Mental health stigma and undergraduate nursing students: A self-determination theory perspective

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Mental health stigma and undergraduate nursing students: A self-determination theory perspective Dana Perlman a,∗ , Lorna Moxham b , Christopher Patterson b , Anita Cregan a , Stewart Alford c , Amy Tapsell d a

School of Education, University of Wollongong, New South Wales, Australia School of Nursing, University of Wollongong, New South Wales, Australia c Health Science, University of Western Sydney, New South Wales, Australia d Global Challenges Program, University of Wollongong, New South Wales, Australia b

a r t i c l e

i n f o

Article history: Received 4 June 2019 Received in revised form 5 August 2019 Accepted 5 August 2019 Available online xxx Keywords: Clinical placement Mental health Nursing Stigma Self-determination theory

a b s t r a c t Background: Clinical placements are essential in preparing students for professional practice. Given the serious negative impact of stigma on people with lived experiences of mental illness, it is essential to explore whether the educational setting of a clinical placement can influence mental health stigma. Aims: Using a Self-Determination Theory lens, this study aimed to examine whether the educational setting of a clinical placemen influences the stigma of undergraduate nursing students toward people with lived experiences of mental illness. Design: Quasi-experimental; pre-test post-test. Methods: Ninety-nine undergraduate students enrolled in an accredited nursing program within Australia completed two surveys pre- and post-clinical placement. The surveys measured the educational setting (learning climate) and mental health stigma (social distance). Findings: Students who partook in an Autonomy-Supportive mental health clinical placement reported a significant decrease in stigma from pre-to-post placement, whereas the Balanced/Neutral group reported a significant increase in stigma from pre-to-post-placement. Discussion: The findings of this research have considerable implications for nursing facilitators and preceptors. Those that support autonomy amongst future nursing professionals are more likely to positively influence students’ mental health stigma. Those who do not promote an autonomy-supportive setting may actually worsen mental health stigma. Conclusion: The educational setting in which a clinical placement occurs can influence nursing students’ mental health stigma. © 2019 Australian College of Nursing Ltd. Published by Elsevier Ltd.

Summary of Relevance Problem Little is known about whether the educational setting of a clinical placement can influence students’ attitudes toward people in their care living with mental illness. What is already known Many staff in clinical placement settings promote negative attitudes toward people living with mental illness. What this paper adds

The educational setting of a mental health clinical placement can influence students’ stigmatising beliefs about people living with mental illness. Nursing facilitators and preceptors should be cognisant of the autonomy-supportive context of clinical placement settings, promoting choice and control for students at every opportunity in pursuit of better attitudes and behaviours toward people living with mental illness. ;1;

1. Introduction

∗ Corresponding author at: School of Education, University of Wollongong, Northfields Ave., Wollongong, New South Wales, 2522, Australia. E-mail address: [email protected] (D. Perlman).

Undergraduate health students must undertake clinical placement hours in off-campus ‘real world’ health care settings as part of their studies (Courtney-Pratt, FitzGerald, Ford, Marsden, & Marlow, 2011). Though there are no universal rules for how learning occurs

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within a clinical placement setting, it is apparent that clinical placements are influential in shaping students’ attitudes toward learning and professional development (Henderson, Cooke, Creedy, & Walker, 2012). Clinical placements also teach students how to integrate theory and practice (Warne et al., 2010), and how to work in an interdisciplinary healthcare team (Takahashi, Brissette, & Thorstad, 2010). Tertiary institutions arrange clinical placements with healthcare institutions that they believe will provide quality training for their future health professionals (Courtney-Pratt et al., 2011). Clinical placements are essential in preparing students for professional practice, and provide opportunities for students to explore what career path they may wish to choose (McCall, Wray, & McKenna, 2009). For nursing students, their clinical practice is currently gained entirely through clinical placements undertaken throughout their undergraduate degree (Newton, Billett, & Ockerby, 2009). Yet, it can prove to be a challenging undertaking, when the values and practices they came to be familiar with within their studies are not necessarily favoured in practical, clinical settings (Newton & McKenna, 2007). The educational setting in which a clinical placement occurs can be conducive to the promotion of safe practice, and many are inclusive towards students, however many staff in clinical placement settings are not open to innovation or attitudinal or behavioural change (Henderson et al., 2012). 2. Background Across different areas of healthcare, including nursing, some healthcare providers demonstrate stigmatising behaviours and attitudes toward people with conditions such as HIV/AIDS (Naughton & Vanable, 2013), different sexual orientations (Austin, 2012), and obesity (Falker & Sledge, 2011). This is also the case for people living with mental illness (consumers), who experience public stigma, whereby they are discriminated against on the basis of stereotypes surrounding mental illness (Corrigan, Druss, & Perlick, 2014). Healthcare professionals who endorse stigmatising characteristics associated with mental illness are more likely to believe a consumer will not adhere to their treatment regime, and are therefore less likely to refer them for specialist treatment or refill a prescription (Corrigan, Mittal et al., 2014). There is some evidence that the educational setting of a clinical placement may have an influence on students’ stigma. For instance, Chadwick and Porter (2014) evaluated the effect of a mental health clinical placement on 65 nursing students’ attitudes toward consumers in Melbourne, Australia. They administered two self-report surveys, pre- and post-placement. They found various significant changes post placement, including a positive change in attitudes toward people living with mental illness. Students also reported an understanding that their attitudes could influence the way consumers feel. 2.1. Self-determination theory Self-Determination Theory (SDT) may be used to explore students’ clinical placement experience. SDT (Deci & Ryan, 1985) is a theoretical framework exploring human motivation and personality, which has been utilised to study and explain human behaviour. Of relevance to the present research, SDT can be used to look at the influence of educational settings on attitudes, motivation, and beliefs held by undergraduate nursing students (Deci & Ryan, 2000). SDT (Deci & Ryan, 2008) denotes that our attitudes, motivation, and beliefs are influenced by three essential psychological needs: competence, relatedness, and autonomy. Competence entails a feeling of success or optimal challenge. Relatedness refers to a feeling of social connection and belongingness with others. Autonomy refers

