CONCLUSIONES

Participants reported they did not know what health problems their patients had because they did not understand the pathologies of their patients‘ conditions. Sometimes, they knew what information was abnormal but they could not connect this to what pathologies it came from and why their cases had been treated in particular ways. Although they knew the actions of the medications that were being used in treatment, they did not understand how they functioned to assist the patients. A second year participant cited an example that:

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As I saw, most were CHF [congestive heart failure] patients, they were treated with Lasix. Yes! I knew. Ah! Lasix could dehydrate fluid out. Anyway, I didn‟t know why it had to be injected. Injected for what? The fluid was there [extracellular fluid] and the fluid came out as urine here. I mean it was in the different parts, I thought about that [laugh], things like that. ...Until now I didn‟t understand much [laugh]. I had to learn more. (Supat, Interview 2, page 40)

Some participants who had moderate-high GPA reported that they tried to review the pathologies but they still did not understand what problems their patients had. They could not explain how those pathologies were connected to their patients‘ symptoms. They had memorised the symptoms of their cases, but still could not respond to their supervisors about what health problems the patients risked. They could not analyse how the conditions they could see and/or the symptoms their patients reported affected them. A fourth year participant with high GPA said:

At that time, if asked whether I could understand or not, only some, I thought. ... Like our instructors taught, I thought I understand. But! When I saw patients, there were more things to know. ....Like each disease, as I read, if [patient] had symptoms listed in pathology part, so I knew. But! If about its complications, I couldn‟t connect. When I was in the second year, I couldn‟t make a right connection that was a complication. Like, why a bed ridden patient had atelectasis, things like that. I meant I only knew that patient had a stroke. He [patient] couldn‟t move himself, things like that. If I had to…like, my instructor asked ah! What complication(s) he might risk, …I had no idea. … (Kanda, Interview 1, page 7; Interview 3, page 36)

Others with low GPA revealed they could not see the problems of their patients. They thought at that time, they did not have any problems any more. As a third year participant said:

...When I was in the second year, I couldn‟t specify many [nursing] diagnoses. Yes! I felt [laugh] my patients didn‟t have any problems. …When in my second year, like, I couldn‟t see the problems of my patients. (Rhoba, Interview 2, page 33)

In this stage, the participants felt they could not assess the significant problems of their cases. Their uncertainty affected their communications with the relatives of their patients. They could not respond to questions about whether the conditions could be treated or not. They also could not tell the relatives how to rehabilitate their patients when they were being discharged. A second year participant talked about her concerns about her patient with subarachnoid haemorrhage:

...I still didn‟t know, not fully understand! …I thought I didn‟t understand all of his problems, maybe. I didn‟t know what condition(s) he might have tomorrow. …Why my case couldn‟t speak, as before this he could. Why he couldn‟t speak after the x-ray. …Or why he had more hemorrhaging. Eh! Why the doctor made an appointment on the twenty-second. Apart from iv fluid, why she [doctor] didn‟t give him other treatments first. Just let him do active-passive exercise on a bed, things like that. I had lots of questions about this case. I didn‟t know why the doctor didn‟t give him any medication or something or whether she

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was waiting for the investigations to make sure before treating him with any medication. …Mmm! His relatives also asked me too! You know? “Could he walk or not?” “Could he speak or not?” Mmm! Today was his rehabilitation period. How about his rehabilitation? Mmm!! What could I do? (Plyma, Interview 2, page 55)

Not knowing what problems their patients had, led the participants to feel worried and afraid when they had moved to the next subject field that focused on the diseases and problems of their cases, as they thought they should have more knowledge and skills to care for them. They also thought their supervisors might expect that they should know more about their cases‘ problems and how to provide nursing care for them than they actually did. These concerns made the participants who were somewhat familiar with practising feel pressured again. Nearly half of them revealed that in this stage, they considered they needed to know more about the diseases and pathologies of their cases. Without that knowledge they could not identify appropriate nursing care for their patients, so they felt stressed about having to care for them. They had to adapt to practices that were new to them and to the expectations of supervisors and their clients, based on not understanding case problems and how to provide appropriate nursing care. A third year participant described:

Yes! Starting to practise about diseases led me to feel more stressed. Like, I had to write. I had to read and know more. I had to know about pathologies, things like that. ...Like nursing care plans in „Adult‟ 29 had a pathology part, and „labs‟ [lab results] that I had to know the reasons for. Before that, „BCPN‟ field, I only indicated that [lab results] were lower or higher [than normal ranges], no more explanation. But! In „Person with Health Problem‟, I had to specify the reasons [why they were abnormal]. I had to know. I had to read more. ...Practising in this period, I had to read more and more. If I couldn‟t respond to [supervisors‟ questions], I had to search more and then tell them in the following days, things like that. (Kasaree, Interview 1, page 11)

Some also disclosed that they were worried that their assigned cases were difficult, which made them even less confident as they did not know if relevant content could be found in the texts to prepare for caring for them. Sometimes, they felt they were not ready to go to clinical settings if their search did not find enough information about the problems and how to provide nursing care. A fourth year participant said:

Like, sometimes, I was assigned a case and I didn‟t know whether I could find the information [about that disease] or not. ….Like, I had to prepare something for tomorrow, and if I could, I felt good and ready to go to a ward too. But If I felt I couldn‟t find enough information, I didn‟t want tomorrow to come. I didn‟t want to go to a ward at all as I didn‟t know the information I had was right or wrong, so I wasn‟t ready. Yes! I meant I was worried when I went there. Eh! Whether I might be reprimanded or not because the

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‗Adult‘ is the previous paper name of the practical papers, Nursing care of Persons with Health Problems.

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answer(s) I found might be not enough for what my instructors needed me to obtain. (Arun, Interview 3, page 28)

Thinking about not knowing how to care for patients‘ problems led the participants to be stressed about participating in the pre-conferences before starting their nursing care activities every morning shift.