Exploring Sustainability of Educational Environment among Health Science Students at the Largest Public University in Brunei Darussalam: A Convergent Mixed-Methods Study

Abstract

Health science students are the future healthcare workforce. Understanding and fostering a sustainable educational environment (EE) is essential in optimising their learning and the successful completion of their studies. A convergent mixed-methods study was conducted to explore health science students’ experiences of their EE at the largest public university in Brunei Darussalam. A cross-sectional design using the DREEM questionnaire (n = 150) and four focus group discussions (n = 31) involving five health science programs (biomedical sciences, dentistry, medicine, nursing/midwifery, and pharmacy) was conducted between November 2021 and May 2022. Descriptive and linear regression analyses and thematic analysis were respectively performed on the quantitative and qualitative data. Although the university EE was experienced by students as “more positive than negative” (86.7%), 13.3% perceived it as having “plenty of problems”. This perception of learning was statistically significant among nursing/midwifery students (p = 0.012). Dentistry students reported positive perceptions across all five domains of the DREEM (an overall mean of 119.3 ± 10.3). The importance of a stimulating home learning environment, supportive peers, innovative teaching methods, soft skill development, and clinical learning enhancement were highlighted. To foster independence and student-centred learning, an educational program that empowers students on their EE, including ‘survival skills’ is recommended. Future research should compare health science students’ experiences in university and clinical EE, nationally and abroad (medical and dentistry twinning program), and develop indicators measuring the sustainability of the EE throughout health science programs.

1. Introduction

The educational environment (EE) refers to the overall atmosphere and conditions within a classroom, department, or institution that can impact the learning experience of students [1]. EE is a significant indicator for assessing and evaluating the success of learning of students [2], facilitating the development of essential skills needed to address challenges. A positive EE is essential for promoting student motivation, critical thinking, independence, and self-confidence, all of which are important for academic success [1,3]. EE has been fundamentally associated with the abilities of students to learn, their performance and their satisfaction in their study [1,4]. To date, there are various quantitative instruments that were used for measuring the various facets of the EE of health science or health profession students. A systematic review conducted in 2010 indicated that there were already 31 instruments used in 79 studies, which were predominantly focused on medicine, nursing, dentistry, osteopathy and chiropractic students [5]. Surveys and questionnaires are common quantitative instruments which have been widely used for collecting data on stakeholders, including students, professors, and administrators of their knowledge, perceptions and interactions with the EE system [6,7]. Instruments like MEEM (medical education environment measure) and tools designed to measure EE in specific medical settings such as PHEEM (postgraduate hospital educational environment measure), STEEM (surgical theatre educational environment measure) and ATEEM (anaesthetic theatre educational environment measure) are used to measure the EE [3]. However, four instruments were identified to be the most frequently used: the Dundee ready education environment measure (DREEM), which is popularly adopted in medicine, nursing, dentistry and chiropractic, both in undergraduate and postgraduate studies; PHEEM, clinical learning environment and supervision (CLES); and the dental student learning environment (DSLES) [5]. Out of these four, the DREEM was found to be the most universally used internationally, cross-culturally adaptable and applicable across programs and years of study, be it in the clinical or university environment [1]. Additionally, the DREEM has been used in more than 20 countries in 40 publications [3] and is regarded as the most suitable instrument for measuring the educational environment in undergraduate medical institutions [2,5,7,8,9,10].

In Refs. [1,2,3,4,7,8,9,10,11,12,13,14], the DREEM has also been found to be widely translated into many different languages, and increasingly adopted in Asian universities, such as among medicine, nursing, pharmacy and dentistry students in Korea [8], India [15], Iran [16], Saudi Arabia [2,17], Pakistan [18], Indonesia [19], Malaysia, China and Singapore [20,21,22]. The findings vary between institutions in these countries due to the different settings, educational systems, and programmes evaluated. Generally, findings have been consistent where the senior health science students have overall high DREEM scores as compared to junior health science students; hence, it is perceived that their EE is ‘more positive than negative’ [20]. These findings imply that students gradually adapt to their EE as they move to the next year, i.e., when they become seniors in their studies. It was also noted that there were conflicting findings on the preference of imparting knowledge, where teacher-centred knowledge is preferred among students in Saudi Arabia [2,17], Indonesia [19], India [15,23], Pakistan [18] and China [20], as compared to Iran, Malaysia and Singapore [16,20,22] who preferred the student-centred learning approach. These differences are due to the exposure to twinning programs in European countries that advocate independent learning, either prior or after two to three years of studying in the Asian countries [5,16,20,22].

