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Year : 2009  |  Volume : 22  |  Issue : 2  |  Page : 148

The Educational Environment and Selfperceived Clinical Competence of Senior Medical Students in a Malaysian Medical School

International Medical University, Malaysia

Date of Submission10-Dec-2007
Date of Acceptance16-Mar-2009
Date of Web Publication12-Aug-2009

Correspondence Address:
N M Lai
Clinical School Batu Pahat, International Medical University, 12, Jalan Indah, Taman Sri Kenangan, Batu Pahat, 83000 Johor Darul Takzim
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Source of Support: None, Conflict of Interest: None

PMID: 20029744

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Introduction: The educational environment is widely considered to be a major factor affecting students' motivation and learning outcomes. Although students' perceptions of their educational environment are often reported, we are unaware of any published reports that relate this information to students' clinical competence, either self-perceived or objectively measured.
Objectives: We aimed to correlate students' perceptions of their learning environment and their self-perceived competence in clinical, practical and personal skills, using validated scales.
Methods: Subjects included a cohort of 71 final-year medical students who were posted to a peripheral campus affiliated with a district hospital. Two questionnaires were administered concurrently: a modified DREEM (50 items) to assess the learning environment and an abbreviated IMU Student Competency Survey (29 items) to examine self-perceived competence across a wide range of skills and work-readiness. We correlated the major domains in both surveys using Spearman's Correlation.
Findings: Fifty-nine students (83%) completed the questionnaires. Comparing correlations of the five major domains of the modified DREEM questionnaire ("Perception of learning", "Perception of teachers", "Academic self-perception", "Perception of atmosphere" and "Social self-perception") with all subscales in the abbreviated IMU Student Competency Survey (clinical, practical, personal skills and overall work-readiness), we found that academic self-perception domain had the strongest correlations (r:0.405 to 0.579, p:0.002 to < 0.001) and perception of teachers bears the weakest correlations (r:0.171 to 0.284, p:0.254 to 0.031). Self-perceived competence in practical skills in the IMU Student Competency Survey correlated the weakest with all domains of the modified DREEM (r:0.206 to 0.405, p:0.124 to 0.002).
Discussion and conclusion: The overall weak-to-moderate correlations between perceptions of learning environment and selfperceived clinical competence suggest that other factors might interact with the learning environment to determine students' confidence and achievements.

Keywords: Medical education, educational environment, self-perceived competence, work-readiness

How to cite this article:
Lai N M, Nalliah S, Jutti R C, Hla Y Y, Lim V. The Educational Environment and Selfperceived Clinical Competence of Senior Medical Students in a Malaysian Medical School. Educ Health 2009;22:148

How to cite this URL:
Lai N M, Nalliah S, Jutti R C, Hla Y Y, Lim V. The Educational Environment and Selfperceived Clinical Competence of Senior Medical Students in a Malaysian Medical School. Educ Health [serial online] 2009 [cited 2023 Jun 6];22:148. Available from:


The importance of the educational environment in student learning is widely acknowledged (Genn, 2001a, 2001b; Hutchinson, 2003). The elements that constitute the educational environment for a medical student include the physical facilities, the clinical setting where learning takes place, the design and delivery of the curriculum, and the ability and motivation of the teachers (Genn, 2001a, 2001b; Hutchinson, 2003; Kurth et al., 2000). The Dundee Ready Education Environment Measure (DREEM) (Roff, 2005; Roff et al., 1997) has been used extensively in different countries to provide information on various aspects of the learning environment in medical schools (Al-Hazimi et al., 2004; Bassaw et al., 2003; Mayya & Roff, 2004; Roff et al., 2001; Varma et al., 2005). We have previously used it to profile the learning environment for our students in the pre-clinical phase at the International Medical University (IMU) in Malaysia (HlaYeeYee et al., 2007).

A conducive learning environment, for example, comfortable learning rooms, receptive clinical environment and motivated, skilled and approachable teachers, is believed to increase learner motivation, which in turn leads to better engagement in learning and improved performance (Hutchinson, 2003). However, for undergraduate medical students, we have seen no reports that assess the relationship between students’ perception of learning environment and their educational outcomes, such as students’ confidence, work-readiness and clinical competence.

