Issues in Mental Health Nursing, 35:50–57, 2014 Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2013.837123
It’s the Anxiety: Facilitators and Inhibitors to Nursing Students’ Career Interests in Mental Health Nursing Brenda Happell, PhD, RN, Chris Platania-Phung, BA (Hons), PhD, Scott Harris, RN, CMHN, Dip Health Sci, M Ment Health Nurs, and Julie Bradshaw, RN, B Health Nurs, M Nurs (Hons) Central Queensland University, Institute for Health and Social Science Research, Centre for Mental Health and School of Nursing and Midwifery, Rockhampton, Queensland, Australia
tal health nurses worldwide, and in some countries (such as Australia) the projected shortfalls of mental health nurses compared to other health care professions is particularly acute (Gough & Happell, 2007; Health Workforce Australia, 2012). Given that the average age of nurses generally continues to increase (Australian Institute of Health & Welfare, 2012), sustaining even the minimal numbers of mental health nurses to ensure provision of mental health services currently, and for the future, is a considerable challenge. For a more effective approach to the promotion of MHN as a career specialty, it is important to understand the views of students seeking to enter the nursing workforce and, in particular, attitudes that may influence interest in pursuing MHN. For instance, fear and anxiety about people with mental illness (Corrigan, Kuwabara, & O’Shaughnessy, 2009) appear to generalise to nursing students and nurses (Hoekstra et al., 2010; Surgenor, Dunn, & Horn, 2005) and detract attention from MHN as an area for providing care (Hayman-White & Happell, 2005). However, there is a shortage of empirical research identifying factors that may account for student differences in interest in MHN as a career. Two previous studies have reported on correlates of selfreported interest in MHN as a career. Hayman-White and Happell (2005) investigated precursors to interest in MHN as a career among undergraduate nursing students in Victoria, Australia. Through a correlational design, they found that interest in a career in MHN was associated with preparedness for working in mental health, anxiety towards people with a mental illness, and the view the MHN makes a valuable contribution to recovery. Similarly, Happell and Gough (2007) asked students at the undergraduate level about their views on MHN and mental illness, before and after completing a clinical placement. Their regression analysis found interest in MHN to be significantly predicted by perceived preparedness for MHN, anxiety with respect to people with mental illness, and the belief that MHN makes a valuable contribution. Happell and Gough (2007) also
Increasing the rate of recruitment of nursing students into mental health nursing (MHN) is vital to long-term sustainability of health care system support for people diagnosed with mental illness. However MHN is not a popular career path; this raises questions about what attitudes and beliefs may divert or attract students to this specialisation. The current research involved a survey of undergraduate nursing students at a regional university in Australia to clarify the nature of relationships between attitudes (e.g., the value of mental health nursing, stereotypes of people with mental illness) and how they may be antecedents to considering MHN as a career path. Through a structural equation model, it was ascertained that anxiety surrounding mental illness leads to less interest in MHN as a future career and suggests that anxiety is (a) partly due to negative stereotypes, and (b) countered by preparedness for a MHN role. Beliefs on how MHN can make a valuable contribution to people’s well-being did not affect interest in pursuing MHN. These findings reconfirm the need to reduce anxiety about mental illness by educational approaches that effectively prepare students for MHN, combined with challenging negative stereotypes.
Mental health nursing (MHN) is a critically important profession for supporting individuals who have mental illness. However, it is not a popular career choice for nursing students (Happell & Cutcliffe, 2011; Happell & Gaskin, 2013; Happell, Welch, Moxham, & Byrne, 2013; Stevens, Browne, & Graham, 2013). Studies of nursing students’ views consistently demonstrate a preference for other types of nursing as a career, relative to mental health nursing (Happell, 2001; Stevens & Dulhunty, 1997). Unequivocally, those indicating an interest in MHN as a career are few (Evangelou, 2010; Happell & Gough, 2009; Hayman-White & Happell, 2005; Hoekstra, van Meijel, & van der Hooft-Leemans, 2010). The lack of general nursing students who choose mental health nursing is problematic given the current shortage of menAddress correspondence to Brenda Happell, CQUniversity Australia, School of Nursing & Midwifery, Bruce Highway, Rockhampton, 4701 Australia. E-mail: [email protected]
50
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ANXIETY AND NURSING STUDENTS’ CAREER INTERESTS
Negave Stereotype Anxiety Surrounding Mental Illness
Future Career in MHN
Preparedness
Valuable Contribuon
FIGURE 1. Model of Antecedents to Interest in Mental Health Nursing as a Career.
