1 Introduction

Learning environment refers to things that influences students learning such as physical setting, instructors, peers, and culture [1]. One of the primary factors considered while assessing the quality of education program is found to be the learning environment [2]. Factors like school policies, governing bodies, and others are considered to be crucial components of a learning environment [3] that influenced effectiveness of the  learners experience and students achievement [4]. Furthermore, the efficacy of an educational program can be determined by the level of quality of the learning environment helps to increase students learning motivation to acquire the required knowledge, value, and skill [5].

According to the World Federation for Medical Education, learning environment was identified as one of the evaluation criteria for medical education initiatives and programs  [6]. For educators to deliver the best possible instruction, they must first establish a welcoming classroom atmosphere [6, 7], because it affect students learning experience expected outcomes, and positively correlate with meaningful learning [8].

Taking into account the current concern to improve quality evaluation processes in the medical field  [9], institutions have sparked a resurgence of curiosity around how students view learning environment  [10], and learning environment has a significant impact on the expected learning outcomes  [11]. Perceptions of students on learning environment can serve as a foundation for making changes that will optimize the teaching learning process [4]. Numerous studies across the globe have concluded to assess learning environment as a reflection of the quality of a curriculum and pinpoint weaknesses for designing right kind of remediation [12, 13].

In line with this, studies conducted at Sharjah Medical College, UAE  [14], King Fahad Medical City at, Riyadh, Saudi Arabia [15], Enugu Medical School, Nigeria  [16] and Faculty of Medicine at Suez Canal University, Egypt  [17] found that there were widespread and major defects in their respective medical school learning environment. Their findings conveyed the requirement for systems to support anxious students, prepare inspiring lesson plans, curriculum overload, and improve scheduling in order to make the learning environment enjoyable to their students that help to achieve greater results. A study conducted in Tikur Anbessa Medical School, Ethiopia, also reported that regular appraisal of the medical students’ perceptions of the learning environment is necessary to get continual information feedback from students which helps to hold up productive learning and teaching  [18].

For the last five years, the quality of the learning environment in Ethiopian medical schools has been assessed to evaluate the physical environment of the institutions against the Ethiopian Higher Education Relevance and Quality Agency (HERQA) standards. The existing assessment tool used by the HERQA does not measure the student’s perception of the learning environment. Even though JUMC aimed at providing quality education and graduating competent professionals, there is no research-based evidence that showed the quality of the learning environment to achieve the intended goals and students’ perceptions of their learning environment. Therefore, the purpose of the current study was to assess the quality of the learning environment using the DREEM inventory tool among undergraduate medical students during clinical attachment wards of JUMC.

2 Materials and methods

2.1 Study design

Institution-based cross-sectional study was conducted using the DREEM English version tool of Roff et al.  [19] to assess the quality of the learning environment in JUMC.

2.2 Study area

Jimma University Medical Center (JUMC) is one of the biggest teaching hospitals and provides clinical services for the community at the level of a referral teaching hospital. JUMC has been offering teaching services for health and medical science students in different clinical years. The curriculum of the undergraduate medical education is a 6-year program and classified in to preclinical and clinical teaching years.

2.3 Study participants

All undergraduate clinical year medical students at JUMC of the 2018/19 academic year were used as the source population of this study. The sample size was calculated by taking prevalence rate (p) = 50%, confidence interval of 95%, and margin of error 5% sample size. Therefore, the minimum sample size was 324 and considering the 10% non-response rate the total sample size was 356.

2.4 Data collection instrument and procedures

The Medical Education Center at Dundee University in Scotland, UK, published the initial copy of the Dundee Ready Education Environment Measure (DREEM) inventory tool, which was used for the assessment of learning environment. It is a validated tool with good reliability that has been used in various countries to evaluate the teaching environment of health science and medical schools  [20].

The inventory was modified and improved to eliminate any potential issues of items' clarity and ambiguity. There are 50 items in DREEM, under five sub scales: 8 items of students’ academic self-perception (SASP), 12 items of students’ perceptions of environment (SPA), of 13 items of students’ perceptions of learning (SPL), 10 items of students’ perceptions of teachers (SPT), and 7 items of social Self-Perception of Students (SSSP)  [21].

An individual’s level of Students’ perceptions of the learning environment was assessed using 50 items concerning the different levels of perception in a five-point Likert scale. The DREEM instrument guidelines for the interpretation of the total scores, subscales scores, and individual item scores were used  for the analysis of this study  [21, 22].

