The educational environment strongly influences the students’ learning outcomes because the educational environment is a corner stone for effective learning.[1–4] Learning environment and learning outcomes are close related to each other. Learning environment is related strongly to the curriculum and a good Key Performance Indicator for the curriculum.
The College of Medicine in the Jazan region, established in 2001 in the city of Jazan, adopted a traditional system of education. However, in 2005, the traditional discipline-based, lecture-intensive coursework was replaced by the Integrated Medical School Curriculum. The new curriculum divided the faculty of medicine program at Jazan University into three stages: Basic sciences, basic medicine, and clerkships. Under this curriculum, students are expected to learn all body systems in an integrated manner across all departments.
Evaluation of curriculum is the starting point for determining the success of a curriculum. The results of such an evaluation let teachers know whether what they are doing in the classroom is effective and let the developer know if the curriculum achieves their objectives and how to improve it.
Dundee Ready Education Environment Measure (DREEM) was published in 1997 as a tool for evaluating the educational environments of medical schools and other health training settings. A recent review concluded that it was the most suitable instrument for doing so.
Awareness of students’ perceptions of their learning environment is important for the continuous improvement of educational environments and curricula. The objective of this is to study explores medical students’ perceptions of their learning environment at the Jazan Faculty of Medicine in Jazan City, Saudi Arabia. Students’ perceptions of various aspects of the educational environment were compared based on year level and gender.
The study presented here employed an observational cross-sectional design, which was appropriate given that the purpose was to investigate students’ perceptions of the ongoing training program. The student’s perceptions were the dependent variable, and student class level and student gender were investigated as independent variables.
The students of Jazan University, Faculty of Medicine, were the target group. Inclusion criteria included registration in the medical program at Jazan University for the 2017–2018 academic year.
College of Medicine, Jazan University, is one of the youngest medical schools in Saudi Arabia, running an integrated, organ/system based, community-oriented curriculum. Currently, 1051 students are registered in the college of medicine; 517 male and 534 female.
The program of College of Medicine (curriculum) is arranged in three phases. In the first phase (during first year), students learn basic concepts in Chemistry, Physics, and Biology as well as English and Arabic languages. In the second phase (during second and third years), students study the organ systems. During these years, the students gain basic skills in taking histories, performing physical examinations and learn clinical decision-making and clinical problem solving. The third phase (during the 4th, 5th, and 6th years) forms the clinical clerkships in the hospitals and community health settings where the students practice the skills, attitudes and behaviors specific to each discipline and common to the practice of medicine in general.
Sample size and design
Following Cochran, the suitable sample size was determined based on the standard formula:
Where n is the sample size, p is the anticipated proportion of levels (here refers to DREEM response), Z is the standardized variable that corresponds to a 95% confidence level, and d is the desired marginal error.
Since no prior knowledge of student perceptions was available, 50% of the total DREEM scores provided the maximum sample size based on the values π =0.5, d = 0.05, and z = 1.96. Using a finite sample correction factor and a nonresponse rate of 10%, the required sample size was approximately 400 students. The sample size distributions in the different study levels and the two genders were proportionate to the total population size.
Data were collected from the students using the structured and standardized questionnaire DREEM, which is commonly used in similar studies. A professional English/Arabic translator translated the questionnaire into Arabic, and a pilot survey of the questionnaire was carried out. The questionnaire was administered to the students electronically using Monkey Survey, a web-based program. The students received a link to the questionnaire by E-mail.
DREEM was used to explore students’ perspectives on their learning environment. DREEM was chosen because it has been used internationally for different purposes, is regarded as a useful and suitable tool by researchers worldwide, and has been found to be highly reliable in different geographical areas and have universal face validity.
The DREEM inventory involves 50 items divided into the following five subscales:
- Students’ perceptions of learning (SPoL): 12 items with a maximum score of 48.
- Students’ perceptions of teachers (SPoT): 11 items with a maximum score of 44.
- Students’ academic self-perceptions (SASP): 8 items with a maximum score of 32.
- Students’ perceptions of atmosphere (SPoA): 12 items with a maximum score of 48.
- Students’ social self-perceptions (SSSP): 7 items with a maximum score of 28.
The students were asked to read all the statements and respond using a five-point Likert scale ranging from “strongly agree” to “strongly disagree.” The scoring of items was as follows: 4 = strongly agree, 3 = agree, 2 = uncertain, 1 = disagree, and 0 = strongly disagree.
