Medical Students’ Perceptions of the Medical Education Learning Environment at the University of Nairobi: A Qualitative Study

Daniel Ojuka,1 Faith Aseta,2Beth Githambo,2Brian Wambua2
1. Department of Surgery, University of Nairobi
2. School of Medicine, University of Nairobi

Correspondence to: Dr. Daniel Ojuka; email:

Received: 25 November 2019; Revised: 09 September 2020; Accepted: 10 November 2020; Available online: 20 December 2020


Background: The educational environment (EE) has a significant influence on effective student learning. The Dundee Ready Education Environment Measure (DREEM) is a validated tool to assess the EE. A DREEM survey done in early 2019 among medical students at the University of Nairobi highlighted many problems. It was therefore important to explore why such perceptions existed among the medical students. Objectives: To explore medical students’ perceptions of the medical education learning environment at the University of Nairobi. Methods: Qualitative focus group discussions (FGD) were held among medical students in years III to VI in groups of between 8and 12 students. The discussions were recorded using a Samsung J6 phone voice recorder, transcribed, coded, and analysed for themes until saturation was reached. Results: We held six FGD with medical students in years III to VI and identified four thematic areas: 1) poor educational infrastructure, 2) poor educational structure, 3) teacher-centred teaching, and 4) lack of social support for students in difficulties. Conclusion: Exploring the perceptions of the EE confirmed students have a poor view of the educational environment. The issues raised are good feedback on teaching, governance and the social culture of the institution.

Keywords: Learning environment, DREEM, Medical students, Qualitative methods

Ann Afr Surg. 2021 ; 18(2) : 103–108
Conflicts of Interest: None
Funding: None
© 2021 Author. This work is licensed under the Creative Commons Attribution 4.0 International License 


An educational environment is a combination of the curriculum, infrastructure, administrative structure, and the personalities of teachers and students (1). The experiences the students have of these factors affect the quality of learning (2). The Dundee Ready Education Environment Measure (DREEM) is an internationally validated instrument for evaluating the learning environment of medical education and outlines the strengths and weaknesses of institutions based on students’ perceptions (3). High scores indicate a good perception of the environment and low scores a poor or problematic environment. Central to the learning environment is the curriculum; a traditional curriculum has been found to be associated with low scores (4–8). Other factors include authoritarianism by teachers, and students in their final clinical classes who seem to always score low marks for unknown reasons (6,7). DREEM has been used to improve the quality of the surgical environment through reflecting on its outcomes (9,10). In improving quality, the reasoning of the responses received should be explored to understand and increase students’ achievement, happiness, motivation, and success. This is done to improve the learning environment without compromising standards, through feedback.
DREEM is one of the validated, culturally non-specific tools used to measure medical education environments to demonstrate the weaknesses or strengths of an institution (9,10). A survey done recently at the University of Nairobi’s School of Medicine (11) had a score of 96/200, implying a weakness in the learning environment. We sought to explore the factors that contributed to this negative perception by students.


Students and Methods

After obtaining ethical approval from Kenyatta National Hospital–University of Nairobi Ethics and Research Committee (P55/01/2019), focus group discussions (FGD) of8–12 students were held in the principal researcher’s office for 45–60 min, using guiding questions by the principal researcher together with the co-investigators. The guiding question was: “The DREEM survey showed more negative perceptions than positive. What could be the reasons?” The study population were medical students in years 3 to 6, who consented in writing to be interviewed. Purposive sampling was used to recruit the students in stratification according to year of study until each group had 8–12 members. Six FGD were held in total. Individual were recruited into group for interview until themes were saturated. Interview conversations were recorded using a Samsung J6 phone recorder. All interviews were held in the presence of the three researchers: BG, FA, and OD.
Next, the three researchers discussed the interviews to agree on the codes and themes emerging, and memos were written on the same. The voice recorders were shared among the three investigators to listen to for a second time and confirm the content after being transcribed for a member check by the investigators. After transcription, the notes were coded and entered into ATLAS. Ti (ATLAS.ti Scientific Software Development GmbH; Berlin, Germany) for analysis into themes.


Six FGD were held: one with 5thyear students, two with 4thyears, two with 6thyears, and one with 3rdyears. Four themes were elicited from the interviews.


Poor or lack of learning infrastructure
The students indicated that whereas the number of students had tripled since 2005, the infrastructure has remained the same. Infrastructure includes classrooms, wards, the library, and accommodation. Some students feel they need to arrive early for class while another class is going on in order to get a place to sit, while others are forced to sit and listen from outside the classroom.
“The discussion venues are not avai