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International Journal of Mental Health Nursing (2015) 24, 272–280
doi: 10.1111/inm.12129
Feature Article
Factors influencing mental health nurses’ attitudes towards people with mental illness Chiu-Yueh Hsiao,1,2 Huei-Lan Lu3 and Yun-Fang Tsai4,5 1
School of Nursing, College of Medicine, Chung Shan Medical University, 2Department of Nursing, Chung Shan Medical University Hospital, Taichung, 3Jianan Psychiatric Centre, Ministry of Health and Welfare, Tainan, 4School of Nursing, College of Medicine, Chang Gung University, Tao-Yuan, and 5Department of Nursing, Chang Gung Memorial Hospital, Keelung City, Taiwan
ABSTRACT: This study aimed to investigate the factors influencing mental health nurses’ attitudes towards people with mental illness. A descriptive correlation design was used. A sample of 180 Taiwanese mental health nurses was recruited from mental health-care settings. Data were analyzed with descriptive statistics, Pearson’s product-moment correlation, Student’s t-test, one-way ANOVA, and a hierarchical multiple regression analysis. Negative attitudes were found among mental health nurses, especially with respect to individuals with substance abuse compared with those with schizophrenia and major depression. Mental health nurses who were older, had more clinical experiences in mental health care, and demonstrated greater empathy expressed more positive attitudes towards people with mental illness. Mental health nurses working at acute psychiatric units demonstrated more negative attitudes towards mental illness compared with those working in psychiatric rehabilitation units and outpatient clinics or community psychiatric rehabilitation centres. Particularly, length of mental health nursing practice and empathy significantly accounted for mental health nurses’ attitudes towards mental illness. Understanding nurses’ attitudes and their correlates towards people with mental illness is critical to deliver effective mental health nursing care. KEY WORDS: attitudes, empathy, mental health nurses, mental illness, nursing.
INTRODUCTION Stigma against people with mental illnesses and their families is a global concern with significant clinical and public health issues (World Psychiatric Association 2001). In particular, people suffering from drug addiction, alcoholism, schizophrenia, and major depression elicit greater stigmatized opinions among the general public compared with other psychiatric illnesses (Crisp et al. 2005). The shame of having a mental illness has been found to be a formidable obstacle that impedes recovery, reintegration Correspondence: Yun-Fang Tsai, School of Nursing, College of Medicine, Chang Gung University, 259 Wen-Hwa 1st Road, KweiShan, Tao-Yuan 333, Taiwan. Email: [email protected] Chiu-Yueh Hsiao, PhD, RN. Huei-Lan Lu, MSN, RN. Yun-Fang Tsai, PhD, RN. Accepted January 2015.
© 2015 Australian College of Mental Health Nurses Inc.
into society, and access to mental health services (Cheng et al. 2012; Chien et al. 2014; Delaney 2012). Therefore, the need for addressing prejudice and discrimination against mental illness is crucially needed. Mental health nurses, as the largest health-care professional team, provide the most direct care for individuals with mental illness and their families. Nursing staff in psychiatric practice should be aware that their attitudes may influence the quality of nursing care they deliver. Research on attitudes of mental health nurses toward people with mental illness appears to be limited. Negative attitudes and prejudice against persons with mental illness are deeply shaped by culture (Abdullah & Brown 2011; Ahmead et al. 2010; Mellor et al. 2013). In Asian societies, many people perceive individuals with mental illnesses to be unpredictable, dangerous, aggressive, immoral, supernatural in origin, and punished for
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ancestral misconduct, especially people with substance use problems (Abdullah & Brown 2011; Lam et al. 2010; Lauber & Rössler 2007). Such aetiological beliefs regarding mental illness may be more profound in Chinese culture and therefore contribute to more negative attitudes towards mental illness compared with Western counterparts (Knifton et al. 2010; Mellor et al. 2013). Existing evidence on attitudes of the public and various health-care professionals towards people with mental illness is controversial. Much of the research concerning attitudes held by the general population towards mental illness points out that public perception generally remains unfavourable towards people with mental illnesses (Angermeyer & Dietrich 2006; Song et al. 2005). Attitudinal studies indicate that mental health-care professionals express similar or less optimistic attitudes regarding the progress of the treatment for people with mental health problems in comparison with the general population (Adewuya & Oguntade 2006; Lauber et al. 2006; Schulz 2007) and people with mental illness (Hansson et al. 2011). Furthermore, it would appear that the client’s particular problems or illness may inevitably influence discriminatory attitudes displayed by health-care professionals. It has been found that health-care professionals hold more stereotypical views about working with substance users, especially drug addiction, than clients with schizophrenia (Björman et al. 2008) and major depression (Björman et al. 2008; Gilchrist et al. 2011). Also, less negative attitudes among mental health nurses towards major depression have been noted compared with schizophrenia (Björman et al. 2008; Nordt et al. 2006). In contrast, the study of Chambers et al. (2010), which compared nurses’ attitudes in five European countries, indicated that nurses generally hold positive attitudes towards persons with mental illnesses. Vibha et al. (2008) found that mental health professionals demonstrated more favourable attitudes towards people with mental illness than general health-care staff. Findings in attitudinal research regarding factors associated with mental health-care personnel towards people with mental illness remain contradictory. Nurses who are male (Chambers et al. 2010; Munro & Baker 2007), older (Vibha et al. 2008), have less psychiatric nursing experience (Björman et al. 2008; Chang & Yang 2013; Linden & Kavanagh 2012), and hold junior positions (Chambers et al. 2010; Chang & Yang 2013) tend to express less favourable attitudes towards people with mental illness. In contrast, negative attitudes towards persons with mental illnesses have been noted among younger mental health-care professionals (Björman et al. 2008; Chang & © 2015 Australian College of Mental Health Nurses Inc.
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Yang 2013; Hansson et al. 2011). Age and exposure to affected individuals are not related to nurses’ attitudes towards individuals with mental illnesses (Chambers et al. 2010). Nurses working in psychiatric clinics express more positive attitudes towards people living with mental illness compared with those working in general care (Björman et al. 2008; Chang & Yang 2013). It is likely that mental health-care professionals working in inpatient psychiatric units tend to view individuals with mental illnesses as more dangerous and desire less interaction with these individuals than those working in outpatient psychiatric services (Hansson et al. 2011; Linden & Kavanagh 2012). Furthermore, empathy is a cognitive attribute in a way of recognizing and conveying understandings of patients’ concerns that allow them to feel respect, comfort, and support and may improve the quality of patient care (Hojat 2007). Accordingly, empathy is a core ingredient in building a therapeutic alliance, which in turn influences attitudes of mental health-care professionals towards people with enduring mental health difficulties (Gateshill et al. 2011). Likewise, far less is known to what extent empathy exerts an influence on attitudes towards mental illness in a sample of mental health nurses during their daily psychiatric care. As indicated, attitudinal research on mental healthcare personnel towards mental illness has been correlated with optimal recovery-oriented care for people with mental health problems. Mental health nurses are in a unique position to assist individuals with mental illness to successfully adapt. More importantly, the knowledge of attitudes possessed by mental health nurses towards people with mental illnesses is of utmost interest because these attitudes may affect nurses’ interactions with patients and ultimately the quality of integrated nursing care provided. However, the extent of the information about mental health nurses’ attitudes concerning mental illnesses (e.g. substance abuse, schizophrenia, and major depressive illnesses) is rarely known in Asian societies such as Taiwan. It is unclear whether or not the attitudes of mental health nurses regarding mental health problems and their attributes in Taiwan are similar to those of other cultures. The aim of this study was to investigate factors influencing mental health nurses’ attitudes towards people with mental illness.
MATERIALS AND METHODS Study design and sampling This was a cross-sectional study with a descriptive correlation design that adhered to the Strengthening the Reporting of Observational Studies in Epidemiology
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(STROBE) standards of reporting observational research (von Elm et al. 2014). Potential mental health nurses were recruited. To be eligible for this study, participants were required to meet the following criteria: (i) aged 20 years or older (the legal age of consent in Taiwan is at least 20 years old); (ii) registered nurse; (iii) employed in mental health-care services for at least 1 year; and (iv) able to communicate in Chinese or Taiwanese language. Of the 206 eligible nurses approached to participate in this study, a total of 180 nurses completed the valid questionnaires. This sample size achieved the statistical requirement for correlation, and multiple regression analysis was detected with a power of 0.80, a medium effect size of 0.15, and an alpha level of 0.05 (Cohen 1988).
