Exploring the Association and Dissociation Between Lectures and Practicums in the Process of Learning Experience in Psychiatric and Mental Health Nursing Education: a Qualitative Study in Japan

Objective: This study aimed to clarify the process of students’ experience of learning to identify association and dissociation between lectures and practicums in psychiatric and mental health nursing (PMHN) education at a university. Methods: An interview survey of 21 students from a regional national university in Japan was conducted, and the interview data were analyzed with a modied grounded theory approach. Results: The analysis identied 12 categories and 32 concepts regarding the process of learning experience in PMHN among university nursing students. Through lectures, the students accomplished “self-developmental knowledge retention” or “acquisition of supercial knowledge about PMHN” toward “formation of learning attitude based on life experience.” The outcomes of lectures signicantly affected practicums; the former possibly resulted in “non-discovery of signicance of practicums;” however, the latter possibly approached “developmental self-learning.” Discussion: The association between students’ interests based on life experience and contents of lectures affected practicums, and the lecture design readily imaginable from students’ experience was desirable. Practicums must be built on teaching strategies that make students aware of the particularity of communication. practical training, including faculty members, instructors, and facilities, to acquire such comprehensive knowledge and skills and in the eld of PMHN in Japan (27). Further educational improvements are required to promote nursing students’ understanding and interest with limited resources, and multiple recent studies demonstrated the effectiveness of simulation in the eld of PMHN (28–30). In Japan, while simulation-based education is being increasingly introduced in nursing education, there are various issues to be solved, including education system-related problems, such as the training of instructors and establishment of assessment methods, and the budget availability for the realization of small-group education. Diversity may be brought to PMHN education in Japan while solving the education cost problems by building a system for introduction and sharing of PMHN education resources designed based on evidence accumulated by teachers and researchers. This study demonstrated that nursing students' ability to link abstractive knowledge and skills unique to PMHN with their own experiences had a major effect on learning outcomes. The motivation for PMHN was largely improved when lectures were linked with students’ personal life experience or previous experience of interacting with someone close to them with mental illness and was maintained during practicums. Furthermore, nursing students failed to make this association during lectures tended to foreground negative outcomes of practicums. A previous study has reported that the satisfaction of practicums improved when time to prepare for practicums was available (23). Given the perspective of the association of PMHN knowledge and skills with nursing students’ own experience, which was revealed in this study, the increased amount of preparation for practicums may have served to increase opportunities for nursing students to link their own experiences with the knowledge and skills of PMHN. Furthermore, faculty members and instructors involved in practicums play an important role to allow nursing students to link knowledge and experience. A previous study reported that nursing students' attitudes toward PMHN considerably affect the specialties of faculty members and instructors (31). Furthermore, the attitude toward PMHN has been reported to improve when additional time was spent with instructors during practicums (32). Our results along with the ndings of Gough & Happell suggest that the increased opportunities for instructors and faculty members to attempt the association between students' previous experience and experience during practicums induced attitude improvement. Therefore, faculty members and practicum instructors may be able to induce positive changes in students’ levels of interest and attitudes by generating

speci cally, M-GTA requires a qualitative analysis to interpret meaning. Therefore, in M-GTA, one does not use segmented data by prede ned units such as a word or a sentence, allowing for a deeper interpretation of meaning (18).

Setting and participants
There are sampling strategy discrepancies between the GTA and M-GTA, e.g., the strategy of the GTA is to collect and analyze data in parallel and its process proceeds by comparing participants. However, the strategy of the M-GTA is to collect data for a speci c group; then, the researchers analyze this "base data." After this process, researchers collect additional speci c data as required (18).
This study recruited participants from a national university in Western Japan who had agreed to cooperate. In the curriculum of this university, students studied in classroom or training room primarily by sophomore and they had rst clinical practice in fundamental nursing at the end of the year. Junior participants primarily learned in certain clinical practices, which were adult nursing, maternal nursing and PMHN. Senior participants had clinical practice for child health nursing, gerontological nursing, home care nursing and public health nursing. The PMHN clinical practice was a two-week program. In the rst week, student learned in hospital's psychiatric units and they had a patient in charge. Moreover, they learned at certain facilities for people with mental illness in community in another week. These facilities had each role, such as supporting employments and works, counseling for daily lives and providing the place in the daytime. Most participants were junior who had experienced all clinical practices in the year. However, a few students were sophomore or senior. The reason of this recruitment was for comparison, which would be clarifying characteristics and learning process of clinical practices in PMHN on the junior. The participants of sophomore were only students who experienced fundamental nursing clinical practice in a psychiatric unit. Firstly, in this study, junior participants were recruited after a lecture conducted at about three months later all junior's clinical practice nished. Furthermore, snowball sampling was used. Sophomore's and senior's participants were recruited by snowball sampling. Although this study was mainly conducted joint interview, one-to-one interview was conducted when a participant hoped.

