This study adopts the experiential learning theory as the theoretical framework that provides a holistic model of the learning process.²⁰ The conception of experiential learning is an established approach in the tradition of adult education theory.²¹ With an emphasis on the idea that experience plays the central role in the learning process, experiential learning theory is a theoretical synthesis of Dewey's philosophical pragmatism, Lewin's social psychology and Piaget's cognitive development. Kolb defines learning as "the process whereby knowledge is created through the transformation of experience.²⁰ Knowledge results from the combination of grasping and transforming experience. Kolb proposed a model in which this transformation of experience occurs in a cyclical fashion of four stages: concrete experiences, reflective observation, abstract conceptualization, and active experimentation. According to the four-stage learning cycle, concrete experiences are the basis for observations and reflections. These reflections are assimilated and distilled into abstract concepts from which new implications for action can be drawn. These implications can be actively tested and serve as guides in creating new experiences.²²

Moreover, at the stages of abstract conceptualization and active experimentation that leads to the next learning cycle, learners' reflective practice would affect their identity formation, particularly in professional education. Key elements of professional identity formation include experiential and reflective processes.^23-24 In this sense, the concept of professional identity formation is key to exploring students' or residents' learning experiences in the OSTIPH. Physician's professional identity is defined as "a representation of self, achieved in stages over time, during which the characteristics, values, and norms of the medical profession are internalized, resulting in individual thinking, acting, and feeling like a physician".²⁵ In this regard, Cruess, Cruess and Steinert argue that a fifth level 'is' should be added at the apex of Miller's pyramid (i.e., knows, knows how, shows how, and does) in the movement to ensure that professionalism is taught throughout the continuum of medical education.²⁶ 'Is' refers to being or identity-related to "consistent attitudes, values and behaviors expected of one who has come to think, act, and feel like a physician".²⁷

Drawing on Kolb's model of the learning cycle²⁰ with the concept of professional identity formation,²⁶ this study will examine the students'/residents' internal cognitive processes through their experiences of staying at the patients' homes overnight by qualitative research. Specifically, this study focused on describing the students'/residents' learning processes, including the following: 1) having an experience with elderly patients at their home overnight; 2) reflecting on the experience; 3) learning from the experience, and 4) trying out what they have learned. Furthermore, this study also assumes that social interactions with attending physicians, other health professionals, patients and family members can be the key to better understanding residents' learning processes.

The OSTIPH was introduced and developed in the Ibi Community Medical Center in central Japan in 2005.²⁸ Three general practitioners work as full-time medical staff in this center and mainly engage in home care in Ibi District in Gifu Prefecture. They offer a short clinical training program of CBME (for two to four weeks) for medical students and residents. Approximately 50 trainees participate in this program every year.²⁹

The main objective of the OSTIPH program is for trainees to learn a whole process of providing daily life support and healthcare support for patients and their families in a home visit setting by staying overnight with them. Specifically, the trainees in the OSTIPH are expected to fully understand the life circumstances of the patients and explore the problems of continuing home care through the experience of both providing patient support by themselves and observing how health professionals in a team carry out patient support and caregiving. They are also encouraged to reflect on what they have learned through experience in this program every day.

At the beginning of clinical training at the Ibi Community Medical Center, each trainee was assigned an elderly and terminally ill patient with the "do not attempt resuscitation (DNAR)" status who was provided home care. When the trust relationship was established, the OSTIPH was implemented. The OSTIPH is a 2-day program. On day 1, before the home visit, the supervisors give an induction session to explain the aims of the OSTIPH to the trainees, particularly with an emphasis on the fact that the patient has a DNAR status. The patients and their family members have also received information about the OSTIPH and the roles of the trainees from the supervisors in advance. The trainee and healthcare team members visit the patient's home in the afternoon. The trainee is required to bring healthcare supplies and his/her bedclothes for an overnight stay. In the evening, the healthcare team members return to the center, and only the trainee remains at the patient's home. The trainee is expected to communicate with the patient and family and provide healthcare support for their daily activities overnight. In case the patient is in critical condition at night, the trainee must call a healthcare team member immediately. In such cases, the supervisor would rush to the patient's home and handle his/her problems. On day 2, the trainee returns to the center from the patient's home at 8 am. Then, a debriefing/feedback session is held among the trainee and the healthcare team members. The trainee is required to report what he/she experienced and learned in the OSTIPH based on the information from medical records and his/her own reflections.

This study selected 19 research participants, including 8 fifth- or sixth-year medical students (all males, code "a" to "h") and 11 PGY1 and PGY2 residents (1 female and 10 males, code "i" to "s") who were all Japanese and from medical schools and teaching hospitals from all over Japan and joined the clinical training program of CBME offered by the Ibi Community Medical Center during the period from April 2014 to March 2015. All but several female trainees who cared for male patients were asked to join the OSTIPH, and all but one trainee agreed to participate.

