The purpose of this study was to evaluate the effects of a psychiatric clinical clerkship on the attitudes of third-year nursing students toward mental health and those with mental illness. In particular, we examined students’ attitudes toward four hypothetical patients with schizophrenia characterized by different etiologies and levels of adjustment.
The mind-body split may be traced to the second creation story in the Bible:
And the Lord God formed man of the dust of the ground, and breathed into his nostrils the breath of life; and the man became a living soul. (Gen. 2:7; Koren version)
Yet, unlike most individuals with health conditions culturally defined as physical, individuals with mental illness have been subject to negative stereotypes, prejudices, and discrimination for centuries (Bhugra, 1989; Corrigan & Watson, 2002; Halter, 2004).
Throughout history, psychiatric conditions were associated not only with witchcraft and supernatural forces, but also with antireligious behavior, sin, social disruption, and dangerousness. In western societies today, negative attitudes toward mental illness are nurtured by the use of the term mental illness as representing irrational and unpredictable behavior in daily language and as an excuse for criminal and violent behavior in the juridical system (Duckworth, Halpern, Schutt, & Gillespie, 2003; Schulze, Richter-Werling, Matschinger, & Angermeyer, 2003). Such negative attitudes and perceptions, which are learned through the process of socialization, have important consequences for those with mental illness (Adler & Wahl, 1998; Link, Struening, Neese-Todd, Asmussen, & Phelan, 2001; Watson et al., 2004). Negative cultural perceptions may prohibit help seeking, stigma may constrain long-term compliance with treatment and adequate follow-up, and discrimination could hinder rehabilitation within the community. In addition, negative stereotypes may propel the deterioration of any given condition by hampering self-esteem and increasing social isolation (Corrigan & Watson, 2002; Link et al., 2001).
Another product of stigma and prejudice is the “mythology of the four uns” [italics added], which easily leads to discrimination on social and political level (Pollack, Mc-Farland, George, & Angell, 1994, p. 516). According to this perception, mental illness is undefinable, untreatable, unpredictable, and unmanageable. Beliefs that mental health conditions are not as serious as physical conditions, that their causes are nonbiological, or that treatment is ineffective lead to further denial of parity. This approach relies heavily on the mind-body split, disregarding the physiological etiology of many serious, chronic, mental health conditions and the role of the mind in stimulating or intensifying biological processes leading to physical illness. Yet many serious mental illnesses involve changes in the chemistry of the brain, undesirable emotions, and stress, inhibiting the immune system. In addition, such attitudes ignore the uncertainty involved in treating many physiological conditions and the degree of relativity of success and risks in treating physiological ill health.
Some health care professionals may have vested interests in sustaining these misperceptions to maintain the priority of physical health in financing services and research. Yet health care professionals could play an important role in increasing the access to care for individuals with mental illness. This is particularly true in societies where citizens enjoy universal health coverage. Yet past research has indicated that the attitudes held by some health care professionals are similar to those found among laypersons in the society within which they grew up, live, and practice (Bailey, 1998; Lauber, Nordt, Falcato, & Rösslar, 2004; Morgan & Killoughery, 2003).
The nursing profession is characterized by close and ongoing interaction with patients under care (McLaughlin, 1997). Nurses’ attitudes toward social deviance and anomalous and normatively irregular behaviors are crucial for acceptable professional performance. Nursing education should thus ensure that graduates will hold attitudes enabling them to care for individuals with mental illness in settings ranging from a general community clinic or hospital to specialized psychiatric services.
Often, the curricula of health care professional training programs include psychiatric conditions and some clinical application of this knowledge. It is assumed that scientific knowledge and social exposure to psychiatric patients will decrease discrimination or stigmatization. Empirical research largely supports this suggestion, both among laypersons and students of nursing and medicine (Halter, 2004; Madianos, Priami, Alevisopoulos, Koukia, & Rogakou, 2005; McLaughlin, 1997; Pinfold et al., 2003; Reddy et al., 2005; Schulze et al., 2003; Tan et al., 2005; Watson et al., 2004).
