nurses’ attitudes to mental illness: a comparison of a sample of nurses from five european...
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Nurses’ attitudes to mental illness: A comparison of a sample of nursesfrom five European countries
Mary Chambers a,*, Veslemøy Guise a, Maritta Valimaki b,c, Maria Antonia Rebelo Botelho d,Anne Scott e, Vida Staniuliene f, Renzo Zanotti g
a Faculty of Health and Social Care Sciences, St George’s, University of London and Kingston University, Cranmer Terrace, London SW17 0RE, UKb Department of Nursing Science, University of Turku, Finlandc The Hospital District of Southwest Finland, Finlandd Nursing Research and Development Unit, Escola Superior de Enfermagem de Lisboa, Portugale School of Nursing, Dublin City University, Irelandf Department of Nursing Science, Klaipeda College, Lithuaniag Faculty of Medicine and Surgery, University of Padova, Italy
International Journal of Nursing Studies 47 (2010) 350–362
A R T I C L E I N F O
Article history:
Received 20 February 2009
Received in revised form 15 June 2009
Accepted 25 August 2009
Keywords:
Attitudes to mental illness
Stigma
Mental health
European nursing
Cross-cultural research
International comparison
A B S T R A C T
Background: Mental health problems are of serious concern across Europe. A major barrier
to the realisation of good mental health and well-being is stigma and discrimination. To
date there is limited knowledge or understanding of mental health nurses’ attitudes
towards mental illness and individuals experiencing mental health problems.
Objectives: To describe and compare attitudes towards mental illness and those
experiencing mental health problems across a sample of registered nurses working in
mental health settings from five European countries and the factors associated with these
attitudes.
Design: A questionnaire survey.
Settings: A total of 72 inpatient wards and units and five community facilities in Finland,
Lithuania, Ireland, Italy and Portugal.
Participants: 810 registered nurses working in mental health settings.
Methods: The data were collected using The Community Attitudes towards the Mentally Ill
(CAMI) scale, which is a 40-item self-report questionnaire. The data were analysed using
quantitative methods.
Results: Nurses’ attitudes were mainly positive. Attitudes differed across countries, with
Portuguese nurses’ attitudes being significantly more positive and Lithuanian nurses’
attitudes being significantly more negative than others’. Positive attitudes were associated
with being female and having a senior position.
Conclusions: Though European mental health nurses’ attitudes to mental illness and
people with mental health problems differ significantly across some countries, they are
largely similar. The differences observed could be related to wider social, cultural and
organisational circumstances of nursing practice.
� 2009 Elsevier Ltd. All rights reserved.
Contents lists available at ScienceDirect
International Journal of Nursing Studies
journal homepage: www.elsevier.com/ijns
* Corresponding author.
E-mail address: [email protected] (M. Chambers).
0020-7489/$ – see front matter � 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2009.08.008
What is already known about the topic?
� N
egative attitudes to mental illness can lead to stigmatis-ing views of people with mental health problems. � S tigma on the part of mental health professionals affectsthe quality of care provided for those with mental healthproblems, as well as their rates of recovery.
M. Chambers et al. / International Journal of Nursing Studies 47 (2010) 350–362 351
� C
urrently little is known of the attitudes towards mentalillness held by registered nurses working in mentalhealth environments.What this paper adds
� T
his study shows that the attitudes of nurses working inEuropean mental health settings are largely positive. � C ountry of practice is the main predictor of differences innurses’ attitudes.
� N urses’ attitudes are also associated with their genderand the position they hold.
1. Introduction
Mental health and well-being is critical to the quality oflife of individuals and the productivity of communities(WHO, 2005). Improving the mental health of Europe’scitizens is a fundamental part of the European Union’s (EU)long term strategic policy objectives (EC, 2005). One of themajor impediments to the realisation of positive mentalhealth and well-being is stigma and discrimination, whichcan impact on all aspects of an individual’s life (Byrne,2000). Stigma and discrimination towards those experien-cing mental illness is the greatest barrier to recovery anddevelopment of effective care and treatment (Sartorius,2002). At worst stigma can exacerbate people’s mentalhealth problems and can seriously affect their chances ofrecovery, reinforcing negative attitudes and discriminatingbehaviours in the process (Sartorius, 2007).
Despite various initiatives and campaigns againststigma (e.g. Paykel et al., 1997; Crisp, 2000), stigmatizedattitudes still exist (Crisp et al., 2000, 2005). Negativeattitudes have been attributed to a lack of knowledge(Wolff et al., 1996; Papadopoulos et al., 2002), although therelationship between attitudes and knowledge is not clear-cut (Addison and Thorpe, 2004). Reviews of populationstudies found that older, less educated people tended tohave less favourable attitudes to mental illness, whereasfamiliarity with mental illness and people with mentalhealth problems was associated with positive attitudes(Hayward and Bright, 1997, Angermeyer and Dietrich,2006).
A range of health and social care professionals havebeen 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) andsocial workers (Murray and Steffen, 1999). Some havefound that health care professionals hold more negativeattitudes towards mental illness than the general public(Jorm et al., 1999; Caldwell and Jorm, 2000). Althoughattention has been given to the attitudes of health carestudents, especially nursing and medical students, mosthave concentrated on measuring attitude change resultingfrom an educational intervention (Mino et al., 2001; Baxteret al., 2001; Evagelou et al., 2005), or direct contact withpeople with mental illness (Callaghan et al., 1997;Madianos et al., 2005) Others have investigated the impactof both education and contact (e.g. McLaughlin, 1997; Readand Law, 1999; Emrich et al., 2003). Studies that have
considered nursing students’ attitude change over timehave concluded that exposure to a mental health focusedcurriculum can significantly change and improve attitudesto mental illness (Emrich et al., 2003; Evagelou et al.,2005).
