Pandemic Perceptions of Future Health Professionals: An Examination of Turkish Nursing Students’ Metaphorical Perceptions and Cognitive Structures of Monkeypox

Abstract

Objectives

This study aims to explore the metaphorical perceptions and cognitive structures of nursing students regarding Monkeypox.

Methods

A qualitative study based on metaphor analysis was conducted with 40 nursing students enrolled at a public university in northern Türkiye. Data were collected between December 2024 and January 2025 using a Sociodemographic Information Form and the Monkeypox Data Collection Form, which incorporated two techniques: a metaphor elicitation technique using the prompt “Monkeypox is like… because…” and a drawing‐writing technique. Content analysis and document analysis were employed to analyze the data. Inter‐rater reliability was assessed using Miles and Huberman's formula (88%) and Cohen's kappa coefficient (0.88). The study was designed and reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

Results

A total of 12 metaphors were identified through the writing technique and grouped under two categories: characteristics of Monkeypox (9 metaphors; e.g., wart, COVID‐19, and chickenpox) and effects of Monkeypox (3 metaphors; e.g., lockdown, negative mental health impact). Three metaphors were identified through the drawing technique and categorized under considerations for appearance (bubbles, redness, and monkey). technique. With the writing technique, they were analyzed under two categories: features and effects.

Conclusion

Nursing students perceived Monkeypox as a threatening and destructive phenomenon, reflecting negative cognitive schemas shaped by limited knowledge and uncertainty. These findings highlight the need for nursing education programs that address both cognitive and psychosocial dimensions of emerging infectious disease preparedness.

1. Introduction

Monkeypox virus (MPXV) belongs to the genus Orthopoxvirus in the Poxviridae family and is the causative agent of Monkeypox. MPXV has two distinct evolutionary strains in Central Africa (Congo Basin) and West Africa (Girometti et al. 2022; Heskin et al. 2022). Orthopox viruses include viruses of great importance for human and veterinary medicine, including Camelpox, Cowpox, Variola, and Vaccinia virus, which is both a vaccinia virus and the cause of outbreaks of bovine pox (bovine vaccinia [BV]) in South America (Girometti et al. 2022; Heskin et al. 2022; Bunge et al. 2022).

Monkeypox's most common clinical manifestations in humans are nonspecific symptoms such as fever, chills, malaise, head and body aches, lymphadenopathy, and characteristic skin rashes that crust over and heal into papules and vesicles. In the differential diagnosis, diseases caused by chickenpox, herpes simplex virus, smallpox, and other pox viruses (tanapox, orf) should be considered (Petersen et al. 2019). Although the clinical symptoms of Monkeypox are generally milder and self‐limiting than smallpox, it can lead to severe clinical pictures that may be accompanied by several important medical complications (Yıldız and Akçalı 2022). In pandemic processes, not only sick individuals/society but also healthcare professionals, especially nurses, are physically and psychosocially affected by the process due to being a member of the society and working under serious risk on the front line (Maben and Bridges 2020). Previous studies have also shown that nurses’ mental health is negatively affected in high‐pressure situations such as past disasters and pandemics, as close witnesses of the process (Cheung et al. 2024; Liang et al. 2022). Reemerging infectious diseases such as Monkeypox can negatively affect nursing students' self‐esteem, thereby negatively impacting their perception of professional competence and increasing their perceived stress levels, which can challenge their psychological resilience (Bayrak and Emirza 2025; Yıldız and Akçalı, 2022; Liang et al. 2022).

Previous studies have shown that nursing students’ knowledge, attitudes, and perceptions regarding global pandemics and infectious diseases significantly affect their professional roles and psychosocial well‐being. Studies conducted during the COVID‐19 pandemic have shown that students have experienced infection fears, feelings of uncertainty, and doubts about their professional competence. Similarly, it has been suggested that reemerging zoonotic diseases such as Monkeypox may trigger anxiety, disease stigmatization, and concerns about future professional practice among nursing students (Amin et al. 2025). The literature shows that such diseases reshape students’ approach to public health crises, crisis management skills, and perceptions of infection control measures (Ediz and Uzun 2025; Akpınar and Çoban 2022; Amin et al. 2025). Furthermore, it is emphasized that this situation may have long‐term effects on students’ professional identity development and health literacy.

