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Journal of Psychiatric and Mental Health Nursing, 2016, 23, 427–437

Stigmatizing attitudes in nurses towards people with


mental illness: a cross-sectional study in primary
settings in Finland
€ AN
N . I H A L A I N E N - T A M L A N D E R 1 R N , M N S c , A . V AH € IEMI2 RN, MNSc,
€ T T Y N I E M I M S c , T . S U O M I N E N R N , P h D & M . V AL
E . L OY 3 4 € I M AK
€ I5,6,7 RN, P hD
1 2 5
PhD-student, PhD-student and Professor, Department of Nursing Science, University of Turku, Turku,
3
Biostatistican, Department of Biostatistics, University of Turku, Turku, 4Professor, University of Tampere,
Tampere, 6Nursing Director, Turku University Hospital, Turku, Finland and 7Professor, Hong Kong Polytechnic
University, Hong Kong Special Administrative Region

Keywords: attitude, Attribution Ques- Accessible summary


tionnaire-27, mental illness, nurse, pri-
mary health care, stigma What is known on the subject?

Correspondence:
• Stigma related to mental illnesses is a great burden on societies globally. Factors
associated with nurses’ attitudes towards people with mental illness in health-
M. V€
alim€
aki
care settings are discrepant.

Department of Nursing Science
Stigmatized attitudes among staff members towards patients with mental illness
20014 University of Turku
Turku
have widely been studied in various specialized health care contexts, but less
Finland often in primary health-care settings.
E-mail: [email protected] What this paper adds to the existing knowledge?
Accepted for publication: 27 May 2016 • Nurses’ attitudes towards people with mental illness in general were positive in
primary care health settings. Younger nurses expressed feeling afraid of mentally
doi: 10.1111/jpm.12319
ill patients.
• They not only lacked a feeling of safety around these patients but were also often
of the opinion that people with mental illness should be segregated from the gen-
eral population.
What are the implications for practice?
• Systematic and continuous mental health on-the-job training for primary care
nurses is recommended to strengthen the positive attitudes of young nurses
towards patients.
• Young nurses especially should be prevented from developing stigmatized atti-
tudes towards patients with mental problems and to ensure a skilled workforce
for the future in this demanding area of health care.

Abstract

Introduction: Despite the development of mental health services in many countries,


nurses working in different health care specialties may still have concerns and nega-
tive attitudes towards people with mental illness. Aim: To describe nurses’ attitudes
towards people with mental illness and examine factors associated with their atti-
tudes in primary care health centres. Method: The data were collected from nursing
staff (N = 264, response rate 84%) in 15 primary care health centres in two Finnish
cities (spring 2014) with a self-report questionnaire (Attribution Questionnaire-27,
Corrigan 2003) and analysed by descriptive statistics and multiway covariance anal-
ysis. Results: Nurses’ attitudes towards people with mental illness were generally
positive. The nurses mostly reported willingness to help and feelings of concern and
sympathy towards these patients. However, younger nurses or those without

© 2016 John Wiley & Sons Ltd 427


N. Ihalainen-Tamlander et al.

additional mental health training expressed a fear of patients. Discussion: Special


attention should be paid to nursing education and on-the-job training to prevent young
nurses from developing stigmatized attitudes towards patients. Implications for prac-
tice: Higher confidence in nursing staff could ensure a skilled work force in areas of
mental health in the future, prevent young nurses from developing a fear of patients
at work and support positive attitudes towards patients with mental problems.

