Nursing Students’ Attitudes toward People with Mental Illness: Do they change after instruction and clinical exposure?

People with mental illness are among the most stigmatized groups of patients in the healthcare setting (Putnam, 2008). Nurses comprise roughly 15.3 percent of the healthcare team (U.S. Bureau of Labor Statistics, 2010) and have frequent direct interactions with patients. As one of the larger groups of healthcare providers, nurses can potentially influence this stigma, either by contributing to the prevalent negative attitudes, or by confronting expressions of stigma. A requirement for licensure is to take a course in Mental Health. One of the goals of this course is to decrease stigma toward people with mental illness (American Association of Colleges of Nursing [AACN], 2008). To measure whether or not this course is effective in reducing stigma, the Community Attitudes toward Mental Illness (CAMI) scale created by Taylor and Dear (1981) was utilized to measure nursing students attitudes before and after taking the required Mental Health course at the University of South Florida (USF). The results of this study support that there was a decrease in authoritarian and socially restrictive attitudes towards people with mental illness after completion of the course, with the results being a close to significant. The recommendations include repeating the study over another semester in order to test validity of results, as well as to then utilize the results to assess the need for changes in course delivery or content. NURSING STUDENTS’ ATTITUDES 3 Nursing Students’ Attitudes toward People with Mental Illness: Do they change after instruction and clinical exposure? The word “stigma” originated in ancient Greece as the marking or ‘branding” of slaves (Falk, 2001, p. 32). It has come to mean the labeling, discrimination and rejection of people who are socially and behaviorally different (Phelan & Basow, 2007). People with mental illness fall into the category of ‘different,’ because the symptoms of the various mental illnesses may interfere with their ability to fulfill society’s expectations. Society expects us to “think and act rationally and in a meaningful fashion” as well as to be actively and adequately involved in our family, community, work, and other social relationships (Falk, 2001, p. 40). People with mental illness as a whole are portrayed as violent and dangerous people that have severely disturbed thought processes and therefore have unpredictable behavior and should be feared (Ross & Goldner, 2009). The media and cinema have facilitated this portrayal of the mentally ill by depicting them in various distasteful ways. Horror movies about ‘psycho’ killers that have escaped from mental institutions are a prime example. The public, including many nurses, believe that mental illness is related to the persons own failings, such as weakness of character and morals, laziness, and lack of discipline and self-control (Ross & Goldner). These beliefs and portrayals cause discrimination leading to adverse effects on employment, income, and housing and in effect, self-esteem and self-concept (Markowitz, 1998). The stigma towards people with mental illness by healthcare providers results in disparities in access, treatment, and outcomes (Birch, Lavender, & Cupitt, 2005; De Hert et al., 2011; Phelan & Basow, 2007). People with mental illness have a higher incidence of lifetime disease and a shorter lifespan than the general population. Illnesses that are more prevalent within the population of people with mental illness include metabolic syndrome, diabetes, NURSING STUDENTS’ ATTITUDES 4 cardiovascular disease, infectious diseases, and sexual dysfunction (De Hert et al.). Women with psychiatric illness face stigmatization in the area of reproductive care, including decreased instruction regarding parenting skills, breastfeeding, and increased feelings of powerlessness and depersonalized care. (Birch et al., 2005). Healthcare providers may hesitate to fully assess the physical status of a patient with a mental illness due to discomfort with the patient’s symptomology or diagnosis (Phelan, Stradins, & Morrison, 2001). Nurses, comprising approximately 15.3 percent of the healthcare team, can have a significant impact on decreasing or contributing to the multiple healthcare disparities experienced by mental health patients (U.S. Bureau of Labor Statistics, 2010). Nurses need to be self-aware of their own stigma in order to avoid inadvertently discriminating against their patients through inappropriate distancing, inadequate teaching, or other nursing actions based in fear. Fear is a major cause of discrimination and stigma (Allport, 1954). Instruction and direct clinical exposure may help to decrease or eliminate fear. Napoletano (1981) found that instruction positively changed nursing students’ attitudes toward mental illness, especially, the etiology of mental illness. Direct contact with people who are stigmatized is an effective method of decreasing fear, increasing