International Journal of Mental Health & PsychiatryISSN: 2471-4372

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Research Article, Int J Ment Health Psychiatry Vol: 2 Issue: 4

Nurses Attitudes towards People with Mental Illness

Amira Ali Alshowkan*
Psychiatric and Mental Health Nursing Department, College of Nursing, University of Dammam, Saudi Arabia
Corresponding author : Amira Alshowkan
Assistant Professor, University of Dammam, College of Nursing, Dammam 31441, Saudi Arabia
Tel: 966544312234
E-mail: [email protected]
Received: May 18, 2016 Accepted: July 15, 2016 Published: July 19, 2016
Citation: Alshowkan AA (2016) Nurses Attitudes toward People with Mental Illness. Int J Ment Health Psychiatry 2:4. doi:10.4172/2471-4372.1000131

Abstract

Introduction: Stigma toward people with mental illness was found to be the greatest barrier to treatment and recovery. Nurses were found to face several challenges in nursing people with mental illness, such as patients being more acute, demanding, and aggressive. These challenges may impact the nurses’ role and practice. Little is known about the attitude of nurses toward people with mental illness in Saudi Arabia.

Aim: This study aims to investigate the nurses' attitudes toward people with mental illness and the sociodemographic factors associated with their attitude. Method: The data were collected from 225 registered nurses using the Community Attitude toward Mental Illness (CAMI) scale. The data were analysed by SPSS 20 software.

Results: The results revealed that nurse's attitudes toward people with mental illness were generally positive. Nurses' positive attitudes were associated with age, years of experience, previous contact with people with mental illness, and position.

Conclusion: Positive nurses' attitudes toward people with mental illness are an important outcome indicator for the prospect to improvement with treatment and prospect of recovery. The understanding of such a phenomenon may also result in an increased possibility of provided care, as well as recovery and a better life for people with mental illness. Suggestions for mental health practices, nursing education, and future research were discussed.

