Stigma for Mental Disorders among Nursing Staff in a Tertiary Care Hospital.

Objective  This study aimed to evaluate the prevalence of stigma for mental disorders among nursing staff in a tertiary care hospital, and the secondary objective of the study was to assess the correlation of stigma with the socio-demographic profile and previous experience with mentally ill patients. Methods  This cross-sectional study was performed among the 210 nurses working in a tertiary care multispecialty teaching public sector hospital in north India. They were evaluated on community attitudes toward the mentally ill (CAMI) scale. Results  About two-thirds of the participants (67.1%) were females and had done graduation (64.2%) in nursing. Nearly 50% of the study participants had an experience of working with mentally ill patients. Female had a more significant positive attitude on the domain of social restrictiveness. Authoritarianism had a significant positive correlation with benevolence and social restrictiveness domains. The benevolence domain had a significant correlation with all other domains. Social restrictiveness domain also had a significant correlation with other domains. Conclusion  Nurses have a positive attitude toward mentally ill patients.

Introduction

Mental illnesses are a major contributor to the global burden of disease. One in every four person in the world is affected by one or other mental disorder at some point of their life. 1 Mental illnesses are treatable. However, nearly two-thirds of the people suffering from mental disorders do not seek help from a psychiatrist or a mental health-related professional and prefer to hide their problems. 2 Among the various factors, which influence help seeking, stigma, discrimination, social prejudice, and negligence are considered to be important factors which prevent mental health care and treatment. 3

Stigma can be understood as an attribute that is deeply discrediting. Authors have pointed out that the difference between a nonstigmatized and a stigmatized person was always a question of perspective, rather than a reality. 4 Stigma is in the eye of the beholder, and a body of evidence supports the concept of stereotypes against the psychiatric illnesses in the society. Often, when an individual with a stigmatized trait is not able to perform a duty or action, because of the condition, other people view the individual as the problem rather than viewing the condition as a problem. This stigmatized trait sets the sufferer apart from the rest of society, bringing with it feelings of isolation and shame. Many people with mental illnesses (PwMIs) believe that their being mentally ill reduces the honor of their families. 5 Stigma often leads to the avoidance, discrimination, prejudice, and rejection. These are the things which directed at people believed to have an illness, disease, or other trait perceived to be undesirable and unacceptable. 6 Stigma causes endless suffering, probably causing a person to deny his/her symptoms, resulting in to delay in treatment and refrain from daily activities. Stigma can exclude people from access to insurance, appropriate medical care, employment opportunities, and housing. Stigma is identified as the important factor of social exclusion, isolation, poor social networking, and loneliness among PwMIs. 7 8 9 10 11 Stigma also interferes with the prevention efforts, and examining and combating stigma is a public health priority. 12

Although various types of stigma are described in relation to mental disorders, public stigma is one of the important types of stigma, which determines the attitude of the general population toward those with psychiatric illnesses. Further, the public stigma also shapes the perceived stigma or internalized stigma, as when a person who holds negative view about mental disorders becomes ill, he tries to apply the same to the self, which leads to internalized stigma. 13 Hence, mitigating public stigma should be one of the most important strategies to address the negative views about mental illnesses in the society.

Many factors are known to increase the stigmatizing behavior of general public. Having beliefs that mental illnesses are an outcome of evil spirits and PwMIs are dangerous to the other people because of their violent behavior increase the stigmatizing attitude of general public. 14 These beliefs contribute to increase in social distance and inappropriate medical care of PwMIs. Similarly, people’s belief and attitudes about mental illness predict whether they help and support the mentally ill subjects. By tracing the attitude of people toward mental illness, it is possible to predict the knowledge and awareness regarding mental illnesses among people in the community. According to the CDC-BRFSS’s (Centers for Disease Control and Prevention- Behavioral Risk Factor Surveillance System 2012 report) only 35 to 67% of the adults have a caring and sympathetic attitude toward mental illness. 15