The total score for all subscales was 200. Each item was scored from 0 to 4 with 4 strongly agree, 3 agree, 2 unsure, 1 disagree, and 0 strongly disagree. Nine negative items were scored in reverse for analysis (4, 8, 9, 17, 25, 35, 39, 48, and 50). A higher score indicates a more positive evaluation; in its original version, the DREEM has a maximum score of 200, which indicates a perfect educational environment. According to the literature, individual items with a mean score ≥3.5 are particularly strong areas, items with a mean score of ≤2.0 need attention, and items with mean scores between 2 and 3 are areas of the educational environment that could be improved.
Data analysis and interpretation
Survey Monkey prevents the submission of questionnaires with missing items, ensuring complete data collection. Data analysis was performed using the SPSS software.
The data analysis involved descriptive and inferential statistics. Simple tabulation and frequency tests were used to evaluate the differences in mean scores between the groups. Mean scores for subgroups were also compared.
The data were analyzed using the SPSS software version 20 (IBM Corp, Armonk, NY, USA). Comparisons were made of the mean scores of males and females in the total sample and in each class level.
A total of 334 students completed the online questionnaire, and almost equal participation was observed between males (50.6%) and females (49.4%).
The mean score of the total sum for each questionnaire score in all subscales was 104.9 (standard deviation [SD]: 26.353), with male students having a mean score of 100.36 (SD: 26.078) and female students having a mean score of 109.54 (SD: 25.897). Table 1 show the mean for each group of students according to their class and gender sorted by mean value, with third-year female students having the highest mean (115.57) and fifth-year students having the lowest ninety-two.
Students’ perceptions of learning subscale (items 1, 7, 13, 16, 20, 22, 24, 25, 38, 44, 47, and 48)
This subscale comprises 12 items, with 48 as the maximum score. As per the main objective of the integrated curriculum, the author of the present study expected more enjoyment in the learning subscale. Out of 48, the mean of the total sample was 22.98, which is less than the mean for female students (24.24) and greater than the mean for male students (19.35). Except for 2nd-year students, the mean of all female students was above the mean of the total sample, whereas the mean of all male students was lower than the mean of the total sample. Table 2 shows the mean sum of the SPoL subscale, sorted according to the value for each group and the total sample.
Students’ perceptions of teachers (items 2, 6, 8, 9, 18, 29, 32, 37, 39, 40, and 50)
This subscale comprises 11 items, with 44 as the maximum score. The mean of the total sample was 23.81, with 3rd-year female students having the highest score and 6th-year male students having the lowest. Except for 4th-year male students, all male subgroups had a mean score below the mean of the total sample. All the female subgroups had mean scores above the mean score of the total sample. Table 3 shows the mean sum of the SPoT subscale, sorted according to the value for each group and the total sample.
Students’ academic self-perceptions (items: 2, 10, 22, 26, 27, 31, 41, and 45)
This sub-scale comprises eight items, with 32 as the maximum score. 5th-year male students and 3rd-year female students had the lowest score, with means of 16.68 and 17.82, respectively. Although students at the same level share the same learning context, the mean scores for 5th-year male and female students were found to be extremely different, with the lowest mean score in the male student group and the highest in the female student group. The percentage of male and female students in the 5th-year group was almost equal. The total mean score was 19.14. Table 4 shows the mean sum of the SASP subscale, sorted according to the value for each group and the total sample.
Students’ perceptions of atmosphere (Items 11, 12, 17, 23, 30, 33, 34, 35, 36, 42, 43, and 50)
This subscale comprises 12 items, with 48 as the maximum score. The mean score of the total sample was 24.24, which is equal to 50% of the total score. Second-year female students and 5th-year male students, with mean scores of 21.91 and 20.27, respectively, had the lowest mean scores among all groups, while 3rd-year female students had the highest mean score (27.22). Table 5 shows the mean sum of the SPoA subscale sorted according to the value for each group and total sample.
Students’ social self-perception (items 3, 4, 14, 15, 19, 28, and 46)
This subscale comprises seven items, with 28 as the maximum score. The mean of the total sample was 14.72, with the lowest mean score (13.32) belonging to 2nd-year female students. The total mean scores of males (14.67) and females (14.78) were nearly equal to the mean of the total sample (mean score = 14.72 ± 0.05). Table 6 shows the mean sum of the SSSP subscale, sorted according to the value for each group and total sample.