Data collection Prior to initiating this study, approval for this study was obtained from the institutional review boards (IRB) of three psychiatric hospitals. Also, this study was granted by the supervisors at the community psychiatric rehabilitation centres because they did not have IRB. Participants were informed of the purpose of this study and then invited to participate. Those who signed a consent form were given a package of questionnaires. Participants were instructed to return their questionnaires and informed consent forms in sealed envelopes directly to the trained research assistant. Voluntary participation and confidentiality were assured.
Measure Demographic characteristics
Mental health nurses’ demographic characteristics were assessed with a questionnaire designed specifically for this study. Demographic information sheets included age, sex, mental health-care setting, position, and length of mental health nursing practice. Empathy
Empathy was measured using the 20-item Jefferson Scale of Empathy–Health Profession version (JSE-HP version) (Hojat et al. 2002), which detects health-care providers’ empathic reactions to patient care. Each item is scored on a 7-point Likert-type scale (1 = strongly disagree, 7 = strongly agree). The score for the 20 items was summed giving a total score between 20 and 140. Higher scores indicated greater empathy. Cronbach’s alphas in samples of physicians (Hojat et al. 2002) and nurse practitioners (Hojat et al. 2003) were 0.81 and 0.85, respectively. Cronbach’s alpha was 0.91 in our study.
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Mental health nurses’ attitudes towards people with mental illness
Mental health nurses’ attitudes towards people with mental illness were evaluated using the 5-item Attitudes of Mental Illness Questionnaire (AMIQ; Luty et al. 2006). Participants were asked to read a short fictional vignette depicting an individual with substance abuse, schizophrenia, and major depression. Then, all nurses responded to the AMIQ of each fictional vignette. The AMIQ adapted from Cunningham et al.(1993) is a 5-item scale with a 5-point Likert scale ranging from a minimum of −2 to a maximum of +2 where ‘neutral’ and ‘don’t know’ are scored 0. The total scores ranged from −10 to +10. Higher (more positive) scores are representative of favourable attitudes. The AMIQ achieved adequate validity and reliability (Cronbach’s α = 0.93) (Luty et al. 2006). In this study, Cronbach’s alphas for substance abuse, schizophrenia, and major depression were 0.85, 0.83, and 0.82, respectively. Translation process
Following permission granted by Professors Mohammadreza Hojat and Jason Luty, the JSE-HP version and AMIQ were translated from Chinese into English. The procedure of translation was conducted with a guideline of cultural and linguistic adaptation of psychometric measures (Wild et al. 2005). Initially, two bilingual nursing professionals independently translated the English versions of JSE-HP version and AMIQ into Chinese. Then, the principal investigator compared these preliminary Chinese versions of the JSE-HP version and AMIQ and reconciled the drafts of the Chinese versions of the JSE-HP version and AMIQ. The forwardtranslated versions were then back-translated by a bilingual language expert fluent in both English and Chinese who was blind to either the English or Chinese versions of the JSE-HP version and AMIQ. The research team compared the back-translated versions to the originals to ensure the cross-cultural equivalency. A panel of three experts in mental health nursing and psychiatry were invited to rate each item of the instruments. The content validity index of the JSE-HP version and AMIQ were 0.91 and 0.93, respectively. Then, a pilot test using a sample of 10 mental health nurses was undertaken and indicated that the Chinese versions of the questionnaire were comprehensible and easy to fill out. Participants in a pilot study were not involved in the subsequent analysis.
Data analysis SPSS software version 17 (SPSS, Chicago, IL, USA) was used to perform data analysis. Descriptive statistics were © 2015 Australian College of Mental Health Nurses Inc.
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calculated to characterize the study sample and variables. Pearson’s product–moment correlation was computed to examine the directions and correlations among mental health nurses’ characteristics (i.e. age and length of mental health nursing practice), empathy, and attitudes towards people with mental illness. Differences in mental health nurses’ characteristics (i.e. sex, position, and mental health-care setting) and the level of mental health nurses’ attitudes towards people with mental illness were estimated with an independent-sample Student’s t-test or one-way anova. Scheffé’s post-hoc test was analyzed for the multi-comparison when an equal error variance in groups was detected. The assumptions of multiple regression analyses were first examined, and multicollinearity was checked with correlation coefficients, tolerances, and the variance inflation factors. Then, hierarchical multiple regression analyses were conducted to examine the determinants of mental health nurses’ attitudes towards people with mental illness. Statistical significance was set at P < 0.05.
RESULTS Mental health nurses’ characteristics Completion of the valid questionnaires were received from 180 nurses (87.4% response rate). Nurses’ characteristics are shown in Table 1. Participants were in their 30s with an average of approximately 8.26 years of mental health nursing practices. The majority of nurses were female, staff nurses, and working at acute psychiatric inpatient units.
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Mental health nurses’ attitudes towards people with mental illness The values of means and standard deviations (SD) of mental health nurses’ attitudes towards people with mental illness responding to vignettes of substance abuse, schizophrenia, and major depressive illness were −4.69 (SD = 3.29), −2.87 (SD = 3.58), and –0.62 (SD = 4.02), respectively. There was a statistically significant difference among the degree of attitudes of mental health nurses towards patients diagnosed with substance abuse, schizophrenia, and major depression (F = 56.44, P < 0.001), indicating more negative attitudes towards patients with substance abuse followed by patients with schizophrenia and major depression.
Relationships among mental health nurses’ characteristics, empathy, and attitudes towards people with mental illness As indicated in Table 2, mental health nurses who were head nurses or supervisors held more positive attitudes towards people suffering from substance abuse (t = −3.15, P = 0.002), schizophrenia (t = −2.51, P = 0.013), and major depression (t = −2.95, P = 0.004) compared with those who were nursing staff. In relation to mental healthcare settings, a significant difference was found in mental health nurses’ attitudes toward people with substance abuse (F = 4.24, P = 0.016) and schizophrenia (F = 5.34, P = 0.006). There were no significant differences in mental health nurses’ attitudes towards people with major depression among mental health-care settings. Further, Scheffé’s post-hoc test revealed more negative attitudes
TABLE 1: Mental health nurses’ characteristics and study variables (n = 180) Variables Sex Male Female Position Staff nurse Head nurse/supervisor Mental health-care setting Acute psychiatric inpatient units Psychiatric rehabilitation units Outpatient clinics/community psychiatric rehabilitation centres Age (years) Length of mental health nursing practice (years) Empathy Mental health nurses’ attitudes towards substance abuse Mental health nurses’ attitudes towards schizophrenia Mental health nurses’ attitudes towards major depression SD, standard deviation.
© 2015 Australian College of Mental Health Nurses Inc.
n (%)
Mean (SD)
Range
33.45 (7.21) 8.26 (5.98) 98.44 (14.74) −4.69 (3.29) −2.87 (3.58) −0.62 (4.02)
20–52 1–29.58 75–137 −10 to 1 −9 to 5 −9 to 9
31 (17.2) 149 (82.8) 163 (90.6%) 17 (9.4%) 95 (52.8) 71 (39.4) 14 (7.8)
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TABLE 2: Attitudes towards people with mental illness by mental health nurses’ characteristics (n = 180) Substance abuse Mental health nurses’ characteristics Sex Male Female Position Staff nurse Head nurse/supervisor Mental health-care setting ① Acute psychiatric inpatient units ② Psychiatric rehabilitation units ③ Outpatient clinics/community psychiatric rehabilitation centres
Mean (SD)
t/F t = −0.2
Schizophrenia P 0.84
−4.58 (3.33) −4.71 (3.30)
t/F t = 0.5
Major depression P
t = −3.15
0.013*
−3.08 (3.56) −0.82 (3.13) F = 4.24 ①>③
0.016* −3.47 (3.56) −2.55 (3.44) −0.36 (3.25)
t/F
P
t = 0.34
0.736
t = −2.95
0.004**
F = 2.94
0.055
−0.84 (3.88) −0.57 (4.06) t = −2.51
0.002**
Mean (SD)
0.616
−3.16 (3.88) −2.81 (3.52)
−4.93 (3.26) −2.35 (2.67) −5.11 (3.19) −4.58 (3.31) −2.43 (3.2)
Mean (SD)
−0.9 (3.94) 2.06 (3.91) F = 5.34 ①>③
0.006** −0.8 (3.91) −0.86 (4.16) 1.86 (3.39)
*P < 0.05, **P < 0.01. SD, standard deviation, t/F = t value of independent-sample Student’s t-test or F-value of anova, Scheffé’s test for multi-comparison.
