Change in Attitude among Nursing Undergraduate Students Following One-Month Exposure in a Mental Healthcare Setting.

BACKGROUND: Attitude of treating professionals plays an important role in the treatment of mental illnesses. Nursing professionals are an important part of the mental health care team. As a part of their nursing coursework, nursing students are posted in a mental health setting. It is important to assess the impact of such postings on their attitudes.
MATERIALS AND METHODS: A total of 235 undergraduate nursing students posted in a mental healthcare setting for one month participated in the study. Their attitude towards mental illness and psychiatry was assessed before and after the posting, using Personal data sheet, Attitude Scale of Mental Illness (ASMI), and Attitude towards Psychiatry Scale (ATP).
RESULTS: At pre-assessment, the nursing students had a negative attitude on all dimensions of ASMI except benevolence, and positive attitude on all the six domains of ATP. At post-assessment, attitude improved significantly on pessimistic prediction dimension of ASMI, and they were able to maintain their positive attitude on ATP.
CONCLUSIONS: One-month posting had a weak positive impact on attitude towards mental illness and no detrimental impact on attitude towards psychiatry. There is a need for better efforts to increase the impact of training on attitude towards mental illness.

Nursing professionals are the backbone of any treating team.[1] They have the maximum amount of direct contact with the patients and their caregivers. Their role is receiving due consideration in the current healthcare scenario in India.[1] Attitude and behaviour are directly or indirectly related to each other.[2] Attitude sets the stage for how people interact with and treat objects. In the management of mental illnesses, the attitude of the treating professionals towards mental illness and towards psychiatry plays an important role. The attitude of the nurse is crucial in the treatment of mental illness. Since attitude once developed during training can remain stable over the years,[3] research needs to focus on the attitude of the nursing students. Efforts have been made to assess the attitude of nursing students toward mental illness and psychiatry.[4567] Researchers have reported nursing students' having a negative attitude and have suggested that there is an urgent need to evolve innovative teaching strategies to improve their attitude. Efforts have also been made to assess the impact of teaching strategies,[8] brief educational intervention[9] and four weeks' mental health placement[10] on the attitude of nursing students in different countries. However, there is a need for more research assessing the impact of these interventions and clinical postings on the attitude of nursing students. In India, undergraduate nursing students have one month posting in a mental health setting as part of their course curriculum. But there is a dearth of studies assessing the impact of the posting on their attitude. In view of the above, the present study aimed to assess the impact of the one month posting on the attitude of nursing students. The specific objectives were to assess the change in the attitude of undergraduate nursing students (a) towards mental illness and (b) towards psychiatry following one-month posting in a mental healthcare setting.

MATERIALS AND METHODS

The sample of the study consisted of undergraduate (second and third year) nursing students posted for one month as a part of their course in a tertiary care academic institution at institute of human behaviour and allied sciences (IHBAS) Delhi in India. The study duration was from January to August 2016. All the students posted during the data collection period were invited to participate. Written informed consent was obtained from all participants. The quantitative pre-post assessment design was used. The pre-assessment was carried out at the first week of their posting and post-assessment was carried out in the last week of the posting, in about 25-30 minutes, in a group setting. The study protocol was approved by the Departmental committee, Master of Philosophy (M. Phil.) committee and Ethics committee of the Institute. The following tools were used:

Personal data sheet

A personal data sheet to collect various socio-demographic details.

Attitude Scale of Mental Illness

Attitude Scale of Mental Illness (ASMI) consists of 34 items and is a modified version of the questionnaire, 'Opinions about Mental Illness in the Chinese Community' (OMICC).[11] It is a self-report measure of attitude in which each item consists of a five-point Likert scale from 1 to 5 (1 = strongly disagree; 5 = strongly agree). ASMI items are categorised into six conceptual factors as Separatism, Stereotyping, Restrictiveness, Benevolence, Pessimistic prediction, and Stigmatization. High scores on benevolence and low scores on the other five dimensions indicate a better and favorable attitude, whereas the reverse indicates an unfavorable and negative attitude.