Phase 1 of the Integrated Medical School Curriculum is basic science, managed by the College of Science in the Faculty of Medicine at Jazan University. The author of the present study did not have direct access to the students, and they do not belong to the curriculum and study. Second-year medical students are often new to the experience of participating in research, which may explain a slight decrease in the number of 2nd-year students who participated in the survey (n = 55) compared to other levels (n = 70±). However, there was equal participation by students in subsequent class levels (third year: 19.2%, fourth year: 21.9, fifth year: 21.6%, and sixth year: 21%).
Although participation appeared equal across the different levels, there were more female participants in the 3rd-year group (n = 46) than males (n = 18), and the participation of males in their 4th year (n = 48) was greater than that of females (n = 25) in the same year. The total number of participants in their third year was 122, of which 73 (60%) were female, which makes this group’s representation in the study’s statistics unequal. However, the total number of participants in their 4th year of study was 118, with 60 being male. Although they were equal, unequal representation in the statistics was observed.
The following points are approximate guidelines for interpreting the overall score of the DREEM questionnaire:
- 0–50Very poor
- 51–100Plenty of problems
- 101–150More positive than negative
The mean score of the total sample was 104.9 (SD: 26.353), which, according to the literature, is one of the lowest scores worldwide.[1,3,10–21]
Table 7 lists the scores of different international institutes according to the value of the score.
In this study, 22 out of 50 items had a mean score of <2, indicating that these areas require attention. Two items had a mean score ≥3, indicating an area where the curriculum is strong, and 26 items had a mean score between 2 and 3, indicating a need for improvement in these areas. Consideration of the items based on gender revealed that males had more low mean scores (30 items) than females (19 items), and females had more high mean scores (4 items) than males (2 items). A comparison with related literature revealed that 82% (18 out of 22) of the items that had lower scores (<2) in this study are also problematic in other medical schools in Saudi Arabia, including King Abdulaziz University and Umm Alqura University.
Students’ perceptions of learning
The total sample mean score for SPoL was 22.98 (SD: 6.83), which is <50% of the maximum score. Male students had a lower mean score (21.75) than females (24.24). The SPoL results for this study were almost the same as those for other medical schools in Saudi Arabia, except for King Saud Bin Abdulaziz University, which has the highest mean score in SPoL (36.44) in the country. Studies of other schools have had similar results, with mean values ranging from 20 to 26.[14–16,21] Observing the individual items in the SPoL subscale revealed seven items with mean scores <2 (items 48, 25, 44, 16, 47, 20, and 1) needing attention. No single item in the SPoL section of the questionnaire was found to be a strong area, indicated by a mean score ≥3, and 5 items were found to need improvement (items: 24, 7, 13, 38, and 22), with a mean score range of 2–3.
Although the main objective of the curriculum is to improve the competency of graduates, the students in this study did not see the teaching as improving their competency, as indicated by the mean score of item 16, “The teaching helps to develop my competence,” of 1.84.
The total sample score for item 25, “The teaching over-emphasizes factual learning,” indicates that this area requires attention (mean score: 1.57). There was an obvious score difference between male and female 5th-year students, with females having the highest mean score (1.89) and males the lowest (1.31). These findings are in line with those in a study by Mohd Said et al., who noted a trend for reduced scores in the senior years.
The curriculum of an institute of higher learning is expected to engage students in relevant learning activities. For item 44, “The teaching encourages me to be an active learner,” the overall mean score was 1.83. For item 47, “Long-term learning is emphasized over short-term learning,” the mean score was 1.85, and for item 48, “The teaching is too teacher-centered,” the mean score was 1.55. The low scores on these items demonstrate a failure of the curriculum to support principles of adult learning, according to Knowles.
Students’ perceptions of teachers
The SPoT subscale included 11 items, and the findings obtained from an analysis of the scores were similar to those of the first subscale: A low total sample mean score of 23.81 out of 44 (SD: 7.094) and a lack of strong items.
Feedback is an integral part of the teaching and learning environment in the medical field, as it improves learners’ knowledge, skills, and other competencies. Unfortunately, response results to item 29, “The teachers are good at providing feedback to students,” indicated that none of the students were satisfied with the quality and quantity of the feedback they received (total sample mean score: 1.92; SD: 1.098). It was noted that teachers gave more feedback to female students (mean score: 2.13) than males (mean score: 1.7).
This study had SPoT scores similar to those found in studies of other schools in Saudi Arabia, with mean scores ranging from 21 to 25.[14–16,21] This study examines the need for a shift in teachers’ attitudes toward providing students with feedback while they study. It is important for teachers and medical education offices to implement professional development programs with intensive courses to improve teachers’ feedback skills.