Aside from the above, quantitative instruments are limited in terms of in-depth data that provide justification, explanation and rationales for the perceptions of the EE. Hence, having in-depth discussions with students, educators, administrators, and other pertinent stakeholders allows for a deeper study of their experiences and viewpoints on the EE [24]. Focus group discussions (FGDs) offer rich qualitative data that can shed light on certain issues for evaluating the EE in higher education. The importance of involving students and other stakeholders in quality assurance activities through participatory discussions and group dynamics is stressed [25]. FGDs make it possible to identify commonalities, discrepancies, and emergent EE issues [26]. Therefore, a more thorough and deeper understanding of the EE is possible when using a mixed-methods approach, by combining the DREEM instrument and FGDs that eventually enable the results from both methods to be triangulated and converged.

Health science students are future healthcare workers. It is crucial to prepare them with the required education so that they are immediately job-ready upon joining the workforce. Learning may not be sustainable if they are not provided with a comprehensive, conducive and holistic EE. It is not just a matter of getting the students to acquire the required knowledge, but also their process of learning and their ability to apply the knowledge into practice. Creating and sustaining a positive and supportive EE for health science students is essential for their academic success.

In Brunei Darussalam (henceforth: Brunei), five health science programmes have been established: biomedical science and medical programmes since 2000; nursing and midwifery in 2009; pharmacy in 2016; and dentistry in 2017. Yet, they have not undergone a comprehensive and systematic evaluation aside from end-of-module feedback and informal evaluation. There is currently inadequate documented evidence that can be used to improve the EE of health science students in Brunei. This study aims to assess and evaluate health science students’ perceptions and experiences of their EE in the largest public university in Brunei Darussalam.

2. Materials and Methods

2.1. Ethics

The study abides by the Declaration of Helsinki [27] on research ethics involving human subjects. Ethics approval was obtained from the Institutional Research Ethics Committee (ERN: UBD/PAPRSBIHSREC/2021/39). A full explanation was provided through the participant information sheet and again reiterated verbally for those participating in the qualitative study. Informed consent was obtained, and students signed the consent form digitally through the Qualtrics link provided.

2.2. Design, Study Setting and Participants

A convergent mixed-methods study was conducted from November 2021 to May 2022. The study targeted all male and female undergraduate students undertaking five programmes (biomedical sciences, dentistry, medicine, nursing/midwifery and pharmacy) in the health science faculty of the largest public university and the sole provider of health science education in Brunei. Medicine and dentistry students study for 3 years at this university and for 3 years in their respective partner medical and dental schools abroad, whereas biomedical science, nursing/midwifery, and pharmacy students complete 4 years at the university.

2.3. Quantitative Study

A descriptive cross-sectional design through an online self-administered survey using the DREEM inventory was utilised. The DREEM was developed at the University of Dundee to measure the undergraduate EE of health professional schools [4]. DREEM has undergone an exceptional process of reliability and validity, and has been repeatedly replicated for conducting diagnostic analyses for perceptions of the educational climate within an institution, and for comparison within an institution and between institutions [7]. The instruments have undergone validation studies and psychometric testing across educational settings, translated into eight languages to date, and proved to be cross-culturally adaptable, where they have been adopted globally [1,3,7,8,9]. Previous studies also validated the score of the DREEM instrument for assessing favorable attributes and limitations within an institutional setting, and contrasting diverse courses or programmes, sub-groups within a course/programme and the different years of study [1,2,3,4,7,8,9,10,11,12]. The DREEM inventory facilitates the improvement of the educational environment, including the move from conventional to interactive pedagogy, such as the integration of student-centred approaches, the enhancement of student–teacher relationships, and the provision of constructive feedback. The DREEM score also served as an indicator for enhancing the optimum mental growth of students by essentially correcting the domains of the educational environment [1,2,4,8,9,10,11,13,14].

There are 50 items in the DREEM questionnaire that provide an overall score of 200 and consists of five sub-scales with items on the following: students’ perceptions of learning (SPL), students’ perceptions of teachers (SPT), students’ academic self-perceptions (SAP), students’ perceptions of the atmosphere (SPA) and students’ social self-perceptions (SSP) [4,10]. The details of the domain are attached in the Supplementary Data.

