Challenges and Growth as a Mental Health Professional from Volunteering Experiences in the Community Gambling Awareness Campaign

: As the demand for high-quality mental health services increases, producing expert nurses with the skills and expertise to deal with various complex mental health situations involving diverse subjects is critical. Nursing programs should be prepared to provide education that can improve mental health professional competence. Using a qualitative study and focus group interviews, we focused on the experiences of nursing students who voluntarily participated in campaign activities to prevent gambling problems. The respondents were 23 nursing students who participated in the campaign for more than four months. Data were analyzed using Downe-Wamboldt’s eight steps of content analysis. The experiences of the participants were integrated into the theme of challenge and growth for a mental health professional with five sub-themes: challenging for an active nursing student, committing to gambling awareness campaign club activity, promoting interpersonal relationships, improving problem-solving skills, and developing a mental health professional identity. Planning and implementing various volunteer activities, in addition to the existing regular curriculum in nursing education, will provide a foundation for nursing students to become good nurses and ultimately help produce competent mental health professionals.


Introduction
The rapid development of medical technology and increasing level of patient demands have led to increasing demand for high-quality mental health nursing services. Nurses should possess the ability to use specialized knowledge and skills regarding mental health management to cope with situations in complex and diverse nursing fields [1]. Mental health is an important factor that influences overall health and recovery [2]. Therefore, nursing students need to acquire professional mental health management skills. In nursing education, in addition to regular curricula components such as classroom lessons and clinical practice, extracurricular activities such as volunteering are conducted.
College students who voluntarily plan and practice volunteer activities gain community awareness and social responsibility. These activities provide the opportunity to realize individual growth and potential [3]. They also gain positive experiences that help them grow socially and morally, improve social responsibility, give them relevant social and work exposure, and help them accept social culture and pursue changes [4][5][6]. Volunteering can help students acquire professional skills and abilities as well as impart social experience in the professional field. This allows for the formation of a sense of social responsibility through ties with others [7].
Gambling issues have emerged as a major mental health problem of modern society. In recent years, gambling has sharply increased in Korea, causing serious socio-economic damage [8]. As a result, the Korea Centre for the Prevention of Gambling Addiction has launched a gambling addiction prevention team comprising college students as part of its measures to promote social and mental health. The club allows volunteers to lead gambling addition prevention activities, spreading a healthy culture and promoting social and mental health.
This study aimed to identify the benefits of volunteering by exploring the inner growth of nursing college students who participated in the gambling awareness campaign. In particular, this study aimed to explore how volunteer activities develop mental health professionals' awareness of social needs. The results can guide the planning and practice of various activities outside the regular nursing curriculum if they confirm that volunteer activities related to mental health have a positive effect on cultivating competency as a mental health professional. Hypothesis 1. The gambling awareness campaign will bring internal growth and change to nursing students.
Hypothesis 2. The gambling awareness campaign will foster nursing students' identity as a mental health professional.

Research Design and Participants
This is a qualitative study conducted to understand the value of nursing students' volunteer experiences in Korea's gambling awareness campaign. The qualitative research method of focus group interviews was used to understand the diverse motives and experiences of the participants [9].
The participants included nineteen female and four male nursing students aged between 20 and 23 years (Tab. 1). Participants with more than four months of volunteer experience in the gambling prevention campaign were recruited via social networks from a nursing department in a K university. They were encouraged to freely make decisions without threat or undue influence. They were informed that they could stop the interview at any time and end their participation without any repercussions. Furthermore, they were assured that the interviews were confidential and anonymous and would not be used for purposes other than research. The participants were notified before the interview that they could use a symbol instead of their name. They were assured that their identity would be kept hidden for three years after completion of the study, and that their records would be stored using passwords in offline databases. The number of participants was determined according to the theoretical saturation level of the qualitative research data, until new information was no longer found.

