Agrobacterium tumefaciens DNase effector Tde1 to unravel the mechanism of translocation from attacker to prey. We demonstrate that Tde1 binds to its adaptor Tap1 through the N‐terminus, which harbors continuous copies of GxxxG motifs resembling the glycine zipper structure found in proteins involved in the membrane channel formation. Amino acid substitutions on G39xxxG43 motif do not affect Tde1–Tap1 interaction and secretion but abolish its membrane permeability and translocation of its fluorescent fusion protein into prey cells. The data suggest that G39xxxG43 governs the delivery of Tde1 into target cells by permeabilizing the cytoplasmic membrane. Considering the widespread presence of GxxxG motifs in bacterial effectors and pore‐forming toxins, we propose that glycine zipper‐mediated permeabilization is a conserved mechanism used by bacterial effectors for translocation across target cell membranes.Type VI secretion systems (T6SSs) can deliver diverse toxic effectors into eukaryotic and bacterial cells. Although much is known about the regulation and assembly of T6SS, the translocation mechanism of effectors into the periplasm and/or cytoplasm of target cells remains elusive. Here, we use the  This study describes how the type VI secretion DNase effector Tde1 is translocated from the bacterial attacker into the competitor cell, demonstrating a new and maybe a conserved role of glycine zipper motif(s) in effector delivery. Each specialized protein secretion system  as the major antibacterial weapons, in which the cognate immunity proteins (namely Tdi1 and Tdi2) prevent autointoxication  in effector delivery into target cells.A. tumefaciens C58 caused growth inhibition, and the immunity protein Tdi1 only partially protected against this cytotoxicity  under an IPTG‐inducible promoter showed that N‐Tde1 was sufficient to inhibit growth owth Fig . This evet al, To test whether Tdi1, the immunity protein for the DNase toxicity of Tde1 (Ma Agrobacterium/Rhizobium as well as tape measure proteins (TMP) encoded in genomes of Paraburkholderia/Burkholderia  database and identified Tde1 homologs encoded in the T6SS gene clusters of ria Figs  and EV2AGLGL and Tde1(M)GLGL, respectively. The growth analysis of E. coli DH10B cells by counting viable cells and OD600 measurement showed that both N‐Tde1GLGL and Tde1(M)GLGL lost the ability to cause growth inhibition , and the resulting N‐Tde1 and Tde1(M) variants were named as N‐Tde1ion Figs  and EV3Atant Fig , indicatE. coli inner membrane permeability. To do so, we used the β‐galactosidase activity assay to measure the entry of ortho nitrophenyl galactopyranoside  into the cytosol. ONPG normally requires a functional permease LacY to enter into the cytosol but can enter if the inner membrane is permeabilized/compromised . The BW25113∆lacY(pYTA‐lacZ) complemented with lacY was used as a positive control. The E. coli cells were induced with IPTG to express Tde1 variants for 1 h and collected for ONPG uptake assay. This time point was chosen because there is no obvious difference in the number of viable cells among the strains tested GLGL only exhibited background‐level activity as the negative controls . Hoechst (616 Da) is a nucleic acid staining dye that is permeable to live Gram‐negative bacterial cells while PI (668.4 Da) can only enter through a compromised inner membrane or dead cells. The PI/Hoechst staining showed strong PI signals in cells expressing N‐Tde1 and Tde1 (M) but no or few signals were detected in cells expressing N‐Tde1GLGL, Tde1(M)GLGL, or vector control, indicating that N‐Tde1 is able to enhance membrane permeability to allow molecules with size 668.4 Da to pass  and after 1 h, washed with fresh media without IPTG for continuous cultivation. We found that growth was recovered when cells were washed of the IPTG inducer, in contrast to the growth inhibition of cells with continuous IPTG induction  interact with Tap1 but not the C‐terminal variants, C1‐Tde1(M) and C2‐Tde1 GLGL remain capable of interacting with Tap1 . The secretion is in a T6SS‐dependent manner as secretion was essentially abrogated in ∆tdei∆tssK, which lacks both tdei and tssk encoding the baseplate component. N‐Tde1GLGL and Tde1(M)GLGL are also stably expressed and secreted  with a flexible (GGGS) linker between Tde1 and sfGFP to avoid the Tde1 functional/structural interference by GFP. The sfGFP‐fused Tde1 variants were expressed in A. tumefaciens ∆tdei and ∆tdei∆tssK mutants. The secretion assay results showed that both WT and G39L and G43L substitution of N‐Tde1‐sfGFP and Tde1(M)‐sfGFP are secreted ‐sfGFP protein signal could not be unambiguously determined in the cellular fraction due to the overlapping of its predicted protein band with cross‐reacted proteins, and no corresponding C1‐Tde1(M)‐sfGFP band was detected in the extracellular fraction. The secretion assay of Tde1 variants fused with either HA or sfGFP concluded that N‐Tde1 is necessary and sufficient for secretion and the G39L and G43L substitution does not affect Tde1 being secreted, which is correlated with the ability to interact with Tap1.Because the Geted Fig . No or tA. tumefaciens ∆tdei, expressing sfGFP‐fused Tde1 variants, with E. coli cells expressing mCherry. A. tumefaciens expressing sfGFP only (Vector‐sfGFP) was used as a negative control. After co‐culture, we imaged populations for mCherry  and GFP (green) to detect E. coli and A. tumefaciens, respectively. We merged images to identify cyan‐colored cells , which represent E. coli cells with translocated Tde1 variants carrying sfGFP ‐sfGFP was co‐cultured with E. coli mCherry whereas the GFP and mCherry signals were not overlapped in the E. coli cells co‐cultured with A. tumefaciens strains expressing GFP only or sfGFP‐fused C1‐Tde1(M), N‐Tde1GLGL, Tde1(M)GLGL, respectively GLGL‐sfGFP could be secreted but not translocated into target cells, G39xxxG43 motif is necessary for delivering Tde1 into the target cell.The data suggest that Tde1 is translocated into target cells in a T6SS‐ and G39xxxG43 motif for target cell intoxication in the context of interbacterial competition, A. tumefaciens C58 ∆tdei expressing either Tde1‐Tdi1, Tde1(M)‐Tdi1, or single/double G39L and G43L substitution variants, was competed with target E. coli (DH10B) cells. By counting the survival rate of E. coli prey cells, the data showed that A. tumefaciens ∆tdei (Tde1‐Tdi1) exhibits an antibacterial activity but not in the negative controls, the secretion deficient mutants ∆tssL and ∆tdei∆tssK ‐Tdi1, indicating the DNase‐mediated killing of E. coli. The antibacterial activity of ∆tdei was not detectable, similar to that of negative controls. We also performed interbacterial competition assays using A. tumefaciens strain 1D1609, which is susceptible to T6SS killing by C58  and C58 against 1D1609 but no competitive advantage could be detectable for any of glycine zipper variants or Tde1(M) . Accordingly, Tde1GLGL was secreted at lower levels.To assess the role of the G1(M) Fig . The obseted Fig . It is nin vivo plasmid DNA degradation assay. Tde1 and the variants were each expressed by the tightly controlled arabinose‐inducible promoter for in vivo plasmid DNA degradation assay in E. coli BW25113 as described . The VgrG1–Tap1–Tde1–Tdi1 complex is then recruited onto the membrane‐associated baseplate, which serves as a docking site for polymerization of Hcp tube and TssBC sheath (Step 2). Upon TssBC sheath contraction (Step 3), Tap1 and Tdi1 may fall off and Hcp‐VgrG‐Tde1 puncturing device is then ejected for secretion. In contact with a target cell, Tde1 may be delivered to the periplasm of the target cell where Tde1 permeabilizes the inner membrane in a G39xxxG43 motif‐dependent manner (Step 5). Once delivered, Tde1 exerts its toxicity by attacking DNA for degradation (Step 6).Through the dissection of Tde1 DNase effector, we provide strong evidence for a role of the N‐terminal glycine zipper motif(s) of Tde1 in delivering the T6SS effector into target cells. Here, we propose a model explaining the loading, firing, and translocation of Tde1  system and bacteriocins  does not influence protein stability may suggest that the adjacent glycine residues (G35 or G47) are sufficient to compensate the loss of one glycine of G39xxxG43 motif for structural integrity in both variants. The importance of G39xxxG43 motif in Tde1 protein stability is consistent with the role of glycine zippers in structural impact ‐sfGFP while others including E. coli cells with GFP signals were found to be uniformly distributed throughout the cells. Based on the role of glycine zippers in interacting with membrane, we propose that Tde1 proteins may preferentially bind to the microdomain of the cytoplasmic membrane, which was recently found in A. tumefaciens  representing N‐Tde1‐sfGFP and Tde1(M)‐sfGFP translocation from erry Fig . Adding et al, et al, et al, et al, E. coli cells where they exert fluorescence also suggests potential applications of N‐Tde1 for the delivery of proteins of interest such as genetic modifiers. This strategy provides advantages over transforming foreign DNA for expressing a protein of interest from creating undesired genome manipulation.With the knowledge of effector translocation mechanisms, the bacterial protein secretion apparatus also offers a strategy for delivering heterologous proteins to specific cells. T6SS is a promising vehicle for such purpose because effectors or secreted proteins appear to be delivered with their folded or partially folded form, unlike those to be transported as unfolded forms in most of the other specialized secretion systems  medium  at 37°C unless stated. Where appropriate, the media were supplemented with 100 μg ml−1 spectinomycin (Sp), gentamycin (Gm) 25 μg ml−1 (for E. coli) and 50 μg ml−1 (for A. tumefaciens), 50 μg ml−1 ampicillin (Amp), 50 μg ml−1 kanamycin (Km), 1 mM Isopropyl β‐d‐1‐thiogalactopyranoside (IPTG).The strains and plasmids used in this study are listed in Appendix Tables E. coli (DH10B) harboring pTrc200 vector or the derivatives expressing Tde1 variants were grown overnight in LB medium supplemented with Sp prior to 1:30 dilution in a fresh medium and incubated for 2 h at 37°C with 250 rpm. After 2 h, the cultures were normalized to OD600 0.1 in LB with 1 mM IPTG for continuous culture in the same growth condition. The growth of E. coli was monitored for OD600 every 1 h using ULTROSPEC® 10 cell density meter  or viable cell by counting colony forming units (CFUs) on LB agar containing Sp. For growth inhibition assay of arabinose‐inducible expression, E. coli BW25113 harboring pJN105 vector or the derivatives expressing Tde1 variants were used. Overnight cultures of E. coli cells were adjusted to an OD600 of 0.1 in 200 μl LB with 0.2% L‐arabinose in a 96‐well plate. The OD600 values were measured by the Synergy H1 microplate reader  with agitation at 37°C. The OD600 values or CFUs of indicated time points were used to calculate mean ± SD of three biological repeats. One‐way analysis of variance (ANOVA) was used for the analysis of statistical significance followed by the Tukey's multiple comparison.For growth inhibition assay of IPTG‐inducible expression of Tde1 and its variants, in vivo plasmid DNA degradation assay was performed as described  every hour.The et al, ∆lacY(pYTA‐lacZ), or BW25113∆lacY harboring pTrc200 vector or the derivatives expressing Tde1 variants were grown overnight and refreshed to a fresh medium as stated for growth inhibition assay. After subculture for 2 h, the cells were induced with 1 mM IPTG, and incubated for one more hr. Part of the culture was adjusted to OD600 = 0.3 in Z‐buffer and the Intracellular β‐galactosidase activity was measured by mixing 100 μl of 4 mg ml−1 ONPG with 900 μl of the cells and incubation at room temperature for 10 min prior to measurement at OD420. The remaining cells were normalized to OD600 0.3 in 0.9% sterile saline and after serial dilution, 10 μl was spotted on the LB plate without antibiotics to recover the viable cells. Data from OD420 were used to calculate mean ± SD of three independent experiments. One‐way ANOVA was used for the analysis of statistical significance followed by the Tukey's multiple comparison.