Sixteen patients who received home care from the medical center agreed to cooperate on the OSTIPH (see Table 1). All of them were Japanese, 11 patients were over 80 years old, 12 were male, and 4 were female. Eleven patients were terminally ill and agreed to DNAR status. Three patients died during the OSTIPH, and 8 patients died within a week after the OSTIPH. Thirteen patients were cared for by a family member, and three were living alone.

This study collected data from the trainees' reflective reports, in which their experiences, feelings and thoughts during the OSTIPH were written immediately after their overnight stay at the patient's home. The structure of this reflective report was developed based on Kolb's ELT.²⁰ In other words, the trainees were asked to write about their actual experiences during the OSTIPH (concrete experiences), their feelings and acquired knowledge after the experiences (reflections), the impact of their experience on their own personal and professional development (abstract conceptualization), and their thoughts on their future careers related to their experience in the OSTIPH (active experimentation) (see Table 2).

Drawing on 'the stages of experiential learning' as classified by Kolb, the trainees' perceptions of learning in the OSTIPH and thoughts about their future careers were examined with a more inductive labeling process for qualitative data. More specifically, a thematic analysis approach was employed to inductively generate and develop salient categories of their experiences.³⁰ To enhance the trustworthiness of the qualitative analysis, two researchers (MY and YS) were independently involved in coding and categorizing the data before cross-checking their data interpretation and analysis. The preliminary results were carefully reviewed multiple times by all the members of the research team.

The trainees had mixed feelings about their participation in the OSTIPH at the predeparture to the program; these feelings included hope, excitement, anxiety, fear, and nervousness. Some trainees had positive affect toward staying at the patient's home. For example, trainee (n) said,

"I had felt excited because I would be given an opportunity to see the true life of the patient and family."

In other words, the trainees aimed to better understand the complexities of the activities and discourse of the patient and family in the given context. Moreover, they already had a feeling of gratitude toward the patient and family at this stage. For example, trainee (f) said,

"I was grateful that the patients and families were willing to accept me as a participant in this program. To requite their kindness, I would work hard for them."

On the other hand, most trainees had stronger negative emotional states than positive affect, which were induced by their lower confidence in their professional skills to handle uncertain and unexpected patient situations and to provide satisfactory care for the family. For example, trainee (o) said,

"I heard that as the condition (of the patient) was not good, the patient would possibly pass away during my stay at the patient's home. When I knew about this situation, I was worried about whether I could handle this on my own. And, I was worried that the family members would be upset if this should happen, since only I, a trainee, was with them."

Although they had complicated feelings, all the trainees prepared themselves before starting the program for some challenging situations that would happen during their stay at the patient's home. Trainee (g) said, "I was told what would happen in this program by a colleague before. So, the only health professional at their home would be me. Even in a serious situation, I would have to work for them as a (future) doctor."

The trainees gained a variety of experiences through interaction with the patient and his/her family members overnight. First, the trainees provided support for the daily life of the patients and their family. In particular, spending time with the patients and families themselves, such as by cooking, dining, watching TV and taking their dog for a walk together, facilitated the trainees' understanding of the lifestyle of the patients and families situated in the social context. Moreover, the trainees could learn through casual conversation with the family members about their experiences and true feelings regarding caregiving at home. For example, trainee (i) said,

"I talked over coffee at night with patient's daughter. She stated that caring for the patient was harder and more stressful than she thought. I could understand the importance of short stays to reduce the burden of care."

As they communicated more with each other and were involved in supporting the patient, the trainees strongly felt that they could build better relationships with the patient's family. They found that the family members welcomed them and relied on them as health professionals. For instance, trainee (p) said,

"His wife was very pleased when I was assigned to stay at her home, so I was thinking about the best approach. At the beginning, the patient apologized and hesitated to state his request. But during the night, he gradually told me that he felt so anxious and nervous. This was so impressive for me."

Second, as the trainees were the only health professionals at the patients' homes, they were expected to provide basic healthcare support, such as vital sign measurement, the suctioning of sputum, toileting assistance, meal assistance, assistance with turning over in bed and night calls. Trainee (i) said,

"I did the suctioning of sputum through the tracheal tube every hour by using the tube."

Some trainees experienced a more serious situation, as trainee (l) commented,

"When I was checking the patient's respiratory condition, I noted that it was getting worse. So, I called the center urgently urgently, and after the supervisor came, we worked hard to care for the patient, who eventually passed away."

Out of 19 trainees, six experienced taking care of a dying patient during their stay at the patient's home or knew that the patient had died soon after the trainee returned to the center. This experience appeared to be an influential event in their careers as doctors. For instance, trainee (d) said the following:

"The patient I was taking care of died and stopped moving. It was an unforgettable and shocking event. I was surprised that the patient's daughter seemed to be relieved, but I think it is understandable."