Keywords: Nurses; Attitude; Mental illness; CAMI; Saudi Arabia

Keywords

Nurses; Attitude; Mental illness; CAMI; Saudi Arabia

Background

Stigma toward people with mental illness was identified as the utmost obstacle to development of an effective treatment strategy, recovery [1,2], and social integration [3]. In addition, it negatively affects the quality of life for people with mental illness [4], especially in regard to their employment, financial condition, and participation in leisure activities [5,6]. Negative attitudes have been attributed to a lack of knowledge and skill in dealing with people with mental illness, as well as the community fear and view of people with mental illness as dangerous [7,8]. Previous studies showed that people with mental illness were represented in prime-time television as 10 times more likely to be involved in criminal problems when compared with healthy people. Therefore, people would prefer to locate mental health services outside the residential neighborhood [9]. However, a result of a meta-analysis study showed that most people who are violent criminals are not psychotic [10]. Therefore, stigma can aggravate a person’s mental health problems and strengthen negative attitudes and discrimination [1]. Public attitudes toward people with mental illness were widely studied. In general, negative attitudes were found in some countries, such as Nigeria [11], and were correlated with the culture such as in Oman [5]. Concerning the sociodemographic characteristics associated with the attitude, it was found that being female, older, and less educated increased the negative attitudes toward people with mental illness. However, being familiar with a person diagnosed with mental illness was related with positive attitudes [12-15].
Nurses were found to face several challenges in nursing people with mental illness, such as patients being more acute, demanding, distressed, and aggressive. These challenges may impact the role and practice of mental health nursing. Nurses are the most important contributor of care during patients’ hospitalization and have become an important source in the delivery of mental health care [16]. On the other hand, the attitudes and ability of many nurses in providing this care have been shown to be insufficient, and this may have a negative effect on providing patients’ care [17,18]. Several studies examined the nurses’ perceptions and attitudes toward people with mental illness in different countries. For example, Chambers et al. [17] compared the attitudes of 810 mental health nurses to mental illness in 72 inpatient wards and units across five European countries (Finland, Lithuania, Ireland, Italy, and Portugal). The data were collected using the CAMI scale which contains 40 items in a self-reported questionnaire. The results show that nurses’ generally hold a positive attitude toward people with mental illness. However, while nurses in Portugal hold a positive attitude toward mental illness, nurses in Lithuania hold significantly more negative attitudes. Nurses who hold a positive attitude toward people with mental illness were females in a superior position.
Some studies compare the attitudes of the mental health profession, public, and relatives toward people with mental illness. Nordt et al. [19] examined the attitudes of 1,073 mental health professionals and 1,737 members of the public toward people with schizophrenia and major depression in Switzerland. The result showed that both mental health professionals and the general public have negative stereotypes about people with mental illness. The general public accepted restrictions toward people with mental illness to a much higher degree, with the exception of compulsory admission. As anticipated, the description of schizophrenia showed the highest level of social distance. Nordt et al. [19] propose that it would be unsophisticated to think that mental health professionals hold more positive attitudes than the general public and advocated mental health professionals to investigate their attitudes more directly. In addition, in Sweden, Björkman, Angelman, and Jönsson [20] undertook a study to explore the attitudes of psychiatric and somatic care nursing staff toward individuals with mental illness. The sample consisted of 120 registered nurses or assistant nurses who were interviewed using the modified Level of Familiarity Questionnaire and the Attitudes to Persons with Mental Illness questionnaire. The result showed that nursing staff in somatic care reported more negative attitudes toward people with schizophrenia as being dangerous and unpredictable. On the other hand, psychiatric nurses showed a positive attitude toward people with mental illness. Therefore, the qualified psychiatric nursing experience, familiarity with mental illness, and the nature of the care organization were found to be more connected with mental illness concerning the prospects of improvement with treatment and recovery.
In Italy, Magliano et al. [21] compared the expressed beliefs about people with schizophrenia in 190 psychiatric nurses, 110 psychiatrists, and 709 relatives of people with schizophrenia using a vignette followed by the Questionnaire on the Opinions about Mental Illness. The researchers found that nurses had similar attitudes as psychiatrists related to the causes of schizophrenia (e.g., genetics, stress, and family conflicts, while family members reported stress, trauma, and love breakdowns). Nurses and psychiatrists held similar beliefs about the ability of a person with schizophrenia to work and understand illegal intention. In addition, nurses were found to have similar attitudes as relatives of people with schizophrenia related to the volatility and political rights of these patients.
Concerning the relationship between the sociodemographic factor and nurses attitudes toward people with mental illness, previous studies show inconsistent results regarding the age [20,22], type of qualification, educational level [23-25], position, and nurses’ years of experience [20,23,25]. All studies agree that female nurses [17,26] and previous contact with people with mental illness [20,22,24] were associated with positive nurses’ attitudes toward people with mental illness.
An extensive literature search showed no published research has been found that specifically explores nurses’ perception of people with mental illness and specifically in the Arab world. Therefore, this study aims to explore the attitude of nurses toward people with mental illness in Saudi Arabia.

Study Aims

This study aims to explore the attitude toward mental illness and persons diagnosed with mental illness held by registered nurses working in different hospital wards and to identify nurse’s sociodemographic characteristics associated with their attitudes.