β‐galactosidase assay was performed as described . After cell lysis by lysozyme treatment and sonication, the lysate was centrifuged and a 100 μl aliquot of the lysate was saved for the input fraction. The remaining 900 μl lysate was mixed with 25 μl of pre‐equilibrated Ezview red Anti‐HA agarose and incubated at 4°C for 1 h. The beads were then washed 3 times with ice‐cold PBS buffer and the proteins bound to the beads were eluted with 100 μl of 2× SDS sample loading buffer. Similarly, the aliquoted input fraction was mixed with an equal volume of 2× SDS sample loading buffer for analysis by western blotting.The co‐IP was performed according to the manufacturer's recommendations of EZview red Anti‐HA agarose (Sigma‐E6779) with minor modifications. To identify Tap1‐interacting domain of Tde1, the HA‐tagged Tde1 variants were expressed from pTrc200 plasmid. For co‐IP in et al, A. tumefaciens strain was cultured overnight in 523 medium and normalized to OD600 of 0.2 in a fresh medium. After 6 h of culturing, the secreted proteins were collected by centrifuging at 10,000 g for 5 min. The resulting pellet was adjusted to OD600 of 10 as a cellular fraction. The culture supernatant was filtered with 0.22 μm Millipore filter membrane, and the resulting filtrate was subjected to TCA precipitation , A. tumefaciens strain (attacker) was grown overnight at 28°C in 523 broth with appropriate antibiotics if needed. E. coli DH10B harboring pRL662 plasmid was grown at 37°C in LB broth with Gm. After harvesting and washing the cells in 0.9% saline, the attacker to target cell density was adjusted to 30:1 (OD600 = 3: 0.1) and the mix was spotted on LB medium containing 1.5% (wt/vol) agar. After incubation of the mixed strains for 16 h at 28°C, the spot was resuspended in 0.9% saline, serial diluted, and spotted on a gentamycin‐containing LB agar square plate at 37°C to calculate E. coli survival rate by CFU counts. Similar procedure was used when using A. tumefaciens strain 1D1609 as a target, which was grown at 28°C in 523 broth prior to competition. The competition was carried out on AK medium for 16 h at 28°C with CFU counting at both initial and final time points by the selection of C58 strains with Sp resistance and 1D1609 with Gm resistance. To calculate the competitive index, CFUs of A. tumefaciens attacker C58 strain were divided by the CFUs of target 1D1609 strain at both 0 h and 16 h, and the ratio of C58/1D1609 at 16 h was divided by the ratio of C58/1D1609 at 0 h to obtain competitive index. One‐way ANOVA was used for the analysis of statistical significance followed by the Fisher's least significant difference (LSD) test.For interbacterial competition with E. coli cells (BW25113) harboring pTrc200 vector or derivatives expressing Tde1 variants were grown overnight and refreshed to a fresh medium as stated for growth inhibition assay. After subculture for 2 h, the cells were induced with 1 mM IPTG for 1 h and OD600 equivalent to 0.3 was collected in 1 ml PBS and stained with Hoechst 33342 (H3570) to a final concentration of 12.3 and 1 μg ml−1 propidium iodide (2208511) and incubated for 2 min in dark. Finally, 2 μl was spotted on 2.5% agarose pad.For propidium iodide and Hoechst staining, A. tumefaciens ∆tdei cells (attacker). E. coli (target) cells were labeled with mCherry  expressed from pBBRMCS2. A. tumefaciens attacker cells were cultured in 523 broth overnight, and E. coli target cells were separately cultured on LB broth. Overnight cultured attacker and target cells were mixed at a 5:1 ratio (OD600 = 1.0:0.2), and 10 μl of the mix was cultured on an LB agar plate without IPTG. After 20 h of co‐culture, the cells were washed with 100 μl PBS and 2 μl of suspension was spotted on the 2.5% agarose pad on a microscopic slide. The translocation signal was detected as the merge of GFP and mCherry , which is of cyan fluorescence.For the translocation experiment, the sfGFP‐fused Tde1 variants were expressed in Fluorescence microscopy was performed using Axio Observer 7  microscope equipped with an Axiochem 702 digital camera and a Plan‐Apochromat 100×/1.4 Oil DIC H objective. Exposure times were adjusted to 20 ms for Phase, 50 ms for Hoechst, 150 ms for PI, 200 ms for GFP, and 5,000 ms for mCherry. Multiple images were taken from different fields and all the experiments were performed at least in triplicate and a representative image is shown. Images were analyzed by using ZEN 2.3 (blue edition) software.et al, et al, et al, et al, Full‐length Tde1 (1–278) was used as a query for conserved domain search on the conserved domains database (CDD; Lu Jemal Ali: Conceptualization; investigation; writing – original draft. Manda Yu: Conceptualization; investigation; writing – review and editing. Li‐Kang Sung: Investigation; writing – review and editing. Yee‐Wai Cheung: Investigation; writing – review and editing. Erh‐Min Lai: Conceptualization; resources; supervision; funding acquisition; writing – original draft; project administration.The authors declare that they have no conflict of interest.AppendixClick here for additional data file.Expanded View Figures PDFClick here for additional data file.PDF+Click here for additional data file.Source Data for Figure 1Click here for additional data file.Source Data for Figure 2Click here for additional data file.Source Data for Figure 3Click here for additional data file.Source Data for Figure 4Click here for additional data file.Source Data for Figure 5Click here for additional data file.


Background and Objectives: The aim of this study is to develop and implement a comprehensive person-centered care (PCC) education program for nursing students and assess its effects on individualized care, empathy, communication competence, and clinical practice stress. Materials and Methods: A non-equivalent control group non-synchronized design was used. Participants were 60 third-year nursing students undergoing clinical practicum in a nursing school. They were assigned either to the control group (29 students) or experimental group (31 students). The experimental group participated in a comprehensive PCC education program, while the control group did not. Four 65-min sessions were conducted over two weeks; each session comprised 5 min of introduction, 50 min of education, and 10 min of sharing of thoughts and training. Individualized care, empathy, communication competence, and clinical practice stress were measured. Data were collected immediately before the education program and two weeks after program completion. Results: After the education program, the experimental group showed significant improvements in individualized care, empathy, and communication competence and significantly reduced clinical practice stress compared to the control group. Conclusions: The comprehensive PCC education program is a potentially beneficial intervention for nursing students to help them practice person-centered care with confidence. Longitudinal randomized controlled trials are needed to substantiate these findings. The paradigm of global healthcare is shifting from a disease-centered to a person-centered perspective. Person-centered care (PCC) refers to a type of care that considers individuals’ values and preferences, informs the patient about all aspects of health management, and supports realistic health and life goals . In otheNursing students become partially involved in patient care during their clinical practicum ; therefoAn effective educational approach is critical to enhance nursing students’ levels of caring ,17. FurtNo study has yet reported the effects of a comprehensive PCC education program that encompasses a theoretical approach, PCC cases that help apply knowledge in practice, and education to boost communication competence and empathy. Therefore, this study developed a comprehensive PCC education program for nursing students undergoing clinical practicum and investigated the effects of the program on the key elements of PCC—individualized care, empathy, and communication competence—and clinical practice stress. This study used a non-equivalent control group non-synchronized design. Conducting the study simultaneously with the experimental and control groups would have elevated the risk of diffusion effect, as participants were undergoing clinical practicum at the same hospital. Therefore, this study used a non-synchronized design, wherein the control group underwent the study first, followed by the experimental group.The inclusion criteria were (1) third-year nursing students who had experienced clinical training for more than one semester at a general hospital, (2) scheduled for clinical practicum during the study period, and (3) no prior participation in a similar PCC education program. The exclusion criteria were (1) unavailable to undergo at least two weeks of on-campus practicum and clinical practicum in the hospital after the completion of the education program and (2) unable to participate in all sessions of the education program.Sample size was calculated using the G*Power 3.1 software. For independent t-tests with a significance (α) of 0.05, power of 0.8, and effect size of 0.8, the minimum sample size was 26 for each group. The dropout criteria were missing any of the four sessions of the program or failure to complete the pre-test or post-test. Participants were recruited among third-year nursing students at a nursing school in C city in South Korea through social network service and bulletin board. The researcher anticipated a high dropout rate as the study was conducted during clinical practicum. Considering about 30% dropout, the researcher intended to recruit 68 participants, but 73 participants were enrolled. The recruiting process, educational intervention, and surveys were conducted from 18 May 2021 to 10 December 2021. A third person not involved in the study arbitrarily assigned participants into the experimental group and control group. Participants were given a detailed explanation about the study procedure during the informed consent process; they were aware of which program they were participating in. The researcher administered the education program; therefore, the researcher was also aware of the provided content. To reduce the consequent bias by these problems, this study used a non-synchronized design to ensure that the control group and experimental group did not have any contact with each other, and the researcher followed a manual