towards people with substance abuse and schizophrenia among nurses working in acute psychiatric inpatient units compared with those working in psychiatric rehabilitation units and outpatient clinics or community psychiatric rehabilitation centres. Mental health nurses who were older expressed more positive attitudes towards individuals with substance abuse (r = 0.41, P < 0.01), schizophrenia (r = 0.51, P < 0.01), and major depression (r = 0.41, P < 0.01). In addition, mental health nurses with longer mental health nursing practices were found to have more positive attitudes towards people having substance abuse (r = 0.43, P < 0.01), schizophrenia (r = 0.48, P < 0.01), and major depression (r = 0.45, P < 0.01). Positive correlations were found between empathy and attitudes towards people having substance abuse (r = 0.56, P < 0.01), schizophrenia (r = 0.61, P < 0.01), and major depression (r = 0.61, P < 0.01). That is, greater empathy was correlated with more positive attitudes of mental health nurses towards people with schizophrenia, major depression, and substance abuse.
Factors related to mental health nurses’ attitudes towards people with mental illness Hierarchical multiple regression analyses were performed to identify the determinants of mental health nurses’ attitude towards people with mental illness. Only variables that were significantly correlated with mental health nurses’ attitudes towards people with substance abuse, schizophrenia, and major depression were entered into the regression analyses. A high correlation was found between age and length of mental health nursing practice; age was excluded from the regression models. As demonstrated in Table 3, model 1 indicates that length of mental
health nursing practice significantly influences mental health nurses’ attitudes towards people with substance abuse (β = 0.4, P < 0.001), schizophrenia (β = 0.49, P < 0.001), and major depression (β = 0.45, P < 0.001) and explained 17%, 23%, and 19% of the variance in mental health nurses’ attitudes towards substance abuse, schizophrenia, and major depression, respectively. Model 2 indicates that length of mental health nursing practice and empathy significantly accounted for mental health nurses’ attitudes towards people with substance towards substance abuse (β = 0.23, P = 0.004 and β = 0.46, P < 0.001, respectively), schizophrenia (β = 0.3, P < 0.001 and β = 0.49, P < 0.001, respectively), and major depression (β = 0.23, P = 0.001 and β = 0.52, P < 0.001, respectively) after controlling for mental health nurses’ characteristics. The model 2 explained the 35%, 42%, and 41% of the variance in mental health nurses’ attitudes towards people with substance abuse, schizophrenia, and major depression, respectively.
DISCUSSION This study, to our knowledge, is one of few to investigate factors related to attitudes towards people with mental illnesses among Taiwanese mental health nurses. Our results demonstrated that negative attitudes were prevalent among mental health nurses and in particular, towards individuals with substance abuse as opposed to those with schizophrenia and major depression in mental health care. In general, mental health nurses who were older, had more clinical experiences in mental health care, and possessed greater empathy expressed more positive attitudes towards people with mental illness. Additionally, nurses working in acute psychiatric units © 2015 Australian College of Mental Health Nurses Inc.
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TABLE 3: Factors related to mental health nurses’ attitudes towards people with mental illness (n = 180) Model 1
Variable Length of mental health nursing practice Position Mental health-care setting (acute psychiatric inpatient units)† Mental health-care setting (outpatient clinics/community psychiatric rehabilitation centres)† Empathy R2 Adjusted R2 F change
Substance abuse β
Model 2
Schizophrenia β
Major depression β
Substance abuse β
Schizophrenia β
Major depression β
0.4*** 0.02 −0.03 0.05
0.49*** −0.07 −0.07 0.04
0.45*** −0.01 0.02 −0.03
0.23** 0.01 0.01 0.04
0.3*** −0.08 −0.02 0.03
0.23** −0.01
0.19 0.17 10.43***
0.24 0.23 13.97***
0.2 0.19 21.99***
0.46*** 0.37 0.35 47.44***
0.49*** 0.44 0.42 60.79***
0.52*** 0.42 0.41 65.9***
**P < 0.01, ***P < 0.001. †Referent category: Mental health-care setting (psychiatric rehabilitation units).
presented less negative attitudes towards people with mental illness compared with those working in psychiatric rehabilitation units and outpatient clinics or community psychiatric rehabilitation centres. These findings are similar to the results of previous work on nurses’ stigmatizing attitudes in Western mental health-care practice (Björman et al. 2008; Hansson et al. 2011; Rao et al. 2009). Moreover, this study expands knowledge regarding attributes of attitudes of mental health nurses towards people with mental illnesses in non-Western societies such as Taiwan. Mental health nurses in the present study demonstrated pessimistic attitudes towards people suffering from mental illnesses as an indication of stigmatization. This does not correspond with previous studies indicating that mental health nurses hold generally positive attitudes towards individuals with mental illness (Chambers et al. 2010; Munro & Baker 2007; Vibha et al. 2008). Moreover, mental health nurses held more negative attitudes compared with earlier findings in samples of mental health professionals in the UK (Rao et al. 2009) and medical students in Australia (Galletly & Burton 2011) as well as the general population in the UK (Luty et al. 2006; 2009) when measured by the AMIQ. In particular, mental health nurses in our study expressed more unfavourable attitudes towards people with substance abuse followed by schizophrenia and major depression, respectively. As in a study by Björman et al. (2008), schizophrenia, drug addiction, or alcohol addiction were more likely to be perceived as unpredictable and dangerous as compared with other mental illnesses such as major depression. In this regard, however, our results indicated that mental health nurses hold negative attitudes towards people with major depression in contrast to positive attitudinal responses reported in a study of Luty et al. (2006). © 2015 Australian College of Mental Health Nurses Inc.