et al. 2004). Furthermore, vignettes are another commonly


Introduction
used methodological approach in stigma studies, and have
Stigma relating to mental illnesses is a great burden on been found to be especially useful when respondents
mentally ill patients as well as their family members (Had- express their reactions and specific thoughts regarding the
dad et al. 2005, Stuart 2008, Lammie et al. 2010). Stigma object of study (Corrigan et al. 2004, Polit & Beck 2012).
has been identified as the main cause of discrimination Vignettes are typically used in studies that examine atti-
and social exclusion (World Health Organization 2005) tudes related to vulnerable patient groups, such as patients
impacting quality of life (Munro & Baker 2007), self- with HIV, obesity and mental illness (Link & Phelan 2001).
esteem (Ilic et al. 2011), housing and employment oppor- Studies related to stigma towards people with mental ill-
tunities (World Health Organization 2005), social net- ness have shown that the general population (Nordt et al.
working (Thornicroft et al. 2009) and isolation and 2006, Schulze 2007, Aromaa et al. 2011) and health care
loneliness (Hansson et al. 2013). Due to a fear of being professionals alike (Arvaniti et al. 2009, Hansson et al.
stigmatized, not all people with mental illness seek health 2013, Hendersson et al. 2014) have stigmatized and nega-
care and treatment (Halter 2008). tive attitudes towards the mentally ill (Angermeyer & Diet-
In existing literature, definitions for the concept of rich 2006, Lauber et al. 2006, Bj€ orkman et al. 2008, Hori
stigma can vary greatly. Stigma is often understood as a et al. 2011). These patients may be considered to be danger-
multifaceted concept, which can refer to problems with ous, unpredictable (Angermeyer & Dietrich 2006, Bj€ ork-
knowledge (ignorance), problems with attitudes (preju- man et al. 2008, Hamdan-Mansour & Wardam 2009,
dice) or problems with behaviour (discrimination) (Thor- Aromaa et al. 2011, Hori et al. 2011, Stuber et al. 2014)
nicroft et al. 2007b). According to Corrigan et al. (2003), and there may be a desire of others to keep social distance
stigmatizing attitudes consist of stereotypes, prejudices (Kukulu & Erg€ un 2007, Schulze 2007, Ahmead et al. 2010,
and discrimination behaviours. One stereotype is the Aromaa et al. 2011). A common belief among the general
belief that a particular group of unwell people, such as population is that people with mental illness are responsible
people with mental illness, are dangerous and responsible for their own disorders, such as depression (Aromaa et al.
for their own sickness. Prejudice comes into play when 2011), even though nurses have assessed these people as
one agrees with a stereotype and responds emotionally, being incapable of making decisions about their own lives
such as being fearful of all people with mental illness. Dis- (Kukulu & Erg€ un 2007, Svediene et al. 2009) or not being
crimination, then, is the behavioural result that may be responsible enough to care for themselves (Hamdan-Man-
caused by prejudices (Corrigan et al. 2012). Stigma can sour & Wardam 2009, Ahmead et al. 2010).
take the form of a public stigma when common stereo- The consequences of stigma associated with the men-
types are held by the general population, while self-stigma tally ill patients are fairly similar across cultures and soci-
refers situations when a person internalizes a public eties (Angermeyer & Dietrich 2006, van Brakel 2006).
stereotype and prejudice, leading to self-discrimination Previous studies have reported various characteristics
(Corrigan & Watson 2002a). associated with attitudes of the general population and
Due to the multidimensionality of this concept, a num- health care professionals towards people with mental ill-
ber of approaches and instruments have been developed ness. For example, a lower level of education in the gen-
and used to measure stigma. The most commonly used eral population has been linked with the perception that
approach involves self-report survey questionnaires, which patients with a mental disorder are responsible for their
have been used to measure various types of stigma (Link own illness (Angermeyer & Dietrich 2006, Aromaa et al.
et al. 2004, Brohan et al. 2010) by assessing stereotypes, 2011), while a lower level of nursing education has been
the desire for social distance and emotional reactions (Link associated with social discrimination and social restriction
et al. 2004, Hendersson et al. 2014). Interviews and partic- (Munro & Baker 2007, Arvaniti et al. 2009). Regarding
ipant observations are also used to measure stigma (Link gender, females have been found to have more positive