Unfortunately, stigma toward mentally ill people not only originates in general public but also among health care professionals. Stigma toward psychiatric illness is also highly prevalent among health care professionals. Studies done among the nurses of having experience 6 years or more show that the nurses have unsympathetic attitude toward PwMI. Nurses accused patients with mental illnesses as criminals. 10 There is some evidence to suggest that mental illness among nurses elicits negative coworker’s attitude toward people returning to their jobs after suffering from mental illness. This negative attitude eventually leads to the increased absenteeism from jobs. 16

Attitude toward the patient suffering from a mental illness influence both personal as well as professional behavior among nurses. Unfortunately there is very less data on public stigma among health care professionals from India. Hence, there is a need to evaluate the same, so that intervention programs can be designed to reduce the stigma among nurses. It is expected that reduction in public stigma among nurses can help in improving the identification and management of mental illnesses in patients seen at various other specialties. However, before addressing the public stigma among nurses, it is necessary to identify the extent of stigma among nurses. Accordingly, the present study aimed to evaluate the level of public stigma among nursing staff working in a tertiary care hospital.

Methods

This was as cross-sectional study performed among the nurses working in a tertiary care multispecialty teaching public sector hospital in north India. The study sample comprised 210 nurses from various departments selected by purposive sampling. Institute Ethics Committee approved the index study, and all nurses were recruited after obtaining written informed consent. To be a part of this current study, nurses were required to be working in the hospital in which the study was conducted. Those who were unwilling to participate were excluded.

The study participants were assessed on community attitudes toward the mentally ill (CAMI) scale. 17 The scale consisted of 40 attitudinal statements about mental illness, with participants scoring on a 5-point Likert scale (ranging from agreed to disagree). The scale was divided further in into four subscales, that is, authoritarianism (AU), benevolence (BE), social restrictiveness (SR), and community mental health ideology (CMHI). AU is a “view of the mentally ill patient as someone who is inferior and requires supervision and coercion.” BE reflects “a humanistic and sympathetic view toward mentally ill patients” and higher BE score corresponds to a less humanistic and less sympathetic (malevolent) view toward PwMI. SR reflects the “the belief that mentally ill patients are a threat to society and should be avoided.” CMHI is “the acceptance of mental health services and the integration of mentally ill patients in the community” with higher score on the CMHI subscale indicating a rejection of mental health services and the integration of PwMI into the community. BE and CMHI are referred as positive attitudes. Meanwhile, AU and SR are referred as negative attitudes. There are 10 items for each subscale and each consists of five positive statements and five negative statements. Respondents were required to rate how much they strongly disagree or strongly agree with each statement. Each item was scored using 5-point Likert's scale (5—strongly agree, 4—agree, 3—neutral, 2—disagree, and 1—strongly disagree). Negative statements for each subscales were reversed-coded. Total score were calculated to detect the attitudes toward the mentally ill patients. Higher score indicates that community has a high attitude. For instance, high score for BE indicated that community have a benevolent attitude toward the mentally ill patients. The scale has been shown to have good test–retest reliability (Cronbach’s Alpha) and validity.

Statistical Analysis

Statistical Package for the Social Sciences, Windows version 14 (SPSS-14, SPSS Inc., Chicago, Illinois, The United States) was used for analysis of data. For continuous variables, descriptive analysis (mean and standard deviation [SD]) was done and for categorical variables calculation of frequencies and percentages was done. Correlation and comparison analysis was done by using Pearson’s correlation coefficient, Spearman correlation coefficient and Chi-square test, Student’s t -tests, Mann-Whitney U tests, and Fischer exact test, respectively.

Results

As depicted in Table 1 , the mean age of the index study was 28.1 (range 21–48; SD = 4.7), with a median of 27.5 years. Two-thirds of the participants (67.1%) were females and had done graduation (64.2%) in nursing and a small proportion of them had postgraduation in nursing. Only about half of the study participants had an experience of working with mentally ill patients. Only two participants reported that they were diagnosed with a mental illness in the past.

