ORIGINAL RESEARCH PAPER

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

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

NM Lai, S Nalliah, RC Jutti, YY Hla, VKE Lim
International Medical University, Malaysia

Correspondence Address:
N M Lai
Clinical School Batu Pahat, International Medical University, 12, Jalan Indah, Taman Sri Kenangan, Batu Pahat, 83000 Johor Darul Takzim
Malaysia

Source of Support: None, Conflict of Interest: None

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PMID: 20029744

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

Introduction



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.



Objectives



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.



Methods



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”.

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)”



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