Data Collection
Data collection took place from June 3 to June 21, 2019. Four focus groups were interviewed. The group size was around six nursing students, in line with previous research recommendations of 6-10 people per group [9]. The interviews were conducted in a quiet and safe place with researchers experienced in qualitative research and trained research assistants who were familiar with the clinical practicum of therapeutic communication and interpersonal relationships. Each group interview lasted for about 60 minutes. The interviews were recorded with a digital recorder. The researchers retained the audio files until the analysis ended; these files were then deleted and the participants notified of their deletion.
Structured questions were asked in the focus group interviews, such as about the participants' introduction to the campaign, their transition to the activities, major aspects of their experience, and resultant changes in them [10] (Tab. 2). During the interview process, the researchers listened to the participants' statements and made notes on themes, points, kinesics (facial expressions, gestures, etc.), and the atmosphere. After the interviews ended, the researchers and research assistants summarized their notes and compared them. Recordings were instantly copied, and the researchers read and listened to the contents repeatedly, examining the vocabulary and degree of emotions. At a certain threshold, there were no further comments, and the analysis was finalized.

Question contents
Introduction · How did you first learn about volunteering activities with the gambling addiction prevention group? · What motivated you to join the gambling addiction prevention activities group for college students? Transition · Did you face any difficulties during your volunteer gambling addiction prevention activities? · Why did you continue to volunteer for gambling addiction prevention activities?

Main Questions
· What was the best part of your volunteering experience? · What changes did you experience the most intensely during your volunteering in the gambling addiction prevention activities? · What did you learn about yourself through volunteer gambling addiction prevention activities? · What new experiences did you have working with others through volunteer gambling addiction prevention activities? · Did your perception of gambling addiction change? · Have there been any changes in your perception of your majors after your volunteering activity? If so, please tell us about these changes in detail.

Final Questions
· How did the volunteering experience affect your future plans? · How was your interview today?

Data Analysis
The data analysis was carried out concurrently with the data collection according to the eight steps of content analysis by Downe-Wamboldt [11] (Tab. 3). To ensure reliability of the study, the results of the content analysis were evaluated according to the qualitative research evaluation criteria of credibility, transferability, auditability, and neutrality [12]. Credibility was ensured by having two participants perform checks on the data used in the analysis and the results. Transferability was achieved by presenting the results of this study to two nursing students who had experience in volunteering but were not participating in this study to verify that the results were applicable. To ensure auditability, two nursing researchers with extensive experience in qualitative research reviewed the entire process and the results. Neutrality was ensured by comparing the participants' interview contents with data from other sources. Table 3: Eight steps of content analysis Step Contents

1
The researchers read the sentences and clauses of the data in analysis units based on a copy of the data.

2
The initial category is derived while reading. 3 Analysis and coding are repeated three times while reading through the entire data, and compatibility between the initial category and coding data is examined.

4
To validate the initial category and the coded data analysis, a nursing professor experienced in qualitative research is commissioned to review the research.

5
Categories and coding are added or integrated based on feedback.
6 Based on the above results, the researchers refine the coding by reading the data again in depth.

7
By deriving the upper and lower categories, final analysis and coding of all data are completed. 8 To confirm the validity of the analysis, two research participants and a nursing professor experienced in qualitative research confirm the analysis result again and go through the feedback process.

Ethical Consideration
Ethical approval was obtained from the institutional review board of the participating university. The principle of informed and voluntary consent was maintained, and all participants signed a consent form that informed them of their right to withdraw from the research at any time. The confidentiality of the participants was protected as far as possible by not including information that could identify them.

Results
A total of 27 condensed meaning units, one theme, and five sub-themes were derived through qualitative content analysis from the nursing students' volunteering experiences of the gambling awareness campaign. The five sub-themes were challenging for an active nursing student, committing to gambling awareness campaign club activity, promoting interpersonal relationships, improving problem-solving skills, and developing a mental health professional identity, which were integrated into the theme of challenge and growth for a mental health professional (Tab. 4).

Sub-Theme 1: Challenging for an Active Nursing Student
The nursing students who participated in this study gained confidence that they could learn about the mental health risks of gambling through club participation and help those with gambling addictions using the professional skills they gained at campaign activities. They were able to improve interpersonal relations and become active as the campaign activities were activated.

