Attitudes of Nursing Students towards Individuals with Mental Illness before Doing the Mental Health Nursing Course ()
1. Introduction
The World Health Organization reported that about 450 million people worldwide suffer from some form of mental disorder or brain condition, and that one in four persons meet criteria for mental disorder at some point in their life [1] . Globally, it is an ongoing concern that the subject of psychiatry, psychiatrists, mental health professionals and the mentally ill patients are affected by the negative prejudices and the cultural stereotypes of the general public. Health care professions are not immune to social prejudices and surprisingly share the general public’s attitude attributed to people with mental illness [2] . Nurses play a key role in caring for the mentally ill in sickness and in rehabilitating the mentally ill after an episode of illness. In addition, majority of patients and their families who are seeking help for their mental illness rightfully expect the hospital and nursing staff to be cognisant of their needs and treat them as unique individuals without any prejudice and discrimination [3] [4] .
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 [5] . Direct contact with people who are stigmatized is an effective method of decreasing fear, increasing tolerance, and changing negative attitudes [5] . Being acquainted with someone with mental illness has also been shown to positively influence attitudes [6] .
The attitudes and knowledge of the health professionals on mental illness have been argued to be a major determinant of the quality and outcome of care for mentally ill [7] . Students starting the nursing course bring with them stereotypes and prejudice in relation to mentally-ill people, thus show lack of knowledge as to their possibilities of recovery and social living. Nursing students are likely to share the view that people experiencing a mental illness are dangerous, unpredictable, more prone to violence and at least partially responsible for their illness [2] . Exploration of stigmatizing attitudes in young people is of critical importance due to indications that, despite adolescence being the period of peak onset of mental disorders, help-seeking rates remain lower than those in other age groups [8] [9] . Some studies have examined young people’s stigmatizing attitudes towards people with mental disorders, including beliefs about those with the disorders (known as personal or, alternatively, public stigma) [10] [11] , participants’ beliefs about the attitudes of others (perceived stigma) [10] [12] , or a desire for social distance [13] .
Negative perceptions of mental illnesses have multiple ramifications for people with mental illness. It prevents people with mental illness from fully living, studying or working in the community. It is a barrier to proper care and it may even make the public less willing to pay for the care of people with mental illnesses; and contributes to the sense of hopelessness, isolation and low self-esteem for people with mental illness [14] .
Alexander and Link [15] in their study reported that the 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). Attitudes and beliefs about mental illness are shaped by personal knowledge about mental illness, knowing and interacting with someone living with mental illness, cultural stereotypes about mental illness, media stories, and familiarity with institutional practices and past restrictions (e.g., health insurance restrictions, employment restrictions; adoption restrictions) [16] [17] .
Stigma has been described as―“a cluster of negative attitudes and beliefs that motivate the general public to fear, reject, avoid, and discriminate against people with mental illnesses” [18] (p. 4). When stigma leads to social exclusion or discrimination (experienced || stigma), it results in unequal access to resources that all people need to function well: educational opportunities, employment, a supportive community, including friends and family, and access to quality health care [16] [17] [18] [19] . Those who do initiate treatment for their mental illness often fail to adhere to their treatment schedule [20] . A major factor contributing to reluctance to seek and maintain treatment is the continued stigmatization of mental illness [21] [22] [23] .
Social avoidance is common among people with mental illness and various studies suggested that the general population may accept people with mental illness socially, but tend to withdraw from more personal relationships such as working or living together [24] [25] . As a result, people with mental illness face social isolation, social distance, unemployment, homelessness, and institutionalization [26] . Negative perceptions of mental illnesses have multiple ramifications for people with mental illness. It prevents people with mental illness from fully living, studying or working in the community. It is a barrier to proper care and it may even make the public less willing to pay for the care of people with mental illnesses; and contributes to the sense of hopelessness, isolation and low self-esteem for people with mental illness [14] .