Explorations of the attitudes of mental health profes-sionals appear to be less common (Hugo, 2001). Many ofthe studies that do feature mental health professionals arecomparative, where professional attitudes, mainly psy-chiatrists’, 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 (mentalhealth) nurses (Sevigny et al., 1999; Hugo, 2001; Lauberet al., 2006), often comparing the attitudes of nursesworking within mental health settings with those ofgeneral nurses (e.g. Weller and Grunes, 1988; Tay et al.,2004; Bjorkman et al., 2008). Studies looking at registerednurses indicate that qualified staff with higher levels ofeducation, and those with specialised psychiatric traininghold more positive attitudes than unqualified staff andthose without any psychiatric training (Scott and Phillip,1985; Mavundla and Uys, 1997; Brinn, 2000). Such findingsshould, however, be viewed with caution as it may bepositive attitudes that lead to the undertaking of mentalhealth training rather than the training itself positivelyimpacting on attitudes.
It has also been suggested that being acquainted withsomeone living with mental illness will positively influ-ence attitudes (Wolff et al., 1996; Song et al., 2005). Fornursing and psychology students exposure to a psychiatricsetting during training and having personal contact haveboth been associated with positive attitudes (Bairan andFarnsworth, 1989; McLaughlin, 1997; Read and Law,1999). It has also been noted that nurses working inpsychiatric settings have more positive attitudes thanthose working in somatic care (Bjorkman et al., 2008).These findings are supported by a comprehensive litera-ture review on the effect of interpersonal contact on stigmaof mental illness by Couture and Penn (2003). They assertthat both personal and professional contact is associatedwith increased positive attitudes to mental illness and thatthe positive impact of the ‘so-called’ contact hypothesisseems to be universal. Other studies, however, have foundno support for the contact hypothesis (e.g. Kahn, 1976;Weller and Grunes, 1988; Callaghan et al., 1997). Theoverall correlation between contact and attitudes is still amatter of debate, prompting calls for more research intothe influence of contact upon attitudes of mental illness(Addison and Thorpe, 2004).
The debate about which factors contribute to theformation of certain attitudes becomes even more complexwhen attitudes are looked at from an internationalperspective. Stigma associated with mental illness isknown to be pervasive across cultures, societies andprofessions (van Brakel, 2006). To better understand thenature of attitudes towards mental illness, there have beencalls for more cross-cultural assessments of concepts of,beliefs about and responses to mental illness (Corrigan andWatson, 2002; Angermeyer and Dietrich, 2006). A popula-tion studies review by Angermeyer and Dietrich (2006)found only two cross-national attitude studies, in addition
M. Chambers et al. / International Journal of Nursing Studies 47 (2010) 350–362352
to a handful of studies featuring regional and ethniccomparisons within countries. Considerable differences inbeliefs and attitudes were noted in all these studies.
Nurses are the group of professionals responsible forthe majority of direct care for mentally ill patients acrossEurope (Baker et al., 2005). Studies examining the attitudesof psychiatric and mental health nurses only are rare andwhen they are featured it has been impossible todetermine if the observed attitudes were negative orpositive (Munro and Baker, 2007). Munro and Baker (2007)note therefore that it is impossible to draw any consistentconclusions about what attitudes this group of nurses hold.Further, there is no consensus or understanding of thefactors that form and maintain either negative or positiveattitudes to mental illness. What is clear is that attitudesare multifaceted and are likely to be closely linked withknowledge, which is constituted of different forms andacquired through a variety of sources such as education,training and experience. Knowledge is likely to have acomplex relationship with individuals’ socio-demographiccharacteristics and it is therefore debateable whether ornot socio-demographic factors precipitate levels of knowl-edge and thus attitudes (Addison and Thorpe, 2004).
It would appear there are no recent cross-Europeanstudies featuring nurses’ attitudes, let alone those ofpsychiatric and mental health nurses. A study from 1972compared attitudes between general nurses in GreatBritain and nurses from (the former) Czechoslovakia andconcluded that nationality was the main difference in theattitudes observed, and that these differences were likelyto be an extension of the wider social and political contextwithin which nurses practice (Levin, 1972). These findingswere also reported by a similar cross-cultural studycomparing Chinese and English psychiatric nurses’ atti-tudes towards schizophrenia (Thornicroft and Trauer,1987).
The present dearth in research is largely due to thechallenges involved in undertaking cross-cultural studies,which include language, non-standardised methods ofdata collection, and culturally defined definitions andunderstandings of the roles of nurses and other mentalhealth professionals. The EC (2004) asserts, however, thatsound comparisons are feasible and can help ‘‘stimulateinter-country exchange on diverse practices for promotionand prevention as well as health care organisationalpatterns’’. Comparative European based mental healthstudies have been encouraged; not only to gain anoverview of the situation within countries but to attainreliable comparable data and promote data exchangebetween EU countries (EC, 2004).
It has also been noted that up-to-date, comparableinformation is needed on the age, gender, training,employment and specialisations of European health careworkers, including nurses (EC, 2008), as increased work-force mobility becomes a reality across the EU (Cowanet al., 2005; Cowan and Wilson-Barnett, 2006). This hasimplications for the homogenisation of nursing educationand training across the European countries (see e.g. WHO,2003). The focus on nurses is especially important as theyare the biggest group of health care professionals withinEurope and are often involved in mental health promotion
(WHO, 2007). A highly skilled, flexible and culturally awareEuropean nursing workforce will ultimately have apositive impact on practice (Ludvigsen, 1997). The aboveall indicate the need for a study such as the one describedhere as it addresses several gaps in the cross-culturalliterature.
2. Aims
The aim of this study was to describe and compareattitudes towards mental illness and those experiencingmental health problems held by registered nurses workingin mental health settings across five European countries(Lithuania, Italy, Ireland, Portugal and Finland) and factorsassociated with these attitudes. The research questions areas follows:
1. W
hat are nurses’ attitudes towards mental illness? 2. D o nurses’ attitudes towards mental illness differ acrossfive European countries?