Table 1

Socio-demographic profile of the study participants

Variables	Frequency (%)/Mean (SD) ( N = 210)
Age (in years)	28.1 (4.7)
Sex
Female	141 (67.1)
Male	69 (32.9)
Educational qualification
Diploma	45 (21.2)
Graduate	136 (64.2)
Postgraduate	29 (13.7)
Previous experience with mentally ill patients
Yes	107 (51.7)
No	100 (48.3)

Attitude toward Mentally Ill Subjects

Tables 2 and 3 show the results of study participants on the CAMI scale. As is evident from Table 3 , highest score was obtained for subscale of CMHI, followed by SR, BE, and AU. It shows the least score was obtained for item “Mental illness is an illness like any other.”

Table 2

Attitude of nurses toward mentally ill subjects

CAMI item	Strongly agree (%)	Agree (%)	Neither agree nor disagree (%)	Disagree (%)	Strongly disagree (%)	Mean (SD)
Abbreviation: CAMI, community attitudes toward the mentally ill.
Authoritarianism
1. As soon as person shows sign of mental illness he should be hospitalized.	33 (15.7)	71 (33.8)	14 (6.7)	69 (32.5)	23 (10.8)	2.9 (1.3)
5. There is something about the mentally ill that makes it easy to tell them from normal people.	3 (1.4)	45 (21.4)	66 (31.4)	80 (38.1)	16 (7.6)	3.3 (0.9)
9. Less emphasis should be placed on protecting the public from the mentally ill.	13 (6.2)	58 (27.6)	41 (19.5)	66 (31.4)	32 (15.2)	2.8 (1.2)
13. Mental patients need the same kind of control and discipline as a young child.	30 (14.3)	81 (38.6)	32 (15.2)	56 (26.7)	11(5.2)	2.7 (1.2)
17. Mentally ill should not be treated as outcasts of society.	79 (37.6)	82 (39.0)	19 (9)	26 (12.4)	4 (1.9)	3.9 (1.1)
21. The best way to handle the mentally ill is to keep them behind locked doors.	7 (3.3)	13 (6.2)	14 (6.7)	82 (39)	94 (44.8)	4.2 (1.0)
29. Mental hospitals are an outdated means of treating the mentally ill.	30 (14.3)	52 (24.8)	43 (20.5)	54 (25.7)	31 (14.8)	2.9 (1.3)
33. One of the main causes of mental illness is a lack of self-discipline and will power.	18 (8.6)	56 (26.7)	50 (23.8)	60 (28.6)	26 (12.4)	3.1 (1.2)
37. Virtually anyone can be mentally ill.	80 (37.7)	94(44.8)	21 (10)	11 (5.2)	4 (1.9)	4.1 (0.9)
Total	31.9 (3.6)
Benevolence
2. More tax money should be spent on care and treatment of mentally ill.	37 (17.6)	76 (36.2)	59 (28.1)	29 (13.8)	9 (4.3)	3.5 (1.1)
6. Mentally ill are burden on society.	3 (1.4)	12 (5.7)	27 (12.9)	77 (36.3)	91 (43.3)	4.1 (0.9)
10. Mentally ill have for too long been the subject of ridicule.	4 (1.9)	20 (9.5)	48 (22.9)	86 (41.0)	52 (24.8)	30 (1.2)
14. Increased spending on mental health services is a waste of tax money.	11 (5.2)	18 (8.6)	11 (5.2)	95 (45.2)	75 (35.7)	3.9 (1.1)
18. We need to adopt a far more tolerant attitude toward the mentally ill in our society.	73 (34.8)	107 (51)	16 (7.6)	9 (4.3)	5 (2.4)	4.1 (0.9)
22. There are sufficient existing services for mentally ill.	11(5.2)	40 (19)	30 (14.3)	91 (43.3)	38 (18.1)	3.5 (1.1)
26. Our mental hospitals seem more like prisons than like places where the mentally ill can be cared for.	20 (9.5)	57 (27.1)	38 (18.1)	58 (27.6)	37 (17.6)	2.8 (1.3)
30. The mentally ill do not deserve sympathy.	12 (5.7)	25 (11.9)	14 (6.7)	93 (44.3)	66 (31.4)	3.8 (1.2)
34. We have the responsibility to provide the best possible care for the mentally ill.	94 (44.8)	99 (47.1)	9 (4.3)	4 (1.9)	4 (1.9)	4.7 (0.8)