The tool was pretested in 5% of similar group students in the institution, and appropriate revisions were made before being used for actual data collection. All study participants were asked for informed consent before enrolment in the study and confidentiality of information was assured.

2.5 Data management and statistical analysis

Response of students were coded and entered in Epi data version 3.1, and exported to SPSS® version 20 to conduct the statistical analysis. Mean, SD, percentage, and frequencies were computed and outliers were eliminated in each variable. To describe the outcome variable, means and SD were computed and presented. To understand the existing variations across students year, ANOVA was computed and later Post hoc tests were conducted to analyse the existing mean difference across clinical years. A t-test for two independent samples was computed to compare the mean scores difference between male and female students.

3 Results

3.1 Participants characteristics

The survey questionnaire was distributed to 356 with response rate of 90.7% (323) and the proportion of the study participants from different categories were presented in Fig. 1. Among them, 197 (61%) were male and 126 (39%) were females. Most of the respondents 129 (40%) were from clinical year II (Fig. 1).

Fig. 1
figure 1

Demographic characteristics of study participants by Sex, year of study, and attachment wards

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3.2 Descriptive statistics

The study participants’ responses to the overall DREEM and its five sub-domains were summarized in Table 1 below. As shown in Table 1, the scores fall between the 50 to 60% category, which is interpreted as a moderate positive perception of the learning environment.

Table 1 Mean scores distributions for the overall DREEM and its subdomains of medical students (n = 323)
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3.3 Group difference test results

As shown in Table 2, both female and male students’ had demonstrated positive perception for their learning environment. However, female students scored higher mean scores (113.35 ± 15.68) than their male counterparts in the overall DREEM mean score (110.09 ± 12.08) and in four subdomains except SASP. Statistical analysis also exhibited that the differences of female students were significantly higher than male students in the overall DREEM mean score (P = 0.038), and the sub-domians such as SPT  subdomain (P = 0.001), SPA subdomain (P = 0.001) . However, there were no statistically significant differences for the SPL, SASP, and SSSP subdomains.

Table 2 Mean scores for the overall DREEM and its subdomains of medical students (n = 323) by gender students
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The DREEM ANOVA test revealed that there were statistically significant (P < 0.05) perception differences among the three different clinical year study groups in the overall DREEM and in four DREEM subdomains except in SPL subdomain mean scores . Higher mean scores were obtained for SPL (28.15 ± 4.73), SPT (25.71 ± 3.08), and SSSP (16.58 ± 3.05) subdomains in the clinical year I students. Moreover, statistically significant higher 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 = 0.012) (Table 3).

Table 3 Mean scores for the overall and its subdomains of medical students (n = 323) by their level of clinical study year
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The overall DREEM and the five subdomain scores were analysed and student perceptions in all major attachment wards were found positive. However, there were differences in the overall and subdomain mean scores among students in different attachment wards.

The mean score of students in the internal medicine ward revealed significance positive mean values for SPA (26.53 ± 4.98) and SSSP (16.00 ± 3.03) domains as compared other attachment wards. However, the mean scores for SPL (28.69 ± 5.83) and SASP (18.36 ± 3.67) domains were found to be higher for GYN/OBS groups, and students in the surgery ward demonstrated highest mean score (24.77 ± 3.77) for SPT domain. Again, comparing the four ward groups, Internal medicine group elucidated statistically significant differences (p = 0.007) in SPA domain.

According to Roff et al.  [20] guideline of scores interpretation criteria, 3 out of 50 items; one from SPT, and two from SSSP subdomains were obtained a mean score greater than 3 and identified as “Positive points” (Table 4). The students percieved their instructors are found to be knowledgeable (3.17 ± 0.72), I have good friendship in the school (3.17 ± 0.7) and my social life is good (3.09 ± 0.795). The majority (30) of DREEM items had scores between 2 and 3 that indicated theses aspects of the learning environment could be enhanced.

Table 4 Mean scores for the over DREEM and its subdomains of medical students (n = 323) by their attachment ward
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As depicted in Table 5 seventeen items had a mean scores of less than 2; three from SPL, and two from each SPT and SASP, six from SPA, and four from SSSP subdomains that evidenced as real problematic areas of learning environment of JUMC (Table 5).