428 © 2016 John Wiley & Sons Ltd


Stigmatizing attitudes in nurses

attitudes towards people with mental illness compared to care. We used the Attribution Questionnaire-27 (AQ-27;
males, both in the general population (Aromaa et al. Corrigan et al. 2003) for data collection. The question-
2010, 2011, Stuber et al. 2014) and among health care naire is based on the Weiner et al. (1988) attribution the-
professionals (Lethoba et al. 2006, Munro & Baker 2007, ory, a widely used framework, to explain the relationship
Hamdan-Mansour & Wardam 2009, Chambers et al. between stigmatizing attitudes and discriminatory beha-
2010). Further, older nurses have been found to have viour (Weiner et al. 1988).
more positive attitudes towards patients than younger
ones (Bj€ orkman et al. 2008, Hamdan-Mansour & War-
Design
dam 2009, Lammie et al. 2010, Haddad et al. 2012,
Hansson et al. 2013). Having had previous personal con- This was a cross-sectional study, using a convenience sam-
tact with a person with a mental illness has also been ple, and validated self-report questionnaire. This specific
associated with more positive attitudes towards people approach was chosen because survey questionnaires are a
with mental illness, both in the general public (Anger- widely accepted method to describe attitudes towards peo-
meyer & Dietrich 2006, Stuber et al. 2014) and among ple with mental illness (Mehta et al. 2015).
health care staff members (Corrigan & Watson 2002b,
Bj€orkman et al. 2008, Arvaniti et al. 2009, M artensson
Settings
et al. 2014), although there have also been study results
from a health-care setting that indicate that this type of The study was conducted in primary health-care settings in
personal contact is associated with negative attitudes Finland. The decision to collect this type of data was based
(Lethoba et al. 2006) or that personal contact has no on the assumption that integrating mental health care into
association with attitudes towards people with mental ill- primary care services is the most profitable way to diminish
ness (van der Kluit et al. 2013). stigma and discrimination, and to ensure that people get
Although the amount of research studies concerning the mental health care they need (World Health Organiza-
stigma towards mental health problems and interventions tion & Wonca 2008). Therefore, nurses working in pri-
aiming to reduce health-related stigma has steadily grown mary health-care settings have an important role in
(Weiss et al. 2006, Bj€ orkman et al. 2008, Hamdan-Man- reducing stigma towards people with mental health prob-
sour & Wardam 2009, Hansson et al. 2013, Hendersson lems (Haddad et al. 2007, Hori et al. 2011). The data were
et al. 2014), only a few studies have focused on the attitudes collected in two of the cities in Finland and their primary
of staff members towards people with mental illness work- health care centres (N = 15). In Finland, the responsibility
ing in the community or nurses’ attitudes towards mental for organizing public mental health services rests with the
health issues in primary health-care settings (Haddad et al. municipalities (Finnish Mental Health Act 1116/1990)
2007, Svediene et al. 2009, Ndetei et al. 2011). Some find- who organize primary health care services for its citizens.
ings have suggested that primary care staff, including nurses, In serious cases, mental health services are offered under
have significantly more negative attitudes towards people specialized health care with referrals. Health care centres
with schizophrenia or other mental illnesses than nursing offer primary mental health care services in outpatient care
staff in mental health-care settings (Kapungwe et al. 2011, during office hours (8 am–4 pm) 5 days a week. In cases of
Mittal et al. 2014). On the other hand, in primary and emergency, the patients are directed to an emergency unit
school health-care settings, nurses’ attitudes towards (Ministry of Social Affairs and Health 2014).
patients with depression have found to be mainly positive
and optimistic (Haddad et al. 2005, 2010, Postuvan et al.
Population, sampling and data collection
2007). In order to better understand nurses’ attitudes
towards patients with mental health problems and mental The permission to conduct the study was granted by the
illness in primary care, we aimed to describe these attitudes two directors of the health care services (ID 3277-2014,
and find out if certain characteristics of the nurses are associ- 19 March 2014; Decision date of permission 24 March
ated with their attitudes in primary care health centres. 2014). According to the Finnish requirements for ethical
approval, no ethical review was necessary because the
study was not medical research; it focused on nursing
Methods
staff, and no patient groups were included in the study
(Medical Research Act 488/1999; Finnish Advisory Board
Theoretical framework
on Research Integrity 2012).
Our study focuses on stigmatizing attitudes among nurses In this study, total population sampling was used. This
towards patients with mental health problems in primary convenience sampling technique was chosen because we

© 2016 John Wiley & Sons Ltd 429


N. Ihalainen-Tamlander et al.

wanted to examine the entire population (nurses) within a The nurses’ attitudes regarding people with mental ill-
specific setting (primacy health care services) and with a ness were collected with the AQ-27: a self-administered
particular set of characteristics. The study population instrument comprising 27 items, which examine nine
(N = 264 nurses) was therefore formed from all of the dimensions (three items in each dimension), with each
health care centres (N = 15) in two cities offering primary dimension representing a specific stereotype (Corrigan
health care services for their areas; the power analysis to et al. 2003). These stereotypes explain attitudes, emo-
estimate sample size was not calculated. All relative health tional effects and behaviours related to a hypothetical per-
care centres were invited to participate, and in fact did par- son with schizophrenia (Corrigan et al. 2004, Brown
ticipate, in the study. Inclusion criteria consisted of all Fin- 2008). The nine dimensions for specific stereotypes are as
nish speaking nurses working in health care centres in two follows: (1) blame (the notion that people with mental ill-
cities, having a licensed nursing education (i.e. registered ness have control over and are responsible for having the
nurses included public health nurses, practical nurses illness); (2) anger (irritability or annoyance because people
included primary care nurses and enrolled nurses) and regis- are blamed for having the illness); (3) pity (sympathy for
tered by the Finnish National Supervisory Authority for people because of their mental illness); (4) help (people
Welfare and Health (Valvira 2014). On the contrary, we with mental illness need assistance); (5) dangerousness
excluded nurses who do not practice nursing on a daily (people with mental illness are not safe); (6) fear (based
basis (radiographers, laboratory scientists), nursing stu- on the notion that people with mental illness are danger-
dents, as well as those on sick leaves or on holiday. Those ous); (7) avoidance (keeping away from people with men-
nurses were recruited for participation based on who was tal illness); (8) segregation (sending people out of their
on duty during the data collection period (14–28 of May, communities to institutions); and (9) coercion (forcing
2014). Agreement to participate in the study and a returned people to participate in medication management or receive
completed questionnaire constituted informed consent. other treatment) (Corrigan 2012).
To ensure systematic data collection procedure, we Respondents were asked to report their attitudes
organized appointments with the directors of nursing as regarding a hypothetical person in a vignette. The use of
well as the head nurses of the study organizations. Infor- this technique as the data collection method was selected
mation about the study was made available to them in because vignettes could potentially shed new light on the
written format and orally. Head nurses were asked to study area (Link et al. 2004). The content of the vignette
inform potential participants about the study and to dis- was as follows: Harry is a 30 year-old single man with
tribute the information letters, questionnaires and return schizophrenia. Sometimes he hears voices and becomes
envelopes to the nurses. The response time was 2 weeks. upset. He lives alone in an apartment and works as a clerk
One email reminder was sent to all head nurses during the at a large law firm. He has been hospitalized six times
data collection. Closed envelopes containing the completed because of his illness (Corrigan 2012). Respondents were
questionnaires were picked up from the health centres by asked to answer to each item using a 9-point Likert scale
the researchers. Altogether, 264 blank questionnaires were (1 = ‘not at all’ or ‘not likely’ to 9 = ‘very much’ or ‘very
distributed to the centres and 222 envelopes enclosing likely’). Three items regarding the stereotype of ‘avoid-
questionnaires were returned. Four uncompleted question- ance’ were reversed (Crespo et al. 2008, Lammie et al.
naires were returned, which left us with 218 questionnaires 2010, de Sousa et al. 2012). The attitudes were calculated
to be analysed (response rate 84%). considering the mean scores obtained for the items com-
prising each stereotype (de Sousa et al. 2012): the higher
the score, the greater the extent to which the specific
Instrument
stereotype was endorsed (Corrigan 2012).
The instrument included background information on the As far as we are aware, this was the first time the
respondents as well as questions regarding nurses’ atti- instrument was being used in Finland. Therefore, the
tudes towards people with mental illness. The following questionnaire was translated using the standard transla-
background information was collected of participating tion-back translation method with a four-step process
nurses: age (in years), gender, type of degree (registered (Grove et al. 2013). First, the original questionnaire was
nurse, public health nurse, practical nurse, primary care translated from English into Finnish. Second, the Finnish
nurse, enrolled nurse), total length of work experience in version was then translated back into English by a profes-
health centres and in primary care (in years) and mental sional translator (not involved in the first phase of the
health training (yes, no). Respondents were also asked if translation process). Third, the developer of questionnaire
they had any personal contact with people with mental ill- inspected whether the translated version of the instrument
ness outside of work (yes, no). corresponded with the original instrument. Fourth, a new