tolerance, and changing negative attitudes. (Allport, 1954). Being acquainted with someone with mental illness has also been shown to positively influence attitudes (Song, Chang, Shih, Lin, & Yang, 2005). In a study by Alexander & Link (2003) it was shown that participants with more overall contact with the mentally ill, “regardless of type”, viewed the mentally ill as less dangerous and “reported less desired social distance” (p. 284-285). A different study done in the social work setting found that incorporation of people with mental health issues into the classroom setting was effective in decreasing the negative attitudes held by the students toward NURSING STUDENTS’ ATTITUDES 5 the mental health population (Shor & Sykes, 2002). Surgenor, Dunn, and Horn (2005) showed significantly more positive attitudes toward people with mental illness in “final year students” than those in their first year of schooling. It was hypothesized that this was resulted from the greater likelihood of exposure to and contact with mental health patients in the final year of training. The results of a different study done in Greece suggests that practicum and clinical psychiatric exposure for a “substantial time period” can change the stereotyped and discriminating beliefs of undergraduate nurses toward those with mental illness (Madianos, Priami, Alevisopoulos, Koukia, & Rogakou, 2005). Educational programs that prepare student nurses for the professional nursing role have the obligation to foster positive attitudes towards people with mental illness (American Nurses Association [ANA], 2011). Students in baccalaureate programs are required to take a course in Psychiatric/Mental health nursing which includes objectives that focus on decreasing healthcare disparities and stigma towards people with psychiatric diagnosis (American Association of Colleges of Nursing [AACN], 2008). Outcome measures regarding attitudinal change resulting from completion of the required psychiatric course are sparse in the United States. The Community Attitudes Towards Mental Illness (CAMI) scale is one reliable instrument utilized to measure attitudes towards people with mental illness (Taylor & Dear, 1981), therefore making it a valid tool for measurement of whether or not nursing student’s attitudes towards people with mental illness change following the completion of the psychiatric mental health course. It is hypothesized that after completion of the psychiatric mental health nursing course, student attitudes will show a decrease in authoritarianism, and social restrictiveness, and an increase in benevolence and community mental health ideology and acceptance. NURSING STUDENTS’ ATTITUDES 6 Methods The CAMI scale (Taylor & Dear, 1981), a standardized tool which measures community attitudes toward the mentally ill, was integrated into a survey with additional demographic questions and given to two groups of Psychiatric/Mental Health Nursing classes in Spring 2011 at the University of South Florida (USF). The additional demographic questions included age, whether or not they have a previous college degree, gender, marital status, whether the student or a family member had utilized mental health services, subjective socioeconomic status, and the degree to which religion influenced their lives. There were also questions separate from the CAMI that measured items that were thought to be significant to the care of people with psychiatric illness in the clinical setting. These questions asked about the student’s preconceived ideas about drug use, personal cleanliness, housing status, and the student’s level of comfort in speaking to people with mental illness. The survey was administered in the beginning and at the end of the Spring 2011 semester to gauge the change in attitude toward people with mental illness after completing the required Psychiatric/Mental Health course. Statistical analysis was performed using IBM SPSS statistics version 19. (see Appendix A) Participants The participants were the students enrolled in the Psychiatric/Mental Health courses (both upper division and second degree) during the spring 2011 semester. There were N = 90 voluntary participants in the first administration of the survey and N = 82 in the second administration. 60 students were enrolled in the upper division course and 34 students were enrolled in the second degree course with one withdrawal, resulting in a total of 93 enrolled students. NURSING STUDENTS’ ATTITUDES 7 The descriptive statistics for the background characteristics of the sample are presented in the Table 1. The majority of participants were female (85.8%) and single (77.6%). Participants’ age ranged from 18 to over 50 with the largest number of participants falling between 18-20 (32.9%) years of age. The majority of participants did not have a Bachelors degree (65.1%). The majority of participants attended church (51. 5%) and most did not use mental health services (69.8%). The majority also reported that their family did not use mental health service