ARTÍCULO ORIGINAL / ORIGINAL ARTICLE/ ARTIGO ORIGINAL

Bachelor of nursing student' attitude towards people with mental illness and career choices in psychiatric nursing. An Indian perspective

Actitudes de las estudiantes de Enfermería hacia las personas con enfermedad mental y futuro desempeño profesional en enfermería psiquiátrica. Una perspectiva hindú

Atitudes das estudantes de Enfermagem para as pessoas com doença mental e futuro desempenho profissional em enfermagem psiquiátrica. Uma perspectiva indiana

Vijayalakshmi Poreddi¹; Rohini Thimmaiah²; Rama Chandra³; Suresh BadaMath⁴

¹RN, RM, BSN,MSN. College of Nursing, Department of Nursing, National Institute of Mental health and Neurosciences, India. email: pvijayalakshmireddy@gmail.com.

²MBBS,MD. Department of Psychiatry, Videhi Medical College, Bangalore, India. email: drrohinimd@gmail.com.

³RN,RM, BSN,MSN, Ph.D. College of Nursing, Department of Nursing, National Institute of Mental health and Neurosciences, India. email: ramachandra_nimhans@yahoo.co.in.

⁴MBBS, MD. Department of Psychiatry, National Institute of Mental health and Neurosciences, India. email: nimhans@gmail.com.

Receipt date: September 25, 2014. Approval date: November 4, 2014.

Article pnked to research: none.

Subventions: none.

Confpcts of interest: none.

How to cite this article: Poreddi V, 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(1): 148-154.

ABSTRACT

Objective. To examine undergraduate nursing student' attitudes toward people with mental illness and mental health nursing. Methodology. This was a cross sectional descriptive study carried out among conveniently selected nursing students (N=116). Data was collected through self- reported questionnaires. Results: Majority of the participants agreed that the theoretical (81.1%) and cpnical placement (85.4%) was adequate. Similarly, 62.9% would pke to apply for a post-basic program in Psychiatric nursing and 69.8% of the students intend to pursue their career as mental health nurses. However, a majority expressed that people with mental illness are unpredictable (80.2%), cannot handle too much responsibipty (71.5%), more pkely to commit offences or crimes (84.5%) and more pkely to be violent (44%). Negative stereotype domain had significant relationships with future career (r=-0.2, p= 0.003), course effectiveness (r=-0.4, p<0.001), valuable contribution (r=-0.3, p<0.001) and readiness of the students (r=-.3, p<.000) domains. Conclusion. There is an urgent need to address these negative perceptions among nursing students towards people with mental illness. Innovative teaching strategies and appropriate changes in the nursing curriculum is required to prepare future nurses to deal mental health problems effectively.

Key words: attitude; curriculum; students, nursing; mental health.

RESUMEN

Objetivo. Explorar en las estudiantes de enfermería las actitudes hacia las personas con enfermedad mental y su relación  con  la elección de desempeño profesional en enfermería psiquiátrica. Metodología. Estudio descriptivo de corte transversal reapzado en 2014 una muestra por conveniencia de 116 estudiantes de tercero y cuarto año de enfermería. Se utipzó la Encuesta sobre Educación en Salud Mental en Enfermería de Hapell et al., la cual fue respondida por autorreporte. Resultados. El 98.3% de los participantes fueron mujeres. La mayoría de los encuestados estuvieron de acuerdo en que la teoría (81.1%) y la práctica clínica (85.4%) fueron adecuados. Del mismo modo, a un 62.9% le gustaría appcar a un programa avanzado de enfermería psiquiátrica  y 69.8% de los estudiantes tienen la intención de continuar su carrera como enfermeras de salud mental. Sin embargo, la mayoría expresó que las personas con enfermedad mental son impredecibles (80.2%), no pueden manejar demasiada responsabipdad (71.5%) y que son más propensos a cometer deptos o crímenes (84.5%)  y ser violentos (44.0%). El estereotipo negativo se asoció significativamente con los dominios de elección de la futura carrera (r = -.2), efectividad del curso (r = -. 4), la contribución del curso (r = -. 3) y la preparación de los estudiantes (r = -. 3). Conclusión. Los estudiantes de enfermería tienen percepciones negativas hacia las personas con enfermedad mental. Es necesario que las instituciones que forman a los futuros profesionales introduzcan los cambios que sean necesarios en el plan de estudios  con el fin de prepararlos para tratar problemas de salud mental de manera efectiva.

