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International Journal of Mental Health Nursing (2014) 23, 316–325

doi: 10.1111/inm.12052

Feature Article

Stigma towards nurses with mental illnesses: A study of nurses and nurse managers in hospitals in Japan Maki Tei-Tominaga,1 Takashi Asakura2 and Kyoko Asakura3 1

Department of Nursing, Kyoto Tachibana University, Kyoto, 2Department of Education, Tokyo Gakugei University, Tokyo, and 3Department of Nursing, Graduate School of Medicine, Tohoku University, Sendai, Japan

ABSTRACT: In the present study, we examined the current situation of nurses with mental illnesses, the stigma associated with these illnesses, and nurses’ and nurse managers’ perceptions of workplace mental health issues. We conducted a questionnaire survey of 880 nurses and nurse managers in Japan. After we carried out a descriptive analysis to examine the characteristics of stigma, the data of 585 participants were used for comprehensive analyses. In all, 71% of participants reported having worked with nurses with mental illnesses, and 40% reported having supported them. Of the participants, 90% believed a growing number of nurses would have mental illnesses in the near future. Stigma scores were significantly higher for items related to nurses with mental illnesses than for those with physical health problems. There was no significant difference in stigma scores according to sociodemographic and organizational characteristics. Scores for stigma items related to nurses with mental illnesses were significantly higher for participants who had worked with or supported nurses with such illnesses than for those who had not. Our findings suggest that effective approaches are needed to decrease stigma, ensure support in the workplace, and address mental illnesses to counter nurse absenteeism. KEY WORDS: mental health, nurse, nurse manager, physical health, stigma.

INTRODUCTION According to the World Health Organization’s World Mental Health surveys, the proportion of lifetime cases of mental illnesses over a 12-month period ranges from 6% to 52.1% for mood disorders, 0.8% to 36.4% for anxiety disorders, and 0.9% to 18.6% for substance use disorders (Kessler et al. 2007). In Japan, the Ministry of Health, Labour and Welfare reported that although the number of patients with schizophrenia had slightly decreased, the estimated number of patients with mood disorders (e.g. major depression) underwent a 1.7-fold increase from Correspondence: Maki Tei-Tominaga, Faculty of Nursing, Kyoto Tachibana University, 34 Yamada-cho Otake, Yamashina-ku, Kyoto, Japan. Email: [email protected] Maki Tei-Tominaga, PhD, RN, PHN, PSW. Takashi Asakura, PhD. Kyoko Asakura, PhD, RN, PHN. Accepted October 2013.

© 2013 Australian College of Mental Health Nurses Inc.

1996 to 2011 (Ministry of Health, Labour and Welfare, Statistics and Information Department 2011). The number of workers who have taken sick leave because of mental illnesses (e.g. major depression) is rising (Japan Productivity Center 2012), and nurses are among them. The Japanese Nursing Association (2012) reported that among full-time nurses, absenteeism of over 1 month because of mental illnesses accounted for more than one-third of all absenteeism in 2010. Although nursing shortages are a global issue (Armstrong 2004), and Japan is no exception (Ministry of Health, Labour and Welfare 2010), an increase in mental illnesses among nurses will affect the domestic shortage of such workers. Patients with mental illnesses, such as depression, are reported to exhibit a reduction in social functioning at a level equivalent to or more significant than those living with chronic physical illness (e.g. cardiopulmonary disease, arthritis, hypertension, and diabetes) (Von Korff