Similarly, the contact hypothesis (Amir, 1969) posits that interaction with social groups other than one’s own can bring about significant changes in attitudes. However, the direction of the change and the degree to which contact increases or decreases discrimination or stigmatization are difficult to anticipate. In a thorough literature review, McLaughlin (1997) found some reports that presented empirical evidence that contact with psychiatric patients brought about a decline in the negative attitudes toward individuals with mental illness, and some that documented that such contact nurtured negative attitudes. At the same time, the possibility that the nature of the contact and its features have the potential power to influence the direction of change was not discussed. In this study, attitudes toward mental illness and caring for individuals with mental illness are studied in the context of a clinical clerkship by nursing students.
The program under study is based on the assumption that most students will not choose to specialize in psychiatry but will provide care for individuals with mental illness in different settings in the community, whether primary care clinics, preventive health services, or general hospitals. The purpose of the clerkship is to provide the students with the knowledge, skills, and attitudes that will enable them to provide professional care for individuals with mental illness in various health services and their families. The knowledge presented to the students includes the natural course of mental illness, epidemiology, symptomatology, psychopharmacology currently in use, and common side effects.
Of the skills, communication with the patient and his or her family are central to the program. In addition, students are taught nursing diagnosis, evidence-based assessment and, on the basis of these, planning and implementing intervention focusing on the main problem or problems of one patient. Among the criteria for choosing the problem are urgency, level of disturbance to the patient, and the likelihood that the student will be able to perform the intervention during the 4-week clerkship.
Finally, another important aim of the clerkship is attitudinal modification. Students’ attitudes toward mental illness, as found in past research, tend to reflect those of their social environment. During the clerkship, effort is made to qualify these attitudes and to reduce anxiety, prejudices, and negative stigma and stereotypes. The principal goal is to enable students to accept mental illness as any other health condition in need of care and treatment. Additional goals include enhancing the mind-body defragmentation and educating students to accept recent evidence suggesting that mental illness, although multifactorial, involves basic molecular disturbances on the cellular level.
To achieve these goals, students in the program under study are exposed to a 4-week clinical clerkship, after a 1-semester academic course, presenting basic psychiatric diagnosis and treatment regimens. The first day of the clerkship is devoted to establishing a warm, open, and trustful atmosphere between group members and tutors. A communication exercise is performed in which both students and tutors take part. Each student creates an image of his or her family in play-clay, and presents it to the group. Group members are allowed to present questions, but there is no obligation to answer the questions. During this process, students feel emotionally closer to both colleagues and instructors, which later enables them to freely express their attitudes and feelings.
During the clerkship, students spend 28 hours per week in a mental hospital, working in groups of 5 or 6 under the supervision of a faculty member (psychiatric nurse) who is not part of the hospital’s staff. The students learn how a locked ward in a mental hospital operates, and they participate in all the activities of the ward, such as staff meetings, group therapy, and ward rounds. In addition, each student is assigned a patient for supervised nursing intervention. This activity includes supervised anamnesis taking, assessment-based intervention planning, performance, and evaluation. At the end of each clinical day, students and instructors meet for a group discussion.
The goals of the group discussion go beyond the academic aims. Academically, theoretical knowledge, learned in the classroom before the clerkship commenced, is strengthened. Students present their assigned case according to elaborated guidelines, forcing them to rehearse criteria for diagnoses, drugs, and the possible adverse effects of drugs. Yet the group discussions provide the students with an opportunity to discuss their feelings and to express fear, disapproval, personal threat and susceptibility, rejection, and compassion. Such discussion is strongly encouraged by the discussion tutors, who supervised, guided, and observed the students during the morning activity on the ward. The purpose of this part of the discussion is to raise students’ awareness of their own feelings and to present these feelings as acceptable and legitimate as long as they do not interfere with care provision.
The Current Evaluation Study
The purpose of this study was to assess the degree to which the clinical clerkship achieves the goals planned, drawing on the attribution model recently proposed by Corrigan, Markowitz, Watson, Rowan, and Kubiak (2003). According to this model, the degree to which individuals with mental illness are believed to control their condition affects nursing students’ emotional response to patients, influencing discrimination and willingness to help. The more the mental condition is perceived to be under a patient’s control, the higher the responsibility ascribed to individuals with mental illness. Attributed responsibility evokes negative emotions, which in turn decreases the nursing students’ willingness to help and augments the tendency to segregate such patients. After the 4 weeks of clinical training, we expected students to hold more professional attitudes than they did before the clerkship. We hypothesized that after the clerkship:
- Students will hold patients less responsible for their condition.
- Negative emotions, such as fear and anger, will be ameliorated.
