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A Comparative Study of Attitudes Toward Psychiatry Among Nursing Students Across Successive Training Years

a Context: Psychiatry nurses are an integral component of a multidisciplinary mental team. Aim: The current study aimed at understanding the attitude of undergraduate nursing students toward psychiatry. Additionally, the attitudes toward psychiatry have been compared across the training years among these students. Materials and Methods: The study was carried out at a tertiary care nurse-training institute. All the nursing students enrolled with the institute at the time of the study constituted the sample frame. The study questionnaire used in the current study was a 29-item questionnaire that assessed attitudes toward psychiatry. Statistical Analysis: The data were analyzed using SPSS ver 17. Results: Overall, the majority of the nursing students from all four groups had a favorable response to the statements of the Likert scale. Most of the significantly positive responses (as assessed by the Kruskal-Wallis analysis of variance of the rank order) were from the third-year and internship students. These findings were supported by the significant correlation between these statements and ranked order of the nurse-training years. Conclusions: The findings of the current study present some interesting insights into the attitude of nursing students toward psychiatry.

The attitude of nursing students toward mental illness has been studied in great detail. However, barring a few questions related to choice of future career, these studies have not explored the 'attitude of nursing students toward psychiatry as a discipline'. The current study aimed at understanding the attitude of undergraduate nursing students toward psychiatry. Additionally, the attitudes toward psychiatry have been compared across the training years among these students.

MATERIALS AND METHODS
The study was carried out at a tertiary care nurse-training institute in India. It is a university-affiliated training program attached to an approximately 1,000 bedded multispecialty hospital. The training in nursing is a bachelor-level program of four years' duration. All the nursing students enrolled with the institute at the time of the study constituted the sample frame. We used a questionnaire-based survey. The nursing students in the different training years were approached after their lectures. They were explained about the study and voluntary nature of the survey. Additionally, they were assured of the confidentiality and anonymity of the information collected during the study. Those consenting to participate in the study were given the study questionnaire.

Study questionnaire
The study questionnaire used in the current study is the one developed by Balon et al. [10] Permission to use the questionnaire was obtained from the authors. It is a 29-item questionnaire that assesses attitudes toward psychiatry across six domains. All the items are rated on a Likert scale scored from 1 (strongly disagree) to 4 (strongly agree). This questionnaire has been used in different studies across different countries and has been found to be a reliable and valid instrument. [11,12] The data were analyzed using SPSS ver 17. Betweengroup analysis was carried out for the different training years, namely, first year, second year, third year, and internship. Analysis of variance (ANOVA) with Bonferroni correction was used to compare the different groups for continuous variables. The Likert scale scores were compared using Kruskal-Wallis ANOVA of the rank order. Additionally, a Chi-square test was performed for ascertainment of between-group differences for different items on the Likert scale. Mann-Whitney U test was used for ANOVA for the items scored only for the third year and internship groups, as these items pertained to the experiences during clinical rotation in psychiatry. Spearman's rho correlation coefficient was calculated to find the correlation between the training year groups and the individual items of the Likert scale. The level of statistical significance was kept at P<0.05 for all the tests.
The four groups were comparable for the number of physicians (F=0.84, P=0.48), surgeons (nil for all groups), and psychiatrists (F=0.81, P=0.49) in the family, and no significant differences were observed using between-group analysis. Additionally, no differences were observed between the four groups for previous consultation with a psychiatrist for themselves or for a first-degree relative (phi=0. 16, P=0.24).
The frequency distribution of responses of nursing students from the four groups on different items of the Likert scale has been represented in Figures 1 and 2. Kruskal Wallis analysis and Mann-Whitney U test for rank order comparison for different items of the Likert scale have been represented in Tables 1-6.

Overall merits of psychiatry
Maximum support for the statement "Psychiatric research has made good strides in advancing care of the major mental disorders" was found among first-year nursing students. Similarly, maximum agreement for the statement "Psychiatry is a rapidly expanding frontier of medicine" was also observed among the first-year students. A statistically significant (Chi-square=25.36, df=3, P<0.005) lesser disagreement for the statement "Psychiatry is unscientific and imprecise" was reported by the internship students. This statement had a significant negative correlation with increasing years of nursing training (rho=−0.17, P=0.03) [ Table 1].