3. W hat characteristics are associated with nurses’ atti-tudes?
3. Methods
3.1. Settings
The five countries featured in this study, Finland, Italy,Lithuania, Portugal and Ireland, were part of a EuropeanCommission (EC) funded pilot project on vocationaltraining for mental health nurses. The countries wereselected because they represent a cross-section of Eur-opean countries with significant commonalities, as well asdifferences in their respective (mental) health statistics(OECD, 2009; State Mental Health Centre of Lithuania,2009). The prevalence of mental health problems is around25–30% in all countries, expect Lithuania, where no reliableprevalence data on mental and behavioural disorders exist(Staniuliene, 2007). In all countries, the most commonmental health problems include mood disorders, anxietydisorders and substance abuse, whereas the most commondiagnoses in psychiatric hospitals include schizophreniaand mood disorders (Bothelo et al., 2007; Camuccio, 2007;Irish Department of Health and Children, 2006; IrishMental Health Commission, 2007; Pirkola and Sohlman,2005; Staniuliene, 2007). There are, however, notabledifferences between the countries in the ways that nursingeducation and mental health services are organised, anotable example being the contrast between the Italianmental health system, where the vast majority ofpsychiatric services are based in the community, andservices in the other countries, which are under varyingstages of reform from hospital to community care(Valimaki et al., 2007).
A total of 63 wards in 21 psychiatric hospitals, inaddition to nine acute units at general hospitals and fivecommunity facilities from the five countries participated inthe study. Except in Lithuania and Italy, the majority ofwards were acute inpatient wards. The average number ofbeds on each ward was 25, ranging from 15 in Finland andItaly to 45 in Lithuania.
M. Chambers et al. / International Journal of Nursing Studies 47 (2010) 350–362 353
3.2. Participants
Registered nurses working on psychiatric inpatientwards, acute units and community facilities were recruitedto participate in the study because of a variation in staffinglevels. The number of nurses per 1000 population in thefive countries range from 4.6 in Portugal to 15.4 in Ireland,whereas the number of psychiatric care beds per 1000population ranges from 0.1 in Italy to 1.3 in Finland (OECD,2009; Valimaki et al., 2007).
The survey was initially distributed to a sample ofEnglish nurses too, however, due to a poor response rate(32.4%) this data was not included in the cross-culturalanalysis presented here. Rather, it will be presentedelsewhere as a survey utilising a mixed-mode approach.
3.3. Instruments
The Community Attitudes towards the Mentally Ill(CAMI) scale was used to measure attitudes (Taylor et al.,1979; Taylor and Dear, 1981). The CAMI was originallydeveloped for use with the general population but has beenused with various samples of mental health professionals,including psychiatrists in the United Kingdom (Kingdonet al., 2004; Lauber et al., 2004) and both nursing andmedical staff at a psychiatric hospital in China (Sevignyet al., 1999). Measuring several aspects of attitudes(including perceptions of people with mental illness,attitudes to contact with people with mental illness, andattitudes to community care), it consists of 40 statementseach necessitating a response as to the level of agreement/disagreement on a 5-point scale ranging from 1 stronglydisagree to 5 strongly agree.
The questionnaire is scored on four factors: (1)authoritarianism—a view that people with mental illnessare inferior and require a coercive approach; (2) bene-volence—a sympathetic view of those experiencing mentalhealth problems, based on humanistic principles; (3) socialrestrictiveness (SR)—a view that people with mental illnessare a threat to society; (4) community mental healthideology (CMHI)—supporting the therapeutic value of thecommunity and acceptance of de-institutionalised care.Reliability for the scale ranges from alpha 0.68 to 0.88 withconstruct validity also showing a positive result (Taylorand Dear, 1981).
Three items were modified for use in this study toensure that the language was gender neutral, withoutchanging the original meaning of the items (for example:‘A woman would be foolish to marry a man who hassuffered from mental illness, even though he seems fullyrecovered’ became ‘A person would be foolish to marrysomeone who has suffered from mental illness, eventhough they seem fully recovered’). For our purposes, theCAMI was translated into Finnish, Lithuanian and Portu-guese prior to its use in the respective countries. The samerigorous protocol for the translation process was adoptedin all three countries, based on Jones et al. (2001) andIRGGA (2007). This involved translation and blind backtranslation of the tool, followed by an assessment of theface-validity, content validity, and semantic and con-ceptual equivalence of the translated tool. In Italy, the
local researchers tested the face-validity of the pre-existing Italian translation (Buizza et al., 2005) and foundit to be satisfactory for use within the Italian nursingpopulation.
Nurses’ background characteristics were collected byan eight item questionnaire requesting information aboutage, gender, highest educational attainment, qualificationtype, length of experience, position held, personal contactwith people with mental health problems, and proximityof contact.
3.4. Data collection
Data collection took place between May and July 2007.The survey was conducted either as an electronic or papersurvey according to the resources available in eachcountry. In Finland and Portugal an electronic surveywas conducted, distributed as a link embedded in an emailand sent to the work based email address of individualnurses. Two email reminders were sent to all potentialparticipants, at the end of the second and third week ofdata collection. In Ireland, Lithuania and Italy, papersurveys were distributed and collected after completion bymembers of the respective local research teams. Allsurveys were distributed together with a letter informingparticipants of the study and the nature and purpose of theoverall project.
Out of 1095 distributed questionnaires, 813 werereturned and 810 were included in the data analysis.The total response rate was 74.2%, varying from 60.9% (inPortugal) to 92.5% (in Lithuania). The response rate was67.9% overall for the electronic survey and 78.1% overall forthe paper survey.
3.5. Statistical analysis
The data were analysed using SPSS 14. First, the fourattitude factor scores were calculated by adding the 10relevant items for each factor and dividing by 10 to arriveat the mean score. The scoring of each scale ranges from 1(strongly disagree) to 5 (strongly agree). Second, nurses’socio-demographic data were analysed with descriptivestatistical methods. The continuous age and length ofexperience variables were each collapsed into two equalgroups, using the medians of each total sample (40 yearsfor age and 18 years for experience) as the respective cutoff points.