International Medical University (IMU), Malaysia is a private medical university established in 1992. The university adopts a system-based, integrated curriculum, with problem-based learning (PBL) being the chief means of curricular delivery. The university strongly encourages self-directed learning, with faculty acting mostly as facilitators. Student learning is aided by online modules, practical skills training in the clinical skills unit (CSU) and the use of simulated patients. There are separate campuses dedicated to pre-clinical training (first 2.5 years), clinical training (the following two years) and senior clerkship (final six months) with affiliated training hospitals and clinics.

A distinctive feature in the undergraduate medical training at IMU is the senior clerkship programme, the final six months of the five-year MBBS training. In this programme, senior students who have completed their core training and passed a major clinical examination at their 4.5-year mark are posted to a new training location at Batu Pahat, a town 200 kilometers away from their main clinical school, with a 300-bed district hospital serving as the affiliated teaching hospital. Here, students consolidate their clinical, practical and personal skills by assuming greater responsibilities in patient care, acting as shadow housemen under supervision of faculty members who are active in clinical services. In this programme, learning and interaction with the supervisors take place mostly in the clinical wards rather than the classroom. There are six resident faculty members who mentor the students. This training programme offers a unique learning opportunity in a setting dedicated only to the senior clerkship. Evaluating students in the senior clerkship therefore provides a valuable addition to the profile of the educational environments in our university.

At IMU, a 44-item survey tool (IMU Student Competency Survey) has been developed to profile the self-perceived competence of our impending graduates across a range of clinical, practical and personal skills and overall work-readiness (Lai & Ramesh, 2006; Lai et al., 2007). This survey tool serves alongside our formal assessments as an indicator of the effectiveness of our curriculum and student preparedness for their internship. There have been concerns about the use of tools that measure self-perceived competence, as previous studies show that self-perceived clinical competence does not correlate well with observed competence (Barnsley et al., 2004; Coberly & Goldenhar, 2007; Jones et al., 2001; Morgan & Cleave-Hogg, 2002; Weiss et al., 2005; Woolliscroft et al., 1993). However, most of these studies focus on practical skills. To make an all-rounded and competent doctor, other attributes such as communication skills, team-working and coping abilities are essential and increasingly emphasised in newer medical curricula (Hill et al., 1998; O'Neill et al., 2003; Watmough et al., 2006). Educators have relied on the degree of student confidence in these areas as a key indicator of curricular success for students in the final stages of training (Clark et al., 2004; Whitehouse et al., 2002), and comparatively better agreements were shown between students’ and supervisors’ ratings for these attributes (Jones et al., 2002; Wall et al., 2006). Perhaps more importantly, evaluating self-perceived competence, as a measure of self-efficacy, might be the key to understanding the likely behaviours of the subjects in relation to the skills examined. People with a strong sense of efficacy have often been observed to show high motivation and deep engagement in acquiring, improving and maintaining the skills that they value, and they are likely to heighten and sustain their efforts in mastering such skills the face of failures (Bandura, 1994). On the other hand, collective low self-perceived competence in certain skills discrepant to expectation would point to gaps in curricular delivery and a need to improve training. These factors combined lend support to evaluating self-perceived competence, as we have undertaken in this study.


We undertook this study to evaluate the correlation between students’ perceptions of their learning environment and their self-perceived competence, utilizing the modified DREEM and an abbreviated IMU Student Competency Survey for our medical students undergoing senior clerkship training in a peripheral clinical school. Our research question was whether the degree of students’ satisfaction with their learning environment, as measured by the modified DREEM, is significantly and highly correlated with the degree of their self-perceived clinical competence, as measured by the abbreviated IMU Student Competency Survey.


An anonymous, self-administered questionnaire was conducted on a cohort of final-year medical students posted to the Clinical School campus of International Medical University (IMU) in Batu Pahat, Malaysia for senior clerkship training from February to August 2006. The entire cohort of students (n=71) were invited to participate in the survey, which was conducted in May 2006, mid-way through the clerkship.

The survey combined two assessment tools: a modified version of DREEM (50 items) which assessed five major domains of educational environment (perception of learning, perception of teachers, academic self-perception, perception of atmosphere and social self-perception), and an abbreviated version of IMU Student Competency Survey (abbreviated from 44 to 29 items), which assessed self-perceived competence in a range of clinical, practical and personal skills and overall work-readiness. A more detailed description of each survey tool follows.

