Special Article - Psychiatric Nursing
Austin J Nurs Health Care. 2016; 3(2): 1034.
A Survey of the Attitudes of Nurses towards Caring for the Mentally Ill at a Rural General Hospital
Matthews LM¹, Rhoden-Salmon DD²*, Silvera H², Waite MJ² and Barton-Gooden AO²
¹St. Thomas Health Department, Jamaica
²UWI School of Nursing University of the West Indies, Jamaica
*Corresponding author: Rhoden-Salmon DD, UWI School of Nursing University of the West Indies, 9 Gibraltar Camp Way, Mona, Kingston 7, Jamaica
Received: November 16, 2016; Accepted: December 12, 2016; Published: December 14, 2016
Abstract
Background: Mental illness is a global problem affecting millions of people. There has been an increase in the number of mentally ill persons who are treated in the general hospital setting due to decentralization of mental health services.
Objectives: The purpose of the study is to explore the attitudes of nurses at a rural general hospital, with an aim to improve services offered to persons with mental illness.
Methods: A descriptive study survey was carried out among nurses in a general hospital. The data was collected through a self-administered questionnaire which was taken from a previous study. Data was analyzed using SPSS® version 20.
Results: A total of 84 questionnaires were administered with a response rate of 92.8%. All respondents were females with an average age of 35.7±8.3 years. Most of the nurses (42%) had 11-41 years of work experience. Most of the nurses (70.5%) had a negative attitude towards caring for the mentally ill. All nurses had psychiatric nursing in their basic training but only 98.7% had no additional training and 88% had no continuing education in psychiatric nursing. The majority (88%) of the nurses had a positive attitude towards the environment in which care is offered to the mentally ill.
Conclusion: Most of the nurses surveyed had a negative attitude towards mental illness. There needs to be more trained psychiatric nurses in the hospital and continuing education sessions/workshops to reduce the negative attitudes of these nurses. More research is needed to have an in-depth understanding of the issues.
Keywords: Nurses; Attitude; Mentally ill; General hospital
Abbreviations
WHO: World Health Organization; UHWI/UWI/FMS: University Hospital of the West Indies/University of the West Indies/ Faculty of Medical Sciences
Introduction
Mental illness is a global problem affecting over 179 million persons [1]. The effects on disability, co-morbidity and mortality are felt universally [2]. In 2000, the Ministry of Health in Jamaica introduced the concept of decentralization and deinstitutionalization of mental health services from the mental hospital [3]. As a result, each parish is required to treat all their mentally ill in the general hospital setting instead of sending them to a psychiatric hospital. The implications for this are that patients would be cared for in general hospitals throughout the country and will be exposed to nursing personnel who have minimal experience or exposure dealing with the mentally ill.
Hogberg, Magnusson and Lutzen conducted a study of psychiatric nurses which reveals that additional knowledge about mental illness doesn’t always bring about positive attitudes towards persons with mental illnesses [4]. Mental health nurses were also found to have negative views and discriminatory behaviors towards clients suffering with a mental illness [5]. A descriptive correlational design of 92 mental health nurses found that 60% of the psychiatric nurses in Jordan have negative attitudes toward these patients with mental illness, and the quality care provided to those patients were of low standards [6].
A cross sectional study done across five European countries, found that nurses working in mental health in general have a more positive attitude towards persons with mental illness based on their country’ practice, gender and position. In Portugal, the nurses have a more positive attitude compared with Lithuania. These differences could be as a result of the organization of the psychiatric services in Portugal [7]. This study can be generalized as the study was done across five countries and a sample size of 810 nurses.
The aim of this study is to investigate the attitude of nurses working in a general hospital towards the care of the mentally ill. The objectives are to determine nurses’ attitude towards care of the mentally ill patients in a general hospital; to describe the demographic characteristics of nurses working in a general hospital and to explore the nurse attitude to the environment in which care is offered to the mentally ill in a general hospital.