Furthermore, it was an opportunity to consider how the trainees had to behave by taking the family members' feelings and attitudes toward the reality of the patient's death into account. For example, trainee (s) could directly discern a family member's feelings about the patient's death:

"When I visited the patient's home the next morning, I confirmed his death. His wife stayed calm and said to the patient, 'Your doctor is here to visit you. He kindly cared for you last night.' I felt that her words to the patient were actually a form of positive feedback on my involvement in his death."

The trainees reflected on their experiences of direct interaction with the patients and their family in the OSTIPH in terms of their own behavior, feelings and views of home care. Although they had strong anxiety about their participation in this program at the predeparture stage, their negative affect was gradually removed through their active involvement in patient support. At the same time, they started to feel a sense of achievement to some extent and began to regard the OSTIPH as a positive learning experience. For example, positive feedback from the patients and families led to the trainees' confidence in their professional skills. Trainee (d) said,

"I was very pleased to hear that the patient was comfortable with the posture change I did. Although I was anxious about how to do it, the patient's comment made me feel rewarded."

On the other hand, at the reflective observation stage, they realized that they could not do anything on their own and needed help from more experienced people. Specifically, they identified that there were many points to be improved, including observational, procedural and decision-making skills. For the trainees who had not had enough clinical experience, it was difficult to address patients' problems in real-life situations on their own. For instance, trainee (e) said the following:

"I was truly worried if I would overlook any critical changes in the patient's condition. If this happened, I couldn't have judged if it would be the onset of a serious problem. Should I call my teacher? I didn't know when to call him. I regretted my lack of knowledge and smaller amount of clinical experience."

In addition to reflecting on their professional skills, they recognized that as they had not directly observed patients' real lives in a social context, they had not seen the patients from various aspects. Particularly, they realized that they only looked at one side of the patient when they were hospitalized. For example, when dining with the patient, trainee (k) found that the patient could do many housework tasks by himself, which was not seen in the hospital. Trainee (k) said,

"The patient was able to put the soup in a bowl with a ladle without spilling it. When the patient was in the hospital, I had never imagined he could do housework like this after discharge."

Moreover, they reflected their own perspectives on caregiving through their observation of the behavior and psychological state of family members as caregivers. Specifically, the trainees noticed that they focused exclusively on a negative aspect of caregiving, such as troublesome, time-consuming and tough tasks. However, in talking about experiences and beliefs regarding caregiving with both the patients and family members, the trainees found there was also a positive aspect of caregiving. Their reflection on the discussions of caregiving with the 'stakeholders' allowed them to have a new perspective on caregiving and healthcare in the community. For example, trainee (m) said,

"His wife seemed to feel at ease that the patient was at home. I felt that sometimes caregivers themselves could be saved by caregiving."

Furthermore, trainee (b) said,

"The daughter-in-law and grandchildren all seemed to enjoy caring for the patients. I was grateful that they had accepted me. I have never been so worried about another person as I was this time."

Finally, trainee (p) remarked,

"The family said it was very nice that the family could say goodbye with their hands before the patient was gone. I was lucky enough to be there for this last moment."

The trainees conceptualized the approaches to healthcare and the roles/responsibilities of medical doctors through reflective observation on their concrete experience in the OSTIPH. The abstract conceptualization in their mind can be connected to their professional identity formation because they could gain a more holistic viewpoint toward healthcare and a new perspective on their future careers as physicians. Specifically, they realized the importance of understanding the psychosocial aspects of the patient to provide patient-centered medical care and that the physician should take the role of a healer who respects for the autonomy of the patients as a member of the healthcare team. For instance, trainee (m) said about a holistic approach to patient care,

"I was able to obtain insights into the patient- and family-centred medical care, which will be my lifelong goal for achievement in my career."

Moreover, trainee (h) said the following:

"I want to become a doctor who can propose the best care plan for home visits by taking the patient's desires into account. For example, for a patient who is unable to recover his/her disease completely and who does not want any further treatments at the hospital, health professionals have to preferentially ensure the patient's quality of life."

Regarding the importance of understanding the patients' psychosocial aspects, trainee (b) said,

"From now on, I try to pay more attention to not only patients' physical state but also their mental state, their everyday life situations, and their human relations."

In relation to the provision of comprehensive patient care, they also recognized the necessity of interprofessional collaboration for community-based medicine through their experience in remaining alone at the patient's home as a 'physician.' In the program, they found that what could be offered only by the physician was relatively limited. Trainee (f) said,

"I found that collaboration with other professionals is essential to the successful provision of home care, because I truly understood that better medical service could not be offered only by the doctor."

The authors thank the healthcare staff who practiced home visits, the patients and families who cooperated, and the trainees who participated in this study. We also express our deep gratitude to Mr. Phillip Evans, University of Glasgow, and Prof. Erik Driessen, Maastricht University, for their helpful advice and encouragement.

The authors declare that they have no conflict of interest.