Third, the data were checked for normality, linearity,univariate and multivariate outliers, homogeneity ofvariance–covariance matrices, and multicolinearity. Thedistribution of the scores was reasonably normal on allfour subscales, however, some outliers were noted and thethree most extreme cases were excluded from the data set.
Fourth, a series of one-way between groups multi-variate analysis of variance (MANOVA) were performed toinvestigate whether country of practice and individualcharacteristics (age, gender, education, qualification type,position held, contact and contact type) predicted nurses’attitudes on the four subscale factors: authoritarianism,benevolence, social restrictiveness and community mentalhealth ideology. MANOVA is preferred because it can test
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M. Chambers et al. / International Journal of Nursing Studies 47 (2010) 350–362354
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M. Chambers et al. / International Journal of Nursing Studies 47 (2010) 350–362 355
several dependent variables simultaneously (in this casethe four CAMI subscales). It controls for the intercorrela-tions among the various dependent variables, thusprotecting against Type I error due to multiple tests ofcorrelated dependent variables (Tabachnick and Fidell,2001).
Finally, to control for any observed differences in thesingle variable MANOVAs and explore any confoundinginfluences the variables may have on one another, allvariables from the individual tests that showed signifi-cance at the 5% level were entered as covariates intoMANOVA along with the country variable.
Where Box’s M test of equality of covariance matricesindicated that the assumption of homogeneity of variance–covariance matrices had been violated, the Pillai’s tracestatistic was used instead of Wilks’ Lambda to calculate theF-value. Due to some inequality in sample sizes theGames–Howell test was chosen for the post hoc compar-isons to pinpoint significant subscale score differencesaccording to nurses’ socio-demographic characteristicsand country of practice (Pallant, 2004). For all tests, p-values less than 0.05 were considered to be statisticallysignificant.
3.6. Ethical approval
Ethical approval was sought and granted locally in eachcountry. As a principle of sound research, all participantswere given an information letter describing the study andexplaining that submission of a completed questionnairewould imply consent to participate. It was stressed thatparticipation was entirely voluntary, that all informationwould be confidentiality stored and that only members ofthe research team would have access to it.
4. Results
4.1. Sample
The majority of respondents were female in allcountries (Lithuania 99%, Italy 63%, Portugal 53%, Finland52%) except Ireland (33%). Nurses’ mean age in the totalsample was 41.09 years, ranging from 36.4 years (inPortugal) to 44.3 years (in Lithuania). The average length ofnursing experience was 18.52 years overall, being shortestin Portugal (13.8 years) and longest in Lithuania (22.3years). Basic diplomas in nursing were held by a majorityof nurses in Lithuania and Italy, whereas undergraduatedegrees in nursing were held by a majority of nurses inIreland, Portugal and Finland (see Table 1).
In Ireland, Lithuania and Finland a majority of nursesheld a Mental Health/Psychiatric Nurse qualification,whereas in Italy and Portugal those with a non-mentalhealth qualification, such as general nurse, were in themajority. Further, the majority of participants in allcountries are staff nurses, ranging from approximately65% in Ireland and Portugal, upwards to 90% in Finland andItaly (see Table 1). A majority of nurses in all countries(Portugal 70%, Italy 66% and Ireland 56%) except Lithuania(47%) and Finland (48%) reported personal contact withsomeone with a mental illness.
M. Chambers et al. / International Journal of Nursing Studies 47 (2010) 350–362356
4.2. Nurses’ attitudes to mental illness
As a total sample, nurses were found to have positiveattitudes to mental illness as measured on all foursubscales. Their score was most positive on the bene-volence subscale (the higher the score the more positivethe attitude), indicating that they hold a sympathetic viewof those experiencing mental health problems. Attitudeswere least positive on the authoritarianism subscale (thehigher the score the more negative the attitude), thoughnot sufficiently to indicate that nurses reject the view thatpeople with mental illness are inferior and require acoercive approach (see Table 2).
4.3. Comparison of nurses’ attitudes across the five countries
In order to test whether nurses in the five Europeancountries differ regarding their attitudes to mental illness,multivariate analysis of variance (MANOVA) was carriedout. The results showed that nurses’ attitudes to mentalillness differed across countries on all four CAMI subscales.Overall, Portuguese nurses’ attitudes are more positivethan those of nurses in the other countries, whileLithuanian nurses’ attitudes are more negative than others’
Table 3
Relationship between CAMI scores and socio-demographic characteristics (MA
Authoritarianism Benevolence So
re
Variables n Mean (SE) n Mean (SE) n
Gender
Female 535 2.26 (0.021) 535 3.89 (0.021) 53
Male 273 2.10 (0.029) 273 3.99 (0.030) 27
Age
�40 376 2.20 (0.025) 376 3.97 (0.024) 37
41+ 371 2.19 (0.025) 371 3.92 (0.024) 37
Education
Secondary school 45 2.14 (0.070) 45 3.92 (0.070) 4
Basic diploma 378 2.35 (0.024) 378 3.82 (0.024) 37
Basic degree 293 2.06 (0.028) 293 4.04 (0.027) 29
Post-basic
qualification
84 2.09 (0.051) 84 4.10 (0.051) 8
Qualification
RMH/RPN 464 2.27 (0.023) 464 3.89 (0.022) 46
Other 336 2.12 (0.027) 336 3.98 (0.026) 33
Position
Nurse manager 113 2.03 (0.045) 113 4.07 (0.046) 11
Staff nurse 646 2.26 (0.019) 646 3.90 (0.019) 64
Other 51 2.00 (0.067) 51 3.94 (0.068) 5
Contact
No 360 2.28 (0.026) 360 3.88 (0.026) 36
Yes 449 2.15 (0.023) 449 3.96 (0.023) 44
Contact type
Acquaintance Yes 301 2.17 (0.028) 301 3.94 (0.028) 30
No 508 2.23 (0.022) 508 3.92 (0.022) 50
Friend Yes 107 2.04 (0.047) 107 4.08 (0.047) 10
No 702 2.23 (0.018) 702 3.90 (0.018) 70
Family Yes 118 2.04 (0.045) 118 4.08 (0.045) 11
No 690 2.24 (0.018) 690 3.90 (0.018) 69
Self Yes 29 2.02 (0.091) 29 4.07 (0.091) 2
No 780 2.21 (0.018) 780 3.92 (0.018) 78
(F (16, 3220) 22.14; p< 0.001). The mean subscale scores ofeach country are presented in Table 2.
