Effect on students’ perception of learning environment among first-year medical students exposed to competency-based curriculum: A mixed-methods evaluation

INTRODUCTION

There is ample evidence that the learning environment prevailing in an educational institution has an impact on the learning outcomes of students.^1,2 Evaluating a teaching-and-learning environment from the angle of the students’ perception is helpful to provide key elements for guidance and corrections at the management level.³ The World Federation for Medical Education emphasized the learning environment as one of the goals for the appraisal of medical education plans.⁴

The student support system (SSS) of our institution is concerned with the improvement of the learning environment of the students. As a part of the SSS, we did a survey of students’ perceptions of the learning environment prevailing in our medical college among students belonging to the traditional batch (2018 batch) in the year 2019. We used the Dundee ready education environment measure (DREEM), a 50-item measure of students’ perception of a specific environment, allowing for various forms of comparative assessments of the learning environment.⁵

The newly introduced competency-based medical education (CBME) curriculum has various modules such as a 1-month foundation course, a properly structured mentoring programme, AETCOM (attitude, ethics and communication), self-directed learning (SDL) and early clinical exposure for 1st year medical students of the 2019–20 batch. The students of the CBME batch participated in almost all the activities implemented before their course was interrupted due to the Covid-19 crisis when face-to- face teaching was shifted to the online mode.

The faculty members of our college were trained in faculty development programmes such as the curriculum implementation support programme conducted by the Medical Council of India (MCI) and the different modules of CBME were discussed, planned and implemented by all three preclinical subjects of first year MBBS. We wanted to elucidate the effect of CBME modules on the learning environment, especially on the domains of students’ perception of atmosphere and the domain of social self-perception, which received low scores from the traditional curriculum batch.

We therefore assessed the effect on students’ perception of the learning environment after the introduction of the CBME curriculum.

METHODS

RESULTS

A total of 134 students from the 2018 batch (traditional batch) and 143 students from the 2019 batch (CBME) responded to the DREEM questionnaire. The mean (SD) age of the participants was 19 (1) years (±1SD) for the traditional batch and 19.8 (0.5) years for the CBME batch. The men and women populations were 64 (48%) and 70 (52%) in the traditional batch and 64 (45%) and 79 (55%) in the CBME batch, respectively. There was no statistical difference between the two batches with respect to age and gender.

There was significant improvement in most of the domain items in the batch exposed to the CBME curriculum compared to the batch exposed to the traditional curriculum, except for items such as ‘The students irritate the teachers, the teachers get angry in class, I am confident about passing this year, and I seldom feel lonely’ (Table I).

The suggestions given by students exposed to the CBME curriculum were organized into five categories and two subcategories under each category (Table II).

DISCUSSION

The overall scores between the two batches indicated that there was a statistically significant improvement in the students’ perception of the learning environment after exposure to the newly introduced CBME curriculum. In the traditional batch, the results showed less scores for perception of atmosphere and social self-perception. In the CBME batch, the results showed a significant improvement in the scores of these domains.

The overall significant improvement in the DREEM scores of the CBME batch can be attributed to different modules included in the CBME curriculum such as 1-month foundation course, AETCOM, early clinical exposure, alignment and integration in the curriculum, SDL sessions and extracurricular activities. A study from our institute by Velusami et al. on 1-month foundation course of CBME batch concluded that all aspects of the foundation course were well received by the students.¹⁰ A revised, properly structured and more student-centred SSS was also established for the CBME batch. We cannot deny the effect of that in the improvement of the perception of CBME batch on the learning environment as the perception of students on the item: ‘There is a good support system for students who get stressed’ significantly improved in the CBME batch (2.0–3.0). The requirement of a good support system for students appeared frequently in the suggestions of non-CBME batch students, but none appeared in the suggestions of the CBME batch.

The scores reflected the beneficial effects of the CBME modules mentioned above on perceptions of students about their learning. The students of the CBME batch were positive about their active participation and engagement, which is the cornerstone of the CBME curriculum. The CBME modules such as the foundation course, AETCOM and early clinical exposure involved many collaborative activities, which allowed them to get insight into their course and had helped them to develop confidence about not only their academic skills but also their social skills. That is why they proposed small group activities in teaching. The SDL sessions for students of the CBME batch had improved their attitude towards reading books. This is complemented in their suggestions of increasing the timing of library working hours.

The item of perception of learning domain which did not show any significant difference was that the teaching over- emphasizes factual learning. Students of both batches did not differ much in the perception of teaching for the items—the teachers are authoritarian, the students irritate the teachers, the teachers provide constructive criticism here, and the teachers get angry in the class. Among these, the items teachers are authoritarian and the teachers get angry in the class received a negative score in the CBME batch meaning the students agree with them. Though that change in perception is insignificant, we need to be concerned about these perceptions. These perceptions were reflected in their suggestions to improve the learning environment. They suggested inclusion of more student-centred activities such as tutorials/small group discussions, hospital visits, discussion on clinical scenarios, multiple-choice questions, conducting quizzes and SDL sessions.

The items that did not show significant improvement between the two batches in the domain of academic self-perception were learning strategies—‘which worked for me before continue to work for me now, last year’s work has been good preparation for this year’s work, I am able to memorize all I need, and I have learnt a lot about the way scientific research is carried out’. Among these, the item of perception on the way scientific research is carried out did not show any improvement and received low scores from both the batches. This area has not been included in CBME activities and is a potential remedial measure in the future. All other items received positive scores from both the batches and also showed statistically significant improvement in the CBME batch.

There is an appreciable statistically significant improvement in the overall scores and also the individual items of domains of perception of atmosphere and social self-perception except for the items—‘the enjoyment outweigh the stress of the course in the domain of perception of atmosphere, I am rarely bored on this course and I seldom feel lonely in the domain of self- perception’. These scores go along with their suggestions of planning for more extracurricular activities as relaxation activities and de-stressors. They have also requested for counselling sessions to explore the psychological issues.

To the best of our knowledge, this is the first study in India that examines the effect of CBME on students’ perception of the learning environment. However, a limitation of the study is that it was based on the comparison of two batches where there could be many unknown confounders affecting the results.