Mental illness refers to a wide range of disorders characterized by emotional disturbance, abnormal behaviour and impaired functioning (Funk, 2016). Globally, one in three persons suffer from mental illness during their lifetimes (Vigo et al., 2016), with higher prevalence where the populations are faced with overwhelming existential challenges (Naslund et al., 2021; Javed et al., 2021). The evidence in-dicates that 80% of people living with mental illness worldwide reside in low and middle-income coun-tries (Rathod et al., 2017; Alloh et al., 2018).

Furthermore, depression which is one of the com-monest mental health problems globally has been estimated to become the third and second highest cause of disease burden in many LMICs and middle-income countries, respectively by the year 2030 (Rathod et al., 2017). Given the rising prevalence of traumatic conditions and the deteriorating humanita-rian problems including hunger, poverty, internal displacement and diseases in many of the LMICs and middle-income countries, it is likely that the 2030 projections regarding mental health problems may be outstripped. Due to the poor understanding of mental illness as a public health challenge, the concept has been bedevilled with misconceptions, myths, and stigma (Labinjo et al., 2020), often as-sociated with negative attitudes including prejudicial stereotypes, social distancing, discrimination and abuses from the public (Gureje et al., 2005; Obembe et al., 2013; API-EpiAFRIC, 2020). Mental health -related stigma encourages suboptimal treatment & human rights violations, associated with poor out-comes (WHO, 2013; Javed et al., 2021). 

According to Pathare and colleagues, (2018), over 90% of persons experiencing mental health problems in LMICs lack access to standard (evidence-based) treatment. Thus, stigma remains a major challenge to quality mental healthcare delivery, particularly in LMICs where, as earlier stated, a disproportionate share of the worlds mental health burden exist (Nas-lund et al., 2021). It is, however, ironic that majority of those who perpetrate stigmatization against men-tal illness are well trained medical/health profess-sionals including Nurses rather than the psychia-trically uninformed public (Gureje et al., 2005; Rao et al., 2009; Högberg et al., 2012; Poreddi et al., 2015; Armiyau, 2015). For instance, a study revealed that 60% of Nigerian Nurses hold misconceptions about mental illness and exhibit negative attitudes towards mentally ill individuals (Obembe et al., 2013). Additionally, nurses across various jurisdic-tions have been found to hold more negative views and manifest stronger resentment towards mentally-ill individuals than the uninformed general public (Chambers et al., 2010; Bennet et al., 2015; Emrich et al., 2003; Corrigan et al., 2015). Considering that Nurses constitute the largest group of health profess-sionals directly involved in patients care (WHO, 2007), and their attitude impact illness experience and therapy outcomes, these revelations are concer-ning. The path to becoming a professional nurse entail formal education through enrolment in an accredited School of Nursing or University where student nurses spend between 3 to 5 years and pass mandatory qualifying examinations. Research fin-dings indicate that students carry along into the nur-sing institutions previously held negative beliefs, misconceptions & stereotypes about mental illness (Poreddi et al., 2014; 2015; Hastings et al., 2015; Bennet et al., 2015). These pre-conceived notions are believed to have significant influence on the attitudes of the students towards mentally ill per-sons and their future career choices. Most nursing students have shown least preference for the psy-chiatric nursing speciality after graduation (Mark-strom et al., 2009; Hoekstra et al., 2010; Stevens et al., 2013), likely due to lack of interest arising from the misconceptions about mental illness. Arguably, the negative views of student nurses which influence their attitudes can be significantly addressed by in-troducing relevant mental health contents including theory and clinical exposure into the nursing edu-cation curriculum.