STIGMA TOWARDS NURSES WITH MENTAL ILLNESSES

et al. 1992; Wells & Burnam 1991). A prospective cohort study of workers with mental illnesses among paediatric residents revealed that those who were depressed made 6.2-fold more medication errors per resident per month than residents who were not depressed (Fahrenkopf et al. 2008). Another study revealed that in terms of total working hours lost because of primary chronic health conditions, depression was among the top three conditions (Wada et al. 2007). An additional survey conducted in Japan found that 66% of 469 hospitals reported having workers who had been absent from work because of mental illnesses (Kuroki 2009). Of the 279 reported cases of absenteeism because of mental illnesses, 59% were nurses. Mental illnesses among nurses can exert a negative effect on health-care consumers (e.g. quality of nursing care), as well as on organizations (e.g. financial impact), and the work environment might produce a negative effect on nurses (e.g. returning to work). Stigma is a ‘collection of negative attitudes, beliefs, thoughts, and behaviours that influence the individual, or the general public, to fear, reject, avoid, be prejudiced, and discriminate against people’ (Gary 2005, p. 980). Underutilization of mental health services and the early termination of mental health treatment are largely attributed to stigma (Corrigan 2004). In addition, stigma and discrimination present a hurdle for individuals with mental illnesses in finding and keeping work (Brohan et al. 2012). Stuart (2004) revealed that returning to work after sick leave for mental illnesses is more complex than for musculoskeletal problems because of stigma in the workplace. Likewise, Glozier et al. (2006) reported increased discriminatory action and attitudes towards nurses with mental illnesses compared with nurses who had physical health problems. Stigma towards nurses who have taken sick leave because of mental illnesses might cause their greatest difficulties when they return to work, as discrimination acts as a barrier to social participation and successful vocational integration. Although the Japanese Government recommends cooperation among all parties concerned (e.g. the primary physician, psychiatrist, managers) in dealing with absenteeism and returning to work for employees with mental illnesses (Ministry of Health, Labour and Welfare 2004), studies have found an uncooperative, unconstructive environment in the workplace for nurses. One study investigated the workplace experience of nurses who had mental illnesses, and revealed that although such nurses voiced the need for support and trust, most portrayed their workplace as an unsupportive, negative environment © 2013 Australian College of Mental Health Nurses Inc.

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(Joyce et al. 2009). Another study discovered that nursing staff were significantly more negative towards co-workers returning after psychiatric illnesses than to those returning to work after sick leave because of diabetes (Glozier et al. 2006). Although it might be expected that other nurses’ understanding of mental health issues would decrease stigma in the workplace and enhance support for colleagues with mental illnesses (Joyce et al. 2012), the experience of working with, supporting, or managing nurses with such illnesses might actually increase stigma in the workplace. To date, no studies related to the current situation of nurses with mental illnesses and the related stigma in the workplace have been conducted in Japan. The aims of this study were as follows: (i) to investigate the current situation of nurses in hospitals in Japan with mental illnesses, and the perception of mental health issues at work among nurses and nurse managers; and (ii) to examine the characteristics of the related stigma among nurses and nurse managers according to sociodemographic and organizational characteristics, and also to record experiences of working with, supporting, or managing nurses with mental illnesses.

MATERIALS AND METHODS Definition of mental illnesses In this investigation, we referred to previous studies (Ito 2006; Otsuka & Kosugi 2004), and we operationally defined ‘mental illnesses’ as follows. Even without a formal diagnosis, it is a state with persistent symptoms and behaviour related to mental illness (e.g. depression, maladjustment, personality disorder) that results in adverse effects on a person’s daily life and work.

Participants and setting Convenience sampling was used in this study. Six nursing associations located in different prefectures in Japan (which has 47 prefectural and city governments) agreed to participate in this survey. The participants were nurses and managers who were members of nursing associations.

Data collection From September to November 2010, self-administered questionnaires (to be returned anonymously) were distributed to all nurses and nurse managers (n = 880) who attended themed lectures related to administrative issues (e.g. workplace violence), which were organized by the six nursing associations. If the participants agreed to participate, they completed the questionnaire, placed it in a

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sealed envelope, and put it into a strictly controlled box as they exited on the day of the lecture. A total of 701 participants returned their questionnaires, giving a response rate of 80%.

Ethical issues Ethical approval was obtained from the institutional ethics committee at the institution of one of the co-researchers in 2010. Participating nurses and nurse managers were not required to sign consent forms; returning the questionnaire implied consent. Participants were informed of the voluntary nature of their participation, and were assured of confidentiality in the handling of data.

Measures The questionnaire, including sociodemographic, organizational characteristics, and other question items, was written in Japanese for the participants in this study. The sociodemographic details included in the questionnaire were sex, age, job position, and working tenure; and the organizational characteristics were hospital capacity and type of hospital. Additionally, two questionnaire items dealt with experiences that the participants had working with and supporting nurses who had mental illnesses. Further items related to the mental health of such nurses (i.e. age group and clinical conditions), and there was a prediction regarding nurses with mental illnesses in the future. The questionnaire included the definition of mental illnesses as a reference in order to help participants understand the questions. As there is no existing stigma scale for nurses with mental illnesses, we developed an original stigma scale.