However, out of the 50 items, 9 are negative statements and are spread across the questionnaire (numbers 4, 8, 9, 17, 25, 35, 39, 48 and 50). The validity of the instrument was tested in a previous study among medical students in the Aga Khan University where the questionnaire was found reliable at 91.3% [28]. The calculation of the mean and standard deviation was conducted for the scores of the five domains and the global score. The approximate guide for interpreting the overall score is as follows: Very Poor (0–50); Plenty of Problems (51–100); More Positive than Negative (101–150), and Excellent (151–200).

In addition, demographic factors including age, gender, year of study, marital status, level of education, residence, and time spent for study (other than classes), were also collected. To attain a precision (power) of 5% (d = 0.05) within a population of approximately 400 health science students at the university, a minimum sample size of 200 was required. This was determined based on an expected proportion of 50% and a confidence level of 95% [29]. Considering the small number of students in the institute, all health science students were recruited without sampling. The Qualtric survey link of the DREEM inventory was sent by email to all health science student through the programme leaders of the five programmes. The participants accessed the survey link, read the participant information sheet and if they agreed to participate, they were required to click the ‘I Agree’ option in the online consent form and proceeded with answering the survey. Participation in the study was voluntary, and participants had the freedom to withdraw at any point provided that they refrained from clicking the “Submit” button.

As per usual quantitative analysis practice, descriptive statistics were employed to describe the scale scores, and one-way ANOVA was utilized to compare the scores across demographic factors. The relationship between demographic factors and the overall DREEM score was examined using univariate linear regression analysis. The level of significance was taken at 0.05. All analyses were computed using RStudio v.4.3.3.

2.4. Qualitative Study

The qualitative component aimed to explore in-depth the experiences of health science students regarding their educational environment. This is an exploratory method to gauge a phenomenon of interest where nothing or little is known about it [30]. Students were invited through email and encouraged to contact the research team to express their interest in participation. The definite number of participants was determined by applying the principles of data saturation. This is concerned with the adequacy of the data in terms of depth and width, which is identifiable when no more new data emerged and repetitive data were observed [31,32].

Semi-structured open-ended questions were pre-designed from the five domains of the DREEM inventory [4,10]. These questions were asked through focus group discussion (FGD) conducted by FA and KHA via the online method through the Zoom platform in view of practising physical distancing due to the increase in COVID-19 cases in the country during the research period. FGD uncovers people’s perceptions and values [25] and enables participants to share their diverse views [33]. The rules of the FGD were clearly explained to ensure equity in participation, mutual respect, and acknowledgement of each other’s contributions. The online method enhanced the participatory nature of FGDs and facilitated conversation during data collection [33]. Consent was obtained from the participants to record all the FGDs.

The recorded FGDs were then transcribed by FA using Free Online Otter software (https://otter.ai accessed on 17 January 2022). The accuracy of the transcriptions was checked by both primary authors. Thematic analysis [34] was performed by KHA through the process of coding where the five domains of the DREEM were framed as themes. The initial open coding was performed line-by-line, which was proceeded by focus coding [31]. Next, categorization was performed where words that meant or sounded the same were grouped together [35] under the five domains. Audio data, and all the transcripts and preliminary findings underwent constant comparative methods for data analysis [36]. This was to ensure that all data were accurate, accounted for, concrete and explicit, with no repetition of similar data from one to another themes [37]. Participants’ quotes were used as exemplars of the themes. The final findings were checked and discussed by all the researchers to ensure member-checking and validation for qualitative research rigour in terms of the dependability, transferability, credibility and conformability of the findings [38].

3. Results

3.1. Quantitative Analysis

There were 150 students who participated in the quantitative study: biomedical sciences (n = 34), dentistry (n = 24), medicine (n = 60), nursing and midwifery (n = 16), and pharmacy (n = 16) students.

Table 1. Health science students’ characteristics and overall DREEM score (n = 150).

