|Year : 2022 | Volume
| Issue : 2 | Page : 112-116
Attitude of nursing students toward people living with mental disorder
Kinley Gyaltshen1, Dawa Gyeltshen2, Nima Dorji3, Kuenzang Kuenzang4, Nguldup Gyeltshen5
1 Assistant Professor, Nursing Department, Faculty of Nursing and Public Health, Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu, Bhutan
2 Registered Nurse, Department of Medical and Health Services, Daga Hospital, Dagana, Bhutan
3 Registered Nurse, Department of Medical and Health Services, Punakha Hospital, Punakha, Bhutan, Bhutan
4 Lecturer, Nursing Department, Faculty of Nursing and Public Health, Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu, Bhutan
5 Associate Lecturer, Midwifery Department, Faculty of Nursing and Public Health, Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu, Bhutan
|Date of Submission||06-Sep-2021|
|Date of Decision||11-Jan-2022|
|Date of Acceptance||13-Jan-2022|
|Date of Web Publication||27-Dec-2022|
Prof. Kinley Gyaltshen
Department of Nursing and Midwifery, Faculty of Nursing and
Source of Support: None, Conflict of Interest: None
Background: Stigma held by health-care professionals toward people with mental illness can have serious negative impact on the quality of care provided by them. It is essential to adequately train the nursing students to develop favorable attitudes toward mental illness. In Bhutan, the level of stigma among student nurses remains understudied. Objective: The objective of this study is to investigate the attitudes of student nurses toward people with mental illness. Methods: It was a cross-sectional survey. A total population sampling technique was used. Two hundred and thirty-six student nurses completed a 40-item Community Attitudes toward Mentally Ill (CAMI) questionnaire to determine whether people with mental illness were viewed as “inferior;” deserving “sympathy;” perceived as a “threat” to the society or “acceptable” in the community. Independent t-tests and the analysis of variance were performed to determine the association of categorical variables with the CAMI. Results: Nursing students had favorable attitudes toward people with mental illness. The mean scores for the authoritarian (27.56 ± 3.95), benevolence (39.33 ± 3.71), social restrictiveness (21.51 ± 4.54), and community mental health ideology (37.29 ± 4.85) subscales reflected a positive attitude of student nurses. There was significant difference (F = 4.79, P < 0.01) only in the dimension of authoritarianism when CAMI subscales were compared according to the level (year) of the course. Conclusion: The study confirmed positive attitudes of student nurses toward people with mental illness. However, no significant difference in attitudes of student nurses according their level (year) of study underscores the need for revisiting current psychiatric curriculum and calls for further studies in the area.
Keywords: Attitude, Community Attitudes toward Mentally Ill Scale, mental disorder, nursing students, stigma
|How to cite this article:|
Gyaltshen K, Gyeltshen D, Dorji N, Kuenzang K, Gyeltshen N. Attitude of nursing students toward people living with mental disorder. Indian J Psy Nsg 2022;19:112-6
|How to cite this URL:|
Gyaltshen K, Gyeltshen D, Dorji N, Kuenzang K, Gyeltshen N. Attitude of nursing students toward people living with mental disorder. Indian J Psy Nsg [serial online] 2022 [cited 2023 May 28];19:112-6. Available from: https://www.ijpn.in/text.asp?2022/19/2/112/365474
| Introduction|| |
Attitudes toward mental illness have been considered a crucial challenge in the lives of individuals with mental disorders. Not only does it exist among the general population, researches have mentioned that stigma and discrimination toward people with mental disorders might exist within the medical environment and may compromise patient care., For example, researches have reported these negative attitudes held by mental health professionals, such as doctors, psychiatrists, psychologists, nurses, or nursing students.,,,,,,
In the management of mental illnesses, the attitude of the treating health professionals toward mental illness can affect the quality of care provided by them. Nurses are health-care professionals who are most likely to interact with people with mental illness. Studies have reported the negative attitudes of nursing students and have suggested urgent need to improve their attitudes through innovative teaching strategies.,, A study has reported that an attitude once developed during training can remain stable over the years.