38. It is best to avoid anyone who has mental problems.	10 (4.8)	17(8.1)	15 (7.1)	92 (43.8)	76 (36.2)	3.9 1(1.1)
Total	37.2 (5.0)
Social restrictiveness
3. Mentally ill should be isolated from rest of the society.	0	10 (4.8)	21(10)	94 (44.8)	85 (40.5)	4.2 (0.8)
2. Mentally ill are far less of a danger than most people suppose.	29 (13.8)	96 (45.7)	28 (13.3)	43 (20.5)	14 (6.7)	3.4 (1.2)
11. A woman would be foolish to marry a man who has suffered from mental illness, even though he seems fully recovered.	4 (1.9)	20 (9.5)	48 (22.9)	86 (41)	52 (24.8)	3.8 (0.9)
15. No one has the right to exclude the mentally ill from their neighborhood.	96 (45.7)	85 (40.5)	16 (7.5)	12 (5.7)	1 (0.5)	4.3 (0.9)
19. I would not want to live next door to someone who has been mentally ill.	11 (5.2)	16 (7.6)	36 (17.1)	95 (45.2)	52(24.8)	3.8 (1.1)
23. Mental patients should be encouraged to assume the responsibilities of normal life.	55 (26.2)	102 (48.6)	39 (18.6)	12 (5.7)	2 (1)	3.3 (0.9)
27. Anyone with a history of mental problems should be excluded from taking public office.	5 (2.4)	17 (18.1)	28 (13.3)	105 (50)	55 (26.2)	3.9 (0.9)
31. The mentally ill should not be denied by their human rights.	91 (43.3)	80 (38.1)	12 (5.7)	23 (11)	4 (1.9)	4.1 (1.0)
35. The mentally ill should not be given any responsibility.	14 (6.7)	6 (2.9)	38 (18.1)	116 (55.2)	36 (17.1)	3.7 (1.0)
39. Most women who were once patients in a mental hospital can be trusted as baby sitters.	12 (5.7)	47(22.4)	68 (32.1)	65 (31)	18 (8.6)	2.9 (1.0)
Total	37.9 (4.8)
Community mental health ideology
4. Residents should accept the location of mental health facilities in their neighborhood to serve the needs of the local community.	69 (32.9)	102 (48.6)	27 (12.9)	11 (5.2)	1 (0.5)	4.1 (0.9)
8. Locating mental health facilities in residential areas downgrades the neighborhood.	3 (1.4)	21 (10)	17 (8.1)	100 (47.6)	69 (32.9)	4.0 (0.9)
12. As far as possible mental health services should be provided through community-based facilities.	87 (41.4)	98 (46.7)	14 (6.70)	9 (4.3)	2 (1)	4.2 (0.8)
16. Having mental patients living within residential neighborhood might be good therapy, but the risks to residents are too high.	26 (12.4)	54 (25.7)	60 (28.3)	55 (25.9)	15 (7.1)	2.9 (1.1)
20. Best therapy for mental patients is to be a part of normal community.	78 (37.1)	92 (43.8)	25 (11.9)	11 (5.2)	3 (1.4)	4.1 (0.8)
24. Local residents have good reason to resist the location of mental health services in their neighborhood.	8 (3.8)	33 (15.7)	47 (22.4)	93 (44.3)	29 (13.8)	3.49 (1.0)
28. Locating mental health services in residential neighborhoods does not endanger local residents.	58 (27.6)	102 (48.6)	29 (13.8)	13 (6.2)	8 (3.8)	2.1 (0.9)
32. Mental health facilities should be kept out of residential neighborhood.	4 (1.9)	13 (6.2)	29 (13.8)	121 (57.6)	43 (20.5)	3.9 (1.0)
36. Residents have nothing to fear from people coming into their neighborhood to obtain mental health services.	54 (25.7)	97(46.2)	34 (16.2)	22 (10.5)	3 (1)	3.8 (0.9)
40. It is frightening to think of people with mental problems living in residential neighborhoods.	2 (0.9)	7 (3.3)	54 (25.7)	103 (49)	44 (21)	3.9 (0.8)
Total	38.3 (3.9)
Total CAMI score	145.3 (7.8)

