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February, 2018 >>

Perceptions of nursing students of educational environment at a private undergraduate School of Nursing in Karachi

Salima Farooq, Rehana Rehman, Jacqueline Maria Dias  ( Aga Khan University )

Mehwish Hussain  ( Dow University of Health Science, Karachi )


Objective: To assess educational environment at a nursing school.
Methods: The cross-sectional survey was carried out from May to October 2016 at Aga Khan University School of Nursing and Midwifery, Karachi, using the Dundee Ready Educational Environment Measure tool. The scores were obtained by merging five sub-scales of the inventory. The average scores of the scale and sub-scales were compared in terms of age, year of study, and living status using Mann-Whitney U test, and among years of study by Kruskal Wallis test.
Results: Of the 442 students, 228(51.6%) had age below 20 years. Overall, 131(29.1%) subjects were in the first year, 152(33.8%) second year, 91(20.2%) third year and 76(16.9%) fourth year. The average Dundee Ready Educational Environment Measure score was 129.92±19.97 with reliability of 88.9%. Students aged 20 years and less had more positive perceptions than students over 20 years (p<0.0001). Students living in hostel secured higher scores (p<0.0001). First year nursing students attained significant highest scores in all sub-scales compared to the rest (p<0.0001).
Conclusion: Scores reveal better perception from younger nursing students, as well as those living in the hostel and those who were in their initial years of nursing education.
Keywords: Dundee ready education environment measure (DREEM), Learning environment, Nursing students. (JPMA 68: 216; 2018)


Education Environment (EE) is recognised as an essential indicator for quality of education programme.1 It has a crucial role in enhancing nursing student's growth, competency, critical thinking, independency, sense of mental wellbeing and self-confidence.2-4 EE develops essential skills among nursing students to address future challenges. Moreover, it leads to achievements, fun, and engagement in the students' during their learning journey. There is a recognised association between positive EE and development of learning capabilities of students, performance and their satisfaction.5,6 EE represents the climate within the classroom, department and even the institution. It includes: learner perspective regarding infrastructure, learning opportunities, faculty competency, faculty attitude, and their socialisation with peers.6-8
The EE of any medical or nursing school is assessed by the Dundee Ready Educational Environment Measure (DREEM) scoring system which takes into account perceptions of learning (PoL), perceptions of teachers (PoT), perception of atmosphere (PoA), academic self-perception (ASP) and social self-perception (SSP) of the educational institutes.9 This tool consists of 50 items, each scored 0-4 on a 5-point Likert Scale. It has a global maximum score of 200. There are nine negative stated items related to student's perceptions about different domains of EE. Sub-scale interpretation and scoring was done as per instruction given for DREEM questionnaire.10,11 Attaining high DREEM scores indicates EE a productive for the students' academic, emotional and intellectual wellness.5,12 The validity and reliability of the DREEM inventory has been well recognised in various Educational settings.7,13,14 Literature is replete with evidence that DREEM inventory has been translated into numerous languages and affirmed to measure the educational climate at several educational organisations.12 Literature suggested that student-centred approaches need to be adopted to improve DREEM scores in nursing schools in order to strengthen student-teacher relationship and provide constructive feedback to them.3,4,6 Aga Khan University (AKU) is a private institution charted in 1980 to deliver education and health programmes with an aim to raise the status and education of nursing in Pakistan. The Aga Khan University School of Nursing and Midwifery (AKUSONAM) is one of the pioneers to initiate Bachelors of Science in Nursing in the country. This programme was introduced in 1997. Since then the institution has graduated 744 students. The curriculum of AKUSONAM has served as a template for the first national nursing curriculum.15 The main aim of the programme is to provide the foundational knowledge, skills, and attitudes required to practice nursing and is dedicated to preparing clinically competent professional nurses. Thus, the objective of this study was to assess the EE from the perspectives of nursing students in one of the private undergraduate schools of nursing in Karachi using DREEM tool.

