Nurses' Attitude Towards Patients with Mental Illness in a General Hospital in Kuwait.

INTRODUCTION: Stigma and discrimination have been reported to cause unnecessary delay in mentally-ill patients seeking help, which adversely affects a patient's outcome. The attitude of health care professionals has been described as being, even more, negative than that of the general public, which worsens the prognosis for patients with a mental illness. AIMS: The aim of this study was to describe the attitude of nurses toward mentally-ill patients in a general hospital.
METHODS: All the nurses in the hospital were administered a 40-item Community Attitudes Toward the Mentally-Ill (CAMI) questionnaire which determines whether the mentally-ill are viewed as "inferior;" deserve "sympathy;" perceived as a "threat" to society or "acceptable" if residing in community dwellings. The analysis of variance was performed to determine association of the four subscales with the individual characteristics, including age, gender, education, qualification type, position held, contact and contact type.
RESULTS: Out of a total of 990 nurses, 308 (31%) completed the CAMI questionnaire. The mean scores for the authoritarian (2.85), benevolent (3.66), social restrictiveness (2.97) and community mental health ideology (3.48) subscales reflected a negative attitude of nurses toward mentally-ill patients. The direct or indirect utilization of the mental health facilities resulted in significantly higher authoritarian and lower benevolence scores, indicating a positive attitude change in this group of nurses.
CONCLUSION: Despite the small size and selective nature of the sample, the nurses' negative attitude toward the mentally-ill patients provides useful baseline data for further large-scale studies and underscores the need for psychoeducation of different health care professionals, including nurses.

INTRODUCTION

Mental health and well-being are critical to the quality of life of individuals and the productivity of communities.[1] One of the major impediments to the realization of positive mental health and well-being is stigma and discrimination, which can impact all aspects of an individual's life.[2] Thornicroft considers stigma to be an amalgamation of (a) ignorance and misinformation due to lack of knowledge, (b) prejudice flowing from negative attitudes, and (c) discrimination resulting from social exclusion or avoidance.[3] Research has shown that stigma contributes to a delay in seeking treatment.[45] Some studies have found that even in developed societies, about a quarter of people go to a faith healer or member of the clergy group for help initially before consulting a psychiatrist or general practitioner.[6] Stigma and discrimination toward those experiencing mental illness is the greatest barrier to recovery and provision of effective care and treatment.[7] It has also been reported that many psychiatric patients experience discrimination by health care professionals, including doctors, nurses and social workers.[891011] In fact, some studies have found that health care professionals hold more negative attitudes toward mental illness than the general public, which further restricts the recovery rates and quality of care,[121314] while positive attitudes in nurses are said to inspire hope, encourage individuals to take control of their lives and engage in proactive decision making about their future.[15]

The focus on nurses is especially important as they are the biggest group of health care professionals involved in the direct care of patients, including those with mental health problems.[16] A highly skilled, flexible, and culturally aware nursing workforce can ultimately have a positive impact on practice.[17] Studies looking at registered nurses indicate that qualified nurses with higher levels of education and those with specialized psychiatric training have more positive attitudes than unqualified staff and those without any psychiatric training.[81819] For nursing and psychology students, exposure to a psychiatric setting during training and having personal contact have both been associated with positive attitudes.[20212223] Other studies, however, have found no association of formal psychiatric training and interpersonal contact with a positive attitude toward mental illness.[242526] There seems little consensus or understanding of the factors that form and maintain either negative or positive attitudes to mental illness. What is clear is that attitudes are multifaceted and are likely to have a complex relationship with an individual's education, training and experience, on the one hand, and his sociodemographic, cultural and religious characteristics, on the other.[27] There are few if any, studies in the Arab world addressing this important question of nurses' attitude toward mentally-ill patients.

Aims

The aim of the study was to describe the attitudes of nurses toward subjects experiencing mental illness and determine if the attitude was related to their sociodemographic characteristics.

The specific research questions were as follows:

What are the nurses' attitudes toward mental illness?

What characteristics are associated with nurses' attitudes?