It appears that mental health nurses in Taiwan endorse negative attitudes, particularly in relation to people with substance abuse although contemporary psychiatric and mental health nursing curricula in Taiwan are primarily based on the Western model of aetiology and treatment of mental illness. This may partly reflect the fact that people experiencing mental illness are often labelled and discriminated against in a traditional Chinese culture, including the degree of negative attitudes associated with particular illnesses or symptoms individuals with mental illnesses manifest. A Taiwanese study by Chang and Yang (2013) claimed that nurses tend to possess moralistic views about substance abusers with regard to potentially adverse social outcomes (e.g. criminal behaviours) rather than health issues. As such, these negative attitudes held by mental health nurses towards people who have mental illnesses, especially substance abuse, are considered as an obstacle to the quality of mental health nursing care delivered. Apparently, the research is confounded due to the use of various measures of attitudes towards people with mental illness. More specific attitudinal measures require further investigation. Furthermore, it remains unknown to what extent these negative attitudes influence their caring behaviours and the quality of mental health-care services. This is among the first studies on mental health nurses’ attitudes towards people with mental illness in Taiwan. Research into attitudes of mental health professionals and allied health-care professionals towards people with mental illnesses is recommended. In the current study, older age and longer years of mental health nursing practice attributed to less negative attitudes towards people with mental illness (i.e. substance abuse, schizophrenia, and major depression) which support earlier findings (Björman et al. 2008; Chang & Yang 2013; Hansson et al. 2011). Nurses in senior
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positions (i.e. head nurse or supervisor) were found to be more positive in their attitudes towards people experiencing substance abuse, schizophrenia, and major depression than those in junior positions (i.e. staff nurse) which is in line with previous research (Chambers et al. 2010; Chang & Yang 2013). Collectively, it is likely that older and more experienced nurses in senior positions tend to be increasingly exposed to, and have had more contact with, individuals with mental illnesses which may bolster more favourable attitudes towards mental illness. In comparisons of mental health-care settings, our study revealed that nurses employed at acute psychiatric units demonstrated more negative attitudes compared with those working at psychiatric rehabilitation units and outpatient clinics or community psychiatric rehabilitation centres. This result contradicts the findings of Munro and Baker’s (2007) survey indicating positive attitudes of acute mental health nurses. This may be due, in part, to acute mental health nurses primarily driven by the taskoriented care with restricted time in direct contact with the patients. Additionally, mental health nurses in acute psychiatric units often encounter severely afflicted patients, which may likely instil negative attitudes. A relatively small sample of nurses in this study working within the community facilities was sampled. As a consequence, caution is advised when interpreting the results concerning the differences among attitudes of mental health nurses in various mental health-care settings. Contrary to the aforementioned reports (Björman et al. 2008; Chambers et al. 2010; Munro & Baker 2007), however, no sex differences in attitudes towards specific mental illnesses (i.e. substance abuse, schizophrenia, and major depressive illness) were found in this study. Similarly, some studies also reported no statistically significant differences between males and females in a sample of mental health professionals (Hamdan-Mansour & Wardam 2009; Hansson et al. 2011; Nordt et al. 2006). Attitudes of mental health nurses are shaped not only by individual characteristics (e.g. sex) but also by multiple attributes. Arguably, the effect of sex on mental health nurses’ attitudes should be viewed with caution. Further research should be undertaken to elucidate the impact of other potential factors (e.g. personality, marital status, having relatives or friends with mental illness, knowledge of mental illness, additional continuing education or training in psychiatric practice, or cultural climate within health-care systems) with sex on the attitudes of nurses working in mental health-care settings. Our findings support the hypothesis that mental health nurses with greater empathy endorse more positive attitudes towards caring for people with mental illness. This
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is in accordance with earlier results suggesting that empathy, as a backbone of therapeutic relationships, enables health-care providers to accurately elicit and identify patient preferences and values in response to health problems, and thus, improves patient health outcomes (Gateshill et al. 2011; Hojat 2007). Yet, there is limited work available on mental health nursing in regard to the role that empathy plays in shaping attitudes towards mental illness in clinical practice. Given the critical value of empathy in the provision of health-care services, effective interventions should be designed to address empathic engagement in patient care. Continued efforts to foster empathy in ways such as role playing, case scenario-based learning (e.g. problem-based learning), and reflection on clinical experiences appear warranted. The AMIQ is brief and convenient to assess an individual’s own stigmatized attitudes towards mental illness (Luty et al. 2006). Likewise, the items of other stigma scales tend to be longer, more costly, and may require an interviewer to assess the opinions of the general population towards contacting people who have mental illness (e.g. Community Attitudes Toward the Mentally Ill scale; Taylor & Dear 1981) or emphasize the internalized feelings of stigma of people suffering from mental illness (e.g. Internalized Stigma of Mental Illness scale; Ritsher et al. 2003). Overall, negative attitudes among Taiwanese mental health nurses exist, particularly among those who are younger, less experienced, hold junior positions, work at acute psychiatric units, and have decreased empathy towards people with mental illness. Our findings suggest that cultural values of attribution and anticipated prognosis of mental illness are deeply rooted in mental health nurses, even if they have at least received academic knowledge about mental illness and 4–6 weeks of clinical training in mental health nursing during baccalaureate or postgraduate programs. As noted, current Taiwanese nursing education is less likely to reduce negative attitudes of mental health nurses towards people suffering from mental illness, especially for people with substance abuse. Nursing educators should integrate culturally enshrined perspectives of mental illness into academic curricula. Mental health nurses as role models in the general public should carefully reflect their own attitudes towards mental health problems and the impact of such attitudes on the quality of patient care delivered. Continuing education and training regarding knowledge of nature and treatment effects of mental illnesses may enhance nurses’ positive attitudes towards caring for people experiencing mental health problems. In addition, the potential impact of education regarding genomics knowledge and its clinical implications may help stimulate nurses’ optimistic attitudes towards © 2015 Australian College of Mental Health Nurses Inc.
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mental health care. Accordingly, education may help individuals with mental illness and their families alleviate their self-stigma, and therefore, improve adaptation to living with the hereditary nature of mental illness. As well, it is recommended that mental health nurses be provided support in clinical supervision in conjunction with education to assist them with guidance through thoughtful discussions and reflection of personal and clinical issues when working with patients.
Limitations of the study Findings from this study should be interpreted with caution due to some limitations. First, it is a crosssectional study which is less informative than longitudinal research in relation to a causal relationship of attributes. Future research applying a prospective design to assess changes of stigmatizing attitudes is recommended. Second, participants were not randomly selected and the majority of our sample was female; therefore, we cannot generalize the results as applicable to the population of Taiwanese mental health nurses. A nationwide, randomselected sample would be recommended to generalize our findings. Third, both the AMIQ and JSE-HP version were self-administered instruments that assess an individual’s opinions in response to mental illness. It is possible to underestimate mental health nurses’ perspectives, particularly their actual behaviours toward people experiencing mental illness, which may be appropriately measured by means of observation. Additionally, a social desirability bias may exist although anonymity was assured.
CONCLUSION This study demonstrated that mental health nurses, in general, were negatively disposed to individuals with mental illnesses, especially those caring for persons with substance abuse. Younger, less experienced, and less empathic nurses as well as those working in acute psychiatric wards were prone to more pessimistic attitudes compared with their counterparts. To deliver therapeutically effective nursing care in mental health-care services, increased recognition of nurses’ attitudes concerning mental illnesses is an imperative issue. Nursing education and training programs should aim to equip mental health nurses with empathic reactions and positive attitudes in the care of individuals suffering from mental illnesses.
ACKNOWLEDGEMENTS The authors acknowledge and thank the participants. Sincere thanks to the Ministry of Science and Technology, Taiwan for funding this study (100-2410-H-040-007MY2). © 2015 Australian College of Mental Health Nurses Inc.
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280 Galletly, C. & Burton, C. (2011). Improving medical student attitudes towards people with schizophrenia. Australian and New Zealand Journal of Psychiatry, 45, 473–476. Gateshill, G., Kucharska-Pietura, K. & Wattis, J. (2011). Attitudes towards mental disorders and emotional empathy in mental health and other healthcare professionals. Psychiatric Bulletin, 35, 101–105. Gilchrist, G., Mosklewicz, J., Slezakova, S. et al. (2011). Staff regard towards working with substance users: A European multi-centre study. Addiction, 10, 1114–1125. Hamdan-Mansour, A. M. & Wardam, L. A. (2009). Attitudes of Jordanian mental health nurses toward mental illness and patients with mental illness. Issues in Mental Health Nursing, 30, 705–711. Hansson, L., Jormfeldt, H., Svedberg, P. & Svensson, B. (2011). Mental health professionals’ attitudes towards people with mental illness: Do they differ from attitudes held people with mental illness? International Journal of Social Psychiatry, 59, 48–54. Hojat, M. (2007). Empathy in Patient Care: Antecedents, Development, Measurement, and Outcomes. New York: Springer. Hojat, M., Gonnella, J. S., Nasca, T. J., Mangione, S., Vergare, M. & Magee, M. (2002). Physician empathy: Definition, components, measurement, and relationship to gender and specialty. American Journal of Psychiatry, 159, 1563–1569. Hojat, M., Fields, S. K. & Gonnella, J. S. (2003). Empathy: An NP/MD comparison. The Nurse Practitioner, 28 (4), 45–47. Knifton, L., Gervais, M., Newbigging, K. et al. (2010). Community conversation: Addressing mental health stigma with ethnic minority communities. Social Psychiatry and Psychiatry Epidemiology, 45, 497–504. Lam, C., Tsang, H. W. H., Corrigan, P. W. et al. (2010). Chinese lay theory and mental illness stigma: Implications for research and practices. Journal of Rehabilitation, 76, 35–40. Lauber, C. & Rössler, W. (2007). Stigma towards people with mental illness in developing countries in Asia. International Review of Psychiatry, 19, 157–178. Lauber, C., Nordt, C., Braunschweig, C. & Rösler, W. (2006). Do mental health professionals stigmatize their patients? Acta Psychiatrica Scandinavica, 113, 51–59. Linden, M. & Kavanagh, R. (2012). Attitudes of qualified vs. student mental health nurses towards an individual diagnosed with schizophrenia. Journal of Advanced Nursing, 68, 1359–1368.