Palabras clave: actitud; estudiantes de enfermería; salud mental

RESUMO

Objetivo. Explorar nas estudantes de enfermagem as atitudes para as pessoas com doença mental e sua relação com a eleição de desempenho profissional em enfermagem psiquiátrica. Metodologia. Estudo descritivo de corte transversal reapzado em 2014 uma mostra por conveniência de 116 estudantes de terceiro e quarto ano de enfermagem. Utipzou-se a Enquete sobre Educação em Saúde Mental em Enfermagem de Hapell et al., a qual foi respondida por autorreporte. Resultados. 98.3% dos participantes foram mulheres. A maioria dos interrogados estiveram de acordo em que a teoria (81.1%) e a prática clínica (85.4%) foram adequados. Do mesmo modo, a um 62.9% lhe agradaria appcar a um programa avançado de enfermagem psiquiátrica e 69.8% dos estudantes têm a intenção de continuar sua carreira como enfermeiras de saúde mental. No entanto, a maioria expressou que as pessoas com doença mental são imprevisíveis (80.2%), não podem manejar demasiada responsabipdade (71.5%) e que são mais propensos a cometer deptos ou crimes (84.5%) e ser violentos (44.0%). O estereótipo negativo se associou significativamente com os domínios de eleição da futura carreira (r = -0.2), efetividade do curso (r = -0.4), a contribuição do curso (r = -0.3) e a preparação dos estudantes (r = -0.3). Conclusão. Os estudantes de enfermagem têm percepções negativas para as pessoas com doença mental. É necessário que as instituições que formam aos futuros profissionais introduzam as mudanças que sejam necessários no plano de estudos com o fim de prepará-los para tratar problemas de saúde mental de maneira efetiva.

Palavras chave: atitude; estudantes de enfermagem; saúde mental.

INTRODUCTION

People with mental illness are common across the world, with 14% of the global burden of disease.¹ Mental health is a priority health area in India since the prevalence of mental illness is high, as in other parts of the world.² It has been estimated that at least 58 per 1 000 people have a mental illness and about 10 milpon Indians suffer from severe mental illness.³ On the other hand, people with mental illness are among the most stigmatized and vulnerable groups of patients in the healthcare setting.⁴ Mental health nurses are an integral component of a multidiscippnary mental healthcare team. They play a critical role in psychiatric treatment and safeguarding the human rights of persons with mental illness both in the hospital and in the community.⁵ However, there is a dearth of mental health professionals including psychiatric nurses in India. According to a World Health organization (WHO) report, there are 0.05 psychiatry nurses per 100 000 people in India.⁶ Available evidence clearly demonstrates that psychiatric nursing was not a desirable career choice for undergraduate nursing students.⁷ Additionally, psychiatric nurses were least pkely to be described as skilled, logical, dynamic, and respected by the peers.⁸ However, contemporarily nursing professionals can no longer ignore mental health, as it will play an increasingly important role in the care of all patients.

Undergraduate nursing programs provide opportunities to influence nursing student' attitudes toward people with mental illness through theoretical preparation and appropriate cpnical exposure in mental health nursing. pterature suggests that nursing students hold stigmatizing attitudes toward people with mental illness.^9-11 However, documented evidence indicate that the theoretical preparation¹² and positive cpnical experiences in Psychiatric nursing proved to be having a significant impact on nursing student’s attitudes toward people with mental illness and mental health nursing as a career.⁷ In the year, 1964–1965, Indian Nursing Council incorporated mental health nursing in to curricula of nursing diploma and degree courses with the aim of meeting the increasing mental health problems of the society. Hence, it was expected that there would be a positive change in nursing student' attitude towards people with mental illness after completion of the Psychiatric/Mental Health Nursing course. Further, research that examined the impact of mental health course in changing attitudes of the nursing students toward people with mental illness is pmited from India.¹³ Thus, the present study was aimed to examine undergraduate nursing student' attitudes toward people with mental illness and mental health nursing.

METHODOLOGY

This was a descriptive study carried out among undergraduate nursing students at a deemed university in the month of March 2014.The study participants were selected through non-probable convenient samppng method. The inclusion criteria for the present study was; nursing students from 3^rd year and 4^th year of BSN course, those who completed mental health nursing course and students those were wilpng to participate. We have excluded students from 1^st year and 2^nd year since they had no exposure to mental health nursing course. In India, mental health nursing content is included in the 3^rd year of BSN. While, 156 students met the inclusion criteria, few of them refused to participate due to lack of time and interest (n=13), 20 of the questionnaires were incomplete and 7 of them were absent during data collection. Hence, the final sample comprised of 116 students with 74.3% response rate.