430 © 2016 John Wiley & Sons Ltd


Stigmatizing attitudes in nurses

round of translations was conducted until no discrepan- ranged from 24 to 67 years. Overall, 81% of the partici-
cies were found. After the translation process, the Finnish pants were registered nurses and 19% of the respondents
instrument was pilot tested in two psychiatric wards with were practical nurses. Table 1 summarizes the demo-
20 volunteer nurses (not participated in the main study) to graphics characteristics of the participants.
find out the clarity and understandability of the items,
effectiveness of instructions and time required to complete
Nurses’ attitudes regarding people with mental illness
the questionnaire. No modifications were made on the
basis of the pilot test. Out of the nine stereotypes, helping people with mental
illness received the overall highest score from the nurses in
primary health care centres (Med = 7.0) (see Table 2).
Statistical analyses
This was indicated by questionnaire items focusing on
To describe nurses’ attitudes towards people with mental willingness to help and to talk to people about their men-
illness, descriptive statistics were used [percentages, counts tal health problems (see Table 3). Nurses also felt pity
for categorical variables: minimum, maximum, median towards people with mental illness (Med = 5.3).
with the interquartile range (IQR) for numerical vari- On the contrary, the lowest scores were indicated for
ables]. The type of health care degree was classified as the items representing patients’ dangerousness (Med = 2.0);
level of health care education (basic level, second level). Table 1
Age groups were classified for the table of demographic Demographic characteristics of participants (N = 218)
characteristics; in statistical analysis, age was handled as n % Min Med (IQR) Max
numerical. Age (years) 216 24 48 (38–54) 67
The distribution for each stereotype was examined. Under 35 19
The normal distribution assumption was not met for all 35–44 20
45–54 37
scores because of the skewness of distribution. Therefore, Over 55 24
median score values are reported for these variables. Log- Gender 217
arithmic transformation was conducted for anger, danger- Female 212 98
Male 5 2
ousness, fear and segregation scores, and square root Health care education 215
transformation was conducted for help scores to achieve a Practical nurse 42 19
normal distribution assumption. Further, multiway covari- (enrolled nurse,
primary care nurse)
ance analysis was used to examine nurses’ demographic
Registered nurse 173 81
characteristics [age, level of education, personal contact included public
(yes/no) and additional mental health training (yes/no)] as health nurse
associated with nurses’ attitudes (blame, anger, pity, help, Work experience in 210 0 96 (36–180) 516
health centres
dangerousness, fear, avoidance, segregation, coercion) (months)
regarding people with mental illness. In addition, interac- Under 10 years 55
tion of personal contact and additional mental health 10–20 years 32
Over 20 years 13
training were examined. Other interactions tested in the Work experience in 212 1 168 (60–264) 516
same model (age 9 personal contact, additional mental primary care
health training 9 level of education) were non-significant, (months)
Under 10 years 36
with a significant level of 0.1, and thus removed from the
10–20 years 36
final model for every nurses’ attitudes. The data entering Over 20 years 28
process was done with SPSS (version 22: IBM SPPS Statis- Additional mental 216
tics for Windows, Armonk, NY) and data analysis with health training
Yes 19 9
SAS software (version 9.3 SAS Institute Inc., Cary, NC, No 197 91
USA). In all statistical tests, P-values of <0.05 were con- Personal contact with 218
sidered statistically significant (two-tailed). mentally ill people
outside work1
Yes 103 47
Friend 58
Results Family member 12
Relative 38
Participants Other 8
None 115 53
Of the 218 study participants, almost all were female IQR, interquartile range.
(98%). The respondents’ median age was 48, and the ages 1
Can be more than one personal contact.