Subjects and Methods

The cross-sectional study was conducted from May-October 2016 at Aga Khan University School of Nursing and Midwifery (AKUSONAM), Karachi. Sample size was calculated using the rule of factor analysis of 10 subjects per items.16 Accordingly, a total of 500 samples were needed for 50 items in DREEM questionnaire. However, later universal sampling approach was employed to invite all BScN students enrolled at the time of the study after approval was taken from the institutional ethical review committee. After getting informed consent from the subjects, they were requested to complete the structured questionnaire (Annexure). The structured questionnaire had two parts: a) demographics, and b) DREEM inventory.
The details of content in the DREEM inventory are substantially defined in literature.2,3,14,17 This instrument has been validated in an earlier study on medical students in the same institution and reliability of the questionnaire from that study was 91.3%.2 Student took an average of about 20 minutes to fill the questionnaire. Participants who refused to give consent or were absent on the given day were excluded from the study.
Frequencies with percentages were computed to describe socio-demographic characteristics of the students. Mean with standard deviation were computed to report scores of each items, sub-scales and scales of DREEM inventory. The internal consistency within the responses was measured by Cronbach's alpha. To check the assumption of normality for the scores, we performed Shapiro-Wilk's test. It was found that all scores (except PoT between age groups) were non-normal within each study factor. Therefore, t-test was used to compare PoT score between age groups, whereas, non-parametric analyses were performed to proceed for the rest of comparative analyses. The average scores of DREEM scales and sub-scales were compared between age group and living status using Mann-Whitney U test. For comparing average scores among 4 years of BScN, Kruskal Wallis test was run. Prior to running post-hoc text scores were ranked and homogeneity of the test was checked by Levene's test. Tukey's test was further used to observe pairwise comparison of scores in case of fulfilment of homogeneity of variance assumption. Only, DREEM overall score possessed heterogeneous variance across year of study, hence Games-Howell test was used as post-hoc test instead in this case.


Out of the 551 invited students, 442(80.2%) participated. Among them, 228 (51.6%) students had age 20 years or below. Besides, 131(29.1%) were from the first year, 152(33.8%) second year, 91(20.2%) third year and 76(16.9%) from the fourth year. Intermediate education was the most common certificate that students had prior to enrolment in the BScN 418 (94.5%). Only a few had done 'A' level or graduation in the past.
The descriptive statistics were noted with 95% confidence interval (CI) of each item in the questionnaire (Table-1).

Higher scores indicated encouraging opinions of students towards environment. We set an item score greater than 2.5 as indication of "good" opinion and an item score at-least 3 as an "excellent" opinion. It was observed that item "I am confident about my passing this year" received highest average score (3.40±0.69) followed by "My accommodation is pleasant" (3.24±0.88) and "I have good friends in this school" (3.22±0.92). Other items that received score of more than 3.0 were respectively "I am encouraged to participate in class", "I feel comfortable in class socially", "I have learned a lot about empathy in my profession" and "The teachers have good communication skills with patients". The other 28 items had an average score of greater than 2.5. Seven items had an average score of less than 2.0 stipulating improvement should be considered in these areas. These items were "The teacher over-emphasises factual learning" (1.40±1.21), "The teachers are authoritarian" (1.44±1.01), "The teaching is too teacher-centred" (1.73±1.01), "The students irritate the teachers" (1.79±1.11), "I am too tired to enjoy the course" (1.87±1.15), "The schedule is well timetabled" (1.91±1.30) and "I am rarely bored on this course" (1.97±1.11). The other items scored between 2.0 to 2.5 and hence needed considerable changes to improve students' satisfaction.
The average score of overall DREEM scale by our students was 129.9±19.9 (Table-2).

The reliability of the scale was measured to be 88.9% indicating excellent internal consistency within the responses by the students. Nevertheless, this reliability could be improved if 7 items in the questionnaire would be deleted (Table-2). The reliability measures of the sub-scales PoL and PoA were quite high and interpreted as "more positive approach" corresponding to their mean values. PoT and ASP also indicated good consistency in the responses with the reliability statistics as 70.5% and 76% respectively. However, the value of Cronbach's alpha for the sub-scale SSP was quite low highlighting substantial heterogeneity in the responses of this sub-scale items by the students.
Comparisons of DREEM and sub-scales scores with respect to age, class year and living status revealed that the average DREEM score of students aged 20 years and below was significantly more than the average DREEM scores of more than 20 years of age (130.5±18.5 v/s 124.7±19.1, p < 0.0001). Students with this age group also scored significantly higher in all sub-scales than students with age above 20 years (p <0.05) except ASP and SSP were not significantly different in the two groups (p >0.05).
Those students who lived in the hostel secured higher scores in overall DREEM score (p<0.0001). SAP score from the day scholars was nearby significantly different as compared to their class mates living in the hostel (p =0.075). In all other aspects, scores from hostel students were significantly higher compared to the day scholars (p <0.05).
When comparing scores with respect to class year of BScN it was found that 1st year nursing students attained the significant highest score in all aspects (p <0.05) while the least scores were received by 3rd year students in DREEM scale and sub-scale except in perception towards learning environment (PoL). Scores of ASP were not observed significantly different among students of all 4 years (p >0.05). Also, SSP of 1st and 3rd year student was significantly different (p <0.05). Nevertheless, 2nd and 4th year students' social self-perception was not significantly different to 1st and 3rd year students (p>0.05) (Table-3).


