The response rate in the present study was 90.7%, which is higher than the response rate of 85%, 59%, and 50% reported from studies conducted in Saudi Arabia, Greece, and Malaysia medical schools, respectively (Al-Kabbaa et al., 2012; Dimoliatis et al., 2010; Ugusman et al., 2015). The high response rate in this study might be attributed to the students' expectation that the survey's findings will have a beneficial impact on their learning environment as well as the study's brief description of its goal. A summary of the clinical year medical students' opinions of their JUMC learning environment was given by the DREEM questionnaire, which also emphasized the variations in views based on gender, academic year, and attachment wards. Comparative evaluations of medical students' perceptions of educational environments within an institution and between gender, year of study, and attachment wards were also carried out using the DREEM inventory tool (Abera, 2016; Al-Saleh et al., 2018; Nosair et al., 2015).
In this study, the overall DREAM score was 111.3 ± 13.67/200 (55.7%), which falls within the range of Roff et al. (1997) a practical guide (101–150) that suggests a view of the learning environment that is "more positive than negative”. This result might reflect the experience of JUMC in teaching medical students and the standard of the infrastructure and human resources available to create the best possible conditions for learning and teaching. The present study's mean score was comparable to the total DREEM score of; 114.4/200, 109.9/200, 112/200, and 110/200 reported from medical schools in Pakistan (Jawaid et al., 2013), Trinidad (Bassaw et al., 2003), Faisalabad (Umber et al., 2011) and Ethiopia (Abera, 2016), respectively. However, the overall DREEM mean score found in this study was higher than the DREEM score of 89.9/200 obtained from King Saud University, Riyadh (Al Ayed & Sheik, 2008), and 101.82/200 from the University of Nigeria (Okoye et al., 2017). This result was lower than the mean scores of 125.3/200 (Al-Naggar et al., 2014) and 134/200 (Lai et al., 2009) reported in Malaysia, and 139/200 reported in the United Kingdom (Varma et al., 2005).
Based on the findings of this investigation and the useful manual by McAleer and Roff (McAleer, 2001), the mean score for each five-domain indicated that SPL was positive, SPT was heading correctly, SASP was doing well, and SPA exuded a more positive atmosphere, and SSSP was fair enough. None of the subscales found a mean score in the range of excellent. This result is in agreement with the findings reported from another study conducted in Ethiopia (Abera, 2016), Bangladesh (Mohsena et al., 2016), Malaysia (Al-Naggar et al., 2014; Lai et al., 2009), and Saudi Arabia (Al-hazimi et al., 2004). Moreover, several other studies have reported similar perceptions in four of the five domains except for a lower mean score for the SASP subdomain (Al-hazimi et al., 2004; Roff et al., 2001), and a lower mean score for the SSSP subdomain was reported in the College of Medicine, King Saud University (Al Ayed & Sheik, 2008) and Suez Canal University, Egypt (Youssef et al., 2013).
Regarding gender-wise comparison in each of the five domains, this study showed a higher mean score in females than males. However, significant differences were observed only in SPT and SPA subscales. Significant gender disparities were also observed in other research, with female students having more positive perceptions of the learning environment (Al-Naggar et al., 2014; Ugusman et al., 2015).
In this study, Female students obtained higher mean scores (113.35 ± 15.68) in overall DREEM compared to students who were male, and the variation was statistically significant (P = 0.038), which is similar to studies found that in Sweden, the perceptions of female students were positive than those of male students (Jakobsson et al., 2011), Nigeria (Roff et al., 2001), and Iran (Bakhshialiabad et al., 2015). However, studies conducted in the Middle East did not identify any substantial differences between males and females (Al-hazimi et al., 2004; Bouhaimed et al., 2009), Trinidad (Bassaw et al., 2003), and India (Abraham et al., 2008). Overall, the findings suggested a higher degree of positive perception of learning settings among female students compared to male students. This implies that female students seemed to be in a happier mood than male students. On the one hand, there has long been proof that the learning styles of men and women are generally distinct (Philbin et al., 1995), which could partly explain differences in ways of learning. This difference may be attributed to the fact that in JUMC, female students are more encouraged through different empowerment programs, and thus may have a positive implication on learning environment perception.