Attitudes and perceptions towards mental illness are colored by one’s cultural values and beliefs. However, there is a paucity of studies on public perceptions and attitudes towards mental illness in non-Western countries: a recent survey of 61 of such studies, found that only nine were from non-Western countries [27] . Although the tendency for health care students to avoid mental health as a career specialty is not limited to occupational therapy, it is of particular concern to a holistic profession with a long and proud tradition in mental health care. Some authors have suggested that negative attitudes toward mental illness may be one factor in students’ decisions not to enter mental health practice [28] [29] [30] .
Consistent with Link and Phelan’s [19] stigma model, laboratory research has documented that when participants are informed that another individual is mentally ill, negative attitudes are expressed. In particular, a label of mental illness evokes perceptions of dangerousness and unpredictability (e.g. [31] [32] [33] ). The second step in Link and Phelan’s [14] model of social stigma is stereotyping. As noted previously, based on a label of mental illness, people may perceive the described individual as dangerous. Despite the public’s increased familiarity with mental health issues, the association between mental illness and dangerousness persists, which has a strong negative influence on tolerance [11] [23] [32] [33] . In fact, there is evidence that this negative stereotype of dangerousness is actually more widely endorsed by society today than it has been in the past [34] . In particular, alcohol and drug problems, as well as schizophrenia, seem to connote increased perceptions of dangerousness [11] [33] . Furthermore, several studies have demonstrated that these negative stereotypes about mental illness translate into tangible consequences, such as job and housing discrimination [32] [35] [36] [37] [38] .
2. Method
A cross-sectional survey research design was used which allowed for the utilizing of quantitative data collection and data analysis. A total of 110 undergraduate students were selected using the stratified random method. Data for the study were collected through the use of a questionnaire. The data were coded and entered into SPSS version 20.
To be able to select a representative sample for the study, a sampling frame was obtained from the first, second and third year students. Gerrish and Lacey added that this “increases the precision of the estimates of error compared with simple random sampling and gives more confidence in the results” [39] (p.145). This was achieved by grouping the population according to strata (year groups). Within each stratum, the participants were further grouped by gender [40] [41] .
Inclusion and exclusion criteria. Only the undergraduate full-time students in the bachelors of science nursing program who have at least completed the first year, second year and commenced the first semester of their third year will be included in the study. Students in year 4, critical care, midwifery and the nurse anesthetist program was excluded from the sampling frame.
Ethical approval was obtained from the Research Ethics Committees of the University of Technology, Jamaica.
3. Results
Demographic Data
To describe the participants, 5 demographic items were included in the questionnaire.
Gender. Of the 110 participants in the study 5 (4.5%) were males, while 105 (95.5%) were females.
Eighty or (72.5%) of the respondents were between the ages of 18 and 25 years, 25 (22.7%) 26 - 35 years; 5 (4.5%) 36 - 45 years.
Gender by marital status. 90 (81.8%) of the respondents were single at the time of this study. This is followed by 10 (9.0%) who indicated that they were in a common-law relationships, and 10 (9.0%) were married.
Gender by student status. Most of the respondents 60 (54.5%) were in the third year, 30 (27.2%) second year and 20 (18.2%) of their programme when the study was conducted.
Research Question. What are the views of undergraduate students towards individuals identified as having a mental illness? (Table 1).
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Table 1. Views of undergraduate students towards individuals with mental illness.
4. Discussion
The intent of the study was to elicit the attitudes of the nursing students towards individuals with mental illness before pursuing the Mental Health Nursing module.
In a recent study [42] conducted among junior and senior nursing students, students with no experience in theoretical or clinical setting held greater negative stereotypes of persons with mental illness and expressed more anxiety about mental illness. Interestingly in the same study, students with prior mental health experience were more interested in a future career in mental health nursing than those who did not. More favourable attitudes towards psychiatric nursing were found when undergraduate nursing students received more hours of theoretical preparation and undertook longer clinical placement [43] .