when providing education to ensure consistency in each session.The experimental group completed the pre-test immediately before beginning the education program and completed the post-test after two weeks of on-campus and clinical practicum following program completion. The control group also completed the post-test after two weeks of on-campus and clinical practicum following the pre-test. The researcher and research assistants administered the pre-test and post-test.Of 73 participants, 6 participants who could not undergo at least 2 weeks of on-campus and clinical practicum following the completion of the education program were excluded. Of 67 participants meeting the criteria, the control group was expected to have a higher dropout rate because they only complete the pre-test and post-test without intervention; therefore, 36 participants were assigned to the control group and 31 were assigned to the experimental group. A total of 7 participants in the control group failed to complete the post-test, resulting in a total of 29 participants, and all 31 participants in the experimental group were included. Thus, a total of 60 participants were included in the final analysis .Existing studies were reviewed to identify the essential contents for the comprehensive PCC education program. Nursing students need to know the concept and principles of PCC to perform PCC during clinical practicum. Thus, this study reviewed previous studies ,2,3,21. Moreover, empathy, communication, respect, relationship, and individualized focus are important factors in PCC . This stThe program was structured to include the definition of PCC, core premises, and effects of PCC to help students gain an understanding of PCC, broaden their view, and cultivate a positive attitude toward PCC. Case studies of PCC were taken from the book written by Price  and tranEmpathy training included contents about understanding the concept of empathy, knowing one’s emotions, expressing emotions, and listening. The goal of the empathy training was to ensure that the students had an accurate understanding of empathy, knew how to express empathy, recognized their own emotions, and listened correctly to identify others’ emotions. Communication training comprised open-ended questions, affirmations, I-message, and reflective listening. The goal of communication training was to help nursing students to build a relationship of trust with the patient, identify the patient’s values, needs, and preferences, deliver information individually, and help patients actively improve their own lifestyle. This study set the program to 4 sessions with reference to the 2–6 sessions used by a study providing a person-centered dementia care education program to nursing care providers in long-term care facilities  and a stThe educational materials were written in 12-point font size to provide to the participants at each session. Moreover, a training manual for each session was developed to ensure consistency in the education program. The lectures consisted of 20 min of understanding of PCC and case study analysis, 15 min of empathy training, and 15 min of communication training for each session .The content validity of the developed comprehensive PCC education program was evaluated. The content on understanding of PCC and the case studies were reviewed by a professor with experience in PCC research and two nursing students, and the empathy and communication training contents were reviewed by three professors with experience in administering relevant education and two nursing students. The developed comprehensive PCC education program consisted of a total of four sessions (two sessions per week) for 65 min per session. The researcher conducted the program in a quiet lecture room. The students were divided into three-person or four-person groups to promote interaction.In the initial part of the program, the researcher introduced the outlines for the corresponding session and had students share their thoughts on the changes they had during clinical practicum since the preceding session. During hands-on training, the students could practice what they learned during the education, and during sharing of thoughts, they shared their thoughts after each session. Both lecture and practice were included in each session to enhance students’ understanding and utilization of educational contents. In addition, the researcher tried to identify and solve students’ difficulties during practice. The researcher asked students to think about and express what appropriate empathy and communication should be provided to patients and how to address situations through a case study. However, whether the students understood the contents of each session well was not objectively evaluated in each session. The lectures were given according to the manual, and the students were given educational materials and a book containing PCC cases. The education program was administered by the researcher, who has experience in research on communication-enhancing programs and PCC and has translated a book on PCC.Participants’ sex, age, religion, health status, satisfaction with college, satisfaction with nursing major, and academic performance in the preceding semester were surveyed. Individualized care, empathy, communication competence, and clinical practice stress were measured immediately before the intervention and two weeks after the intervention using the self-report questionnaires. The pre-test was written based on students’ experience of providing care to patients during clinical practice before the comprehensive PCC education program, and the post-test was written based on the experience of providing care to patients during the on-campus practicum and the clinical practicum in the hospital after the completion of the education program.Individualized care was assessed using the Individualized Care Scale-Nurse A version (ICS-A-Nurse) developed by Suhonen et al.  and adapEmpathy was assessed using the Jefferson Scale of Empathy-Health Profession Students’ version (JSE-HPS) developed by Hojat et al.  and adapCommunication competence was measured using the Global Interpersonal Communication Competence (GICC) scale developed by Hur . This 15Clinical practice stress was assessed using the instrument developed by Beck and Srivastava  and adapThe collected data were analyzed using SPSS version 25.0 . The baseline homogeneity of general characteristics between the experimental and control groups was tested using the chi-squared test, Fisher’s exact test, and independent t-test, and the normality of the dependent variables was analyzed with the Shapiro–Wilk test. The baseline homogeneity of the dependent variables and the effects of the comprehensive PCC education program were analyzed using the Mann–Whitney test or independent t-test depending on the normality of the data. This study was approved by the Ethics Committee of Kangwon National University (IRB No.: KWNUIRB-2021-04-011-001) prior to data collection and intervention administration. All participants volunteered to participate in the study and were provided detailed explanations about the purpose and procedure of study, guarantee of anonymity of collected data, benefits and risks, confidentiality, and withdrawal from the study both verbally and in writing. The study began after obtaining written informed consent. There were no significant differences in sex, age, religion, subjective health status, satisfaction with college life, satisfaction with nursing major, and academic performance in the preceding semester between the two groups, confirming baseline homogeneity in the general characteristics between the two groups .p = 0.363, control group W = 0.919, p = 0.029), all dependent variables, namely empathy , communication competence , and clinical practice stress , were normally distributed. There were no significant differences in these dependent variables between the two groups, confirming baseline homogeneity , empathy , and communication competence  were significantly improved. Individualized care scores increased in the experimental group (5.61 ± 11.38) but decreased in the control group (−0.24 ± 6.26). Empathy scores increased in the experimental group (3.29 ± 6.90) but decreased in the control group (−2.96 ± 4.48). Additionally, communication competence scores in the experimental group increased (0.77 ± 4.42) but decreased in the control group (−2.96 ± 4.48). Finally, clinical practice stress  was significantly reduced in the experimental group compared to the control group. Clinical practice stress scores decreased in the experimental group (−1.41 ± 7.93) but increased in the control group (4.48 ± 7.81) ( ± 7.81) .This study aimed to evaluate the effects of a comprehensive PCC education program on nursing students undergoing clinical practicum in the hospital. No study has yet reported the effectiveness of a comprehensive PCC education program for nursing students in Korea and abroad. Therefore, this study is significant as the first study investigating the effects of a comprehensive PCC education program on individualized care, empathy, communication competence, and clinical practice stress among nursing students undergoing clinical practicum.First, the comprehensive PCC education program significantly improved individualized care compared to the control group. We could not compare our results directly with those in the literature since the study that applied flipped and simulated learning to enhance nursing students’ understanding of PCC . HoweverSecond, the comprehensive PCC education program also significantly enhanced empathy compared to the control group, and empathy is an essential attribute for nursing students to promote PCC, owing to its strong association with PCC competence . UnderstThird, the comprehensive PCC education program significantly improved communication competence compared to the control group. Effective communication between patients and nurses is an essential requirement for PCC . Among tFinally, the comprehensive PCC education program significantly reduced nursing students’ clinical practice stress compared to the control group. Nursing students have been reported to be under heavy stress during clinical practicum, primarily due to fear of unknown situations, lack of competence, and lack of control in their relationship with patients ,33. The This study is significant as the first study in Korea and abroad to implement and evaluate a comprehensive PCC education program in nursing students. Moreover, the fact that we developed a feasible comprehensive PCC education program for nursing students undergoing clinical practicum adds to the significance of this study. Nursing students who completed the education program applied what they had learned into practice during on-campus and clinical practicum and evaluated the effectiveness of the program themselves, thereby improving the accuracy of the assessment. Finally, this study showed that a program that simultaneously boosts empathy and communication competence as well as PCC through theoretical and case-based education is effective, thereby establishing evidence supporting the implementation of a comprehensive intervention.This study has a few limitations. We could not use a randomized experimental design and used a non-synchronized design to prevent any diffusion effects between the experimental group and control group. Hence, bias caused by various exogenous variables that might have occurred during this period could not be controlled. Moreover, we conducted the comprehensive PCC education program at one university in Korea; therefore, these results have limitations in generalizing the findings. Lastly, although we administered the post-test after the students had about two weeks of on-campus and clinical practicum following the completion of the intervention, we did not use a longitudinal design and thus could not evaluate whether the effects are retained in the long term. In the future, longitudinal randomized controlled trials are needed to substantiate the findings of this study. Moreover, replication studies are needed with nursing students from diverse universities. Finally, studies should develop more patient scenarios for case-based learning, an essential component of comprehensive PCC education, and assess the effects of such education. This study developed, implemented, and evaluated the effects of a comprehensive PCC education program in nursing students undergoing clinical practicum. The program improved nursing students’ PCC competence, empathy, and communication competence while reducing their clinical practice stress. Thus, a comprehensive PCC education program could be utilized as a pre-practicum intervention for nursing students to boost their confidence and promote PCC practice during clinical practicum.