It is imperative that we examine the attitudes of nursing students toward people with mental disorders to guide reforms in teaching strategies. To our knowledge, no studies are done to evaluate the nursing students' attitudes toward people with mental illnesses in Bhutan. This study, therefore, aimed to investigate the attitudes among student nurses toward people living with mental illness and determine the association of categorical variables with stigma. Furthermore, this study aimed to compare the attitudes and stigma of nursing students based on the level (year) of their course. The findings from this study were expected to reveal the nursing students' attitudes toward people with mental illness and appropriately guide in designing their mental health curriculum.
| Methods|| |
This study used a cross-sectional survey method. In Bhutan, there are in total four nursing institutes: (1) Faculty of Nursing and Public Health, (2) Apollo Bhutan Institute of Nursing, (3) Faculty of Nursing and Midwifery, Royal Thimphu College, and (4) Arura Academy of Health Sciences. There were about 298 nursing students altogether pursuing diploma level General Nursing and Midwifery (GNM) and Bachelor of Science in Nursing (BSc Nursing) courses in these four nursing institutes during the time of data collection. A total population sampling technique was used to recruit all nursing students of all four nursing institutes. The response rate was 80% and there were no missing data. In total, 236 nursing students completed the survey questionnaires. The survey was done in March 2020, and the questionnaires were administered face-to-face where respondents were asked to fill in the questionnaires using paper and pen, except for students of Arura Academy of Health Sciences who were under lockdown due to COVID-19 local transmission for which data were collected online using the free Google survey form. All participants were given a verbal explanation of the aims and objectives and the methodology used.
Two questionnaires were used: The Sociodemographic questionnaire and the Community Attitudes to Mental Illness (CAMI) scale to measure the level of stigma. CAMI scale was developed by Taylor and Dear and consists of 40 items rated on a 5-point Likert scale (1 = strongly agree, 2 = Agree, 3 = Neutral, 4 = Disagree, and 5 = Strongly disagree). CAMI scale is divided into four subscales: Authoritarianism (AU), Benevolence (BE), Social Restrictiveness (SR), and Community Mental Health Ideology (CMHI). Authoritarian attitudes are based on the belief that patients with mental disorders are inferior, and therefore require assertive handling; BE is a humanistic and sympathetic view of mentally ill persons; social restrictiveness refers to viewing the mentally ill as a threat to the society and should be avoided; and CMHI is the acceptance of mentally ill patients in the community. Each subscale consists of 10 items and scores range between 10 and 50. Overall stigma is computed by summing the scores across all subscales. Negatively stated items are reverse coded for analysis. Higher numerical scores indicate greater stigma. A total CAMI score of greater than the mean indicates an overall negative attitude and vice versa. The internal consistency values for the subscales from a previous study ranged from satisfactory (AU, α = 0.68) to good (BE, α = 0.76, SR, α =0.80, CMHI, α = 0.88).
The ethical clearance to conduct this study was sought from the Research Ethics Board of Health, Bhutan vide approval number REBH/Approval/2020/037. Participants were informed of the study aims and the involvement procedures including their right to withdraw from the study at any time or stage without any penalty. Informed consent was obtained from all study participants. Confidentiality and anonymity were maintained whereby names or identifiers were not disclosed.
The data were entered into Microsoft Excel and analyzed using Minitab version 17. Descriptive statistics were used to analyze the sociodemographic data. Reverse coding was performed for negative statements of the CAMI scale. Before performing the parametric tests, the stigma values were checked for normality using the Anderson-Darling test. After performing the assumption tests, independent sample t-test and one-way ANOVA were used to compare the mean scores of the outcome variable between the categorical variables by using a significance level of <0.05. The Tukey post hoc test was performed to reveal the categorical variables with significantly different mean score of the outcome variables.
| Results|| |
The sample consisted of 236 nursing students. 72.46% (n = 171) were females and 63.14% (n = 149) were pursuing GNM course [Table 1]. 22.88% (n = 54) were in the first year of their study, 43.22% (n = 102) in second year, and 33.90% (n = 80) in 3rd year. The mean age of the participants was 20.59 + 1.69 years. Majority of the participants (64.83%, n = 153) were from private nursing institutes.
Parametric test (independent sample t-test) highlighted significant differences between nursing students' attitudes toward people with mental illness and their gender (t = −4.23; P ≤ 0.001), and course, whether GNM or B.Sc. Nursing (t = −3.20; P = 0.002). However, there was no significant difference in attitudes between nursing students of government and private nursing institutes (t = −0.44; P = 0.661).
Mental health information
Almost all the participants (99.58%, n = 235) had heard about mental illness before [Table 2]. 88.14% (n = 208) reported that they had seen a patient with mental illness before and 25.85% (n = 61) had worked with people with mental illness. Majority (86.86%) reported that they had no family history of mental illness.
There were no significant differences in CAMI results between participants for following variables: who had seen a patient with mental illness before and who had not (P = 0.562), who had worked with people with mental illness and who never had (P = 0.647), and with and without family history of mental illness (P = 0.920).
