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APNA 29th Annual Conference Session 4014: October 31, 2015 Hastings 1

Nursing Student Attitudes toward Mental Illness: A Quantitative Quasi-Experimental Study

Todd Hastings, PhD, RN Bloomsburg University

Disclaimer

This presenter has no conflicts of interest, commercial support, or off-label use to disclose.

The Problem and Purpose

Problem: Nursing students have negative attitudes about the mentally ill and psychiatric treatment Purpose: To examine and clarify nursing student perceptions of mental illness relative to attitudes, sense of knowledge, preparedness, and potential career choice

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The Literature

Nursing students have negative attitudes about the mentally ill and psychiatric treatment, influenced by a range of contributing factors:



Society – stereotypes passed on, poor media portrayals



Staff nurses and psychiatrists – pass on their own stigma



Nursing faculty – even instructors pass on their own prejudice

Nursing students do not feel insightful about mental illness or ready to work with mental health patients Evidence supports how adverse clinical experiences, poor treatment for psychiatric patients, and less interest in psychiatric nursing as a career may all follow negative attitudes held by nursing students about mental illness.

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The Literature

However more classroom content and clinical exposure promote improved nursing student attitudes relative to mental health treatment cultures Other strategies including targeted classroom interventions using media or problem-based learning, role play, simulation, and reflection show promise for improving nursing student attitudes

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Theoretical Framework

Labeling Theory Benner Model Peplau’s Theory on Interpersonal Relations

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APNA 29th Annual Conference Session 4014: October 31, 2015 Hastings 2

Research Method and Design

Quasi-experimental quantitative study pre-test/post-test format: NR-O-X-O design

 NR=non-randomized  O=assessment/survey (dependent variables)  X=intervention or independent variable (PMH class)

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Research Questions

Is there a difference in attitudes towards mental illness and mental health patients amongst nursing students after enrollment in a psychiatric nursing course? Is there a difference in how knowledgeable nursing students feel regarding mental illness and mental health treatment after enrollment in a psychiatric nursing course? Is there a difference in the perception of preparedness to work in the psychiatric mental health specialty amongst nursing students after enrollment in a psychiatric nursing course? Is there a difference in undergraduate student’s interest for pursuing the psychiatric mental health specialty as a career area in nursing after a psychiatric nursing course?

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Population and Sample

Eight Bachelor of Science in Nursing programs – students in their mental health nursing course (junior or senior year) Total nursing students completing pre- and post-test surveys – 310 (power =>253)

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Data Collection Method

Only those agreeing to participate – voluntary Informed consent obtained Surveys = First and Last Day of Placement – 24 questions about student perceptions of mental illness and treatment of mentally ill Administered prior to starting clinical and at end

• f PMH course

Matched for participant

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Demographic Data

Sample Characteristics Frequency (N=310) Valid Percent

Gender:

Male 40 12.9 Female 270 87.1 Year of Placement Second Year (Junior Level) 160 51.6 Third Year (Senior Level) 150 48.4

Institutional Placement – Professional (BSN) Programs Traditional Programs College A (mid-sized public university) 34 11.0 College B (small private university) 46 14.8 College C (small private university – 2 sections) 67 21.6 College D (mid-sized public university – 2 sections) 55 17.7 College E (large public university) 39 12.6 Non-Traditional Programs College B - Part Time Evening Program 24 7.7 College F – branch campus of large public university 14 4.5 College G – branch campus of large public university 31 10.0

Results: Item Means for First and Last Day of Placement Surveys for Items Associated with Factors Studied: Factor for Attitudes Toward Mental Illness – Negative Stereotypes (Items 8, 21, 24)

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Item from First Day and Last Day of Placement Surveys First Day (pretest) Last Day (posttest) M SD M SD Item 8: People with mental illness are unpredictable. 4.36 1.33 3.66 1.35 Item 21: People with mental illness can’t handle too much responsibility. 3.19 1.32 3.04 1.23 Item 24: People with mental illness are more likely to commit offences or crimes. 3.83 1.43 3.79 1.49

APNA 29th Annual Conference Session 4014: October 31, 2015 Hastings 3

Results: Item Means for First and Last Day of Placement Surveys for Items Associated with Factors Studied: Factors for Knowledge About Mental Illness (Items 9, 18, 19, 23)