The Games–Howell post hoc test was conducted todetermine where the significant differences in meansubscale scores between countries lie. The results of thepost hoc test were as follows. First, with regard toauthoritarianism, nurses practicing in Lithuania had morenegative attitudes than nurses in all other countries(p< 0.001), whereas Italian nurses had more negativeattitudes than nurses in Ireland (p = 0.005), and Portugal(p< 0.001), as did nurses in Finland (p = 0.027).
Second, regarding benevolence, again, Lithuaniannurses had more negative attitudes than all other nurses(p< 0.001). Nurses in Ireland had more positive attitudesthan Italian (p = 0.020) and Finnish nurses (p = 0.024).Third, regarding social restrictiveness, Lithuanian nurses’attitudes were more negative than those of all other nurses(p< 0.001), whereas Portuguese nurses’ attitudes weremore positive than all others’ (p< 0.001).
Lastly, with regard to community mental healthideology, Lithuanian nurses’ attitudes were more negativethan all others (p< 0.001 to p = 0.002) and nurses inPortugal had more positive attitude scores than all othernurses (p< 0.001). In addition, Finnish nurses’ attitudes
NOVA).
cial
strictiveness
Community mental
health ideology
F (df) p-Value
Mean (SE) n Mean (SE)
5 2.18 (0.022) 535 3.77 (0.025) 8.20 (4,803) <0.001
3 1.98 (0.031) 273 3.87 (0.035)
6 2.10 (0.027) 376 3.82 (0.029) 0.896 (4,742) 0.466
1 2.12 (0.027) 371 3.82 (0.029)
5 2.11 (0.073) 45 3.81 (0.082) 8.26 (12,2385) <0.001
8 2.29 (0.025) 378 3.68 (0.028)
3 1.93 (0.029) 293 3.92 (0.032)
4 1.96 (0.054) 84 3.97 (0.060)
4 2.21 (0.024) 464 3.71 (0.026) 12.02 (4,795) <0.001
6 1.98 (0.028) 336 3.94 (0.031)
3 1.95 (0.048) 113 3.99 (0.053) 6.00 (8,1610) <0.001
6 2.17 (0.020) 646 3.75 (0.022)
1 1.83 (0.071) 51 3.95 (0.080)
0 2.21 (0.027) 360 3.71 (0.030) 5.92 (4,804) <0.001
9 2.04 (0.024) 449 3.87 (0.027)
1 2.08 (0.30) 301 3.84 (0.033) 0.97 (4,804) 0.442
8 2.14 (0.023) 508 3.78 (0.025)
7 1.90 (0.050) 107 4.06 (0.055) 7.51 (4,804) <0.001
2 2.15 (0.019) 702 3.76 (0.021)
8 1.90 (0.047) 118 3.99 (0.053) 6.78 (4, 803) <0.001
0 2.15 (0.019) 690 3.77 (0.022)
9 1.87 (0.096) 29 4.09 (0.106) 2.27 (4,804) 0.060
0 2.13 (0.019) 780 3.79 (0.021)
Table 4
Relationship between CAMI scores and socio-demographic characteristics controlling for ‘country’ (MANOVA).
Authoritarianism Benevolence Social
restrictiveness
Community mental
health ideology
F (df) p-Value
Variables n Mean (SE) n Mean (SE) n Mean (SE) n Mean (SE)
Country
Lithuania 251 2.45 (0.052) 251 3.65 (0.052) 251 2.43 (0.052) 251 3.56 (0.061) 14.29 (16, 3104) <0.001
Italy 127 1.93 (0.052) 127 4.16 (0.053) 127 1.97 (0.053) 127 3.99 (0.061)
Ireland 111 2.13 (0.054) 111 4.01 (0.055) 111 2.01 (0.055) 111 4.03 (0.063)
Portugal 125 1.94 (0.050) 125 4.08 (0.050) 125 1.71 (0.050) 125 4.20 (0.058)
Finland 175 2.03 (0.045) 175 3.98 (0.046) 175 1.90 (0.046) 175 3.77 (0.053)
Gender
Female 522 2.06 (0.034) 522 4.03 (0.035) 522 1.98 (0.035) 522 3.96 (0.040) 2.46 (4, 773) 0.044
Male 267 2.13 (0.040) 267 3.092 (0.040) 267 2.03 (0.040) 267 3.86 (0.046)
Education
Secondary school 44 2.12 (0.073) 44 3.85 (0.073) 44 2.07 (0.074) 44 3.82 (0.085) 0.65 (12, 2325) 0.797
Basic diploma 374 2.12 (0.036) 374 3.99 (0.036) 374 2.02 (0.036) 374 3.95 (0.042)
Basic degree 289 2.09 (0.038) 289 4.03 (0.038) 289 1.98 (0.038) 289 3.99 (0.044)
Post-basic
qualification
82 2.06 (0.052) 82 4.04 (0.053) 82 1.96 (0.053) 82 3.97 (0.061)
Qualification
RMH/RPN 459 2.09 (0.038) 459 4.00 (0.038) 459 1.99 (0.039) 459 3.91 (0.045) 0.48 (4, 773) 0.753
Other 330 2.10 (0.038) 330 3.95 (0.039) 330 2.02 (0.039) 330 3.91 (0.045)
Position
Nurse manager 113 2.02 (0.045) 113 4.03 (0.046) 113 1.93 (0.046) 113 3.98 (0.053) 2.37 (8, 1548) 0.016
Staff nurse 633 2.19 (0.025) 633 3.92 (0.025) 633 2.10 (0.025) 633 3.81 (0.029)
Other 43 2.07 (0.071) 43 3.98 (0.071) 43 1.99(0.072) 43 3.93 (0.083)
Contact
No 349 2.13 (0.038) 349 3.95 (0.038) 349 2.05 (0.038) 349 3.88 (0.044) 1.77 (4, 773) 0.134
Yes 440 2.06 (0.033) 440 3.99 (0.034) 440 1.96 (0.034) 440 3.94 (0.039)
M. Chambers et al. / International Journal of Nursing Studies 47 (2010) 350–362 357
were more negative than those of both Irish (p = 0.022) andItalian (p = 0.004) nurses on this subscale.
