Acceptance vs. Rejection: Nursing Students' Attitudes About Mental Illness

by Mary Keane, RN, Dr. PH

The influence of a psychiatric nursing course on

BSN students' attitudes toward mental illness was

the subject of quasi-experimental research. Atti-

tude the0 y was the conceptual framework for the

study. The Opinion about Mental Illness (OMI)

questionnaire was given to a group of nursing stu-

dents before and after an eight-week course. Half of

the students took the course, the other half sewed

as a comparison group. Nursing students faking

the course changed more than the control group on

authoritarianism and interpersonal etiology but

expressed higher stereo typical attitudes .

Att i tudes are probably one of the most important forces determining an individual's response to treat- ment and rehabilitation. Theorists (Warren, 1988; Lar- son, 1987; Reverby, 1987; Brenner & Wrubel, 1988) have commented that human attitudes among professionals are the most important element of a helping relation- ship. These theorists have reported that patients im- prove significantly more with caring professionals than they do with those who function at a low level of car- ing. On the other hand, Leininger (1986) reports that the impact of high technology, DRGs, and the emphasis on efficiency may have contributed to a decline in the caring components of the nurse-patient relationship.

Mentally ill patients are sensitive to and influenced by the attitudes of members of the health care team (Cohen & Struening, 1965; Ackerhalt, 1987; Lebman, 1989). Few studies have been done recently regarding the sensitivi- ty of students and their perceptions of mentally ill per- sons. Conducting periodic attitude surveys may idenhfy areas in which attitudes are influenced by increased knowledge and guided learning experiences provided by a psychiatric nurse educator. The author's purpose is to report the findings of a quasi-experimental study mea- suring the influence of a psychiatric nursing course on at- titudes of BSN students toward mental illness.

A second purpose of the study was to measure the ef- fect of stress on attitude change. Stress is defined as a "response to stressful conditions consisting of a pattern of psychological and physiological reactions both im- mediate and delayed" (Rabkin & Streuning, 1976). High levels of stress in the education of nursing students are related to academic requirements, clinical demands, and emotional pressures. Since previous studies have men- tioned lack of or negative changes on specific dimen- sions of the Opinion about Mental Illness (OMI) ques- tionnaire, symptoms of psychological distress might be a contributing factor to these outcomes.

Review of the Literature

An attitude is a relatively enduring organization of beliefs around an object or situation, predisposing one

Perspectives in Psychiatric Care Vol. 27, NO. 3,1991 w

Acceptance vs. Rejection: Nursing Students’ Attitudes About Mental Illness

to respond in a preferential manner (Newcomb, Turn- er & Converse, 1965; Rokeach, 1972; Ajzen, & Fish- bein, 1980). New information that is favorably re- ceived may modify attitudes (Watson, 1975). Affective experiences may also mod$ attitudes, often to a point midway between the original position and that of the source of the experience (Ajzen & Fishbein). Direct experience is a potent attitude changer, even for deeply rooted attitudes which initially were based on misperceptions and inadequate information (New- comb et al.).

On the other hand, Rabkin (1975) has stated that at- titudes are relatively stable and not always accessible to change through educational methods and direct expo- sure. Katz (1960) thinks that attitudes are very difficult to change, even with appropriate information and di- rect object contact, because of ego defenses involved in maintaining self-image. Psychiatric nursing courses in- clude knowledge, affective opportunities, and direct experience with mentally ill persons, and therefore have the potential for positively affecting attitudes about mental illness.

Methodology

The purpose of the study was to measure the impact of a psychiatric nursing course on attitudes of nursing students towards mental illness using the ”Opinions about Mental Illness” (OMI) questionnaire.

Sample. Senior nursing students were encouraged to participate in the study during the first orientation class. At that time three questionnaires-the OMI, the DeRogatis Symptom Checklist, and a demographic form-were distributed to 111 students, to be completed in class. After six months, the same questionnaires were dis- tributed to 111 students in small groups of 25 each. Ap- proximately 50% of the nursing students had complet- ed an eight-week psychiatric nursing experience. The other 50% constituted a comparison group since they had not taken the course yet.