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Item from First Day and Last Day of Placement Surveys First Day (pretest) Last Day (posttest) M SD M SD Item 9: Mental illness is not a sign

• f weakness in a person

5.76* 1.44 6.01* 1.46 Item 18: Someone I know has experienced a mental health problem. 5.84* 1.72 6.00* 1.50 Item 19: When a person develops a mental illness it is not their fault. 5.88 1.18 5.96* 1.23 Item 23: The way people with mental illness feel can be affected by other people’s attitudes towards them. 6.00 1.00 6.13 .9327

Results: Item Means for First and Last Day of Placement Surveys for Items Associated with Factors Studied: Factors for Preparedness for Mental Health Field (Items 1, 4, 7, 10)

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Item from First Day and Last Day of Placement Surveys First Day (pretest) Last Day (posttest) M SD M SD Item 1: I feel well prepared for my psychiatric/mental health clinical placement 3.63 1.32 4.71 1.33 Item 4: I have a good understanding of the role

• f a psychiatric nurse

3.52 1.32 5.46 1.20 Item 7: I feel confident in my ability to care for people experiencing a mental health problem. 3.62 1.37 5.15 1.07 Item 10: My theoretical component

• f PMH nursing has prepared me

well for my clinical placement. 3.61 1.27 5.09 1.27

Results: Item Means for First and Last Day of Placement Surveys for Items Associated with Factors Studied: Factors for Future Career Interest in Mental Health (Items 6 and 12)

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Item from First Day and Last Day of Placement Surveys First Day (pretest) Last Day (posttest) M SD M SD Item 6: I will apply for a Graduate Program in psychiatric/mental health nursing. 2.11* 1.29 2.24 1.38 Item 12: I intend to pursue a career in psychiatric/mental health nursing. 2.61 1.48 2.69 1.74

Results: Instrument Reliabilities (Cronbach’s alpha values) for Factor Subscales

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Factor Subscale First Day

• f

Placement Tool Last Day

• f

Placement Tool Original Reliabilities by Tool Authors* Negative Stereotypes/Attitudes (NSs) .56 .60 .51 (items 8, 21, 24) Knowledge of Mental Illness (KMI) .51 .57 .56 (items 9, 18, 19 23) Preparedness to Work in Mental Health (PMHF) .79 .75 .72 (items 1, 4, 7, 10) Future Career Interest in MH (FC) .84 .88 .92 (items 6, 12 )

Results: Dependent Sample means and standard deviations with correlations for First Day of Placement (pre-test) and Last Day of Placement (post-test) Score for Subscales related to Nursing Student Responses to Surveys (N=310)

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Subscales (factor variables) Mean (SD) Pre- Test Mean (SD) Post-Test Difference Post-Test minus Pre-Test Correlation for Paired Samples Negative Stereotypes (Attitudes)

• f the Mentally Ill (NSs)

11.39 (2.99) 10.49 (3.04)

• .90

.46 Knowledge about Mental Illness (KMI) 23.49 (3.48) 24.10 (3.43) .61 .58 Perception of Preparedness to Work in Mental Health Field (PMHF) 14.37 (4.12) 20.40 (3.67) 6.03 .09 Future Career Interest in Mental Health Specialty (FC) 4.72 (2.57) 4.93 (3.43) .22 .57

Results: Paired differences (pre-test minus post-test) and Dependent Sample t-tests for First Day of Placement (pre-test) and Last Day of Placement (post-test) Scores for Subscales related to Nursing Student Responses to Surveys (N=310, df=309)

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Subscales (factor variables) Difference of Means Post-Test - Pre-Test Confidence Intervals Lower Upper t statistic Sig.(2-tailed) α=.05 Negative Stereotypes (Attitudes) of the Mentally Ill

• .90
• .55 -1.25
• 5.03

.000* Knowledge about Mental Illness .61 .96 .25 3.36 .001* Preparedness to Work in Mental Health Settings 6.03 6.62 5.44 20.16 .000* Future Career Interest in Mental Health Specialty .215 .505 -.075 1.46 .146

APNA 29th Annual Conference Session 4014: October 31, 2015 Hastings 4

Results Interpreted in Summary

Stigma is an ongoing problem but can be improved upon in nursing students Nursing student sense of knowledge of mental illness improves with class exposure Preparedness for engaging mental health patients is low at pretest but improves greatly following PMH class experience Career choices of nursing students do not favor psychiatric nursing even after their PMH program class

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Significance of Results to Leadership

Nursing student stigma is a classroom and clinical practicum concern Further research needed: see how the problem of limited knowledge and sense of preparedness can be improved Nurse Educators, Administrators, and Practitioners can now better address the concern

• f limited interest in psychiatric nursing as career
• ption by nursing students

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Modification of psychometric rating tools or new tool Study the influence of targeted exposure and teaching strategies Examine effect of relationship development Benefits of a thorough and focused orientation and reflection upon nursing student perceptions of mental illness

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Questions

What questions do you have?