Methods
A self-administered questionnaire was utilized to explore the attitudes of nurses working in a general hospital. The hospital has a total population of 102 registered and enrolled assistant nurses. The study was conducted with nurses at Princess Margaret hospital that provides medical, surgical, obstetrics and pediatric care and treatment to patients.
The sample was determined using the Raosoft sample size calculator. The margin of error accepted was 5%, confidence level was set at 95%, a distribution response of 50% and a population of 102 (Raosoft, 2004). This resulted in a sample size of 81. However, to take into consideration the rate of attrition and the fact that a number of these nurses are on leave a census sample of the total population of 102 was used. Nurses on leave and nurses who do not wish to participate will be excluded from the study.
Data was collected using a self-administered questionnaire, which consists of 40 items. The study was done in two parts, a selfadministered questionnaire which consists of likert type questions. Section A consist of demographic data and section B contain statements about the nurses’ attitude towards caring for the mentally ill. The attitude questions were adapted from a questionnaire developed by Lethoba [8]. The question asking “I believe that mental illness is caused by “witchcraft” was modified to “I believe that mental illness is caused by “obeah” since the latter term is used in Jamaica.
The data was collected in April - May, 2013 from nurses while they were working on their assigned shift. A consent form explaining the aim of the study and their rights as a participant was given prior to the administering of the questionnaire. Nurses who participated in the study signed the consent form, a copy was given to the participant and one copy was kept by the researcher. The participants were asked not to put their names on the questionnaire. Confidentiality and anonymity was maintained. Each completed questionnaire was placed in an envelope and sealed by the participants. A large envelope was placed on each ward, where each participant placed their sealed envelopes which was kept in a locked cabinet to which only the charge nurse had the key. This was collected daily.
The instrument was pretested among the masters student of the University of the West Indies School of Nursing. Items were refined based on feed-back received from the participants. One question was deleted “Mentally ill patients communicate with body gestures” based on feedback from masters student. Seven (7) items were deleted to improve internal consistency of the scale resulting in a cronbach alpha of 0.79.
Data was analyzed using the Statistical Package for Social Sciences version 20® 2010. This method employs coding of some variables into differences variables and aggregation of attitudinal variables. Tables and bar charts were used to highlight results of the findings. A descriptive analysis using frequency, means and distribution of data was carried out and also looked at correlation between relevant variables, such as age, nursing qualifications and years of experience.
Ethical approval was sought and granted by the UHWI/UWI/ FMS Ethics Committee, Ministry of Health and South East Regional health Authority. Permission was requested and granted by the Chief Executive Officer of the Princess Margaret Hospital. The data collection tool utilized was adapted from a previous study. Participants of the pre-test and main studies confidentiality were respected. Participants were assured that information would be kept confidential and will only be used by the researcher.
Results
Respondents were registered and enrolled assistant nurses who were employed in a general hospital. They had psychiatric training in their nursing education or may have done an additional course in psychiatric nursing. A total of 78 responses (92.8% response rate) were analyzed. Table 1 shows the demographic characteristics of the sample. All the nurses were females with age ranging from 23-64 years. Mean age was 35.7±8.3 years. Most of the nurses (64%) were in the 31-44 year age group. More than half (65%) of the respondents were registered nurses. Regarding nursing qualification, 45% of the registered nurses had a certificate in their specialty. Twenty percent were nurses with bachelor’s degree and were registered nurses. All the enrolled assistant nurses (35%) had diplomas. The data shows that 42% of the respondents had 11-41 years of work experience. Mean years of experience was 9.6±7.7 years (Table 1).
Variables
N
%
Gender
females
78
100
males
0
0
Age groups
23-30
20
26
31-44
50
64
45-64
8
10
mean±SD
35.7±8.3
Job title
Nursing Administrator
4
5
Ward supervisor
5
6
Staff nurse/midwife
18
23
Staff nurse
24
31
EAN
27
35
Educational qualification
RNs
Certificate
35
45
Bachelors
16
20
EANs
Diploma
27
35
Years employed
1-5 years
6-10 years
28
17
36
22
mean±SD
11-41 years
9.6±7.7
33
42
Table 1: Demographic characteristics of sample.