to a feeling of choice and control, where one acts with their own interests and values in mind. 2.2. Different educational settings Deci and Ryan (1985) contend that the settings within which humans function can influence their self-determination. Within these settings, there exists levels of autonomy-support and control, which influence the individual’s motivation, attitudes, and beliefs (Deci & Ryan, 2008). An autonomy-supportive setting is one in which participants are influenced by intrinsic factors (such as individual accomplishment), the language used is positive and conducive to choice (such as “you could”), the activities are personally meaningful, and care is shown by facilitators (Reeve, Jang, Carell, Jeon, & Barch, 2004). Conversely, controlling settings are those which are influenced by extrinsic factors (such as deadlines), the language used implies no choice (such as “you must”), and the activities are not meaningful and may evoke negative emotions (Reeve et al., 2004). Research has demonstrated that autonomy-supportive education settings are more likely to result in positive outcomes for students. For example, Black and Deci (2000) examined the effect of an autonomy-supportive education setting on students’ motivation toward learning organic chemistry. Those students who undertook a chemistry course where the instructor demonstrated autonomy-supportive behaviours reported greater perceived competence and enjoyment, and lower anxiety. This resulted in better course performance. 2.3. The role of educators In areas such as teacher education, K-12 education and the health sector, the examination of teaching using autonomy-support is well researched and supported (Amoura et al., 2015). Instructors who adopt an autonomy-supportive style employ different instructional behaviours to motivate their students (Reeve & Jang, 2006). This teaching style is centered on nurturing a student’s psychological needs, preferences and values, in order to promote internal locus, volition and a sense of choice (Reeve & Jang, 2006; Reeve et al., 2004). Haerens, Aelterman, Vansteenkiste, Soenens, and van Petegem (2015) surveyed 499 secondary school students and found that those who perceived autonomy-supportive teaching reported greater autonomous motivation. Conversely, controlling teaching related to controlled motivation and amotivation, as well as oppositional defiance. Some literature also demonstrates a link between autonomy-support and positive outcomes in the field of medical education. In addition, Williams and Deci (1998) reviewed studies that examine the relationship between autonomy-supportive educational settings and medical students’ autonomous motivation and competence. These authors found that, overwhelmingly, if students reported that their instructor was autonomously supportive, students became more autonomously motivated and, in turn, felt more competent. Further, they placed more emphasis on the psychosocial components of medicine, such as being more autonomy-supportive towards their patients. 2.4. Nursing student attitudes and educational settings Sadow, Ryder, and Webster (2002) explored nursing students’ attitudes toward consumers after receiving health education, training, and experience. Students who reported that they knew someone with a lived experience of mental illness reported less stigmatising attitudes after being exposed to health education and experience. All other students reported an increase in stigmatising attitudes. Indeed, the setting in which nurses are educated represents an opportunity to foster the knowledge and skills required to provide high quality, respectful care among future nursing pro-

