Assessment of Perceptions of Nursing Undergraduates towards Mental Health Practices

Background: Undergraduate nursing students, like the general population, are not devoid of negative attitudes relating to mental health. As future manpower, undergraduate nursing students need to be trained in a manner that inspires confidence in the way they perceive and handle mentally ill persons.

Aim: This study aimed to investigate undergraduate students' perceptions and attitudes toward mental health practices.

Methods: The study adopted a cross-sectional descriptive design approach. A self-reported questionnaire was prepared and sent to 140 undergraduate nursing students studying at King Saud University. A total of 128 students took part in the study by filling out self-reported questionnaires.

Results: Undergraduate nursing students have a positive perception and attitude (social relationships) towards people living with mentally ill persons in three of the five Attitudes towards Mental Illness (AMI) categories investigated. AMI1 (18.93), AMI2 (9.55), AMI3 (16.88), AMI4 (8.34), AMI5 (9.82), Average AMI (62.98).

Conclusion: Undergraduate nursing students hold unjustified views regarding people with mental illness, which leads to negative attitudes held throughout their studies and professional practice. As future manpower, it is important that psychiatric training is reformed to offer undergraduate nursing students comprehensive skills necessary for future practice.

There is a growing concern regarding mental illness among people across the globe. Mental illness has been recognized as among the leading causes of global disease burden worldwide without signs of reduction since 1990 [1]. The World Health Organization (WHO) reports that 1 in every eight people globally lives with a mental disorder [2]. Further, WHO estimates that over 450 million people globally live with some form of mental disorder. The high prevalence rate has exacerbated concerns among public health authorities owing to the debilitating effects the disorders have on the victims. Mental disorders affect different aspects of patients, including their thinking, emotions, and behaviour, thereby leading to functional impairment [3]. According to the WHO, the effects of mental illness will become the second leading cause of disability among individuals. As a result of their condition, mentally ill patients tend to be quite vulnerable as they regularly face discrimination, not only from their families but also from healthcare professionals- people who, ordinarily, are supposed to understand and protect them [4].

The perception and attitudes of health professionals towards people living with mental illness influence the quality of care administered/offered and the subsequent outcome. Positive perception and attitude are correlated with a positive result in mentally ill patients. Usually, caregivers expect that health professionals will help their patients based on the principles acquired during training as well as their experience, without discrimination or prejudice [5]. Regrettably, some healthcare providers exhibit negative perceptions and attitudes towards the mentally ill, which end up affecting not only the patients but also their families. Some nursing students, like the rest of the population, equally exhibit negative tendencies towards the mentally ill. The dangers of such behaviours are that they are likely to affect how they engage mentally sick patients under their care and can also cause poor management of mentally ill patients, thereby causing prolonged recovery [6].

Currently, stigma and discrimination remain major societal problems preventing mentally ill patients from receiving unfettered access to quality care for their disorders. This contributes to the rising cases of mental illness in Saudi Arabia as they potentially interfere with help-seeking, treatment, and rehabilitation [6,7]. Undergraduate nursing students have been reported as showing stigmatising and discriminatory behaviours towards people with mental disorders [8]. This is in tandem with various studies whose findings reveal that some nursing students hold unsavoury thoughts about mental health nursing [3,9]. This could be a source of grave concern as these students are the future health manpower, and such attitudes could have implications for nursing practices around the globe. As people who will have, among other responsibilities, taking care of mentally challenged patients, negative attitudes towards these people would affect their self-esteem. As a result, they will likely experience a lack of satisfaction in life and social exclusion [10].

Undergraduate nursing students, like the general population, are not devoid of negative attitudes relating to mental health [11]. In one of the studies to assess nursing students’ perception of mentally ill patients, 38 nursing students were interviewed before and after attending a mental health class. The findings from this study showed that before attending the mental health class, the students had a generally skewed view of the mentally ill as people who are dangerous, unpredictable, and often susceptible to violence [12]. In a similar study, although in a different context, 605 nursing students were interviewed before and after their clinical placement in a mental health facility. The findings of the study showed that a large number of nursing students who took part in the survey either agreed or held neutral sentiments concerning the stigma associated with mental illness, their deep knowledge of mental illness notwithstanding.

Various studies have shown that the nursing principles taught in nursing schools can positively influence the students’ perception and attitude toward nursing [8,13,14]. For example, while researching the perception and attitudes of nursing students, Thongpriwan, et al. found that student nurses who got more exposure to mentally ill persons were more tolerant of them, less anxious, and bore little or no stereotypes towards mentally ill patients [8]. In another study, a positive correlation was established between the number of hours nursing students spent learning and working in a clinical mental health facility and the intention to continue with a career in mental health nursing over time [14]. Consistent with these study findings is qualitative research that sought to find the influence of nursing psychiatric training on the attitudes of nursing students towards mentally ill persons [15]. The study participants included nursing students at a university in Tokyo, Japan. The study, which incorporated psychiatric lectures and clinical practice as the variables, showed a notable change in attitude towards mentally ill patients from students following psychiatric training.

