Medical laboratory science and nursing students’ perception of academic learning environment in a Philippine university using Dundee Ready Educational Environment Measure (DREEM)

Purpose This study aimed to compare the perception of the academic learning environment between medical laboratory science students and nursing students at Saint Louis University, Baguio City, Philippines. Methods A cross-sectional survey research design was used to measure the perceptions of the participants. A total of 341 students from the Department of Medical Laboratory Science, School of Natural Sciences, and the School of Nursing answered the Dundee Ready Education Environment Measure (DREEM) instrument from April to May 2016. Responses were compared according to course of study, gender, and year level. Results The total mean DREEM scores of the medical laboratory science students and nursing students did not differ significantly when grouped according to course of study, gender, or year level. Medical laboratory science students had significantly lower mean scores in the sub-domains ‘perception of learning’ and ‘perception of teaching.’ Male medical laboratory science students had significantly lower mean scores in the sub-domain ‘perception of learning’ among second year students. Medical laboratory science students had significantly lower mean scores in the sub-domain ‘perception of learning.’ Nursing students identified 7 problem areas, most of which were related to their instructors. Conclusion Medical laboratory science and nursing students viewed their academic learning environment as ‘more positive than negative.’ However, the relationship of the nursing instructors to their students needs improvement.


Introduction
The Dundee Ready Educational Environment Measure (DREEM) instrument is commonly used to evaluate the learning environment of medical science and other health science students in various academic settings, and the results can be used to compare different institutions offering health courses [1,2,3,4]. Since having been developed over 10 years ago, this instrument has been used to outline the strengths and weak-nesses of institutions based on the perceptions of their students [5]. In the Philippines, the DREEM is not commonly utilized to determine the perceptions of students concerning their learning environment. Aside from the lack of records on the strengths or weaknesses of institutions offering health professions courses, the Commission on Higher Education has also reported that tertiary level schools in the Philippines face several problems, such as having unqualified or poorly trained teachers, inadequate facilities, and dilapidated instructional materials (Southeast Asian Ministers of Education Organization, Innovation and Technology [SEAMEO INNOTECH], 2003). In recent years, non-traditional instruction methodologies such as the utilization of technology have been adopted and implemented at some higher education institutions in the http://jeehp.org J Educ Eval Health Prof 2016; 13: 33 • http://dx.doi.org/10.3352/jeehp.2016. 13.33 Philippines, but a gap exists between the level of prioritization of this educational reform and its degree of implementation [6]. Hence, it would be ideal to determine the perceptions of health science students concerning their learning environment, in order to initiate relevant educational reforms.
This study describes the perceptions of medical laboratory science students and nursing students at Saint Louis University, Baguio City, Philippines. Specifically, the study compared the total DREEM scores, sub-domain scores, and DREEM item scores between medical laboratory science and nursing students. The results could provide a reference point for further improvement of the curricula of medical laboratory science and nursing studies in the Philippines.

Study design
A cross-sectional survey research design was used.

Materials and subjects
The participants in this study were students of Saint Louis University, Baguio City, Philippines. The inclusion criteria in the study are currently enrolled students in their second and third year during the academic year of 2015-2016. First-year students were excluded because their basic professional courses were not yet completed. Fourth-year students were also excluded because they are deployed across various primary, secondary, and tertiary health institutions in different provinces of Luzon, making it difficult to distribute and retrieve questionnaires.
The total number of participants was 1,147 (571 second-year students and 576 third-year students) and the significance level was set at 5%, with the confidence level at 95%. A total of 421 questionnaires were distributed to randomly selected students in the Department of Medical Laboratory Science, School of Natural Sciences, and in the School of Nursing. Only 341 students answered and returned the questionnaire. The questionnaires were distributed and the data were collected from April to May, 2016.
The DREEM instrument was used to determine the students' perception of learning, teaching, academic atmosphere, and their social and academic self-perception. For each item on the questionnaire, students provided a score rangingfrom0 to4 (0 = strongly disagree, 1 = disagree, 2 = unsure, 3 = agree, and 4 = strongly agree). Out of a total of 50 questions, 9 negative items were scored in a reverse manner prior to analysis and interpretation (items 4,8,9,17,25,35,39,48, and 50) [6]. The demographic profiles of the respondents, including details such as course, year level, and age, were also obtained to compare the mean scores. The DREEM instrument has been used in several countries, translated into 8 languages, and applied to evaluate the perceptions of medical students and students of other allied health courses [1]. As a generic instrument for providing a profile of a health institution's strengths and weaknesses, the DREEM instrument is generally accepted as valid [6]. The use of DREEM tool from Roff et al. [7] was permitted by Dr. Sue Roff.