Students’ academic self-perception
The mean score for this subsection (19.14) was almost equal to that given by students in King Saud Bin Abdulaziz University (19.81), which has the highest total DREEM score in Saudi Arabia (total mean score: 131).[14–16,21]Table 8 summarizes the DREEM results from various local medical schools.
Although the score for item 10, “I am confident about my success this year,” was 2.97 (SD: 0.94), female students were more confident, with a mean score of 3.12 (SD: 0.86), than male students, with a mean score of 2.83 (SD: 0.99). This is in accordance with the percentage of students passing exams, in which more female students passed than male students. In general, as per Sattar, female medical students are more motivated and have more humanitarian grounds for choosing the medical profession than their male counterparts.
The results of item 21, “I feel I am being well prepared for my profession,” suggested that juniors (second-level mean score: 1.9; third-level mean score: 2.08) are more optimistic than senior students (fifth-level mean score: 1.57; sixth-level mean score: 1.74). This section of the study encourages stakeholders to develop a medical student preparation program that provides students with a clear road map for their journey in medical schools.
All students expressed difficulty memorizing all the information being given to them, as indicated in the responses to item 27. This agreement among all students may be due to the content of the subject being studied, which contains more information than necessary. Many studies reported generally similar findings,[3,14–16,21] Most clinical teachers in medical schools are clinical practitioners, and they need some support and guidance to improve their teaching strategies which will undoubtedly improve students’ learning ability and skills.
Students’ perceptions of atmosphere
The total sample mean score for this subsection was 24.42 out of 48 for 12 items. The mean scores for the male and female groups were almost the same as the mean of the total sample, with 23.17 and 25.33, respectively. The educational environment in the medical field is novel for junior students, particularly female students, as the previous academic activities of female students were conducted solely by female staff. Thus, due to a shortage of female faculty in the 2nd year, female students must deal with the new experience of being taught by male faculty members. This could explain why the group of 2nd-year female students had the lowest mean score in this subsection (mean score: 21.91). According to O. D. Dumitru, although it is not in medical field, despite being similarly engaged as men in tutoring interactions, women face psychological barriers in this context that may affect their perception of their learning environment.
The scores of this subsection are almost identical to those of other schools, ranging from 21 to 26, with the exception of King Saud Bin Abdulaziz University, which has the highest score in Saudi Arabia (SPoA mean: 32.77).
Research in the field reveals that the first year of university is a time of significant change and adjustment. Transitioning from high school to college can be a difficult challenge for many students. For some, transitioning from a ‘controlled’ school or college environment to one in which they take responsibility for their own academic and social needs is stressful and anxiety-inducing and can feel like entering an ‘alien environment’.
The academic atmosphere during ward teaching, lectures class, seminars, and tutorials was perceived negatively by both males and females (items 11, 23, and 34), which had an effect on item 42, “The enjoyment outweighs the stress of the course,” which also had a low mean score (mean: 1.48). This indicates a lack of satisfaction with the motivation provided by the atmosphere, which may explain some of the low SASP subscale scores, as scheduling affects the overall atmosphere of teaching and learning.
Although junior medical students participate in some academic activities in the hospital, bedside teaching takes place mainly in the hospital and is restricted to fourth-, fifth-, and sixth-year students. Thus, the current study must note the scores given by senior students. The results for item 11, “The atmosphere is relaxed during ward teaching,” were particularly concerning, with a mean score of 0.85 and 1.23 for fifth-and sixth-level students, respectively, which is less than studies of other schools in Saudi Arabia.[14–16,21] Despite our belief that the content of hospital-taught curricula is sufficient to give students more pleasure in learning, there are barriers that may lead to the absence of an appropriate learning environment. The lack of sufficient space for bedside teaching and the lack of sufficient patients, in addition to the absence of a teaching hospital dedicated to the university, are all barriers that may lead to students’ dissatisfaction with not achieving the desired goal, whether from the curriculum or the goals they set for themselves.
The curriculum-related issue must be studied to redesign bedside teaching strategies that are aligned with current resources and allow overcoming these barriers.