© 2016 John Wiley & Sons Ltd 431


N. Ihalainen-Tamlander et al.

Table 2 their will. A more detailed description of nurses’ attitudes


Medians [interquartile range (IQR)], minimum and maximum scores
regarding people with mental illness as stereotypes is pre-
for each stereotype
sented with median scores in Table 2. Further, detailed
Stereotype1 N Med (IQR) Min (1) Max (9)
indicators of all 27 discrete items are presented in
Help 218 7.0 (5.7–8.0) 1.0 9.0
Pity 218 5.3 (4.3–6.3) 1.0 9.0
Table 3.
Coercion 218 5.3 (4.3–6.0) 2.0 9.0
Avoidance 218 4.3 (3.0–5.7) 1.0 9.0
Blame 218 4.3 (3.7–5.0) 1.0 7.3 Associations of nurses’ characteristics and their
Segregation 218 2.3 (1.3–3.7) 1.0 9.0 attitudes and beliefs towards people with mental illness
Fear 218 2.3 (1.3–3.3) 1.0 8.3
Dangerousness 218 2.0 (1.6–3.1) 1.0 8.7 Multiway covariance analysis was conducted to indicate
Anger 218 1.7 (1.0–2.7) 1.0 8.0 whether there were any statistically significant associa-
1
The higher median score is ranked as the stronger stereotype endorsed. tions between nurses’ attitudes according to their age,
additional mental health training and personal contact
nurses generally do not feel unsafe or threatened by peo- with people with mental illness. Based on the analysis, all
ple with mental illness. Questionnaire items regarding three of these characteristics (age, additional mental
anger, operationalized by feeling aggravated or irritated health training, personal contact with people with mental
by people with mental illness, also received low scores illness) were associated with nurses’ stigmatized attitudes.
(Med = 1.7). At the same time, however, the nurses First, older nurses thought less often than younger ones
reported coercive attitudes towards mental health patients that people with mental illness are frightening
(Med = 5.3). This was apparent in the reporting of nurses [F(1, 204) = 5.54, P = 0.020], should be segregated
making mentally ill patients adhere to their medication [F(1, 204) = 4.41, P = 0.037] or that nurses themselves
management or forcing them into treatment even against are not safe [F(1, 204) = 4.27, P = 0.040]. Second, the

Table 3
Medians obtained in Attribution Questionnaire-27 items
Item Stereotype N Med (IQR)1
I would think that it was Harry’s own fault that he is in the present condition. Blame 218 1.0 (1.0–2.0)
How controllable, do you think, is the cause of Harry’s present condition? 215 5.0 (4.0–7.0)
How responsible, do you think, is Harry for his present condition? 215 5.0 (4.0–7.0)
I would feel aggravated by Harry. Anger 218 2.0 (1.0–3.0)
How angry would you feel at Harry? 217 1.0 (1.0–2.0)
How irritated would you feel by Harry? 218 2.0 (1.0–2.0)
I would feel pity for Harry. Pity 218 3.0 (2.0–5.0)
How much sympathy would you feel for Harry? 216 7.0 (5.0–8.0)
How much concern would you feel for Harry? 217 6.0 (5.0–7.0)
I would be willing to talk to Harry about his problems. Help 218 7.0 (5.0–8.0)
How likely is it that you would help Harry? 218 8.0 (6.0–9.0)
How certain would you feel that you would help Harry? 217 7.0 (6.0–8.0)
I would feel unsafe around Harry. Dangerousness 218 2.0 (1.8–3.0)
How dangerous would you feel Harry is? 218 2.0 (1.8–3.0)
I would feel threatened by Harry. 217 2.0 (1.0–3.0)
Harry would terrify me. Fear 218 2.0 (1.0–3.0)
How scared of Harry would you feel? 217 2.0 (2.0–4.0)
How frightened of Harry would you feel? 217 2.0 (1.0–3.0)
If I were an employer, I would interview Harry for a job. Avoidance 217 4.0 (2.0–6.0)
I would share a car pool with Harry every day. 218 4.0 (2.0–7.0)
If I were a landlord, I probably would rent an apartment to Harry. 217 5.0 (3.0–6.0)
I think Harry poses a risk to his neighbours unless he is hospitalized. Segregation 217 2.0 (1.0–4.0)
I think it would be best for Harry’s community if he were put away 217 2.0 (1.0–4.0)
in a psychiatric hospital.
How much do you think an asylum, where Harry can be kept away 218 2.0 (1.0–3.0)
from his neighbours, is the best place for him?
If I were in charge of Harry’s treatment, I would require him to Coercion 217 8.0 (7.0–9.0)
take his medication.
How much do you agree that Harry should be forced into treatment 216 6.0 (4.0–7.0)
with his doctor even if he does not want to?
If I were in charge of Harry’s treatment, I would force him to live in a group home. 216 2.0 (1.0–3.0)
IQR, interquartile range.
1
Higher value of each item represent stronger stereotype.