The respondents in this study had no theoretical or clinical experience when this study was conducted. The findings of this study indicated that 30% of the nursing students agreed that “the best way to treat the mentally ill is to keep them at the hospital for years”. With the current thrust towards deinstitutionalization in Jamaica the Mental Health Nursing curriculum needs to include a unit on deinstitutionalization. In order for the students to understand the significance of deinstitutionalization-its advantages and disadvantages in order to be better informed. Stigma and discrimination continue to be deterrent to deinstitutionalized services. Pusey-Murray, et al., [44] in their study reported that the psychiatric workers see it as their right to be the custodian of the mentally ill patients care hence they questioned the ability of families and communities to relieve them of those duties. This finding is consistent with other findings on institutionalized services [45] , and inconsistent with caregivers [46] .
Although majority 101 (88%) of the students disagreed with the statement “I feel embarrassed in caring for the mentally ill patient”. It is of great necessity that the student nurses face the reality that they will be caring for the psychiatric patients. They do have medical and surgical conditions that requires them receiving quality care. Expanding our teaching strategies such as involving students in workshops and allowing them to do reflective pieces will increase their self-awareness, build self-confidence and ability to cope psychologically as they proceed to their clinical practicum at the end of this module.
However 22% of the respondents reported that they would not listen to the concerns of the mentally ill. Student nurses need to be good communicators, which takes into account being cognizant of their own communication style and taking the time to listen to their patients as this is critical to the care they deliver to the patients. They need to be able to dispel this type of attitude towards the mentally ill and communicate with them professionally and compassionately. Positive attitudes towards the mentally ill individuals will be fostered throughout the delivery of the mental health nursing module. Conversely in a study conducted by McLaughlin [47] amongst 72 student nurses took part in the study and all were second year; just over 43%, responded that being a poor listener and saying “the wrong thing” to a patient was greatest fear (p. 1224).
A little over quarter of the respondents (28%) disagreed with the statement “The mentally ill must be encouraged to live in their community and be supported by their family”. This response may have been triggered by what these students may have observed in their communities as it relates to the lack of resources and support from family members, community members, private sector and the government. Pusey and Miller [48] highlighted the fact that the systems were not in place to support caregivers, then what they on their own are able to offer may not be sufficient and may not achieve the most effective outcomes for the mentally ill patient.
From this study 59% disagreed with the statement “Whenever a person starts showing signs of mental illness they should be taken to the health facility for treatment”. There are times, however, when one’s mental illness becomes a noteworthy concern shared by the community members, as when the person is a danger to self or to others. It is important for the members to seek help for the mentally ill patient as he or she may inflict harm to self and others. Their judgment may be impaired and speech may be irrational due to hallucinations and delusions being experienced at the time. This makes them at risk of losing their lives whether by homicidal or suicidal. With regards to the statement “Anyone with a history of mental illness should be excluded from working” 51% of the respondents disagreed. Examples of stereotypes depicting people with mental illness as being incompetent can lead to active discrimination, such as are as follows: excluding people with these conditions from employment and social or educational opportunities [49] . In medical settings, negative stereotypes can make providers less likely to focus on the patient rather than the disease, endorse recovery as an outcome of care, or refer patients to needed consultations and follow-up services. The outcome would lead to the patient relapsing and having multiple admissions that will affect their socio-economic status. Campaigns and programming should be aimed at allies to help them speak out on behalf of people with mental illness against prejudicial attitudes and discriminatory behavior [50] .
In Surgenor’s research, however, 83% of students had previous contact with someone with mental disorder and a more positive attitude was reported toward them. It is not sufficient to be in contact with patients to foster positive attitudes toward them [51] . This notion is different in this study as 15% of the respondents reported that they would not associate with someone once they know they are mentally ill. It is hoped that after completing the module their perceptions would change. This has serious implications as our students at some point along their nursing journey would come across individuals with the illness or may have to care for patients on the medical, surgical, paediatric, obstetric wards etc.