Attitude toward people with mental illness
The mean attitude score was on a lower side (92.45 ± 13.01), i.e., lesser than the neutral score of 120, reflecting a favorable attitude of nursing students toward people with mental illness [Table 3]. The highest mean score (39.33 ± 3.71) was found in the benevolence dimension and the lowest (21.51 ± 4.54) was in the social restrictiveness dimension.
|Table 3: Attitudes of nursing students toward people with mental illness|
Click here to view
Level (year) of study and attitude
There were no statistically significant differences in total CAMI scores by year in which nursing students were studying [Table 4]. However, when the CAMI subscale scores were compared based on their level (year) of the course, there was statistically significant difference in the dimension of AU (P = 0.009). The Tukey post hoc test revealed that nursing students in first year and third year had significantly different mean score of AU (P = 0.006). No significant differences were observed between level of course and the dimensions of BE (P = 0.613), social restrictiveness (P = 0.525), and CMHI (P = 0.183).
|Table 4: Scores of stigma and community attitudes towards mentally ill subscales according the level (year) of the course|
Click here to view
| Discussion|| |
This study mainly highlighted the overall attitude of nursing students toward people with mental illness and the comparison of the effectiveness of the mental health module on nursing students' attitudinal changes. The findings from this study are encouraging as it demonstrated a generally favorable attitude toward people with mental illness within nursing student population. In this study, the attitudes were more positive for benevolence and CMHI subscales suggesting that nursing students had a humanistic and sympathetic view toward mentally ill and were accepting mental health services and people with mental illness in the community. The mean score for social restrictiveness subscale was on a lower side (21.51 ± 4.54) suggesting that nursing students did not believe people with mental illness as a threat to the society. The AU dimension had a slightly lower mean score (27.56 ± 3.95) suggesting that nursing students do not consider people with mental illness as inferior requiring close supervision.
The findings of this study are congruent with previous studies where nursing students were reported to hold generally positive attitude toward mental illness., Considering the participants' age range of 17–22 years in this study, it could reflect a growing knowledge and understanding about mental disorders among the younger age group. Similarly, studies have found that people from younger age group tend to be less stigmatizing than ones from older age groups., Moreover, as nursing students, they are more familiar and knowledgeable about mental disorders and that might have led to less stigmatizing attitudes toward people with mental illness.
The findings of this study highlighted significant difference in the attitudes toward mental illness between the two genders (P ≤ 0.001). Similar findings were reported in previous studies where female students had expressed more favorable attitudes toward people with mental illness.,, Furthermore, this study found no significant difference in attitudes toward people with mental illness between nursing students with or without family history of mental illness (P = 0.920). This is in contrast to the findings from earlier studies where having a family member who had mental illness was found to be associated with lower stigmatizing attitudes., The reason could be because only 13.14% of the participants in this study had family history of mental illness out of which just 7.63% had lived with the family member who had mental illness, thereby underrepresenting the group. No significant difference in the nursing students' attitude toward people with mental illness was found in this study between those who have seen or worked with people having mental illness before and those who had not. This finding is contrary to previous findings where having experienced mental illness had a positive impact on the attitudes of the students toward people living with mental disorders. The reason could be because there were too less participants in this study who had not seen (11.86%) or worked with people having mental illness before (25.85%).
This study found no significant difference in attitudes toward people with mental illness in respect to their level (year) of study, except for the dimension of AU. The finding indicates that mental health curriculum did not change students' beliefs about mental illness in the dimensions of benevolence, social restrictiveness, and CMHI. This contrasts with previous findings where psychiatric training was found to improve the attitude toward mental illnesses among the nursing students.
The present study has several limitations. First, it was a cross-sectional study and causal link cannot be established. Second, the data were self-reported, and therefore, not immune to reporting bias. Third, the sampling technique used is also one of the limitations and thus, result may represent the population studied but generalization of result to a larger population should be done with caution.
| Conclusion|| |
The findings of this study suggest that nursing students in Bhutan have a favorable attitude toward people with mental illness. However, their attitudes have not changed after the completion of their psychiatric course. Therefore, revision and modification of mental health educational programs of the nursing institutes in Bhutan may further improve the nursing students' attitudes toward people with mental illness. More hours of theoretical preparation and longer clinical placement are recommended to instill more favorable attitudes toward psychiatric nursing.
The authors would like to thank the Dean, faculty members, and the nursing students of Faculty of Nursing and Public Health, Apollo Bhutan institute of Nursing, Royal Thimphu College, and Arura Academy of Health Sciences for their kind help and co-operation. We also extend our gratitude separately to Faculty of Nursing and Public Health for the financial support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Arvaniti A, Samakouri M, Kalamara E, Bochtsou V, Bikos C, Livaditis M. Health service staff's attitudes towards patients with mental illness. Soc Psychiatry Psychiatr Epidemiol 2009;44:658-65.
Ay P, Save D, Fidanoglu O. Does stigma concerning mental disorders differ through medical education? A survey among medical students in Istanbul. Soc Psychiatry Psychiatr Epidemiol 2006;41:63-7.