found that negative stereotypes of mental illness were not associated with interest in MHN as a career. There remains little research on antecedents to nursing students’ intentions to pursue MHN as a career. In addition, analyses that look more at the complexity of relationships among potential antecedents are needed. For instance, the finding of Happell and Gough (2009), demonstrated that negative stereotypes might be influential in an indirect way, such as by impacting on anxiety towards people with a mental illness. Furthermore, regression and correlational analyses previously applied do not address measurement error that is characteristic of self-report instruments. By employing latent variable structural equation modelling (Byrne, 2012), pathways among antecedents can be investigated, while at the same time, accounting for error in measurement. This article reports on an analysis aimed at clarifying the nature of relationships among antecedents to interest in MHN as a career, with a sample of undergraduate nursing students at a regional university in Australia. Figure 1 presents a model of the anticipated effects of attitudes on interest in MHN as a career, described as “Future Career in MHN.” In light of previous research and conceptual considerations, it was anticipated that anxiety would be an immediate predictor of interest in MHN as a career, and that anxiety, in turn, would be affected by negative stereotypes on mental illness (where these beliefs promote anxiety), and preparedness for the MHN role (more preparedness dampening feelings of anxiety). In addition, it was anticipated that preparedness (e.g., perceived confidence in doing the role)
would influence interest in MHN independently of anxiety (as shown by the direct path in Figure 1). The role of negative stereotypes is argued to be indirect, where the influence of this domain of attitudes on interest in MHN only takes place via anxiety. The pathway at the bottom of Figure 1 presents the final prediction—that the perceived contribution of MHN has a direct bearing on interest in MHN as a career, and does so independently of the other attitude domains described above. METHODS The aim of this study is to understand how nursing students’ attitudes relate to career intentions for MHN prior to their undertaking the theoretical and clinical component of mental health nursing. Participants Participants were undergraduate nursing students (n = 116) at a regional university in Australia. Most participants were female (n = 108, 93.1%). The largest age group was 18–29 years (n = 49, 42.2%), followed by 30–39 years (n = 32, 27.6%), 40–49 years (n = 24, 20.7%), and 50 years and over (n = 11, 9.5%). Measure This study employed the Mental Health Nursing Education Survey, otherwise known as the Psychiatric/Mental Health Clinical Placement Survey for First Day of Placement (Happell &
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Gough, 2007). This was the same survey employed in the two previous studies that described correlates or antecedents to interest in MHN as a career that were reviewed earlier (Happell & Gough, 2007; Hayman-White & Happell, 2005). In this survey, participants are asked to indicate their level of (dis)agreement with 28 statements, covering attitudes to mental illness and mental health services, and interest in mental health nursing as a career. The seven-point rating scale has anchors of 1 (strongly disagree) and 7 (strongly agree). Although the survey is comprised of seven subscales, due to the small sample size of the current study, it was not possible to robustly investigate the overall survey, so only those scales that were viewed as most likely to be connected to interest in MHN are described here: Preparedness for the Mental Health Field is about perceived confidence in carrying out the MHN role (e.g., “I feel confident in my ability to care for people experiencing a mental health problem.”). Negative Stereotypes include statements about presumed weaknesses and problem behaviours, such as, “People with mental illness are more likely to commit offences or crimes.” Anxiety Surrounding Mental Illness refers to anticipated feelings, for instance, “I am anxious about working with people experiencing a mental health problem.” Valuable Contribution is about the capacity to make a difference through MHN and mental health services in general, for instance: “Psychiatric/mental health nursing can assist people with mental illness in their recovery.” Future Career is concerned with the interest to strive to become a MHN, with one item on intention to do a graduate program (“I will apply for a graduate program in psychiatric/mental health nursing.”) and the other on the assertion to do MHN (“I intend to pursue a career in mental health nursing.”). Internal consistency levels of these scales, as assessed by Happell and Gough (2007) were .72, .51, .67, and .92, respectively. Procedure This study was reviewed and permitted to proceed by the university’s ethics committee. Data collection took place during class time, and surveys were administered in hard copy. An information sheet on the topic of the research, provisions for anonymity, and voluntary consent of participation was provided to all students. Participants were asked to provide their name on the survey. They were informed during the introduction to the study that their names were entirely for the purpose of matching participants across the evaluation research, and that only researchers would have access to identifying information. Data collection took place in the latter half of 2012. Procedures for Data Analysis Structural equation modeling with maximum likelihood estimation was conducted in Mplus 6.1. The maximum data missing for any variable in the current analysis was two cases (1.7% missing). Missing data was treated with Full Information Maximum Likelihood in Mplus. Negatively worded state-
ments were reverse scored in order to facilitate interpretation of results. In accordance with assessment procedures in structural equation modelling, a set of indices of fit were carried out in conjunction with the main criterion of the chi-square (χ 2 ) statistic of the difference between the observed covariance matrix and the restricted (or “implied”) matrix (cf. Byrne, 2012). Specifically, the following criterion were applied to ascertain model fit (Byrne, 2012; Hu & Bentler, 1999): a Root Mean Square Error of Approximation (RMSEA) under .08; a Root Mean Square Residual (RMSR) of under .05; and, for incremental fit, a Tucker Lewis Index (TLI) over .95 and a Comparative Fit Index (CFI) of over .95. For indications of the presence of indirect effects, Sobel’s test was carried out (Baron & Kenny, 1986). Internal consistency (scale reliability) was determined by the Cronbach alpha index (see Cronbach, 1951).
RESULTS Descriptive Statistics The current article focuses only on those items that were considered as potential antecedents to mental health nursing as a career. Table 1 provides the descriptive statistics and intercorrelations among items included to test the model in Figure 1. The average rating for Item 6 shows that the sample was typically in disagreement with the statement on the intention to apply for a graduate program in MHN, and the rating for the statement on intending to pursue MHN as a career was also low. Also, it is noted from Table 1 that correlations tended to be small to moderate in magnitude.