Method and Subject

Design
This study employs a descriptive, cross-sectional, and correlational design.
Participants
The participants of the study were recruited through the use of a convenient sampling procedure from a general hospital in Saudi Arabia. The study participants were nurses who are working in different hospital wards. The nurses were provided with the research package, which includes a questionnaire, information sheet, and consent form. Study data were collected during a 2-week period after distribution of the questionnaire. The sample size was determined based on the Yamane formula n = N/1+ (Ne2), where n = sample size, N = population size, and e = significant level. The minimum sample size was 222 nurses at 95% confidence level and P=0.5. After obtaining the ethical approval to undertake the research, a total number of 250 research packages were distributed to different hospital wards, of which 225 questionnaires were returned and completely filled out, providing a 90% response rate.
Measure
Data were collected through the use of the CAMI scale [27]. The CAMI scale was used widely for the general community [14] and different samples of mental health professionals (psychiatrists, nurses, and medical staff) in different countries such as in Finland, Lithuania, Ireland, Italy, Portugal [17], the United Kingdom [28,29] and China (Sevigny et al.).
The CAMI scale is a self-reported questionnaire designed to measure the attitude toward people with mental illness, perception of mental illness, and community care. It consists of 40 items with a response of a 5-point scale rating: 1 strongly agree, 2 agree, 3 neutral, 4 disagree, and 5 strongly disagree. According to Taylor et al. [27], the 40 items are categorized under four main constituents which have 10 questions divided into 5 positive and 5 negative statements. The four main constitutes of CAMI are:
• Authoritarianism: denotes the interpretation of the person with mental illness as someone inferior who needs strong control.
• Benevolence: resembles a patriarchal compassion for the person with mental illness.
• Social Restrictiveness: refers to the belief that a person with mental illness is intimidating and must be avoided.
• Community Mental Health Ideology: refers to the acceptance and support of persons with mental illness and mental health facilities in the community.
Minor modification for CAMI scale was done in order to fit into Saudi Arabian culture. For example, questions that ask specifically about “a woman” were changed to “a person” in order to give an equal chance to both genders. In addition, as tax money is not applicable in Saudi Arabia, questions that focus on tax money were replaced with charity money. The validity and reliably of the CAMI scale were found to be positive with a reliability alpha range from 0.68 to 0.88 [30]. Nurse’s sociodemographic characteristics were collected by a questionnaire concerning age, gender, educational level, type of qualification, length of experience as a nurse, position held, and personal contact with people with mental illness.
Data analysis
Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 22 for Windows (SPSS Inc, Chicago, III). Descriptive statistics, e.g., mean, standard deviation (SD), were used to summarize data. Regarding the inferential statistics, a t-test was used for analyzing of continuous variables such as gender. Concerning the relationship between categorical variables (e.g., age) and scores on various domains of CAMI were examined with one-way analyses of variance (ANOVA). Variables that had significant bivariate association of p<0.05 were considered significant.
Ethical considerations
The study received permission to be undertaken from the Human and Research Ethics Committee, University of Dammam and from the King Fahad Hospital of the University. The study’s participants received written information about the study aim and procedure and voluntary participation, and they were guaranteed complete confidentiality and that the study results would be presented only at the group level.