This study examines nursing students' perceptions of new infectious diseases, such as Monkeypox, which have become a global concern in the wake of the COVID‐19 pandemic, shedding light on the level of preparedness and awareness of healthcare professionals during times of crisis. Studies evaluating Monkeypox's perceptual and cognitive effects on healthcare workers through metaphors are extremely limited in the literature (Ediz and Uzun 2025; Apaydın‐Cırık et al. 2023; Swed et al. 2023). In this regard, the study produces original findings that will contribute to developing nursing education curricula, strengthening crisis management strategies, and enhancing cultural sensitivity in health services by revealing how nursing students understand infectious diseases. Additionally, analyzing metaphorical perceptions offers an innovative approach to deeply understanding nursing students' attitudes and behaviors toward complex health threats. In this context, this study examines the metaphorical perceptions and cognitive structures of nursing students regarding Monkeypox.

In line with this purpose, answers to the following sub‐objectives were sought;

1. What are the metaphorical perceptions of nursing students toward the Monkeypox?

2. What are the cognitive perceptions of nursing students, toward Monkeypox?

2. METHOD

Throughout this study, the authors will follow the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al. 2007) and report accordingly (Appendix 1).

2.1. Study Design

The research was conducted as a qualitative study based on metaphor analysis. The data for the study were collected between December 2024 and January 2025. In this study, using metaphor analysis, one of the qualitative research methods, the metaphorical perceptions and cognitive structures of nursing students toward Monkeypox were examined (Creswell and Poth 2016). Metaphor is a perception process and can be defined as the perceptions that a concept or event evokes in an individual (Kaplan and Kızdırıcı 2017).

2.2. Research Team and Reflexivity

Research team members included two faculty members from nursing schools and two researchers with doctoral degrees in psychiatric nursing. Additionally, one team member is employed as a paramedic. Two researchers have received training in qualitative research methodologies.

The research team adopted various strategies to prevent their own biases and assumptions from unnecessarily influencing the data collection, analysis, and interpretation processes. First, the researchers systematically reviewed their social, cultural, and professional positions and kept reflexive journals to identify their possible effects (Berger 2015). These journals enabled researchers to question their preconceptions that could influence their interpretations, particularly in analyzing metaphors. Additionally, the research team met regularly to discuss themes that emerged in the data analysis and reached consensus to minimize interpretive differences (Malterud 2001).

The researchers used their positionality (e.g., expertise in nursing education and experience with healthcare professionals) as a strength. This provided an advantage in contextualizing students’ metaphorical expressions and developing culturally nuanced interpretations (Holmes 2020). However, in addition to this advantage, researchers used triangulation to reduce potential confirmation bias; the reliability of the findings was enhanced by comparing the independent analyses of multiple researchers (Creswell and Poth 2016). This reflexive approach strengthened the research's methodological rigor and ethical responsibility. The research team worked with the awareness that their positionality was not only a potential source of bias but also a factor contributing to the in‐depth and meaningful interpretation of the data.

2.3. Sample Group

The study group was determined using criterion sampling, a type of purposive sampling method. This approach involves selecting individuals, events, objects, or situations that meet predefined criteria relevant to the research problem (Altunay et al.; Başkaya and Demir). In addition to criterion sampling, a snowball sampling strategy was also employed to reach potential participants; initial participants were asked to refer other nursing students who met the inclusion criteria, enabling access to a broader and more diverse sample across multiple recruitment pathways rather than being limited to a single institutional setting. The data collection process was completed when saturation was reached. To achieve data saturation, the data obtained from participants were continuously analyzed, and it was observed that the information obtained from new interviews did not repeat previous data and that no new themes or concepts emerged. The researchers ended the data collection process when they determined that each new participant's contribution did not add meaningfully to the previous findings. This process was based on determining saturation through the richness of the data and recurring patterns, as recommended in qualitative research (Guest et al.).

The inclusion criteria for the study were: (a) being enrolled as a nursing student, (b) having the ability and willingness to communicate, and (c) providing consent to participate. The exclusion criteria included: (a) the presence of any language, speech, or hearing difficulties that could hinder communication, and (b) refusal to participate in the study.

2.4. Data Collection Tools

The data were collected using the “Sociodemographic Information Form” and the “Data Collection Form on Monkeypox in Nursing Students”.

The Sociodemographic Information Form consists of three questions about age, gender, and class to collect participants’ sociodemographic data.