Participants had significant positive changes in their eating pattern. They reported improvements in biometric measures as well as in how they were feeling. They all reported that they planned to continue to eat a more WFPB diet than they did prior to Jumpstart. All either agreed or strongly agreed that they learned important information, were confident that they knew the best eating pattern for health, and gained the skills they needed to make changes. Although this was a small pilot program, it suggests that this model can be used to provide education and support for behavior change that will lead to improved health in a DHH community.Deaf and Hard of Hearing (DHH) patients are at high risk of developing chronic illness, and when they do, are at higher risk of poor outcomes than in a hearing community. Rochester Lifestyle Medicine Institute adapted its online, Zoom-based, medically-facilitated 15 Day Whole-Food Plant-Based (WFPB) Jumpstart program, to give DHH participants knowledge, skills, and support to make dietary changes to improve their health. Adaptations included having a medical provider present who is fluent in American Sign Language (ASL), is board-certified in Lifestyle Medicine, and has a Master of Science in Deaf Education; spotlighting participants when asking a question during the Q&A session; using ASL interpreters; utilizing closed captioning/automatic transcription during all Zoom meetings; and employing a Success Specialist to provide outreach  Deaf and Hard of Hearing (DHH) patients are at high risk of developing chronic medical conditions through several causal pathways. First, hearing loss can lead to more difficulty with communication and reduced social engagement, resulting in higher risk of loneliness, depression, and dementia .Second, Deaf individuals are almost 7 times more likely than hearing individuals to have inadequate health literacy, which can lead to missed opportunities for health promotion and disease prevention. Factors that contribute to lower health literacy include lack of education, as well as communication issues. The mean reading level has been reported to be grade 5.9; thus, DHH patients often have lower health terminology recognition . VariabiAll of these issues lead to a high prevalence of chronic illness. DHH individuals are at increased risk of having hypertension, hyperlipidemia, pre-diabetes and diabetes, cardiovascular disease, and depression , 3.Additionally, DHH patients experience many barriers to care, and are therefore at high risk for poor medical outcomes once chronic disease is established. Adults who have been deaf since birth or early childhood are less likely to have seen a physician than the general population . Cost caAccording to the American College of Lifestyle Medicine, Lifestyle Medicine (LM) is “a medical specialty that uses therapeutic lifestyle interventions as a primary modality to treat chronic conditions.” LM clinicians “apply evidence-based, whole-person, prescriptive lifestyle change to treat and… often reverse such conditions” . LM focuPoor diet has been identified as the leading risk factor for mortality and for disability-adjusted life-years since 2010, superseding tobacco use, which had been the leading risk factor prior to that time . A wholeRochester Lifestyle Medicine Institute (RLMI) has developed a 15-day medically-facilitated Jumpstart program that gives participants the knowledge, skills and support to establish a WFPB lifestyle. Previously published results demonstrate that participants experience benefits in a short period of time. Program participants increase their consumption of WFPB components , and decrease animal products and processed food. As a result, they experience weight loss, and improvements in blood pressure, cholesterol and blood sugar. They also report better energy, sleep, and mood, and less pain , 15.Recognizing the baseline increased risk of chronic disease among DHH individuals, the barriers that they face in healthcare, and the predisposition to poor outcomes, RLMI launched a pilot project to see whether the Jumpstart program could be adapted to a DHH population, whether participants could be recruited, and whether they experienced positive outcomes from the program. The cost of participation in the program was covered through grant funding. This was the first time that this program was adapted for a DHH population, and the first WFPB educational program that we are aware of that has been provided exclusively for a DHH population.The Jumpstart program is an online, Zoom-based, medically-facilitated group program. Enrollees in the program take part in 11 h of live, interactive programming over 7 sessions. They receive menus and shopping lists, and participate in a Google Classroom that has additional teaching and support materials. Participants are counseled to eat a low-fat, whole-food plant-based diet, consisting of minimally processed vegetables, fruits, whole grains and legumes. Participants who ask about a minimum number of servings of each component are referred to the advice of Dr. Michael Greger, a nationally recognized expert in WFPB nutrition. Dr. Greger recomends at least 3 daily servings of legumes, 4 servings of whole grains, 5 servings of vegetables, and 4 servings of fruits .Participants are asked to obtain and report baseline fasting cholesterol and glucose tests, as well as biometrics, including weight, blood pressure, and waist circumference. They have frequent opportunities to ask questions of a medical provider throughout the program. They participate in a cooking demonstration on the second day of the program and a “virtual potluck,” in which they send in and then discuss recipes, on the eighth day of the program. Daily emails provide additional support throughout the program. Participants are asked to get follow-up labs and biometrics at the end of the program, and voluntarily share these with RLMI as part of the quality improvement (QI) program.A convenience sample of 24 adults was recruited from nine states (USA) and Canada. Potential participants were identified through multiple contacts, including DHH networks, a Deaf nutritionist, online communities, word of mouth, non-profit organizations, social media posts, and emails and calls to colleges with large DHH communities. An email template with a coupon code was created, along with a script for phone calls. Calls were made, and targeted emails were sent to administrators of 4 US colleges and 1 high school known for their services for the hearing impaired: Gallaudet University, Washington, DC; Southwest College for the Deaf, Big Spring, Texas; California State University at Northridge, Deaf Studies Department; the National institute for the Deaf at Rochester Institute of Technology, Rochester, NY; and Lexington School for the Deaf, New York, NY. Non-profit organizations with programs for hearing impaired were targeted as well. An event flyer with links to RLMI’s website page, “About Jumpstart,” and an events calendar featuring the DHH cohort were included in correspondence. The Deaf nutritionist and the medical provider for the program both promoted the program widely on their social media channels, mainly Facebook; a preponderance of participants enrolled as a result of this notification. RLMI staff received inquiries from interested parties by email, text, and telephone. They responded to all inquiries with emailed instructions for registration and, when necessary, manually registered participants who needed help.Several adaptations were made to the Jumpstart program in order to facilitate participation from a DHH population . A grantThe medical provider for the program (KS) is board-certified in Lifestyle Medicine, has a Master of Science in Deaf Education, is fluent in American Sign Language (ASL), and understands the culture of the Deaf community. She is hearing, with Deaf and Hard of Hearing family members. Before becoming a practicing physician, she taught Deaf and Hard of Hearing students in multiple different schools in the United States and other countries. She has been a professional interpreter in many settings in the United States and internationally.via text and email throughout the program, for additional support.Participants in the program were asked to raise their electronic hands so that they could be spotlighted when asking a question during the Q&A session, providing better visibility for the other participants. Multiple ways of communicating were employed, including use of ASL and closed captioning/automatic transcription during all Zoom meetings. For any session lasting more than 1 h, 2 interpreters participated, to allow them time to rest, as it is physically taxing to interpret for more than an hour at a time. On days of small group “breakout” sessions, several interpreters participated so that one interpreter was available for each breakout room. All ASL interpreters were Board Certified Interpreters who had passed the National Interpreter Certification (NIC) test that is given jointly by the National Association of the Deaf (NAD) and the Registry of Interpreters for the Deaf (RID). Finally, a Success Specialist provided outreach Permission was given from the University of Rochester Institutional Review Board to use the data collected from RLMI as part of the QI program. The study was considered exempt.via 2-tailed paired t-tests.Forty-two people registered for the program, and 24 attended. Of those, 18 provided one or more responses to questions. Changes reported from the beginning to the end of the Jumpstart were compared The 11 participants who provided pre-post data to the QI program reported significant changes in their dietary pattern . They atParticipants who provided pre-post data also had changes in clinical and self-reported measures . They loThis pilot program