C-Y. HSIAO ET AL. Luty, J., Fekadu, D., Umoh, O. & Gallagher, J. (2006). Validation of a short instrument to measure stigmatised attitudes towards mental illness. Psychiatric Bulletin, 30, 257–260. Luty, K., Umoh, O. & Nuamah, F. (2009). Effect of brief motivational interviewing on stigmatised attitudes towards mental illness. Psychiatric Bulletin, 33, 212–214. Mellor, D., Carne, L., Shen, Y. C., McCabe, M. & Wang, L. (2013). Stigma toward mental illness: A cross-cultural comparison of Taiwanese, Chinese immigrants to Australia and Anglo-Australians. Journal of Cross-Cultural Psychology, 44, 352–364. Munro, S. & Baker, J. A. (2007). Surveying the attitudes of acute mental health nurses. Journal of Psychiatric and Mental Health Nursing, 14, 196–202. Nordt, C., Rössler, W. & Lauber, C. (2006). Attitudes of mental health professionals toward people with schizophrenia and major depression. Schizophrenia Bulletin, 32, 709–714. Rao, H., Mahadevappa, H., Pillay, P., Sessay, M., Abraham, A. & Luty, J. (2009). A study of stigmatized attitudes towards people with mental health problems among health professionals. Journal of Psychiatric and Mental Health Nursing, 16, 279–284. Ritsher, J. B., Otilingam, P. G. & Grajales, M. (2003). Internalized stigma of mental illness: Psychometric properties of a new measure. Psychiatry Research, 121, 31–49. Schulz, B. (2007). Stigma and mental health professionals: A review of the evidence on an intricate relationship. International Review of Psychiatry, 19, 137–155. Song, L. Y., Chang, L. Y., Shih, C. Y., Lin, C. Y. & Yang, M. J. (2005). Community attitudes towards the mentally ill: The results of a national survey of the Taiwanese population. International Journal of Social Psychiatry, 51, 174–188. Taylor, S. M. & Dear, M. J. (1981). Scaling community attitudes toward the mentally ill. Schizophrenia Bulletin, 7, 225–240. Vibha, V., Saddichha, S. & Kumar, R. (2008). Attitudes of ward attendants towards mental illness: Comparisons and predictors. International Journal of Social Psychiatry, 54, 469–478. Wild, D., Grove, A., Martin, M. et al. (2005). Principles of good practice for the translation and cultural adaptation process for patient-reported outcomes (PRO) measures: Report of the ISPOR task force for translation and cultural adaptation. Value in Health, 8, 94–104. World Psychiatric Association (2001). The WPA Global Programme to Reduce Stigma and Discrimination Because of Schizophrenia. An Interim Report. Geneva: World Psychiatric Association.
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International Journal of Mental Health Nursing (2015) 24, 272–280
doi: 10.1111/inm.12129
Feature Article
Factors influencing mental health nurses’ attitudes towards people with mental illness Chiu-Yueh Hsiao,1,2 Huei-Lan Lu3 and Yun-Fang Tsai4,5 1
School of Nursing, College of Medicine, Chung Shan Medical University, 2Department of Nursing, Chung Shan Medical University Hospital, Taichung, 3Jianan Psychiatric Centre, Ministry of Health and Welfare, Tainan, 4School of Nursing, College of Medicine, Chang Gung University, Tao-Yuan, and 5Department of Nursing, Chang Gung Memorial Hospital, Keelung City, Taiwan
ABSTRACT: This study aimed to investigate the factors influencing mental health nurses’ attitudes towards people with mental illness. A descriptive correlation design was used. A sample of 180 Taiwanese mental health nurses was recruited from mental health-care settings. Data were analyzed with descriptive statistics, Pearson’s product-moment correlation, Student’s t-test, one-way ANOVA, and a hierarchical multiple regression analysis. Negative attitudes were found among mental health nurses, especially with respect to individuals with substance abuse compared with those with schizophrenia and major depression. Mental health nurses who were older, had more clinical experiences in mental health care, and demonstrated greater empathy expressed more positive attitudes towards people with mental illness. Mental health nurses working at acute psychiatric units demonstrated more negative attitudes towards mental illness compared with those working in psychiatric rehabilitation units and outpatient clinics or community psychiatric rehabilitation centres. Particularly, length of mental health nursing practice and empathy significantly accounted for mental health nurses’ attitudes towards mental illness. Understanding nurses’ attitudes and their correlates towards people with mental illness is critical to deliver effective mental health nursing care. KEY WORDS: attitudes, empathy, mental health nurses, mental illness, nursing.
INTRODUCTION Stigma against people with mental illnesses and their families is a global concern with significant clinical and public health issues (World Psychiatric Association 2001). In particular, people suffering from drug addiction, alcoholism, schizophrenia, and major depression elicit greater stigmatized opinions among the general public compared with other psychiatric illnesses (Crisp et al. 2005). The shame of having a mental illness has been found to be a formidable obstacle that impedes recovery, reintegration Correspondence: Yun-Fang Tsai, School of Nursing, College of Medicine, Chang Gung University, 259 Wen-Hwa 1st Road, KweiShan, Tao-Yuan 333, Taiwan. Email: [email protected] Chiu-Yueh Hsiao, PhD, RN. Huei-Lan Lu, MSN, RN. Yun-Fang Tsai, PhD, RN. Accepted January 2015.
© 2015 Australian College of Mental Health Nurses Inc.
into society, and access to mental health services (Cheng et al. 2012; Chien et al. 2014; Delaney 2012). Therefore, the need for addressing prejudice and discrimination against mental illness is crucially needed. Mental health nurses, as the largest health-care professional team, provide the most direct care for individuals with mental illness and their families. Nursing staff in psychiatric practice should be aware that their attitudes may influence the quality of nursing care they deliver. Research on attitudes of mental health nurses toward people with mental illness appears to be limited. Negative attitudes and prejudice against persons with mental illness are deeply shaped by culture (Abdullah & Brown 2011; Ahmead et al. 2010; Mellor et al. 2013). In Asian societies, many people perceive individuals with mental illnesses to be unpredictable, dangerous, aggressive, immoral, supernatural in origin, and punished for
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ancestral misconduct, especially people with substance use problems (Abdullah & Brown 2011; Lam et al. 2010; Lauber & Rössler 2007). Such aetiological beliefs regarding mental illness may be more profound in Chinese culture and therefore contribute to more negative attitudes towards mental illness compared with Western counterparts (Knifton et al. 2010; Mellor et al. 2013). Existing evidence on attitudes of the public and various health-care professionals towards people with mental illness is controversial. Much of the research concerning attitudes held by the general population towards mental illness points out that public perception generally remains unfavourable towards people with mental illnesses (Angermeyer & Dietrich 2006; Song et al. 2005). Attitudinal studies indicate that mental health-care professionals express similar or less optimistic attitudes regarding the progress of the treatment for people with mental health problems in comparison with the general population (Adewuya & Oguntade 2006; Lauber et al. 2006; Schulz 2007) and people with mental illness (Hansson et al. 2011). Furthermore, it would appear that the client’s particular problems or illness may inevitably influence discriminatory attitudes displayed by health-care professionals. It has been found that health-care professionals hold more stereotypical views about working with substance users, especially drug addiction, than clients with schizophrenia (Björman et al. 2008) and major depression (Björman et al. 2008; Gilchrist et al. 2011). Also, less negative attitudes among mental health nurses towards major depression have been noted compared with schizophrenia (Björman et al. 2008; Nordt et al. 2006). In contrast, the study of Chambers et al. (2010), which compared nurses’ attitudes in five European countries, indicated that nurses generally hold positive attitudes towards persons with mental illnesses. Vibha et al. (2008) found that mental health professionals demonstrated more favourable attitudes towards people with mental illness than general health-care staff. Findings in attitudinal research regarding factors associated with mental health-care personnel towards people with mental illness remain contradictory. Nurses who are male (Chambers et al. 2010; Munro & Baker 2007), older (Vibha et al. 2008), have less psychiatric nursing experience (Björman et al. 2008; Chang & Yang 2013; Linden & Kavanagh 2012), and hold junior positions (Chambers et al. 2010; Chang & Yang 2013) tend to express less favourable attitudes towards people with mental illness. In contrast, negative attitudes towards persons with mental illnesses have been noted among younger mental health-care professionals (Björman et al. 2008; Chang & © 2015 Australian College of Mental Health Nurses Inc.