Data collection
The data were collected via semi-structured interviews conducted from October 2017 to March 2018. In this study, joint interview was conducted. Joint interview is one of the interviews involving two interviewees for one interviewer. It is because that participants were students who might hesitate to tell the interviewer the negative or critical aspects of educational programs. The advantages of joint interview are interaction between interviewees that would promote to freely talk and improve the trustworthiness of the study (19,20). Each participant was interviewed once for 60-90 min by an interviewer in a private room and ensured that their comment would remain anonymous. The interviewer proceeded through the interview using an interview guide. The interviewer took notes about participants' voices and reactions. Moreover, the interviewer asked participants additional questions (e.g., "why?" and "how?") to obtain more detailed information. Although the researcher used the interview guide to enhance e ciency and equity, the participants were encouraged to freely talk. The interview guide was created through certain pre-interviews. The researchers began each interview by telling the participants, "We would like to know about your experience of clinical practice in PMHN. Please tell us about your experiences of particularly impressive event in it." The major questions covered in the interview guide were about student's thought and behavior in clinical practice and classroom lecture. For example, "What kind of knowledge did you obtain and what did you think about you had obtained?", What did you do and think in clinical practice?" Moreover, the questions were involved such as "Please tell me the gap between clinical practice and lecture that you experienced" and "Please tell me the link between clinical practice and lecture that you experienced." Furthermore, the interviewer actively asked out-of-school experience behind the participants' narrative. For promoting participants recall, the interviewer asked participants to bring their notebook or material using at their clinical practice or lecture in the interview. All interviews' datum were recorded with participants' consent and transcribed verbatim later.

Analysis
First, the researchers decided the analysis theme to determine the rage of using data about actions and emotions, thought of the students for analysis; then, the researchers determined the person to focus on for analysis to determine the person as the subject doing the analytical theme. The former comprised "the experience of learning PHMN." The latter comprised "nursing students learning PMHN in the university." In M-GTA, the minimum analytical unit is the concept. Each concept is derived from several pieces of data known as variations, which are collected along the analysis theme and transcribed verbatim and repeatedly analyzed to obtain their meaning. When a concept emerged, similar or antithetical data related to the concept were examined to prevent arbitrary interpretation. The relationships between concepts were examined and categories were deduced from related concepts. Then, the relationships between the categories were examined, and the data comparison and analysis were repeated. Finally, the researcher wrote "storyline," which was a simple explanation mainly comprising categories as the result of analysis. Figure about result were written based on storyline.

Rigor
The criteria of trustworthiness, credibility, dependability, and transferability were used to ensure rigor (21). All recording data were transcribed verbatim and researchers shared them. The rst author was the only one involved in the coding process; however, the analysis sessions were conducted in conjunction with the remaining researchers. The discussions were held until all researchers reached agreement on the codes. The researchers conducted memberchecking, which was discussion with researchers and informant together about the results of our analysis to obtain their feedback. 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 super cial 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 "rede ning 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 "di culty in understanding practical skills in PMHN;" "non-discovery of signi cance 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 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 bene cial 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 "di culty in developing concrete image of lecture knowledge." This shows that students themselves see ambiguity in PMHN because an image of knowledge about PMHN is di cult 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 super cial knowledge about PMHN" in certain cases, this served as a positive motivation in certain other cases in the form of selfquestioning.
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 super cial knowledge about PMHN
This category comprised the following three concepts: "acquisition of simpli ed expertise," "increased prejudice because of lecture knowledge," and "acquisition of knowledge for written examination." This denotes passive and super cial learning, which is in contrast with the above-mentioned "selfdevelopmental knowledge acquisition." Super cial learning indicates theories and skills of PMHN received exactly as explained in textbooks or by teachers without questioning. Students were aware of their in exibility in interpretation in practicums as follows.

Rede ning 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 super cial understanding of lecture knowledge is not su cient to understand phenomena and situations occurring in practicums. "Di culty 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. "Di culty in nding problems related to mental illness" and "di culty in understanding recovery" are di culties related to development of the nursing process. The former is related to problem nding; however, the latter is di culty in goal setting unique to PMHN.

Di culty in understanding practical skills in PMHN
This category, which is composed of three concepts, represents di culties associated with skills that students provide patients during the practicum. "A sense of embarrassment because nursing skills cannot be seen" was attributable to di culty 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 di culty in seeing the ow of systematic nursing skill, such as clinical pathways, and students told that comparison with other practicums helped to make the ow 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 simpli ed expertise " was attributable to the super cial understanding of expertise in clinical settings involving complex factors concomitantly. Moreover, such di culty 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 nd 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 signi cance 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 rst 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.