In many countries, mandatory psychiatric placement is a vital component of the nursing education curri-culum. This programme offers nursing students oppor- tunity for robust experiential exposure in settings where effective mental health-psychiatric nursing care is provided to patients with various mental health problems. For example, Nigerian nursing stu-dents undertake 8 weeks psychiatric nursing place-ment, and are required to carry out supervised care to patients during the period. The over-arching obje-ctive is to enable the students familiarize themselves with mental healthcare settings, change their pers-pectives, and consequently develop healthy attitude towards people faced mental health problems. This is in tandem with research evidence that pre-conceived negative beliefs about mental illness can be reduced among student nurses by providing them the oppor-tunity to directly engage with psychiatric patients (Gamez et al., 2017; Sari et al., 2018; Stuhlmiller et al., 2019; Gandhi et al., 2019; Cingol et al., 2020; Lim et al., 2020). However, the established empiri-cal position regarding the impact of the psychiatric posting (above cited) has been contradicted  by other studies that failed to show significant association between psychiatric exposure and positive attitudes towards mental illness (Schafer et al., 2011; Gyl-lensten et al., 2011; Al-Awadhi et al., 2017; Çingöl et al., 2020). Notably, some other studies (e.g., Cal-laghan et al., 1997; Thongpriwan et al., 2015) have argued that psychiatric nursing exposure in for-mal treatment settings can increase the formation of ne-gative attitudes towards mental illness among stu-dent nurses, thus questioning the validity of the pla-cement programme. It is important to recognize that studies undertaken to examine the psychiatric nur-sing posting programme and attitudes of student nur-ses towards mental illness predominantly come from developed western countries whereas not much is known in LMICs where mental illness-related stigma remains more prevalent (Obembe et al., 2013; Nas-lund et al., 2021). For example, despite the re-ported alarming rate of mental illness in Nigeria (Alabi & Kanabe, 2021) and the revelation that an average of 14,000 nurses are produced yearly (Abubakar, 2020), there are very few Psychiatric Nurses catering to the needs of over 200 million people at an estimated ratio of  4 per 100,000 people (Eaton et al., 2017). This statistics seems to suggest lack of interest in the psychiatric nursing speciality (Hoekstra et al., 2010; Stevens et al., 2013) which, presumably, explains the high prevalence of negative attitudes towards mental illness among nurses in Nigeria (Obembe et al., 2013). Given the above, therefore, it is imper-ative to systematically examine the psychiatric pla-cement programme to ascertain whether its objective of changing student nurses attitudes towards mental illness is being met. 

Consequently, this study aimed to investigate the at-titude of fourth year undergraduate nursing students with a view to evaluating the influence of the psy-chiatric nursing placement programme on their atti-tudes towards mental illness. Specifically, the study examined the influence of the psychiatric nursing posting on the attitude of nursing students towards mental illness, and the influence of gender in the at-titudinal change. Findings have implication for nur-sing education, global mental health care, and exis-ting literature.

Design/participants

This study employed a within group quasi-experi-mental design which compares baseline and outcome measures following 8 weeks psychiatric nursing placement. Participants were fourth year undergrad-duate nursing students   undergoing the mandatory 8 weeks psychiatric nursing posting at the Neuro-Psychiatric Hospital, RumuigboPort Harcourt, and Rivers State, Nigeria. The Neuro-Psychiatric Hos-pital, Rumuigbo-PortHarcourt, Rivers State, esta-blished in 1977, serves as a regional clinical training hub for medical and health students of universities, colleges and nursing institutions in the Niger Delta Region of Nigeria. Participants in this study con-sisted of 7 male and 105 female who met the fol-lowing inclusion criteria: (a) a fourth year under-graduate nursing student undergoing the psychiatric nursing posting programme without previous similar experience (b) aged 18 years and above, (c) willing-ness to participate. The participants were selected using convenience sampling method. During the placement period, the student nurses had direct con-tact with psychiatric patients and carried out super-vised routine nursing care and psycho-social acti-vities involved in the care of both in-patients and out-patients at the hospital.

Instrument

The study used the Attitude to Mental Illness Ques-tionnaire (AMIQ) to measure the student nurses atti-tude towards mental illness. A section was created by the researchers in the questionnaire to obtain information regarding participants socio-demogra-phic characteristics and previous psychiatric expo-sure. The Attitude to Mental Illness Questionnaire (Luty et al., 2006) is a short (5-item) self report questionnaire used to assess individuals attitude towards mental illness. The five items represents occupational ability, co-worker preference, inviting to social gathering, ability to maintain personal rela-tionships, and risks of legal problems. Each of the items are subjected to a 5-point likert scale response system with scores ranging from -2 to +2 being the minimum and  maximum scores, respectively. Items 1, 4 and 5 are reversed scored and scores on the five questions are added to give a total score ranging from -10 to +10. Higher scores indicate more posi-tive attitude towards the person being perceived or viewed. The scale has reliability coefficient with Cronbachs alpha as 0.933 (Luty et al., 2006). Not-ably, the AMIQ construct validity has strong cons-truct validity in comparison with Corrigans 21 items Attribution Questionnaire validated for measuring stigmatisation towards mentally ill individuals (Cor-rigan et al., 2003; Luty et al., 2006). The instrument has been used successfully with Nigerian samples (Abedin et al., 2020; Bakare et al., 2021).