Sub-Theme 2: Committing to Gambling Awareness Campaign Club Activity
The students devoted their time spent on club activities to meeting their expected roles. They actively participated in the campaign and felt rewarded by their participation. They were proud that their club won the first prize for college student volunteering in the gambling awareness campaign in a nationwide competition.
"I realized that if I did not do what I was doing, the other departments would be affected and slowed down, causing damage to the activities of the entire club. So, I tried to meet the time by whatever means, and it made me capable to handle my work." (P11) "Some people come to the campaign because of a real gambling problem. When I educated them, they gave me feedback that "It is good information. I've got help." I think this is very rewarding." (P9)

Sub-Theme 3: Promoting Interpersonal Relationships
During campaign activities, the students learned to cooperate with colleagues by exercising their communication skills and considering others' situations. They also tried to understand different opinions and actively reach agreements with their colleagues. The students sometimes employed conflict resolution between themselves to build rapport in trusted relationships, which is an essential skill for mental health professionals.
"I know that there are people of different personalities, and that's just because I'm this personality, and he has that personality too! I think that I learned to cooperate with so many people through such activities." (P14) "The experiences that had been difficult became fun experiences. It seems that you would have not won if you did not have such colleagues, and you know that they were supporting each other." (P16)

Sub-Theme 4: Improving Problem-Solving Skills
In preparing the gambling awareness campaign, the students learned to organize tasks systematically for efficient time management. They developed their self-directed learning and critical thinking skills in this process. They actively sought solutions and persisted when faced with difficult problems.
"I found it hard to do lots of tasks at the same time. So, I organized things and worked out one by one, and I was able to work systematically. I've learned that through club activities." (P10) "We have been doing various things that we have not done before. We have improved our coping ability. We developed the ability to cope with situations and to solve problems with the help of members." (P12)

Sub-Theme 5: Developing a Mental Health Professional Identity
The campaign activities enhanced students' self-awareness and confidence in providing mental care, creating a sense of responsibility and leadership in group activities. They thought that such developments would help them carry out nursing practice efficiently as mental health professionals.
"It's a part of the nursing practices that we did in club activities......There was a change in perception that we had to do the same thing that we practiced during the campaign in the hospital." (P8) "In the community health center, nurses are planning and making things for the mental health campaign. It's a good idea to work as a community nurse in a way that we already know. I've been doing a lot of things, …… and I think I could play a leading role in future in those places." (P3)

Theme: Challenge and Growth for a Mental Health Professional
The students took up the challenges involved in the voluntary club activities for gambling awareness to develop their mental health professional identity. They committed to the club activities by devoting time and developed shared values and pride. The students faced challenges in coping with conflicts or problems that arose in carrying out the campaign activities, and addressing them eventually promoted interpersonal relationships and problem-solving skills. Through these experiences, they realized that the challenges they faced helped them grow in their identity as mental health professionals.
"I was interested in psychiatric nursing care, but was not sure because it was hard work. But if I could care for these people as a result of this club activity, I would be able to help such people." (P17) "I am confident that I can pursue projects or tasks more actively while pursuing club activities. Through this experience, I got the courage to challenge myself in the future. Growth seems to have occurred." (P1)