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fessionals (Happell et al., 2018). Hospitals are generally regarded as the traditional clinical placement setting for nursing students to complete their education (Bjørk, Berntsen, Brynildsen, & Hestetun, 2014). However, students may also complete their placements in mental health care, community care and nursing homes, depending on the country they reside in and healthcare system. In contrast, non-traditional clinical placements are increasingly being considered (Moxham et al., 2016), and may occur in settings such as prisons, parishes and children’s day care centres (Harwood, Reimer-Kirkheim, Sawatsky, Terblanche, & Van Hofwegen, 2009). Therapeutic recreation-based clinical placements have also been utilised as a non-traditional approach to educating students (Moxham et al., 2016). Moxham et al. (2016) surveyed 79 thirdyear nursing students in Wollongong, Australia, 40 of whom attended a therapeutic recreation-based clinical placement (called Recovery Camp), and 39 of whom attended a traditional mental health clinical placement in a hospital setting. Participants completed the Social Distance Scale (SDS) (Link, Cullen, Frank, & Wozniak, 1987), which measures stigma, pre- and post-placement. Responses revealed a statistically significant difference in stigma between the two groups, with Recovery Camp participants reporting significantly less stigmatisting attitudes post-placement. There was no significant difference post-placement for those attending the traditional clinical placement. The authors argued that the latter result was concerning, in that appropriate clinical placements should facilitate a reduction in stigma among healthcare workers, to ensure strengths-based, recovery-oriented care. More research is therefore required to determine the influence of the clinical placement educational setting on nursing students’ stigma, given the negative influence it can have on consumers. As such, the purpose of this study was to examine whether the educational setting of a clinical placement, using a Self-Determination Theory lens, influences the stigma of undergraduate nursing students toward people with lived experiences of mental illness. 3. Methods 3.1. Participants Ninety-nine undergraduate students enrolled in an accredited nursing program within Australia took part in this study. As part of their degree, each student is required to engage in an 80 h mental health clinical placement. To ensure consistency across clinical placements, the students needed to be on a (a) mental health clinical placement, (b) had a preceptor or nurse facilitator, and (c) lasted 80-hs. In the context of this study, the setting in which clinical placements takes place has been referred to as ‘educational setting’. 3.2. Ethical approval This study was granted approval through the University of Wollongong Ethics Committee (Approval No: HE16/060). Participants were provided with a consent form and informed that they could withdraw from the research at any time. 3.3. Instruments There were two quantitative measures used within this study to examine (a) the educational setting of a clinical placement (autonomy-supportive or controlling) and how this relates to (b) attitudes toward people living with mental illness. This was achieved by utilising the Learning Climate Questionnaire (LCQ; Williams & Deci, 1996) and the Social Distance Scale (SDS; Link, 1987) respectively.

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3.3.1. Learning climate questionnaire Assessment of the educational setting to examine the level of autonomy-support within each clinical placement setting was conducted using an abridged version of the Learning Climate Questionnaire (LCQ; Williams & Deci, 1996). The abridged LCQ is a 7-item scale that uses a 7-point Likert scale ranging from 1 = ”Strongly Disagree” to 7 = ”Strong Agree”. The LCQ assesses autonomy support in educational settings (Williams & Deci, 1996). To obtain a score for autonomy-support, an average of all responses is calculated. As such, a higher score is associated with a higher perception of autonomy-support within a specific setting and/or learning context. The application across a wide array of educational settings provides support for the validity and reliability of the LCQ within this study (Black & Deci, 2000; Perlman, 2013; Standage, Duda, & Ntoumanis, 2005). 3.3.2. Social distance scale Stigma toward people with a lived experience of mental illness was assessed using the Social Distance Scale (SDS; Link, 1987). The SDS is a 7-item survey that uses a 5-point scale asking each participant to rate their level of agreement on each item. The SDS measures the degree to which one is willing to engage in social contact with an individual living with mental illness (Link, Yang, Phelan, & Collins, 2004). An overall stigma score is calculated by adding all responses for each participant. It should be noted that a higher score is associated with a person who is more stigmatising toward people living with mental illness. The SDS has been used in previous mental health research, which has indicated adequate reliability and validity (Link, Struening, Neese-Todd, Asmussen, & Phelan, 2001; Moxham et al., 2016). 3.4. Data collection and analysis Data were collected using a pre-test post-test design. Participants were asked to complete both the LCQ and SDS one week before and one week after completing their approved mental health clinical placement. Each survey was completed using a paper and pencil format that took between 10–15 minutes to complete. Data from pre-test and post-test surveys were transcribed by a member of the research team into the Statistical Package for Social Sciences (SPSS; IBM Corporation, 2012). To ensure that data were transferred accurately, another member of the research team checked for any data that did not match the survey responses. Analysis of data was completed in four stages of (a) group classification, (b) descriptive/reliability analysis, (c) fidelity of clinical placement, and (d) examination of research questions. Group classification analysis was conducted to place students into either the Autonomy-Supportive or Balanced/Neutral group (n = 48; male = 8; female = 40) or Balanced/Neutral (n = 51; male = 9; female = 42) groups. The classification was based on the level of perceived autonomy-support within these specific clinical placements. Data from the post-test LCQ was used to classify students. This process was conducted over two steps. First, students who scored above 5.50 were placed into the Autonomy-Supportive group, while students who scored between 4.00 and 5.00 were classified into the Balanced/Neutral group. Any student who did not fall into these categories was omitted from the study. Next, a deeper examination was conducted to ensure removal of participants from settings that could be classified as both autonomy-supportive and balanced/neutral. Any clinical placement site that had students classified into both groups were omitted from the study. It should be noted that only one clinical placement met this exclusion criteria. Furthermore, to assist with deciding the level of analysis (group or individual), intra-class correlation coefficients (ICCS) were calculated for the pre-test measures of the social context (i.e. LCQ) and Stigma. A positive ICC would use the group level, while a negative

