Undergraduate Nursing Students' Attitudes towards Mental Illness: Implications for Specific Academic Education.

BACKGROUND: Health care professions are not immune to social prejudices and surprisingly share the general public's attitude attributed to people with mental illness. Nursing students are future health manpower research related to nursing students attitudes toward mental illness is limited. AIM: The aim of this following study is to examine the undergraduate nursing students' attitudes toward people with mental illness.
MATERIALS AND METHODS: Cross-sectional descriptive design was adopted for the present study. A total of 148 undergraduate nursing students were purposively selected to complete self-reported questionnaires.
RESULTS: THE NURSING STUDENTS HAVE SIGNIFICANT POSITIVE ATTITUDES TOWARDS MENTAL ILLNESS IN THREE OF THE SIX ATTITUDES FACTORS: Restrictiveness (8.59), benevolence (29.8) and stigmatization (9.18). However, these students have negative attitudes in separatism (27.1), stereotype (11.5) and pessimistic predictions (11.7) domains as they rated high.
CONCLUSION: Academic education in this area must be planned so as to favor the change of the attitudes that include greater use of teaching strategies that challenge beliefs and assumptions and promote a commitment to provide holistic care to people with mental illness.

INTRODUCTION

Globally, it is an ongoing concern that the subject of psychiatry, psychiatrists, mental health professionals and the mentally ill patients are affected by the negative prejudices and the cultural stereotypes of the general public. Health care professions are not immune to social prejudices and surprisingly share the general public's attitude attributed to people with mental illness.[1] Nurses play a key role in caring for the mentally ill in sickness and in rehabilitating the mentally ill after an episode of illness. In addition, majority of patients and their families who are seeking help for their mental illness rightfully expect the hospital and nursing staff to be cognisant of their needs and treat them as unique individuals without any prejudice and discrimination.[23] The attitudes and knowledge of the health professionals on mental illness has been argued to be a major determinant of the quality and outcome of care for mentally ill.[45] Unfortunately, the universality of harmful beliefs and subsequent negative attitudes toward mentally ill is not in doubt even among nursing students. Stigma and discrimination are the main obstacles facing the mentally ill today and it is the shame and fear of this discrimination that prevents the mentally ill from seeking help and care for their disorders. On the other hand, the number of people with mental illness is increasing in India.

Students starting the nursing course bring with them stereotypes and prejudice in relation to mentally-ill people, thus showing lack of knowledge as to their possibilities of recovery and social living. Available evidence clearly demonstrates that undergraduate nursing students typically hold unfavorable attitudes toward psychiatric/mental health nursing as a career.[6]

Exploring trends in student nurses attitudes toward mental illness would have implications for nursing practices world-wide. This study was carried out to examine the nursing students’ opinion about mental illness for a number of reasons. Nursing students are future health manpower. They will be part of societal development. In order to fulfill their role, they need to be trained in such a way to develop positive attitudes toward needy people. Nurses need to be able to provide mental health education and care with a positive attitude in the community, as community care is the most accessible form of care world-wide. Further, in view of the severe scarcity of mental health personnel, student nurses should develop a positive attitude toward psychiatric nursing and the mentally ill is more critical in Indian scenario. Research on student's opinions about mental illness shows it has an impact on curriculum development, work recruitment and specialty choices in mental health related fields. The use of educational setting as a way to effect attitudes of students toward work with persons with major mental illness has also been studied.

Very few studies have comprehensively investigated the general attitude of all undergraduate nursing students[789101112] and looked at the impact of existing psychiatric nursing curriculum in these students.[13] However, limited research is evident in India that examined the student nurses attitudes towards mentally ill. Hence, it is important to understand the existing status of these future nurses to understand what areas need to be addressed. In addition, the present examination system emphasizes on the evaluation of change in knowledge and skill rather than attitudinal change after a prescribed course. Attitudinal change being an important objective of the mental health nursing course. In this background, we planned to investigate the attitude of undergraduate nursing students who were studying 1st year and 2nd year of B.sc nursing at selected colleges of nursing at Bangalore, toward people with mental illness.

