Written approval was obtained from the Institutional Ethics Committee of KLE University. A total of 914 of the 1,004 students (91.0%) who were majoring in medicine, dentistry, nursing, physiotherapy, and public health responded to the questionnaire. We used the DREEM questionnaire along with a demographic component concerning age, gender, educational status, and area of study within the health sciences [2, 3]. The questionnaire was scored according to standard guidelines [4]. The DREEM questionnaire consists of five-point Likert-scale questions, scored as follows: strongly agree (4), agree (3), neutral (2), disagree (1), and strongly disagree (0). The score is reversed for negatively oriented questions. For the purpose of statistical analysis, the total score corresponding to which ranged from 0 to 200. The total DREEM score was then divided into four categories for interpretation, as follows: very poor (0-50), problematic (51-100), more positive than negative (101-150), and excellent (151-200). Furthermore, sub-scores were calculated for the following five domains of the educational environment: students’ perceptions of learning, students’ perceptions of course organizers, students’ academic self-perception, students’ perceptions of the institutional atmosphere, and students’ social self-perception. The students were formally briefed about the questionnaire in their classroom. If they consented to take part in the study, they were requested to provide their demographic details and mark their responses to each of the 50 statements. The mean, standard deviation, and frequency distribution were calculated, and the unpaired t-test, and one way analysis of variance were performed to assess whether responses showed significant variance according to sex, grade, and major. The Kolmogorov-Smirnov test and Lilliefors tests were applied to assess the normality of the distribution of the DREEM scores. SPSS version 21.0 (IBM Corp., Armonk, NY, USA) was used for statistical analysis. P-values <0.05 were considered to indicate statistical significance. The outcomes of the analysis were interpreted according to the guidelines accompanying DREEM.

Of the 914 students, 34.0% were male, 66.0% were female. The majority of students (67.1%) were 20-24 years of age, while 30.9% of students were 25-29 years of age. The mean age was 23.5±2.68 years. The surveyed students consisted of medical (40.6%), dental (28.7%), physiotherapy (13.5%), nursing (10.8%), and public health (6.5%) students. Furthermore, 48.4% were postgraduate students, 44.5% were undergraduate students, and 7.1% were interns. The overall DREEM Score was 120.2 (Table 1). The distribution of DREEM scores is presented in Fig. 1. When plotted graphically, the overall DREEM score showed an approximately normal distribution (Kolmogorov-Smirnov test, d=0.0783; P<0.01; Lilliefors, P<0.01). Medical students had more positive perceptions than public health students (P<0.05). Dental students reported more positive outcomes than nursing and physiotherapy students (P<0.05) (Tables 2, 3). Postgraduate students had more positive perceptions than undergraduate students (P<0.05) (Table 4). Male students responded more positively to statements assessing perceptions of learning, perceptions of the institutional atmosphere, and social self-perception (P<0.05) (Table 1). Tables 2 and 3 present survey responses according to the area of study of the respondents. Medical and dental students had more positive perceptions than nursing and physiotherapy students (P<0.05). Dental students had more positive academic self-perception than all other groups of students (P<0.05). A significant difference was found regarding perceptions of institutional atmosphere between medical and physiotherapy students (P<0.05). Postgraduate students showed more positive attitudes than undergraduate students in all five areas of study (P<0.01) (Tables 4, 5). The overall mean score for individual DREEM items was 2.8. Above-average scores were observed for items 2 (the teachers are knowledgeable), 10 (I am confident of passing this year), 15 (I have good friends in the school), and 19 (my social life is good). Scores below 2.8 were observed for items 3 (there is a good support system for students who get stressed), 8 (the teachers ridicule the students), 9 (the teachers are authoritarian), 17 (cheating is a problem in this school), 25 (the teaching over-emphasized factual learning), 39 (the teachers get angry in the class), and 48 (the teaching is too teacher-centred).

The overall DREEM score was 120.2 (60.1% of the maximum possible score), indicating that students perceive their educational environment to be more positive than negative. Differences in the five sub-domains of scores depending on the course of study should be interpreted individually, since they did not always correspond to differences in the total DREEM scores. From the above results, it is possible to verify the weak points of the educational environment which should be reformed. Although the regimented structure and regulatory procedures of the institution are necessary, some scope for innovation may also be required [5]. In conclusion, it was possible to use the DREEM questionnaire to obtain a quantitative assessment of the educational environment and identify items for improvement in this institution.