Data Collection Form on Monkeypox in Nursing Students: This form consists of two stages and two questions in line with the literature (Apaydın‐Cırık et al. 2023; Holmes 2020; Creswell and Poth 2016).

1. Metaphor Technique: Data Collection Form on Monkeypox in Nursing Students is a tool that helps to generate questions about the determined topics and areas. This method covers all dimensions related to the research problem (Patton 2002; Yıldırım and Şimşek 2013). Data collection interviews are one of the most preferred data collection tools in metaphor analysis methods (Apaydın‐Cırık et al. 2023). It is stated that it is used in studies based on metaphor analysis (Ekici and Akdeniz 2018; Apaydın‐Cırık et al. 2023). The researchers created the data collection form in line with the literature on nursing students’ perceptions of Monkeypox (Ekici and Akdeniz 2018; Apaydın‐Cırık et al. 2023). The form includes a metaphorical question. In order to determine which metaphor the participants associated with the concept of “nursing students' perceptions of monkeypox”, they were asked to fill in the section starting with the words “Monkeypox is like… because…”

2. Drawing‐Writing Technique: In the second part of the data collection tool, data were collected using the drawing‐writing technique. Drawing‐writing technique is beneficial in that it aims to activate the visual structures related to thoughts, meanings, attitudes, images, and cognitive structures that make the concepts in the minds of individuals passive and not used, and to obtain them in the form of personalized and scientifically high‐value data in the mental storage (Holmes 2020; Creswell and Poth 2016). In this respect, in this study, nursing students were asked, “What are your thoughts about the monkeypox? Explain by drawing (picture‐figure). What is your opinion about the monkeypox? Express your ideas about this subject freely and without limitation.” and they were asked to express their opinions in detail. It was stated that the data obtained would be used in a scientific study, and no personal information would be given.

2.5. Data Analysis

Document analysis and content analysis were used to evaluate the metaphors created by nursing students for Monkeypox. Document analysis, one of the innovative data collection methods, facilitates data transfer and accelerates analysis (Creswell and Poth 2016; Kıral 2020; Özsoy 2021). Content analysis is based on grouping relevant information into predetermined themes and concepts and interpreting them in an understandable way (Yıldırım and Şimşek 2013). Content analysis is carried out in five stages: naming, classifying, categorizing, ensuring validity and reliability, and quantifying the data (Creswell and Poth 2016; Özsoy 2021).

During the naming phase, the metaphors that nursing students used to describe Monkeypox were identified and listed. Forms lacking any metaphorical expression were excluded from the analysis. In the classification phase, the metaphors were examined based on their similarities through researcher discussions. At this point, each researcher independently reviewed and interpreted the meaning of each metaphor. The analysis focused on the subject of the metaphor, its source, and the connection between them, leading to the creation of a comprehensive metaphor list. In the subsequent categorization phase, six distinct categories were developed by grouping similar metaphors based on this list. To ensure the study's validity and reliability, both the Cohen's kappa coefficient and a reliability calculation formula were employed (Kvålseth 1989).

2.6. Validity and Reliability

The two most important criteria for ensuring the validity of metaphor studies are analyzing the data in detail and categorizing each metaphor appropriately (Creswell and Poth 2016; Yıldırım and Şimşek 2013; Apaydın‐Cırık et al. 2023). This study utilized both written and visual (drawing) techniques to present metaphors, following a detailed data analysis process. To ensure the reliability of the findings, the initial stage involved creating a list of identified metaphors and their corresponding categories, which was then submitted to two expert reviewers. In the next phase, numerical codes were assigned to each category, and the experts were asked to indicate the number of the category they believed each metaphor fit into. In the third phase, the categorizations made by the experts were compared with those of the research team. Finally, in the fourth stage, agreements and disagreements between expert and researcher classifications were identified; the metaphors lacking consensus were re‐evaluated through discussion, and the final category assignments were determined collaboratively. In the fifth stage, the reliability of the research was determined using the reliability formula (Reliability = consensus/agreement + disagreement X 100) according to Miles and Huberman (1999).