- Students will be less reluctant to provide care for individuals with mental illness.
- Attributed responsibility will be related to negative emotions but not to willingness to provide care.
- Negative emotions will no longer be associated with willingness to provide care.
Participants included 136 nursing students in an academic program granting both RN certification and a bachelor’s degree in nursing on completion. All third-year students participated in the study (i.e., there was no sampling procedure). Twenty students were men, and the mean age was 26.1 years; 47% of the students were born in Israel, 48% immigrated to Israel from the former Soviet Union, and 5% were born in other countries (Canada, Argentina, United Kingdom, France).
A pencil-and-paper questionnaire was administered to the students before and after the 4-week clinical clerkship. To ensure anonymity, students were asked to mark their questionnaires with a self-chosen four-digit number. Eight questionnaires marked with nonidentical numbers were excluded from the analysis, as were two questionnaires with incomplete data. Therefore, the analysis is based on 126 respondents.
The Attribution Questionnaire-27 (AQ-27) was adapted from Corrigan (2004). The AQ-27 is composed of 27 survey items designed to examine a series of 9 constructs, 3 items each, that measure attitudes, affect, and behavioral intentions related to a hypothetical individual with mental illness. However, following Corrigan et al. (2003), 6 constructs with 3 to 4 items each were used in this study. Translation was performed by three independent judges, and differences in wording were discussed until the final version was agreed on by all three judges. One question was excluded because it could not be translated to keep both the original meaning and grammatically appropriate Hebrew. The final questionnaire included vignettes about four 30-year-old men with schizophrenia, which vary in the level of danger and controllability attributed to the patient:
- Case 1, no danger: a well-functioning man who lives in the community, has a job, complies with the recommended chemotherapy, and whose condition is well-controlled.
- Case 2, danger: the described individual assaulted his landlady, the officers who drove him to the hospital, and an orderly in the emergency department.
- Case 3, danger, cause of condition uncontrolled: a violent patient is described, similar to case 2. However, it is explained that his mental illness is the result of a severe head injury he acquired during a car accident approximately 8 years earlier, which also caused chronic migraine. He becomes violent only when he experiences a migraine.
- Case 4, danger, cause of condition controlled: the fourth vignette is similar to case 3, except that in this case, origin of the mental illness was illegal drug abuse, and violence is caused by cocaine shortage.
Students were asked to indicate, for each case, on a 5-point Likert scale the degree to which they felt:
- The patient is responsible for his condition. This subscale included three items, Cronbach’s alpha = 0.55 (before the clerkship) and 0.66 (after the clerkship).
- Pity: three items, Cronbach’s alpha = 0.87 (before) and 0.86 (after).
- Anger: three items, Cronbach’s alpha = 0.87 (before) and 0.83 (after).
- Fear: four items, Cronbach’s alpha = 0.87 (before) and 0.82 (after).
- Willingness to help: three items, Cronbach’s alpha = 0.78 (before) and 0.80 (after).
- The patient should be segregated: four items, Cronbach’s alpha = 0.84 (before) and 0.87 (after).
These values are similar to those reported by Corrigan et al. (2003): 0.70, 0.74, 0.89, 0.96, 0.88, and 0.89, respectively.
Students were also asked to indicate their gender, age, and country of birth.
Five scores were calculated for each subscale: a total score and a score for each of the four vignettes. Partial correlations were used to examine the interrelationships among the six attitudes under study and the changes that took place in these relationships during the clerkship, controlling for age, gender, and country of birth. Within-subject repeated measures analysis of variance (ANOVA) was used to examine the degree to which changes in attitudes occurred during the clerkship, controlling for age, gender, and country of birth. Structural equation models were used to explore whether the theoretical attribution relationships between perceived responsibility, emotions, and attitudes toward care provision, suggested by Corrigan et al. (2003), changed during the 4-week clerkship toward a more professional attitude.
The highest correlation observed was between fear and segregation before the clinical clerkships took place, indicating 34% overlapping variance (Table 1). We thus proceeded and explored each attitude under the assumption that these were largely independent of the others.
Table 1: Interrelationships Between Attitudes Toward Individuals with Mental Illness Before and after the Clinical Clerkship
The correlations reported in Table 1 reveal that an attitudinal change took place during the clerkship. Before the clinical training, the perception that the patient brought on his or her mental illness was not significantly related to any of the other five attitudes; after the clerkship, perceived personal responsibility became positively and statistically significantly associated with anger at and fear of the patient. At the same time, the associations between fear and willingness to help, between anger and willingness to help, and between anger and segregation were no longer statistically significant after the clerkship.
