Nurses’ attitudes to mental illness: A comparison of a sample of nurses from five European countries
Introduction
Mental health and well-being is critical to the quality of life of individuals and the productivity of communities (WHO, 2005). Improving the mental health of Europe's citizens is a fundamental part of the European Union's (EU) long term strategic policy objectives (EC, 2005). One of the major impediments to the realisation of positive mental health and well-being is stigma and discrimination, which can impact on all aspects of an individual's life (Byrne, 2000). Stigma and discrimination towards those experiencing mental illness is the greatest barrier to recovery and development of effective care and treatment (Sartorius, 2002). At worst stigma can exacerbate people's mental health problems and can seriously affect their chances of recovery, reinforcing negative attitudes and discriminating behaviours in the process (Sartorius, 2007).
Despite various initiatives and campaigns against stigma (e.g. Paykel et al., 1997, Crisp, 2000), stigmatized attitudes still exist (Crisp et al., 2000, Crisp et al., 2005). Negative attitudes have been attributed to a lack of knowledge (Wolff et al., 1996, Papadopoulos et al., 2002), although the relationship between attitudes and knowledge is not clear-cut (Addison and Thorpe, 2004). Reviews of population studies found that older, less educated people tended to have less favourable attitudes to mental illness, whereas familiarity with mental illness and people with mental health problems was associated with positive attitudes (Hayward and Bright, 1997, Angermeyer and Dietrich, 2006).
A range of health and social care professionals have been featured in studies of attitudes to mental illness, including doctors (Mukherjee et al., 2002, Nordt et al., 2004), nurses (Mavundla and Uys, 1997, Brinn, 2000) and social workers (Murray and Steffen, 1999). Some have found that health care professionals hold more negative attitudes towards mental illness than the general public (Jorm et al., 1999, Caldwell and Jorm, 2000). Although attention has been given to the attitudes of health care students, especially nursing and medical students, most have concentrated on measuring attitude change resulting from an educational intervention (Mino et al., 2001, Baxter et al., 2001, Evagelou et al., 2005), or direct contact with people with mental illness (Callaghan et al., 1997, Madianos et al., 2005) Others have investigated the impact of both education and contact (e.g. McLaughlin, 1997, Read and Law, 1999, Emrich et al., 2003). Studies that have considered nursing students’ attitude change over time have concluded that exposure to a mental health focused curriculum can significantly change and improve attitudes to mental illness (Emrich et al., 2003, Evagelou et al., 2005).
Explorations of the attitudes of mental health professionals appear to be less common (Hugo, 2001). Many of the studies that do feature mental health professionals are comparative, where professional attitudes, mainly psychiatrists’, are compared with those of the general public (e.g. Jorm et al., 1999, Kingdon et al., 2004, Lauber et al., 2004). Other comparative studies have included (mental health) nurses (Sevigny et al., 1999, Hugo, 2001, Lauber et al., 2006), often comparing the attitudes of nurses working within mental health settings with those of general nurses (e.g. Weller and Grunes, 1988, Tay et al., 2004, Björkman et al., 2008). Studies looking at registered nurses indicate that qualified staff with higher levels of education, and those with specialised psychiatric training hold more positive attitudes than unqualified staff and those without any psychiatric training (Scott and Phillip, 1985, Mavundla and Uys, 1997, Brinn, 2000). Such findings should, however, be viewed with caution as it may be positive attitudes that lead to the undertaking of mental health training rather than the training itself positively impacting on attitudes.
It has also been suggested that being acquainted with someone living with mental illness will positively influence attitudes (Wolff et al., 1996, Song et al., 2005). For nursing and psychology students exposure to a psychiatric setting during training and having personal contact have both been associated with positive attitudes (Bairan and Farnsworth, 1989, McLaughlin, 1997, Read and Law, 1999). It has also been noted that nurses working in psychiatric settings have more positive attitudes than those working in somatic care (Björkman et al., 2008). These findings are supported by a comprehensive literature review on the effect of interpersonal contact on stigma of mental illness by Couture and Penn (2003). They assert that both personal and professional contact is associated with increased positive attitudes to mental illness and that the positive impact of the ‘so-called’ contact hypothesis seems to be universal. Other studies, however, have found no support for the contact hypothesis (e.g. Kahn, 1976, Weller and Grunes, 1988, Callaghan et al., 1997). The overall correlation between contact and attitudes is still a matter of debate, prompting calls for more research into the influence of contact upon attitudes of mental illness (Addison and Thorpe, 2004).
The debate about which factors contribute to the formation of certain attitudes becomes even more complex when attitudes are looked at from an international perspective. Stigma associated with mental illness is known to be pervasive across cultures, societies and professions (van Brakel, 2006). To better understand the nature of attitudes towards mental illness, there have been calls for more cross-cultural assessments of concepts of, beliefs about and responses to mental illness (Corrigan and Watson, 2002, Angermeyer and Dietrich, 2006). A population studies review by Angermeyer and Dietrich (2006) found only two cross-national attitude studies, in addition to a handful of studies featuring regional and ethnic comparisons within countries. Considerable differences in beliefs and attitudes were noted in all these studies.