In Saudi Arabia, undergraduate nursing students are required to take a mandatory psychiatric course where they are taught basic knowledge regarding psychiatry regardless of their final specialisations. The course is meant to, among others, equip these students with skills and positively transform their attitudes toward mental illness [16]. Such preparation remains critical because, as future health manpower, it is thought that nursing students will come into contact with mental health patients at some point in their professional lives. The skills acquired in the psychiatric course help in handling such patients. The occurrence of psychiatric disorders in Saudi Arabia's primary healthcare institutions is estimated at 30% - 46% [17]. Thus, nursing students must receive adequate training to help them once they begin their professional practice. To enhance the quality of learning, one must first understand the students' perceptions and attitudes about mental illness. This is critical because it will aid the relevant authorities in designing and developing holistic mental health training for nursing students [18].

Studies reviewed so far reveal divergent views on the attitudes of nursing students toward mentally ill patients. Moreover, only minimal studies delved into the perception and attitudes of undergraduate nursing students and determined the effect of existing psychiatric nursing courses on their practice. In particular, there is no single study conducted at King Saud University to determine the considerations and attitudes of nursing undergraduates towards persons living with mental illness conditions. Therefore, it is critical to understand the perceptions and attitudes of undergraduate nursing students toward mental illness. As future professionals in health care, an investigation into undergraduate nurses' perceptions and attitudes toward mentally ill patients remains critical. One of the objectives of the psychiatric course is to transform learners' attitudes toward mentally ill patients. A positive impact of the nursing curriculum on the students would be welcome as it will portend a future of quality care for mentally ill patients.

The study involved nursing undergraduate students at King Saud University’s College of Nursing. The study took place from October to November 2022. The selection of study participants was made using non-probability convenience sampling. The selection criteria included: a) undergraduate nursing students from 1st year to 4th year of the nursing course, b) those who volunteered to participate in the study. The exclusion criteria entailed participants who did not wish to participate and students not pursuing the nursing course. Questionnaires were sent to 140 students; however, only 128 undergraduates filled out and returned the questionnaire. As a result, only 128 questionnaires were used for this study, representing a 91.4% response rate.

Measures

The sociodemographic data survey instrument: The form listed four items to determine from the participants, namely: gender, age, marital status, and number of family members with mental illness.

Attitudes towards Mental Illness (AMI): Evaluation of the students’ attitudes towards mental illness was done using the AMI questionnaire as developed by Amini, et al. [19]. AMI was measured by a 22-item questionnaire. The scale assessed attitude on five categories:

1. Attitude towards social relationships (six questions, AMI1)
2. Tendency to inform others when one or a close relative has a mental illness (Three questions, AMI2)
3. The concept of treating patients (Three questions, AMI3)
4. Concept of etiology of mental illness (Three questions, AMI4)
5. Stereotyped attitude towards mental illness (AMI5)

AMI was a valid instrument, with the reliability of the scale (Cronbach’s alpha) ranging from 0.603 to 0.85. Consequently, the self-reported questionnaire was deemed fit for this study.

Procedure

An online questionnaire was prepared, ready to be sent to the respondents to fill out. The respondents were briefed accordingly about the purpose of the study and the reasons why they needed to take part in the study. It was explained that participation was voluntary and that any information provided would be kept confidential. The respondents were then requested to provide their emails during regular lecture sessions, after which the questionnaire was sent to everyone who heeded the request. The data collection tool did not contain identifying information.

Ethical considerations and approvals

The study was approved by the institutional review board of King Saud Medical City (Reference #: KSU-HE-22-795). Participation was completely anonymous and voluntary, and informed consent was ensured before data collection. All data relating to the study will be retained and available for at least 3 years after the study end date. After that, all data relating to the study will be destroyed.

A total of 128 respondents participated in the study. Table 1 shows their characteristics.

Based on the demographic data of the participants, female undergraduate nursing students (67.2%) were more compared to males (32.8%). The data also shows that most of the participants were between the ages of 18-24 years (59.4%). Those who were between the ages of 25-34 were 19.5%, while those aged 35 years and above were 21.1%. Data about marital status showed that a majority of the students (68.8%) were single, while 28.1% were married. 2.3% of the participants were divorced, and 0.8% were widowed. Data on families with mental illness showed that a majority of families, 71.9%, did not have a family member experiencing some form of mental illness. However, 28.1% of the participants admitted to knowing a close relative or themselves experiencing some form of mental illness.