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Yang 2013; Hansson et al. 2011). Age and exposure to affected individuals are not related to nurses’ attitudes towards individuals with mental illnesses (Chambers et al. 2010). Nurses working in psychiatric clinics express more positive attitudes towards people living with mental illness compared with those working in general care (Björman et al. 2008; Chang & Yang 2013). It is likely that mental health-care professionals working in inpatient psychiatric units tend to view individuals with mental illnesses as more dangerous and desire less interaction with these individuals than those working in outpatient psychiatric services (Hansson et al. 2011; Linden & Kavanagh 2012). Furthermore, empathy is a cognitive attribute in a way of recognizing and conveying understandings of patients’ concerns that allow them to feel respect, comfort, and support and may improve the quality of patient care (Hojat 2007). Accordingly, empathy is a core ingredient in building a therapeutic alliance, which in turn influences attitudes of mental health-care professionals towards people with enduring mental health difficulties (Gateshill et al. 2011). Likewise, far less is known to what extent empathy exerts an influence on attitudes towards mental illness in a sample of mental health nurses during their daily psychiatric care. As indicated, attitudinal research on mental healthcare personnel towards mental illness has been correlated with optimal recovery-oriented care for people with mental health problems. Mental health nurses are in a unique position to assist individuals with mental illness to successfully adapt. More importantly, the knowledge of attitudes possessed by mental health nurses towards people with mental illnesses is of utmost interest because these attitudes may affect nurses’ interactions with patients and ultimately the quality of integrated nursing care provided. However, the extent of the information about mental health nurses’ attitudes concerning mental illnesses (e.g. substance abuse, schizophrenia, and major depressive illnesses) is rarely known in Asian societies such as Taiwan. It is unclear whether or not the attitudes of mental health nurses regarding mental health problems and their attributes in Taiwan are similar to those of other cultures. The aim of this study was to investigate factors influencing mental health nurses’ attitudes towards people with mental illness.
MATERIALS AND METHODS Study design and sampling This was a cross-sectional study with a descriptive correlation design that adhered to the Strengthening the Reporting of Observational Studies in Epidemiology
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(STROBE) standards of reporting observational research (von Elm et al. 2014). Potential mental health nurses were recruited. To be eligible for this study, participants were required to meet the following criteria: (i) aged 20 years or older (the legal age of consent in Taiwan is at least 20 years old); (ii) registered nurse; (iii) employed in mental health-care services for at least 1 year; and (iv) able to communicate in Chinese or Taiwanese language. Of the 206 eligible nurses approached to participate in this study, a total of 180 nurses completed the valid questionnaires. This sample size achieved the statistical requirement for correlation, and multiple regression analysis was detected with a power of 0.80, a medium effect size of 0.15, and an alpha level of 0.05 (Cohen 1988).
Data collection Prior to initiating this study, approval for this study was obtained from the institutional review boards (IRB) of three psychiatric hospitals. Also, this study was granted by the supervisors at the community psychiatric rehabilitation centres because they did not have IRB. Participants were informed of the purpose of this study and then invited to participate. Those who signed a consent form were given a package of questionnaires. Participants were instructed to return their questionnaires and informed consent forms in sealed envelopes directly to the trained research assistant. Voluntary participation and confidentiality were assured.
Measure Demographic characteristics
Mental health nurses’ demographic characteristics were assessed with a questionnaire designed specifically for this study. Demographic information sheets included age, sex, mental health-care setting, position, and length of mental health nursing practice. Empathy
Empathy was measured using the 20-item Jefferson Scale of Empathy–Health Profession version (JSE-HP version) (Hojat et al. 2002), which detects health-care providers’ empathic reactions to patient care. Each item is scored on a 7-point Likert-type scale (1 = strongly disagree, 7 = strongly agree). The score for the 20 items was summed giving a total score between 20 and 140. Higher scores indicated greater empathy. Cronbach’s alphas in samples of physicians (Hojat et al. 2002) and nurse practitioners (Hojat et al. 2003) were 0.81 and 0.85, respectively. Cronbach’s alpha was 0.91 in our study.
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Mental health nurses’ attitudes towards people with mental illness
Mental health nurses’ attitudes towards people with mental illness were evaluated using the 5-item Attitudes of Mental Illness Questionnaire (AMIQ; Luty et al. 2006). Participants were asked to read a short fictional vignette depicting an individual with substance abuse, schizophrenia, and major depression. Then, all nurses responded to the AMIQ of each fictional vignette. The AMIQ adapted from Cunningham et al.(1993) is a 5-item scale with a 5-point Likert scale ranging from a minimum of −2 to a maximum of +2 where ‘neutral’ and ‘don’t know’ are scored 0. The total scores ranged from −10 to +10. Higher (more positive) scores are representative of favourable attitudes. The AMIQ achieved adequate validity and reliability (Cronbach’s α = 0.93) (Luty et al. 2006). In this study, Cronbach’s alphas for substance abuse, schizophrenia, and major depression were 0.85, 0.83, and 0.82, respectively. Translation process
Following permission granted by Professors Mohammadreza Hojat and Jason Luty, the JSE-HP version and AMIQ were translated from Chinese into English. The procedure of translation was conducted with a guideline of cultural and linguistic adaptation of psychometric measures (Wild et al. 2005). Initially, two bilingual nursing professionals independently translated the English versions of JSE-HP version and AMIQ into Chinese. Then, the principal investigator compared these preliminary Chinese versions of the JSE-HP version and AMIQ and reconciled the drafts of the Chinese versions of the JSE-HP version and AMIQ. The forwardtranslated versions were then back-translated by a bilingual language expert fluent in both English and Chinese who was blind to either the English or Chinese versions of the JSE-HP version and AMIQ. The research team compared the back-translated versions to the originals to ensure the cross-cultural equivalency. A panel of three experts in mental health nursing and psychiatry were invited to rate each item of the instruments. The content validity index of the JSE-HP version and AMIQ were 0.91 and 0.93, respectively. Then, a pilot test using a sample of 10 mental health nurses was undertaken and indicated that the Chinese versions of the questionnaire were comprehensible and easy to fill out. Participants in a pilot study were not involved in the subsequent analysis.
Data analysis SPSS software version 17 (SPSS, Chicago, IL, USA) was used to perform data analysis. Descriptive statistics were © 2015 Australian College of Mental Health Nurses Inc.
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calculated to characterize the study sample and variables. Pearson’s product–moment correlation was computed to examine the directions and correlations among mental health nurses’ characteristics (i.e. age and length of mental health nursing practice), empathy, and attitudes towards people with mental illness. Differences in mental health nurses’ characteristics (i.e. sex, position, and mental health-care setting) and the level of mental health nurses’ attitudes towards people with mental illness were estimated with an independent-sample Student’s t-test or one-way anova. Scheffé’s post-hoc test was analyzed for the multi-comparison when an equal error variance in groups was detected. The assumptions of multiple regression analyses were first examined, and multicollinearity was checked with correlation coefficients, tolerances, and the variance inflation factors. Then, hierarchical multiple regression analyses were conducted to examine the determinants of mental health nurses’ attitudes towards people with mental illness. Statistical significance was set at P < 0.05.
RESULTS Mental health nurses’ characteristics Completion of the valid questionnaires were received from 180 nurses (87.4% response rate). Nurses’ characteristics are shown in Table 1. Participants were in their 30s with an average of approximately 8.26 years of mental health nursing practices. The majority of nurses were female, staff nurses, and working at acute psychiatric inpatient units.
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Mental health nurses’ attitudes towards people with mental illness The values of means and standard deviations (SD) of mental health nurses’ attitudes towards people with mental illness responding to vignettes of substance abuse, schizophrenia, and major depressive illness were −4.69 (SD = 3.29), −2.87 (SD = 3.58), and –0.62 (SD = 4.02), respectively. There was a statistically significant difference among the degree of attitudes of mental health nurses towards patients diagnosed with substance abuse, schizophrenia, and major depression (F = 56.44, P < 0.001), indicating more negative attitudes towards patients with substance abuse followed by patients with schizophrenia and major depression.