4.4. Characteristics associated with nurses’ attitudes towards
mental illness
MANOVA was also carried out to test whether nurses’socio-demographic characteristics had an impact on theirattitudes to mental illness. First, six socio-demographicvariables (age, gender, education, qualification, positionand contact) were each tested separately. Results showedthat five of the six characteristics were significantlyindicative of differences in nurses’ attitudes across allfour subscales: gender, qualification, education, position,and contact. These results are presented in Table 3.
In the next step, confounding influences on theobserved differences in the single independent variableMANOVAs were controlled for. This was done by enteringthe five significant variables from these tests (gender,education, qualification, position and contact) as covari-ates into MANOVA along with the country variable. Theanalysis showed that the differences in mean subscalescores, and thus in nurses’ attitudes remained significantonly for the gender, post, and country variables (seeTable 4).
The results of the MANOVA indicate first of all thatfemale nurses had higher scores and thus more positiveattitudes than male nurses on the Benevolence (p = 0.004)and CMHI (p = 0.021) subscales specifically. Secondly,regarding nurses’ position, the results of the Games–
Howell post hoc test show that staff nurses have morenegative attitudes than both nurse managers and nurses inother positions, across all four subscales (p< 0.001–0.041).Lastly, the post hoc test reveals that differences in nurses’CAMI scores according to country all remain as observedabove across all subscales (p< 0.001–0.020), with Lithua-nian nurses’ attitudes more negative than those of nursesfrom other countries, and Portuguese nurses’ attitudesmore positive than those of the other nurses.
The MANOVA results thus indicate that the country ofpractice variable has a confounding effect on the educa-tion, qualification and contact variables, as these variablesno longer remain significant when the country variable isadded. Thus, out of the six socio-demographic character-istics originally analysed (age, gender, education, qualifi-cation, position and contact), only two were related tosome degree of positive attitudes, namely nurses’ positionand gender, in addition to country of practice.
5. Discussion
The aim of this study was to describe and compareregistered nurses’ attitudes towards mental illness andthose experiencing mental health problems across asample of nurses from five European countries (Lithuania,Italy, Ireland, Portugal and Finland), and factors associatedwith these attitudes. The study showed that nurses’attitudes to mental illness were generally positive. Theseresults are supported by findings from other studies ofboth student nurses’ attitudes (Callaghan et al., 1997) and
M. Chambers et al. / International Journal of Nursing Studies 47 (2010) 350–362358
registered nurses’ attitudes (Weller and Grunes, 1988).However, as Munro and Baker (2007) have noted, researchinto the attitudes of mental health nurses specifically isstill uncommon and it has therefore been difficult todetermine the nature of this group of nurses’ attitudesfrom previous studies.
In the context of our study, having a positive attitudemeans disagreeing with the view that people with mentalillness are inferior or a threat to society and thus need to becoercively handled or excluded; and rather, holdingsympathetic and compassionate views and appreciatingthe therapeutic value of de-institutionalised and commu-nity based care. Nurses’ positive attitudes to communitycare are comparable to those of psychiatrists surveyedusing the same questionnaire (Kingdon et al., 2004; Lauberet al., 2004). There is indication that nurses were equallysympathetic but less authoritarian in their attitudes topeople with mental illness than nurses working in apsychiatric hospital in China (Sevigny et al., 1999). Ourfinding regarding positive attitudes is important andencouraging as it suggests that nurses are likely topromote care in the community and independent livingfor those experiencing mental health problems. As mentalhealth problems are likely to affect one in four Europeans(WHO, 2005) positive attitudes are essential. With respectto supporting and promoting the recovery approach(Repper and Perkins, 2006), nurses with positive attitudesto mental illness are more likely to encourage individualsto take control of their lives and be proactive in decisionmaking about their future. Such nurses will also be morelikely to inspire hope and be willing to consider alternativeapproaches to care and support.
When comparing nurses’ attitudes between countries,we found that Lithuanian nurses’ scores were consistentlymore negative than those of nurses from the othercountries. This finding is in line with general attitudesto mental illness seen within Lithuania. Puras et al. (2004)note that the general population holds stigmatisingattitudes towards several vulnerable groups, includingpeople affected by mental health problems. Stigma wasmost likely to manifest in the context of people’s place ofwork, but was also present in other areas of everyday life.One of the main strategic priorities of current Lithuanianmental health policy is to change socio-cultural attitudesto mental illness in order to improve the psychologicalwell-being and mental health of the population (Lithua-nian Ministry of Health, 1998). Both Rutz (2001) andTomov (2001) observe that mental illness stigma, whichcontinues to be a problem in Eastern European countries, islinked to the region’s history and wider socio-politicalclimate. Establishing democracy, pluralism and tolerancein society is necessary to be able to foster good mentalhealth (Rutz, 2001).