432 © 2016 John Wiley & Sons Ltd


Stigmatizing attitudes in nurses

nurses who had received additional mental health training

0.367
0.238
0.042
0.919
0.541
0.904
0.334
0.842
0.226
more frequently reported willingness to help people

P
with mental illness [Med = 8.0 vs. 7.0, F(1, 204) = 4.74,

4.0 (3.3–5.0)
1.7 (1.0–2.3)
5.3 (4.3–6.7)
7.0 (5.7–8.0)
2.3 (1.7–3.3)
2.3 (1.7–3.7)
4.3 (3.3–6.0)
2.3 (1.3–4.0)
5.3 (4.7–6.0)
P = 0.031]. Nurses with additional training, when

Med (IQR)
compared to their counterparts lacking this training, less
frequently reported thinking that mentally ill patients
are frightening [Med = 1.7 vs. 2.3, F(1, 204) = 4.59,

115
115
115
115
115
115
115
115
115
No
P = 0.033], these persons should be segregated

N
[Med = 1.3 vs. 2.3, F(1, 204) = 5.00, P = 0.026] or that

(3.7–5.0)
(1.0–2.7)
(4.3–6.0)
(6.0–8.2)
(1.3–3.0)
(1.3–3.0)
(3.0–5.5)
(1.3–3.2)
(4.3–6.0)
nurses are not safe [Med = 1.7 vs. 2.3, F(1, 204) = 3.91,

Med (IQR)
Personal contact
P = 0.049]. Third, the nurses who had personal contact

4.3
1.7
5.3
7.3
2.0
2.0
4.0
2.0
5.3
with people with mental illness less frequently reported
feeling pity for people with mental illness, compared

101
101
101
101
101
101
101
101
101
Yes
to those nurses who had no such personal con-

N
tact [Med = 5.3 vs. 5.3, F(1, 204) = 4.18, P = 0.042]

0.026
0.858
0.110
0.350
0.031
0.049
0.033
0.086

0.204
(Table 4).

P
Furthermore, personal contact interactions and addi-
tional mental health training were also tested. Interactions

4.0 (3.7–5.0)
1.7 (1.0–2.7)
5.3 (4.3–6.3)
7.0 (5.7–8.0)
2.3 (1.7–3.3)
2.3 (1.7–3.5)
4.3 (3.2–4.3)
2.3 (1.3–3.7)
5.3 (4.3–6.0)
Med (IQR)
where P-value was >0.1 were removed from the final
model. Association measurements did not reach a statisti-
cally significant level (all P-values > 0.05), but when anal-
ysed pity (P = 0.072) or coercion (P = 0.056), interaction

197
197
197
197
197
197
197
197
197
No
N
was almost significant. In regard to pity, medians were as

Additional training
follows: nurses with both personal contact and additional

4.5 (3.7–5.0)
1.0 (1.0–2.3)
5.3 (3.7–6.3)
8.0 (7.3–8.7)
1.7 (1.0–2.3)
1.7 (1.0–2.3)
3.3 (3.0–4.3)
1.3 (1.0–2.3)
5.3 (3.7–5.7)
Med (IQR)
mental health training, Med = 4.3; nurses with personal
contact and without additional mental health training,
Med = 5.3; nurses without personal contact and with
additional mental health training, Med = 6.3; and nurses
Yes

19
19
19
19
19
19
19
19
19
N

without personal contact and without additional mental


health training, Med = 5.3. In addition, in regard to
0.312
0.949
0.467
0.459
0.839
0.561
0.443
0.226
0.627
coercion, medians were as follows: nurses with both per-
P

sonal contact and additional mental health training,


4.3 (3.7–5.0)
1.7 (1.0–2.5)
5.3 (4.3–6.3)
7.0 (5.7–8.2)
2.0 (1.7–3.0)
2.0 (1.4–3.0)
4.3 (3.0–5.8)
2.0 (1.3–3.3)
5.3 (4.3–6.0)
Med (IQR)