Relationships among mental health nurses’ characteristics, empathy, and attitudes towards people with mental illness As indicated in Table 2, mental health nurses who were head nurses or supervisors held more positive attitudes towards people suffering from substance abuse (t = −3.15, P = 0.002), schizophrenia (t = −2.51, P = 0.013), and major depression (t = −2.95, P = 0.004) compared with those who were nursing staff. In relation to mental healthcare settings, a significant difference was found in mental health nurses’ attitudes toward people with substance abuse (F = 4.24, P = 0.016) and schizophrenia (F = 5.34, P = 0.006). There were no significant differences in mental health nurses’ attitudes towards people with major depression among mental health-care settings. Further, Scheffé’s post-hoc test revealed more negative attitudes
TABLE 1: Mental health nurses’ characteristics and study variables (n = 180) Variables Sex Male Female Position Staff nurse Head nurse/supervisor Mental health-care setting Acute psychiatric inpatient units Psychiatric rehabilitation units Outpatient clinics/community psychiatric rehabilitation centres Age (years) Length of mental health nursing practice (years) Empathy Mental health nurses’ attitudes towards substance abuse Mental health nurses’ attitudes towards schizophrenia Mental health nurses’ attitudes towards major depression SD, standard deviation.
© 2015 Australian College of Mental Health Nurses Inc.
n (%)
Mean (SD)
Range
33.45 (7.21) 8.26 (5.98) 98.44 (14.74) −4.69 (3.29) −2.87 (3.58) −0.62 (4.02)
20–52 1–29.58 75–137 −10 to 1 −9 to 5 −9 to 9
31 (17.2) 149 (82.8) 163 (90.6%) 17 (9.4%) 95 (52.8) 71 (39.4) 14 (7.8)
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TABLE 2: Attitudes towards people with mental illness by mental health nurses’ characteristics (n = 180) Substance abuse Mental health nurses’ characteristics Sex Male Female Position Staff nurse Head nurse/supervisor Mental health-care setting ① Acute psychiatric inpatient units ② Psychiatric rehabilitation units ③ Outpatient clinics/community psychiatric rehabilitation centres
Mean (SD)
t/F t = −0.2
Schizophrenia P 0.84
−4.58 (3.33) −4.71 (3.30)
t/F t = 0.5
Major depression P
t = −3.15
0.013*
−3.08 (3.56) −0.82 (3.13) F = 4.24 ①>③
0.016* −3.47 (3.56) −2.55 (3.44) −0.36 (3.25)
t/F
P
t = 0.34
0.736
t = −2.95
0.004**
F = 2.94
0.055
−0.84 (3.88) −0.57 (4.06) t = −2.51
0.002**
Mean (SD)
0.616
−3.16 (3.88) −2.81 (3.52)
−4.93 (3.26) −2.35 (2.67) −5.11 (3.19) −4.58 (3.31) −2.43 (3.2)
Mean (SD)
−0.9 (3.94) 2.06 (3.91) F = 5.34 ①>③
0.006** −0.8 (3.91) −0.86 (4.16) 1.86 (3.39)
*P < 0.05, **P < 0.01. SD, standard deviation, t/F = t value of independent-sample Student’s t-test or F-value of anova, Scheffé’s test for multi-comparison.
towards people with substance abuse and schizophrenia among nurses working in acute psychiatric inpatient units compared with those working in psychiatric rehabilitation units and outpatient clinics or community psychiatric rehabilitation centres. Mental health nurses who were older expressed more positive attitudes towards individuals with substance abuse (r = 0.41, P < 0.01), schizophrenia (r = 0.51, P < 0.01), and major depression (r = 0.41, P < 0.01). In addition, mental health nurses with longer mental health nursing practices were found to have more positive attitudes towards people having substance abuse (r = 0.43, P < 0.01), schizophrenia (r = 0.48, P < 0.01), and major depression (r = 0.45, P < 0.01). Positive correlations were found between empathy and attitudes towards people having substance abuse (r = 0.56, P < 0.01), schizophrenia (r = 0.61, P < 0.01), and major depression (r = 0.61, P < 0.01). That is, greater empathy was correlated with more positive attitudes of mental health nurses towards people with schizophrenia, major depression, and substance abuse.
Factors related to mental health nurses’ attitudes towards people with mental illness Hierarchical multiple regression analyses were performed to identify the determinants of mental health nurses’ attitude towards people with mental illness. Only variables that were significantly correlated with mental health nurses’ attitudes towards people with substance abuse, schizophrenia, and major depression were entered into the regression analyses. A high correlation was found between age and length of mental health nursing practice; age was excluded from the regression models. As demonstrated in Table 3, model 1 indicates that length of mental
health nursing practice significantly influences mental health nurses’ attitudes towards people with substance abuse (β = 0.4, P < 0.001), schizophrenia (β = 0.49, P < 0.001), and major depression (β = 0.45, P < 0.001) and explained 17%, 23%, and 19% of the variance in mental health nurses’ attitudes towards substance abuse, schizophrenia, and major depression, respectively. Model 2 indicates that length of mental health nursing practice and empathy significantly accounted for mental health nurses’ attitudes towards people with substance towards substance abuse (β = 0.23, P = 0.004 and β = 0.46, P < 0.001, respectively), schizophrenia (β = 0.3, P < 0.001 and β = 0.49, P < 0.001, respectively), and major depression (β = 0.23, P = 0.001 and β = 0.52, P < 0.001, respectively) after controlling for mental health nurses’ characteristics. The model 2 explained the 35%, 42%, and 41% of the variance in mental health nurses’ attitudes towards people with substance abuse, schizophrenia, and major depression, respectively.
DISCUSSION This study, to our knowledge, is one of few to investigate factors related to attitudes towards people with mental illnesses among Taiwanese mental health nurses. Our results demonstrated that negative attitudes were prevalent among mental health nurses and in particular, towards individuals with substance abuse as opposed to those with schizophrenia and major depression in mental health care. In general, mental health nurses who were older, had more clinical experiences in mental health care, and possessed greater empathy expressed more positive attitudes towards people with mental illness. Additionally, nurses working in acute psychiatric units © 2015 Australian College of Mental Health Nurses Inc.
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TABLE 3: Factors related to mental health nurses’ attitudes towards people with mental illness (n = 180) Model 1
Variable Length of mental health nursing practice Position Mental health-care setting (acute psychiatric inpatient units)† Mental health-care setting (outpatient clinics/community psychiatric rehabilitation centres)† Empathy R2 Adjusted R2 F change
Substance abuse β
Model 2
Schizophrenia β
Major depression β
Substance abuse β
Schizophrenia β
Major depression β
0.4*** 0.02 −0.03 0.05
0.49*** −0.07 −0.07 0.04
0.45*** −0.01 0.02 −0.03
0.23** 0.01 0.01 0.04
0.3*** −0.08 −0.02 0.03
0.23** −0.01
0.19 0.17 10.43***
0.24 0.23 13.97***
0.2 0.19 21.99***
0.46*** 0.37 0.35 47.44***
0.49*** 0.44 0.42 60.79***
0.52*** 0.42 0.41 65.9***
**P < 0.01, ***P < 0.001. †Referent category: Mental health-care setting (psychiatric rehabilitation units).
presented less negative attitudes towards people with mental illness compared with those working in psychiatric rehabilitation units and outpatient clinics or community psychiatric rehabilitation centres. These findings are similar to the results of previous work on nurses’ stigmatizing attitudes in Western mental health-care practice (Björman et al. 2008; Hansson et al. 2011; Rao et al. 2009). Moreover, this study expands knowledge regarding attributes of attitudes of mental health nurses towards people with mental illnesses in non-Western societies such as Taiwan. Mental health nurses in the present study demonstrated pessimistic attitudes towards people suffering from mental illnesses as an indication of stigmatization. This does not correspond with previous studies indicating that mental health nurses hold generally positive attitudes towards individuals with mental illness (Chambers et al. 2010; Munro & Baker 2007; Vibha et al. 2008). Moreover, mental health nurses held more negative attitudes compared with earlier findings in samples of mental health professionals in the UK (Rao et al. 2009) and medical students in Australia (Galletly & Burton 2011) as well as the general population in the UK (Luty et al. 2006; 2009) when measured by the AMIQ. In particular, mental health nurses in our study expressed more unfavourable attitudes towards people with substance abuse followed by schizophrenia and major depression, respectively. As in a study by Björman et al. (2008), schizophrenia, drug addiction, or alcohol addiction were more likely to be perceived as unpredictable and dangerous as compared with other mental illnesses such as major depression. In this regard, however, our results indicated that mental health nurses hold negative attitudes towards people with major depression in contrast to positive attitudinal responses reported in a study of Luty et al. (2006). © 2015 Australian College of Mental Health Nurses Inc.