MATERIALS AND METHODS

The study was carried out among undergraduate nursing students, at selected Colleges of Nursing Bangalore, India from April 2011 to June 2011.

Participants

A non-probability convenience sample with quantitative descriptive method was used. Selection criteria for participants included (a) nursing students studying 1st year and 2nd year of their course (b) who were willing to participate. Exclusion criteria included participants who were not willing to participate. A total of 168 students were enrolled in the study. However, 20 questionnaires were discarded as incomplete. Hence, 148 questionnaires were analyzed for this study.

Measures

Demographic data survey instrument

The demographic form consists of five items to seek the background of the participants in the study that includes “age, education, monthly family income, residence and contact with mental illness”.

Attitude scale for mental illness (ASMI)

The ASMI-a valid and reliable, self-report measure of attitudes-was administered to students along with a brief demographic form. A modified version of the questionnaire, Opinions about Mental Illness in the Chinese Community[14] in English version was used to collect the data. The ASMI section has 34 items and measures the general attitude to mental illness. Respondents were given the choice of five response categories to tick based on their feelings from totally disagree to totally agree (totally disagree = 1, almost totally disagree = 2, sometimes agree = 3, almost totally agree = 4, totally agree = 5) accordingly. It consists of six conceptual factors: Benevolence, separatism, stereotyping, restrictiveness, pessimistic prediction and stigmatization. Benevolence was intended to measure the paternalistic and sympathetic views of the respondents. Separatism: This factor was intended to measure the respondents’ attitude of discrimination. Stereotyping: This factor was intended to measure the degree of respondents’ maintenance of social distance toward the mentally ill. Restrictiveness: This factor was intended to measure viewing the mentally ill as a threat to society.[15] Pessimistic prediction is the negative evaluative component toward the mentally ill. This factor was intended to measure the level of prejudice toward mental illness. Stigmatization is the feeling of disgrace or discredit, which sets a person apart from others.[16] This factor was intended to measure the discriminatory behavior of the students toward mental illness.

Procedure

On introduction, verbal explanation of the research aims and methods provided to all participants. If they agreed to participate in the study, they were asked to complete the questionnaire by themselves. They could complete both questionnaires in about 20 min. Data collection tools contained no identifying information and therefore kept the individual responses confidential.

Ethical considerations

Permission was obtained from the administrators of the colleges where the study was conducted. Participants were introduced to the aims and procedures of the study to decide if they would like to participate. After they agreed to participate verbally, the researcher gave them the confidential questionnaire.

RESULTS

The final sample consisted of 148 participants whom age ranged between 17 and 23 years old (Mean [M] = 19.7, standard deviation [SD] = 1.62). Regarding the place of residency, most of the participants (52.7%) came from urban followed by 33.1% from rural and 14.2% were from semi urban. Average income for the participants was 1.21 ± 1.60 (M ± SD). Only 35 (23.6%) out of 148 participants have a relative who has a mental illness.

Table 1 explains the responses (mean scores) of the participants to the Attitude toward mentally ill scale. High scores were observed in both the positive and negative domains of the scale as discussed below. However, higher scores on the negative domains of the scale indicated an overall unhealthy attitude of nursing students toward those with mental illness. Higher scores were observed on the positive domain of benevolence (29.8), but equally high scores were noted on other domains also, namely, Separatism (27.1), Stereotypy (11.5) and Pessimistic prediction (11.7). However, less than cut-off point scores were observed in restrictiveness (8.59) and Stigmatization (9.18) domains.

Table 1

Mean scores of responses of the participants to the attitude towards mentally ill scale

No significant differences were found between nursing students’ attitudes toward mental illness and their age, gender, socio-economic status and place of residency.