Factors	Grouping	Frequency	Percentage
Age group (years)	<20	64	42.7
	≥20	86	57.3
Gender	male	46	30.7
	female	104	69.3
Marital status	single	145	96.7
	married	5	3.3
Living arrangement	Live w/parents	140	93.3
	Hostel	10	6.7
Discipline	Biomedical sciences	34	22.7
	Nursing & Midwifery	16	10.7
	Medicine	60	40.0
	Pharmacy	16	10.7
	Dentistry	24	16.0
Year of study	Year 1	61	40.7
	Year 2	43	28.7
	Year 3	35	23.3
	Year 4	11	7.3
Time spent for study per day	1–2 h	37	24.7
	3–4 h	46	30.7
	>4 h	67	44.7
Overall DREEM score category	Plenty of Problems (51–100)	20	13.3
	More Positive than negative (101–150)	130	86.7

illustrates the sample characteristics and overall DREEM score category for health science students.

Table 1 presents the descriptive statistics of the health science students. Initially, the survey received participation from 264 students (response rate = 66%). After data cleaning, 150 valid data points were used for data analysis. The majority of the sample were female (69.3%), not married (96.7%), and living with parents (93.3%). A total of 69.7% of them were in Year 1 and Year 2. A total of 40.0% were medicine students, followed by biomedical sciences (22.7%), dentistry (16.0%), nursing and midwifery (10.7%), and pharmacy (10.7%).

Table 2. Overall and domain-specific mean DREEM score and dispersion for health science students (n = 150).

Domains	Mean Score	Standard Deviation	Score Range
Overall	113.51	12.7	0–200
Perception of learning	28.49	3.19	0–48
Perception of teachers	23.19	2.57	0–44
Academic self-perception	19.49	3.73	0–32
Perception of environment	28.56	6.22	0–48
Social self-perception	13.77	2.77	0–28

shows the overall and specific domains of the DREEM scores among health science students. The mean overall DREEM score was 113.51 points. By category, 86.7% perceived the EE in the university as “more positive than negative” and the remaining 13.3% perceived the EE as having “plenty of problems”. By domain stratification, we observed that all domains were perceived as average and none of the categories were particularly excellent or poor.

The overall and domain-specific DREEM scores by program disciplines are illustrated in

Table 3. Overall and domain-specific DREEM score by discipline (n = 150).

	Biomedical Science		Nursing & Midwifery		Medicine		Pharmacy		Dentistry
Domains	Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD	p-Value
Overall	110.8	13.4	118.1	13.0	111.8	13.3	112.8	8.6	119.3	10.3	0.043
Perception of learning	27.9	4.1	30.5	2.2	27.9	3.1	28.4	2.2	29.6	2.1	0.012
Perception of teachers	23.0	2.6	23.4	2.9	23.3	2.8	22.9	2.3	23.3	1.9	0.957
Academic self-perception	19.1	3.7	20.1	3.2	19.1	4.0	18.8	2.7	21.2	3.6	0.142
Perception of environment	27.0	7.5	30.0	7.2	28.3	5.8	28.6	4.7	30.6	5.0	0.217
Social self-perception	13.9	2.6	14.1	2.5	13.2	2.8	14.0	3.2	14.6	2.7	0.282

. We observed that dentistry students (mean score = 119.3) perceived their EE significantly more positively compared to biomedical science students (mean score = 110.8) (p = 0.043). By domain stratification, we observed that nursing and midwifery students (mean score = 30.5) had significantly more positive perceptions of learning compared to other disciplines (p = 0.012).

Table 4. Factors related to overall DREEM score (n = 150).

Factors	b	2.5%	97.5%	p-Value
Age group (reference: less than 20 years)
More than 20 years	1.77	−2.38	5.91	0.401
Gender (reference: male)
Female	−1.64	−6.09	2.81	0.467
Marital status (reference: single)
Married	−3.84	−15.27	7.59	0.508
Living arrangement (reference: living with parents)
Hostel	−1.51	−9.75	6.72	0.717
Discipline (reference: biomedical science)
Nursing & Midwifery	7.27	−0.19	14.72	0.056
Medicine	0.96	−4.32	6.23	0.721
Pharmacy	1.96	−5.50	9.41	0.605
Dentistry	8.46	1.90	15.01	0.012
Year of study (reference: Year 1)
Year 2	1.48	−3.56	6.52	0.562
Year 3	1.32	−4.04	6.69	0.627
Year 4	−0.55	−8.84	7.74	0.896
Time spent for study per day (reference: 1 to 2 h)
3–4 h	0.21	−5.34	5.77	0.939
>4 h	−2.02	−7.18	3.13	0.439

illustrates the factors related to the overall DREEM score using univariate linear regression. We observed that demographic factors and time spent on studying did not have a significant effect on the perception of the EE. There is, however, a significant difference by discipline where we observed that dentistry students perceived their EE as 8.46 points better than students from biomedical science (p = 0.012).