Statistical analysis
The scores of students were obtained and reported as mean ± standard deviation. A perfect score on the DREEM questionnaire is 200. The means of the subscales and individual DREEM items were also obtained to determine problem areas. The software program IBM SPSS ver. 20.0 (IBM Co., Armonk, NY, USA) was used for statistical analysis. To determine significant differences in total mean scores, subscale mean scores, and DREEM item mean scores, independent t-test was utilized. If applicable, one-way analysis of variance with a post hoc Tukey honest significant difference test was also utilized. A finding of

Results
The total average DREEM score from the students' evaluations was 121.26 ± 20.18 out of a total of 200 points, which can be interpreted as a 'more positive than negative' perception of the learning environment at the academic institution. Mean scores for all students were also calculated for the sub-domains of perception of learning (27.67± 5.11/40), perception of teaching (26.70 ± 4.84/44), perception of the academic atmosphere (29.28 ± 5.59/48), academic self-perception (21.06 ± 4.32/32), and social self-perception (16.55± 3.25/28). Table 2 shows that, generally, nursing students had higher mean scores in the subdomains of perception of learning, perception of teaching, and social self-perception. Among them the differences in the mean sub-domain scores for perception of learning and perception of teaching between the two student groups were statistically significant In contrast, the mean scores of medical laboratory science students in academic self-perception were higher, but the difference was not statistically significant. Table 3 shows that female nursing students had the highest mean total DREEM scores and highest mean scores in perception of learning, perception of atmosphere, and social selfperception, while female medical laboratory science students   had a higher mean score on academic self-perception, and male nursing students had the highest mean score on perception of teaching. Male medical laboratory science students had the lowest mean total DREEM score and lowest mean scores in perception of learning, perception of teaching, academic self-perception, and social self-perception. Male nursing students had the lowest mean score in perception of atmosphere. However, only the difference in mean score in perception of learning was statistically significant. Table 4 shows that the mean total DREEM scores were higher among third-year students than second-year students in both courses. The highest average total DREEM score and highest average scores in perception of learning, perception of teaching, academic self-perception, and social self-perception were provided by third-year nursing students. The lowest mean total DREEM score and lowest scores in perception of learning, perception of teaching, and social self-perception were provided by second-year medical laboratory science students, while the lowest mean scores in academic self-perception and perception of atmosphere were provided by second-year nursing students and third-year nursing students, respectively. Only the mean score in the perception of learning among the students was significantly different. Table 5 shows the mean DREEM scores of medical laboratory science and nursing students per item. The scores ranged from 1.07 ± 1.10 to 2.44 ± 0.98 for negative items (scores were reversed) and 2.25 ± 0.82 to 2.97 ± 0.91 for positive items, indicating that the students perceived these items as either problem areas or aspects that needed improvement. Furthermore, there were 7 negatively stated items rated by nursing students, which had mean scores greater than 2. Since the scores were reversed, a mean score of > 2 is interpreted as a problem area. Hence, a lower score on negatively stated items is desirable [2]. Medical laboratory science students and nursing students had significantly different scores on item 7 ('teaching is often stimulating'), item 25 ('over-emphasis on factual learning'), item 48 ('teaching is too teacher-centered'), item 9 ('instructors are authoritarian'), item 39 ('the instructors get angry in class'), item 50 ('the students irritate the instructors'), item 12 ('the program is well-scheduled'), and item 4 ('being too tired to enjoy the course'). For negatively stated items, nursing students had a mean score greater than 2 (scores are reversed), implying a less desirable response compared to medical laboratory science students.