Nursing students (34%) in this study reported that the mentally ill should not be spoken to about their sexual practices. It is essential to appreciate that the mentally ill patients are human beings, just as individuals without a history of mental disorder. These individuals do have sexual desires and are likely to engage in sexual activity as some of their medications may increase their sexual libido. They should be educated on safe sexual practices as they would be vulnerable to sexually transmitted infections. This kind of behavior could be dangerous and there is a possibility of transmitting and spreading STIs including HIV/AIDS [52] . This may have an adverse impact on the general population in view. More than 50 percent of chronically mentally ill patients reported engaging in sexual activity over time periods that varied from one month to one year [53] [54] [55] .
Primary preventive interventions must also facilitate patients’ communication and behavioral skills. This may enhance patients’ ability to avoid or abstain from unwanted sex, to refuse unwanted advances from men, or to advocate for alternative methods of sexuality other than sexual intercourse. Patients should also be encouraged to develop skills in insisting that prospective male partners use a condom when appropriate. Indeed, such skills can be directly targeted, in a fashion similar to those recommended for non-psychiatric patient populations [56] [57] [58] , by providing patients with an opportunity to role-play comments in response to those likely made by a resistant, defensive, or manipulative partner.
One of the many implications of chronically and variably impaired autonomy is that patients’ ability to process information about how AIDS is transmitted and prevented may fluctuate as a function of the variable impairment. Studies have revealed a number of substantial deficits in patients’ AIDS knowledge [59] [60] . For example Affro et al., [59] found that nearly 50% of their female patients did not know that a condom helps reduce the chance of contracting AIDS. They found in their study that patients with chronic mental illness scored significantly less well on questions on their AIDS knowledge compared to patients who were not psychiatrically unwell and who were of the same socioeconomic status matched for gender and age. However, score on knowledge may not differentiate high-risk from lower-risk behavior [59] .
It is noteworthy to report that 61% from this study would not be comfortable working with a mentally ill co-worker who is maintaining their treatment regimen. It is of importance that certain concepts be enforced such as the need to embrace the idea that people with mental illness are working towards recovery and they can contribute to society in a meaningful way. Notwithstanding some initial uneasiness about their behavior while on the job may be present; however this must not be directed towards them as there is just a thin line between sanity and insanity. Co-worker support is important in the rehabilitation of these individuals. Once they maintain their treatment and follow up with their appointments they can function appropriately.
5. Conclusions
The findings suggest that the attitudes of the nursing students were both positive and negative towards the mentally ill before doing the mental health nursing course. Considering the results of the present study, it seems that revision of the teaching strategies and modification of mental health educational programs of nursing schools are necessary. Reducing the stigmatization of mental illness continues to be an important goal for mental health professionals. Every student nurse needs to be grounded in the basic principles of communicating with patients and providing patient-centered care in a culturally sensitive way. Mental health assessment needs to be part of the routine nursing assessment, like taking a blood pressure or temperature, so patients can be identified and the appropriate care provided.
The information gathered could be used to create awareness amongst curriculum developers. It is also hoped that the strategies will serve as a catalyst that will engender meaningful education and mental health reform in Jamaica. Ultimately, it is the desired outcome of this study to evoke further investigations into the subject of student’s attitude toward the mentally ill in Jamaica. Although the findings in this present study cannot be generalized, they posit the belief that attitudes can be influenced by their classroom theory and their supervised clinical experience.
6. Limitations
The following limitations were encountered during the conduct of this study. First, the study was carried out at only one university, thus the finding cannot be generalized to the entire population of undergraduate students in Jamaica. A further limitation is that the present study was cross-sectional, this design only provides a snapshot: hence the situation may provide differing results if another time-frame had been chosen. Studies older than 10 years were used; due to their immense value they were included. Regardless of these limitations this study has relevance and is useful for the university in planning its orientation services on campus and the school of nursing in preparing the students during the pre-orientation segment before they are assigned to the clinical areas.