As predicted, clerkship brought about attitudinal change, although a statistically significant change was observed for only four of the six attitudes studied (Table 2). Using within-subjects repeated measures ANOVA, we observed that after the clerkship, students felt more pity for individuals with mental illness, expressed less fear of them, expressed more readiness to care for them, and were less convinced that individuals with mental illness should be segregated from the public eye. Our hypotheses related to decreased negative emotions and reluctance to provide care were thus fully supported.
Table 2: Attitudes Toward Individuals with Mental Illness Before and After Clinical Clerkship
Our hypotheses related to attributed responsibility and willingness to provide care were also supported by the data (Figures 1 and 2, Table 3). In this analysis, three latent variables were created: responsibility attributed to the patient for his condition, constructed of the responsibility scores of the individual case vignettes because the combined scores had a particularly low Cronbach’s alpha (0.55 before the clerkship and 0.66 after the clerkship), whereas the Cronbach’s alpha for responsibility in the individual vignettes ranged between 0.72 and 0.78; emotions, constructed of the combined scores of fear, anger, and pity; and attitudes toward care provision, constructed of willingness to help and segregation.
Figure 1. Attribution Model (standardized Sem Coefficients) for Students' Attitudes Toward Individuals with Mental Illness Before the Clinical Clerkship. *p < 0.05; **p < 0.01; †p < 0.001.
Figure 2. Attribution Model (Standardized Sem Coefficients) for Students' Attitudes Toward Individuals with Mental Illness After the Clinical Clerkship. *p < 0.05; **p < 0.01; †p < 0.001.
Table 3: Attitudes Toward Individuals with Mental Illness Before and After the Clinical Clerkship, Goodness of Fit
Our hypotheses about attributed responsibility and willingness to care predicted that the clinical clerkship will bring about changes in the paths leading from responsibility to emotions and attitudes toward care provision, and from emotions to care provision (the bold coefficients in Figures 1 and 2). These hypotheses were largely supported. Before the clerkship, the path from responsibility to emotions was equal to zero; after the clinical training, this association increased almost to a level of statistical significance (p = 0.06). In addition, the increase from before the clerkship to after it was statistically significant (p < 0.001).
The path leading from responsibility to attitudes toward care provision was not statistically significant at both times. Yet, as expected, this association declined significantly during the clinical clerkship, from beta = 0.01 to beta = −0.36 (the decline is statistically significant at p < 0.001). It should be noted that for two of the hypothetical cases (2 and 4) presented to the students, the responsibility assigned to the patient decreased below the statistically significant level.
The path from emotions to care provision was statistically significant before the clerkship and declined to a non-significant level after it. Nevertheless, the reduction in the association between the emotions evoked in the student by a patient with schizophrenia and the student’s willingness to care for individuals with mental illness, as measured by the beta coefficient, was not statistically significant.
Discussion and Limitations
The purpose of this study was to explore the degree to which a psychiatric clinical clerkship altered students’ attitudes toward mental health and individuals with mental illness. Past research suggested that the attitudes held by health care professionals largely resemble those of the general public and interfere with care provision (Corrigan, Edwards, Green, Diwan, & Penn, 2001; Corrigan & Watson, 2002; Halter, 2004). Given these findings, one goal of the 4-week clinical program was attitudinal change. As described above, the clerkship program paid special attention to provide the students not only with the knowledge and skills necessary to care for patients with mental illness, but also with professional attitudes and perceptions that will enable them to do so throughout their career, in different health care settings.
It was expected that the theoretical knowledge, the exposure to hospitalized psychiatric patients, the involvement in the ward’s regular work, and the discussion of the students’ own feelings and reactions will educate the students about professional attitudes. It was thus hypothesized that after the clinical experience, students will hold patients less responsible for their condition, will express less intensive negative emotions such as fear and anger, and will be less reluctant to provide care for individuals with mental illness. Drawing on Halter’s (2004) suggestions, it was expected that after the clerkship, students will be more aware of their own perceptions and feelings, but these will not interfere with their willingness to provide care.