3.2. Qualitative Analysis

A total of 31 students of the five health science programs participated (

Table 5. Participants of the FGD and their genders.

Groups	Male	Female	Total
FGD1	4	3	7
FGD2	4	4	8
FGD3	6	3	9
FGD4	3	4	7
OVERALL	17	14	31

). As there was a small number of students per programme, to avoid the risks of the students being identified, the exact year of study will not be presented in the table. The breakdown of participation from all programmes according to the year of study are Year 1 (n = 8), Year 2 (n = 8), Year 3 (n = 9) and Year 4 (n = 6). As the study employed FGDs for data collection, the findings are presented as a set of discussions instead of detached single quotes. In this way, the findings are presented in the context of FGDs, providing a comprehensive understanding of the participants’ perspectives and insights.

3.2.1. Overall Educational Environment

The findings in this theme significantly highlighted the unique and extensive EE not expanded in the DREEM [3,4,10]. This include a stimulating home learning atmosphere, a supportive network of peers, innovative and creative teaching approaches, and the enhancement of clinical learning experiences that were repetitively echoed by the participants. An example of the sentiments summarizing the overall educational environment of health science students is captured in FGD2.

P1FGD2: “To me… a stimulating educational environment should not just focus on the classroom learning, skills laboratories and clinical attachment but also the home environment is also important…”.

P3FGD2: “… There must be a give and take among our parents, siblings and us… we are performing our duty as their children… to study and get a better job… but in return… we need them to ensure that we learn in a conducive environment… no noise… give us time to spare for study…”.

P2FGD2: “…I view my classmates’ and seniors’ support as integral… I asked what I don’t understand with them, and do group work and discussion with them. This is important so that I learnt from them and do not repeat the same mistake that they did during their study…Especially in the clinical… We do reflective analysis and share our experiences and learn from each other strengths and weaknesses… they [the student’s classmates] are my social support system… we cry and laugh together… we support each other…”.

P4FGD2: “The way the lecturers teach us is also important… In the classroom, they should be creative and sustain our attention in learning. Aside from that, clinical teaching should enable us to perform skills and procedures confidently…”.

These findings imply that the EE is more than just classroom learning and clinical settings but also includes several elements. These findings reinforced previous studies that emphasized peer support as a psychosocial support system for students which is not only eminent during the COVID-19 pandemic [39] but also throughout their program of study. The findings also revealed that students are self-empowered with respect to a student-centred approach to learning, and supported the previous study for a well-rounded approach to learning that goes beyond traditional classroom instruction [20,24]. A salient finding is concerned with a conducive environment at home, which was not sufficiently addressed in previous studies. In this study, family is viewed as the first source of social support for health science students to thrive in their studies. They require space and time to study and to not be overburdened with their roles and responsibilities in the family. Indeed, not only in education but from the beginning and throughout life, family is the essential and central support system for an individual [40]. It is important to note that there is a tendency for families to perceive a diminishing need for attention to studying as their children grow up, when in fact the needs are greater as they grow up [41]. These findings also point to the importance of the comprehensive and complex nature of the EE, which should be appropriately addressed to enhance students’ learning.

3.2.2. Students’ Perceptions of Learning and Teachers

Health science students’ perceptions of the EE, their learning and teachers is majorly perceived as unique, encompassing the classroom, and practical and clinical learning. An example of these immense thoughts was identified during FGD1.

P3FGD1: “I think we should maintain the lecture… It might be viewed as traditional but it never failed to work… it [lecture style] is still needed. I learnt well if things are described clearly through lectures. Another thing is recorded lectures which we popularly used during COVID [COVID-19 pandemic]…we don’t have to worry that we missed anything…we just have to replay and can study during our free time”.

P2FGD1: “For me, creativity of the lecturers is important…not just using PowerPoint slides, but also… through problem-based learning… Although this is a challenging learning approach… It is stimulative… I don’t like spoon-feeding [a term used by the student to denote to throwing information to the students through lecture] … Maybe also use role-play, simulation and topic debates”.

P4FGD1: “Skills attainment is important… We must learn skills during our practical classes in the skills lab (skills laboratory). No skills mean poor clinical… how to perform procedures if you do not have any skills? And how can we understand the justifications of why we performed the procedure according to the steps if we do not have the knowledge?”.

