Note that 21 nursing students were recruited and 12 interviews were conducted, and two interviews were one-to-one. The mean of interview time was 66 min (range = 45-111). Participants were 17 female and 4 male students. The mean of age were 21.1 years (range: 20 – 26 years) and 2 were second year students, 14 were third year students, 3 were fourth year students.
The categories and concepts are presented in Table 1, and the relationships between categories are illustrated in Figure 1. Note that four categories were related to experiences in classrooms and other seven categories were about clinical practice. The storyline and the explanations about each category were written as follows.
Storyline
Nursing students’ learning experience processes over the course of PMHN in lectures reached positive and active “self-developmental knowledge acquisition” or passive “acquisition of superficial knowledge about PMHN” through “formation of learning attitude based on life experience.” Moreover, students’ passive learning was promoted by the “encounter with ambiguity in PMHN,” and there was a tendency toward polarized learning outcomes. In practicums, students initially had “a feeling of unrest evoked by the start of practicum,” but “partial adaptation with practicum resources” solved students' tension. After students transiently had “Facing the reconsideration of students' own communication skills” albeit to a varying extent, they obtained success by “redefining communication.” However, other results had considerable effects on learning outcomes of lectures. Students whose result of lectures was passive learning outcomes had “confusion in knowledge about people with mental illness” and “difficulty in understanding practical skills in PMHN;” “non-discovery of significance of practicums” was prone to become foreground as a learning experience in these students. The other group of students was able to readily identify meaning in practicums as a learning experience characterized by positive and active “developmental self-learning.”
Table 1. Categories and concepts
Formation of learning attitude based on life experience
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evoking interest with visual teaching materials
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formation of learning motivation dependent on individual's interest
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motivation based on everyday interest
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motivation based on experience with close relationship with mental illness
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Encounters with ambiguity in PMHN
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anxiety when no answer is presented
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difficulty in developing concrete image of lecture knowledge
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Self-developmental knowledge acquistion
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updating existing knowledge with lecture knowledge
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promotion of understanding through development of images
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Acquisition of superficial knowledge about PMNH
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acquisition of simplified expertise
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increased prejudice because of lecture knowledge
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acquisition of knowledge for written examination
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A feeling of unrest evoked by the start of practicum
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a feeling of anxiety from negative image of psychiatric wards
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a feeling of tension evoked by entering a psychiatric ward
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a mental burden from patient's narrative for understanding a patient
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Partial adaptation with practicum resources
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information provision by other participants in practicum
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familiarization with psychiatric wards
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Facing the reconsideration of students' own communication skills
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awareness of insufficient communication skills
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communication different from 'usual' one
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Redefining communication
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return to 'usual' communication
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success of strategic communication.
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Confusion in knowledge about people with mental illness
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difficulty in understanding mental illness
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instinctive understanding of mental illness
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difficulty in finding problems related to mental illness
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difficulty in understanding recovery
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Difficulty in understanding practical skills in PMHN
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A sense of embarrassment because nursing skills cannot be seen
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Awareness of the unavailability of practice templates
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Awareness of the inapplicability of simplified expertise
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Developmental self-learning
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Developmental postponement of questions in practicums
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Diversion of experience in practicums
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multifaceted understanding of mental illness
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Non-discovery of significance of practicums
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Giving up on achievements of practicums
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drifting questions in practicums
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Categories
Formation of learning attitude based on life experience
This category denotes the formation of motivation composed of following four concepts: “evoking interest with visual teaching materials;” “formation of learning motivation dependent on individual's interest;” “motivation based on everyday interest;” and “motivation based on experience with close relationship with mental illness,” representing the starting point of learning process. Students’ motivation for lectures were formed before the lecture in certain cases through daily life and experiences seeing or hearing about illness or disabilities of someone close to them or were formed through the lecture in certain other cases. Moreover, the formation of motivation among students was highly individualized; motivation for PMHN did not increase in certain students because they compared PMHN with perioperative nursing and nursing for physical illnesses. Furthermore, visual teaching materials using, for example, familiar variety programs and dramas, tended to be beneficial in helping to motivate such students.