Modified DREEM questionnaire

The development and validation of this survey tool have been reported (Roff, 2005; Roff et al., 1997). The 50 items in the questionnaire are grouped under five major domains of 10 items each. The following are selected examples of the items under each domain:

  1. Students’ perception of learning: “I am encouraged to participate in class”, “The school is well-time-tabled”, “The teaching is too teacher-centred”

  2. Students’ perception of teachers: “The teachers are knowledgeable”, “The teachers ridicule the students”, “The teachers are well-prepared for their classes”

  3. Students’ academic self-perception: “I am confident about my passing the end of semester examination”, “I feel I am being well-prepared for my profession”, “My problem-solving skills are being well-developed here”

  4. Students’ perception of atmosphere: “The atmosphere is relaxed during the CSU/ward/clinic teaching”, “I am rarely bored on this course”, “The enjoyment outweighs the stress of studying medicine”

  5. Students’ social self-perceptions: “I am too tired to enjoy this course”, “I have good friends in this school”, “My accommodation is pleasant”.

    Some items are phrased positively and others negatively. Ratings for negative items were changed to the equivalent ratings for positive items. Scores for each item were summed up under the major domains. The guide for interpretation is shown along with our findings under Table 1. For the current study, we made minor modifications in five items, as follows, to reflect the curricular design and learning setting of our university:

  6. Question 10: “I am confident about passing this year” to “I am confident about passing my end-of-semester examinations”.

  7. Question 11: “The atmosphere is relaxed during the ward teaching” to “The atmosphere is relaxed during Clinical Skills Unit (CSU), clinic or ward teaching”

  8. Question 18: “The teachers have good communication with patients” to “The teachers have good communication with patients/simulated patients”

  9. Question 26: “Last year’s work has been a good preparation for this year’s work” to “Last semester’s work has been a good preparation to this year’s work”

  10. Question 34 “The atmosphere is relaxed during seminars/tutorials” to “The atmosphere is relaxed during seminars/problem-based learning (PBL) sessions”.

Table 1: Average sum scores in the major domains in IMU-REEM Survey and their interpretations

IMU Student Competency Survey

The original survey (44 items) assesses students’ self-perceived competence and estimated experiences in a range of skills and work-readiness. The 44 items are grouped under five subscales: i) Self-perceived competence in clinical skills (seven items with Likert scale), ii) Self-perceived competence in practical skills (14 items with Likert scale), iii) Estimated experiences (total no performed) in practical skills (14 items with Likert scale), iv) Self-perceived competence in personal skills (seven items with dichotomous response: “comfortable” or “uncomfortable”) and v) Work-readiness (two items: one on the most daunting aspect of being a doctor and one on overall work-readiness). For items with dichotomous responses, a positive response (“comfortable”) is given a score of two, while a negative response (“uncomfortable”) is given a score of one. For other items, the response on the Likert scale is taken as the score. Sum scores are obtained under each subscale.

This questionnaire was first developed in November 2004. Content validity was first determined by a panel of seven academician-clinicians from different disciplines (Internal Medicine, Surgery, Paediatric Surgery, Obstetrics and Gynaecology (two members), Orthopaedics and Paediatrics) who are also supervisors in senior clerkship. The first version (44 items) was drafted by the first author, who was also a member of the panel. The items in the questionnaire were assessed by other members of the panel based on importance and relevance. Four items were re-worded following the evaluation. The expected standards on each item under clinical skills and practical skills were determined through discussion. The questionnaire was piloted in January 2005 on a group of medical students (n=51) in senior clerkship. Following the pilot, three items on practical skills were added. The revised questionnaire was run on a subsequent cohort of students (n=65) in July 2005. The combined findings from the first and second versions of the survey have been reported (Lai & Ramesh, 2006). This report was submitted to the Professional Education Advisory Committee (PEAC) of the university in August 2005 for further assessment. The Professional Education Advisory Committee of the university comprised five medical education experts from the partnering universities overseas and one representative from Malaysia. Following this assessment, four items were discarded as they were considered either confusing or less relevant at undergraduate level; an additional item on practical skill (obtaining ECG) was included; Likert scale for the seven items under clinical skills was re-defined; and a linear scale replaced Likert scale for the item on work-readiness. Internal reliability (Cronbach’s alpha) of the remaining items with ordinal responses (n=33) was 0.92 (95% CI for intraclass correlation coefficient: 0.88 to 0.95). There was no significant change in Cronbach’s alpha following the deletion of any item, suggesting that all the items were of similar importance. The latest version of the full questionnaire with 44 items was administered to a new cohort of students (n=65) in senior clerkship in January 2006 (Lai et al., 2007).