Data collection Instrument. Mental health nursing education survey developed by Hapell et al.¹⁴ was adopted for the present study. This tool consists of 43 statements (10 negative items) to measure the nursing student' attitude towards people with mental illness and mental health nursing. This scale has 9 sub scales namely; the preparation of nurses for the mental health field (8 items) ; knowledge of mental illness (4 items); negative stereotypes (6 items); future career options (2 items); course effectiveness (4 items); anxiety surrounding mental illness (5items); valuable contribution and cpnical skills of the mentors (5 items); and the readiness of students(9 items). The present study used a four point pkert scale ranging from strongly agree (4), agree (3), disagree (2), strongly disagree (1). This scale was used for the present study because it is simple to use and has good psychometric properties (α = 0.89). However, a pilot study was conducted among a group of students (n=15) and found that this tool was feasible to administer among Indian Nursing students. The questionnaire also included 5 items regarding socio-demographic information such as; age, gender, monthly income, background and repgion.

Data collection procedure. The questionnaire was administered on the students in their class rooms after the regular lectures. One of the researchers (PV) explained briefly about the purpose and procedure of the study. It took approximately 20-40 minutes to complete the questionnaire.

Ethical considerations. After obtaining the permission from the administrators of the colleges, participants were informed about the aims and procedures of the study by one of the researcher (PV). Students were given freedom to decide regarding their participation in the study. After taking the verbal consent from the students those were wilpng to participate, the questionnaire was administered. Since the questionnaire contained no identifying information, the individual responses were kept confidential.

Statistical analysis. Before the data analysis, negative items were reverse coded. The data were analyzed using appropriate statistical software. Descriptive and inferential statistics were used to interpret the results. Statistical significance was assumed at p<0.05.

RESULTS

The sample comprised of one hundred and sixteen students, of whom 98.3% were women. The mean age of the participants was 20.96± 0.95 (M±SD). Table 1 represents the participant' responses to the mental health nursing experience questionnaire. With regard to participant' preparedness to mental health field, it was observed that the majority of the students had good understanding of the role of psychiatric nurses (88.8%) and were confident in taking care of people with mental illness (82.8%), since the theoretical component (81.1%) prepared them well to work as a graduate nurse in psychiatric nursing program (92.3%). While, 86.2% of the participants agreed that ‘mental illness is not a sign of weaknes' and ‘not their fault’ (84.4%), 83.6% of them felt that people with mental illness are affected by the way other people view them. Majority of the participants stated that people with mental illness are unpredictable (80.2%), cannot handle too much responsibipty (71.5%), more pkely to commit offences or crimes (84.5%) and three fourths of them agreed that would not tell people if they develop mental illness. A further, significant number of participants and bepeved that people with mental illness were more pkely to be violent (44%). Similarly, majority of the students opined that they were uncertain to act towards people with mental illness (60.4%) and a vast majority (89.7%) were concerned about they may be harmed by people with mental illness. However, majority of the participants felt that they were safe about psychiatric placement (78.5%) and were famipar about needs of people with mental illness (94%), noteworthy numbers of participants were anxious to work people with mental illness (40.5%).

While nearly and more than one third of participants disagreed, majority of the students indicated that they would pke to apply for a post basic program in Psychiatric nursing (62.9%) and intend to pursue their career as mental health nurses (69.8%). Majority of the participants approved that psychiatric nursing makes a positive contribution (94.9%) and assist people with mental illness in their recovery (72.4%). Although, more than three fourths of the participants felt that nursing staff provided proper support (78.4%), welcome the students (80.1%) and famipar with the learning objectives of the students (87.9%), merely less than half of the participants agreed that they were not encouraged by the nursing staff to consider psychiatric nursing as a career. However, a majority of the participants agreed that they enjoyed psychiatric placement (88.8%) and supported by the mentor/cpnical instructor (89.7%). Table 2 shows Pearson’s correlation coefficients between various domains that are significant at both 0.01 and 0.05 levels. Statistically significant positive relationship found between preparedness for mental health field with knowledge of mental illness (r=0.2, p<0.002), future career (r=0.5, p<0.001), course effectiveness (r=0.4, p<0.001), anxiety surrounding mental illness (r=0.2, p<0.028), valuable contribution (r=0.4, p<0.001) and readiness of students (r=.5, p<0.001). Negative stereotype domain had significant negative relationships with future career (r=-0.2, p=0.003), course effectiveness (r=-0.4, p<0.001), valuable contribution (r=-0.3, p<0.001) and readiness of the students (r=-0.3, p<0.001). Finally, valuable contribution domain had significant relationship with readiness of students (r=0.6, p<0.001).

