The Medical Education Environment at the University of Nairobi, Kenya: An Assessment with the DREEM Tool 

Daniel Ojuka1, Faith Aseta2, Beth Githambo2, Brian Wambua2

1. Department of Surgery, University of Nairobi
2. School of Medicine, University of Nairobi

Correspondence to: Dr. Daniel Ojuka; email:

Received:30 July 2019; Revised:9 September 2020; Accepted: 10 November 2020; Available online: 20 December 2020


Background: The supportive learning environment can enhance impartating of knowledge and skills. Objective: To assess the learning environment at the School of Medicine of the University of Nairobi using the Dundee Ready Educational Environment Measure (DREEM) tool. Methods: A cross-sectional survey carried in 2019 out among medical students during their clinical years to obtain their perceptions about the learning environment at the School of Medicine of the University of Nairobi. The DREEM tool was used for the survey. Data were entered and analyzed in SPSS version19. Comparisons were performed using analysis of variance (ANOVA). p≤0.05 was considered statistically significant. Results: We obtained 619 responses (77.4%) from 800 tools distributed. The total mean score of DREEM was 93.3/200. This is a 46.7% score overall indicating a poor perception of the learning environment. Year IV was the class with the poorest perception with a p<0.05. Conclusion: The DREEM score shows numerous problems, with perception of learning and social support being the areas requiring the most improvement. Although teachers are knowledgeable, students are wary of their ability to transfer knowledge and skills.

Keywords: Learning environment, DREEM, Medical students
Ann Afr Surg. 2021 ; 18(2) : 96–102
Conflicts of Interest: None
Funding: None
© 2021 Author. This work is licensed under the Creative Commons Attribution 4.0 International License 


The educational environment consists of, among other factors, a documented curriculum and a perception of teacher–student interaction both in and out of class (1). The anticipation and experiences of students concerning these factors can either motivate or demotivate them in their learning approaches and learning style, crucial to these being how the learner is engaged (2).
The learning environment as perceived by students determines their behavior and aspirations (3). The learning  environment is one of the factors affecting quality that can be measured and actions taken to improve, correct, or change the environment in order to improve the quality of education (3,4). The Dundee Ready Education Environment Measure (DREEM) is a culturally non-specific tool that has been applied in many cultures and languages. It has been validated to be good for measuring the learning environment among medical students (5,6). It has also been used to determine the weaknesses or strengths of an institution’s learning environments, make comparative analyses of students’ perceptions within and between different cohorts, and can identify academic achievers (7).
To the best of our knowledge no study using the DREEM tool or any other tool to determine students’ perceptions of the learning environment has previously been carried out in Kenya or at the University of Nairobi; thus, this study was undertaken.

Materials and Methods

This was a cross-sectional survey of 3rd to 6th year medical students at the School of Medicine of the University of Nairobi. Ethical approval was obtained from Kenyatta National Hospital–University of Nairobi Ethics and Research Committee (P55/01/2019). We used the DREEM tool to gauge students’ perceptions of the educational environment.
DREEM contains 50 statements on a range of topics directly relevant to the medical educational environment, scored on a 5-point Likert scale ranging from 0 to 4 (4: strongly agree–SA; 3: agree; 2: have no idea; 1: disagree; 0: strongly disagree–SD). The 50 items have a maximum score of 200. However, 9of the 50 (8, 12, 15, 16, 21, 23, 34, 39, 45) were given a reverse score, i.e., 0=SA and 4=SD, so that a higher score would indicate more positive responses. The inventory encompasses five subscales: (1) students’ perceptions of learning (SPL)–12 items; (2) students’ perceptions of teachers (SPT)–11 items; (3) students’ academic self-perception (SASP)–8items; (4) students’ perceptions of atmosphere (SPA)–12 items; and (5) students’ social self- perceptions (SSSP)–7items.
Students who agreed to participate consented in writing. The tool was completed during class after an explanation from one of the research assistants and returned at the end of class. Data collection for DREEM consisted of paper-based demographics that included year of study and gender.
Data were analyzed using SPSS version 19 (IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp). Analysis was on the overall score out of 200, subscale score (SPL–48, SPT–44, SASP–32, SPA–48, SSSP–28) and individual score (0–4). Overall score of 0–50 is interpreted as extremely poor, 51–100 indicates plenty of problems, 101–150 is more positive than negative, and 151–200 as excellent.
Individual items with a mean score ≥3.5 are particularly strong areas, items with a mean score ≤2.0 need attention, and items with mean scores between 2 and 3 are areas of the educational environment that could be improved. Cronbach’s alpha was calculated for internal validity of the DREEM tool within our context. The Kaiser–Meyer–Olkin test was performed for sampling adequacy. Comparison of mean used Student’s t-test and analysis of variance (ANOVA). Statistical significance was taken as p<0.05.


We obtained a 77.4% response rate (619/800). The highest number of responses (32.1%) was obtained from 4th year students. The gender response rates were: female 50.2% and male 49.8% (Table 1).
Cronbach’s α was 0.882 while the Kaiser–Meyer–Olkin test was 0.904 (p<0.001), indicating sample size was adequate and had a high internal validity. The mean score was 93.3/200 (46.7%), implying that generally there are numerous problems with how our students perceive their educational experience.
On the subscale scores, only year V seems to have overall and specific areas such as SPL, SPT, and SSAP that appear to be moving towards a positive experience. In addition, year III has positives for SPT and year VI has positives for SSAP (Figure 1). The student perception on the learning subscale is an area that requires attention as the only statement that scored above 2 was “I am clear about the learning objectives of the course” (Figure 2).
ANOVA revealed significant differences in the scores across the clinical years in all questions except 47 (p=0.772) and 48 (p=0.072), all other questions had p less than 0.05. The differences in gender were significant only for questions 13 (p=0.006), 22(p=0.022), 44 (p=0.009), and 47(p=0.012).

Students’ perceptions of teachers
Across this subscale, only statement 2 had a mean above 3.0. Areas that require action include every item statement where the score was less than 2 (Figure 3). A one-way