Portuguese nurses had the most consistently positiveattitudes. This is in contrast to a recent Portuguesepopulation study of attitudes to mental illness whichfound that while there was a high level of recognition ofmental health problems, beliefs about dangerousness andincurability were associated with authoritarian attitudes(Loureiro et al., 2008). The observed differences betweenLithuanian and Portuguese nurses’ attitudes could be due
to differences in their respective response rates. InLithuania, 92% of nurses participated and the results herethus reflect the attitudes of a wide range of nurses, whereasin Portugal the likelihood of non-response bias is greater asthe 60% response rate was considerably lower. The positiveresults may therefore simply reflect the fact that Portu-guese nurses with negative attitudes chose not toparticipate in the study.
Nurses in Italy, Finland and Ireland have fairly similarattitudes, though nurses in Finland had significantly morenegative attitudes than Irish and Italian nurses on thebenevolence and community mental health ideologyscales. Further, in respect of the CMHI subscale, concernedwith attitudes to community based mental health services,it might be expected that Italian nurses would holddistinctly more positive attitudes to community care giventhe primary role of community care within Italian mentalhealth services (Camuccio, 2007). However, Portuguesenurses were significantly more positive to community carethan Italian nurses.
Significant national differences in nurses’ attitudeswere also noted by Levin (1972) as well as Thornicroft andTrauer (1987), and could in part be explained by the widerorganisational, social and political contexts of care. Bothstudies concluded that the main observed differences inattitudes between nurses from Britain and the thenCzechoslovakia and China, respectively, were primarilydue to nationality. They argued that these differences werelikely to be part of a general orientation to social issues andan extension of the socio-political surroundings of thecommunity concerned. This resonates with our findingsconcerning Lithuanian nurses. It may not fully explainnational differences, however, as evidenced by thePortuguese nurses seemingly having more positive atti-tudes to mental illness than that reported in the populationstudy. The observed differences could be a function of theculturally dependent ways psychiatric services, andpsychiatric inpatient services in particular, are organised.For example, the number of beds on a ward, the nurse topatient ratio, and staff (gender and grade) mix on a givenshift. These features are known to differ across Europeancountries. It has been noted that such aspects could make adifference to clinical practice in terms of, for example,levels of distress and aggression among patients as well asnurses’ response to such behaviours (Bowers et al., 1999).These are experiences that could in turn affect nurses’attitudes to patients (Jansen et al., 2005).
In addition to country of practice, we wanted to explorewhat socio-demographic characteristics are associatedwith nurses’ attitudes towards mental illness. Of the sixcharacteristics surveyed (age, gender, education, qualifica-tion, position and contact), only gender and position werefound to be associated with nurses’ attitudes. Femalenurses were found to have a more sympathetic attitude tothose living with mental illness and to be more positive tocommunity care than male nurses (see also Munro andBaker, 2007; Bjorkman et al., 2008). Munro and Baker(2007) suggest, however, that when gender differencesare noted, gender is likely to be interacting withother individual characteristics to influence attitudes. Inour study though, the confounding influences of other
M. Chambers et al. / International Journal of Nursing Studies 47 (2010) 350–362 359
socio-demographic variables were eliminated. Theobserved gender differences in the current study aretherefore not related to any of the other socio-demographic characteristics we measured.
Sadow et al. (2002) have suggested that attitudesbecome increasingly stigmatising the more expert apractitioner becomes and the higher up in the hierarchyof the profession he or she moves. The present study,however, found that those in junior positions – in this casestaff nurses – were consistently more negative in theirattitudes than those in more senior positions. This findingis supported by Scott and Phillip (1985) and more recentlyby Tay et al. (2004), and may be explained by the differencein the amount and type of contact with patients betweennurses in junior and senior positions (Scott and Phillip,1985). As this study did not survey frequency of profes-sional contact it is not possible to measure whether or notthis type of contact is correlated to staff position in thisinstance. Another explanation for the positive attitudesseen in senior nurses is that this group have presumablyremained working in mental health settings, as opposed tonurses with more negative attitudes who may have left themental health field before reaching senior positions.
In contrast to a number of previous studies, our surveyresults did not find support for the influence on attitudes ofeither age (Scott and Phillip, 1985; Tay et al., 2004;Bjorkman et al., 2008), education level (Mavundla and Uys,1997; Brinn, 2000; Tay et al., 2004), type of qualification(Kahn, 1976; Munro and Baker, 2007) or contact (Coutureand Penn, 2003; Bjorkman et al., 2008) once theconfounding influence of the country of practice variablewas removed. Our study thus gives no evidence in supportof the contact hypothesis, in keeping with the outcome ofseveral earlier studies (e.g. Kahn, 1976; Weller and Grunes,1988; Callaghan et al., 1997). As mentioned above, it isunclear whether or not type and frequency of contactaffects nurses’ attitudes and this is something futureresearch could help clarify (Addison and Thorpe, 2004).
Lastly, a comparison of nurses’ socio-demographiccharacteristics reveals noteworthy cross-cultural differ-ences, for example in gender mix, age range and length ofnursing experience, between the participants in the fivecountries surveyed. These are interesting due to thedearth of information on the demographic characteristicsof the pan-European (mental health) nursing population(EC, 2008). The differences are most apparent betweenLithuanian and Irish respondents: in Ireland male nursesare in the majority, which is in stark contrast to Lithuania,where less than one percent of the nurses in the samplewere men. Nurses in Ireland are also markedly youngerthan their Lithuanian colleagues and have half the length ofnursing experience.