Results

Sociodemographic characteristics
The total sample size was 225 (Table 1) with mean age of the respondents being 35.3 (S.D. 8.45). The majority of the participants were female (95.1), with an age range 18-29 (74.1), Filipino (75.1%), holding an associate degree (71.6%), and were married (69.8%). In addition, regarding years of experience, 35.1% has experience of less than 5 years, 24.4% has experience between 5 and 10 years, and 40.4% has experience of more than 10 years as a nurse. Most of the nurses were working as staff nurses (86.7%), while only 13.3% are working in managerial positions. In addition, the majority (82.2%) of the nurses reported they had no previous contact with persons diagnosed with mental illness.
Table 1: Socio-demographic characteristics of the participants (n=225).
Nurses’ attitudes toward people with mental illness
In general, nurses were found to hold positive attitudes toward people with mental illness. Nurses had higher scores on the Benevolence and Community Mental Health Ideology subscale (Table 2).
Table 2: Descriptive statistic of CAMI variables.
Characteristics associated with nurses’ attitudes toward mental illness
Table 3 shows the nurses’ characteristics associated with their attitude toward people with mental illness. An independent-samples t-test was conducted to compare previous contact with mental illness and the CAMI scale. For Authoritarianism, there was a significant difference in the scores for nurses with no previous contact with people with mental illness (M=1.91, SD=0.3) and nurses with previous contact with mental illness (M=1.76, SD- 0.4); t (223) =2.06, p=0.040. For Social Restrictiveness, there was a significant difference in the scores for nurses with no previous contact with people with mental illness (M=2.37, SD=0.46) and nurses with previous contact with mental illness (M=2.18, SD= 0.56); t (223)=2.31, p=0.02. Regarding the t-test of the relationship between nurse’s position and the CAMI subscale, there was a significant difference in the scores of authoritarianism for staff nurse (M=1.91, SD=0.3) and manager nurse (M=1.70, SD- 0.4); t (223)=2.73, p=.00. For Social Restrictiveness, there was a significant difference in the scores for staff nurse (M=2.35, SD=0.47) and manager nurse (M=2.25, SD=0.56); t (223)=1.12, p=0.026. Therefore, staff nurses hold more authoritarian and socially restrictive attitude toward people with mental illness in compare to nurse manager.
Table 3: T-test of relationship between previous contacts with mental illness, position and CAMI subscales.
Therefore, from the relationship between previous contacts with mental illness, position, and CAMI variables, the p-value shows that nurses with no previous contact with mental illness and work as a staff nurse had more negative attitudes on Authoritarian and Social Restrictiveness.
Table 4 shows the nurses’ level of education, age, and years of experience, which was associated with their attitude toward people with mental illness. A one-way ANOVA between subjects was conducted to compare the relationship between CAMI scales and education (master’s degree, baccalaureate degree, associate degree, and diploma). There was a significant relationship between benevolence, ideology, and educational level of nurses. For both Benevolence and Ideology, there was a significant effect of master, bachelor, associate, and diploma degree at the p<.05 level for the four levels [F (3,221)=5.39, p=0.001]. Post hoc comparison using a Tukey HSD test indicated that the mean score for the master’s degree (M=1. 68, SD=0.62) was significantly different than that of the baccalaureate degree (M=1.60, SD=0.43), associate degree (M=1.39, SD=0.33), and diploma (M=1.35, SD, 0.34). Therefore, nurses who hold master’s degrees have a benevolent and ideological attitude.
Table 4: ANOVA of the relationship of nurses’ level of education, age, and years of experience and CAMI subscales.
There was a significant relationship between benevolence, ideology and age at the p<0.05 level for the three age categories [F (2,222) =, P=3.99, p=0.02]. Post hoc comparisons using the Tukey HSD test indicated that the mean score for the age 18-29 (M= 1.39, SD=0.34) was significantly different than those aged 40-65 (M= 1.59, SD 0.31). Therefore, old age nurses hold more benevolent and ideological attitudes. Concerning the nurses’ years of experience, there was a significant relationship between benevolence, ideology and years of working as a nurse at the p<0.05 level for the three years of experience categories [F (2,222)=, P=7.69, p=0.00]. Post hoc comparisons using the Tukey HSD test indicated that the mean score for nurses with less than 5 years of experience (M=1.36, SD=0.32) was significantly different than those who have experience of more than 10 years (M=1.56, SD.40). Therefore, nurses with an experience of more than 10 years are scoring high in benevolence and ideology subscale, and consequently, they have a positive attitude toward people with mental illness.
Therefore, nurses who had a higher level of education, older age, and more years of experience had a more positive attitude for Benevolence and Community Mental Health Ideology.