Measurement Model A confirmatory factor model to assess construct and discriminant validity (measurement model) is required before the investigation of relationships among the measured constructs through structural equation modeling (Byrne, 2012). The confirmatory factor model demonstrated fit: χ 2 (67) = 84.85, p = .07, RMSEA = .05 (90% CI: .00, .08), CFI = .96, TLI = .94, SRMR = .06. However the item “people with mental illness are unpredictable” had a low loading with negative stereotype (λ = .40). When this item was removed the model fit indices were: χ 2 (55) = 64.14, p = .19, RMSEA = .04 (90% CI: .00, .07), CFI = .98, TLI = .97, SRMR = .06. Table 2 presents the standardized factor loadings of the confirmatory factor model and indicates that factor loadings ranged from .48 to .93. The standardized inter-correlation coefficients are presented in Table 3. The highest correlation coefficient was between preparedness for the mental health field and anxiety. As the anxiety items were reverse scored, this correlation suggests that preparedness is associated with less anxiety. Three of the five internal reliabilities (α) at the bottom of Table 3 were moderate to good (preparedness, anxiety, and MHN career), while two scales
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ANXIETY AND NURSING STUDENTS’ CAREER INTERESTS
TABLE 1 Inter-Correlations and Descriptive Statistics Statement Psychiatric/mental health nursing makes a positive contribution to people experiencing a mental health problem. I am anxious about working with people experiencing mental health problem. I have a good understanding of the role of a psychiatric/mental health nurse. I am uncertain how to act towards someone with a mental illness. I will apply for a graduate program in psychiatric/mental health nursing. I feel confident in my ability to care for people experiencing a mental health problem. Psychiatric/mental health nursing can assist people with mental illness in their recovery. People with mental illness are more likely to be violent. I intend to pursue a career in mental health nursing. My course has prepared me to work as a graduate nurse in a psychiatric/mental health graduate program. Mental health services provide valuable assistance to people experiencing a mental health problem. People with mental illness are more likely to commit offences or crimes. People with mental illness can’t handle too much responsibility. Mean (SD)
Item
2
2
1
3 −.07
3
4
5
6
7
8
13
15
19
23
24
25
1
4
.26
.21
1
5
.08
.59
.22
6
.13
.25
.21
.29
7
.09
.41
.52
.50
.37
8
.51
–.15
.16
.02
.00
.04
13
.11
.19
.17
.22
.29
.13
.09
15
.12
.34
.21
.36
.79
.40
.11
.30
19
.13
.29
.43
.31
.39
.59
.05
.22
.37
23
.38
.00
.12
–.06
–.01
–.10
.31
.15
–.03
.09
24
.06
.21
.21
.17
.19
.02
.01
.48
.18
.16
.09
25
.10
.07
–.00
.16
–.01
.03
.18
.40
.04
.10
.12
1
1
1
1
1
1 1
1
1
.33
1
5.87 4.41 4.11 4.45 3.00 3.77 5.96 4.62 3.29 4.10 5.98 4.55 4.52 (1.10) (1.73) (1.34) (1.52) (1.76) (1.56) (1.05) (1.44) (1.80) (1.38) (1.21) (1.40) (1.46)
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TABLE 2 Parameter Estimates for Confirmatory Factor Model Factor Negative Stereotype
Preparedness for Mental Health Field
Valuable Contribution
Anxiety Surrounding Mental Illness Interest in MHN as career
Indicator Variable
Factor Loading
People with mental illness are more likely to be violent. (Item 13) People with mental illness are more likely to commit offences or crimes. (Item 24) People with mental illness can’t handle too much responsibility. (Item 25) I have a good understanding of the role of a psychiatric/mental health nurse. (Item 4) I feel confident in my ability to care for people experiencing a mental health problem. (Item 7) My course has prepared me to work as a graduate nurse in a psychiatric/mental health graduate program. (Item 19) Psychiatric/mental health nursing makes a positive contribution to people experiencing a mental health problem. (Item 2) Psychiatric/mental health nursing can assist people with mental illness in their recovery. (Item 8) Mental health services provide valuable assistance to people experiencing a mental health problem. (Item 23) I am anxious about working with people experiencing a mental health problem. (Item 3) I am uncertain how to act towards someone with a mental illness. (Item 5) I intend to pursue a career in mental health nursing. (Item 15) I will apply for a graduate program in psychiatric/mental health nursing. (Item 6)
.81 .60
did not have strong reliability (stereotypes and valuable contributions). Structural Equation Model The structural equation model demonstrated reasonably good fit: χ 2 (57) = 69.03, p = .13, RMSEA = .04 (90% CI: .00, .07), CFI = .97, TLI = .96, SRMR = .06. The model accounted for 45.4% of variance in anxiety, and 29.9% of variance in interest in MHN as career. The standardized regression paths are presented in Figure 2. Although global fit was found, not all specified pathways had statistically significant coefficients. Full lines represent statistically significant paths and the light lines indicated paths specified that were not significant. For brevity, the other parameters are not shown in Figure 2 (e.g., parameters fixed to unity, and factor loadings). Although there was demonstrated global fit, not all specified pathways had statistically significant coefficients. While, anxiety significantly predicted future career intentions in mental health nursing (ß = .24, t = 1.98, p < .001), preparedness did not predict MHN intentions (ß = .24, t = 1.89, p > .05), nor did perceptions of valuable contributions of MHN (ß = .29, t = 0.93, p > .05). The two specified antecedents to anxiety surrounding mental illness were statistically significant: negative stereotypes as a predictor of anxiety (ß = .24, t = 2.11, p < .05), and preparedness as a predictor of anxiety (ß = .58, t = 6.57, p < .05). However, the anticipated
.50 .58 .89 .68 .78 .66 .48 .73 .81 .84 .93
indirect effects pictured in Figure 1 did not turn out to be statistically significant—namely, from stereotypes to interest in MHN via anxiety (Sobel’s t = 1.33, p > .05), and from preparedness to interest in MHN via anxiety (Sobel’s t = 1.86, p > .05). At the same time, the total effect (sum of indirect and direct effects) of preparedness on interest in MHN was significant (ß = .46, t = 4.72, p < .05). DISCUSSION The current findings suggest that of all the potential influences on whether a student considers mental health nursing as a career, it was self-reported anxiety that was the most important. This reconfirms evidence from past research that demonstrated the significant bearing anxiety has on interest in mental health nursing (Hayman-White & Happell, 2005; Hoekstra et al., 2010), and probably reflects a more general problem of social distancing from people diagnosed as having a mental illness (Corrigan, Markowitz, & Watson, 2004). Initiatives to provide a more accurate understanding of people who are experiencing mental health challenges such as through mental health clinical placements (Happell, 2008a, 2008b) and direct instruction on the topic of recovery by a mental health consumer (Happell et al., 2013) may effectively address anxiety, as well as the negative stereotypes that may be a precursor to anxiety. Furthermore, general strategies for countering stigma of mental illness