In this study, 15 items from the original questionnaire were excluded: the entire subscale (14 items) on the estimated experiences of practical skills performed, and one item on the most daunting aspect anticipated as a doctor. These items were excluded because the former was not part of the objective of the current study, and the latter because the nominal responses would be unsuitable to be correlated with DREEM.

Following are selected examples of questionnaire items under each subscale with corresponding Likert scale statements. For generic clinical skills and practical skills, students are asked “How confident are you on the following?”

i) Generic clinical skills (total of 7 items) included “recognizing sick patients”, “taking a history and performing relevant examination as first assessment of new admissions” and “answering questions from patients/relatives on admission “.

Likert scale statements:

  1. Grossly inadequate.

  2. Know the approach in theory, not confident at all in real situations.

  3. Only confident in making certain decisions, need seniors to be readily available or on constant standby.

  4. Reasonably confident, but need seniors at least being contactable for consultation.

  5. Very confident, can be relied on without supervision.

The expected level of competence for our senior medical students for all items under this domain is at level three. The expected sum score is therefore 21.

ii) Practical skills (total of 14 items) included “starting resuscitation in hospital”, “intravenous line insertion in adult”, “blood taking in adult”, “assisting operations” and “handling blood containers (selecting appropriate tubes and labeling)”.

Likert scale statements:

  1. Have not a clue.

  2. Know in theory but not confident al all in practice.

  3. Know in theory, can perform some parts in practice independently, and need supervision to be readily available.

  4. Know in theory, confident in practice, need sources of supervision at least being contactable.

  5. Know in theory, competent in practice without any supervision.

The expected level of competence for our senior medical students for all items under this domain is at level three, with the exception of procedures on children (expected level: two). The expected sum score for a student for this category is 40.

iii) Personal skills (total of seven items): Students were asked “Are you comfortable on the following?” This subscale contained items such as “referring cases to seniors”, “handling criticisms from your senior colleagues”, “coping with additional, unexpected tasks” and “working independently away from home”.

We expect all our students to be comfortable on at least five out of the seven items listed.

iv) Work-readiness

Students were asked: “If you were offered a position as house officer to report for work tomorrow, how ready are you?

(Please circle your response on the scale below)”


Far from readyLooking forward to it

We expect all students to indicate work-readiness at level 4 or 5 at the end of senior clerkship.

Conduct of the survey

The following measures were taken to ensure anonymity. Prior to the survey, students were briefed on the purpose of the study by the first author who then left the premises. A supporting staff not involved in the study then handed out the questionnaires. Completion of the questionnaires was taken as consent to participate in the study. None of the authors were present during the entire conduct of the study, nor when the questionnaires were returned by the respondents.

In February 2006 the study was approved by the Centre for Medical Education (CtME) and the Deanery, Clinical School, International Medical University (IMU), Malaysia.

Statistical analyses

Reliability analyses were performed for DREEM, IMU Student Competency Survey and both surveys combined, presenting as Cronbach’s alpha with 95% Confidence Interval (CI) for intraclass correlation coefficients. Standard descriptive statistics were also presented. Correlations between DREEM and IMU Student Competency Survey were indicated using Spearman’s correlation coefficient (r), with significance level set at 0.01. All statistical analyses were performed and charted using SPSS version 11 (Chicago, IL, USA).


Fifty-nine out of 71 students (83.1%), 75.5% females and 24.5% males returned the survey. Some survey forms were incomplete, giving rise to variable item response rates, as illustrated under the respective items. Reliability analyses of the survey items are reported as follows:

i) for DREEM (50 items), Cronbach’s alpha: 0.90 (95% CI for intraclass correlation coefficient: 0.85 to 0.93),

ii) for the IMU Student Competency Survey (29 items), Cronbach’s alpha: 0.94 (95% CI for intraclass correlation coefficient: 0.91 to 0.96),

iii) for both surveys combined (79 items), Cronbach’s alpha: 0.94 (95% CI for intraclass correlation coefficient: 0.91 to 0.96).