Discussion
A major characteristic of learning in PMHN is that the core knowledge and skills are primarily based on communication and are more abstractive than those used in other clinical departments. Therefore, students' ability to understand abstractive contents, which are unique to PMHN, signi cantly affected how they received their own achievements in practicums. Previously, studies reported that education in PMHN requires improvements in terms of both quantity and quality for improved understanding of knowledge and practice unique to PMHN by students (22). For example, studies demonstrated that qualitative and quantitative improvements in PMHN education had a positive effect on psychiatry-oriented career choice in nursing students and that nursing students' knowledge signi cantly correlated with the quality of PMHN education (23,24). This study showed that the background of each student was a major determinant of interest in PMHN and had a persistent effect on practicums. In discussion, some factors responsible for differences in levels of understanding and interest among students were considered.
First, the quantity of PMHN education is examined. A study in nursing education facilities in Australia has reported a large variability in the amount of time allocated for PMHN education (25). The variability between facilities in Japan is unlikely to be as large as in Australia because there are guidelines on how much portion of the curriculum should be allocated for PMHN. Furthermore, this indicates that time allocation to enhance PMHN education is di cult, and a body of evidence on the relationship between the quantity of PMHN education and students' understanding and interest levels should be built for policy recommendations. Moreover, it is necessary to examine measures to improve the quality of practicums and lectures in PMHN in Japan. Graham et al. argued that PMHN involves a broad range of expertise in the eld of psychiatry and the requirement to acquire that range of expertise is a unique characteristic of PMHN (26). It has been reported that faculty members feel that they have too little teaching time and human and other resources for practical training, including faculty members, instructors, and facilities, to acquire such comprehensive knowledge and skills and in the eld of PMHN in Japan (27). Further educational improvements are required to promote nursing students' understanding and interest with limited resources, and multiple recent studies demonstrated the effectiveness of simulation in the eld of PMHN (28)(29)(30). In Japan, while simulation-based education is being increasingly introduced in nursing education, there are various issues to be solved, including education system-related problems, such as the training of instructors and establishment of assessment methods, and the budget availability for the realization of small-group education. Diversity may be brought to PMHN education in Japan while solving the education cost problems by building a system for introduction and sharing of PMHN education resources designed based on evidence accumulated by teachers and researchers. This study demonstrated that nursing students' ability to link abstractive knowledge and skills unique to PMHN with their own experiences had a major effect on learning outcomes. The motivation for PMHN was largely improved when lectures were linked with students' personal life experience or previous experience of interacting with someone close to them with mental illness and was maintained during practicums. Furthermore, nursing students failed to make this association during lectures tended to foreground negative outcomes of practicums. A previous study has reported that the satisfaction of practicums improved when time to prepare for practicums was available (23). Given the perspective of the association of PMHN knowledge and skills with nursing students' own experience, which was revealed in this study, the increased amount of preparation for practicums may have served to increase opportunities for nursing students to link their own experiences with the knowledge and skills of PMHN. Furthermore, faculty members and instructors involved in practicums play an important role to allow nursing students to link knowledge and experience. A previous study reported that nursing students' attitudes toward PMHN considerably affect the specialties of faculty members and instructors (31). Furthermore, the attitude toward PMHN has been reported to improve when additional time was spent with instructors during practicums (32). Our results along with the ndings of Gough & Happell suggest that the increased opportunities for instructors and faculty members to attempt the association between students' previous experience and experience during practicums induced attitude improvement. Therefore, faculty members and practicum instructors may be able to induce positive changes in students' levels of interest and attitudes by generating students' interest during the practicum and timely facilitation of the link between the interest and practicum experience. Even for students who are reported not to be PMHN-oriented as per the present results, faculty members and instructors may be able to improve their interest and attitude by intentionally asking and presenting associations between other clinical departments and psychiatry. While our results showed a large impact of students' background on their interest and attitude in PMHN education, the originality of instructors and faculty members was another possible major in uencing factor. Because knowledge and skills of PMHN are abstractive, they are practiced in a variety of manners, and nurses are providing patients with care while experiencing uncertainty (10). This uncertainty, which is almost situation-dependent, leaves room for individual nurses to think and make case-by-case decisions in the practice of PMHN. To address these problems, there are important issues remaining to be solved, including construction of an education system and training of educators to see into the character of nurses who practice PMHN and train them as well as clari cation of underlying philosophy of practice.
The survey in this study was conducted at one national university in Japan. Because there are variations in both lectures and practicums on PMHN between universities, the effects of such variations should be considered in studies on association between lectures and practicums. Moreover, as we studied only the effects of learning in PMHN that could be perceived by nursing students, it is possible that faculty members and clinical instructors are aware of educational effects that students are not. A more effective education system needs to be constructed after examining the effects of PMHN education as perceived by faculty members and clinical instructors.