P1FGD1: “I respected lecturers who know their stuff. Have a well-planned lesson…understand what they taught us, concerned and caring about us… teach from the simple to complicated [knowledge/skills]… and help us to understand complex topic by chunking it [the topic] to simpler explanation…”.

In the FGD above, the students acknowledged the fundamental importance of being able to integrate classroom and practical learning into clinical experience. This is in line with earlier studies, finding that the application of theory into practice is essential for developing skills, fostering critical thinking, and enhancing the scientific reasons behind actions undertaken in clinical practice [42,43]. Creativity in teaching approaches and a structured and systematic timetable is also repeatedly addressed that reiterates the existing literature on the organization of innovative teaching approaches [44,45]. These findings corroborate previous studies on the significance of lecturers being knowledgeable and providing explanations of complex topics to students in a way that is understandable to them [6,24].

3.2.3. Students’ Academic Self-Perceptions

Students had varying perceptions of their academic life, which they viewed as a ‘maze’ or a ‘see-saw’ game, and even compared it to a wheel. The most salient disposition is concerning the ability ‘to survive’ throughout their study. For example, this is prominently identified in FGD3 among three of the participants.

P3FGD3: “The most important thing that I learnt right away as soon as I join the degree programme is the need to survive the ‘maze’ journey of studying”. [Note: the student uses the term ‘maze’ to metaphor having to deal with various challenges throughout the degree study, like playing a ‘maze’ game]

P1FGD3: “It [the journey of studying] is like playing a ‘see-saw’. It is like a wheel. Sometimes you are up high in the sky and sometimes you are down at your very lowest and dirt by the earth…it is a matter of whether you can successfully survive and end the journey or die in the middle of the journey…”.

P6FGD3: “And… if I may add… To survive… It needs more than just the scientific knowledge written in textbooks…we need to master the survival skills… to be likeable, influential, respected, strong, able to justify and defend ourselves…able to communicate across different age gaps and… people who are older or younger than us…It [the way they communicated] should be appropriate to their [other people’s] age…”.

These findings imply that studying health science education is found to be not straightforward but rather challenging, which is in line with previous studies that health science profession education is considered difficult due to the need for clinical skill acquisition and interactions with human [43,46,47,48]. Thriving in their study is again reiterated as self-perceptions of their academic performance. It implies that students desire to be empowered through a specific educational program that inculcates interpersonal and soft skills [2,11,49,50,51,52]. Intergenerational gaps are also pointed out as inhibitors to their communication skills.

3.2.4. Students’ Perceptions of Atmosphere and Social Self-Perceptions

The students distinctively acknowledged that the home environment is an important atmosphere or learning environment. Learning does not only have to be in the classroom, practical room or laboratories and clinical placement, but continues at home. As an example, the following are debated in FGD4.

P3FGD4: “At home, there should be a space for learning…give us time to breathe and learnt…it is difficult if we have to fulfil the duty as a son or daughter and then also juggle with our study… we are studying for degree level…not secondary schools anymore… it is challenging…”.

P1FGD4: “Bonding with each other among us [students] is very important. We support each other in good and bad times and during the sunny and rainy days [supporting each other to overcome any difficulties in their study]”.

P2FGD4: “An old and never fully remedied problem is mentorship. I think this [mentorship] is a never-ending problem. Like a circle of life for each one of us [students], now and I think forever… It is difficult to address…not all of them [mentors] are unhelpful, but this kind of mentor still exists…”.

P3FGD4: “…It is important for them [clinical staff] teach us ‘to become’ not demotivate, ridicule and bully us…I try to think positive, but I cannot entirely do it [thinking positively] … when it is negatively experienced…”.

The development of soft skills was also highlighted again in this theme as a core fundamental need of the students in managing their sustainability in completing their programme. The skills are explained as interconnected to and inseparable from the survival skills that they mentioned in the previous section. The following excerpts from four of the participants in FGD3 are examples of students’ desire for the enhancement of their communication skills, time management, and for developing positive workplace relationships. They perceived that these skills, in essence, contributed to a positive mental well-being.

P3FGD3: “I do not know if it is just me. I found my communication skills need some boosting. I am quite shy to talk to others”.

P4FGD3: “If you asked me to write, I can write a thousand words… but when it comes to talking… I immediately turn on my ‘mute mode’”.