Concerning the mean score reported among the different clinical year students, Clinical year I students had a significantly highest mean score for the SPT subdomain (mean ± SD = 25.71 ± 3.08 and P = 0.000), and the SSSP subdomain (mean ± SD = 16.58 ± 3.05 and P = 0.012), besides that non-significant highest mean score was reported for the SPL subdomain (mean ± SD = 28.15 ± 4.73 and P = 0.59), and for the overall DREEM (mean ± SD = 112.61 ± 10.73, and P = 0.071). Moreover, the highest mean scores were observed for the SASP subdomain in the Internship year (mean ± SD = 20.03 ± 3.73 and P = 0.000) and for the SPA subdomain in clinical year II students (mean ± SD = 26.32 ± 4.55 and P = 0.000).
The relatively highest mean score reported in the clinical year I students and reduced scores in the senior years are consistent with the findings of previous studies undertaken in Saudi Arabia (Al-Saleh et al., 2018), Malaysia (Al-Naggar et al., 2014), and Iran Bakhshialiabad et al. (2015) additionally observed that there is no clear pattern in the change between years. It was proposed that this trend might be the result of students who were emotionally sick of being students and eager to move on from their time as students because they truly felt that the learning environment was failing. This might be because in JUMC, the clinical year I students’ learning mainly focused on the theoretical aspects, and their higher perception of the learning environment could be explained by the enthusiasm and excitement to practice a hands-on clinical skill.
On the other hand, low perception of the learning environment by Internship students in JUMC could be attributed to the overloaded curricula, independent work to manage patients, and night and weekend duties that might have negative implications on their learning environments. Also, no individual item obtained more than a 3.5 mean score. This implies that none of the items qualified as a “true positive point,” as per the practical guide (McAleer, 2001). However, three items had a mean score greater than 3.0, which implicated the students at JUMC perceived that their teachers are knowledgeable (3.17 ± 0.72), they have good friends in the school (3.17 ± 0.7), and their social life is good (3.09 ± 0.795).
Our findings coincided with findings in Saudi Arabia (Soliman et al., 2017), Spain (Palomo-López et al., 2018), and Malaysia (Ugusman et al., 2015) reported the highest mean scores for these items. In contrast, studies conducted in Iran (Aghamolaei & Fazel, 2010) and Malaysia (Al-Naggar et al., 2014) reported a lower mean score for these items. The majority (30) items had scores between 2.0 to 3.0 which indicated aspects of the learning environment that could be enhanced. A similar finding was reported in Nigeria and Nepal (Roff et al., 2001). Furthermore, seventeen items received mean scores ≤ 2.0, indicating problem areas (Roff et al., 1997). Out of these items, three were from the SPL subdomain, two were from the SPT subdomain, two were from the SASP subdomain, six were from the SPA subdomain, and the last four items were from the SSSP subdomain.
The three items that received the lowest mean scores were: The ward teaching environment is relaxed, the satisfaction outweighs the stress, and the teachers get angry in class/ward, which received scores of 1.53, 1.24, and 1.57, respectively. All are stress‑related problem areas. These might be attributed to the curriculum, as the JUMC undergraduate medical students’ curriculum is a conventional curriculum It had a significant decrease in the core curricular competencies (what pupils need to know), which may have been caused by the teacher's attitude and ineffective teaching strategy, which could have created a stressful environment. This finding is in line with the results of several studies (Abera, 2016; Al-Saleh et al., 2018; Okoye et al., 2017). In contrast, other studies reported higher mean scores (Al-Naggar et al., 2014; Palomo-López et al., 2018; Soliman et al., 2017; Ugusman et al., 2015) than scores reported by other studies.
The results of the findings conclude that undergraduate clinical year medical students at the major clinical attachment wards of JUMC generally have a positive perception of their learning environment. Significant disparities in overall perception were seen across gender differences and study levels of the learning environment. Regarding the student’s perception across each DREEM subdomain; SPL was positively rated, SPT indicated moving in the right direction, SASP revealed students feel more positive, and students perceived a more positive SPA and SSSP was fair enough. While the mean score of most items was in a good range (greater than 2.0), 17 items across all subdomains of DREEM inventory tools, few items received a mean score of less than 2.0 (problematic items). These low ratings point to areas that need closer examination and show that these items are problematic. In general, the findings of this study identified positive perceptions of educational environments, but some areas need to be revised across all five domains of the DREEM inventory tool to make improvements. This study also identified some items that need consideration to improve for the future.