demonstrates that an online medically-facilitated program designed to give participants the knowledge, skills and support to develop a WFPB lifestyle, can be adapted for a DHH cohort. Despite multiple potential barriers in this population, participants were identified and recruited from several networks across North America. Participants made changes to their eating pattern and expressed an intent to continue to eat a more healthy diet following the program. They noted positive changes – both in how they were feeling, and in biometric measures. Finally, they reported that they got information and gained skills needed to improve their health.Although we are not aware of other programs that have provided education to a DHH community to help them adopt a WFPB lifestyle, many interventions have been developed to try to reduce barriers and improve access to health education in the Deaf community. A recent systematic review demonstrated that several innovations led to improved outcomes, and could serve to reduce health inequities. These included the use of online interventions, and using Sign Language during telehealth visits. However, it was noted that stronger evidence was needed to assess these interventions .via email and text. Finally, comprehension was improved through giving 5 days of lead time to review written materials; multimodal communication as described above; and email responses to individual questions.The adaptations to the program included multiple accommodations to improve communication, connection, and comprehension. Communication was enhanced in multiple ways: by using ASL interpreters and closed captioning/automatic transcription during all Zoom meetings, spotlighting participants during Q&A for better visibility, and having a Lifestyle Medicine physician who had a Master of Science in Deaf Education for personalized counseling. Connection was enhanced through a Success Specialist who communicated An in-person variation of this program could help to promote engagement and social support. Prior to the pandemic, the Jumpstart was run exclusively as an in-person program. Since the pandemic, all programs are run online, which enables reaching a larger and more geographically diverse group. An adaptation of the program is being developed using a shared medical visit approach, so it is feasible that practitioners with a large DHH cohort of patients could run the program in person.Feedback was obtained through standard questionnaires on Day 15 of the program. These questionnaires are sent to all participants in the Jumpstart program, and questions were not specific to this cohort. When asked what the program could do to help participants stay on the path of a WFPB diet, responses from this cohort included sending out recipes, occasional check-in reminders, and availability of ongoing support, including a maintenance program and opportunities to communicate with program staff. When asked about barriers, none of the respondents mentioned communication issues. More qualitative feedback from DHH participants would be helpful to improve future iterations of a DHH WFPB program.Despite the adjustments to make the program accessible, the team still encountered some issues in running the program. Some participants preferred the interpreters to use American Sign Language, and felt the interpreters were not as skilled as desired in that language. Those participants noted that the interpreters were using a pidgin of signed English instead of ASL, which has a different and distinct grammar and syntax, making it much harder to understand .Some individuals signed up but did not participate. Since the cost of attending was covered by a grant, potential participants did not have a financial incentive to follow through with the program. Future iterations of this program could consider charging a nominal amount, so that participants are not limited by financial barriers, but still have “skin in the game” to follow through.This was a small pilot study, designed as a “proof of concept,” to demonstrate that an online Zoom-based medically-facilitated Lifestyle Medicine program with previously proven benefits could be adapted to an underserved community with barriers in both access and communication. Because this was not designed as a prospective clinical trial, demonstration of impact is limited to the responses that were voluntarily provided through an ongoing QI program. It is certainly possible that the participants who had less favorable results did not respond to the surveys.Additionally, we used a “post-pre” analysis, in which participants were able to compare their baseline responses to their follow up. This was done so that participants could assess change during the 15 days , and because the way in which participants measure certain outcomes  may change over the course of the 15 days. This approach, as well as a pre-post approach, are vulnerable to a “social desirability” bias of providing responses that are acceptable; however, this is generally a limitation of self-reported measures .A larger, prospective study would reduce these biases, and yield more generalizable results. In addition, it could provide opportunities to evaluate the characteristics that are associated with positive results. However, the breadth of positive results reported by this cohort suggests that this is a model that can be used to provide education and support for behavior change that will lead to improved health in a DHH community.This pilot study provides a framework for adapting an online medically-facilitated program to educate a traditionally underserved community with multiple barriers to care –namely, a Deaf and Hard of Hearing cohort –giving them knowledge, skills and support to adopt a WFPB lifestyle. Preliminary findings suggest that participants are able to make significant changes, leading to short-term health improvements. Further large-scale, prospective studies are needed to rigorously evaluate this approach, building on the “lessons learned” from the pilot program.Bruce.pollock@roclifemed.org.The data analyzed in this study is subject to the following licenses/restrictions: The de-identified dataset is a subset of a quality improvement dataset managed by Rochester Lifestyle Medicine Institute. Requests to access these datasets should be directed to The study involving human participants was reviewed and approved by the University of Rochester School of Medicine and Dentistry Institutional Review Board. Written informed consent for participation was not required for this study in accordance with national legislation and institutional requirements.SF: analysis, drafting, and revision of manuscript. KS and TB: program conceptual framework, review, and revision of manuscript. BB and MD: program conceptual framework, recruitment of participants, review, and revision of manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The Great East Japan Earthquake and the resulting tsunami and nuclear disaster on March 11, 2011 have had a profound and lasting effect on residents of Japan’s Fukushima Prefecture, particularly among evacuees. While there continues to be extensive news coverage and academic study of Fukushima Prefecture’s recovery, there has been little exploration of individual narratives. This study aims to illuminate some individual stories of medical students at Fukushima Medical University (FMU) who lived in the Prefecture at the time of the Earthquake.A qualitative approach was taken in order to investigate individuals’ experiences with the goal of adding a personal dimension to quantitative studies on the subject. 10 open-ended ethnographic interviews were conducted with medical students at FMU in years 1–5 who lived in Fukushima Prefecture at the time of the Great East Japan Earthquake. All interviews were audio recorded and transcribed. Transcriptions were reviewed using inductive thematic analysis under the lens of ethnographic anthropology.Three major themes emerged from these interviews: first, that the events following the Earthquake influenced not only these students’ decisions to pursue careers in medicine, but the ways in which they hope to practice medicine in the future. Second, that these students were motivated to share their experiences by a want to change Fukushima Prefecture’s public image. And lastly, that the students viewed the opportunity to discuss their experiences through these interviews as healing, both for themselves and for the future.While multiple factors undoubtably contributed these students’ medical education, they cite the Earthquake as essential to their approach to their medical careers. Additionally, opportunities for the participants to discuss their experiences following the Earthquake appear to be rare but valued, as the students view their stories as their “legacies.” The enduring, burdening effects of the Earthquake appear to have galvanized the participating students to act on behalf of their communities and their Prefecture. Further qualitative studies in more generalizable populations are needed to improve and deepen our understanding of the societal, cultural, and personal impacts of the Great East Japan Earthquake. There is no shortage of media coverage following disasters, and no shortage of criticisms of the media coverage following disasters. It is a familiar pattern: the first media wave reporting on the event; the second wave of clarifications and professional opinions; then the third, a stream of splashy, sensationalist pieces that play towards a hungry audience’s desire for more information. It all becomes so big and blurry.This is my memory of the media coverage of the 2011 earthquake, tsunami, and nuclear plant explosion in Fukushima, Japan, and my only concept of Fukushima prior to visiting for research. News stories of contaminated fish, mutated plants, terrified and irradiated evacuees. There was no sense of personal narrative – people lost control of their own stories. The same is true in the academic literature; 8 years later, ethnographic studies of the Great East Japan Earthquake (GEJE) are extremely few.During my time at Fukushima Medical University (FMU), my hope was to hear the experiences of students who were there when it happened. As half of my stay in Fukushima overlapped with the university’s exam period, I imagined that students would be reluctant to speak with me for fear of compromising their studying, and that the interviews I did manage to schedule would be very brief. However, the students were more than eager to share both their time and their stories. While I initially came to FMU to pursue questions of ethics in post-disaster research, I quickly found that the participants were more passionate about other topics related to the Great East Japan Earthquake, and I was excited for the discussions to shift. Therefore, a new research focus emerged and I simply began asking participants, “What was it like?” This inductive and discovery-based approach allowed me to reframe and refine the objectives for this study.While there continues to be extensive news coverage and quantitative studies on Fuksuhima Prefecture’s recovery, there remains a paucity of scientific literature on individual narratives during and following the GEJE. A holistic understanding of such an impactful event requires investigations from