In Table 2, the research findings revealed that undergraduate nursing students have a positive perception and attitude (social relationships) towards the mentally ill persons. This is because the AMI1 Score of 18.93 was higher than the cut-off point score of 15. Moreover, the AMI2 results showed that undergraduate students had a relatively high tendency to always inform others, particularly when one or a close friend is mentally ill. The Score was 9.55 against the cut-off point score of 7.5. Further findings on another AMI3 subscale (attitude towards the patient) showed that undergraduate nursing students had an average attitude towards people with mental illness. AMI score for this category was 16.88 against the cut-off point score of 15. AMI4 result of 8.34 was relatively low about the cut-off point score of 7.5. This shows that the students had a negative attitude toward the etiology of mental illness. AMI5 findings were 9.82 against the cut-off point score of 10. This demonstrated the undergraduate nursing students' undesirable stereotyped attitude towards people living with mental illness. Nevertheless, the overall outcome of 62.98 in relation to the cut-off point score of 55 shows that the participants have a positive or a favourable attitude towards mentally ill patients.

The overarching objective of this study was to determine undergraduate students' perceptions and attitudes toward mental health practices. Mental illness remains a serious issue in society, and as future caregivers, understanding nursing students’ perception is critical. The findings of the current study revealed a general view that undergraduate nurses hold favourable attitudes towards mental illness. For instance, in the first category, the AMI score of 18.93 was higher compared to the cut-off point score of 15. This finding could be extrapolated to suggest that undergraduate nursing students are willing to live in a community or work in a place where they are close to people who are mentally ill. This is consistent with other studies, whose findings showed that nursing students had a favourable attitude towards social relationships, with age and training playing an important factor in reducing social restrictiveness [20,21].

The current study found that the participants had some confidence and willingness to self-disclose their mental illness status. Moreover, they also did not hide the fact that they had close relatives who were mentally ill. 9.55 was the AMI2 Score above the cut-off point score of 7.5. The results of this study offer consistent views to other research, which found significant attitudinal change as a result of educational interventions on nursing students [4,19,22]. It can thus be argued that undergraduate students can share or freely disclose their mental illness status or those of their close relatives without feeling guilty or ashamed. Nevertheless, some earlier research found no correlation between nursing education and the willingness to self-disclose or desire to inform others when a close relative has a mental illness [23].

This study found that undergraduate nursing students had an average attitude toward the treatment of mental illness. This is because the AMI3 Score of 16.88 was closer to the cut-off point score of 15. This contradicts the findings of previous research, which show that nursing students have a positive attitude towards the treatment of mental illness [6,24]. A possible reason for the below-average attitude towards mental illness treatment could be attributed to the current study focusing purely on undergraduate nursing students, while previous studies focused on medical students. An existential challenge is determining other methods that can be applied to help correct the misconceptions of future caregivers about the availability of mental illness treatment [19].

Concerning the nursing students’ attitude towards the etiology of mental illness (AMI4), the findings of the current study indicated that there are misconceptions regarding the etiology of mental illness. This is justified by the participants’ AMI4 Score of 8.34, which is closer to the cut-off point score of 7.5. This is consistent with other studies whose results also showed misconceptions regarding the etiology of mental illness [18,25]. These findings contradict the results of other earlier studies whose study participants were medical students [24]. A potential reason for the contradictory results could be because of the participants who were involved in the study. While the current study involved undergraduate nursing students, the other involved medical students.

The current study indicated that undergraduate nursing students had negative stereotyped attitudes toward mentally ill patients. The AMI score for this category was 9.82, a slightly low score compared to the cut-off point score of 10. The findings are consistent with other research focusing on student nurses' attitudes toward mental illness [6,26]. Such stereotypes could be a result of or influenced by evil spirits, religious afflictions, as well as from societal norms where the participants were brought up.

Limitations

The current study has specific limitations. Firstly, the small and convenient sample from one University College made generalising the findings difficult. Secondly, the descriptive design used in the study also has its limitations. Moreover, the participants were selected without considering certain aspects that could be quite influential in the outcome. It is thus suggested that for future studies, large samples should be used together with other methodologies to help arrive at more conclusive findings. Although with limitations, it is envisioned that the findings of this research will be useful in academia.

Implications for nursing practice

Understanding the perception of the undergraduate nursing students towards mental health practices could help policymakers introduce reforms that could lead to better training and more favourable learning outcomes. Finding ways to change the attitudinal perceptions of student nurses could mean more holistic nurses being churned into the profession. This could go on to address the shortage of nurses being experienced in the mental health subsector, not only in Saudi Arabia but also around the world.

Undergraduate nursing students hold unjustified views or misconceptions regarding people living with mental illness, leading to negative attitudes held throughout their studies. The study findings thus point to the critical need to address the negative attitudes levelled against mentally ill persons. As future manpower, nursing students need to be trained in a manner that inspires confidence in the way they perceive and handle mentally ill persons. This research brings to the fore the issues that could derail successful nursing training.

Data Availability Statement: Data are not shared due to privacy and ethical restrictions.

The author is thankful to the Deanship of Scientific Research and the College of Nursing Research Centre at King Saud University for funding this research.

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