Efficacy
Agreement for psychiatric consultation for an emotionally upset family member not improving on his/her own was significantly higher among the first-and third-year students (Chi-square=19.21, df=3, P<0.005). This statement was found to have a significant negative correlation with increasing years of nursing training (rho=−0.17, P=0.03). A significantly greater agreement for the statement "Psychiatric treatment is helpful to most people who receive it" was found among the third-year students (Chi-square=8.43, df=3, P=0.04) [ Table 2]. Role definition and functioning of psychiatric professionals A significantly greater disagreement for the statement "Psychiatr y is not a genuine and valid branch of medicine"' was reported by the internship students (Chi-square=14.38, df=3, P=0.002), followed by the third-year students. An overwhelming majority of the first-year students agreed with the statement "Most psychiatrists are clear, logical thinkers". It was significantly higher as compared to other groups (Chi-square=14.44, df=3, P=0.002). Disagreement with the statement "Psychiatrists are too frequently apologetic when teaching psychiatry" was significantly greater among the internship   Table 3].

Social criticism
The statement "Psychiatrists frequently abuse their legal power to hospitalize patients against their will" found a significantly greater disagreement among the third-year and internship students (Chi-square=11.76, df=3, P=0.008). This statement was found to have a significant correlation with increasing years of nursing training (rho=0.19, P=0.02) [ Table 4].

Career and personal reward
Second-year nursing students expressed a significantly lesser disagreement (Chi-square=10.9, df=3, P=0.01) with the statement "If a student expresses interest in psychiatry, he or she risks being associated with a group of other would-be psychiatric nurses who are often seen by others as odd, peculiar, or neurotic".
A significantly greater disagreement was expressed for the statement "I feel uncomfortable with mentally ill patients" by the third-year and internship students (Chi-square=12.51, df=3, P=0.006). This statement was found to have a significant correlation with the increasing years of nursing training (rho=0.27, P=0.001) [ Table 5].  Specific nursing school factors A significantly greater agreement was reported by the third-year students (mean rank=39.91) as compared to the internship group (mean rank=30.27) for the statement "Attending psychiatrists during my psychiatry rotation were good role models" (z=−2.19, P=0.03) [ Table 6].