both qualitative and quantitative perspectives. Through open-ended interviews, this study aims to illuminate individual stories of medical students at FMU who lived in the Prefecture at the time. Here, we utilize a qualitative approach based in ethnography to delve into their complex lived experiences, explore their responsive belief systems and coping strategies as a result of the Earthquake, and lastly provide a space in which survivors can control the narrative in academic research.th, 2011, a magnitude 9.0 earthquake off the coast of Japan’s Tōhoku region induced a major tsunami. This earthquake – the Great East Japan Earthquake – was the most powerful ever recorded in Japan, and the fourth most powerful recorded worldwide  that one of the most important things is helping people. That’s the biggest thing I learned through the disaster. I think it’s connected to what I want to do in the future.”Other student interview participants viewed their experiences following the Earthquake as essential in their choice of career – Participant 8 is one such example. Though Participant 8 had worked in healthcare prior to the Earthquake as a nursing home aide, they decided to apply to medical school after coming into contact with evacuees from the exclusion zone, including the displaced residents of another nursing home in Namie, a town directly downwind of the Fukushima Daiichi Nuclear Power Plant. Participant 8 explains,, “As a fellow citizen of Fukushima Prefecture, [Participant 8] was always thinking about the…evacuation zone. The people in the evacuation zone, he want[ed] to do something for them, but he [had] a daily life, and work…so he [couldn’t] do enough for them.”Participant 2 was the most emphatic in describing the Earthquake’s role in her choice of career. She recounted, “Before the Earthquake happened, I didn’t know what I wanted to do in the future, I had no goal or dream. But then I’d seen so many friends die, and I went through that experience, and that made me want to save lives.” She went as far as to say, “I think that if I didn’t experience the accident, there’s no way I would have gone into medicine.”It’s important thing to have psychiatric mind, psychiatric comprehension skills. How to feel sympathy, how to open [patients’] minds, how to icebreak. I think, especially for child, like adolescent age…I think it’s kind of like 100% skill of a doctor. It’s essential to me. Psychiatry is important to every medical field…I strongly think so because I can emphasize on people’s depression and people’s negative minds. Especially in people who struggle in harder situations, like attacked by not only nature disaster but also violence. Maybe I can feel sympathy with them. I want to be a different doctor.The aftermath of the Great Earthquake affected not only her decision to pursue medicine, but also her priorities as a future healthcare practitioner. After the Earthquake, she and her friends experienced several years of flashbacks and panic episodes triggered by images and videos of the disaster. “But what saved us,” she said, “was school counselors, doctors, and mental health professionals. So I [want] to be a doctor who can help, not just medically, but mental health as well. Not just physical health, but mental health as well. That’s really important.” This emphasis on an integrated approach to medicine, particularly for children and adolescents, was shared by several of the participating students. Participant 1, who is not at present planning on going into psychiatry, expressed the importance of incorporating psychiatry into his future medical practice:Majority of my classmates, I think…are kind of like more concentrated on their medical things, more than me. They tend to avoid to talk with ordinary people [who aren’t in medicine]…Students totally forget about the normal mind because of the exposed by the medical things. But to have sympathy with “normal” people, maybe we have to still have a kind of normal mind about, like, everything. So I don’t think 100% medical mind is a good thing.Participant 1 describes most doctors as being “100% medical mind,” his shorthand for a scientific approach to the exclusion of the personal, but he describes himself as being “less medical than [his] classmates” at only 90% “medical mind,” a trait he attributes to living in Fukushima after the Earthquake. It is this trait that he hopes to use to become “a different doctor:”When I first wanted to be a doctor, I thought “It’s cool to become a surgeon, very cool.” But after the big earthquake, my feeling changed because a lot of people were affected by a lot of hardship. If I become a surgeon, I will help one person per day. But if I become a home doctor, I will treat many people.Participant 9 describes a similar mindset that they attribute to their experiences as a post-disaster recovery volunteer in Iwaki, the site of the Earthquake’s epicenter. Of those displaced by the Earthquake, Participant 9 states, “It’s very important to do healthcare for them. It’s also very important to chat with them, to talk with evacuees, about a lot of things – for example, their families, their hobbies, and so on – while doing treatment.” While he states the Tōhoku Earthquake did not influence his decision to pursue medicine, he says it did change his field of interest from surgery to family medicine . He explAll of the students with whom I spoke described a relationship between their medical field of interest and their experiences living in Fukushima following the Earthquake. While none of these students will have to decide until after they graduate from medical school, their current thoughts on specialties reveal the lasting impact of the Earthquake.Participant 7 is currently doing research in lifestyle medicine and preventative care, which she says “also includes what to do after a nuclear incident, so I guess I’m ending up studying life after the nuclear accident, because I think it’s important to know how to prevent risks of being sick after that.” As a specialty, she’s interested in “psychiatry, because you have to know how the disaster affects the mind.” Participant 9 is interested in family medicine for the same reason as his friend Participant 8. Participant 4 is considering pediatric psychiatry, inspired by loved ones who struggled with their mental health following the Earthquake – “I want them to know that they don’t need to be ashamed,” she declared.After the disaster, I saw sick people who couldn’t be treated properly, so I thought, you know, I want to provide proper care for sick people… My mother…had cancer. And the time is just when the earthquake happened. So when the earthquake happened, lots of doctors went away to other prefectures, so Fukushima Prefecture had little doctors, so...there were no people, she couldn’t get treatment… And later – she was gone. She died.Participant 3 described a similarly personal motivation for his field of interest. Due to space constraints, his was the only interview conducted in public, and, though nervous about his level of proficiency, he requested we switch our conversation to English for this portion of our discussion. His friends, none of whom spoke English, were sitting at another table on the other side of the room, and he glanced at them before sharing,This difficult experience was the impetus for Participant 3’s interest in a career in regenerative medicine. He explained, “Because of this disaster, we had less doctors, so patients couldn’t be treated properly. Like my mother. So the development of new technology would help patients treat themselves, by themselves, for themselves.”[The Earthquake] was the trigger of my studying radiation and [now] I want to know more about Fukushima. If there were no disaster, I would want to go to some big city, but there was a disaster, so now I want to help Fukushima. It was a great experience for me. But someone who had big damage by the disaster would think that it’s an imprudent point of view.Several participants also expressed a desire to stay in Fukushima to practice medicine once they graduate, out of a want to help heal their prefecture. While this is not unique to these participants – 56% of Fukushima Medical University’s last 5 graduating classes have stayed in the prefecture after graduation for their medical internships  – the stThis desire to help Fukushima heal extends beyond the literal. Many individuals I spoke with in Fukushima, both in the context of interview and out, lamented the fear that many outside of the prefecture feel towards Fukushima. As Participant 2 put it, “…People, especially overseas, around the world, they think that Fukushima is a very dangerous place to live, still, and that everyone who lives in Fukushima is sick. But that’s not true. Ideas like that, they should be fixed.”I have encountered this line of thinking myself, both in the United States and in Japan. In planning my visit to Fukushima, friends – including my classmates in medical school – asked me if it was safe to be there. A bartender in Osaka confided that she would never visit Fukushima, and that her friends from Korea have even asked her if visiting Tokyo is safe, given its “proximity” to Fukushima. A few weeks into my stay, in looking for the address of a shop in downtown Fukushima called Daisy Bell, I made the mistake of running a Google search for “Fukushima daisy.” Instead of the address I had hoped for, my search returned articles with titles such as “These ‘Mutant Daisies’ Near Japan’s Nuclear Disaster Site Are Freaking Everyone Out ,” flankeThese images, accompanied by the claim that the flowers shown had “nuclear birth defects,” were used in a 2016 study by the Stanford History Education Group to investigate the ability of Usonian high school and college students to evaluate the credibility of information that exists on the internet . AccordiThe Sun ran a story with the outrageously dramatic headline “Japan ‘covering up’ Fukushima nuclear danger-zone radiation levels and blackmailing evacuees to return to radiated areas swarming with radioactive pigs and monkeys , but I don’t know. I’m sure some people went to the government site to get information, but there was just so much information on the media, and this is where many people went for their information…People inside of Fukushima, they tried to find out what really happened, but people outside of Fukushima – once you go outside of Fukushima, they’re just not interested in seriously learning the truth, so they still go by biases about Fukushima. Once you go outside of Fukushima, a lot of people have those biased ideas, but I can’t blame them because they don’t get much information.The widespread view of Fukushima as dangerous, its food as radioactive, and its people as sick or even mutated is familiar to the interview participants. “Rumor itself,” Participant 8 said, “is a very evil thing, especially when there are a lot of vulnerable people in Fukushima.” Tabloid and gossip media, he argued, were equally “evil.” Participant 7 was in agreement. She observed,After the incident, people were so stupid sometimes, saying things like “People from Fukushima, they have runny noses all the time,” or “They don’t live that long,” or “You shouldn’t get married to women from Fukushima.” I heard all kinds of terrible, ignorant comments. As a teenager, I was