Most of the respondents (98.7%) reported that they did not have additional training in psychiatry. Of the total 12% or 9 nurses had continuing education (6 registered nurses and 3 enrolled assistant nurses). The data shows that 78% of the respondents had interaction with the mentally ill outside of work (Table 2).
Variables
N
%
Additional training
Yes
1
1.3
No
77
98.7
Continuing education
Yes
9
12
No
69
88
Interaction outside of work
Yes
61
78
No
17
22
Table 2: Education and personal experience with mentally ill patients.
Approximately one third of the respondents (35%) had family members with a mental illness. Of the types mentioned 59% of the respondents had family members diagnosed with schizophrenia.
Attitude
The scores for the 30 attitudinal variables were aggregated and range from 72 to 134. The 75 percentile was used to determine the cutoff score, which was used to describe positive attitudes. Higher scores from 107 to 150 indicate positive attitudes while lower scores represent negative attitudes. This was the value for which 25% of the sample scored above 107.25. 29.5% had a positive attitude compared to 70.5% who had a negative attitude towards caring for the mentally ill in a general hospital.
Table 3 illustrates that 28.6% of the nurses who had a certificate had a positive attitude towards caring for the mentally ill compared to 37.5% who had a bachelor’s and 25.9% who had a diploma. Of the total nurses who had a certificate 71.4% had a negative attitude towards caring for the mentally ill compared to 74.1% with a diploma and 62.5% who had a bachelor’s degree. The enrolled assistant nurses had the most negative attitude towards the mentally ill (Table 3).
Positive Attitude (%)
Negative Attitude (%)
Total (N)
RNS
Certificate
28.6
71.4
35
Bachelor’s
37.5
62.5
16
EANs
Diploma
25.9
74.1
27
Total
29.5
70.5
78
x2= 0.673,p= 0.714
Table 3: Attitude towards mental illness by educational level.
The findings show that a higher proportion (42%) of the staff nurses had a positive attitude towards caring for the mentally ill compared to the other groups with 22% (staff nurse/midwife and nursing supervisors) and 26% with the enrolled assistant nurses. These two groups, the nursing supervisors and staff nurse/midwife had similar rating (78%) for negative attitude towards caring for the mentally ill followed by the enrolled assistant nurses with 74% (Table 4).
Positive Attitude (%)
Negative Attitude (%)
Total (N)
Staff nurse
42
58
24
Staff nurse/ midwife
22
78
18
Nursing supervisors
22
78
9
Enrolled assistant nurse
26
74
27
Total
29.5
70.5
78
x2 =5.234, p=0.264
Table 4: Attitude towards caring for the mentally ill by job title.
Nurses in the age group 23-30 (35%) had a more positive attitude towards caring for the mentally ill in comparison to the other age groups 31-44 years with 28% and 45-64 years with the lowest 25%. The nurses in the 45-64 age groups (75%) had the most negative attitude towards caring for the mentally ill, followed by the 31-44 age groups (72%) and the 23-30 age groups (65%). There were no significant differences among the nurses in regards to job title, represented by a p = value of 0.809.
The nurses with the most years of experience have the most positive attitude towards the mentally ill (36%). There were no significant differences, represented by a p= value of 0.181, between these nurses and the ones with 1-5 years of experience (32%). The nurses with 6-10 years of experience had the least positive attitude (12%). The nurses with 6-10 years of experience have the most negative attitudes towards caring for the mentally ill (88%). Sixty-eight percent of the nurses with 1-5 years of experience have a negative attitude while the nurses with 11-41 years have the least negative attitude (64%).
The majority of the respondents (88%) disagree that the best way to handle a mentally ill is to keep him/her behind locked doors and 82% disagree that it is a waste of time to nurse mentally ill in a general hospital. A total of 62% disagreed that mentally ill patients should always be admitted to hospitals with high fence and security guards; more than half 55% of the respondents did not think that the mentally ill should be nursed in isolation, and must not be in a general hospital (Table 5).