Students’ social self-perception
The SSSP comprises seven items, with a maximum score of 28. This study’s total sample mean score was 14.72, which is just over 50% of the maximum score. This study had almost identical results to those in this subsection from studies of other medical schools in Saudi Arabia, with total mean scores ranging from 12.9 to -16.8.[14–16,21]
Items in the SSSP subscale were classified into three categories:
Social items closely related to the school: These include item 3, “There is a good support system for students who get stressed,” item 4, “I am too tired to enjoy the course,” and item 14, “I am rarely bored on this course.” These items had very low scores compared to other items, with mean scores of 1.02, 1.08, and 1.2, respectively. Surprisingly, studies done in two schools in Saudi Arabia—Umm Al-Qura University and King Abdulaziz University—found the same student perceptions of two items from this category, with mean scores ranging from 0.92 to 1.2 (the mean score for item 14 was 1.5 in the study done at Umm Al-Qura University).
Items partially related to the school environment: These include item 28, “I seldom feel lonely,” and item 19, “My social life is good.” In the present study, these items had mean scores ranging from 2 to 3, indicating a need for improvement in this area.
Items that are independent of the school environment: These include item 46, “My accommodation is pleasant,” and item 15, “I have good friends in this school.” The responses to these items indicated that perceptions of this area were positive, with a mean score of ≥3. It was also discovered that these results match those items found in studies done at King Abdulaziz University and Umm Al-Qura University, where the mean scores were >3.
Looking at this subscale as a whole, second-year students had the lowest mean score (13.71), and among them, females had the lowest mean score (13.32). Students at this level, particularly female students, face great change and challenges, including a new academic environment and new colleagues, which are expected to present some social difficulties. Item 15, “I have good friends in this course,” was scored positively by all subgroups; however, male and female second-year students had the lowest score (mean: 3.29), with the lowest score for female students (mean: 3.18). Medical students are subjected to a range of situations that they find emotionally challenging and distressful and this points to the importance of supporting students in these struggles.
This study identified areas of the Faculty of Medicine program at Jazan University that require attention, especially as they relate to the main objective of the College of Medicine. The study’s overall results and the results of the internal sections of the questionnaire should be considered carefully. The elements assessed in each subsection provided the students’ perceptions of the program’s content. To determine the problems causing negative perceptions, additional study of those elements is required. This could take the form of direct communication with stakeholders, such as students and teachers, to get the information necessary to understand the problem and to find appropriate solutions.
This study should be considered in future evaluations of the medical curriculum at Jazan University, as it is an effort to contribute to the evaluation process. Every person involved in the college’s development process should incorporate the findings of this study into the college’s strategic plan.
This study revealed that female medical students are at higher risk and should be given close attention through social support or an advisory program to improve their social lives in general and female students in particular.
In addition to the results of raw numbers, the results of this study can contribute to reforming the educational environment of the College of Medicine at Jazan University and assist in achieving the desired level.
Finally, because curriculum evaluation is a continuous process, this study, which is a point of curriculum evaluation, can be relied upon as part of curriculum development.
Ethical clearance and permission were obtained from the Standing Committee for Scientific Research-Jazan University, (HAPO-10-Z-001), Reference No.: REC-43/11/246. All procedures performed in this study were in accordance with the ethical standards of the Standing Committee for Scientific Research-Jazan University and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Consent (Not Mandatory)
During questionnaire distribution, participants were informed that the information collected would be kept anonymous and that participation was voluntary.
A single author is responsible for this work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
1. Till H. Identifying the perceived weaknesses of a new curriculum by means of the Dundee Ready Education Environment Measure (DREEM) Inventory. Med Teach 2004;26:39–45.
2. Genn JM. AMEE Medical Education Guide No. 23 (Part 1):Curriculum, environment, climate, quality and change in medical education–A unifying perspective. Med Teach 2001;23:337–44.
3. Roff S, McAleer S, Ifere OS, Bhattacharya S. A global diagnostic tool for measuring educational environment:Comparing Nigeria and Nepal. Med Teach 2001;23:378–82.
4. Hutchinson L. Educational environment. BMJ 2003;326:810–2.
5. El-Naggar MM, Ageely H, Salih MA, Dawoud H, Milaat WA. Developing an integrated organ/system curriculum with community-orientation for a new medical college in Jazan, Saudi Arabia. J Family Community Med 2007;14:127–36.
6. Miles S, Swift L, Leinster SJ. The Dundee Ready Education Environment Measure (DREEM):A review of its adoption and use. Med Teach 2012;34:e620–34.
7. Lo CC. How student satisfaction factors affect perceived learning. J Scholarsh Teach Learn 2010;10:47–54 Available from:http://www.iupui.edu/~josotl
[Last accessed on 2022 Dec 23].
