Eleven semi-structured interviews were conducted with CPH PharmD graduates who completed an APPE rotation in psychiatry. As summarized in Table 1, participants were mainly female (90.9%) and for the most part graduated in 2017. This reflects the programme graduates’ demographics as most students enrol directly from an all-female Bachelor-of-Science Pharmacy programme at QU. Table 1 illustrates the sample’s demographics.

Table 1 Participants' demographics

Five major themes emerged from the transcript analysis: Familiarity with mental illnesses prior to their mental health rotation, opinions on the rotation, mental health-related stigma, barriers hindering graduates’ care provision to patients with mental, and the impact of the rotation on their practice.

Theme 1: Familiarity with mental illnesses before the rotationUndergraduate experiential learning

Some PharmD graduates revealed gaining experience in mental health practice during their undergraduate experiential training, also referred to as Structured Practical Experiences in Pharmacy (SPEP). Participants mentioned that encounters with patients during SPEP rotations at the psychiatric hospital or other hospitals offered them the opportunity to become familiar with some basic mental-health concepts.

“My PharmD wasn't my first mental health rotation. I also went before in my undergrade training so in PharmD. I had an idea.” P10

Personal experiences

Some graduates reported personal experiences with people with mental illnesses, which deepened their understanding of these disorders.

“It was a bipolar patient, one friend of the family. Another encounter… we saw a teenager… we were really really afraid and anxious… after that I really understood what was going on with that patient and what he did and how really his family are suffering.” P09

Undergraduate curriculum

For the most part, PharmD graduates perceived their undergraduate curriculum’s mental health component provided them with knowledge of some psychiatric illnesses, psychopharmacology, and pharmacotherapy, but felt it was insufficient engaging them with persons with lived experience of mental illness or managing the diversity of mental health related presentations. Participants thought that during the rotation, they often needed to review basic concepts in mental health practice, and felt unfamiliar with many psychiatric presentations. They reported that the undergraduate curriculum does not provide them with opportunities to meet real patients, and thus felt unprepared to deal with emotionally challenging situations.

“I felt like the college (tried) to train us (on) how to deal with psychiatric patients emotionally. But of course… seeing it for the first time in real-case scenarios… and seeing how much mental illness affects patients and their lives and their families’ lives was a different thing.” P06

Theme 2: Graduates’ opinions of the mental health rotationExperiences early in the rotation

For the most part, participants mentioned they were keen to learn about mental illnesses and have the opportunity to meet and care for patients receiving mental health services.

“OK, so actually I was initially interested, like even before. I'm still interested in mental health.” P07

Some participants also voiced feeling nervous and even afraid of the patients at the beginning of their psychiatric rotations, although this eased off as the rotation progressed. Some graduates were emotionally affected, feeling helpless when managing patients. This caused some students to feel unprepared or not confident when counselling patients or managing drug therapy, especially at the beginning of the rotation.

“I was a little bit scared of patients... some of them already admitted to crimes… Some of them are quite schizophrenic patients…” P03

“It was so depressing for me to see such patients suffering without being able to help them improve quickly… So, when I saw it, it was so hard.” P08

Similarities with other APPE rotations

The graduates reported that the major similarity between the psychiatric rotation and other rotations was the clinical pharmacists’ role. Like other non-psychiatric rotations, clinical pharmacists are expected to perform medication reconciliation, interview patients, and manage their pharmacotherapy.

“The similarities are basically what we’re supposed to do… The pharmacist’s role is similar between all of the rotations.” P03

Uniqueness of the APPE in psychiatry

Participants stated they felt the mental health rotation’s setting was unique in different ways. For example, they felt they have witnessed increased interdisciplinary collaboration compared to other rotations, with an opportunity to learn about other mental health providers’ roles.

“(the) psychiatry rotation was little bit different, more exciting, because they’re applying multidisciplinary teams efficiently. I interviewed many healthcare providers from the team” P02

Many graduates also noticed that managing patients in the mental health hospital is unique in terms of its stronger focus on factors other than efficacy of the chosen drugs including safety of the medications, social factors such as availability of family or community support and financial status, and patient preferences. One particularly unique aspect was how rounds were carried out. As opposed to bedside rounds observed in non-psychiatric rotations, multidisciplinary (MDT) patient care rounds at the psychiatric hospital are held once or twice per week, whereby patients are invited to the MDT consultation room to discuss their symptoms, treatment, progress, and discharge plans.