Med = 5.3; nurses with personal contact and without


additional mental health training, Med = 5.3; nurses
Secondary

without personal contact and with additional mental


health training, Med = 4; and nurses without personal
173
173
173
173
173
173
173
173
173

contact and without additional mental health training,


N

Med = 5.5.
(3.3–4.7)
(1.0–2.7)
(4.0–6.3)
(5.3–8.0)
(1.3–3.4)
(1.3–4.0)
(3.7–5.7)
(1.7–3.7)
(4.3–6.3)
Med (IQR)

In addition, the model included the level of health edu-


Education level
Nurses’ characteristics associated with stereotypes

cation, but the association between attitudes was non-sig-


nificant (all P-values > 0.22, Table 4).
4.0
1.3
5.3
6.8
2.3
2.5
4.7
2.8
5.3
Basic

42
42
42
42
42
42
42
42
42

Bold value, association was significant.


N

Discussion
0.020

0.037
0.781
0.995
0.635
0.468
0.040

0.197

0.552

As far as we are aware, this is the first study ever con-


P

ducted in Finland, which focuses on nurses’ attitudes


IQR, interquartile range.
Age

216
216
216
216
216
216
216
216
216

towards people with mental illness in primary care health


N

settings. Of the various groups of health care profession-


Dangerousness

als, we focused especially on nurses’ attitudes, because


Segregation
Avoidance

nurses play an important role in patient recovery (Horsfall


Coercion
Table 4

Factors
Blame
Anger

et al. 2010) as well as quality of care in the area of mental


Help

Fear
Pity

health (Thornicroft et al. 2007a).

© 2016 John Wiley & Sons Ltd 433


N. Ihalainen-Tamlander et al.

Our study showed that nurses’ attitudes towards On the other hand, nurses are using coercive measures
patients with mental illness in primary health-care settings towards patients and they justify their behaviour with
were mostly positive (also Haddad et al. 2005, 2010, good intentions (Crespo et al. 2008) to promote patients’
Postuvan et al. 2007, Ndetei et al. 2011), although prob- treatment adherence (Lammie et al. 2010, Valenti et al.
lems still exist. Our study results are supported by previous 2015). However, paternalistic treatment attitudes among
studies, where the same instrument (AQ-27, Corrigan) has nurses still exists (Cody 2003), and an ethical debate is
already been used with the general public (Crespo et al. needed in on-the-job training for nurses (Molodynski
2008), relatives of mental patients (de Sousa et al. 2012) et al. 2010). It is therefore important that health profes-
and health care professionals (Lammie et al. 2010). Our sionals themselves are aware of their own attitudes
results are quite encouraging because nurses in primary towards mental illnesses (O’Reilly et al. 2010, Hansson
health care may also have negative attitudes regarding peo- et al. 2013).
ple with mental illness (Reed & Fitzgerald 2005, Lethoba In our study, younger nurses or those without addi-
et al. 2006, Kapungwe et al. 2011, Mittal et al. 2014). As tional mental health training reported more fear, felt more
in our study, willingness to help and feeling pity received dangerousness and wanted more segregation for people
the highest scores when measuring attitudes among the with mental illness compared to older nurses. The reason
general population (Crespo et al. 2008) and among for this may be attributable to less practical experience
patients’ relatives (de Sousa et al. 2012). Further, health and awareness (Ndetei et al. 2011) or deficient training
professionals (Lammie et al. 2010) have been found to (Haddad et al. 2010). If young nurses are fearful of
show a willingness to help, but when it came to avoiding patients with mental health problems, fewer young gradu-
people with mental illness, high scores were not found in ates may pursue a career in this field (Happel 2009). How-
our study. On the other hand, similar to our study, anger ever, adequate additional mental health training could
and feeling irritated towards people with mental illness confirm knowledge and skills regarding mental health
scored low in other research. Our findings are an important issues and lead to a positive impact on attitudes in primary
basic step in developing a stigma-free treatment environ- health care (Haddad et al. 2005, 2010, Reed & Fitzgerald
ment and to ensure that the treatment in outpatient settings 2005). Therefore, the central concern concerning the atti-
can diminish stigma and discrimination. As outlined by the tudes towards patients with mental illness is related to the
World Health Organization (2008b, 2012); World Health future workforce. The basic question is how to ensure
Organization & Wonca 2008), the development of com- motivation of young nurses or students to work in the field
munity-based mental health approaches in primary care of mental health (Edward et al. 2015). This is a serious
settings requires positive attitudes towards patients with challenge, especially if young nurses are afraid of patients.
mental health problems (OECD 2014).
Nurses in our study reported feeling pity (as sympathy
Strengths and limitations
and concern) for people with mental health problems
(Crespo et al. 2008, Lammie et al. 2010, Obonsawin As a strength of the study was a high response rate (84%,
et al. 2013). However, those nurses with previous per- n = 218) of the study. We have also used of a validated
sonal contact with people with mental illness outside their and well-known instrument (Brown 2008, Pingani et al.
work, reported pity less than the nurses with no such con- 2012), which had previously been used in various studies
tacts. One explanation for this may be tiredness and the identifying attitudes and beliefs towards people with men-
feeling of helplessness among nurses as well as less recog- tal illness (Corrigan et al. 2004, Crespo et al. 2008, Lam-
nition of the recovery process in the care of people with mie et al. 2010, de Sousa et al. 2012). Using the vignette
mental illness (Mittal et al. 2014). Recent studies have technique enables a more elaborate stimulus to respon-
shown that empathy has been seen as a key resource for dents, and can therefore result in a more sensitive measure
supporting the patient’s recovery (Chung et al. 2013, Par- of attitudes (Corrigan et al. 2004, Link et al. 2004).
van et al. 2014). Person-centred care is also better prac- Nonetheless, limitations in this study need to be consid-
ticed if nursing staff place patients and their needs at the ered. First, one limitation may be the survey itself; the
centre of caregiving (Bellchambers & Pelling 2007). At respondents may have been affected by social effects,
the same time, however, nurses in our study were ready which are not an observation of actual behaviour (Corri-
and willing to coerce a person with a mental disorder into gan et al. 2003). Second, in our study, nurses based their
participating in the treatment. Already in previous litera- attitudes on a hypothetical vignette, not a real situation
ture, discrepancy between feelings of pity and coercive (Watson et al. 2004, Obonsawin et al. 2013). Using a
attitudes towards patients raises ethical dilemmas in the vignette as a data collection method may have impacted
nursing profession (Lammie et al. 2010). our results (Watson et al. 2004, Polit & Beck 2012).