METHODS

Setting

The study was conducted in Mubarek Al-Kabeer Hospital, one of the six regional general hospitals in Kuwait. The hospital has 509 beds, serves a population of about 600,000 which constitutes about one-sixth of the country's total population. The hospital is staffed with 607 doctors and 990 nurses.[28] The approval of the relevant research and ethical committee was obtained. All the consenting nurses working in the hospital were administered self-rating questionnaires.

Instruments

The Community Attitudes Toward the Mentally-Ill Scale

The Community Attitudes Toward the Mentally-Ill Scale was originally developed for use with the general population but has since been used with various samples of mental health professionals, including psychiatrists in the United Kingdom and both nursing and medical staff in China.[293031] Measuring several aspects of attitudes, including perceptions of people with mental illness and attitude to community care, it consists of 40 statements each necessitating a response to the level of agreement/disagreement on a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree).

The questionnaire is scored on four factors: Authoritarianism is a view that people with mental illness are inferior and require a coercive approach; benevolence is a sympathetic view of those experiencing mental health problems, based on humanistic approach; social restrictiveness is a view that people with mental illness are a threat to society; and community mental health ideology (CMHI) supports the therapeutic value of the community and acceptance of de-institutionalized care. Reliability for the scale ranges from Alpha 0.68 to 0.88 with construct validity also showing positive results.[32] Three items were modified for the purposes of this study to ensure that language would be gender neutral without changing the original meaning of the items. For example, the statement, “a woman would be foolish to marry a man who has suffered from a mental illness, even though he seems fully recovered” was changed to “a person will be foolish to marry someone who has suffered from mental illness, even though he/she seems fully recovered.”

The background characteristics of the nurses were collected by an 8-item questionnaire requesting information about age, gender, highest educational attainment, qualification type, the length of experience, position held, personal contact with people with mental health problems and proximity of contact.

Data analysis

The data were analyzed using Statistical Package for Social Sciences (SPSS), version 22 (Armonk, NY: IBM Corp).[33] The four attitude factor scores were calculated by adding the ten relevant items for each factor and dividing by ten to arrive at the mean score. The scoring of each scale ranges from one (strongly disagree) to five (strongly agree). The nurses' sociodemographic data were analyzed with descriptive statistical methods. The continuous variable age and length of experience variables were each collapsed into two equal groups using the medians of each total sample (33 years for age and 8 years for experience) as the respective cut-off points. The distribution of the scores was reasonably normal on all four subscales. However, some outliers were noted and the five most extreme cases were excluded from the data set. The four dependent variables including authoritarian, benevolence, social restriction and CMHI were compared between two independent groups using Student's t-test. The Multivariate Analysis of Variance (MANOVA) was performed to determine if there was an association of the four subscales with individual characteristics, including age, gender, education, qualification type, position held, contract and contract type. To control for any observed differences in the single variable and explore any confounding influences that the variables may have on one another, all variables from the individual tests were entered as covariance into MANOVA.

For all tests, P < 0.05 was considered to be statistically significant.

RESULTS

The sample characteristics

The sample consisted of 308 nurses. Eighty-three percent were females (n = 257) and 85% (n = 240) were non-Arabs in origin [Table 1]. The mean age was 34.28 years (standard deviation [SD] =7.8). Ninety-one percent (n = 283) of them held bachelor's degree. Fifty-three percent (n = 146) of the nurses or their families, friends or acquaintances had utilized a mental health care facility. Eighty-nine percent (n = 275) were staff nurses with over 10 years experience. Fifty-eight percent (n = 160) had nursed psychiatric patients while ninety-one percent (n = 256) thought a psychiatric outpatient facility was needed in the hospital.

Table 1

Socio demographic characteristics of the sample

Characteristic
Age	Years
Mean±SD	34.28±7.8
Range	20-58
Median	33
Nursing experience	Years
Mean±SD	10.12±6.54
Range	1-36
Median	8
Gender	n (%)
Female	257 (83.44)
Male	51 (16.56)
•Marital status	n (%)
Never married	65 (23.7)
Ever married	209 (76.3)
••Nationality	n (%)
Arabs	42 (14.89)
Non Arabs	240 (85.11)
Current position	n (%)
Nurse manager	12 (3.9)
Staff nurse	275 (89.3)
Other*	21 (6.8)
Education	n (%)
Degree	283 (91.9)
Diploma	25 (8.1)
Contact type**	n (%)
Acquaintance	61 (19.81)
Friend	90 (29.22)
Family	6 (1.95)
Self	9 (2.92)

•Data for 34 nurses were missing. •• Data for 26 nurses were missing. *This category includes nurses who have diploma. **The percentages in this category do not add up to a hundred , as there are respondents with more than one type of contact. SD – Standard deviation.