so shocked to hear that, so that’s why I’m interested in medicine now, [because] I was so shocked to hear those rumors from people. Before I went to college, I went to a prep school outside of Fukushima, and students and teachers at the prep school, those people would tell me their biased ideas, like that we’re all sick or that we all have cancer, that we all have tumors. I was so shocked to hear this. Even the teachers said that to me…You know, when I heard that, I defended Fukushima, you know, saying “It’s not like that.” I kept telling them that, but after a while, I just started ignoring those people and their words. No matter what I was going to say, they would never change their minds. Those biased ideas were already in there already, so I just stopped correcting people like that.As an evacuee from Minamisōma, Participant 7 is passionate on the topic of misinformation on Fukushima. Since the Earthquake, she has heard these claims from peers and adults alike. She shared:Prejudice about Fukushima, I want to clear it…Any wrong information, such as the idea that Fukushima people cannot live because of the radiation – that’s not true, that’s not correct. Also, the idea that Fukushima produce is not edible, that’s not true…When the incident occurred, there was a lot of news going around which discriminated against Fukushima, and I don’t want that…There’s still a lot of prejudice about Fukushima going around, so by speaking out, I hope I can clear some of it up. This is important to me…That’s the reality, and I want people to know about it.However, many of the student participants felt that by sharing their experiences through these interviews with “foreign researchers,” they had the chance, as Participant 4 put it, “to tell everyone the right situation of Fukushima.” Participant 3 declared:I don’t want to keep in the past, in bad things. I want to go ahead, to forget about that disaster. But we have some impacts still from this disaster, so it is part of our, part of my life. It is part of myself, it is part of my identity. So to educate people is a good thing…I think that the information about this disaster, the information in foreign countries, it’s not exact as in Japan. So some foreign students come to Fukushima and study about it and go back to their home country and spread the exact information, it’s very important thing.Participant 6 also implored me to tell people in my “home country” about the reality of Fukushima’s situation. He sees the Earthquake as an essential time in his life and in the lives of other individuals from Fukushima, and even called the incident “our disaster” several times throughout the interview. Despite his wish for Fukushima to move forward, he feels this cannot be accomplished until the misconceptions have been cleared. He explained,He experienced this importance firsthand in 2018 as an exchange student in Belarus. Like its partnership with the Icahn School of Medicine at Mount Sinai, Fukushima Medical University has an “academic cooperation” with Belarusian State Medical University and Gomel Medical University, facilitated by Nagasaki University’s Atomic Bomb Disease Institute , 29. ParBefore we visited there, I thought Chernobyl is very terrible, destroyed, but it is not exact information. Chernobyl is not terrible condition. And my understanding changed after I visit there, so I have good image about Belarus and about Chernobyl. [For foreign students] to come to Fukushima and go back to their home country helps them, they can have exact information. They can have a similar experience as I had in Belarus.Though Participant 6’s curriculum focused on studying military medicine, shadowing thyroid surgeries, and practicing effective patient communication, what left the most lasting impression on him was how his concept of Chernobyl changed . In our He, like other participants, believes that international collaboration allows for increased opportunity to set the record straight when it comes to Fukushima.People should just know the right thing. I know the right thing because I live in Fukushima. I want to tell the world the right thing because I know the right thing…I [thought] I could tell them [the French students] the right things of Fukushima. The right things instead of harmful rumors about farmers. And I could show them the nice sightseeing places of Fukushima. And the delicious food of Fukushima.Participant 4 had a similar experience as Participant 6, though as a host rather than as a guest. In high school, she took part in a workshop in which Fukushima students partnered with French students as they toured through the prefecture in an effort to show what Participant 4 calls “the right thing” to the visiting students. She elaborated,That earthquake was big turning point of my life. And my high school teacher said that in the future, we are going to be asked about 3/11 and the accident at Daiichi, so we need to know the right situation of Fukushima, and we have duty, we need to tell people around Fukushima, around Japan. We have a duty. So I realized that I have to know the situation of Fukushima, the right situation of Fukushima. Do you know the bad rumors? The bad rumors about Fukushima? ...We, the people who live in Fukushima, have to tell [others] the right things about Fukushima, I think.Participant 4 explained that she felt she had, and still has, a responsibility as a Fukushima resident to represent her prefecture and to ensure that others have an accurate understanding of the place that she calls home. She expressed a wish to replace the damaging, inaccurate ideas I may have received with positive ones, and called this wish her “duty.” She said:However, not all those from Fukushima Prefecture are as clear as Participant 4 as to “the right things about Fukushima.” Participant 8 explained, “[We don’t] know which was rumor and which is truth. Even the people, the local people, [we don’t] know that.” He noted that the media’s platform has been enhanced by a continued lack of trust in the government. Of his fellow Fukushima residents, he said, “They can’t trust the government’s statement…They couldn’t think that they should believe all the information from the government.” When I asked Participants 8 and 9 where they believe the mistrust of the government comes from, they discussed in Japanese for a moment and laughed before offering, “The government said that the nuclear plant was safe. But it wasn’t.”Distrust of the government in Fukushima following the Earthquake has been well documented. The Washington Post describes “a culture of coverups and denials that contributed to the nuclear accident and continues to dog Japan’s efforts to restart its nuclear industry,” referring to the Tokyo Electric Power Company (TEPCO)’s attempt to deny that the nuclear disaster had occurred for months after the accident . SubsequHe has a strong feeling about caring for the people in his community. He has feelings for his community, but his community is not so big. He doesn’t want to change public opinion or something. He just wants to change his people. Everyone has to care for their own.Due to this local wariness of government information, Participant 8 expressed that unlike many of the other participants, his top priority was not to educate “not the whole world, or all Japanese people’s minds, but the people around him.” He was adamant on this point, insisting several times that he wants to enact change “in a small way” rather than on a large scale. His friend translated,My teacher treated me like an evacuee. He felt so sorry for the kids like me in his class. As a kid, moving to my grandparent’s house, moving to the city, I was excited, but the teacher didn’t understand how I was feeling. I think the teacher pitied me. He didn’t treat me like a regular student, and when I was 14, I just wanted to be like everybody else. Teenage life by itself is confusing, but with the accident affecting that time of my life, it was all much more complicated.For some students, the desire for individuals outside of the prefecture to know “the right situation of Fukushima” stemmed from, as Participant 3 phrased it, a want “to be treated like everybody, just like anyone. Not anything special, we’re just like anyone. I want to be treated the same. Equal.” Participant 7 remembers expressing this wish as well and described being treated differently than her classmates. As a high school student, she noticed that her teacher was projecting his idea of an evacuee on her rather than recognizing her true feelings. She recounts:In general, if you see the news, you know that people are kind of horrified about the lasting effects of the nuclear accident. But, you know, I have to tell them, those effects are not as bad as they think…A lot of people [are] living here, in Fukushima, and I don’t want to present that image of Fukushima, because I love it here.However, the motivating factor expressed most often by participants was their love of Fukushima. Participant 5’s to-the-point explanation summarizes the thoughts of many of the students. She shared,Participant 4 was of the same mind; she believes that many residents of Fukushima such as herself want to rectify the negative image of their prefecture “because they love Fukushima,” and repeated, “I want everyone to know the situation of Fukushima.” This was the sixth time in our conversation that she’d said this – she then laughed and said of her goal, “Always the same.”For the participating students at Fukushima Medical University, these interviews appeared to serve multiple purposes. The students were clearly motivated to speak with me by a passion to change the public opinion of their prefecture, and some hoped to practice their English, or else to learn more about North American medical education. But most students also said that they wished for their interviews to be healing, both to themselves and to potential future survivors of similar disasters. Participant 7 said that because of the Earthquake, “everyone knows Fukushima,” and that the prefecture is “famous now.” “I know it’s because of the nuclear accident,” she said, “but I think we can somehow use it for good,” for both her fellow Fukushima residents, and for the future. As Participant 1 said, the interview helped to “evaporate some negative feelings,” and he declared, “I think it was a good thing for me to be interviewed.”It’s good for me to share the emotions. And, um, actually – actually three years, four years after the earthquake, the kind of atmosphere changed. Soon after the Earthquake, everybody thought, “Okay, we have to share the information and share the emotions because of the struggle with the earthquake.” But…years after the earthquake, majority people thought that we mustn’t share the emotions, we mustn’t speak about the earthquake. The main atmosphere shows that we’re already finished with the earthquake. So I think it’s kind of taboo [to] reopen old wounds. And for me, it’s only my family to share my emotions about the earthquake, about evacuation…And I think that it was a precious experience and good experience for me, to share emotions, not only with my family and relatives but also with other people.Participant 1 felt that this was an ideal time to discuss his experiences. He said that while there was plenty of opportunity and encouragement to