Original items on the stigma scale We reviewed relevant studies to develop original items related to stigma experienced by nurses who had either mental illnesses or physical health problems. Seven items related to stigma, such as beliefs and thoughts that influenced the individual in being prejudiced to or discriminating against nurses who had been absent from work because of mental illnesses or physical health problems, were devised in Japanese based on our review of previous studies (Glozier et al. 2006; Joyce et al. 2007; 2009) and discussions with several researchers. The seven items relating to a nurse who had been absent from work because of physical health problems or mental illnesses were as follows: ‘has no aptitude for nursing’, ‘is unable to work properly after returning to work’, ‘causes many problems for work team members’, ‘has a high risk of

M. TEI-TOMINAGA ET AL.

relapse and taking sick leave after returning to work’, ‘has poor management of his or her health’, ‘insists on his or her right to use their illness as an excuse’, and ‘lacks cooperation with work team members’. These items were evaluated using a five-point Likert scale (1, totally disagree; 2, disagree; 3, neither agree nor disagree; 4, agree; 5, totally agree), and they were defined as a 1-D scale after principal component analysis. We confirmed the high reliability of this scale using Cronbach’s alpha (physical health problems = 0.863; mental illnesses = 0.882); we confirmed the face validity by asking the two nursing services directors whether the seven items appeared to be adequate for measuring the stigma of mental illnesses or physical health problems in this study. Each item score and the total scores of the seven items were used, with higher scores representing greater stigma towards nurses with mental illnesses or physical health problems (Table 1).

Analysis To determine the present perception of mental health issues in the workplace, data from the 701 nurses and nurse managers who returned their questionnaires were used to calculate descriptive statistics for sociodemographic and organizational characteristics. We analysed the participants’ experiences working with, supporting, or managing nurses with mental health issues, as well as the age group and clinical condition of the nurses with these issues. We also investigated the predictions made by participants about nurses with mental illnesses in the future. We eliminated 116 questionnaires that had incomplete data (missing or incomplete answers). The remaining complete data from 585 nurses and nurse managers were used to examine the characteristics of stigma according to sociodemographic and organizational characteristics and the participants’ experiences. First, bivariable correlations among age, year of service, each stigma item, and the total scores for mental illnesses or physical health problems were calculated using Pearson’s correlation coefficient. Next, the degrees of stigma related to physical health problems and mental illnesses were compared using the paired t-test. Finally, both the t-test and ANOVA were performed to compare the degrees of stigma of mental illnesses related to sociodemographic (e.g. sex, job position) and organizational characteristics (e.g. hospital capacity, type of hospital) and participants’ experiences (e.g. working with or supporting nurses who had mental illnesses). The statistical package used was SPSS version 15.0 (SPSS, Tokyo, Japan). All P-values were two-tailed with the significance level set at 0.05. © 2013 Australian College of Mental Health Nurses Inc.

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TABLE 1: Question items, descriptive statistics, and Cronbach’s alpha values for the stigma scale (n = 585) n (%) Item/answers†

1

2

3

4

5

Mean (SD)

Range

189 (32) 157 (27) 126 (22) 97 (17)

134 (23) 202 (35) 185 (32) 174 (30)

49 (8) 132 (23) 160 (27) 199 (34)

20 (3) 28 (5) 65 (11) 75 (13)

2.17 (1.08) 2.83 (1.05) 3.11 (1.12) 3.29 (1.10)

1–5 1–5 1–5 1–5

199 (34) 193 (33) 158 (28)

202 (35) 164 (28) 163 (28)

63 (11) 69 (12) 89 (15)

23 (4) 28 (5) 31 (5)

2.51 (1.02) 2.43 (1.10) 2.50 (1.17) 0.863

1–5 1–5 1–5

86 (15) 32 (6) 24 (4) 15 (3)

135 (23) 87 (15) 100 (17) 51 (9)

179 (31) 171 (29) 162 (28) 121 (21)

145 (25) 220 (38) 219 (37) 258 (44)

40 (7) 75 (13) 80 (14) 140 (24)

2.86 (1.15) 3.37 (1.06) 3.39 (1.05) 3.78 (0.99)

1–5 1–5 1–5 1–5

115 (20) 115 (20) 77 (13)

197 (34) 168 (29) 122 (21)

181 (31) 173 (30) 175 (30)

61 (10) 92 (16) 149 (26)

31 (5) 37 (6) 62 (11)