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What do YOU see as educator/practitioner in our students?

Groups of 5-6 up to 10-12 Groups address:

 Issues with attitudes (Group 1)  Issues with student knowledge/insight (Group 2)  Student preparedness for PMH clinical or working

with patients who has comorbid PMH dx

 Career interests- who wants to be a psych nurse?

Key References

Benner, P. (1982). From novice to expert. AJN The American Journal of Nursing, 82(3), 402-407. Cleary, M. (2004). The realities of mental health nursing in acute inpatient environments. International Journal of Mental Health Nursing, 13(1), 53-60. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=2004118796&site=ehost-live Coleman, T. E. (2006). The effects of age and exposure to mental illness educational material on student nurses' attitudes toward the mentally ill. 3247976 Psy.D., Hofstra University, Ann Arbor. Retrieved from http://search.proquest.com/docview/305324834?accountid=35812 Curtis, J. (2007). Working together: A joint initiative between academics and clinicians to prepare undergraduate nursing students to work in mental health

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Emrich, K., Thompson, T. C., & Moore, G. (2003). Positive attitude: An essential element for effective care of people with mental illness. Journal of Psychosocial Nursing & Mental Health Services, 41(5), 18. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2003086295&site=ehost-live Gough, K., & Happell, B. (2009). Undergraduate nursing students attitude to mental health nursing: A cluster analysis approach. Journal of Clinical Nursing, 18(22), 3155-3164. doi:10.1111/j.1365-2702.2008.02764.x Gouthro, T. J. (2009). Recognizing and addressing the stigma associated with mental health nursing: A critical perspective. Issues in Mental Health Nursing, 30(11), 669-676. doi:10.3109/01612840903040274

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APNA 29th Annual Conference Session 4014: October 31, 2015 Hastings 5

Key References

Granskär, M., Edberg, A. K., & Fridlund, B. (2001). Nursing students’ experience of their first professional encounter with people having mental disorders. Journal of Psychiatric & Mental Health Nursing, 8(3), 249-256. doi:10.1046/j.1365-2850.2001.00381.x Grbevski, S. (2009). Health care professionals attitudes towards individuals diagnosed with severe mental illness. Ph.D. 3365817, Wayne State University, United States -- Michigan. Retrieved from http://search.proquest.com/docview/305019403?accountid=35812 Halter, M. J. (2002). Stigma in psychiatric nursing. Perspectives in Psychiatric Care, 38(1), 23-29.Retrieved from http://search.proquest.com/docview/200755909?accountid=35812 Halter, M. J. (2004). Stigma & help seeking related to depression: A study of nursing students. Journal of Psychosocial Nursing & Mental Health Services, 42(2), 42-51. Retrieved from http://search.proquest.com/docview/225539884?accountid=35812 Happel, B., & Gough, K. (2009). Nursing students' attitudes to mental health nursing: Psychometric properties of a self-report scale. Archives of Psychiatric Nursing, 23(5), 376-386.Retrieved from http://mentalhealthgroup.wikispaces.com/file/view/attitudes+towards+MH.pdf Happel, B., Robins, A., & Gough, K. (2008). Developing more positive attitudes towards mental health nursing in undergraduate students: Part 2-the impact

• f theory and clinical experience. Journal of Psychiatric & Mental Health Nursing, 15(7), 527-536.Retrieved from

http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2010016238&site=ehost-live Happell, B. (2005). Clinical-academic partnerships research: Converting the rhetoric into reality. The International Journal Of Psychiatric Nursing Research, 11(1), 1218-1226.Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=16268231&site=ehost-live

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Key References

Happell, B. (2008a). Changing their minds: Using clinical experience to 'convert' undergraduate nursing students to psychiatric nursing. International Journal