Discussion and Implications

The aim of this study was to explore the attitude toward mental illness and persons diagnosed with mental illness held by registered nurses working in different hospital wards and to identify factors associated with their attitudes in Saudi Arabia. The results show that nurses’ attitudes toward people with mental illness were generally positive. These results are supported by findings from other studies of attitudes of nurses toward people with mental illness in five European countries (Lithuania, Italy, Ireland, Portugal, and Finland) [17], student nurses’ attitudes [31], and registered nurses’ attitudes [24]. Based on the results that nurses in general have a positive attitude toward people with mental illness, this contradicts with the societal view of people with mental illness as being dangerous and inferior. Therefore, it’s very important to view people with mental illness sympathetically and provide them with a community care centre [17]. Nurses were found to hold a similar positive attitude of psychiatrists toward community care of mental illness [28,29]. Therefore, the result of this study supports the view that nurses must encourage promoting care in the community for those suffering from mental health problems. Although community mental health care is not yet established in Saudi Arabia [32], it was recommended in order to improve and support the quality of life for people with schizophrenia [4]. The current study supported that nurses with positive attitudes toward people with mental illness are anticipated to inspire persons to be able to control their lives and improve their decision-making about their future. Furthermore, nurses are more likely to motivate hope and be eager to consider alternate approaches while providing patient care and support.
Regarding the relationship between sociodemographic characteristics (age, education, qualification, position, contact, and years of experience as a nurse) and attitudes toward people with mental illness, the result of the study was supported by previous studies in that older age nurses [7,20,33], have a positive attitude toward people with mental illness. This can be rationalized by older nurses scoring higher on social care, social integration, and social discrimination. In addition, high levels of education [33-35], more years of experience as a nurse, and previous contact with people with mental illness were associated with positive attitudes toward people with mental illness [17,33].
It has been found that nurses with a high level of education and who specified their training in psychiatric and mental health nursing were found to have positive attitudes compared to nurses with a low level of education and without any psychiatric training [20,35]. However, these results should be viewed with caution as existing positive attitudes may have led to the choice to study and train in the field of mental health, rather than the training by itself leading to personal positive views of mental illness, and this is supported by the important role of a high level of education [36]. People with a high level of education were found to more motivated to socialize with persons with mental illness and rarely view them as sinful and dangerous. Similar positive connections between educational level and acceptance toward the person with mental illness have been reported in other studies [37,38]. Therefore, it is clear that a higher level of education is definitely the best way to destroy stigmatizing attitudes and that broadcasting of information about mental illness should be powerfully encouraged.
Positive attitude of senior nurses can be explained by the fact that senior nurses have presumably remained working in mental health settings, as opposed to nurses with more negative attitudes who may have left the mental health field before reaching senior positions [17]. Another explanation for the positive connection seen in senior nurses may be explained by the difference in the amount of and type of contact with patients between nurses in junior and senior positions (Scott & Phillip). In addition, the result of this study found that nurses who were familiar with people living with mental illness hold positive attitudes. It has also been reported that nurses who are working in psychiatric and mental health facilities were reported to have more positive attitudes than those working in somatic care [20]. These results are reinforced by a comprehensive literature review undertaken by Courture and Penn [39] on the effect of interpersonal contact on stigma of mental health patients. Courture and Penn [39] emphasize that both personal and professional contact are associated with increased positive attitudes toward persons with mental illness. In addition, this result is supported by Vibha, Saddichha & Kumar [36], who reported that individuals who have family or friends with mental illness recognize people with mental illnesses in general as less hazardous and desire less social distance from them [40].
Based on the result that nurses have positive attitude toward people with mental illness, this suggests that nurses are likely to promote care in the community for people with mental health problems. Therefore, nurses are more likely to encourage individuals to take control of their lives and be proactive in decision-making about their future. Such nurses will also be more likely to inspire hope and be willing to consider alternative approaches to care and support. Greater psychiatric experience might provide a protective effect. Ward managers should capitalize on staff with this experience to facilitate in-service training for other less experienced staff. Nurse training programs should include a greater psychology component. Further cross-cultural research should be undertaken to investigate the presence or otherwise of differences in attitudes in other samples of nurses working in mental health settings across Arab countries.

Conclusion

Positive nurses’ attitudes toward people with mental illness are an important outcome indicator for the prospect to improvement with treatment and prospect of recovery. The understanding of such a phenomenon may also result in an increased possibility of provided care, as well as recovery and a better life for people with mental illness. Nurses in Saudi Arabia were found to hold positive attitude towards people with mental illness. Nurses’ age, years of experience, previous contact with people with mental illness, and positions were found have great effect in their attitude. Suggestions for mental health practices, nursing education, and future research were discussed.

Funding

This study was funded by the University of Dammam (ID#2014005), Dammam, Saudi Arabia.

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