Table 3

Comparison of scores on CAMI between male and female participants

	Whole sample	Male	Females	t -Test ( p -Value)
	N = 210	N = 69	N = 141
	Mean (SD)	Mean (SD)	Mean (SD)
Abbreviation: CAMI, community attitudes toward the mentally ill.
Authoritarian	31.9 (3.6)	31.8 (3.4)	31.9 (3.7)	0.33 ( p = 0.974)
Benevolence	37.2 (5.0)	36.7 (4.5)	37.5 (5.2)	1.03 ( p = 0.306)
Social restrictiveness	37.9 (4.8)	36.9 (4.2)	38.4 (5.0)	1.98 (p = 0.047)*
Community mental health ideology	38.3 (3.9)	37.4 (4.4)	38.6 (3.6)	1.59 ( p = 0.112)

Comparison of Scores on CAMI between Male and Female Participants

As is evident from Table 3 , when male and female participants were compared with each other, only significant difference was noted between the two subgroups on the domain of SR. When those with and without experience of working with PwMI were compared, no significant difference was noted between the two subgroups ( Table 4 ).

Table 4

Comparison of scores on CAMI between those with and without experience of working with people with mental illnesses

	Previous experience of working with mentally ill subjects N = 107	Previous experience of not working with mentally ill subjects N = 103	t -Test ( p -Value)
	Mean (SD)	Mean (SD)
Abbreviation: CAMI, community attitudes toward the mentally ill.
Authoritarian	32.2 (3.6)	31.5 (3.6)	1.48 ( p = 0.139)
Benevolence	37.4 (5.5)	37.1 (4.5)	0.41 ( p = 0.681)
Social restrictiveness	37.9 (5.1)	37.9 (4.6)	0.05 ( p = 0.958)
Community mental health ideology	38.3 (3.9)	38.2 (3.8)	0.64 ( p = 0.819)

When the relationship of attitude toward mentally ill subject was evaluated with age and level of education, no significant correlations emerged between these variables. These results are shown in Table 5 . When the association of various domains of CAMI was evaluated, as shown in Table 5 , authoritarian had significant correlation with BE and SR. The BE domain had a significant correlation with all other domains. Social restrictiveness also had a significant correlation with other domains.

Table 5

Correlation of various domain of CAMI with each other, age, and level of education

	Authoritarian	Benevolence	Social restrictiveness	Community mental health ideology
Abbreviation: CAMI, community attitudes toward the mentally ill. a p -value < 0.001, highly significant.
Age	0.071 (0.308)	0.121 (0.080)	0.113 (0.102)	0.016 (0.817)
Education in years	0.032 (0.643)	0.087 (0.211)	0.021 (0.760)	0.009 (0.894)
Authoritarian		0.279 (0.000) a	0.248 (0.000) a	0.125 (0.071)
Benevolence			0.519 (0.001) a	0.417 (0.000) a
Social restrictiveness				0.464 (0.000) a

*On comparison, the study sample with positive attitude on the item of BE had a mean age which was significantly less (mean = 27.9; SD = 4.5) when compared with the study sample with negative attitude population (mean = 30.0; SD = 5.5).