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ANXIETY AND NURSING STUDENTS’ CAREER INTERESTS
TABLE 3 Estimates of Inter-Factor Correlations
MHN as a career, compared to the previous study, where 16% was explained. The difference in variance explained may be due to having taken account of error variance in the measured Factor: NS P VC ASMI MHN variables. Overall the analytic approach of structural equation modeling was a strength of the current research. Negative 1 The attitudes about mental illness held by undergraduate stuStereotypes (NS) dents were not unlike stances found in the wider population. Preparedness (P) .20 1 It is not surprising that there are negative stereotypes and feelValuable .14 .14 1 ings of anxiety with respect to people diagnosed with mental Contribution illness given the propagation of negative depictions in the me(VC) ∗∗ ∗∗∗ dia (Hannigan, 1999; Sieff, 2003), and the failure, in general, .63 −.02 1 Anxiety .35 for people to appreciate the diversity of individuals to whom a Surrounding label is attached. Going forward, anxiety and negative stereoMental Illness types as impediments to interest in mental health nursing as a (ASMI) ∗∗ ∗∗∗ ∗∗∗ career are identified as a problem that reduces future support Mental Health .35 .50 .13 .47 1 of people with mental illness. Furthermore, based on the emNursing (MHN) pirical findings, these negative factors may be more influential Internal Reliability .67 .77 .66 .74 .88 than potential facilitating factors such as students’ views on the (Cronbach’s contributions of MHN to consumer recovery. alpha) The large regression coefficient of the pathway from pre∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001. paredness for mental health nursing and anxiety is a promising one in terms of nursing education. Even before taking part in (Corrigan, Morris, Michaels, Rafacz, & Rusch, 2012; Corri- a clinical placement, a sense of preparedness by students was gan & O’Shaughnessy, 2007; Dalky, 2011) need to be explored significantly associated with less anxiety. A question urgently in need of addressing is whether placements provide gains in further with respect to general nursing students. The current results are comparable to those of Happell and preparedness (as is their aim) and along with this, stronger intenGough (2007) as the same survey was applied in both stud- tions to pursue MHN as a career, both directly and by dampening ies. Although the current analysis did not look at an identical anxiety about mental illness. Research suggests clinical placecombination of variables as did Happell and Gough (2007), ments can positively influence the popularity of mental health the current model accounted for 30% of variance in interest in nursing (Henderson, Happell, & Martin, 2007), although the
Negave Stereotype
.24 Anxiety Surrounding Mental Illness
.29 Future Career in MHN
.58
Preparedness
.29
.10 Valuable Contribuon
FIGURE 2. Structural Coefficients for Model of Antecedents to Interest in Mental Health Nursing as a Career.
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B. HAPPELL ET AL.
relationship between increased popularity and anxiety has not been specifically examined. There has been a call for an increase in the theory and practice of mental health nursing, not only as discrete content but also included throughout core nursing subjects (Moxham, McCann, Usher, Farrell, & Crookes, 2011) to demonstrate the holistic nature of mental health issues in the wider community and support its relevance for nursing in its application across all health care settings (Happell & PlataniaPhung, 2005). The small sample size was a limitation of the current research. As a result, although there was some support for the final model, the confidence intervals for RMSEA were large. In addition, although preparedness had a total effect on mental health nursing that was statistically significant, this was from combining the indirect effect via anxiety surrounding mental illness and the direct effect. However, on their own, each pathway was not statistically significant. We suggest that the non-significant indirect effect may be due to an insufficient sample size for statistical power, and stress the importance of a larger sample for future studies on the antecedents to mental health nursing as a career. An additional limitation was that students more interested in MHN and mental health care may have been more inclined to have taken part in this voluntary survey. Having said this, it was noted that there was much variability in interest in MHN as a career; 63% disagreed with the intention of pursuing a graduate program in mental health nursing. This suggests that if there was bias with respect to interest in MHN, it would have been minimal. Of final note is that the data analysed were cross-sectional in nature, so although the direction of effects were specified, we acknowledge that this is not a definitive test of determining factors. Further research with the current sample over time (i.e., follow-up analysis after the student clinical placements) will provide a stronger test of whether the currently identified antecedents facilitate interest in MHN as a future career. As there tends to be a lack of detailed analysis of approach-focused and positive aspects of MHN (Happell & Gaskin, 2013), such as promoting quality of life of people with mental illness, a broader array of attitudinal domains need to be measured alongside negative-valence domains (e.g., negative stereotypes of mental illness).
CONCLUSION Anxiety appears to be an influential factor in determining the degree to which nursing students are interested in a career in mental health nursing. Further research is required to ascertain the impact of clinical experience on anxiety levels. A stronger focus on mental health issues throughout nursing programs, preferably commencing from first year, may be effective in reducing levels of anxiety and should therefore be given serious consideration as part of a strategic approach to improving students’ attitudes to mental health nursing.