Table 2:  Self-perceived competence in common clinical skills: mean rating and standard deviations for individual items on the Likert scale of 1 to 5 (Average sum score: 25.85)

Table 3:  Self-perceived competence in common practical skills: mean ratings and standard deviations for individual items on Likert scale of 1 to 5* (Average sum score: 53.10 )

Table 4:  Self-perception of personal skills (n=47)

For the DREEM, the mean sum scores in all domains fell uniformly under the “above-average” category according to the rating guide (Table 1). For the abbreviated IMU Student Competency Survey, on the whole students appeared confident of their abilities on all generic clinical skills, with the vast majority rating themselves at or above the expected level of “3” (Table 2). For practical skills, while most students achieved the expected levels for the majority of the items at the time of survey, some items fell short of expectation, such as initiating resuscitation in the hospital, assisting in operations and prescribing intravenous fluids (Table 3). The vast majority of the students were comfortable handling most generic tasks involving the use of various personal skills. The tasks perceived to be the most difficult were “independently finding out the ward routines” and “coping with unexpected additional tasks”, with nearly one-third expressing discomfort in handling these tasks (Table 4). Overall, most students felt either neutral or reasonably ready to work as a house officer at the time of survey (Figure 1).

Figure 1:  Work-readiness: response to a job offer as a house officer (1: far from ready to 5: looking forward to it)

In general, weak-to-moderate correlations were found between the major domains in DREEM and the subscales in students’ self-perceived competence. Among the various DREEM domains, students’ academic self-perceptions correlated the strongest with their self-perceived competence and work-readiness. In contrast, perceptions of teachers correlated the weakest with self- perceived competence across all subscales. Among the subscales in the abbreviated IMU Student Competency Survey, self-perceived competence in practical skills had the weakest correlation overall with all domains of DREEM.


Overall, this study finds that our senior medical students who were posted to a district hospital for their senior clerkship perceived their learning environment favourably across all six domains of DREEM. In general they also had high self-perceived competence on most clinical, practical and personal skills. However, their perceptions of the learning environment were not as consistently and strongly correlated as expected with their self-perceived competence over a range of clinical, practical and personal skills. Among the domains in DREEM, “academic self-perceptions” stood out with the strongest correlation between self-perceived competence and work-readiness.

From the modified DREEM survey, the average total score in this study was 133.1 (66.56%), 6.5% higher than the average for our students in the pre-clinical phase of training (HlaYeeYee et al., 2007). In addition, the average scores for all domains in this survey were higher than those for the pre-clinical phase and compared favourably to those in most medical schools in other countries (Bassaw et al., 2003; Roff et al., 2001; Varma et al., 2005). The high scores for our students in their final semester might be attributed to several factors, including an increased understanding of their own abilities in relation to the curriculum, more realistic expectations with increased maturity and coping abilities, greater independence and increased perception of relevance and purpose in learning while approaching the completion of their undergraduate training. In addition, because the IMU Clinical School Batu Pahat with its attached hospital catered solely to the learning of this student group and provided them with more patient care involvement than in their earlier training, it might have given them a greater sense of belonging to their place of learning which could have contributed to the higher ratings.

Some interesting findings were observed when correlating students’ perceptions of their learning environments and self-reported competence. With the exception of perception of teachers, significant but nevertheless only weak-to-moderate correlations were found between perceptions of learning environments and self-perceived competence. Students’ self-perceived competence in practical skills was weakly correlated to perceptions of learning environments. These observations suggest that the learning environment, as perceived by our students, although important, was only one of many possible factors that could affect the development of confidence on clinical, practical and personal skills.