**On the domain of CMHI, the study sample with positive attitude had a significantly lesser number of family members (mean = 3.9; SD = 1.3 ) and more in female population (69.6%) when compared with study sample with a negative attitude respectively (mean = 4.5; SD = 0.9, p = 0.049 = 45.4%; p = 0.022 ).

Discussion

The study was conducted with the purpose to measure the attitude among the nurses working in a tertiary care hospital toward the mental illness. The results showed that the nurses had more positive attitude toward the mental illness. The result was almost similar to the previous studies. 9 18 19 20 21 The association with positive attitude could be because of the nurses in the tertiary center having some kind of exposure either during their training or job. Importantly, the socio-demographic characteristics are associated with nurses’ attitudes toward mental illness. Of the various demographic characteristics examined (gender, age, education, number of family members, monthly income, per capita per person), only gender was found to be associated with nurses’ attitudes. This finding is consistent with some of the previous studies. 22 23 24 25

Female nursing staffs were found to be more sympathetic toward the psychiatrically ill patients. Female nurses did not consider them as a threat to our society as compared with the male nurses. Such positive attitude of nurses is vital to promote and encourage patients to take control of their lives and be proactive in deciding about their life and future’s decisions. Munro and Baker 9 suggest that when the difference among the gender was noted, it was found that male gender is likely interacting with other individual characteristics to influence attitude . In some of the previous studies, the female gender was associated with the positive attitude as compared with the male counterpart. 26 But in our study, the mentioned gender differences were not significantly associated with any other socio-demographic characteristics or males were more associated with positive attitude. 27 28 29 30 These inconsistent findings, because the profiles of population were different in previous studies, were mostly not from the health professionals. Younger females scored higher on BE in the previous studies which demonstrated that the younger people generally have more favorable attitude toward mental illness. 31 32 33

This multidimensional scale (CAMI) helps us to identify positive and negative aspects of the attitude toward the psychiatric illness. Accordingly, we can focus to provide and enhance more positive and protective living environment for PwMI. Our study results revealed that nursing staff in PGI held more benevolent attitude, tended to be more sympathetic for the needs of mentally ill, and found themselves responsible for providing best possible care for the mentally ill people. As suggested in one of the Taiwan studies, the benevolent thought could be transferred into compassion for and acceptance of another human being if individuals are given an opportunity to have direct contact with patients with psychiatric disability. 34

The study findings revealed that only fewer numbers of nurses agreed to the hospitalization of the mentally ill, as soon as illness is diagnosed, because foremost task is to find the severity of mental illness and based on these findings, decision will be taken on the hospitalization of the patient. Also our study finds that mentally ill patients should not be kept behind locked doors, rather community-based mental health services should be provided to them. Such positive attitude should be enhanced among medical professionals for the better care of the patients.

Strengths and Limitations of the Study

The study throws the light on the possible prevalence and situations associated with mental health-related stigma among nursing staffs in India. This study suggests that the mental health-related stigma among nurses is prevalent to some extent. The current study sample = 210 was relatively smaller and sample collected was randomized. However, our sample consisted of almost 70% of the younger female staffs that could give biased results. The responses given by the nursing staff to assess the attitude might be affected by the social desirability. Other possible variables of interest, like previous experience or past history of mentally ill patients, were found to be significant predictor of stigma in various studies, 35 36 but we are not able to control them in the present study. The response rate among those approached for participation was fairly good. Moreover, these findings can be used for similar studies using large sample sizes.

Conclusion

In general, nurses’ attitudes to mental illness and people with mental health problems are ambivalent. Already experienced nursing staff found mentally ill patients, a threat to the society, suggesting that more emphasis should be given on mental health awareness campaigns and ways of improving and updating their knowledge about dealing with psychiatric patients.

It was not expected that no significant changes have occurred in the other areas assessed like education, history of mental illness, and so on. For future implications some more variables can be added to the questionnaire, like beliefs and myths toward mental problems, religious views of subjects, which can give better idea about attitudes.