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It’s the Anxiety: Facilitators and Inhibitors to Nursing Students’ Career Interests in Mental Health Nursing Brenda Happell, PhD, RN, Chris Platania-Phung, BA (Hons), PhD, Scott Harris, RN, CMHN, Dip Health Sci, M Ment Health Nurs, and Julie Bradshaw, RN, B Health Nurs, M Nurs (Hons) Central Queensland University, Institute for Health and Social Science Research, Centre for Mental Health and School of Nursing and Midwifery, Rockhampton, Queensland, Australia
tal health nurses worldwide, and in some countries (such as Australia) the projected shortfalls of mental health nurses compared to other health care professions is particularly acute (Gough & Happell, 2007; Health Workforce Australia, 2012). Given that the average age of nurses generally continues to increase (Australian Institute of Health & Welfare, 2012), sustaining even the minimal numbers of mental health nurses to ensure provision of mental health services currently, and for the future, is a considerable challenge. For a more effective approach to the promotion of MHN as a career specialty, it is important to understand the views of students seeking to enter the nursing workforce and, in particular, attitudes that may influence interest in pursuing MHN. For instance, fear and anxiety about people with mental illness (Corrigan, Kuwabara, & O’Shaughnessy, 2009) appear to generalise to nursing students and nurses (Hoekstra et al., 2010; Surgenor, Dunn, & Horn, 2005) and detract attention from MHN as an area for providing care (Hayman-White & Happell, 2005). However, there is a shortage of empirical research identifying factors that may account for student differences in interest in MHN as a career. Two previous studies have reported on correlates of selfreported interest in MHN as a career. Hayman-White and Happell (2005) investigated precursors to interest in MHN as a career among undergraduate nursing students in Victoria, Australia. Through a correlational design, they found that interest in a career in MHN was associated with preparedness for working in mental health, anxiety towards people with a mental illness, and the view the MHN makes a valuable contribution to recovery. Similarly, Happell and Gough (2007) asked students at the undergraduate level about their views on MHN and mental illness, before and after completing a clinical placement. Their regression analysis found interest in MHN to be significantly predicted by perceived preparedness for MHN, anxiety with respect to people with mental illness, and the belief that MHN makes a valuable contribution. Happell and Gough (2007) also
Increasing the rate of recruitment of nursing students into mental health nursing (MHN) is vital to long-term sustainability of health care system support for people diagnosed with mental illness. However MHN is not a popular career path; this raises questions about what attitudes and beliefs may divert or attract students to this specialisation. The current research involved a survey of undergraduate nursing students at a regional university in Australia to clarify the nature of relationships between attitudes (e.g., the value of mental health nursing, stereotypes of people with mental illness) and how they may be antecedents to considering MHN as a career path. Through a structural equation model, it was ascertained that anxiety surrounding mental illness leads to less interest in MHN as a future career and suggests that anxiety is (a) partly due to negative stereotypes, and (b) countered by preparedness for a MHN role. Beliefs on how MHN can make a valuable contribution to people’s well-being did not affect interest in pursuing MHN. These findings reconfirm the need to reduce anxiety about mental illness by educational approaches that effectively prepare students for MHN, combined with challenging negative stereotypes.
Mental health nursing (MHN) is a critically important profession for supporting individuals who have mental illness. However, it is not a popular career choice for nursing students (Happell & Cutcliffe, 2011; Happell & Gaskin, 2013; Happell, Welch, Moxham, & Byrne, 2013; Stevens, Browne, & Graham, 2013). Studies of nursing students’ views consistently demonstrate a preference for other types of nursing as a career, relative to mental health nursing (Happell, 2001; Stevens & Dulhunty, 1997). Unequivocally, those indicating an interest in MHN as a career are few (Evangelou, 2010; Happell & Gough, 2009; Hayman-White & Happell, 2005; Hoekstra, van Meijel, & van der Hooft-Leemans, 2010). The lack of general nursing students who choose mental health nursing is problematic given the current shortage of menAddress correspondence to Brenda Happell, CQUniversity Australia, School of Nursing & Midwifery, Bruce Highway, Rockhampton, 4701 Australia. E-mail: [email protected]
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ANXIETY AND NURSING STUDENTS’ CAREER INTERESTS
Negave Stereotype Anxiety Surrounding Mental Illness
Future Career in MHN
Preparedness
Valuable Contribuon
FIGURE 1. Model of Antecedents to Interest in Mental Health Nursing as a Career.