8. Cochran WG. Sampling techniques 3rd Edition New York John Wiley &Sons, Ltd 1977.
9. Roff S, McAleer S, Harden RM, Al-Qahtani M, Ahmed AU, Deza H, Groenen G, &Primparyon P (1997). Development and validation of the Dundee Ready Education Environment Measure (DREEM). Med Teach1997 19:295–9 https://doi.org/10.3109/01421599709034208..
10. Shehnaz SI, Sreedharan J. Students'perceptions of educational environment in a medical school experiencing curricular transition in United Arab Emirates. Med Teach 2011;33:e37–42.
11. Varma R, Tiyagi E, Gupta JK. Determining the quality of educational climate across multiple undergraduate teaching sites using the DREEM inventory. BMC Med Educ 2005;5:8.
12. Al-Hazimi A, Al-Hyiani A, Roff S. Perceptions of the educational environment of the medical school in King Abdul Aziz University, Saudi Arabia. Med Teach 2004;26:570–3.
13. Al-Naggar RA, Abdulghani M, Osman MT, Al-Kubaisy W, Daher AM, Nor Aripin KN, et al. The Malaysia DREEM:Perceptions of medical students about the learning environment in a medical school in Malaysia. Adv Med Educ Pract 2014;5:177–84.
14. Al-Ayed IH, Sheik SA. Assessment of the educational environment at the College of Medicine of King Saud University, Riyadh. East Mediterr Health J 2008;14:953–9.
15. Al-Hazimi A, Zaini R, Al-Hyiani A, Hassan N, Gunaid A, Ponnamperuma G, et al. Educational environment in traditional and innovative medical schools:A study in four undergraduate medical schools. Educ Health (Abingdon) 2004;17:192–203.
16. Zawawi AH, Elzubeir M. Using DREEM to compare graduating students'perceptions of learning environments at medical schools adopting contrasting educational strategies. Med Teach 2012;34 Suppl 1 S25–31.
17. Bouhaimed M, Thalib L, Doi SA. Perception of the educational environment by medical students undergoing a curricular transition in Kuwait. Med Princ Pract 2009;18:204–8.
18. Mayya S, Roff S. Students'perceptions of educational environment:A comparison of academic achievers and under-achievers at Kasturba medical college, India. Educ Health (Abingdon) 2004;17:280–91.
19. Jiffry MT, McAleer S, Fernando S, Marasinghe RB. Using the DREEM questionnaire to gather baseline information on an evolving medical school in Sri Lanka. Med Teach 2005;27:348–52.
20. Makhdoom NM. Assessment of the quality of educational climate during undergraduate clinical teaching years in the College of Medicine, Taibah University. J Taibah Univ Med Sci 2009;4:42–52.
21. Al-Mohaimeed A. Perceptions of the educational environment of a new medical school, Saudi Arabia. Int J Health Sci (Qassim) 2013;7:150–9.
22. Lai NM, Nalliah S, Jutti RC, Hla YY, Lim VKE. The educational environment and self-perceived clinical competence of senior medical students in a Malaysian medical school. Educ Heal Chang Learn Pract 2009;22:148.
23. Mohd Said N, Rogayah J, Hafizah A. A study of learning environments in the kulliyyah (faculty) of nursing, international Islamic university Malaysia. Malays J Med Sci 2009;16:15–24.
24. Knowles MS, Holton EF III, Swanson RA The adult learner:The definitive classic in adult education and human resource development London Routledge 2020 378.
25. Sattar H, Zain Z, Sheikh AM, Saleem A, Arshad M, Meraj L. A comparison of male and female medical student's motivation towards career choice. J Rawalpindi Med Coll 2021;25:382–5.
26. Dumitru OD, Thorson KR, West TV. Investigating gender differences among tutors and students during STEM peer tutoring:Women are as behaviorally engaged as men but experience more negative affect. Contemp Educ Psychol 2022;70:102088.
27. Murtagh L. Enhancing preparation for higher education. Pract Res High Educ 2012;6:31–9.
28. Dornan T, Tan N, Boshuizen H, Gick R, Isba R, Mann K, et al. How and what do medical students learn in clerkships?Experience based learning (ExBL). Adv Health Sci Educ Theory Pract 2014;19:721–49.
29. Weurlander M, Lönn A, Seeberger A, Hult H, Thornberg R, Wernerson A. Emotional challenges of medical students generate feelings of uncertainty. Med Educ 2019;53:1037–48.