• f Psychiatric Nursing Research, 14(1), 1776-1784.Retrieved from

http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2010258399&site=ehost-live Happell, B. (2008c). The importance of clinical experience for mental health nursing – part 1: Undergraduate nursing students’ attitudes, preparedness and

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Happell, B. (2009). Influencing undergraduate nursing students' attitudes toward mental health nursing: Acknowledging the role of theory. Issues in Mental Health Nursing, 30(1), 39-46. doi:10.1080/01612840802557113 Happell, B., & Gaskin, C. J. (2013). The attitudes of undergraduate nursing students towards mental health nursing: A systematic review. Journal of Clinical Nursing, 22(1/2), 148-158. doi:10.1111/jocn.12022 Happell, B., & Gough, K. (2007). Undergraduate nursing students' attitudes towards mental health nursing: Determining the influencing factors. Contemporary Nurse: A Journal for the Australian Nursing Profession, 25(1-2), 72-81. Happell, B., & Gough, K. (2009). Nursing students' attitudes to mental health nursing: Psychometric properties of a self-report scale. Archives of Psychiatric Nursing, 23(5), 376-386. doi:10.1016/j.apnu.2008.10.005

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Key References

Happell, B., Robins, A., & Gough, K. (2008a). Developing more positive attitudes towards mental health nursing in undergraduate students: Part 1 – does more theory help? Journal of Psychiatric & Mental Health Nursing, 15(6), 439-446. doi:10.1111/j.1365-2850.2007.01203.x Happell, B., Robins, A., & Gough, K. (2008b). Developing more positive attitudes towards mental health nursing in undergraduate students: Part 2-the impact of theory and clinical experience. Journal of Psychiatric & Mental Health Nursing, 15(7), 527-536. doi:10.1111/j.1365- 2850.2007.01233.x Happell, B., & Rushworth, L. (2000). Can educational methods influence the popularity of psychiatric nursing? Nurse Education Today, 20(4), 318-326. doi:10.1054/nedt.1999.0432 Hayman-White, K., & Happell, B. (2005). Nursing students' attitudes toward mental health nursing and consumers: Psychometric properties of a self-report

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Henderson, S., Happell, B., & Martin, T. (2007). Impact of theory and clinical placement on undergraduate students’ mental health nursing knowledge, skills, and attitudes. International Journal of Mental Health Nursing, 16(2), 116-125. doi:10.1111/j.1447-0349.2007.00454.x Hoekstra, H., Meijel, B. v., & Hooft-Leemans, T. v. d. (2010). A nursing career in mental health care: Choices and motives of nursing students. Nurse Education Today, 30(1), 4-8. doi:http://dx.doi.org/10.1016/j.nedt.2009.05.018 Holmes, C. A. (2006). The slow death of psychiatric nursing: What next? Journal of Psychiatric & Mental Health Nursing, 13(4), 401-415. doi:10.1111/j.1365-2850.2006.00998.x

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Key References

Hung, B., Huang, X., & Lin, M. (2009). The first experiences of clinical practice of psychiatric nursing students in taiwan: A phenomenological study. Journal of Clinical Nursing, 18(22), 3126-3135. doi:10.1111/j.1365-2702.2008.02610.x Hunter, L., Weber, T., Shattell, M., & Harris, B. A. (2015). Nursing students' attitudes about psychiatric mental health nursing. Issues in Mental Health Nursing, 36(1), 29-34. doi:10.3109/01612840.2014.935901 Keane, M. (1991). Acceptance vs. Rejection: Nursing students' attitudes about mental illness. Perspectives in Psychiatric Care, 27(3), 13-18. doi:10.1111/j.1744-6163.1991.tb01557.x Ketola, J., & Stein, J. V. (2013). Psychiatric clinical course strengthens the student-patient relationships of baccalaureate nursing students. Journal of Psychiatric & Mental Health Nursing, 20(1), 23-34. doi:10.1111/j.1365-2850.2012.01878.x Linden, M., & Kavanagh, R. (2012). Attitudes of qualified vs. Student mental health nurses towards an individual diagnosed with schizophrenia. Journal of Advanced Nursing, 68(6), 1359-1368. doi:10.1111/j.1365-2648.2011.05848.x Link, B. G., Struening, E., Cullen, F. T., Shrout, P. E., & Dohrenwend, B. P. (1989). A modified labeling theory approach to mental disorders: An empirical

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