found that negative stereotypes of mental illness were not associated with interest in MHN as a career. There remains little research on antecedents to nursing students’ intentions to pursue MHN as a career. In addition, analyses that look more at the complexity of relationships among potential antecedents are needed. For instance, the finding of Happell and Gough (2009), demonstrated that negative stereotypes might be influential in an indirect way, such as by impacting on anxiety towards people with a mental illness. Furthermore, regression and correlational analyses previously applied do not address measurement error that is characteristic of self-report instruments. By employing latent variable structural equation modelling (Byrne, 2012), pathways among antecedents can be investigated, while at the same time, accounting for error in measurement. This article reports on an analysis aimed at clarifying the nature of relationships among antecedents to interest in MHN as a career, with a sample of undergraduate nursing students at a regional university in Australia. Figure 1 presents a model of the anticipated effects of attitudes on interest in MHN as a career, described as “Future Career in MHN.” In light of previous research and conceptual considerations, it was anticipated that anxiety would be an immediate predictor of interest in MHN as a career, and that anxiety, in turn, would be affected by negative stereotypes on mental illness (where these beliefs promote anxiety), and preparedness for the MHN role (more preparedness dampening feelings of anxiety). In addition, it was anticipated that preparedness (e.g., perceived confidence in doing the role)
would influence interest in MHN independently of anxiety (as shown by the direct path in Figure 1). The role of negative stereotypes is argued to be indirect, where the influence of this domain of attitudes on interest in MHN only takes place via anxiety. The pathway at the bottom of Figure 1 presents the final prediction—that the perceived contribution of MHN has a direct bearing on interest in MHN as a career, and does so independently of the other attitude domains described above. METHODS The aim of this study is to understand how nursing students’ attitudes relate to career intentions for MHN prior to their undertaking the theoretical and clinical component of mental health nursing. Participants Participants were undergraduate nursing students (n = 116) at a regional university in Australia. Most participants were female (n = 108, 93.1%). The largest age group was 18–29 years (n = 49, 42.2%), followed by 30–39 years (n = 32, 27.6%), 40–49 years (n = 24, 20.7%), and 50 years and over (n = 11, 9.5%). Measure This study employed the Mental Health Nursing Education Survey, otherwise known as the Psychiatric/Mental Health Clinical Placement Survey for First Day of Placement (Happell &
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Gough, 2007). This was the same survey employed in the two previous studies that described correlates or antecedents to interest in MHN as a career that were reviewed earlier (Happell & Gough, 2007; Hayman-White & Happell, 2005). In this survey, participants are asked to indicate their level of (dis)agreement with 28 statements, covering attitudes to mental illness and mental health services, and interest in mental health nursing as a career. The seven-point rating scale has anchors of 1 (strongly disagree) and 7 (strongly agree). Although the survey is comprised of seven subscales, due to the small sample size of the current study, it was not possible to robustly investigate the overall survey, so only those scales that were viewed as most likely to be connected to interest in MHN are described here: Preparedness for the Mental Health Field is about perceived confidence in carrying out the MHN role (e.g., “I feel confident in my ability to care for people experiencing a mental health problem.”). Negative Stereotypes include statements about presumed weaknesses and problem behaviours, such as, “People with mental illness are more likely to commit offences or crimes.” Anxiety Surrounding Mental Illness refers to anticipated feelings, for instance, “I am anxious about working with people experiencing a mental health problem.” Valuable Contribution is about the capacity to make a difference through MHN and mental health services in general, for instance: “Psychiatric/mental health nursing can assist people with mental illness in their recovery.” Future Career is concerned with the interest to strive to become a MHN, with one item on intention to do a graduate program (“I will apply for a graduate program in psychiatric/mental health nursing.”) and the other on the assertion to do MHN (“I intend to pursue a career in mental health nursing.”). Internal consistency levels of these scales, as assessed by Happell and Gough (2007) were .72, .51, .67, and .92, respectively. Procedure This study was reviewed and permitted to proceed by the university’s ethics committee. Data collection took place during class time, and surveys were administered in hard copy. An information sheet on the topic of the research, provisions for anonymity, and voluntary consent of participation was provided to all students. Participants were asked to provide their name on the survey. They were informed during the introduction to the study that their names were entirely for the purpose of matching participants across the evaluation research, and that only researchers would have access to identifying information. Data collection took place in the latter half of 2012. Procedures for Data Analysis Structural equation modeling with maximum likelihood estimation was conducted in Mplus 6.1. The maximum data missing for any variable in the current analysis was two cases (1.7% missing). Missing data was treated with Full Information Maximum Likelihood in Mplus. Negatively worded state-
ments were reverse scored in order to facilitate interpretation of results. In accordance with assessment procedures in structural equation modelling, a set of indices of fit were carried out in conjunction with the main criterion of the chi-square (χ 2 ) statistic of the difference between the observed covariance matrix and the restricted (or “implied”) matrix (cf. Byrne, 2012). Specifically, the following criterion were applied to ascertain model fit (Byrne, 2012; Hu & Bentler, 1999): a Root Mean Square Error of Approximation (RMSEA) under .08; a Root Mean Square Residual (RMSR) of under .05; and, for incremental fit, a Tucker Lewis Index (TLI) over .95 and a Comparative Fit Index (CFI) of over .95. For indications of the presence of indirect effects, Sobel’s test was carried out (Baron & Kenny, 1986). Internal consistency (scale reliability) was determined by the Cronbach alpha index (see Cronbach, 1951).
RESULTS Descriptive Statistics The current article focuses only on those items that were considered as potential antecedents to mental health nursing as a career. Table 1 provides the descriptive statistics and intercorrelations among items included to test the model in Figure 1. The average rating for Item 6 shows that the sample was typically in disagreement with the statement on the intention to apply for a graduate program in MHN, and the rating for the statement on intending to pursue MHN as a career was also low. Also, it is noted from Table 1 that correlations tended to be small to moderate in magnitude.