Despite listening to the same net, it was like…, there were certain students saying, what is the deal with that? Well, I thought it was really good, but certain other students looked like they did not think so. Therefore, I strongly felt that, even about nursing, one student's impression could be quite different from another student's. (omitted) To me, this difference seems to be bigger than the difference in feeling that students have when reading a piece of writing in Japanese (classes) in which emotions represent a subject of teaching. I felt strongly that the difference was attributed to something like each individual’s previous experience.
Encounters with ambiguity in PMHN
This category comprised the following two concepts: “anxiety when no answer is presented” and “difficulty in developing concrete image of lecture knowledge.” This shows that students themselves see ambiguity in PMHN because an image of knowledge about PMHN is difficult to have based on their own experience and model answers about PMHN skills, such as communication, are not presented to them. While this ambiguity promoted students’ “acquisition of superficial knowledge about PMHN” in certain cases, this served as a positive motivation in certain other cases in the form of self-questioning.
There are many things like “do this when this happens” and “do this for this disease.” However, what are we supposed to do when the patient has delusions? Because it is about what the patient is thinking, I thought it requires to have a rich imagination or really it requires the ability to think.
Self-developmental knowledge acquisition
This category represents active learning composed of the following two concepts: “updating existing knowledge with lecture knowledge” and “promotion of understanding through development of images.” Because this approach of learning is associated with students’ own experience and interests, it helped retention of what was learnt as their own knowledge. Moreover, this independent learning experience promoted an attitude oriented at active understanding in practicums.
I feel like something deep in my memories, similar to a mystery, has been solved by studying this topic. For example, that old man and old woman who had alcohol dependence, now I can understand that, well, they had alcohol dependence, well, I can in retrospect.
Acquisition of superficial knowledge about PMHN
This category comprised the following three concepts: “acquisition of simplified expertise,” “increased prejudice because of lecture knowledge,” and “acquisition of knowledge for written examination.” This denotes passive and superficial learning, which is in contrast with the above-mentioned “self-developmental knowledge acquisition.” Superficial learning indicates theories and skills of PMHN received exactly as explained in textbooks or by teachers without questioning. Students were aware of their inflexibility in interpretation in practicums as follows.
I do not feel comfortable with saying 'yes' easily or saying 'no.' Well, denial or affirmation does not seem to be very appropriate in psychiatric classes. I was hearing what the teacher said with such an attitude, so I did not know what the correct answer was, and all I could do was nod my head.
Moreover, superficial understanding represented by this category can increase anxiety and fear about people with mental illness depending contents of lectures, and students with superficial understanding forget contents of lectures after examinations.
A feeling of unrest evoked by the start of practicum
This category represents a feeling of unrest evoked by the start of PMHN practicum, composed of the following three concepts: "a feeling of anxiety from negative image of psychiatric wards," "a feeling of tension evoked by entering a psychiatric ward" due to the environment of the psychiatric ward, and " a mental burden from patient's narrative for understanding a patient " due to having contact with patients in psychiatric wards. In certain cases, a "negative image of the psychiatric ward" was created through lectures. Moreover, these feelings of unrest were described as a common experience of students.
Partial adaptation with practicum resources
This category represents a condition where the abovementioned feeling of unrest is alleviated, composed of the following two concepts: "information provision by other participants in practicums" and "familiarization with psychiatric wards" in terms of both environmental aspect and patient care. Other participants in practicums included other students, instructors, and faculty members. Information was primarily shared among students and advice about communication accounted for a majority of information from faculty members and instructors. This experience affected the direction in the redefinition of communication.
I learnt, about communication for example, that I made a mistake, and I should have communicated with that patient in this manner. I had something like 'eureka!' when I reflected on the practicum at the end together (with instructors).
Facing the reconsideration of students' own communication skills
This category comprised the following two concepts: "awareness of insufficient communication skills" and "communication different from 'usual' one." The former is an experience that students met people with mental illness and thereby noticed their current communication skills were not enough in clinical setting and oriented themselves toward skill improvements. The latter was different in that students did not have the sense of personal transformation, while they experienced a sense of "unusualness" in the PMHN practicum.
