Introduction

Mental illnesses are a major contributor to the global burden of disease. One in every four person in the world is affected by one or other mental disorder at some point of their life.1 Mental illnesses are treatable. However, nearly two-thirds of the people suffering from mental disorders do not seek help from a psychiatrist or a mental health-related professional and prefer to hide their problems.2 Among the various factors, which influence help seeking, stigma, discrimination, social prejudice, and negligence are considered to be important factors which prevent mental health care and treatment.3

Stigma can be understood as an attribute that is deeply discrediting. Authors have pointed out that the difference between a nonstigmatized and a stigmatized person was always a question of perspective, rather than a reality.4 Stigma is in the eye of the beholder, and a body of evidence supports the concept of stereotypes against the psychiatric illnesses in the society. Often, when an individual with a stigmatized trait is not able to perform a duty or action, because of the condition, other people view the individual as the problem rather than viewing the condition as a problem. This stigmatized trait sets the sufferer apart from the rest of society, bringing with it feelings of isolation and shame. Many people with mental illnesses (PwMIs) believe that their being mentally ill reduces the honor of their families.5 Stigma often leads to the avoidance, discrimination, prejudice, and rejection. These are the things which directed at people believed to have an illness, disease, or other trait perceived to be undesirable and unacceptable.6 Stigma causes endless suffering, probably causing a person to deny his/her symptoms, resulting in to delay in treatment and refrain from daily activities. Stigma can exclude people from access to insurance, appropriate medical care, employment opportunities, and housing. Stigma is identified as the important factor of social exclusion, isolation, poor social networking, and loneliness among PwMIs.7 8 9 10 11 Stigma also interferes with the prevention efforts, and examining and combating stigma is a public health priority.12

Although various types of stigma are described in relation to mental disorders, public stigma is one of the important types of stigma, which determines the attitude of the general population toward those with psychiatric illnesses. Further, the public stigma also shapes the perceived stigma or internalized stigma, as when a person who holds negative view about mental disorders becomes ill, he tries to apply the same to the self, which leads to internalized stigma.13 Hence, mitigating public stigma should be one of the most important strategies to address the negative views about mental illnesses in the society.

Many factors are known to increase the stigmatizing behavior of general public. Having beliefs that mental illnesses are an outcome of evil spirits and PwMIs are dangerous to the other people because of their violent behavior increase the stigmatizing attitude of general public.14 These beliefs contribute to increase in social distance and inappropriate medical care of PwMIs. Similarly, people’s belief and attitudes about mental illness predict whether they help and support the mentally ill subjects. By tracing the attitude of people toward mental illness, it is possible to predict the knowledge and awareness regarding mental illnesses among people in the community. According to the CDC-BRFSS’s (Centers for Disease Control and Prevention- Behavioral Risk Factor Surveillance System 2012 report) only 35 to 67% of the adults have a caring and sympathetic attitude toward mental illness.15

Unfortunately, stigma toward mentally ill people not only originates in general public but also among health care professionals. Stigma toward psychiatric illness is also highly prevalent among health care professionals. Studies done among the nurses of having experience 6 years or more show that the nurses have unsympathetic attitude toward PwMI. Nurses accused patients with mental illnesses as criminals.10 There is some evidence to suggest that mental illness among nurses elicits negative coworker’s attitude toward people returning to their jobs after suffering from mental illness. This negative attitude eventually leads to the increased absenteeism from jobs.16

Attitude toward the patient suffering from a mental illness influence both personal as well as professional behavior among nurses. Unfortunately there is very less data on public stigma among health care professionals from India. Hence, there is a need to evaluate the same, so that intervention programs can be designed to reduce the stigma among nurses. It is expected that reduction in public stigma among nurses can help in improving the identification and management of mental illnesses in patients seen at various other specialties. However, before addressing the public stigma among nurses, it is necessary to identify the extent of stigma among nurses. Accordingly, the present study aimed to evaluate the level of public stigma among nursing staff working in a tertiary care hospital.

Methods

This was as cross-sectional study performed among the nurses working in a tertiary care multispecialty teaching public sector hospital in north India. The study sample comprised 210 nurses from various departments selected by purposive sampling. Institute Ethics Committee approved the index study, and all nurses were recruited after obtaining written informed consent. To be a part of this current study, nurses were required to be working in the hospital in which the study was conducted. Those who were unwilling to participate were excluded.