DISCUSSION

This study was novel in its attempt to examine the student nurses attitudes toward mental illness who was enrolled into the nursing profession. Unlike other studies reported already by other researchers, our study differed in including all the nursing students who were in 1st year and 2nd year of their nursing course. Very few studies in India investigated student nurses attitudes towards mental illness.[13] However, these studies mainly focused on comparing the effectiveness of the mental health course on attitudinal change toward mentally ill. The researchers felt that it is critical to examine the attitudes of student nurses toward mentally ill before their mental health nursing course, which will be introduced to them during the 3rd year. However, the present study used a standardized questionnaire that measures the multi dimensions. Thus, this multidimensional scale helps us identify both the negative and positive aspects of the attitudes where we can work on to intervene, reinforce and enhance the attitudes of nursing students to provide holistic care to persons with mental illness.

In the present study, the results showed that nursing students have significant positive attitudes toward mental illness in three of the six attitudes factors: Restrictiveness, Benevolence and Stigmatization. These findings can be compared with a recent study.[17] However, the researcher concluded that medical students had unhealthy attitudes in all domains except in Benevolence domain.

The participants showed less restrictive attitude toward mentally ill as they rated high to the statements in restrictiveness domain. These findings indicated nursing students agreed that mentally ill people can enjoy personal or social life events such as marriage, working, having children, or family. Fortunately, nursing students had less stigmatizing attitudes toward people with mental illness. These findings contradicted with a previous study that shown mental illness is deeply discredited by the society and rejected as a result of the same also was rated high by medical students.[17] On the other hand, the present study findings concur with a study conducted among Jordanian nursing students as it was found nursing students had significant positive attitudes toward mental illness in four of the five attitudes factors: Authoritarianism; benevolence; mental hygiene ideology; and interpersonal etiology.[18] However, stigma related to mental illness is an international concern and a long-standing challenge for research to understand its basis, mechanisms and consequences in order to be able to formulate means by which stigma and its impact may be ameliorated.[19] In addition, research assessing population attitudes toward mental illness[2021222324252627] reveals that stigma toward the mentally ill is evident in many national and cultural settings. Higher benevolence scores indicated that most of the Nursing students would express kindness and altruism toward the person suffering from any form of mental illness. These findings were congruent with previous research.[817] In addition, in a comparative study, it was found that Brazilian students present more positive attitudes toward mental disorders, as they showed to be less authoritarian, restrictive and discriminative than the Chilean and Peruvian students.[11]

However, nursing students had negative attitudes in separatism, stereotype and pessimistic predictions domains as they rated high. Students starting the Nursing Course bring with them stereotypes and prejudice in relation to mentally-ill people, thus showing lack of knowledge as to their possibilities of recovery and social living.[9] In line with a previous study findings,[17] nursing students had a negative attitude when it came to accepting the autonomy and independence of the mentally ill and in considering them as part of the larger unaffected community. As in most societies, stereotypes about mental illness, such as an influence of evil spirits, religious afflictions and deviations from societal norms, were also rated high by these students. Further, they had pessimistic attitude regarding recovery, rehabilitation of mentally ill patients.

The present study has certain limitations that include small sample size made difficult to draw conclusions. However, it would be useful to conduct similar research among students after completing academic education in this area and perhaps comparing the students from other than nursing disciplines to see if there are any similarities and/or differences in the results. In addition, demand characteristics may have biased the results of the study. These are difficult to control for; however, it may be worthwhile considering how these could be reduced in any future research.

In a nutshell, the present study showed the nursing students have significant positive attitudes toward mental illness in three of the six attitudes factors: Restrictiveness, Benevolence and Stigmatization. However, these students have negative attitudes in separatism, stereotype and pessimistic predictions domains as they rated high. These findings have important implications for nursing training. They demonstrate the need for specifically focusing training to target the students with the most negative attitudes. Thus, academic education from courses in this area must be planned so as to favor the change of the attitudes that include greater use of teaching strategies that challenge beliefs and assumptions and promote a commitment to provide holistic care to people with mental illness.