Questions
Agree %
Undecided %
Disagree %
The best way to handle a mentally ill is to keep him/her behind locked doors. Some percentages do not add up to 100%
4
9
88
It is a waste of time to nurse mentally ill in a general hospital.
11
6.4
82
Mentally ill patients should always be admitted to hospitals with high fence and security guards.
25
13
62
I feel the mentally ill should be nursed in isolation; they must not come to a general hospital.
32
13
55
It is difficult to admit mentally ill in a general hospital
36
11
53
It is easy for me to nurse ten other patients in a general hospital ward than one mentally ill patient.
36
14
49
Table 5: Attitude towards the environment.
Discussion
The aim of this study was to investigate the attitude of nurses working in a general hospital towards the care of the mentally ill. The majority of the nurses had a negative attitude towards caring for the mentally ill; on the other hand, most of the nurses had a positive attitude towards the environment in which care is offered to the mentally ill.
The findings of this study showed that most of the participants (70.5%) have a negative attitude towards caring for the mentally ill in a general hospital. This study has shown that the attitudes of these nurses are comparable to other nurses in the world. Reed & Fitzgerald, found that approximately half of the participants in their study had a negative attitude towards mental illness [9]. Nigerian health workers also have negative attitudes towards mental illness, due to their “deeply rooted negative cultural beliefs” and aggressive behaviour towards health workers [10]. A study survey done among young Jamaicans showed that negative attitudes exist towards the mentally ill in our society [11]. This shows that professional training doesn’t determine the attitude of nurses towards caring for the mentally ill in a general hospital [12]. Previous studies from Sweden and across five European countries showed that nurses had a negative attitude in keeping with the attitude of the general public [7,13].
The findings of this study although limited, points to the fact that 1.3% of the nurses who had additional training had a positive attitude towards mental illness and 6 or 67% with continuing education sessions on caring for the mentally ill and Schizophrenia had a positive attitude. Reed & Fitzgerald suggest that a limited amount of educational session conducted on caring for the mentally ill can be beneficial if done on a continual basis in the workplace [9].
This study also showed that nurses with a bachelor’s degree have a more positive attitude towards patients with mental illness. Previous studies done by Tay, Pariyasami, Ravindran, Ali & Rowsudeen and Ebrahime, Namdar & Vahidi found that education can increase knowledge and skills and nurses with their bachelor’s degree have a more positive attitude than other nurses [14,15].
The findings of this study showed that most of the sample (78%) had some contact with the mentally ill outside of work either in their communities or with relatives. However it was interesting to note that these nurses also displayed a negative attitude towards the mentally ill. However, other studies have shown that increased contact with the mentally ill has increased positive attitude [9,16,17,]. This study has not supported the findings of those studies. Of the respondents who had contact with the mentally ill 76% had a negative attitude towards these clients. Chow, Kam and Leung, agreed that having a family member or having contacts with the mentally ill doesn’t affect attitudes [18]. Chow et al in their study found that negative experiences increase the negative attitude of health care providers and this personal contact can be seen as a “double bind” where positive experience can decrease negative attitudes or negative experience increase negative attitudes [18]. Violent behaviors are most times meted out to family members, caregivers and friends by these mentally ill persons, hence the reason why some family members have negative attitudes towards these clients [10].
Nurses with the most years of experience (11-41 years) had the most positive attitude towards caring for the mentally. This finding is comparable to a study by Chow, Kam and Leung which state that as the years of experience increased so did the attitude towards caring for the mentally ill due to their frequent contact [18]. However, this is contradicted by Minas, Zamzam, Midin & Cohen and Ngirababyeyi who found that work experience did not influence attitudes [19,20]. Bjorkman et al found that years of experience influenced attitudes [21]. As the years of experience increased the nurse would have had several interactions with the mentally ill and developed therapeutic ways of communicating with these patients. On the other hand, if during these years they had negative experiences then the negative attitude might persist.