434 © 2016 John Wiley & Sons Ltd


Stigmatizing attitudes in nurses

AQ-27 has a variety of vignettes, which vary in their pre- towards patients. Especially young nurses could build self-
sented level of dangerousness of a patient (Corrigan et al. confidence in working with people who have mental dis-
2003). It also may be possible that using a vignette in itself orders by increasing their understanding of safety issues at
may affect respondents’ negative attitudes. In our study, the work place and how to develop patient-centred work
we used a neutral vignette to avoid any stigmatized conno- habits and trusting relationships with patients. A work
tations in the instrument, which could further influence environment free of fear would also help ensure a future
nurses’ responses. Third, we used a convenience sampling work force in the field of mental health. Training is a criti-
technique to gain insight into nurses’ attitudes. However, cal issue for capacity building among health care staff.
we can consider how representative the study sample is However, according to the World Health Organization
within the relevant nursing workforce in the whole Fin- (2015), mental health training for primary care staff is still
land. Based on the national workforce statistics of the very low: only 1.8% of nurses have received at least 2 days
Local Goverment Employers (2016), out of 115 402 nurs- of training in mental health in the previous 2 years. There-
ing staff who worked in the Finnish municipalities in 2014, fore, nursing curricula should include appropriate knowl-
the most common degree among them (39.5%) was a regis- edge components of mental health areas, also for general
tered nurse; in our study sample, 81% of respondents were nurses (World Health Organization 2007).
registered nurses. The second most common degree among
nursing staff (25.5%) was a practical nurse; in our study
Conclusions
sample, 19% of respondents were practical nurses. In addi-
tion, as with our study, most of these nurses in entire Fin- This study revealed positive attitudes among primary
land were females (92%), with a mean age of 42 years health care nurses towards people with mental illness.
(Local Goverment Employers 2016). In that sense, our These findings are encouraging for the future development
study sample may represent Finnish nursing staff working of integrated mental health treatment in primary health
in primary care regarding their educational level, gender care. However, more attention should be paid to attitudes
and age. In sum, despite the limitations of the study, we towards people with mental illness. While mental health
assert that the study gives a quite relevant picture of the problems are often treated in primary care health centres
current state of attitudes regarding people with mental ill- in Finland, it is crucial that primary care workers are
ness among primary care health centre nurses. aware of their own attitudes towards patients with mental
health problems.

Implications for mental health nursing


Acknowledgment
Nurses are considered to play a key role in the fight
against stigma and discrimination (Haddad et al. 2007, We thank Professor Patrick Corrigan and his assistants for
Hori et al. 2011). The knowledge to be gained from our co-operation in translation process of AQ-27 instrument.
study exposes those areas where extra support and profes-
sional capacity building for nurses should be provided to
Funding
ensure high-quality outpatient services in primary care,
especially when de-hospitalization is still on the way This study is supported by the University of Turku.
(World Health Organization 2015).
Based on our findings, systematic and continuous men-
Conflict of interest
tal health on-the-job training for primary care nurses is
recommended to strengthen their positive attitudes None declared.

illness: a review of population studies. Acta Psy- population in Finland. Nordic Journal of Psy-
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