Attitude towards Psychiatry

Attitude towards psychiatry (ATP) is a self-report measure of attitude consisting of 29-items rated on a 4-point Likert scale from “strongly agree,” to “strongly disagree”.[12] The scale examines the attitudes towards psychiatry in six areas: overall merits of psychiatry, efficacy, role definition and functioning of psychiatrists, possible abuse and social criticism, career and personal reward, and specific institute factors. A higher score indicates a positive attitude in that domain.

Components of one-month exposure

The students were given orientation and posted in various wards on rotation. They got the opportunity to see almost all kinds of psychiatric illnesses during their posting. They were allowed to interact with the patients under supervision. They had to observe the history taking process and assessment of mental status examination. Theoretical knowledge was provided through classes taken by different mental health professionals of the institute, where the emphasis was on the clinical feature of mental illnesses and treatment approaches. They were required to submit five case reports in which they have taken the detailed history from the patient. The students also participated in various activities and festival celebration held in the institute during their posting period.

Statistical analysis

Data were analyzed with the Statistical Package for Social Sciences (SPSS) version 16 at the pre-assessment levels, independent sample t-test was administered to see the impact of different socio-demographic variables on the attitude. Paired t-test was used for finding levels of significance among the scores of scales at pre- and post-assessment stages, and Bonferroni correction was applied here. The effect sizes are reported using Cohen's d.

RESULTS

A total number of 262 students participated in the study at pre-assessment. At the post-assessment, only 235 students could participate, due to the absence of 27 students on the days of the assessment. Data from a total of 235 students were put for statistical analysis.

Sample characteristics

Age range of the participants was 18–25 years with mean age (±SD) of 20.38 (±1.47) years. The sample was dominated by unmarried female students (n = 223, 91.6%). The majority were Hindus (n = 157, 69.1%), followed by Sikhs (n = 72, 28.6%). Number of participants from the rural background were more as compared to the urban background (n = 139 and 96, 58.4% and 41.6%, respectively). There were an almost equal number of second (n = 115) and third (n = 118) year students.

At the pre-assessment levels, t-test reported no significant difference between the attitude of rural (n = 139) and urban (n = 96) background participants. However, religion did show a significant difference; with Sikhs (n = 72) having better attitude towards mental illness and towards psychiatry in comparison to Hindus (n = 157) on the “stigmatization” domain of ASMI (t = 4.95, P = 0.002, Cohen's d = 0.20) and “career and personal reward” domain of ATP (t = 4.95, P < 0.001, Cohen's d = 0.48) respectively. Third-year students (n = 118), as compared to second-year students (n = 115), were found to have a better attitude to mental illness on stigmatization domain of ASMI (t = 3.07, P = 0.002, Cohen's d = 0.41) and better attitude to psychiatry as well on career and personal reward domain of ATP (t = 2.56, P = 0.000, Cohen's d = 0.91). The significance level was used at P <.004, after Bonferroni correction.

Attitude towards mental illness

The mean scores of students' attitude towards mental illness on ASMI at the pre-exposure level were on the higher side in all the areas [Table 1]. A within-group comparison was carried out between pre- and post-exposure assessment using paired sample t-test. To overcome the possibility of false positive results due to multiple hypothesis testing, Bonferroni correction[13] was done and a stringent criterion of significance level, P < 0.008 was used. As shown in the Table 1, there was a significant difference between means on the pessimistic prediction dimension (t = 2.90, P =0.004, Cohen's d = 0.23). There was no statistically significant difference between mean scores on other domains of ASMI.

Table 1

Pre- and post-assessment findings from ASMI and ATP

Domains	Pre-assessment scores mean±SD	Post-assessment scores mean±SD	Range	Mean difference	t-score	P
ASMI
Separatism	27.74±4.93	26.95±5.61	16-43	0.78	2.16	0.031
Stereotyping	12.25±2.63	12.20±2.74	4-19	0.00	0.00	1.00
Restrictiveness	10.00±2.84	9.85±2.41	2-19	0.15	0.75	0.449
Benevolence	27.93±3.60	28.22±3.44	13-39	0.29	1.18	0.238
Pessimistic prediction	12.55±2.72	11.90±2.87	5-19	0.65	2.90	0.004*
Stigmatization	8.29±2.44	8.47±2.55	4-18	0.17	0.93	0.349
ATP
Overall merit to psychiatry	10.09±1.43	9.91±1.34	5-12	0.18	1.62	0.105
Efficacy	10.58±1.37	9.94±1.77	5-12	0.64	4.95	0.001#
Role definition and functioning	20.00 ± 6.87	19.35±2.35	12-117	1.01	2.21	0.028
Possible abuse and social criticism	5.25±1.89	5.64±1.24	2-26	−.38	2.74	0.007#
Career and personal reward	22.71±4.40	22.91±4.77	13-32	−.20	0.54	0.586
Specific medical school factor	19.11±2.63	18.93±2.89	10-24	0.17	0.86	0.388