“…the importance of providing a safe, non-judgmental, no-stigma environment and the importance of the social background… not only do we care about the medications but also about the patient holistically… you have to take social factors, preferences, what the patient’s priorities are (into consideration).” P06

Satisfaction

Participants were generally satisfied with their psychiatric-rotation experience. Most participants said that the rotation exceeded their expectations. They reported gaining essential knowledge of mental illnesses and of interacting with patients.

“It is between meet and above expectation… by the end of that rotation I felt I'm strong enough to be there, interact with those patients, and start managing and giving my interventions… I know how to deal with those cases in terms of skills and knowledge.” P05

Theme 3: Graduates’ views on mental health-related stigmaPersonal perceptions about mental health stigma

Most participants stated they would never stigmatize patients with mental illness.

“I don't have stigma towards them… I don't judge people based on their condition whether it's psychiatric or not.” P05

However, some of them reflected on their initial feelings of apprehension and how these perceptions changed to empathy by the end of the rotation.

“…I was scared for the first week… the (feeling of) being scared became like feeling sorry for them and empathizing with them.” P03

Societal stigma

For the most part, participants perceived the presence of societal stigma against patients with mental illnesses. Patients and their families are often afraid to seek help and take psychiatric medications in fear of judgement.

“There is a major stigma going on in our society. Even in the psychiatry hospital itself… Some families think that these people have been possessed by Jinn (evil spirits)” P07

Healthcare provider’s stigma

Most participants mentioned that healthcare providers did not stigmatize patients receiving care at the mental health hospital. Nevertheless, stigma still existed. One participant mentioned the story of a provider reluctant to receive his own non-psychiatric prescription from the service’s building, fearing it would be marked on his file that he received medications from the mental health facility.

“…he didn’t want it on the system (to show) that he got the medication from the mental health facility, so people don’t think he’s crazy.” P01

Theme 4: Areas of improvement for the psychiatric rotation experienceLogistical barriers

Graduates reported they would spend their rotation in one ward, mostly providing care to adult male patients. Most mentioned the desire to experience managing females or children and adolescents. Some also mentioned they felt they needed more supervision by their preceptors during rounds and interactions with patients.

“I visited the paediatric psychiatric hospital for one day only and I met only one patient.” P09

Loss of opportunities due to the coronavirus disease 2019 (COVID-19) pandemic

Due to the recent COVID-19 pandemic, students who underwent the psychiatric rotation during 2020 were not able to attend in-person psychiatric-hospital rotations. Instead, rotations were conducted virtually through scheduled online meetings with preceptors and completed at-home assignments. As a result, these students felt their training was incomplete as they were not able to directly see, interact with, or provide care to patients in person.

“We lost the opportunity of actually seeing psychiatric patients face to face. I would have loved to interview or see how healthcare providers interview [these] patients.” P01

Theme 5: Positive impact of the APPE rotation in psychiatryIncreased knowledge and awareness of mental health

Some experiences were described by the participants as “eye-opening”. For instance, before their mental health rotation, graduates were shocked that electro-convulsive therapy (ECT) is brief, painless, and commonly used in the treatment of refractory patients. Additionally, participants mentioned they were surprised to learn that the presentation and management of each patient could greatly vary even if they have the same diagnosis.

“Electro-convulsive therapy is something that shocked me. I expected it to be like movies. People will be in pain and … it's just like torturing the patient. However, when I went there, I was surprised. It was very brief.” P08

Influence of the psychiatric rotation on current practice

Graduates reported that the rotation positively influenced their current practice. For the most part, participants perceived themselves to be more confident in providing care to patients with mental illnesses. Some said that it changed their attitudes and made them more empathetic towards patients.

“I feel more confident on how to actually treat them and manage their medications, their chronic medications. I feel more comfortable talking to them… understanding them.” P08