Nurses are the group of professionals responsible for the majority of direct care for mentally ill patients across Europe (Baker et al., 2005). Studies examining the attitudes of psychiatric and mental health nurses only are rare and when they are featured it has been impossible to determine if the observed attitudes were negative or positive (Munro and Baker, 2007). Munro and Baker (2007) note therefore that it is impossible to draw any consistent conclusions about what attitudes this group of nurses hold. Further, there is no consensus or understanding of the factors that form and maintain either negative or positive attitudes to mental illness. What is clear is that attitudes are multifaceted and are likely to be closely linked with knowledge, which is constituted of different forms and acquired through a variety of sources such as education, training and experience. Knowledge is likely to have a complex relationship with individuals’ socio-demographic characteristics and it is therefore debateable whether or not socio-demographic factors precipitate levels of knowledge and thus attitudes (Addison and Thorpe, 2004).
It would appear there are no recent cross-European studies featuring nurses’ attitudes, let alone those of psychiatric and mental health nurses. A study from 1972 compared attitudes between general nurses in Great Britain and nurses from (the former) Czechoslovakia and concluded that nationality was the main difference in the attitudes observed, and that these differences were likely to be an extension of the wider social and political context within which nurses practice (Levin, 1972). These findings were also reported by a similar cross-cultural study comparing Chinese and English psychiatric nurses’ attitudes towards schizophrenia (Thornicroft and Trauer, 1987).
The present dearth in research is largely due to the challenges involved in undertaking cross-cultural studies, which include language, non-standardised methods of data collection, and culturally defined definitions and understandings of the roles of nurses and other mental health professionals. The EC (2004) asserts, however, that sound comparisons are feasible and can help “stimulate inter-country exchange on diverse practices for promotion and prevention as well as health care organisational patterns”. Comparative European based mental health studies have been encouraged; not only to gain an overview of the situation within countries but to attain reliable comparable data and promote data exchange between EU countries (EC, 2004).
It has also been noted that up-to-date, comparable information is needed on the age, gender, training, employment and specialisations of European health care workers, including nurses (EC, 2008), as increased workforce mobility becomes a reality across the EU (Cowan et al., 2005, Cowan and Wilson-Barnett, 2006). This has implications for the homogenisation of nursing education and training across the European countries (see e.g. WHO, 2003). The focus on nurses is especially important as they are the biggest group of health care professionals within Europe and are often involved in mental health promotion (WHO, 2007). A highly skilled, flexible and culturally aware European nursing workforce will ultimately have a positive impact on practice (Ludvigsen, 1997). The above all indicate the need for a study such as the one described here as it addresses several gaps in the cross-cultural literature.
Section snippets
Aims
The aim of this study was to describe and compare attitudes towards mental illness and those experiencing mental health problems held by registered nurses working in mental health settings across five European countries (Lithuania, Italy, Ireland, Portugal and Finland) and factors associated with these attitudes. The research questions are as follows:
- 1.
What are nurses’ attitudes towards mental illness?
- 2.
Do nurses’ attitudes towards mental illness differ across five European countries?
- 3.
What
Settings
The five countries featured in this study, Finland, Italy, Lithuania, Portugal and Ireland, were part of a European Commission (EC) funded pilot project on vocational training for mental health nurses. The countries were selected because they represent a cross-section of European countries with significant commonalities, as well as differences in their respective (mental) health statistics (OECD, 2009, State Mental Health Centre of Lithuania, 2009). The prevalence of mental health problems is
Sample
The majority of respondents were female in all countries (Lithuania 99%, Italy 63%, Portugal 53%, Finland 52%) except Ireland (33%). Nurses’ mean age in the total sample was 41.09 years, ranging from 36.4 years (in Portugal) to 44.3 years (in Lithuania). The average length of nursing experience was 18.52 years overall, being shortest in Portugal (13.8 years) and longest in Lithuania (22.3 years). Basic diplomas in nursing were held by a majority of nurses in Lithuania and Italy, whereas
Discussion
The aim of this study was to describe and compare registered nurses’ attitudes towards mental illness and those experiencing mental health problems across a sample of nurses from five European countries (Lithuania, Italy, Ireland, Portugal and Finland), and factors associated with these attitudes. The study showed that nurses’ attitudes to mental illness were generally positive. These results are supported by findings from other studies of both student nurses’ attitudes (Callaghan et al., 1997)
Conclusion
In general, mental health nurses’ attitudes to mental illness and people with mental health problems are positive. Mental health nurses’ attitudes have been shown to differ across the five countries surveyed. Indeed, country of practice was the most significant predictor of differences in nurses’ attitudes, with Lithuanian nurses having more negative attitudes and nurses practicing in Portugal having more positive attitudes compared to nurses in the other countries. Further cross-cultural
Conflicts of interest statement
None declared.
Sources of funding
This project has been funded with support from the European Commission's Leonardo da Vinci programme (2006 FI-06-B-F-PP-160701). This article reflects the views of the authors only, and the Commission cannot be held responsible for any use of the information contained herein.
Ethical approval
Due to this being a cross-European study, ethical approval requirements differed across sites. This is detailed below.
Padova, Italy: formal ethical approval was not required since there was no treatment involved and patients were not the subject of data collection. Permissions were obtained from managers and/or directors of all hospitals involved in the study.
Dublin, Ireland: formal ethical approval was sought and granted by the Dublin City University Ethics Committee. Reference: DCUREC/2007/23.
Acknowledgements
Many thanks to all the nurses who participated in the study. Sincere thanks also to Pekka Makkonen, Sarah White and Carol Hanchard, whose kind contributions made the research possible. The authors would also like to acknowledge the insightful comments made by two anonymous reviewers.
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