perception; scores between 25-36 for Students' Perceptions of Atmosphere indicated "a more positive atmosphere" and scores between 15-21 for Students' Social Self-Perceptions suggested "not too bad" for the social self-perceptions.As the domain score of Students' Perceptions of Learning for faculty was 36.8, they perceived "teaching highly thought of " while the students perceived "a more positive approach" for the learning (Students' Perceptions of Learning score of 33.4).The mean domain score for this domain (SPL) was significantly higher for the faculty as compared to the students (P < 0.001).
The faculty identified Perception of Learning as the domain with the highest mean score, whereas the students gave the highest scores to the domains Perception of Learning and Academic Self-Perceptions.Both groups gave the lowest mean scores to the domain Social Self-Perceptions.
There was consensus between the faculty and students with respect to percentage agreement, disagreement and uncertainty.On comparison of percentage agreement, the faculty tended to agree significantly more than the students for two items: #47 Long term learning is given importance over short term learning, and #29 The teachers are good at providing feedback to students.On the other hand, the students tended to agree significantly more than the faculty for 9 items: #  3 & 4].
Analysis of percentage uncertainty identified two items for which faculty were significantly unsure as compared to the students: #11 The atmosphere is relaxed during the hospital ward teaching and #46 The student's accommodation is pleasant.

Discussion
The educational environment is the soul and spirit of the medical curriculum. 1 The success of an effective curriculum depends on a positive educational environment.A curricular modification will customarily affect the educational environment.Hence, we anticipated a positive change in the learning environment of our institution due to a shift to a more student-centered curriculum.
For curricular change to be a successful, the commitment of the faculty must be ensured.Faculty perceptions of the changed educational environment could not be assessed due to the lack of an appropriate instrument, so we dealt with this problem by modifying the DREEM questionnaire and using it to assess the perceptions of the faculty about student experiences in our school.The same instrument was used to investigate whether the views of the faculty and students were univocal with respect to the student experiences in the new integrated curriculum.
We had an acceptable response rate of 93% for both the faculty and students.We found that the total DREEM mean scores of our faculty (139/200) and students (135/200) were lower than that found by Miles and Leinster 10 (144/200 for staff and 141/200 for students).
The results of the present study show that both the faculty and students had positive perceptions of the student experiences in the educational environment, which is similar to that reported by Miles and Leinster. 10These higher scores can be ascribed to the student-centered curricular change which is fully endorsed both by the faculty and the students.The faculty in our study perceived that the students were experiencing significantly more positive learning as indicated by the domain score of Students' Perceptions of Learning.Proportions of agreement between faculty and students showed that more faculty members than students thought there was increased feedback to students and a greater emphasis on long term learning.
"Curriculum generates and establishes environment". 1As the curriculum forms an integral part of the educational environment, we used it as a proxy for comparison between faculty and student perceptions of the educational environment.We therefore looked at studies dealing with faculty and student perceptions of the curriculum.We found a plethora of studies detailing student perceptions of integrated medical curricula, but studies focusing on faculty perceptions and comparing faculty and student perceptions were sparse.Many previous studies [12][13][14] have shown teachers' views on revised, integrated, problem-based medical curricula to be positive, with the students in the new curriculum being perceived as faring better in many respects, including taking self-directed learning initiatives, gaining problemsolving and interpersonal skills, and improved clinical performance in patient care.Our study, which showed a positive effect on faculty members' attitudes to students' experiences and (indirectly) to the curriculum, is similar to that reported by