Data collection (pretest and post-test questionnaires) yielded 79 usable sets of responses41 in the course

group and 38 in the comparison group. The study was limited to female nursing students. There were no sig- nificant differences between the course and comparison ,

groups on demographic characteristics such as age, in- come, religion, marital status, political affiliation, or eth- nic group.

The study measured the impact of a psychi-

atric nursing course on attitudes of nursing

students towards mental illness.

Instruments. The OM1 was composed of 100 Likert- type opinion items with six choices on a strongly agree- strongly disagree continuum. It consists of nine attitude dimensions (factors) underlying opinions about mental illness and the mentally ill, identified through factor analysis. Reliability and validity were well-established for the 1963 version of OM1 (Cohen & Struening, 1965). In 1978 four dimensions were integrated into OMI, re- flecting a community emphasis. Reliability coefficients for the four dimensions have ranged from .83 to .86 (Link, McNamara, Penney, & Ungemack, 1978). The re- vised 100-item OM1 scale provides nine separate scores for each respondent, one for each factor. The six possible response choices for each of the items on the scale were assigned numeric values ranging from one (strongly agree) to six (strongly disagree), regardless of the direc- tion (positive or negative) of the content.

The nine dimensions are: Authoritarianism: a tendency to perceive the men- tally ill as inferior and threatening, requiring co- ercive management Benevolence: a tendency to enact a kindly pater- nalistic orientation toward mentally ill persons, which derives from moralism and humanism rather than science

14 Perspectives in Psychiatric care VoL 27, No. 3,1991

Mental hy@ ideology: a tendency to perceive men- tal illness as an entity that can be successflluy treated Social restrictiveness: a tendency to perceive men- tally ill persons as threats to society, particularly in their social functioning, both during and fol- lowing hospi t aka tion Interpersonal etiology: a tendency to perceive that mental illness arises from lack of nurturing from significant others during childhood Community residence: a tendency to perceive men- tally ill persons as untrustworthy in the commu- nity and to attribute crime, decreased safety, and decreased property values to their behavior Welcome home: a tendency to perceive mentally ill persons as making a better adjustment in the com- munity with the availability of support services and the presence of a caring environment Stigma: a tendency to perceive differences be- tween mentally ill and normal people as reflected in numerous hospitalizations and informing oth- ers about being hospitalized, which results in being treated differently Stereotyping: a tendency to perceive mentally ill persons as unpredictable, which is reflected in re- peated episodes of aggression and hospitalization, lack of interest in personal hygiene, and making others feel uncomfortable and frightened

The DeRogatis Symptom Checklist (SCL-9OR) is a mea- sure of current psychological distress involving nine di- mensions, induding anxiety, depression and hostility, and somatic concerns.

Internal consistency and test-retest reliability mea- sures have been established by DeRogatis (1977). Sev- eral researchers have also compared the SCL-90R with other established psychological distress instruments to establish convergent validity.

The demographic data form consisted of a checklist with variables that might be related to attitudes about mental illness. Some basic descriptors were also col- lected to ascertain whether the sample was representa-

tive of the students enrolled in the nursing program at the university.

Results

Attitude change. To determine the equivalency of pretest attitudes for control and experimental groups, t- tests were performed to measure differences between mean OM1 scale scores. Groups were found to be equivalent on seven of the nine OMI factors. Nonequiv- alent scores occurred on mental hygiene ideology (high for control group) and social restrictiveness (high for experimental group).

The alpha coefficient was used to determine internal consistency of the OM1 factors in this study. The relia- bility coefficients ranged from .65 to .88 for eight of the nine factors. Mental hygiene ideology, with a reliabili- ty of 0.52, was omitted from the study.