Procedure

The students were approached individually to solicit their participation by the researchers and a Senior Psychiatric Nurse (who served as research assistant) upon their arrival at the hospital. Additionally, leaf-lets containing explanations about the study and as-surance of confidentiality were distributed to them. Those who accepted to participate were reminded that participation was voluntary and anyone who felt uncomfortable was at liberty to withdraw. After ob-taining their written consent, the AMIQ was admi-nistered to the student nurses and pre-test data col-lected immediately before their deployment to the various wards of the hospital. On the last day of their 8 weeks placement, the AMIQ was again adminis-tered to them and post-test data collected on the spot. Data analyses were conducted using Paired Sample t-test and Independent Sample t-test with SPSS sta-tistical software.

Participants demographic data as shown in Table 1 indicates that female nurses (93.8%) were more compared to males (6.3%). Furthermore, it reveals that more of the participants were between the ages of 22-23 years (30.4%) and 24-25 years (26.8%). Those aged 26 years and above were 21.4%, 20-21 years (19.6%) and 18-19 years (1.8%). All the parti-cipants (100%) were fourth year undergraduate nur-sing students.

Table 1: Participants Demographic characteristics.  

Analyses carried out regarding the two research questions are presented below.

Research Question 1  

Will there be significant positive change after their 8 weeks psychiatric nursing posting?

Table 2: Paired samples t-test results of changes after their psychiatric nursing posting.

Note. MD = Mean Difference; CI = Confidence interval

Table 2 shows the students responses to the ques-tion of whether mental illness will damage a per-sons career, t(111) = -5.44, p<.001. Participants score before commencement of the psychiatric nursing posting was 1.77 (SD = 1.54) while after the 8 weeks posting, they scored .76 (SD = 1.10). This reflects a reduction in the students belief that mental illness could damage a persons career after the 8 weeks psychiatric nursing posting students belief that men-tal illness could damage a persons career. Further-more, the results indicated significant increase in the students responses regarding whether they would be comfortable with a mentally ill person if he/she were their colleague at work, t(111) = 6.55, p<.001. Scores obtained before the posting was 1.70 (SD = 1.31) while after the posting it was 2.83 (SD = 1.07). Con-cerning the question of whether the students would be comfortable  inviting  him/her a mentally ill per-son to dinner party, there was  significant change in their responses before and after the posting, t(111) = 6.11, p<.001. Scores of participants before the 8 weeks psychiatric nursing posting was 1.83 (SD = 1.43) while the scores obtained after the posting was 2.95 (SD = 1.10). This shows that the students level of comfort about inviting a mentally ill person to a dinner party had increased after the posting. Signi-ficant change was found in students responses to the question about the likelihood of a mentally ill per-sons spouse leaving him/her before and after the posting, t(111) = -2.50, p<.001). Participants scores before and after the posting was 2.01 (SD = 1.41) and 1.49 (SD = 1.57), respectively. Lastly, there was no significant change in the responses of the student nurses about the likelihood of a mentally ill person getting into trouble with the law, t(111) = -1.43, p<.001. Scores of participants before and after the 8 weeks posting was 1.99 (SD = 1.49) and 1.68 (SD = 1.69), respectively.

Research Question 2 

Will there be significant difference between male and female nursing students attitude after the psy-chiatric posting?

Table 3: Independent samples t-test results of attitude of male and female nursing students towards mental illness after their psychiatric nursing posting.

Note. EV = Equality of Variances; SED = Standard Error Difference; Sig = 2-tailed; CI = Confidence interval.

Table 3 showed that there was no difference bet-ween male and female nursing students about the belief that mental illness will damage a persons career, t(112) = .43, p>.05, and whether they would be comfortable if the mentally ill person were their colleague at work, t(112) = 1.53, p>.05. Similarly, the responses of male and female nursing students on whether they would be comfortable about inviting a mentally ill person to a dinner party were not different, t(112) = 1.12, p>.05. 

They did not differ in their responses regarding men-tally ill persons spouse leaving him/-her, t(112) = .86, p>.05. There was no significant responses of male and female nursing students about a mentally ill person getting into trouble with the law, t(112) = -.84, p>.05. 