Table 5 Mean scores of problematic DREEM items and the significant differences between the variables
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4 Discussion

The 90.7% response rate of this study was found to be higher than the response rate of 85%, 59%, and 50% reported from similar studies conducted in Saudi Arabia, Greece, and Malaysia medical schools respectively  [15, 23, 24]. This might be attributed to students’ clarity on the study goal and their expectation on the findings positive impact in improving their future learning environment. A summary of the clinical year medical students' opinions of their learning environment revealed the variations in their perception across gender, academic year, and attachment wards that found to be consistent with studies conducted with the DREEM inventory tool   [14, 18, 25].

In this study, the overall DREEM score was 111.3 ± 13.67/200 (55.7%), which falls within the range of Roff et al.  [20] a practical guide (101–150) that suggests a view of the learning environment that is “more positive than negative”. The overall DREEM result of this study based on the experience of JUMC students evidenced that the standard of infrastructure and human resources were adequate available to create the best possible conditions for learning and teaching and found to be similar with the findings of Roff et al.  [20] conducted using a similar tool. The 113.3 mean DREEM score of this study was found to be somehow similar with 114.4, 109.9, 112, and 110 DREEM mean scores of study findings reported from medical schools of Pakistan  [26], Trinidad [2], Faisalabad  [27] and Ethiopia  [18] respectively. However, the overall DREEM mean score of this study was found to be higher than the DREEM score of 89 of King Saud University, Riyadh  [28], and 101.82/200 in University of Nigeria  [16], and lower than the125.3, and 139 score of the findings of studies conducted in Malaysia and United Kingdom  [29, 30].

Based on the McAleer and Roff guideline [31], 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, but in none of the subdomains excellent mean scores were found. These results are in agreement with findings reported from studies conducted in Ethiopia  [18], Bangladesh  [7], Malaysia  [29, 32], and Saudi Arabia  [33]. Moreover, several other studies have reported similar perceptions in four of the five domains except for a lower mean score for the SASP subdomain  [33, 34], and a lower mean score for the SSSP subdomain that reported in studies conducted in College of Medicine of King Saud University [28] and Suez Canal University of Egypt  [17].

Regarding gender-wise comparison in each of the five subdomains, 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  [24, 29].

In this study, female students obtained higher mean scores (113.35 ± 15.68) in overall DREEM compared male students, and the variation was statistically significant (P = 0.038) that found to be consistent with study findings conducted in Sweden,  [35], Nigeria  [34], and Iran  [4]. However, studies conducted in the Middle East  [33, 36], Trinidad [2], and India [11]  did not identify any substantial differences between males and females. Overall, the findings suggested a higher degree of positive perception of learning environment among female students as compared to their male counterparts that implies female students seemed happier than males. This might be originated from the proven existence of learning style variations of male and female  [37], which could partly explain differences in their perception of learning environment. This difference may be attributed in JUMC, female students are more encouraged through different empowerment programs, and thus may have a contribution to their positive perception of the learning environment.

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  [25], Malaysia [29], and Iran  [4] even-though no clear pattern in the change between years were observed. 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  [31]. 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  [38], Spain  [39], and Malaysia  [24] that reported the highest mean scores for these items. In contrast, studies conducted in Iran [8]and Malaysia [29] reported a lower mean score for these items. The majority (30) items had a mean 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  [34]. Furthermore, seventeen items received mean scores ≤ 2.0, indicating problem areas  [20]. 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 undergraduate medical students’ curriculum is a conventional curriculum and  it had a significant decrease in the core curricular competencies (what pupils need to know). The dissatisfaction 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  [16, 18, 25]. In contrast, other studies reported higher mean scores  [24, 29, 38, 39] 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 year of study for 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 (> 2.0), 17 items across all subdomains of DREEM inventory tools received a mean score of < 2.0 (problematic items). These low ratings were  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.

5 Conclusions

This study concludes that undergraduate medical students in their clinical years at JUMC generally perceive their educational environment positively. However, significant differences were observed based on gender and academic year level. The findings indicated a positive perception of students on their learning, teacher, academic self-perception, the atmosphere,  and with their social self-perception being relatively not too bad. While students generally perceived their learning environment positively, specific domains of the DREEM assessment required closer investigation and remediation. The fifteen items receiving low scores, indicating problematic areas and requiring further improvement. Enhancing institutional systems to meet the student needs would correct deficiencies in their learning environment at the medical wards. Further studies, covering pre-clinical years and minor attachment wards, are essential for a complete evaluation of students’ perception of their educational environment.