Significant at *P≤0.004 and #P≤0.008, ASMI – Attitude towards mental illness, ATP – Attitude towards Psychiatry, SD – Standard deviation

On the ATP scale, the scores were on the higher side at the pre-exposure assessment [Table 1]. The comparison between pre- and post-exposure assessments showed statistically significant difference at the significance level P < 0.008, following Bonferroni correction, on efficacy domain (n = 235, t = 4.95, P = <0.001, Cohen's d = 0.41), and on possible abuse and social criticism domain (n = 235, t = 2.74, P < 0.007, Cohen's d = 0.23). There was no statistically significant difference between the mean scores on other domains of ATP.

DISCUSSION

Unmarried Hindu females dominated the sample, and this finding is not surprising in view of the perception of the nursing profession as “female predominant job,"[14] leading to more girls joining a nursing course.

Attitude to mental illness

At the pre-assessment, the group held a negative attitude in all the areas, except on the benevolence scale. Similar finding of negative attitude has been reported by other researchers.[456] On benevolence scale, the students had a positive attitude of paternalistic and sympathetic view towards the persons with mental illness. The results at the post-assessment showed that there is a significant increase in the optimism about the treatment of mental illness and the future growth of persons with mental illness (pessimistic prediction dimension). However, negative attitude in the sense of keeping persons with mental illness at a safe distance (separatism domain), threat perception (restrictiveness domain), sharing of stereotypical attitudes with society (stereotype domain) and discrimination in terms of disgracefulness of the person with mental illness (stigmatization domain) remained unchanged.

The findings showed only a weak positive impact of the posting on the attitude towards mental illness. It is an area of concern, and concentrated efforts are needed in this direction to bring positive change in nursing student's attitude because they are the future service providers. A very similar study in Australia had shown a more positive outcome than the present study following four weeks' clinical placement in a mental health setting.[10]

At pre-assessment, the students had a positive attitude on all the six domains of attitude towards psychiatry. Similar findings were reported by another study.[7] On a comparison of pre- and post-assessment scores, the more important domain of “possible abuse and social criticism” showed changes in positive direction, which indicated that the one-month direct exposure strengthened their belief that mental health professionals work with integrity and ethics. The positive and high scores on this domain are always desirable. The group's belief in the efficacy of psychiatrists had come down (efficacy domain). There were no significant differences observed in other domains of ATP scale, indicating that the group was able to maintain its positive attitude towards psychiatry after the one-month exposure period.

The present study has some limitations. The assessment in a group setting can influence attitude because of the “feel” that others are present, even though the physical interference was taken care of and clarifications were provided by the researcher only. The assessment was done in the mental health setting itself, and it could have led to an obligation on the part of students to give positive ratings on attitude to psychiatry. However, in order to reduce the possibility of any bias, the researchers had time and again reminded about and emphasized the ethical considerations to the participants. A bigger sample size and a control group could have provided more strength to the findings. A long-term follow-up assessment, to see any late impact on attitude change, could be of interest in future research. However, given the scope and feasibilities of the present study, it was impossible to overcome these limitations.

To conclude, the findings on the attitude to mental illness bring out a significant concern. The results reveal a negative attitude among the nursing student population. More importantly, it does not show significant changes post-exposure to month-long posting, which indicates the need for modifications in the training. The silver lining is their positive attitude towards the field of psychiatry and mental health professionals and the fact that positive attitude remains intact after exposure to the mental health setting. Our findings underline the suggestions provided by other researchers that innovative teaching strategies are needed to improve the attitude of future nursing professionals.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.