It appears that mental health nurses in Taiwan endorse negative attitudes, particularly in relation to people with substance abuse although contemporary psychiatric and mental health nursing curricula in Taiwan are primarily based on the Western model of aetiology and treatment of mental illness. This may partly reflect the fact that people experiencing mental illness are often labelled and discriminated against in a traditional Chinese culture, including the degree of negative attitudes associated with particular illnesses or symptoms individuals with mental illnesses manifest. A Taiwanese study by Chang and Yang (2013) claimed that nurses tend to possess moralistic views about substance abusers with regard to potentially adverse social outcomes (e.g. criminal behaviours) rather than health issues. As such, these negative attitudes held by mental health nurses towards people who have mental illnesses, especially substance abuse, are considered as an obstacle to the quality of mental health nursing care delivered. Apparently, the research is confounded due to the use of various measures of attitudes towards people with mental illness. More specific attitudinal measures require further investigation. Furthermore, it remains unknown to what extent these negative attitudes influence their caring behaviours and the quality of mental health-care services. This is among the first studies on mental health nurses’ attitudes towards people with mental illness in Taiwan. Research into attitudes of mental health professionals and allied health-care professionals towards people with mental illnesses is recommended. In the current study, older age and longer years of mental health nursing practice attributed to less negative attitudes towards people with mental illness (i.e. substance abuse, schizophrenia, and major depression) which support earlier findings (Björman et al. 2008; Chang & Yang 2013; Hansson et al. 2011). Nurses in senior
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positions (i.e. head nurse or supervisor) were found to be more positive in their attitudes towards people experiencing substance abuse, schizophrenia, and major depression than those in junior positions (i.e. staff nurse) which is in line with previous research (Chambers et al. 2010; Chang & Yang 2013). Collectively, it is likely that older and more experienced nurses in senior positions tend to be increasingly exposed to, and have had more contact with, individuals with mental illnesses which may bolster more favourable attitudes towards mental illness. In comparisons of mental health-care settings, our study revealed that nurses employed at acute psychiatric units demonstrated more negative attitudes compared with those working at psychiatric rehabilitation units and outpatient clinics or community psychiatric rehabilitation centres. This result contradicts the findings of Munro and Baker’s (2007) survey indicating positive attitudes of acute mental health nurses. This may be due, in part, to acute mental health nurses primarily driven by the taskoriented care with restricted time in direct contact with the patients. Additionally, mental health nurses in acute psychiatric units often encounter severely afflicted patients, which may likely instil negative attitudes. A relatively small sample of nurses in this study working within the community facilities was sampled. As a consequence, caution is advised when interpreting the results concerning the differences among attitudes of mental health nurses in various mental health-care settings. Contrary to the aforementioned reports (Björman et al. 2008; Chambers et al. 2010; Munro & Baker 2007), however, no sex differences in attitudes towards specific mental illnesses (i.e. substance abuse, schizophrenia, and major depressive illness) were found in this study. Similarly, some studies also reported no statistically significant differences between males and females in a sample of mental health professionals (Hamdan-Mansour & Wardam 2009; Hansson et al. 2011; Nordt et al. 2006). Attitudes of mental health nurses are shaped not only by individual characteristics (e.g. sex) but also by multiple attributes. Arguably, the effect of sex on mental health nurses’ attitudes should be viewed with caution. Further research should be undertaken to elucidate the impact of other potential factors (e.g. personality, marital status, having relatives or friends with mental illness, knowledge of mental illness, additional continuing education or training in psychiatric practice, or cultural climate within health-care systems) with sex on the attitudes of nurses working in mental health-care settings. Our findings support the hypothesis that mental health nurses with greater empathy endorse more positive attitudes towards caring for people with mental illness. This
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is in accordance with earlier results suggesting that empathy, as a backbone of therapeutic relationships, enables health-care providers to accurately elicit and identify patient preferences and values in response to health problems, and thus, improves patient health outcomes (Gateshill et al. 2011; Hojat 2007). Yet, there is limited work available on mental health nursing in regard to the role that empathy plays in shaping attitudes towards mental illness in clinical practice. Given the critical value of empathy in the provision of health-care services, effective interventions should be designed to address empathic engagement in patient care. Continued efforts to foster empathy in ways such as role playing, case scenario-based learning (e.g. problem-based learning), and reflection on clinical experiences appear warranted. The AMIQ is brief and convenient to assess an individual’s own stigmatized attitudes towards mental illness (Luty et al. 2006). Likewise, the items of other stigma scales tend to be longer, more costly, and may require an interviewer to assess the opinions of the general population towards contacting people who have mental illness (e.g. Community Attitudes Toward the Mentally Ill scale; Taylor & Dear 1981) or emphasize the internalized feelings of stigma of people suffering from mental illness (e.g. Internalized Stigma of Mental Illness scale; Ritsher et al. 2003). Overall, negative attitudes among Taiwanese mental health nurses exist, particularly among those who are younger, less experienced, hold junior positions, work at acute psychiatric units, and have decreased empathy towards people with mental illness. Our findings suggest that cultural values of attribution and anticipated prognosis of mental illness are deeply rooted in mental health nurses, even if they have at least received academic knowledge about mental illness and 4–6 weeks of clinical training in mental health nursing during baccalaureate or postgraduate programs. As noted, current Taiwanese nursing education is less likely to reduce negative attitudes of mental health nurses towards people suffering from mental illness, especially for people with substance abuse. Nursing educators should integrate culturally enshrined perspectives of mental illness into academic curricula. Mental health nurses as role models in the general public should carefully reflect their own attitudes towards mental health problems and the impact of such attitudes on the quality of patient care delivered. Continuing education and training regarding knowledge of nature and treatment effects of mental illnesses may enhance nurses’ positive attitudes towards caring for people experiencing mental health problems. In addition, the potential impact of education regarding genomics knowledge and its clinical implications may help stimulate nurses’ optimistic attitudes towards © 2015 Australian College of Mental Health Nurses Inc.
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mental health care. Accordingly, education may help individuals with mental illness and their families alleviate their self-stigma, and therefore, improve adaptation to living with the hereditary nature of mental illness. As well, it is recommended that mental health nurses be provided support in clinical supervision in conjunction with education to assist them with guidance through thoughtful discussions and reflection of personal and clinical issues when working with patients.
Limitations of the study Findings from this study should be interpreted with caution due to some limitations. First, it is a crosssectional study which is less informative than longitudinal research in relation to a causal relationship of attributes. Future research applying a prospective design to assess changes of stigmatizing attitudes is recommended. Second, participants were not randomly selected and the majority of our sample was female; therefore, we cannot generalize the results as applicable to the population of Taiwanese mental health nurses. A nationwide, randomselected sample would be recommended to generalize our findings. Third, both the AMIQ and JSE-HP version were self-administered instruments that assess an individual’s opinions in response to mental illness. It is possible to underestimate mental health nurses’ perspectives, particularly their actual behaviours toward people experiencing mental illness, which may be appropriately measured by means of observation. Additionally, a social desirability bias may exist although anonymity was assured.
CONCLUSION This study demonstrated that mental health nurses, in general, were negatively disposed to individuals with mental illnesses, especially those caring for persons with substance abuse. Younger, less experienced, and less empathic nurses as well as those working in acute psychiatric wards were prone to more pessimistic attitudes compared with their counterparts. To deliver therapeutically effective nursing care in mental health-care services, increased recognition of nurses’ attitudes concerning mental illnesses is an imperative issue. Nursing education and training programs should aim to equip mental health nurses with empathic reactions and positive attitudes in the care of individuals suffering from mental illnesses.
ACKNOWLEDGEMENTS The authors acknowledge and thank the participants. Sincere thanks to the Ministry of Science and Technology, Taiwan for funding this study (100-2410-H-040-007MY2). © 2015 Australian College of Mental Health Nurses Inc.
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