The findings of this study also showed that staff nurses and younger nurses (23-30 year olds) have the most positive attitudes towards the mentally ill. Bjorkman et al found that nurses who recently received their training have a more positive attitude [22]. This might be as a result of them still having the knowledge and skills from their undergraduate studies. They may also be exposed to more up to date ways of dealing with the mentally ill which may influence their attitude and care of the mentally ill.
Minas et al in their study found that the negative attitudes in the senior nurses may be as a result of them receiving training years ago and the impact of such training has waned [23]. In our context the findings might be similar.
Although the majority of the respondents have a negative attitude towards caring for the mentally ill, the nurses had a positive attitude towards the environment in which care should be offered to these patients. The majority (87%) of the nurses believed that the mentally ill should not be nursed behind locked doors and 82% believed it is not a waste of time to nurse the mentally ill in a general hospital. Nurses (62%) thought that the mentally ill should not be admitted to hospital with high fence and security guards. A South African study has contradicted the findings of this study. Lethoba state that nurses believed that the mentally ill should be locked away and shouldn’t be in a general hospital [8]. Most Nigerians believe that mental illnesses are caused by superficial forces and should not be treated by hospital staff. Due to the respondents’ beliefs about dangerousness and unpredictable behaviours staff reject these patients accessing care in a general hospital setting [10]. Although the respondents in this study believe that mentally ill patients are dangerous (50%) and unpredictable (88%) they still had a favorable attitude towards admitting mentally ill persons in a general hospital.
From the study 55% of the nurses feel that patients should not be nursed in isolation and must be in a general hospital. This is much lower than those who think that they should not be behind locked doors. . Bjorkman et al state that the most negative attitudes are meted out to patients with schizophrenia and substance abuse disorders because they show higher levels of unpredictability and dangerousness [13].
It is therefore recommended that further research needs to be done in all the regions on the attitude of nurses towards caring for the mentally ill patients and more in-depth studies to get a better understanding of the nurses’ attitude. There should be mandatory continuing education sessions/workshops in their place of employment in psychiatric nursing and it should include contact with recovering patients. Nurses should also be allowed to attend workshops and seminars in psychiatric nursing. In their handing over sessions or ward meetings nurses could also share what they learned from these workshops.
The general hospitals should be staffed with a number of trained psychiatric nurses who would offer quality care to these clients and act as support for the other nurses. The policy makers and stakeholders can send at least one nurse per year for adequate and professional psychiatric training.
The hospital nursing supervisors in the short term should allow the nurses to be rotated through the psychiatric clinic and perform home visits along with the psychiatric team to allow them to reinforce knowledge and gain skills on managing the mentally ill patients.
There were limitations in this study. The study was conducted in one hospital and only 78 nurses were used in the sample, hence the study cannot be generalized. Only females responded. The instrument used for data collection was a self-administered questionnaire; hence the participants could have reported the accepted responses and not true attitudes and due to time constraints a qualitative study could not have been performed, to explore the key areas of the study.
Conclusion
This study was conducted in a type C hospital in rural Jamaica. There is an increased need for care to be offered to the mentally ill, due to decentralization of the mental health services in Jamaica. In rural areas nurses are the first line contact on entering a general hospital. The attitudes of these nurses will determine the type of care these clients receive. The majority of the nurses in this study had a negative attitude towards caring for the mentally ill in a general hospital.
Nurses educated in schools of nursing or universities study the knowledge and apply skills in caring for the mentally ill and should be competent to cope with the challenges displayed by these patients in caring for them holistically.
This study found that the majority of these nurses had no additional training in psychiatric nursing. Since leaving the undergraduate nurses’ training, there is limited number of nurses with continuing education. There are no continuing education sessions in their place of employment in regards to caring for the mentally ill.
While the study cannot be generalized, it suggests that the negative attitude of these nurses might affect the therapeutic relationship, which may influence the type and quality of care these patients receive. It is important for policy makers and nursing administrators, to make the necessary changes to ensure that the persons suffering from mental illness will be treated with dignity and respect as they seek care in this health facility.
References
- World Health Organization. Atlas: nurses in mental health. 2007.