The absence of any significant association between perception of teachers and self-perceived competence in this study is remarkable. This is in spite of the relatively high rating on the perception of teachers (30.5 points, or 69.3%). This finding is at odds with traditional beliefs on teachers’ roles in student learning (Hutchinson, 2003) and adds to the conflicting current evidence on the relationship between teachers’ perceived quality and student achievement (Fenderson et al., 1997; Roop & Pangaro, 2001; Stern et al., 2000). In the context of this study, this observation might indicate that self-directed learning, as advocated by the university, has been taking place during the senior clerkship, with increased acquisition of clinical experience directly from the bedside and less dependence on the teachers. However, it might also suggest that despite the positive impression of the students, our teachers have not been effective in making an impact on student learning. An important area to evaluate in this regard is the effectiveness of our on-site supervision, as supervision has been shown by others to strongly influence the development of clinical skills (Wimmers et al., 2006). It has also been shown that inadequate supervision might account for significant variations in clinical learning gain within the same learning environment (Daelmans et al., 2004; Murray et al., 2001). It would be interesting to see if the findings would have been the same for more junior students who probably depend more on their teachers for learning.

Our findings of generally weak association between the self-perceived competence in practical skills and perceptions of learning environment might simply echo the current evidence on the lack of correlation between self-perceived competence and actual competence in practical skills, or they might indeed reflect the way practical skills were learnt by our students. In the early training, common practical procedures were taught in dedicated sessions on human models or simulated patients within a sheltered environment in the clinical skills unit (CSU). Within these sessions, students have probably acquired a certain degree of familiarity with common procedures regardless of how they viewed their learning environment. Later, when training took place at the bedside, clinical exposure increased but opportunities to perform practical procedures varied according to factors such as timing, receptiveness of the attending doctors and patients, and the initiative of the individual student. Students might, for example, become frustrated with their lack of experience in learning practical skills even though they enjoyed the overall learning environment. Moreover, some skills were acquired under daunting and stressful circumstances, especially for the novices, like conducting obstetric deliveries, which all our students were required to perform a certain number of within a designated period. Confidence and proficiency in such instances might come at the expense of enjoyment in learning. The lack of a receptive clinical environment where certain skills were usually performed, such as in the emergency department where resuscitations took place, and in the operating theatre where the role of assistants was normally taken up by the theatre nurse or resident doctors, might explain the relatively poor ratings observed for such skills in our study. One recommendation to address this issue would be to incorporate dedicated training sessions on selected practical skills in senior clerkship as a reinforcement of earlier training in clinical skills unit. This might increase student familiarity and confidence on the particular skills, and alleviate anxiety during performance in real-life.

A limitation of this study, as elucidated in our introduction, is that we assessed only students’ self-perceived competence, which may not fully reflect external measures of their competence. Although we have attempted to justify the value of evaluating self-perceived competence in this report, we acknowledge that such measures cannot be stand-alone in the overall assessment of student competence. An obvious follow-up would be to correlate perceptions of educational environment to more objective measures of clinical competence, such as observed performance of clinical skills.


This paper serves to relate the diagnostic information of students’ perceptions of their educational environment in the DREEM with self-reported measures of leaning outcomes in a medical school in Malaysia. Our findings suggest that an educational environment perceived as positive by the students is not necessarily an effective environment for building up confidence in skills essential to the day-to-day work of a clinician. Other factors may operate in developing a positive and effective learning environment. For our students in senior clerkship, we propose that strengthening on-site supervision during the actual acquisition of clinical, practical and personal skills might be an effective way to build up student confidence of such skills. Nonetheless, our finding of comparatively strongest overall correlations between academic self-perceptions and self-perceived competence suggests that one of the major determinants of a student’s confidence, and possibly competence, might come internally. It is possible that even within an optimised learning environment, there may still be significant variations in students’ learning gain, as factors like personal learning styles and motivation could ultimately govern a student’s achievement (Ferguson et al., 2003; Yates & James, 2006). On the other hand, with the wide application of DREEM, more useful information on what constitutes an effective learning environment might be obtained if future studies examine the diagnostic information in DREEM in relation to different learning outcomes across a variety of educational settings around the world.

Source of Funding

Centre for Medical Education (CtME), International Medical University, Malaysia.

Conflict of Interest

None declared


Our appreciations to Ms Sok Hong Goh, Centre for Medical Education (CtME), IMU, for entering data on IMU-REEM; Associate Professor Cheong Lieng Teng for analyzing the IMU-REEM component of the survey; and to the members of the IMU Professional Education Advisory Committee (PEAC) for their invaluable comments on the draft manuscript.

Table 5:  Correlations between major domains in the modified DREEM survey and subscales of the abbreviated IMU Student Competency Survey


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