Correlated t-tests were performed on each attitude dimension to test whether attitudes had changed in ex- perimental and control groups from pre- to post-tests. When the experimental group was evaluated, mean scores on interpersonal etiology increased significantly (pc.001) following guided instruction and experience in a psychiatric nursing course. The mean scores on welcome home (pe.068) changed in a favorable direc- tion on the post-test, though it was not statistically sig- nificant (see Table 1). None of the correlated t-values for the comparison of pre- and post-tests were statistically significant for the control group on any of the eight fac- tors (see Table 2).

Effect of anxiety. To determine how the SCL-90R contributed to the variance in attitude change, the total stress score was entered into the multiple regression equation. The SCL-90R score contributed very little of the variance to any of the eight OM1 variables. Psycho- logical distress did not have an effect on attitude change in the experimental group (see Table 3).

Other factors. Assigned clinical group and pretest scores were also included in the multiple regression for- mula. This procedure determines the proportion of vari- ance in the attitude change scores that was predicted by

PerSpectives in Psychiatric Care Vol.27, NO. 3,1991 1s

Table 1. T-Scores on Eight Attitude Dimensions of OM1 Scale for Experimental Nursing Sample (N = 41)

OM1 Attitude - Pretest - Post-Tes t

Authoritarianism 17.8 6.0 16.3 5.9 -1.5 -1.68 .loo Benevolence 46.7 5.8 45.2 6.2 -1.5 -1.65 .lo7 Social restrictiveness 17.7 4.8 17.3 5.6 -0.4 -0.51 .615 Interpersonal etiology 13.2 3.5 15.2 4.3 2.0 3.75 .001 Community residence 24.7 8.4 26.1 10.1 1.4 1.21 .232 Welcome home 25.5 4.4 26.7 3.8 1.2 1.87 .068 Stigma 24.6 5.8 24.6 5.0 0 -0.03 .977 Stereotyping 26.5 4.2 27.9 5.1 1.4 1.91 .063

Dimensions X S.D. X S.D. Diff. t P

these two variables. Pretest scores contributed most of the variance to the post-test scores. The psychiatric nurs- ing course contributed more positive change in the ex- perimental group over the control group on two fac- tors-authoritarianism and interpersonal etiology. Significant negative change occurred on the factor of stereotyping (see Table 3).

Discussion

The psychiatric nursing experience effected a statisti- cally signhcant change in interpersonal etiology and a positive change in welcome home from the pre-test to post-test in the experimental group. This factor indicated a strong endorsement of the belief that mental illness arises from interpersonal experiences during childhood.

An emphasis on family dynamics, communication strate- gies, and the significance of the nurse-patient relation- ship in promoting recovery in the clinical setting proba- bly increased the post-test score.

A surprising change was the sigxuficant increase in stereotyping for the experimental group over the con- trol group. Items representing this factor include the following beliefs:

”Once a person has an episode of mental illness, he is likely to have another in later life.” “If a group home for mental patients relocated in a neighborhood, property values are sure to go down” “If I had a close relative who had been treated for a serious mental illness, I would advise him or her not to tell anybody about it.”

Table 2. T-Tests on Eight Attitude Dimensions of OM1 Scale for Control Nursing Sample (N = 38)

OM1 Change - Pretest - Post-Test

Authoritarianism 15.9 5.5 17.0 6.3 1.1 1.42 .164 Benevolence 47.9 7.0 47.6 5.9 -0.3 -0.50 .632 Social restrictiveness 15.1 6.0 16.0 6.0 0.9 1.48 .147 Interpersonal etiology 12.3 4.9 13.4 4.0 1.1 1.37 .180 Community residence 22.0 8.2 22.7 8.1 0.7 0.80 .432 Welcome home 27.3 4.0 27.4 5.9 0.1 0.13 .895 Stigma 24.6 5.1 23.1 5.8 -1.5 -1.60 .119