DISCuSSION
The issue of attitude of nursing students toward mental illness has been widely studied in the West. [8,[13][14][15][16][17][18][19] Additionally, a substantial body of literature exists for the choice of psychiatry nursing as a career choice there. [2,3,20] However, information is limited on 'attitude to psychiatry' among nursing students. Moreover, the information is almost nonexistent on these issues from South Asian countries.
The findings of the current study present some interesting insights into the issue. Overall, majority of the nursing students from all four groups had a favorable response to the statements of the Likert scale [ Figures 1 and 2]. Most of the significantly positive responses were from the third-year and internship students. This was true for all the six categories of statements on the scale used in the study. These findings were supported by the significant correlation between these statements and ranked order of the training years. Lectures in psychiatry and exposure to psychiatric practice during the third year and internship are the likely contributors to these observations. A positive impact of psychiatric clinical postings, lectures, and workshops on the knowledge and attitude parameters have been reported in previous studies as well. [21][22][23] However, a surprisingly high rank order for overall merits of psychiatry was observed among the first-year students. In a prospective study by McCann et al., [24] there was a progressive increase in the favorable attitude toward mental health nursing from the first year through the third year of undergraduate training. A previous study by Surgenor et al. [25] also found that the year of training of the students was an independent predictor of their attitude toward psychiatry.  There are multiple factors that influence the choice of specialty of nursing students. [26] Rushworth and Happell [8] assessed an intake sample of 118 respondents. They found that the psychiatry component of the nursing course improved the attitude of the students toward the discipline. However, a majority of students were not in favor of choosing psychiatry as a career. Twenty-five percent of the students refused to commence psychiatric nursing as a career immediately after graduation despite their interest in psychiatry. Similarly, in a study from Israel, psychiatry was at the bottom of the priority career list of the nursing students. [27] Choice of psychiatry as a career option has been found to be low among undergraduate nursing students in developed countries as well. [2,3,20,28] Limitations of the existing training system has been cited as a reason for such observations. [6,28] The international shortage of psychiatry nurses can possibly be attributed to the negative attitudes of the nursing students toward mental illness and the subsequent decision to elect out of psychiatric placements when given a choice. [4] Making a career decision seems to be a complex process among nursing students. A positive attitude observed in the current study suggests the role of additional locally relevant factors during this process.
Attitudes toward mental illness, positive clinical experience, and preparedness for mental health practice have all been considered as factors influencing the views of nursing students about mental health nursing as a career. However, the issue has not been studied in a systematic manner in developing countries.
Studies have shown that nursing students tend to commence their undergraduate teaching program with negative attitudes toward those with psychiatric illness. [2,8,9,13,14,19] Misperceptions and prejudice toward psychiatry are additional contributors to nonpreference of psychiatry as a career choice. Additionally, a positive influence of exposure to the mental health practice setting was found in these studies. Integration of undergraduate training with mental health services has been shown to improve the perception of nursing students. [29] Most of the nursing students entering the undergraduate training program have been shown to have decided on a specialty of nursing practice. [30][31][32][33] However, decision to choose psychiatry as a profession by the nursing students is shaped during the undergraduate training years. [34] Hence, the years of undergraduate training assume a greater significance as possible detriments to the future choice of students.
Psychiatry has been reported by nursing students to be a boring and unfulfilling area of practice in which the patients do not get better. Additionally, they have reported a strong sense of fear of the mentally ill, believing them to be dangerous and unpredictable. Also, a negative view of the clientele and the working environment have emerged as possible reasons for the limited choice of psychiatry as a career choice. [8,20] Negative attitudes toward mental illness have also been implicated in the lack of perceived attractiveness of choosing psychiatric nursing as an area of future specialization. [35] Such negative attitudes have been shown to have a profound effect on the therapeutic relationships and treatment outcomes. [5] Additionally, psychiatric nurses are least likely to be described as skilled, logical, dynamic, and respected by the peers. [36] Negative and stigmatizing beliefs regarding mental health nursing discredit the valuable contributions of mental health nurses. [37] Research has shown that negative attitudes of undergraduate nursing students toward psychiatric illness are amenable to appropriate psychiatric training. [38,39] The role of theoretical teaching in shaping the attitudes of nursing students toward psychiatry has also been established. [18] However, in the absence of appropriate exposure to mental health-care training, the undergraduate nursing students are likely to pass school with their stereotype, negative perception of mental health care intact. [40] Hence, it seems imperative to make necessary changes to the existing nursing curriculum. This would help improve the attitude of the nursing students toward psychiatry.
The findings of the current study add to the existing limited international literature. There is a dearth of mental health professionals including psychiatric nurses in India. The findings of the current study help understand the differences in attitude of the students across the training years. This could be of help while planning appropriate modifications to the existing curriculum. Appropriately modified existing models form other settings could be tested to further improve the attitude of these future professionals.
Findings from the current work have important implications globally for different stakeholders in mental health. A large number of qualified nurses from India migrate to the Gulf countries, Australia, New Zealand, Singapore, Ireland, and the United Kingdom. [41] India is one of the most common countries of origin for the nurses migrating to the United States, Ireland, and Canada. [42] There are more than 1,000 recognized nurse training centers in India, which together admit nearly 10,000 students every year. [43] According to some conservative estimates, around 20,000 nurses migrated to other countries over a two-year period. [44] These nurses carry the attitude shaped during the undergraduate training. Consequently, an understanding of their attitudes toward psychiatry would be of help to the mental health-care teams in these countries.
While providing some answers, the findings from the current study raise additional questions. The study explored prevalent attitudes of the nursing students toward psychiatry. However, the reasons for not choosing psychiatry as a nursing career among professionals remain unexplored. As with all cross-sectional research designs, this study provides a snapshot. It would be informative to follow up this cohort over the years and observe changes as well as future career choices made by these students.