It was very difficult to know what response was best for that person. In particular, because a person with mental illness probably, well, his/her mental equilibrium shifts to left and right, I felt that it is difficult to know where the balance is now at the first quick visit.
Redefining communication
This category comprised the following two concepts: "return to 'usual' communication" and "success of strategic communication." It represents a reaction of students to "requests to review communication." Similarly to the preceding category, the two concepts were confrontational. The former indicates that a feeling of strangeness caused by communication with people with mental illness is resolved and previous communication is applied.
In the medical records, it said something like bipolar disorder but there was no special remark so I did not consider it to be particularly negative. I didn't consider it that way, in a usual neutral condition, well, when talking…
The latter indicates that students intentionally used professional communication skills and reported new ways of communication.
I have learnt mostly (in classes), something like silence, acceptance, and iteration. They dis summarization and what not, I felt them closer like, oh, that's right…
Confusion in knowledge about people with mental illness
This category, which was composed of four concepts, indicates that students become aware that superficial understanding of lecture knowledge is not sufficient to understand phenomena and situations occurring in practicums. "Difficulty in understanding mental illness" indicates that they cannot understand mental illness they encounter during the practicum, and "instinctive understanding of mental illness" indicates that students can understand that the situation arises from mental illness but they cannot explain how. "Difficulty in finding problems related to mental illness" and “difficulty in understanding recovery" are difficulties related to development of the nursing process. The former is related to problem finding; however, the latter is difficulty in goal setting unique to PMHN.
Difficulty in understanding practical skills in PMHN
This category, which is composed of three concepts, represents difficulties associated with skills that students provide patients during the practicum. "A sense of embarrassment because nursing skills cannot be seen" was attributable to difficulty in visually understanding nursing skills used in psychiatric wards, many of which are not medical procedures. " Awareness of the unavailability of practice templates " denotes the difficulty in seeing the flow of systematic nursing skill, such as clinical pathways, and students told that comparison with other practicums helped to make the flow clear.
In cases of surgery for example, or something for which a template is available, a standard theory has already been established, so it is made into a template, but feelings of people are not understandable…
The "Awareness of the inapplicability of simplified expertise " was attributable to the superficial understanding of expertise in clinical settings involving complex factors concomitantly. Moreover, such difficulty in understanding motivated some students. As in the following narrative, there were certain students who wanted to understand it because they did not know it.
I have not found the answer yet, not at all, so I am just interested in it now, really. It is just an interest. Well, it is what I want to know.
In this narrative about a question that occurred to the student during the practicum, the student distinguished "interest" from formal learning but stated that it was at this point that sustained curiosity arose.
Developmental self-learning
This category, which comprised three concepts, represents positive outcomes of practicums. "Developmental postponement of questions" is acquisition of intention to continue thinking, "Diversion of experience in practicums" is to divert learning outcomes of practicums to everyday life, and "multifaceted understanding of mental illness" is to feel the diversity of people with mental illness, including their strengths. Both of these were associated with awareness of personal transformation.
I might not have been able to find this before. I was thinking about a situation (omitted) in which the patient was speaking to themselves for a long time, and I was wondering to whom the patient was talking: then the patient looked at the space next to him/her and talking as if someone was really there; well, nobody was there, but people like that are actually just going about their daily lives, and it made me realize that there are all sorts of people in the world…
Non-discovery of significance of practicums
This category comprised two concepts and represents the negative outcomes of practicums. "Giving up on achievements of practicums" and "drifting questions in practicums" indicated that students stopped thinking about improvements in PMHN. The former was a state where students did not actively seek outcomes of practicums.
Seriously, the only actual feeling I got was that I could actually meet someone suffering from psychosis for the first time. Yup. That is all in term of result.
The latter described a state in which a student became aware of questions and issues during practicums but stopped thinking about additional improvements.
It is true that there are people of different ages; therefore, I understand that variation in care are needed to suit each of them, but I think it is impossible to divide patients so precisely in that environment. To me, staff looked too busy taking care of their existing patients. I did not see much leeway left at all so I do not think it would be possible to divide the program further.