The study participants were assessed on community attitudes toward the mentally ill (CAMI) scale.17 The scale consisted of 40 attitudinal statements about mental illness, with participants scoring on a 5-point Likert scale (ranging from agreed to disagree). The scale was divided further in into four subscales, that is, authoritarianism (AU), benevolence (BE), social restrictiveness (SR), and community mental health ideology (CMHI). AU is a “view of the mentally ill patient as someone who is inferior and requires supervision and coercion.” BE reflects “a humanistic and sympathetic view toward mentally ill patients” and higher BE score corresponds to a less humanistic and less sympathetic (malevolent) view toward PwMI. SR reflects the “the belief that mentally ill patients are a threat to society and should be avoided.” CMHI is “the acceptance of mental health services and the integration of mentally ill patients in the community” with higher score on the CMHI subscale indicating a rejection of mental health services and the integration of PwMI into the community. BE and CMHI are referred as positive attitudes. Meanwhile, AU and SR are referred as negative attitudes. There are 10 items for each subscale and each consists of five positive statements and five negative statements. Respondents were required to rate how much they strongly disagree or strongly agree with each statement. Each item was scored using 5-point Likert's scale (5—strongly agree, 4—agree, 3—neutral, 2—disagree, and 1—strongly disagree). Negative statements for each subscales were reversed-coded. Total score were calculated to detect the attitudes toward the mentally ill patients. Higher score indicates that community has a high attitude. For instance, high score for BE indicated that community have a benevolent attitude toward the mentally ill patients. The scale has been shown to have good test–retest reliability (Cronbach’s Alpha) and validity.

Results

As depicted in Table 1, the mean age of the index study was 28.1 (range 21–48; SD = 4.7), with a median of 27.5 years. Two-thirds of the participants (67.1%) were females and had done graduation (64.2%) in nursing and a small proportion of them had postgraduation in nursing. Only about half of the study participants had an experience of working with mentally ill patients. Only two participants reported that they were diagnosed with a mental illness in the past.

Discussion

The study was conducted with the purpose to measure the attitude among the nurses working in a tertiary care hospital toward the mental illness. The results showed that the nurses had more positive attitude toward the mental illness. The result was almost similar to the previous studies.9 18 19 20 21 The association with positive attitude could be because of the nurses in the tertiary center having some kind of exposure either during their training or job. Importantly, the socio-demographic characteristics are associated with nurses’ attitudes toward mental illness. Of the various demographic characteristics examined (gender, age, education, number of family members, monthly income, per capita per person), only gender was found to be associated with nurses’ attitudes. This finding is consistent with some of the previous studies.22 23 24 25

Female nursing staffs were found to be more sympathetic toward the psychiatrically ill patients. Female nurses did not consider them as a threat to our society as compared with the male nurses. Such positive attitude of nurses is vital to promote and encourage patients to take control of their lives and be proactive in deciding about their life and future’s decisions. Munro and Baker9 suggest that when the difference among the gender was noted, it was found that male gender is likely interacting with other individual characteristics to influence attitude . In some of the previous studies, the female gender was associated with the positive attitude as compared with the male counterpart.26 But in our study, the mentioned gender differences were not significantly associated with any other socio-demographic characteristics or males were more associated with positive attitude.27 28 29 30 These inconsistent findings, because the profiles of population were different in previous studies, were mostly not from the health professionals. Younger females scored higher on BE in the previous studies which demonstrated that the younger people generally have more favorable attitude toward mental illness.31 32 33

This multidimensional scale (CAMI) helps us to identify positive and negative aspects of the attitude toward the psychiatric illness. Accordingly, we can focus to provide and enhance more positive and protective living environment for PwMI. Our study results revealed that nursing staff in PGI held more benevolent attitude, tended to be more sympathetic for the needs of mentally ill, and found themselves responsible for providing best possible care for the mentally ill people. As suggested in one of the Taiwan studies, the benevolent thought could be transferred into compassion for and acceptance of another human being if individuals are given an opportunity to have direct contact with patients with psychiatric disability.34

The study findings revealed that only fewer numbers of nurses agreed to the hospitalization of the mentally ill, as soon as illness is diagnosed, because foremost task is to find the severity of mental illness and based on these findings, decision will be taken on the hospitalization of the patient. Also our study finds that mentally ill patients should not be kept behind locked doors, rather community-based mental health services should be provided to them. Such positive attitude should be enhanced among medical professionals for the better care of the patients.

Conclusion

In general, nurses’ attitudes to mental illness and people with mental health problems are ambivalent. Already experienced nursing staff found mentally ill patients, a threat to the society, suggesting that more emphasis should be given on mental health awareness campaigns and ways of improving and updating their knowledge about dealing with psychiatric patients.

It was not expected that no significant changes have occurred in the other areas assessed like education, history of mental illness, and so on. For future implications some more variables can be added to the questionnaire, like beliefs and myths toward mental problems, religious views of subjects, which can give better idea about attitudes.