2.48 (1.08) 2.60 (1.15) 2.99 (1.19) 0.882

1–5 1–5 1–5

A nurse who has been absent from work due to physical health problems: QPS 1. Has no aptitude for nursing 193 (33) QPS 2. Is unable to work properly after returning 66 (11) QPS 3. Causes a lot of problems for team members at work 49 (8) QPS 4. Has a high risk of relapse and taking sick leave after 40 (7) returning to work QPS 5. Has poor self-management of her/his health 98 (17) QPS 6. Insists on her/his right to use their illness as an excuse 131 (22) QPS 7. Lacks cooperation with team members at work 144 (25) Cronbach’s alpha A nurse who has been absent from work due to mental illnesses: QMS 1. Has no aptitude for nursing QMS 2. Is unable to work properly after returning QMS 3. Causes a lot of problems for team members at work QMS 4. Has a high risk of relapse and taking sick leave after returning to work QMS 5. Has poor management of her/his health QMS 6. Insists on her/his right to use their illness as an excuse QMS 7. Lacks cooperation with team members at work Cronbach’s alpha

QMS, question relating to mental health stigma; QPS, question relating to physical health stigma. †Participants answered the degree of stigma to each question on a five-point Likert scale as follow: 1 (totally disagree), 2 (disagree), 3 (neither), 4 (agree), 5 (totally agree).

RESULTS As shown in Table 2, the majority of the participants were female staff nurses (95%), female nurses working in hospitals ranging in size from 100 to 699 beds (60%), and staff and senior staff nurses (60%). The average length of service at their current hospital was 11 years for both sexes (11.69 ± 11.43 years for males, and 11.18 ± 9.59 years for females). In this study, nurses in their 40s (30.4%) were the most frequent age group; however, according to national statistical data reported by the Japanese Government (Ministry of Health, Labour and Welfare 2011), it was revealed that nurses in their 30s (31.8%) were the most common age group. The results of participants’ experiences and ideas of nurses with mental illnesses are shown in Table 3. Of the respondents, 71% reported that they had worked with nurses who had mental illnesses, and 40% stated that they had supported nurses who had such illnesses at their current workplace. Participants who had supported nurses with mental illnesses reported that such individuals were most frequently in their 20s (except for newly-graduated nurses), and the most common diagnosis was depression. Of the participants, 90% predicted an increase in nurses with mental illnesses in the near future. Although not shown in Table 2, we compared the demographics of the complete data of the 585 participants © 2013 Australian College of Mental Health Nurses Inc.

with the incomplete data of the 116 participants who were eliminated owing to missing or incomplete answers. The average age of the 585 participants was significantly higher than that of the eliminated 116 participants (P < 0.001), but other items (e.g. sex, job position, and average length of service at the current hospital) did not show significant differences. The results of the paired t-test (Table 4) showed that compared with all stigma items and total sum scores, the scores for mental illnesses were significantly higher than for physical health problems (P < 0.001), except for one item: ‘A nurse who has been absent from work because of physical health problems or mental illnesses has poor management of his or her health’. Although not shown in Table 3, there were no significant differences in any of the stigma items and the total scores based on sex, job position (management-level position or not), hospital capacity, and type of hospital. Further, the correlations among age, length of service, and the stigma score (each item and the total scores) were very weak (r = 0.004– 0.109). However, as demonstrated in Table 5, all the stigma items and total scores related to mental illnesses were significantly higher for participants who had worked with nurses who had mental illnesses than for those who had not (P < 0.05). Similarly, five stigma items and the total scores related to mental illnesses were significantly higher

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M. TEI-TOMINAGA ET AL. TABLE 2:

Sociodemographic and organizational characteristics of participants† (n = 701) n (%) or mean (SD)

1. Sex 2. Age 3. Job position

4. Average length of service at current hospital 5. Hospital capacity (no. beds)

6. Type of hospital establishment

Female Male Female Male Staff nurses Senior staff nurses Chief nurses Associate directors of nursing Directors of nursing Others Female Male ≤99 beds 100–399 beds 400–699 beds ≥700 beds National hospitals/national university hospitals Public hospitals Public benefit hospitals Private hospitals Others

665 (95%) 28 (4%) 43.32 (10.00) 41.89 (10.65) 340 (49%) 122 (17%) 140 (20%) 43 (6%) 28 (4%) 16 (2%) 11.18 (9.59) 11.69 (11.43) 89 (13%) 206 (29%) 214 (31%) 170 (24%) 105 (15%) 177 (25%) 64 (9%) 251 (36%) 77 (11%)

†Data are n (%) or mean (standard deviation (SD)). Total number of observations per category do not equal 701 because of missing responses (

Stigma towards nurses with mental illnesses: a study of nurses and nurse managers in hospitals in Japan.

In the present study, we examined the current situation of nurses with mental illnesses, the stigma associated with these illnesses, and nurses' and n...
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