P5FGD3: “I cannot imagine how to talk to patients. They have different work backgrounds and I cannot relate being a nurse or a midwife and then talking to a patient who is an engineer for example…”.

P2FGD3: “Time management is very important… We need these skills so we can manage our assignments well… and being someone that is respected and treated with justice in the clinical is an essence for working happily in the clinical… We certainly would like to have that skills too…When we are happy, we look forward to being in the clinical day in and day out…”.

It is possible that the current health science students are predominantly Generation Z (born between 1995 to 2012) [53,54], who are also called Gen Z, iGen, Gen-Xer, netGeneration, digital natives, and Zers [55]. Existing literature indicated that these students are exposed to the extensive use of technology, less exposure to hardness in their lives, have little socialization, and hence are prone to feel isolated which eventually makes them highly likely to develop mental illness [54]. In comparison with previous older generations, Gen Z pays attention to the preparation of their future employment, prefers to feel satisfied at work instead of being highly paid, and takes fewer risks [56]. This explains the needs that they shared on their EE atmosphere and social self-perceptions in FGD3 above.

4. Discussion

4.1. Discussion and Evaluation of Results

Quantitative and qualitative data collection was conducted in parallel. The quantitative data underwent statistical analyses while thematic analyses were performed on qualitative data, which were framed against the five domains of the DREEM inventory. Consequently, the qualitative data converged with the quantitative results; hence, complementing the quantitative data results by providing justifications and expanding the quantitative data results.

Our study found the overall mean DREEM score to be 113.51/200 (SD ± 12.7) amongst our students who perceived the EE in the university as “more positive than negative”. Our overall mean DREEM score was in the same range (101–150) as those reported by most authors [26,27,28,29]. Other authors have reported higher overall mean scores of 137.3 [30] and 142.91 [31].

Our results showed that the students taking the survey were mainly females; this is consistent with most of the studies which reported a higher preponderance of females [26,27,28,29,30]. Despite this, female students’ overall DREEM score was the same as that of males. This reinforced studies from India, Greece and Australia where the students’ perceptions of the EE showed no gender difference [26,27,28]. However, studies from Pakistan and Malaysia found that the EE was perceived by female students as more positive in comparison to the male students [29,30]. The authors attributed this to in the differing learning styles of female and male students, and that females tended to spend more time studying compared to males.

Another finding of our study was that significant differences between disciplines were observed. Dentistry students perceived their EE as 8.46 points better than students from biomedical science (p = 0.012). This reinforced a previous study that showed students’ perception of EE varies between courses [57]. This may be credited to teaching strategies employed by different programs. In UBD, the teaching strategies for engaging students are variable and the perception may also vary due to the difference in the number of students in each program.

Our results demonstrated no significant difference between the years of study. Our results are unique as many previous studies have identified clinical year students as having higher DREEM scores than preclinical year students [58,59]. That may be attributed to the fact that the initial years are dense and curriculum-based, and students face challenges while adapting to the problem-based curriculum and administrative challenges. Our findings could also be attributed to our unique curricula, which are not only are integrated and vertical, but also spiral. An integrated and vertical approach to the curricula introduces the students to clinical and hospital settings from Year 1, and the spiral approach allows them to maintain their interest throughout subsequent years of study with a positive perception of their EE.

The qualitative finding from this study explicated that the unique EE of the health science students comprised the classroom and skills laboratories at the university, and the clinical areas. Additionally, in this study, a nurturing home environment was also regarded as a significant component of the health science students’ EE. The home environment was first realized during the COVID-19 pandemic [39,60,61] when educational institutions were obligated to resort to online learning, necessitating students to stay at home with the aim of containing COVID-19 infection transmission [62,63,64,65,66,67]. Yet, the significance of a conducive home environment has been recognized by students all along, oblivious to us. Students in our study highlighted the importance of a home environment stimulative to their learning that includes minimal distractions from their siblings, time on their own to do their study and the balancing of work–family conflicts. A similar study conducted on nurses indicated the importance of balancing work and life, and also the balance between work and family, as an imbalance in either one of the two continuums of work–life or family, where usually too much attention is paid to one over the other, posed a risk for the nurses [68].