Characteristics associated with nurses' attitudes toward mental illness

The nurses reported no direct or indirect mental health utilization that had significantly higher (P < 0.031) authoritarian and lower (P < 0.043) benevolence scores indicating that the mental health services utilization resulted in a positive change in attitude toward mental illness [Table 2]. The utilization of services by the nurses themselves (P < 0.030) or by their friends (P < 0.043) had a positive effect on the community mental health scale while utilization of mental health services by their acquaintance (P < 0.026) had positive influence on the benevolence scale.

Table 2

Relationship between CAMI scores and socio-demographic characteristics

Variables	N	Mean±SE				P
		Authoritarianism	Benevolence	Social restrictiveness	Community mental health
Gender
Female	257	2.866±0.024	3.653±0.029	2.986±0.024	3.467±0.027	0.217
Male	51	2.757±0.054	3.690±0.065	2.873±0.055	3.551±0.061
*Age
<33	138	2.840±0.033	3.714±0.040	2.954±0.033	3.451±0.037	0.122
34+	124	2.828±0.034	3.598±0.042	2.955±0.034	3.525±0.039
**Nationality
Arab	42	2.792±0.059	4.002±0.067	3.079±0.060	3.599±0.066	0.001
Non-Arab	240	2.862±0.025	3.605±0.028	2.951±0.025	3.466±0.028
Education
Degree	283	2.846±0.023	3.655±0.028	2.964±0.023	3.470±0.026	0.568
Diploma	25	2.861±0.077	3.701±0.093	2.999±0.078	3.603±0.087
Position
Nurse manager	12	2.792±0.111	3.746±0.134	2.920±0.113	3.717±0.125	0.880
Staff nurse	275	2.849±0.023	3.656±0.028	2.969±0.024	3.471±0.026
Other	21	2.868±0.084	3.659±0.101	2.972±0.086	3.470±0.094
Contact
No	146	2.887±0.032	3.603±0.038	2.960±0.032	3.403±0.035	0.010
Yes	162	2.803±0.030	3.710±0.036	2.973±0.031	3.551±0.03

*Data for 46 nurses were missing **Data for 26 nurses were missing. CAMI – Community Attitudes Toward the Mentally-Ill; SE – Standard error

There were no gender-related differences in authoritarian, benevolence, social restriction, and CMHI mean scores. Similarly, holding a bachelor's degree had no significant effect on the mean scores of the four subscales.

Nurses' attitude toward mental illness

Overall, the mean scores on the four subscales reflected the nurses' negative attitude toward mentally ill patients [Table 3]. On the “authoritarian” subscale, their scores (mean = 2.85; SD = 0.38) were on the relatively higher side (the higher the score, the more negative the attitude), suggesting that the nurses may have been regarding the mentally-ill as being somewhat “inferior” requiring a “coercive” approach. The “social restrictive” subscale score (2.97 ± 0.39) was on the higher side (the higher the score, the more negative the attitude) suggesting “disapproval” of the mentally ill residing in the immediate neighborhood. The “benevolence” subscale score (3.66 ± 0.46) was on the lower side (the higher the score, the more positive the attitude), indicating that they may harbor less sympathetic views of those experiencing mental health problems. The “CMHI” subscale score (3.48 ± 0.43) was again on the lower side (the lower the score, the more negative the attitude) suggesting their reluctance to accept the presence of the mentally ill in the neighborhood.