An agreement rate of 83% or higher between expert and researcher evaluations was considered an indicator of the study's reliability. According to Miles and Huberman (1999), a reliability score above 70% is generally accepted as sufficient for research credibility. In this study, the reliability rate was calculated as 88% using the formula 15/(13 + 4) × 100, indicating a satisfactory level of reliability. To ensure the metaphors were accurately represented within the appropriate categories, input was also obtained from two academic instructors. Furthermore, Cohen's kappa coefficient used to measure inter‐rater agreement was found to be 0.88, reflecting a high degree of consistency among raters. Additionally, two experts in the fields of mental health and nursing reviewed the data collection forms to assess their validity and reliability. In total, four experts contributed to the validation and reliability assessment of the study.

2.7. Ethical Consideration

Regarding ethical issues, the study was approved by the Scientific Research and Publication Ethics Committee of Gümüşhane University Rectorate (E‐95674917‐108.99‐291189; Date: 25.10.2024). Before conducting the interviews, informed consent was secured from all participants. The research was carried out in accordance with the principles outlined in the Declaration of Helsinki and adhered to the ethical guidelines established by the National Research Committee.

3. Results

Thirty‐three of the nursing students participating in the study were female. The average age of the participants was 24.11 ± 3.05.

The demographic characteristics of the study participants are summarized in Table 1.

TABLE 1.

Characteristics of participants.

Participant number	Age	Gender	Classroom
P1	25	Female	4
P2	22	Male	2
P3	23	Female	2
P4	19	Female	1
P5	22	Female	2
P6	20	Female	1
P7	27	Female	3
P8	25	Female	3
P9	21	Male	2
P10	22	Female	1
P11	28	Female	4
P12	25	Female	2
P13	22	Male	2
P14	24	Female	1
P15	23	Female	2
P16	30	Female	1
P17	26	Female	3
P18	25	Female	3
P19	20	Male	2
P20	21	Female	1
P21	28	Female	4
P22	28	Female	2
P23	25	Female	2
P24	22	Male	1
P25	24	Female	2
P26	23	Female	1
P27	30	Female	3
P28	26	Female	3
P29	25	Female	2
P30	20	Male	1
P31	21	Female	2
P32	28	Female	2
P33	30	Female	2
P34	26	Female	1
P35	25	Female	2
P36	20	Female	1
P37	21	Male	3
P38	28	Female	3
P39	24	Female	2
P40	23	Female	2

Twelve metaphors regarding Monkeypox were identified through the writing technique of nursing students. These metaphors were grouped under two categories: characteristics of Monkeypox and effects of Monkeypox (Table 2).

TABLE 2.

Metaphor categories created by nursing students, who are future health professionals, about the Monkeypox.

Categories	Metaphors	Frequency	Examples of participant quotes
A. Characteristics of Monkeypox	A.1. Wart	8	P5: “It is like a wart. Because it spreads throughout the body like a wart.”
	A.2. COVID‐19	7	P11: “It is like COVID‐19. Because it causes fever and fatigue, and is also contagious.”
	A.3. Chickenpox	5	P25; “It is like chicken pox. Because it gives similar symptoms.”
	A.4. Rabies	3	P3: “It is like rabies. Because it is transmitted from animals.”
	A.5. Measles	3	P4: “It is like measles. Because it causes unwanted red blisters on the body and is also fatal.”
	A.6. Mushroom	1	P17; “It is like a fungus. Because it infects every part of the body.”
	A.7. Infection	1	P40; "It is like an infection because it spreads throughout the body and weakens its immunity.
	A.8. Acne	1	P12; “It is like a pimple because it shows symptoms similar to pimples on the body….It bothers people and causes a bad appearance…”
	A.9. Beads	1	P19; “It is like a bead because bead‐like images appear on the body… Bubbles appear on the human”
Total	9 Metaphors	30
B. Effects of Monkeypox	B.1. Lockdown and pandemic	4	P14: “Monkeypox is like quarantine, but you can escape by staying at home or indoors.”
	B.2. Negative impact on mental health	4	P33; “The Monkeypox ends daily life. It negatively affects the mental health of individuals.”
	B.3. Causing deaths	3	P10: “Monkeypox causes deaths. It makes you unhappy.”
Total	3 metaphors	11
General total	12 metaphors	41

Note: Number of participants (n = 40), total metaphors = 12 metaphors; total frequency = 41.

Three metaphors were identified through the drawing technique regarding Monkeypox among nursing students. These metaphors were grouped under one category: characteristics of Monkeypox (Table 3).

TABLE 3.

Metaphor categories created by nursing students through the drawing technique for Monkeypox.