Another important qualitative finding was the exclusive need for the support of peers to be existing in the students’ educational environments that consequently contributes to the positive mental well-being of the health science students. Support for the clinical education environment was highly regarded as requiring more crucial attention than the classroom and skill laboratory environments in the university. The possible reason for this may be the presence of their lecturers in the university as compared to only being dependent on their mentors during their clinical placements. This finding supported earlier studies that identified a prolonged clinical education environment challenges due to the ratio of mentors to students and the efficiency of mentor support for students in the clinical areas, in view of prioritizing their work that unintentionally neglected students’ needs [69,70,71].

The lecture style of teaching has been employed for centuries and may be regarded as authoritarian and teacher-centred [51]. It may not be the most innovative and interactive teaching approach. Particularly, in this digital era, students need to be equipped with computational and critical thinking skills on top of current curricula to help them navigate the complex problems arise from continuous modernization [72]. Yet, lecturing has its merits and has stood the test of time and health science students still regard it as an efficient way of delivery of descriptive information. Despite this, the lecture style should be used cautiously and may not be ideal if delivered without an additional student-centred pedagogical approach [11,46]. In this study, the lecture style via interaction through online asynchronous video recording, along with the implementation of role-play, simulation and problem-based learning were found innovative and stimulative. This finding reiterated a previous study that established that creativity in teaching promotes students’ engagement in the learning process, resulting in better retention of the knowledge acquired [47,73,74,75]. The importance of conveying complex or abstract knowledge by distilling it into digestible information was also highlighted in our study. This finding adds to the existing knowledge that emphasized the significance of presenting an intricate subject matter in simpler terms understood by the students [7,76]. It is noteworthy to highlight here that health science students undertaking their degree programs are on par with other students in other disciplines. However, as health science students encompass various fields, including esteemed disciplines such as medicine and dentistry, there may be an oversight that lecturers assumed these students have inherent intelligence that made lecturers unnecessarily use jargon, complicating the students’ learning process [77]. As a matter of fact, there are still students who are in the process of acquiring knowledge and developing their skills.

Students pointed out their concern about surviving their journey of studying, which they compared to a ‘maze’ or ‘see-saw’ game or even a wheel, which requires a distinct mastery of survival skills. They also stressed that studying at the university level extends beyond textbook learning and the development of interpersonal skills encompassing time management, leadership in dealing with people, communication skills, being influential and respected, and the ability to work happily. They regarded these skills as the key to their survival. Previous studies have highlighted these skills [2,11,49,50,51,52] but in-depth studies on how to inculcate these skills to the students have not been adequately explored. The intergenerational gap is also identified as an inhibitor to the enhancement of the EE. The recent generation of students should not be expected to be independent all the time mainly due to their exposure to technology when growing up, resulting in minimized survival skills [78]. Additionally, those health science professionals and patients from Generation X and Y have more life experience and usually have also confronted more adversity unlike Generation Z who have to learn about life the hard way [55].

4.2. Strengths, Limitations, Implications and Recommendations

This convergent mixed-methods study not only quantified students’ perceptions of their EE using the DREEM inventory [4,10], but the domains and specific items were also qualitatively expanded and justified by the students through their sharing of experiences. This study serves as a baseline to review, structure and innovate the current curriculum to enhance Brunei health science students’ learning. An educational program that empowers students on their EE may also be significant in fostering independence and student-centred learning. It is suggested that, in the future, an in-depth study focusing on intergenerational gaps between the students and their relationships with their social environment may add value to addressing their needs and expectations of their educational environments. Future research may include the in-depth exploration of what the students addressed as ‘survival skills’ and the development of an inventory on measuring these skills as indicators of their sustainability in completing their health science programmes. Additionally, as health science programmes encompassed studying at the university and clinical placement, specific research studying these two environments may be significant to establish whether there are differences in the students’ experiences of the two environments. Furthermore, the perception of the EE prior to students embarking on clinical experiences will also add to a better understanding of the EE after exposure to the clinical experiences.

5. Conclusions

Health science students’ experiences of their educational environments have been the centre of attention for substantial global study using the DREEM inventory. The domains of the DREEM inventory have proved themselves useful for framing the qualitative exploration of health science students’ experiences of unique learning in classrooms, skill laboratories and clinical areas. The current study offers an extensive and detailed understanding of the critical role of a conducive educational environment among health science students that includes the home environment. A holistic educational environment is crucial that addresses the diverse needs of health science students, promoting positive perceptions and enhancing learning experiences. This study is foundational for improving and enhancing the quality of education provided to health science students.