Discussion
This study confirmed that individuals who participated in volunteer activities to promote gambling awareness were able to challenge themselves and grow as mental health professionals. This study's significance lies in that it highlighted the value of volunteer activities for the mental health of college students through qualitative research. In the focus group interviews, participants were able to recognize and confirm the semantic units derived not only as individuals but as a group participating in the same activity by sharing their living experiences. The inductive approach through qualitative research can reflect the actual situation to be explored [9].
In addition, this study demonstrates that the value of the volunteer program is not dependent on the specific target of the volunteer service. Although gambling issues have emerged as a significant mental health problem, the nursing students examined in this study did not simply acquire the competence to address gambling problems. Rather, they were able to cultivate overall knowledge and ability through leading, planning, and executing activities. Specifically, they improved their abilities in active and critical thinking, communication ability, commitment, and problem-solving, all of which are important skills for mental health professionals. Therefore, when planning the curriculum for different majors of college students, it is necessary to organize various extra-curricular activities-not simply for the sake of the activities themselves, but also to utilize the potential possibilities gained from self-directed activities.
Next, we discuss the subcategories derived from this study. Participants' experiences were classified as challenging for an active nursing student. This is in line with Porteous et al.'s [13] phenomenological exploration of the experiences of 30 first-year undergraduate nursing students in the UK. They found that first-year nursing students had the following experiences: uncertainty, expectations, learning to survive, seeking support, and moving forward [13]. The participants in the current study indicated the level of learning required to survive and sought support while participating in the uncertain university life as nursing students, learning nursing knowledge with expectations, complementing the shortcomings in their personality, and improving interpersonal networks. They may also have sought support by committing to club activities. The participants learned how to take responsibility for their roles and, as a result, felt pride far beyond the minimum level needed for survival while actively participating in various club activities. This cannot be achieved by simply implementing the university curriculum, and the acquired pride is the first step toward nursing students' growth as good nurses.
Nursing students are aware that good interpersonal relations and communication is necessary for nurses, who are also mental health professionals [14]. The participants experienced a meaningful process that promoted interpersonal relationships as they formed trust relationships and developed rapport by exercising communication skills, cooperating with colleagues, considering others' conditions, trying to understand different opinions, and actively reaching agreements with colleagues. Fourth-grade nursing students complained of difficulties in clinical experience in communication in the relationship between nurses and patients, and researchers suggested that appropriate training methods and good role models are needed [14]. The significance of the club activities encouraged study participants to promote interpersonal relationships among themselves.
Nursing students also consider scientific knowledge and competence to be a positive attribute [14]. Competence is an important element in ensuring work quality in general [15]. Professional competency helps nurses solve problems in clinical settings. In this study, nursing students organized tasks systematically and independently while participating in voluntary club activities and improved their time management skills, which in turn improved their problem-solving abilities and critical thinking skills. Critical thinking is an important characteristic of the nursing profession and is crucial in decision making in clinical settings. It has been proven that critical thinking can maximize desirable outcomes and minimize errors in the health care field and is therefore a necessary competence for nurses, and accordingly, strategies for promoting critical thinking in nursing education are frequently discussed [16,17]. Makhene [16] pointed out that argumentation is a strategy that improves critical thinking, and that learners get the opportunity to use and integrate critical thinking skills by participating in debates with peers. The participants in this study could improve their critical thinking skills by planning and preparing campaign activities with their peers and actively finding solutions to problems.
The attribute of awareness in mental health professionals can increase satisfaction and improve mental health in post-graduate social and professional activities [18]. Therefore, the fact that the participants of this study developed a mental health professional identity suggests that they are more likely to have a healthy and prolonged career with pride and attachment to a profession when they graduate and become nurses. It is necessary to inculcate in nursing students the pride of being mental health professionals as well as high professional dedication. Furthermore, nursing education should be transformed so that students have a positive perception of and attitude toward mental health professional awareness [19]. In this respect, the significance of the self-directed club activities the participants engaged in lies in that they developed the students' pride and identity.
One limitation of this study is that all participants were recruited from a single university, which may limit the generalizability of the results. More diverse findings could be drawn if participants are recruited from more colleges. However, note that the goal of qualitative inquiry is not general outcomes, but rather, an in-depth understanding of the study group based on an individual's experience; thus, different contexts should be considered in expanding this research to other institutions.

Conclusions
This study focuses on how volunteer activities helps nursing students grow and improve their mental health professionalism by qualitatively examining the experiences of nursing students engaged in campaigns for the prevention of gambling addiction. Their experiences were integrated into a single theme of challenge and growth for a mental health professional with five sub-themes: challenging for an active nursing student, committing to gambling awareness campaign club activity, promoting interpersonal relationships, improving problem-solving skills, and developing a mental health professional identity. This study showed that the nursing students' participation in gambling prevention activities was a significant basis for their growth as mental health professionals.
The results suggest that planning and implementing various activities outside the standard nursing curriculum provides students with the foundation to become competent mental health professionals. By participating in club volunteer activities for a gambling awareness program for college students, they could contribute to the promotion of social and mental health as well as improve their own mental health. These results also indicate the need for further research to develop customized volunteer programs for fostering mental health professionals for college students of various majors and verify their effectiveness.

Conflicts of Interest:
The authors declare that they have no conflicts of interest to report regarding the present study.