Students social self-perceptions (SSP)
There is a good support system for students who get stressed 18  Tavanaiepour et al.where they concluded that a hybrid curriculum had almost as great a positive effect as did the PBL curriculum. 15In two other studies, the students' and faculty's opinions about PBL were found to be closely aligned and positive. 16,17Brynhildsen et al. found that students and teachers highly appreciated horizontal and vertical integration. 18Our findings appear to be consistent with the above studies.
Enduring and successful curricular change necessitates the support of all the stakeholders. 19actors found to be positively associated with successful innovation are 1) participating students' acceptance, feedback and enthusiasm for the change; 2) a cooperative environment, characterised by collaborative problem solving, harmony, effective communication and skillful conflict resolution; 3) involvement of different disciplines or departments in the planning and implementation of curricular innovation; 4) ensuring faculty involvement (through orientations, problem-solving teams, committees) so as to strengthen their collective ownership of the project and deepen their commitment to seeing the innovation through to completion; 5) frequent, timely, substantive and effective communication among participants to promote understanding of the goals; 6) faculty comprehension of the theoretical underpinnings of the desired innovati on and the required training in the skills to implement it; 7) formative evaluation (through focus groups and student feedback) to locate difficulties and solve problems thus fostering a cooperative climate, and renewing ''ownership'' of the project and 8) stable positive leadership with leaders who effectively communicate and promote the organisation's shared vision for curricular change. 20All these factors were an essential component of the curricular change in our institution and may have contributed to most faculty and students finding the experiences of the students in the new curriculum favourable.This study, in fact, contributed to the evaluation process of our curricular change.
The higher mean scores in the domain Students' Perception of Learning by both groups reflects the positive response to our student-centered curriculum which emphasises long term learning and problem solving skills.Low scores in the domain Social Self-Perceptions by the faculty does not reveal perceptions of weaknesses, but suggests staff 's unfamiliarity with these aspects of the students' experience.We had in fact mentioned that the faculty was advised to select "unsure" when the statements dealt with Social Self-Perceptions and other unfamiliar aspects.However, the low student scores for the domain Social Self-Perceptions reveal this to be an area of weakness necessitating rectification.This had already been identified in another study conducted in our institution where the insufficient support system for stressed students, the tiredness of students and the tediousness of the course emerged as areas of concern. 9e were aware that the DREEM was not designed to investigate other stakeholders' opinions on how the students experience their educational climate.Consequently, we compared the percentage of agreement, disagreement and uncertainty rather than analysing subscale and item mean scores so as to provide a clearer view of staff and student perceptions of the students' experience.Comparison of percentage agreement (faculty and students who agreed/strongly agreed) identified two areas where the staff significantly believed that students would have a more positive perception than the students actually did.These two items were: Long-term learning is given importance over short term learning and The teachers are good at providing feedback to students.
Students in PBL curricula tend to use a more in-depth approach of learning and have a greater intrinsic interest in learning and this may foster long-term knowledge retention. 21,22s students' learning approaches are affected by their perceptions of the learning environment, any changes in learning environment will invariably alter their learning approach. 23,24Though our new curriculum had incorporated features to enhance a deep approach to learning (clearly written learning objectives, assessment methods aligned to the learning objectives, student-centered teaching) 25 apparently these were not sufficient to influence the students and thus faculty and students perceptions' were not in consensus.
Effective feedback is a renowned catalyst for effective learning, especially for average or poor performers.Feedback should be given in a way that "helps the recipient to listen to it, receive it constructively, reflect on it, and consider how to take action as a result". 26However, often there is a mismatch between student expectations and faculty feedback practices, 27,28 as also perceived in our study.
The rest of the items with which the students tended to agree significantly more compared to the faculty were mainly items with which the predominantly basic sciences staff were unfamiliar, e.g.The teachers are patient with the hospital patients; or unsure as these concerned the personal views of the students, for example, The students are confident about passing this year; The students have learned a lot about empathy in the profession; The students have good friends in this school; The students' social life is good; Similarly, the two items about which the faculty were significantly unsure compared to the students, The atmosphere is relaxed during the hospital ward teaching; The student's accommodation is pleasant, also dealt with areas involving personal views of the students.
The comparison of student and faculty perceptions revealed the need for certain interventions to improve our curriculum.Constructive and effective feedback techniques should be reinforced through faculty development programmes so as to influence attitudes as well as skills.Formative feedback should be task oriented, simple, timely, provided by the appropriate person, in a friendly non-threatening climate and involve praise alongside constructive criticism and corrective advice. 26,28,29However, as student satisfaction ratings are not an accurate indicator of the quality of feedback, improved performance should instead be the gauge. 27Avoidance of curriculum overload, clearly written objectives, teaching practices promoting conceptual change, assessments which emphasise understanding and application should be adopted to enhance long term learning. 25ur study provides preliminary data about the faculty perceptions' of the student experiences in the new curriculum.We are aware that our study was restricted to one school and our sample size was small.Consequently, it may be premature to come to concrete conclusions, or to generalise the results to other schools.The method we have used is subjective and dependent on students' and teachers' recollections of students' experiences from the previous year; however, these perceptions will inevitably have some relation to actual faculty and student behaviour.Future structured qualitative studies can also deal with the limitations of these questionnaire-based data. 30Another limitation is that the instrument used was not intended to evaluate staff opinions about the students' experience with the educational environment.We dealt with this limitation by analysing the data slightly differently so as to extract valuable differences between the staff and student opinions of the student experiences.While all attempts had been made to ensure validity of the questionnaire, we are aware that a modification of the instrument may have had an effect on the validity.

Conclusion
The desired outcomes of excellent student behaviour, achievement, satisfaction and success have a proven connection to positive perceptions of the educational environment.Moreover, continuous assessments are important for the sustainability of the curriculum.Student and faculty perceptions are essential as they have direct impact on teaching and learning, and the development and well-being of the students. 1In addition, these different perspectives will shed light on alternative focus points in the improvement of the new curriculum.Although the modified DREEM questionnaire identified that both the students and the faculty perceived that the new organ system-based integrated curriculum provided a good educational environment, they also had differing perceptions regarding effective feedback and the emphasis on long term learning.Therefore, the remedial measures identified were that faculty should learn constructive feedback techniques, and a greater emphasis should be placed on long term learning in the new curriculum.

Table 1 .
Demographics of the study sample

Table 2 :
Mean ± standard deviation Dundee Ready Education Environment Measure (DREEM) domain scores (% of maximum score) for faculty and students *P = <0.001was 139/200 and 135/200 respectively.The mean domain scores obtained by faculty and students are shown in Table 2.The domain scores of Students'

Table 3 :
Items with significant differences between faculty and students

Table 4 :
Examples of items without significant differences between faculty and students