Chambers M, Guise V, Välimäki M, Botelho MA, Scott A, Staniuliené V, et al.
Nurses' attitudes to mental illness: A comparison of a sample of nurses from five European countries. Int J Nurs Stud 2010;47:350-62.
Hansson L, Jormfeldt H, Svedberg P, Svensson B. Mental health professionals' attitudes towards people with mental illness: Do they differ from attitudes held by people with mental illness? Int J Soc Psychiatry 2013;59:48-54.
Happell B, Gough Nee Hayman-White K. Undergraduate nursing students' attitudes towards mental health nursing: Determining the influencing factors. Contemp Nurse 2007;25:72-81.
Ross CA, Goldner EM. Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: A review of the literature. J Psychiatr Ment Health Nurs 2009;16:558-67.
Hastings T. Nursing Student Attitudes toward Mental Illness: A Quantitative Quasi-Experimental Study. Phoenix: University of Phoenix; 2015. p. 123.
Morrison R. Nursing Students' Attitudes toward People with Mental Illness: Do They Change after Instruction and Clinical Exposure? Tampa: University of South Florida; 2011. p. 39.
Vijayalakshmi P, Thimmaiah R, Chandra R, BadaMath S. Bachelor of nursing student' attitude towards people with mental illness and career choices in psychiatric nursing. An Indian perspective. Invest Educ Enferm 2015;33:138-54.
Linden M, Kavanagh R. Attitudes of qualified vs. student mental health nurses towards an individual diagnosed with schizophrenia. J Adv Nurs 2012;68:1359-68.
Surgenor LJ, Dunn J, Horn J. Nursing student attitudes to psychiatric nursing and psychiatric disorders in New Zealand. Int J Ment Health Nurs 2005;14:103-8.
Balhara YP, Mathur S. A comparative study of attitudes toward psychiatry among nursing students across successive training years. Indian J Psychol Med 2013;35:159-66.
] [Full text]
Poreddi V, Thimmaiah R, BadaMath S. Medical and nursing students' attitudes toward mental illness: An Indian perspective. Invest Educ Enferm 2017;35:86-94.
Glasman LR, Albarracín D. Forming attitudes that predict future behavior: A meta-analysis of the attitude-behavior relation. Psychol Bull 2006;132:778-822.
Taylor SM, Dear MJ. Scaling community attitudes toward the mentally ill. Schizophr Bull 1981;7:225-40.
Happell B, Platania-Phung C, Bocking J, Scholz B, Horgan A, Manning F, et al.
Nursing students' attitudes towards people diagnosed with mental illness and mental health nursing: An international project from Europe and Australia. Issues Ment Health Nurs 2018;39:829-39.
Shammari M, Waggas DS, Hasan AA. Assessment of nursing students' attitudes and stigma towards mental illness: A cross-sectional study. J Nurs Educ Pract 2020;10:1-11.
Chong SA, Verma S, Vaingankar JA, Chan YH, Wong LY, Heng BH. Perception of the public towards the mentally ill in developed Asian country. Soc Psychiatry Psychiatr Epidemiol 2007;42:734-9.
Subramaniam M, Abdin E, Picco L, Pang S, Shafie S, Vaingankar JA, et al.
Stigma towards people with mental disorders and its components – A perspective from multi-ethnic Singapore. Epidemiol Psychiatr Sci 2017;26:371-82.
Connaughton J, Gibson W. Physiotherapy students' attitudes toward psychiatry and mental health: A cross-sectional study. Physiother Can 2016;68:172-8.
Hailesilassie H, Kerebih H, Negash A, Girma E, Siebeck M, Tesfaye M. Attitude of medical students towards psychiatry: The case of Jimma university, Southwest Ethiopia. Ethiop J Health Sci 2017;27:207-14.
Thongpriwan V, Leuck SE, Powell RL, Young S, Schuler SG, Hughes RG. Undergraduate nursing students' attitudes toward mental health nursing. Nurse Educ Today 2015;35:948-53.
Foster K, Withers E, Blanco T, Lupson C, Steele M, Giandinoto JA, et al.
Undergraduate nursing students' stigma and recovery attitudes during mental health clinical placement: A pre/post-test survey study. Int J Ment Health Nurs 2019;28:1065-77.
Samari E, Seow E, Chua BY, Ong HL, Abdin E, Chong SA, et al.
Stigma towards people with mental disorders: Perspectives of nursing students. Arch Psychiatr Nurs 2018;32:802-8.
Çetinkaya Duman Z, Partlak Günüşen N. Effects of the psychiatric nursing course on students' attitudes towards mental illnesses, perceptions of psychiatric nursing and career choices. Türkiye Klin J Nurs Sci 2017;9:255-64.
[Table 1], [Table 2], [Table 3], [Table 4]