The findings of the current study revealed that overall DREEM score was discovered to be 129.9/200(64.95%), indicating nursing students 'perceptions to be highly positive. Past literature found that higher DREEM scores is linked with student centred, problem based learning and innovative curricula.17 Whereas, literature suggested that scoreless than 120 reflected teacher-centred and traditional curricula.3,18 It is remarkable to report that the study score (129.9) is the highest score obtained among all the private and public medical and nursing colleges of Pakistan.2,4,5,7,13,19 Whereas, various studies conducted in medical colleges at international levels have reported scores between 99-145.1,2,5,18,20,21 A plausible reason of the differences in scores of DREEM could be the variation of educational and cultural systems and facilities or may be the prevailing diversity in educational back ground of students.
In the present study, students aged 20 years and below perceived a more positive perception of learning, teacher and atmosphere as compared to student who were above 20 years of age. Plausible reason could be the minimal exposure of the curriculum and EE among younger students as compared to older students. However, Ali ., et al, and Palmgren & Chandratilake did not find any association between age and DREEM scores.22,23
The present study showed that first year nursing students had more positive perception about EE as compared to second, third and fourth years nursing students. Similar trends have been observed in past medical and nursing schools studies that DREEM score decline as the school years increased.3,14,19,23,24 Whereas, Patil & Chaudhari  found contradictory finding as year of education increase DREEM score raised.17 However, the mean difference of DREEM score was not statically significant among junior and senior students in a study.22 The possible reason might be that first year nursing students were exposed to EE just few months at time of administrating the study questionnaire and not yet experienced the stressful clinical exposure. Clinical exposure within nursing is a challenging part of academia which requires critical thinking and demands to integrate theoretical knowledge into clinical settings. Therefore, there is a great need to promote clinical learning environment positively for nursing students and modify teaching learning strategies at clinical settings.25
One of the determinants of academic performance is healthier social life.4,7M It is vital for nursing institutions to address students' psychosocial and emotional needs. The current study illustrated that students living in hostel had better scores in the domain of perceptions of learning, perceptions of atmosphere and social self-perception as compared to day scholar students. The possible reason could be that students living in hostels perceive hostel life as more secure, nurturing, relaxing and recreational.
To improve EE, compelling view of nursing students regarding five essential components of DREEM inventory was critical. The first domain was student perception of learning nursing students recognised "learning was "positive" rated (30.97/48), student perceptions of teachers was second domain and students rated a scoring which reflects that their faculty are moving in right direction (26.22/44). The next domain was academic self- perception and students rated (23.32/32) which indicated that they acknowledge positively. Perception of atmosphere was the second last domain and students' perceived "positive perception of their environment (31.94/48). Students' social self- perception was the last domain in DREEM inventory based on score student believed "not too bad" about their social self-perception (17.48/28).
Overall, the topmost mean score was reported for an individual DREEM item on a question "I am confident about my passing this year" 3.4. Our findings complement with previous studies.1,17 Students also acknowledged that their accommodation was pleasant by marking a score of 3.24. In addition, they also appreciated their social life by rating a score of 3.22 in response to a question "I have good friends in this school". Our study findings are coherent with previous studies.6,7,26,27 Moreover, in response to questions like "I am encouraged to participant in class", "I feel comfortable in class socially", "the teachers have good communication skills with patient" and "I have learned a lot about empathy in my profession" students scored remarkably well. Similar findings were reported by previous studies.4,17 On the contrary, student highlighted that teachers were authoritarian and they over emphasised on factual learning. Similar findings were reported by past literature.14,17,26,28-30 Hence, instead of emphasising just on information retention, there is a dire need to improve teaching and assessment strategy in order to strengthen integration of knowledge and clinical competency.2 Literature suggested that no learning environment is perfect. Therefore, policy makers and curriculum planners should ensure that student feedback is incorporated to develop
a holistic curriculum thereby preventing stagnation in the development of the learning environment.18
Current study was conducted in a single institute so findings cannot be generalised to similar setups. However, this is the first study that has been conducted in a nursing school in Karachi highlighting the strengths and areas of improvements of EE. The response rate and the reliability were high. This study may serve as a baseline for improvement in curriculum, teaching and learning.


Nursing students perceived that their learning environment was satisfactory. The study score is the highest reported from any medical and nursing college in Pakistan.

Disclaimer: None.
Conflict of Interest: None.
Source of Funding: None.


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