Measurement Model A confirmatory factor model to assess construct and discriminant validity (measurement model) is required before the investigation of relationships among the measured constructs through structural equation modeling (Byrne, 2012). The confirmatory factor model demonstrated fit: χ 2 (67) = 84.85, p = .07, RMSEA = .05 (90% CI: .00, .08), CFI = .96, TLI = .94, SRMR = .06. However the item “people with mental illness are unpredictable” had a low loading with negative stereotype (λ = .40). When this item was removed the model fit indices were: χ 2 (55) = 64.14, p = .19, RMSEA = .04 (90% CI: .00, .07), CFI = .98, TLI = .97, SRMR = .06. Table 2 presents the standardized factor loadings of the confirmatory factor model and indicates that factor loadings ranged from .48 to .93. The standardized inter-correlation coefficients are presented in Table 3. The highest correlation coefficient was between preparedness for the mental health field and anxiety. As the anxiety items were reverse scored, this correlation suggests that preparedness is associated with less anxiety. Three of the five internal reliabilities (α) at the bottom of Table 3 were moderate to good (preparedness, anxiety, and MHN career), while two scales
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ANXIETY AND NURSING STUDENTS’ CAREER INTERESTS
TABLE 1 Inter-Correlations and Descriptive Statistics Statement Psychiatric/mental health nursing makes a positive contribution to people experiencing a mental health problem. I am anxious about working with people experiencing mental health problem. I have a good understanding of the role of a psychiatric/mental health nurse. I am uncertain how to act towards someone with a mental illness. I will apply for a graduate program in psychiatric/mental health nursing. I feel confident in my ability to care for people experiencing a mental health problem. Psychiatric/mental health nursing can assist people with mental illness in their recovery. People with mental illness are more likely to be violent. I intend to pursue a career in mental health nursing. My course has prepared me to work as a graduate nurse in a psychiatric/mental health graduate program. Mental health services provide valuable assistance to people experiencing a mental health problem. People with mental illness are more likely to commit offences or crimes. People with mental illness can’t handle too much responsibility. Mean (SD)
Item
2
2
1
3 −.07
3
4
5
6
7
8
13
15
19
23
24
25
1
4
.26
.21
1
5
.08
.59
.22
6
.13
.25
.21
.29
7
.09
.41
.52
.50
.37
8
.51
–.15
.16
.02
.00
.04
13
.11
.19
.17
.22
.29
.13
.09
15
.12
.34
.21
.36
.79
.40
.11
.30
19
.13
.29
.43
.31
.39
.59
.05
.22
.37
23
.38
.00
.12
–.06
–.01
–.10
.31
.15
–.03
.09
24
.06
.21
.21
.17
.19
.02
.01
.48
.18
.16
.09
25
.10
.07
–.00
.16
–.01
.03
.18
.40
.04
.10
.12
1
1
1
1
1
1 1
1
1
.33
1
5.87 4.41 4.11 4.45 3.00 3.77 5.96 4.62 3.29 4.10 5.98 4.55 4.52 (1.10) (1.73) (1.34) (1.52) (1.76) (1.56) (1.05) (1.44) (1.80) (1.38) (1.21) (1.40) (1.46)
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TABLE 2 Parameter Estimates for Confirmatory Factor Model Factor Negative Stereotype
Preparedness for Mental Health Field
Valuable Contribution
Anxiety Surrounding Mental Illness Interest in MHN as career
Indicator Variable
Factor Loading
People with mental illness are more likely to be violent. (Item 13) People with mental illness are more likely to commit offences or crimes. (Item 24) People with mental illness can’t handle too much responsibility. (Item 25) I have a good understanding of the role of a psychiatric/mental health nurse. (Item 4) I feel confident in my ability to care for people experiencing a mental health problem. (Item 7) My course has prepared me to work as a graduate nurse in a psychiatric/mental health graduate program. (Item 19) Psychiatric/mental health nursing makes a positive contribution to people experiencing a mental health problem. (Item 2) Psychiatric/mental health nursing can assist people with mental illness in their recovery. (Item 8) Mental health services provide valuable assistance to people experiencing a mental health problem. (Item 23) I am anxious about working with people experiencing a mental health problem. (Item 3) I am uncertain how to act towards someone with a mental illness. (Item 5) I intend to pursue a career in mental health nursing. (Item 15) I will apply for a graduate program in psychiatric/mental health nursing. (Item 6)
.81 .60
did not have strong reliability (stereotypes and valuable contributions). Structural Equation Model The structural equation model demonstrated reasonably good fit: χ 2 (57) = 69.03, p = .13, RMSEA = .04 (90% CI: .00, .07), CFI = .97, TLI = .96, SRMR = .06. The model accounted for 45.4% of variance in anxiety, and 29.9% of variance in interest in MHN as career. The standardized regression paths are presented in Figure 2. Although global fit was found, not all specified pathways had statistically significant coefficients. Full lines represent statistically significant paths and the light lines indicated paths specified that were not significant. For brevity, the other parameters are not shown in Figure 2 (e.g., parameters fixed to unity, and factor loadings). Although there was demonstrated global fit, not all specified pathways had statistically significant coefficients. While, anxiety significantly predicted future career intentions in mental health nursing (ß = .24, t = 1.98, p < .001), preparedness did not predict MHN intentions (ß = .24, t = 1.89, p > .05), nor did perceptions of valuable contributions of MHN (ß = .29, t = 0.93, p > .05). The two specified antecedents to anxiety surrounding mental illness were statistically significant: negative stereotypes as a predictor of anxiety (ß = .24, t = 2.11, p < .05), and preparedness as a predictor of anxiety (ß = .58, t = 6.57, p < .05). However, the anticipated
.50 .58 .89 .68 .78 .66 .48 .73 .81 .84 .93
indirect effects pictured in Figure 1 did not turn out to be statistically significant—namely, from stereotypes to interest in MHN via anxiety (Sobel’s t = 1.33, p > .05), and from preparedness to interest in MHN via anxiety (Sobel’s t = 1.86, p > .05). At the same time, the total effect (sum of indirect and direct effects) of preparedness on interest in MHN was significant (ß = .46, t = 4.72, p < .05). DISCUSSION The current findings suggest that of all the potential influences on whether a student considers mental health nursing as a career, it was self-reported anxiety that was the most important. This reconfirms evidence from past research that demonstrated the significant bearing anxiety has on interest in mental health nursing (Hayman-White & Happell, 2005; Hoekstra et al., 2010), and probably reflects a more general problem of social distancing from people diagnosed as having a mental illness (Corrigan, Markowitz, & Watson, 2004). Initiatives to provide a more accurate understanding of people who are experiencing mental health challenges such as through mental health clinical placements (Happell, 2008a, 2008b) and direct instruction on the topic of recovery by a mental health consumer (Happell et al., 2013) may effectively address anxiety, as well as the negative stereotypes that may be a precursor to anxiety. Furthermore, general strategies for countering stigma of mental illness