Factors X S.D. X S.D. Diff. t P

Stereotyping 25.8 6.1 25.3 5.1 -0.5 -0.47 .644

16 Perspectives in Psychiatric Care VoL 27, No. 3,1991

Table 3. Effects of Independent Variables on Eight Attitude Change Factors in NursiniStudent Sample ( N = 79)

Zero OMNI Change Independent Order Factors Variables p-value Beta R2 Correlation Factor A Authoritarianism

Factor B Benevolence

Factor D: Social Restrictiveness

Factor E: Interpersonal Etiology

Factor F:

Residence Program Factor G Welcome Home

community

Factor H: Stigma

Factor I: Stereotyping

Authoritarianism study group SCL-90R total Benevolence study group SCL-90R total Social restrictiveness study group SCL-90R total Interpersonal etiology study group SCL-90R total Community resources program study group SCL-90R total Welcome home study group SCL-90R total Stigma study group SCL-90R total Stereotyping study group SCL-90R tota

.oo

.08

.35

.oo

.14

.35

.oo

.59

.37

.oo

.09

.37

.oo

.36

.30

.oo

.68

.71

.oo

.20

.90

.oo

.03* 37

.64 -.16 -.08 .64

-.12 .07

.69 -.05 -.07

.51

.16

.08

.72

.07

.07

.54

.04

.04

.51

.13

.01

.56

.20

.08

.37

.39

.40

.43

.45

.45

.47 '

.47

.47

.28

.31

.31

.55

.55

.56

.29

.29

.29

.25

.27

.27

.34

.38

.38

.60 -.04 -.01 .66 -.19 .05

.68

.11

.13

.53

.21

.12

.74

.19

.14

.53 -.07 .oo .50 .13

-.04 .58 .24 .12

Caring for chronic mentally ill patients who have had several hospitalizations, who may be homeless or unemployed with few support systems, and who have limited cognitive skills may have contributed to stereotypical views in the experimental group. Because criteria for hospitalization have become more stringent, the group may have observed ag- gressive episodes that influenced attitudes. These events may have reinforced stereotypical views and left nursing students feeling frustrated and hope- less.

Limitations of the Study

The mental hygiene ideology attitude dimension had low reliability and was excluded from the study. Keane (1990) also found low reliabilities on this factor in a study done with medical students. Some of the items on the first five factors of the OM1 may need to be reevaluated because the philosophy and knowledge base of mental health have undergone a revolution since the 1960s. The adequacy of the tool to measure contemporary attitudes could be questioned because

Perspectives in Psychiahic Care VoL 27, No. 3,1991 17

Acceptance vs. Rejection: Nursing Students' Attitudes About Mental Illness

..-

an eight-week psychiatric nursing course appears to have all the ingredients to influence even well-en- trenched attitudes: accurate information about mental illness, affective experiences that challenge simplistic views, and direct clinical experiences with persons who suffer with mental illness. On the other hand, such a questionnaire may be a valuable adjunct to faculty in de- veloping more sensitivity to the learning needs of nurs- ing students, as well as in planning more effective teach- ing strategies to influence attitudes about mental illness.

Implications for Nursing

Both the experimental and control samples of bac- calaureate nursing students revealed a more positive at- titude toward mental iliness on a number of pre-test attitude dimensions than has been reflected in previous studies. It is possible that those who choose the nursing profession are already sensitive or report that they have sensitive attitudes toward mentally ill persons. A sur- prising negative outcome was the sipficant increase in stereotyping in the experimental over the control nurs- ing group. A curricuhm review by the faculty revealed that academic and clinical nursing content had not been targeted to the concepts of stereotyping. When students are unable to imagine solutions to persistent social problems confounding mental illness, discussion of pol- itics and health policy may provide avenues for action.

In summary, class discussions and clinical experi- ences related to the following would assist students with a more realistic as well as a more hopeful view:

mental health research with emphasis in the bio-

positive outcomes associated with medication

monitoring patients for follow-up care in the com-

logical model,

compliance, and

munity.

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