The results also reflect notable cultural differences inthe types of nursing qualifications and training seen acrossEuropean countries (Valimaki et al., 2007, see also Bowerset al., 1999 and Nolan and Brimblecombe, 2007). Forexample, we found that a majority of nurses working inmental health settings in Italy and Portugal are registeredgeneral nurses, whereas most nurses in Ireland andLithuania are registered psychiatric or mental healthnurses. Also, our data show that while the majority of
nurses in all countries have a basic level of nursingeducation, there is a clear split between countries wherebasic diplomas of nursing are most common (Lithuania andItaly) and those where the majority are likely to hold abasic nursing degree (Portugal, Ireland and Finland). Thesefindings reflect broader organisational differences withinthe nursing profession, as well as the structural disparitiesof nursing training across the countries surveyed.
In contrast, a notable similarity among participants wasthat staff nurses were in the majority across all fivecountries. Lithuanian, Irish and Finnish nurses were alsosimilar in that close to 50% report having personal contactwith someone with a mental illness, whereas about 70% ofnurses in Italy and Portugal report having personal contact.In all countries but Ireland, the most common form ofcontact was through an acquaintance. This is in contrast toAddison and Thorpe’s (2004) study of students, where thevast majority of those with personal contact had a familymember with a mental illness.
5.1. Limitations
There are some limitations to our international study.First, due to the small number of nurses surveyed in eachcountry it is not possible to extend our findings to thegeneral population of nurses within mental health settingsin these countries. Secondly, the majority of the observeddifferences in attitude scores according to socio-demo-graphic characteristics have fairly small effect sizes. Theobserved differences in attitudes are therefore notnecessarily noticeable on a practical level. Thirdly, findingscould have been influenced by the use of different modes ofdata collection (web and paper survey) across countries.For example, some nurses may have felt that the websurvey provided less anonymity than a paper survey wouldand thus may have chosen to not participate.
Fourth, although a common translation protocol for theCAMI instrument was developed, as well as a common datacollection protocol, we do not unequivocally know thatthey were followed in all instances. For example, clinicalenvironments other than acute wards were included inItaly, where the vast majority of mental health services arecommunity based. Therefore, some attitude findings couldpotentially be a function of the different clinical environ-ments nurses are working in. Fifth, the CAMI tool wasdeveloped 30 years ago, with the language now dated inplaces. However, because the language was updated forsome items to make it more contemporary, this factor wasnot necessarily a limitation in our study. Rather, the use ofan older tool such as the CAMI could be a benefit in sofar as it has seen sustained use with a wide variety ofparticipants and in a number of differing contexts. TheCAMI has not, however, been validated on a nurse samplebar face validation, and this is a limitation of its use in thisstudy. Finally, as Angermeyer and Dietrich (2006) havenoted, the link between attitudes and actual behaviour istenuous, and this is therefore a weakness of all researchinto attitudes.
In spite of its methodological limitations, however, thisstudy appears to represent an important first step in theeffort to explore and compare attitudes towards mental
M. Chambers et al. / International Journal of Nursing Studies 47 (2010) 350–362360
illness and people with mental health problems held bynurses working within European mental health settings.This is particularly important as this group of profes-sionals, from a highly demanding area of health care, havetraditionally been ignored as participants of empiricalresearch.
6. Conclusion
In general, mental health nurses’ attitudes to mentalillness and people with mental health problems arepositive. Mental health nurses’ attitudes have been shownto differ across the five countries surveyed. Indeed, countryof practice was the most significant predictor of differencesin nurses’ attitudes, with Lithuanian nurses having morenegative attitudes and nurses practicing in Portugal havingmore positive attitudes compared to nurses in the othercountries. Further cross-cultural research should beundertaken to investigate the presence or otherwise ofdifferences in attitudes in other samples of nurses workingin mental health settings across European countries.Attitudes to mental illness have also been found to berelated to gender and position, irrespective of nurses’country of practice. Future research could investigatewhether other circumstances surrounding nursing prac-tice, such as ward size, average nurse to patient ratio, andnurses’ terms and conditions of service impact onattitudes. A survey of attitudes to mental illness of nursesworking in primary care settings, where predominantcontact is likely to be with people with less severe mentalhealth difficulties would also be of importance. In addition,there is a need for research investigating if, and how,nurses’ attitudes to mental illness and people with mentalhealth problems affect nursing practice. Knowing theattitudes of this fundamental group of mental healthprofessionals has implications for the educational pre-paration of all nurses, to ensure that patients are treatedwith dignity and respect in a therapeutically effective andethically sound environment.
Conflicts of interest statement
None declared.
Sources of funding
This project has been funded with support from theEuropean Commission’s Leonardo da Vinci programme(2006 FI-06-B-F-PP-160701). This article reflects the viewsof the authors only, and the Commission cannot be heldresponsible for any use of the information containedherein.
Ethical approval
Due to this being a cross-European study, ethicalapproval requirements differed across sites. This isdetailed below.
Padova, Italy: formal ethical approval was not requiredsince there was no treatment involved and patients werenot the subject of data collection. Permissions were
obtained from managers and/or directors of all hospitalsinvolved in the study.
Dublin, Ireland: formal ethical approval was sought andgranted by the Dublin City University Ethics Committee.Reference: DCUREC/2007/23.
Turku, Finland: in accordance with Finnish require-ments, formal ethical approval was not required becausethe study did not target patients. Permissions wereobtained from managers and/or directors of all hospitalsinvolved in the study.
Klaipeda, Lithuania: formal ethical approval was notrequired because the study participants were staffmembers. Permissions were obtained from managersand/or directors of all hospitals involved in the study.
Lisbon, Portugal: formal ethical approval was notrequired because the study participants were staffmembers. Permissions were obtained from managersand/or directors of all hospitals involved in the study.
Principles of sound research were followed at all sites.This included obtaining participants’ informed consent byway of a study information letter, and by keeping allparticipant information confidential and securely stored.
Acknowledgements
Many thanks to all the nurses who participated in thestudy. Sincere thanks also to Pekka Makkonen, Sarah Whiteand Carol Hanchard, whose kind contributions made theresearch possible. The authors would also like to acknowl-edge the insightful comments made by two anonymousreviewers.
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