Table 3

CAMI scores

Subscales	Mean±SD
Authoritarianism	2.85±0.38
Benevolence	3.66±0.46
Social restrictiveness	2.97±0.39
Community mental health ideology	3.48±0.43

CAMI – Community Attitudes Toward the Mentally Ill; SD – Standard deviation

DISCUSSION

Our results showed that the nurses' attitudes toward mental illness were generally negative. The negative attitudes of the healthcare professionals, particularly nurses, has been known to exacerbate peoples' mental health problems and can seriously affect their chances of recovery.[434] In a conservative Arab society where the behavioral disturbances associated with mental disorders are equated with “social shame,” the negative attitude of nurses can have a particularly harmful effect on the patients and their families. Kuwaitis, like other Arab communities regard spiritual (jinni) possession, the “evil eye” and sorcery as possible explanations for changes in human behavior.[35] Psychiatric patients are regarded by many as “cursed” individuals who having been afflicted with evil spirits, require some kind of divine intervention by the faith healers.[3637] The families are often blamed for their relatives' illnesses and criticized for housing potentially dangerous or violently ill relatives.[3738] Many patients afflicted with mental illness never get to see a psychiatrist and are instead dealt with by faith healers. The presence of stigma in mental health professionals in a society where religio-cultural practices, rather than the modern day multidisciplinary individual patient care plans, determine the type and the nature of mental health services can be especially damaging to people with mental health problems.

A number of studies comparing nurses from different countries have found “nationality” to be the main determinant of difference in the nurses' attitudes toward the mentally ill patients. In a cross-cultural study involving five European countries, for example, Lithuanian nurses were found to harbor a more negative attitude, while Portuguese nurses had a more positive attitude. This was attributed to the overall public attitudes toward mental illness in the respective countries.[14] The attitude of nurses in our hospital was even more negative than those of the Lithuanian nurses. Since the stigma against people with mental illness has been reported to be global, prevalent and persistent.[39] The global trends, rather than the “nationality” factor possibly explain the negative attitude of our nurses as more than 85% (n = 240) of them came from different countries, including India, the Philippines, Indonesia and Pakistan.

The utilization of mental health services by the nurses, their families or acquaintances had a positive effect (P < 0.031) on their attitude toward mental illness, supporting the positive influence of the contact hypothesis. Similar findings have been reported by earlier studies.[3240] It has been suggested that contact with the mental health services removes some of the apprehension and myth commonly associated with the nature of these illnesses.[41] Another possible explanation of the positive influence of contact with patients is the direct observation of the beneficial effects of the therapeutic interventions and the usefulness of their roles in relieving psychological distress, removing thereby some of the uncertainty surrounding treatment of mental disorders. Finally, the direct or indirect suffering due to mental illness may generate empathic concern for the mentally-ill.

Contrary to the previous findings, neither a higher degree nor the seniority level had any effect, positive or negative on our nurses' attitudes toward mentally-ill patients.[810]

It is important to mention some methodological limitations of the study. The relatively lower response rate of our sample, derived from one of the six regional general hospitals in the country, may not be representative of the attitude of the nurses in the general hospitals which makes it difficult to draw firm conclusions. However, to the best to our knowledge, this is the first study of its kind to address the attitude of nurses toward the mentally-ill. The negative attitudes among our nurses highlight an important mental health issue requiring the attention of the media in general and the health care providers, in particular. It is suggested that further methodologically sound studies be carried out to address this matter so that programs can be initiated aimed at public education and the training of the health care workers.

CONCLUSION

The presence of negative attitudes among nurses in a society where severely mentally-ill patients are regarded as “cursed” individuals afflicted with “evil spirits,” can have considerable adverse consequences for people with mental illness resulting in lower self-esteem, reduced self-efficacy and reduced prospects of recovery.[42] It is therefore, important to initiate training programs for the nurses aimed at promoting positive attitudes and make them sensitive to the needs of mentally-ill patients. Such programs can include inter-disciplinary seminars and reflective seminars challenging the nurses' assumptions and attitudes toward mental illness and helping them understand multiculturalism by providing a safe explorative environment through skilled facilitation.[43] The evidence to support the effectiveness of this approach is well-established.[44] A similar program which was launched in the United Kingdom Education Not Discrimination project targeting key groups (medical students, teachers, trainee head teachers and social inclusion officers), has had a significant impact on the lives of people with mental health problems.[45] It offers training courses that utilize ant-stigma workshops.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.