The overarching objective of this research was to understand the impact of psychiatric nursing posting on student nurses. Two research questions were ad-dressed. First was whether psychiatric nursing posting would have impact on student nurses atti-tude towards mental illness. Second was to address the question of whether gender would influence the anticipated change in attitude arising from the posting. Concerning the first question, the results showed that psychiatric nursing posting significantly influenced student nurses. Given that all those who participated were in fourth year with similar know-ledge attainment and class room experience, it can reasonably be assumed that the positive change in attitude found may have been produced by the 8 weeks psychiatric nursing posting experience. The current finding is consistent with previous studies which examined the impact of psychiatric nursing placement on student nurses attitude towards mental health. For example, Jack-Ide et al, (2016) showed that the psychiatric clinical experience impacted positively on undergraduate student nurses attitude towards psychiatric nursing. Happell, (2013) demon-strated that exposure to psychiatric clinical exp-erience positively influenced nursing students atti-tudes. This is also reported by Hunter et al. (2014) and Poreddi et al. (2015) asserting that psychiatric placement has significant positive impact on the attitude of nursing students regarding mental health. More recent research (Sari & Yuliastuti, 2018; Stuhlmiller & Tolchard, 2019; Çingöl et al., 2020; Shammari et al., 2020; Lagunes-Cordoba et al., 2022) also revealed the commonly reported findings indicating that exposure to psychiatric clinical ex-perience can positively change the attitude of student nurses. The aforementioned finding can be ade-quately explained using psychologys contact theory which suggests that prejudice, stigma and conflict between groups can be reduced if groups interact continually and optimally with each other (Allport, 1954). According to Pettigrew and Tropp, (2008), contact reduces prejudice because it arouses emo-tions and increases empathy, and consequently reduces the anxiety that occurs when an individual interacts with people he/she had had no previous contact with. They also argued that decategorization may occur when people begin to see the other in-dividuals whom they had previously treated pre-judicially and stigmatized as being same as them-selves, rather than as only another group (e.g., dis-abled or mentally ill people). It is important to recognize that the context in which contact occurs is critical as prejudice can only be reduced and positive attitude engendered in an atmosphere where there is equal treatment, common goals, cooperation and institutional support (Allport, 1954; Pettigrew and Tropp, 2006; 2008).  The above mentioned factors existed at the study setting where the psychiatric nursing posting took place. Nurses and patients were treated equally as partners, rather than patients being treated as subordinates or inferior individuals. In addition, the warm relationship that existed between nurses and patients as partners with a common goal (of recovery) was encouraged and supported by the hospital management as policy. Arguably, this milieu provided opportunity for the student nurses to gain more insight, disprove their previously held negative beliefs and develop positive attitudes tow-ards mental health as reported in this study. Regar-ding the second research question about gender difference in the attitude of student nurses towards mental health this study found no difference between male and female students. This is in line with pre-vious evidence suggesting that gender had no influ-ence on nursing students attitude towards mental illness (Schafer et al., 2011; Thongpriwan et al., 2015; Sari et al., 2018; Shammari et al., 2020).

Student nurses maintain pre-conceived misconce-ptions including the notion that people experiencing mental health problems are harmful, and consequ-ently engage in negative attitudes during their studies. This study has demonstrated that direct con-tact and exposure to mental health/psychiatric nur-sing settings through the mandatory psychiatric nursing postings programme can influence signify-cant positive change on students attitude. Consequently, the validity or merit of the psychiatric nursing posting programme as an essential element of the nursing education curriculum has been reinforced. Furthermore, the findings underscore the importance of addressing the negative stereotypes of student nurses and other trainee health professionals regarding mental health issues to enable them provide the best possible care. More so, changing nursing students attitude prior to the completion of their studies may encourage them to choose psychiatric nursing speciality as their future career, post-graduation. This may go a long way in addressing the acute manpower shortage currently experienced in the mental health sub-sector globally.  

Limitations

While this study does offer some compelling support for student nurses gaining significant experience in psychiatric settings, we recommend further research in view of certain limitations. First, this study would also have benefitted from feedbacks from the nursing staff that facilitated and supervised the students while undergoing the placement, and other people within the setting with whom the students came into contact during the 8 weeks posting. This is because the students may have perceived themselves as having changed their attitudes but this required confirmation, especially by other individuals inclu-ding the mentally ill people whom they came in con-tact with, and cared for, during the posting. Second, this study used small sample size and adopted un-systematic sampling method which limits generali-sation.

This study was not financed or aided by any indi-vidual/organization to be acknowledged.

We have no conflict of interest with any individual or organization