Discussion
Overall, medical laboratory science students and nursing students did not have significantly different perceptions of their academic learning environments. The mean total DREEM scores of the students were 'more positive than negative. ' This means that the academic learning environment can still be improved to benefit the students. Among the different subdomains, the mean scores on the perception of learning and perception of teaching significantly differed between medical laboratory science and nursing students. When grouped into gender and year level, only the sub-domain 'perception of learning' was considered to be significantly different (Tables 3, 4).
The differences in DREEM scores may be attributed to several factors related to the curriculum, faculty profile, subjects offered, and types of academic requirements. Since medical laboratory science students and nursing students do not have similar academic requirements, especially in third year, the differences in the mean scores under perception of learning may be attributed to academic requirements 'per se' .
Differences in the total DREEM scores and mean scores for sub-domains between male and female students have been reported in other studies [3,[8][9][10] although the results have not been consistent regarding whether either gender has higher mean scores for the total score, sub-domain scores, or individual DREEM item scores. One possible explanation, though, is the difference in the population of female students in these health professions courses compared to males. Similar to what has been found in other studies at several academic institutions, there were more females enrolled in health science courses compared to males in this study [2][3][4][9][10][11]. Having more female students in a course may cause the academic environment to be more suited to women [10], which leads to a 'feminized' assessment design and implementation in the tertiary level [12]. However, male chiropractic students had higher total DREEM scores and higher scores in the five sub-domains, and this population was comprised more of males than females [3]. This inconsistency in the scores may be related to the gender profile of the respondents and may warrant further study.
The differences in the perception of male and female medical laboratory science and nursing students in this study could also be related to differences in their learning styles. Male nursing and midwifery students have been reported to be less reflective observers than females, but more borderline divergers and accommodators in their learning style [13]. However, male physiotherapy students were reported to be more assimilators and convergers, while females were described to be accommodators and divergers [14]. Unfortunately, there is no available data on the learning styles of medical laboratory science students. These data from other studies imply that learning styles may be independent of gender and course.
Several studies have reported different trends in the perception of the academic learning environment based on year level. The perception of nursing students on the academic learning environment, for instance, was less positive among thirdhttp://jeehp.org  year and fourth-year students [15]. The differences in the mean scores of medical laboratory science and nursing students may be attributed to the nature of the course of study itself. The subjects offered to second-year medical laboratory science students and second-year nursing students are almost the same except for introductory professional courses, that is, introductory clinical chemistry for medical laboratory science students and community and public health for nursing students. Similarly, both courses start their clinical duties during their third year. Furthermore, the instructors for non-professional subjects in both courses came from allied departments. It was then expected that second-year medical laboratory science students and nursing students should have similar total scores and subdomain scores on the DREEM instrument. It was also to be expected that the perceptions of third-year medical laboratory science students and third-year nursing students should be different, but only the mean score under the sub-domain 'perception of learning' was statistically significantly different between the two groups of third-year students (Table 4). Nursing students identified more problem areas compared to medical laboratory science students. Most of the problem areas identified by nursing students were related to their instructors, although the greatest problem area was identified as 'over-emphasis on factual learning' . Some of the perceived problem areas for their instructors were: 'teaching is too teachercentered, ' 'instructors ridicule the students, ' 'instructors are authoritarian, ' 'instructors get angry in class, ' and 'the students irritate the instructors. ' The role of instructors is crucial in the formation of their students [16]. Nursing instructors are faced with several challenges when educating their students to ensure that their students provide safe patient care in various healthcare settings. These challenges include managing students in the clinical setting to promote safe patient care. However, instructors who lack experience in managing students may display negative behavior. This could be a reason why instructors may display aloof, intimidating, demeaning, arrogant, or unfair attitudes towards their students [17]. Consequently, the behavior of instructors may cause stress for nursing students.
This study has revealed that there is a need to further improve the academic learning environment of students and to address the concerns revealed by the students in this study. Furthermore, this study reports the perceptions of medical laboratory science and nursing students, providing initial data on profiling the educational setting of medical laboratory science and nursing schools in the Philippines. The information could be used as a basis for improving the academic learning environment of health science students in the country.