Categories	Metaphors	Frequency	Sample Illustrations from participant quotes
A. Considerations for appearance	A.1. Bubbls	16	P19
	A.2. Redness	13	P11
	A.3. Monkey	12	P25
Total	3 metaphors	41

Note: Number of participants (n = 40), total metaphors = three metaphors; total frequency = 41 in the drawing technique for the metaphorical perceptions of nursing students toward Monkeypox.

4. Discussion

Metaphors enable complex concepts to be interpreted in a new light by associating a familiar concept with another familiar concept (Steele et al. 2022). COVID‐19 and Monkeypox, like other infectious diseases, are not only contagious but also biological disasters with severe mental health effects on suspected cases under quarantine, confirmed cases and their families, healthcare workers, and the entire community (Kılınç 2024). Therefore, this study examines the metaphorical perceptions and cognitive structures of nursing students regarding Monkeypox. The findings are discussed under two headings.

4.1. Metaphors Produced by Nursing Students Through the Writing Technique

This study found that the metaphors reflecting nursing students' perceptions regarding monkeypox disease were largely shaped around negative themes. Students' descriptions of the disease as a threatening, frightening, or destructive phenomenon may be related to their lack of knowledge and uncertainties. Indeed, Peng et al. (2023) demonstrated that healthcare workers' possession of adequate knowledge significantly influences their development of positive attitudes toward infectious diseases. Similarly, Hasan et al. (2023) emphasized that healthcare workers with more knowledge about Monkeypox are more likely to exhibit positive attitudes, which could enhance the effectiveness of disease prevention and control efforts.

The study findings also indicate that some participants have misconceptions about Monkeypox's prevalence, etiology, and treatment approaches, revealing gaps in nursing students' knowledge regarding distinguishing between bacterial and viral diseases and identifying appropriate management strategies. Berdida (2023) and Wang et al. (2024) have emphasized that understanding the clinical manifestations, modes of transmission, incubation periods, and prevention strategies of viral infections is of critical importance for healthcare workers.

In this context, it is recommended that nursing education programs adopt a holistic approach that not only transfers technical knowledge but also develops students' critical thinking, problem‐solving, and emotional resilience skills in the face of epidemics. Psychiatric nurses, in particular, can play an important role in supporting students and colleagues in coping with anxiety, fear, and prejudice during future epidemics. Psychiatric nurses can contribute to transforming nursing students' negative attitudes toward infectious diseases, gaining psychosocial resilience, and developing empathy‐based care approaches through education and counseling. Qureshi et al. (2022) emphasize that continuous education on emerging and reemerging diseases increases nurses' knowledge levels and makes them feel more competent and confident in dealing with new infections.

In conclusion, the negativity in nursing students' metaphorical perceptions reflects their lack of knowledge and the psychological burden created by epidemics. This situation points to the need for educators to adopt an educational approach that addresses students' cognitive and emotional needs. Additionally, the role of psychiatric nurses is critical in this context, as they serve as a key source of support in helping nursing students develop psychosocial resilience during times of crisis.

4.2. Metaphors Expressed by Nursing Students Through the Drawing Technique

The metaphors illustrated through the drawing technique by nursing students reveal a profound sense of anxiety and uncertainty surrounding Monkeypox. These visual representations reflect students' perceptions of Monkeypox as a biomedical phenomenon and a psychosocial stressor with implications for individual and global health. As Monkeypox continues to pose challenges to health systems worldwide, it underscores the necessity of integrating up‐to‐date knowledge, clinical experience, and evidence‐based practices into nursing education. This integration is particularly crucial given the diagnostic complexity of Monkeypox, which shares overlapping symptomatology with diseases such as smallpox, chickenpox, and other poxvirus infections (Ferdous et al. 2023; Peng et al. 2023).

Accurate differentiation of Monkeypox from similar infectious diseases requires nurses and nursing students to develop advanced assessment skills. The clinical manifestations, including skin lesions, fever, and systemic symptoms, demand a meticulous and systematic evaluation. As the primary point of contact with patients, nurses are in a critical position to obtain comprehensive patient histories, assess clinical signs, and communicate essential information to the healthcare team—actions that are vital for ensuring timely and accurate diagnosis (Ferdous et al. 2023; Kumar et al. 2022). Furthermore, the ongoing monkeypox outbreaks have exerted considerable psychological strain on the general population and healthcare providers (Kumar et al. 2022). Evidence from a study among university students in China indicated that approximately half of the participants reported greater anxiety about Monkeypox compared to COVID‐19, particularly following the World Health Organization's international alert (Wang et al. 2024). Similar findings by Peng et al. (2023) and Swed et al. (2023) confirmed that many healthcare students and workers experienced heightened concern about Monkeypox as a potential new pandemic threat.