DISCUSSION

To our best of knowledge, this was the first study from India that examined the factors that influence the undergraduate nursing student' attitudes toward people with mental illness and mental health nursing. Although, few studies¹⁵ compared attitude towards mental illness between second year and 4^th year nursing students, student' attitude towards mental health nursing, and the relationship between student' attitude and psychiatric nursing as their career choice yet not explored. Majority of the participants in the present study agreed, that the theoretical component of mental health nursing was adequate for cpnical placement and 85.4% felt cpnical placement was long enough to understand psychiatric nursing. These findings were consistent with previous studies that showed theory and positive cpnical experiences in the field of mental health has significant impact on positive change on nursing student' attitudes toward people with mental illness and mental health nursing.¹⁶ Evidence also suggests that theoretical component prior to cpnical placement plays a critical role in inculcating positive attitudes toward persons with mental illness and psychiatric nursing.¹² Furthermore, cpnical experiences enable the students to develop professional competence to meet the needs of people with mental illness by providing a variety of learning opportunities.¹⁷ In a systematic review, it was found that cpnical experiences promote positive attitudes towards mental health nursing among nursing students.¹⁸ The present study also observed similar findings as majority of the students would pke to do higher studies in Psychiatric nursing (62.9%) and intend to pursue their career as mental health nurses (69.8%). These findings could be due to adequate exposure to people with mental illness during their cpnical postings as well the mother hospital is basically a psychiatric institute. However, nearly one third of participants were reluctant to choose Psychiatric nursing and 30.1% of them were not interested to continue in mental health field. These findings could be due to fear, inabipty to cope people with mental illness, and lack of interest in mental health field.¹⁹

Though, majority of participants had adequate knowledge related to mental illness as they agreed that mental illness is not a sign of persons weakness and it is not their fault, it is of great concern that majority of the students bepeved that people with mental illness are unpredictable, cannot handle too much responsibipty and more pkely to be violent. Further, 75% of the students expressed that they would not reveal if they develop mental illness. These findings were contrary to a recent study that explained that cpnical placement assisted the students change in their predetermined ideas and negative stereotype of mental illness.²⁰ On the contrary; these findings reflect findings of a recent study that evaluated educational intervention among medical students. In this pre-post design study, stigma scores were considerably reduced after psychiatric education (p<0.0001), but were not completely changed in the primary analysis.²¹ Exhaustive pterature indicate that there was significant improvement in nursing student' attitude towards people with mental illness and mental health nursing after completion of mental health training.^7,22 In pne with previous research, present study also shown positive correlations between preparedness for mental health field with knowledge of mental illness future career, course effectiveness , anxiety surrounding mental illness , valuable contribution and readiness of students . This represents that the better nursing students had theoretical and cpnical experiences, the more encouraging attitudes they hold towards people with mental illness and mental health nursing. These findings were in support of previous research.¹⁰

Similarly, those who felt inadequate preparation with mental health course had negative attitudes and were not having confidence to work with people with mental illness. Unfortunately, nearly half of the participants expressed that they have anxious to provide care and 89.7% of them were concerned that they may be harmed by the people with mental illness. These findings were positively comparable to a study that 75% of the students expressed that working with people with mental health problems such as depression, suicidal behaviors, aggressive, abusive, violent, and/or uncooperative would be difficult. Further they also felt that they are anxious to work with people with mental illness.²³ However, these findings could be due to less theory classes with lecture method to deal comprehensively planned psychiatric nursing curriculum and short duration of cpnical placements. The need for adequate preparations in mental health nursing has been suggested in the pterature as a way to motivate the students to practice in mental health field.¹⁰ Research has clearly demonstrated the positive influence of various teaching strategies such as problem-based learning, precpnical undergraduate workshops, role-plays, cpnical experiences with preceptors (24) to improve the nursing student' attitudes toward people with mental illness and mental health nursing. Studies also highpghted the benefits of preceptored cpnical experiences to enable the nursing students in improving professional skills and to foster positive attitude towards psychiatric patients.²⁵

In conclusion, the present study found that majority of students hold positive attitude towards people with mental illness and satisfied with their preparation in mental health nursing. However, students had negative stereotypes towards people with mental illness. Hence, it is of urgent concern for nurse educators to address these negative perceptions towards people with mental illness by using innovative teaching strategies to prepare future nurses to deal mental health problems effectively. Further, these issues cannot be ignored in the Indian context since scarcity of mental health professionals and increased prevalence of mental illness.

The present study has certain pmitations such as small sample size from a single university and convenience sample made difficult to generapze the findings. Hence, future research should include larger sample with diverse nursing population, across the country. Most importantly, quaptative studies such as focus group discussions may be helpful to identify the factors that influence positively student' attitude towards people with mental illness and mental health nursing. However, despite of these pmitations the present study findings may be helpful to nurse educators to implement and evaluate various teaching strategies in mental health nursing to inculcate positive attitude among nursing students towards people with mental illness and mental health nursing.

Acknowledgements. All the researchers thank the participants for their valuable contribution.

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