talk about his thoughts and feelings in the months following the Earthquake, that has since died down, and at present, he feels such activities to be inadmissible. Of the interview, he said:Participant 3 also felt that he no longer had occasions to discuss his feelings. His most memorable experience of the day of the Earthquake was leaving school in a bus and looking out the window to see “snow at the same time as thunder.” Of that sight, he said, “That was something I will never forget.” He went on, “I was with my classmates when this happened, so once and awhile, we [used to] talk about it. The five years after the incident, we’d meet up and talk about it. But not anymore.”I was so afraid of doing an interview or a survey before, when I was young. I was afraid to remember my experiences, the bad things that happened. I was too young to think about what happened. I wasn’t ready to think seriously about it. But now I am old enough, and I feel I can tell you…Right now, I don’t feel anything negative [like I used to feel when] talking about what happened in my past. Actually, I have been talking to my friend who also went through the same experience – we often talk about what happened in our pasts. So right now, I feel I can talk about it more, so I think that means I’m done with it.Participant 7 agreed that she is now in a position to benefit from an interview for different reasons than Participants 1 and 3. She explained that she decided to volunteer for an interview because “I think it’s a good time for me to look back at my past, at what happened during 3/11.” Though in our conversation she recounted difficult memories, her tone was determined, even hopeful. She explained:Like Participants 1 and 3, she found that talking about her experiences was a crucial part of her recovery.[Participant 8] thinks that he feels like he was healed by talking about his experience…He feels very ashamed that he almost forgot about his experience with the disaster, and this is a very good opportunity to remember about the experience, what it was like…These [interviews] give us the chance to think about [the Earthquake]. Not forgetting is very important, I think. It’s not a good experience, but something good can come because of it.Participant 8 also found discussion helpful, calling the interview “a rare situation” in that it offered him a chance to reflect while moving forward. He and Participant 9 discussed in Japanese for a moment before Participant 9 relayed, “These interviews made me rethink about the disaster. Reflect. Think back. Remember my situation and know what other people have to say, and combine these things to give me new ideas and so on.” Participant 8 agreed, and his friend translated the following:This “something” that he and his fellow interviewees hope will come of their experiences following the Earthquake is a healing in two directions, internally and externally. The internal healing appears to come from the interview itself, while the external healing will come from what they hope will be done with their words. As Participants 8 and 9’s friend translated, “They don’t want the memories of the tragedy to decay. They want people to remember the memories of tragedy…And they want to continue the memory, for the future.”Participants 8, 9, and 1 are all members of the University’s student group Fukushima WILL, a club, Participant 1 defined via message, devoted to studying disasters and related issues as well as “radiation/radiation education in Fukushima.” Though capitalized, the name is not an acronym; Participant 1 says that the emphatic “WILL” refers to the “strong mind” of the organization, their determination to keep fresh “the situation [of the Earthquake], people’s mind, [the] difficulties.” Their hope is that by helping to spread the stories of what the residents of Fukushima went through, survivors of future disasters won’t feel as lost as they did.…The Fukushima nuclear incident was worldwide news, it’s an experience that’s already making history, so I think it’s important for people to study what’s happened and [what is currently] happening here so they can use that experience in those difficult conditions so next time, when a similar thing happens in another country, they can use our resources. I think it’s helpful for the future. This was one of the biggest nuclear disasters in the world, in history. And I hope nothing like that happens ever again, but in case it does, I’d like to let people know what we did.This goal is not unique to members of Fukushima WILL; many participants described a hope that their words would improve conditions for survivors of future disasters. As Participant 7 said, “I hope this kind of disaster never happens again, but in case it does, I want to let everyone know, as a good example, what happened here.” Participant 8 expressed a nearly identical sentiment, saying “There are a lot of nuclear power plants around the world, so accidents will happen again in other countries, so people will need to have the right things to treat those accidents. People from Fukushima had a very interesting [unique] experience, so these things should be taken to other people.” Participant 5 also highlighted the uniqueness of the experiences of those after the Earthquake. “My life changed after the accident, so I want to make sure that people know what’s going on, what I went through,” she said. “I’d like to share my experience because…you don’t see that kind of experience often. So I’d like to share as much as possible what we went through.” She elaborated:I wanted people who never had an experience like this to know about the mental health issues that me and my friends had due to the earthquake, the tsunami, and the power plant disaster. It shouldn’t be forgotten, and I don’t want people to forget…I want them to know, other people in the world, I want them to know what we experienced…I want people to understand, when there’s a nuclear accident, an atomic power accident, with a natural disaster like an earthquake, that the damage that causes to people’s mental health, that lasts many, many years. It needs to be dealt with.In particular, Participant 2 hopes that by sharing his experiences, he can offer more insight into the psychological effects of such a disaster. In addition to his want to “help Fukushima get better, help people get better,” he stressed the need for increased attention to mental health in the aftermath of similar events as a reason for his participation in the interview. He explained,I may not do big things, achieve big things, in my life. But if I can tell about [my experiences] to other people, maybe they [those people] will help [other] people with hardships. These people who have had hardships, they might themselves have a high achievement, and that will give us the legacy of their achievement. So, knowing is very important, and conveying my feelings and my knowledge is very important…And people who are from other countries and other prefectures, if I give them some of the truth, maybe they will do things to help the refugees. They can do good things with that truth.The sharing of these post-disaster stories does more than provide an opportunity for healing, or memorialize history for the future, or “lead to improved medicine,” as Participant 9 put it. The experiences of these participants are deeply personal, a part of these students’ lives. Therefore, to tell their stories is to create their legacies. In a quietly determined voice, Participant 8 – once a teacher, now one of the oldest students in his first-year class – told me and his friends why he decided to talk about what he went through:At present, Fukushima is a prefecture of dualities – at once, it is both injured and recovering; mourning and moving forward; unified with the government, and distrustful of it. The GEJE has a similarly complex significance for this study’s interview participants. For most, if not all of these students, the event was career-defining – it opened doors not only to areas of study within the field of medicine, but for some, to medicine as the field of pursuit. At the same time, the lasting, burdening effects of the Earthquake endure: trauma, loss of life and destruction of property, stigma. And yet, even these consequences act as galvanizing agents. These students stand eager, motivated, and poised to make change.In this current study, through interviews and inductive thematic analysis, we explored the individual stories of medical students at FMU who lived in Fukushima during the time of the Great East Japan Earthquake. To our knowledge, this is one of the first studies to not only use a qualitative approach to detail common themes in the personal narratives of evacuees of the Earthquake, but also to provide a space wherein evacuees can control the narrative of the GEJE in academic literature. This study further colors our understanding of the disaster’s impact on the behavioral, societal, cultural, and political aspects of the lives of residents of Fukushima.Our study has several strengths. The qualitative and ethnographic framework adopted for this study allows for a complex and nuanced investigation of the impact of a large-scale disaster. This approach lent itself well to broadening comparative, contextual, and cross-cultural perspectives on the GEJE. Furthermore, the focus on personal narratives and the common threads throughout these narratives adds a humanistic layer to current academic research on the topic. By placing these narratives at the forefront, participants were empowered to contribute to local and worldwide perceptions of Fukushima following the Earthquake.There are a few limitations to our study. Firstly, our study population exclusively included medical students, a group not necessarily representative of all those affected by the Earthquake. The themes discovered in this study may not be generalizable to the entirety of the evacuee population. Secondly, as with most ethnographic studies, the richness of the data depends on both the rapport of the researcher with the subjects and the openness and honesty of the subjects. Though the researcher (AS) felt that good rapport was established through close contact with participants and their friends prior to, during, and following the interview, this is difficult to fully ascertain. Interviews were conducted in private and anonymity was stressed at the beginning of the encounters to increase the likelihood of participants being open and honest.More chances must be given to residents of Fukushima Prefecture, both current and displaced, to provide insight into their experiences following the Great East Japan Earthquake and the associated tsunami and nuclear incident. Further ethnographic research should be conducted to expand upon the themes approached in this research, and to explore the wealth of other stories not touched here. Additionally, longitudinal studies of medical students from Fukushima Prefecture would permit more rigorous data on the impact of the Earthquake on career path. Finally, cross-cultural studies between survivors of nuclear accidents would allow for not only the healing described by the participants, but for the chance to pass on a unique expertise for potential future survivors. As the interview participants noted themselves, these stories are their legacy.