In this context, nursing education should prioritize clinical and technical competencies and focus on developing students' psychological resilience and coping strategies. Psychiatric nurses can play a pivotal role in this transformation by providing psychoeducation, emotional support, and counseling to nursing students. Their expertise in mental health is essential for addressing the fear, anxiety, and stigma associated with emerging infectious diseases, which, if unaddressed, could hinder students' learning experiences and their future effectiveness as healthcare providers. Additionally, incorporating simulation‐based training and hands‐on workshops on monkeypox management into nursing curricula could enhance students' knowledge, skills, and attitudes, preparing them to respond confidently and empathetically to similar public health crises. Such interventions would equip students with technical proficiency and empower them to maintain their psychological well‐being in high‐stress clinical environments.

Ultimately, the anxiety reflected in nursing students’ drawings highlights the dual challenge of addressing both cognitive and emotional dimensions of learning in the face of emerging infectious threats. Educational strategies that integrate clinical expertise with psychosocial support, facilitated by interdisciplinary collaboration including psychiatric nurses, are essential for cultivating a resilient and well‐prepared future nursing workforce.

5. Conclusion

This study revealed that nursing students expressed significant concern regarding Monkeypox in terms of its potential impact on their personal health and the broader global community. The metaphorical expressions analyzed in this research suggest that the students perceived Monkeypox as a threatening and destructive force, reflecting negative cognitive schemas shaped by uncertainty, limited knowledge, and heightened sensitivity to emerging infectious diseases. Such findings underscore nursing students' psychological and educational challenges when confronted with novel health crises. These challenges are particularly critical given their future roles on the frontlines of healthcare, where they will be required to provide both physical care and psychosocial support during outbreaks.

To address these concerns, future research should adopt a multidimensional approach to explore nursing students' knowledge, attitudes, anxiety levels, and perceived mental health needs regarding Monkeypox and similar emerging infectious diseases across diverse educational settings. Such investigations would provide valuable insights into the factors influencing students' preparedness and resilience. Additionally, there is a need to design and implement targeted interventions within nursing curricula that foster technical competencies, psychological readiness, and emotional coping strategies. Incorporating the expertise of psychiatric nurses into these initiatives could play a pivotal role in supporting nursing students' mental health, reducing anxiety, and promoting positive attitudes toward infectious disease management. Strengthening nursing students' cognitive and emotional capacities will contribute to developing a more resilient and responsive future healthcare workforce.

6. Limitations

This study has several limitations that should be acknowledged. First, the research was conducted with nursing students from a specific cultural and educational context in Türkiye, which may limit the generalizability of the findings to nursing students in other countries or healthcare systems. Second, as the data were collected through self‐reported metaphorical expressions, there is a possibility of response bias, with participants potentially providing socially desirable or emotionally charged responses influenced by their perceptions of infectious diseases. Additionally, the study's cross‐sectional design does not allow for assessment of changes in students' perceptions and cognitive schemas over time or in response to educational interventions. Future studies employing longitudinal designs and involving diverse populations across different educational and cultural settings are recommended to validate and expand upon these findings. Furthermore, integrating mixed‐methods approaches could provide a more comprehensive understanding of nursing students' knowledge, attitudes, and emotional responses toward emerging infectious diseases like Monkeypox.

Author Contributions

Sevda Uzun: conceptualization, methodology, data analysis, writing – original draft, review and editing. Elif Güzide Emirza: conceptualization, methodology, data analysis, writing – original draft, review and editing. Medine Şenses: conceptualization, methodology, collect data, writing – original draft, review and editing. All authors meet the criteria for authorship, have approved the final article and that all those entitled to authorship are listed as authors.

Conflicts of Interest

The authors declare no conflicts of interest.

Appendix 1. Combined criteria for reporting qualitative research (COREQ).

1.1.