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ANXIETY AND NURSING STUDENTS’ CAREER INTERESTS
TABLE 3 Estimates of Inter-Factor Correlations
MHN as a career, compared to the previous study, where 16% was explained. The difference in variance explained may be due to having taken account of error variance in the measured Factor: NS P VC ASMI MHN variables. Overall the analytic approach of structural equation modeling was a strength of the current research. Negative 1 The attitudes about mental illness held by undergraduate stuStereotypes (NS) dents were not unlike stances found in the wider population. Preparedness (P) .20 1 It is not surprising that there are negative stereotypes and feelValuable .14 .14 1 ings of anxiety with respect to people diagnosed with mental Contribution illness given the propagation of negative depictions in the me(VC) ∗∗ ∗∗∗ dia (Hannigan, 1999; Sieff, 2003), and the failure, in general, .63 −.02 1 Anxiety .35 for people to appreciate the diversity of individuals to whom a Surrounding label is attached. Going forward, anxiety and negative stereoMental Illness types as impediments to interest in mental health nursing as a (ASMI) ∗∗ ∗∗∗ ∗∗∗ career are identified as a problem that reduces future support Mental Health .35 .50 .13 .47 1 of people with mental illness. Furthermore, based on the emNursing (MHN) pirical findings, these negative factors may be more influential Internal Reliability .67 .77 .66 .74 .88 than potential facilitating factors such as students’ views on the (Cronbach’s contributions of MHN to consumer recovery. alpha) The large regression coefficient of the pathway from pre∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001. paredness for mental health nursing and anxiety is a promising one in terms of nursing education. Even before taking part in (Corrigan, Morris, Michaels, Rafacz, & Rusch, 2012; Corri- a clinical placement, a sense of preparedness by students was gan & O’Shaughnessy, 2007; Dalky, 2011) need to be explored significantly associated with less anxiety. A question urgently in need of addressing is whether placements provide gains in further with respect to general nursing students. The current results are comparable to those of Happell and preparedness (as is their aim) and along with this, stronger intenGough (2007) as the same survey was applied in both stud- tions to pursue MHN as a career, both directly and by dampening ies. Although the current analysis did not look at an identical anxiety about mental illness. Research suggests clinical placecombination of variables as did Happell and Gough (2007), ments can positively influence the popularity of mental health the current model accounted for 30% of variance in interest in nursing (Henderson, Happell, & Martin, 2007), although the
Negave Stereotype
.24 Anxiety Surrounding Mental Illness
.29 Future Career in MHN
.58
Preparedness
.29
.10 Valuable Contribuon
FIGURE 2. Structural Coefficients for Model of Antecedents to Interest in Mental Health Nursing as a Career.
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relationship between increased popularity and anxiety has not been specifically examined. There has been a call for an increase in the theory and practice of mental health nursing, not only as discrete content but also included throughout core nursing subjects (Moxham, McCann, Usher, Farrell, & Crookes, 2011) to demonstrate the holistic nature of mental health issues in the wider community and support its relevance for nursing in its application across all health care settings (Happell & PlataniaPhung, 2005). The small sample size was a limitation of the current research. As a result, although there was some support for the final model, the confidence intervals for RMSEA were large. In addition, although preparedness had a total effect on mental health nursing that was statistically significant, this was from combining the indirect effect via anxiety surrounding mental illness and the direct effect. However, on their own, each pathway was not statistically significant. We suggest that the non-significant indirect effect may be due to an insufficient sample size for statistical power, and stress the importance of a larger sample for future studies on the antecedents to mental health nursing as a career. An additional limitation was that students more interested in MHN and mental health care may have been more inclined to have taken part in this voluntary survey. Having said this, it was noted that there was much variability in interest in MHN as a career; 63% disagreed with the intention of pursuing a graduate program in mental health nursing. This suggests that if there was bias with respect to interest in MHN, it would have been minimal. Of final note is that the data analysed were cross-sectional in nature, so although the direction of effects were specified, we acknowledge that this is not a definitive test of determining factors. Further research with the current sample over time (i.e., follow-up analysis after the student clinical placements) will provide a stronger test of whether the currently identified antecedents facilitate interest in MHN as a future career. As there tends to be a lack of detailed analysis of approach-focused and positive aspects of MHN (Happell & Gaskin, 2013), such as promoting quality of life of people with mental illness, a broader array of attitudinal domains need to be measured alongside negative-valence domains (e.g., negative stereotypes of mental illness).
CONCLUSION Anxiety appears to be an influential factor in determining the degree to which nursing students are interested in a career in mental health nursing. Further research is required to ascertain the impact of clinical experience on anxiety levels. A stronger focus on mental health issues throughout nursing programs, preferably commencing from first year, may be effective in reducing levels of anxiety and should therefore be given serious consideration as part of a strategic approach to improving students’ attitudes to mental health nursing.
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Copyright of Issues in Mental Health Nursing is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