- Canadian Alliance on Mental Illness and Mental Health (CAMIMH) (2007). Mental Health Literacy in Canada: Phase One Draft Report Mental Health Literacy Project. 2007.
- Abel WD, Richards-Henry M, Wright EG, Eldemire-Shearer D. Integrating mental health into primary care: an integrative collaborative primary care model - the Jamaican experience. West Indian Med J. 2011; 60: 483-489.
- Hogberg T, Magnusson A, Lutzen K. To be a nurse or a neighbour? A moral concern for psychiatric nurses living next door to individuals with a mental illness. Nursing Ethics. 2005; 12: 468-478.
- Ross CA, Goldner EM. Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: a review of the literature. Journal of Psychiatric & Mental Health Nursing. 2009; 16: 558-567.
- Hamdan-Mansour AM, Wardam LA. Attitudes of Jordanian Mental Health Nurses toward Mental Illness and Patients with Mental Illness. Issues in Mental Health Nursing. 2009; 30: 705-711.
- Chambers M, Guise V, Välimäki M, Botelho M, Scott A, Staniuliené V, et al. Nurses’ attitudes to mental illness: A comparison of a sample of nurses from five European countries. International Journal of Nursing Studies. 2010; 47: 350-362.
- Lethoba KG. Professional nurses perception of nursing mentally ill people in a general hospital. 2005.
- Reed F, Fitzgerald L. The mixed attitudes of nurse's to caring for people with mental illness in a rural general hospital. International Journal of Mental Health Nursing. 2005; 14: 249-257.
- Chikaodiri A. Attitude of health workers to the care of psychiatric patients. Annals of General Psychiatry. 2009; 8: 19.
- Jackson D, Heatherington L. Young Jamaicans’ attitudes towards mental illness: Experimental and demographic factors associated with social distance and stigmatizing opinions. J. community Psychol. 2006; 34: 563-576.
- Ewhrudjakpor C. Knowledge, beliefs and attitudes of health care providers towards mental illness in delta State, Nigeria. Ethno-Medicine. 2009; 3: 19-25.
- Bjorkman T, Angelman T, Jonsson M. Attitudes towards people with mental illness: a cross-sectional study among nursing staff in psychiatric and somatic care. Scandinavian Journal of Caring Sciences. 2008; 22: 170-177.
- Ebrahime H, Namdar H, Vahidi M. Mental illness stigma among nurses in psychiatric wards of teaching hospitals in the north west of Iran. Iranian Journal of Nursing and Midwifery Research. 2013; 17: 534-538.
- Tay SE, Pariyasami S, Ravindran K, Ali MI, Rowsudeen MT. Nurses' attitudes toward people with mental illnesses in a psychiatric hospital in Singapore. 2004; 42: 40-47.
- Lee S, Lee MT, Chiu MY, Kleinman A. Experience of social stigma by people with schizophrenia in Hong Kong. Br J Psychiatry. 2005; 186: 153-157.
- Luty J, Umoh O, Sessay M, Sarkhel A. Effectiveness of changing minds campaign factsheets in reducing stigmatized attitudes towards mental illness. Psychiatric Bulletin. 2007; 31: 377-381.
- Chow LY, Kam WK, Leung CM. Attitudes of Health care professionals towards psychiatric patients in a general hospital in Hong Kong. Hong Kong Journal of Psychiatry. 2007; 17: 3-9.
- Minas H, Zamzam R, Midin M, Cohen A. Attitudes of Malaysian general hospital staff towards patients with mental illness and diabetes. BMC Public Health. 2011; 11: 317-326.
- Ngirababyeyi A. Attitudes towards mentally ill in professionals working in Ndera neuropsychiatric hospital in Rwanda. 2012.
- Arkar H, Eker D. Effect of psychiatric labels on Attitudes toward mental illness in a Turkish sample. International Journal of Social Psychiatry. 1994; 40: 205-213.
- Lauber C, Sartorius N. At issue: Anti-stigma-endeavours. International Review of Psychiatry. 2007; 19: 103-106.
- Raosoft Inc. (n.d). Raosoft sample size calculator.
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