Area 1: Research team and reflexivity

Personal characteristics

Number	Item	Guiding questions	Explanations
1	Interviewer/facilitator	Which author/authors conducted the interview or focus group?	Third author was conducted the interview.
2	Credentials	What were the credentials of the researcher, e.g., PhD, MD	Two authors are PhD, and one is a paramedic with a bachelor's degree.
3	Profession	What was their occupation at the time of the study?	Two researchers are academics Third researcher is a paramedic
4	Gender	Was the researcher a man or a woman?	Three researchers are women
5	Experience and training	What experience or training did the researcher have?	Two authors have taken qualitative courses have experience in qualitative research and have published qualitative studies in international journals.
Relationship with participants
6	Relationship status	Was a relationship established before the training started?	No.
7	Interviewer's participant knowledge	What did participants know about the researcher, e.g., personal goals, reasons for doing research	Participants were informed that data were collected by a paramedic researcher and that the study was conducted by academics specializing in psychiatric nursing; no personal information beyond the researchers' professional roles was disclosed to participants.
8	Interviewer characteristics	What characteristics were reported about the interviewer/facilitator, e.g., bias, assumptions, motives, and interests in the research?	At the beginning of the interview, participants were informed about the purpose and objectives of the study.
Area 2: Study design
Theoretical framework
9	Methodological orientation and Theory	Which methodological orientation was specified to support the study? e.g., discourse analysis, ethnography, phenomenology, content analysis	This study employed a qualitative design using metaphor analysis to explore nursing students' perceptions and cognitive structures regarding Monkeypox.
Participant selection
10	Sampling	How were participants selected? e.g., purposeful, convenience, consecutive, snowball	This study employed criterion sampling as a purposive sampling strategy, while snowball sampling was additionally utilized to reach participants who would otherwise be difficult to access.
11	Approach method	How were participants approached, e.g., face‐to‐face, telephone, mail	Participants were approached face‐to‐face. The timing of the data collection sessions was determined by the participants who voluntarily agreed to participate in the study.
12	Sample size	How many participants were there in the study?	The study was continued until data saturation was reached and was completed with 40 participants.
13	Disagree	How many people refused to participate or dropped out? Reasons?	−
Setting
14	The setting of data collection	Where was the data collected? e.g., home, clinic, workplace	Detailed information was provided in the data collection section of the study.
15	Presence of non‐participants	Was there anyone else present apart from the participants and the researchers?	There was no observers.
16	Description of the sample	What are the important characteristics of the sample, e.g., demographic data, history	Individuals who agree to participate in the study were included in the study. A key feature of the sample is that it consists of nursing students.
Data collection
17	Interview guide	Were questions, prompts and guidelines provided by the authors? Has it been pilot tested?	Detailed information was provided in the Methods section.
18	Repeat interviews	Have there been re‐interviews? If yes, how many?	No.
19	Audio/visual recording	Was audio or visual recording used to collect data in the study?	No. The data collection forms were stored securely to ensure confidentiality.
20	Field notes	Were field notes taken during and/or after the interview or focus group?	Data obtained through the drawing‐writing technique, along with researcher observations, were recorded and documented in writing throughout the research process.
21	Duration	How long were the interviews or focus groups?	Each data collection session lasted approximately 20 min.
22	Data saturation	Has data saturation been discussed?	Data saturation was achieved and is discussed in the methods section.
23	Transcripts returned	Have transcripts been returned to participants for comments and/or corrections?	No.
Area 3: Analysis and findings
24	Number of data coders	How many data coders coded the data?	Coding was performed by two researchers.
25	Description of the coding tree	Did the authors provide a description of the coding tree?	Themes and sub‐themes were developed collaboratively by the two researchers.
26	Derivation of themes	Were the themes predetermined or derived from the data?	Themes were derived inductively from the data.
27	Software	What software, if any, was used to manage the data?	Data were analyzed manually.
28	Participant control	Did participants provide feedback on the findings?	No.
Reporting
29	Quotes provided	Are participant quotes presented to illustrate themes/findings? Is each quote identified, e.g., participant number	Participant quotes were provided to illustrate the themes and findings, identified by participant number (e.g., P1, P2).
30	Data and findings consistent	Was there consistency between the data presented and the findings?	Yes
31	Clarity of main themes	Are the main themes clearly presented in the findings?	Yes
32	Clarity of small themes	Is there an explanation of the different cases or a discussion of minor issues?	Yes

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.