To examine the degree to which the clerkship program indeed achieved the expectations, 126 third-year students of nursing completed an anonymous questionnaire before and after the clinical clerkship. The questionnaire was constructed of four hypothetical cases of schizophrenia, characterized by different etiologies and levels of adjustment. For each case, we analyzed the degree to which students perceived the patient to be responsible for his or her condition; the extent to which the case brought up emotional responses such as pity, anger, and fear; whether students thought the patient should be segregated from other members of the society; and the degree to which students were willing to provide care to such a patient.
The findings largely supported the hypothesis. Throughout the clerkship, students became more compassionate toward and less intimidated by individuals with mental illness. At the same time, the students expressed more willingness to care for patients with mental illness, whereas their perception that these patients belong in a hospital, away from the public eye, weakened. The method of analysis used, within-subject repeated measures ANOVA, suggests these changes occurred on the individual level.
It appeared that students have learned to be aware of their responses and their feelings regarding individuals with mental illness. During the clerkship, they learned to recognize the association between the responsibility ascribed to patients for their mental illness and the negative emotions this attribution brings about.
In addition, these findings suggest that the goal of developing professional attitudes was largely achieved during the clinical training. First, the responsibility attributed to the patient who endangered others (case 2) and the patient whose mental condition were the result of drug abuse (case 4) declined to a nonsignificant level. Second, the association between students’ negative emotions toward individuals with mental illness and their willingness to attend to these patients weakened and was no longer statistically significant after the clerkship.
Nonetheless, some of the observed changes were small, even if they did not reach statistical significance. Given that the clerkship duration was only 4 weeks, it may be stated that a longer period of clinical experience could have resulted in a more thorough change. We hope that other nursing training programs with a longer psychiatric clinical clerkship will repeat our study to test this hypothesis.
Future research should also search for the origins of change and which component of the clerkship (i.e., the knowledge acquired, the group dynamics, or the daily contact with severe psychiatric conditions) produces the most important change. Such data could, in turn, help in planning the training of nurses and other health care professionals. Given the volume of people whose mental health needs are unmet, it is important to train health care professionals who are aware of these needs and willing to provide care to meet them.
Another limitation was the lack of a control group. Yet it was difficult, for several reasons, to find a control group with sociodemographic characteristics and professional socialization similar to our students. First, curricula changes are planned during the second semester, when third-year students of the previous class were already deeply involved in the psychiatric course and it was too late for collecting baseline data.
Second, the clinical training in the school under study is different from other nursing programs in Israel. It emphasizes primary care and community health, and students responsible for a patient experiencing a psychiatric problem on top of his or her acute condition are expected to relate to it by reading or consulting with a social worker or a staff member of the psychiatric ward or clinic. In this respect, students of other nursing programs start their psychiatric training as tabula rasa, compared with the students who participated in this study, not to mention students of other disciplines.
Nevertheless, an attitudinal change toward the desired professional orientation was clearly observed when baseline perceptions (i.e., before the psychiatric clerkship) were compared with those expressed by students after the clerkship.
Professional attitudes toward individuals with mental illness can be developed during clinical training that goes beyond the provision of pure academic instruction and clinical skills. The clerkship program presented in this article, which includes emotional ventilation and self-awareness, helped students become more compassionate toward, less intimidated by, and more willing to provide care for individuals with mental illness. In addition, their perception that individuals with mental illness belong in a hospital declined in only 4 weeks. The changes observed were moderate, but it is reasonable to expect that a longer period of clinical experience would have resulted in a more profound change.
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Interrelationships Between Attitudes Toward Individuals with Mental Illness Before and after the Clinical Clerkshipa
|Responsibility||Pity||Anger||Fear||Willingness to Help||Segregation|
|Willingness to help||0.01||0.46†||–0.16||–0.09||−0.37†|
Attitudes Toward Individuals with Mental Illness Before and After Clinical Clerkshipa
|Responsibility||31.88 (0.50)||32.18 (0.65)||0.23|
|Pity||37.87 (0.81)||41.06 (0.80)||8.29**|
|Anger||24.10 (0.70)||22.25 (0.77)||1.02|
|Fear||51.56 (0.93)||44.62 (0.97)||4.07*|
|Willingness to help||35.01 (0.68)||36.61 (0.69)||7.21**|
|Segregation||46.03 (0.75)||43.09 (0.99)||7.76**|
Attitudes Toward Individuals with Mental Illness Before and After the Clinical Clerkship, Goodness of Fit