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Table 1 Scores (Mean and Standard Deviation) of the LCQ and SDS pre-and-post and reliability analysis (␣).

anced/Neutral group. In addition, reported stigma among the Balanced/Neutral group significantly increased between the pretest and post-test time point.

Total number of participants (n = 99) AS

LCQ Pre-test LCQ Post-test SDS Pre-test SDS Post-test

B/N

5. Discussion

␣

M

SD

M

SD

5.26 6.03 12.33 9.58

0.85 0.38 333 3.26

5.27 4.54 12.98 14.24

1.21 0.33 3.51 3.78

.88 .85 .80 .83

AS; Autonomy-Supportive, B/N; Balanced/Neutral.

ICC would use the individual as the level of analysis based on the recommendations of Kenny and LaVoie (1985). Descriptive/reliability analysis of data was focused on providing an overall picture of the data and ensuring a level of reliability. As such, descriptive statistics of means and standard deviations for study variables at both the pre-test and post-test were calculated. In addition, Cronbach’s alpha was used to ensure a level of reliability of the data from both surveys. Fidelity of clinical placement was focused on ensuring that students engaged in a clinical placement that was either Autonomy-Supportive or Balanced/Neutral. As such, two one-way ANOVAs were calculated to examine whether there was a significant difference between groups on the scores obtained from the LCQ at both the pre-test and post-test time points. Due to the use of two ANOVA calculations, the significance level was adjusted to p ≤ .025. The goal of these calculations was an insignificant difference at the pre-test and a significant difference at the post-test time point with students involved in the AutonomySupportive clinical placement being higher when compared with the Balance/Neutral group. To address the study aim, a 2 × 2 (Group x Time) RM ANOVA was conducted using scores from the SDS. A significant RM ANOVA was followed-up with Bonferonni pairwise comparisons to examine the location of the significant difference. 4. Findings Results of the ICCs revealed that the individual is the appropriate level of analysis for both data obtained from the LCQ (-0.10) and Stigma (-.06). Descriptive statistics and reliability analysis are displayed in Table 1. The fidelity of clinical placement result indicated an insignificant difference at the pre-test time point F(1,98) = 1.01, p ≥ .025, while results indicated a significant difference at the posttest time point F(1,98) = 429.13, p ≤ .025. These results support the intent and purpose of this study. Finally, results of the RM ANOVA revealed a significant interaction effect for stigma Wilks’ ␭ = .821, F(1,97) = 21.18, p ≤ .025, ␩2 = .179. Bonferonni pairwise comparisons are displayed in Table 2 and revealed a significant difference at three different time points (two within-subjects time points and one that was betweensubjects) whereby students’ stigma in the Autonomy-Supportive group significantly decreased over time and were significantly lower at the post-test time point when compared with the Bal-

The present study explored whether the educational setting of a clinical placement influences undergraduate nursing students’ stigma toward people with a lived experience of mental illness. The findings demonstrate that Self Determination Theory (SDT; Deci & Ryan, 1985) can provide a useful lens to examine the influence of clinical placement settings on tertiary students. This supports Reeve et al.’s (2012) use of a student-teacher dialectical framework, from a SDT perspective, to determine the relationship between classroom conditions (e.g. autonomy-supportive; controlling) and students’ motivation, attitudes, and behaviours. SDT acknowledges that students sometimes lack motivation and exhibit unfavourable attitudes and behaviours. It contends that teachers/facilitators play a role in this, and should facilitate student engagement by nurturing autonomy and actively involving students in the learning process (Niemiec & Ryan, 2009). Within the clinical placement setting, this can be extended to preceptors and facilitators. Levett-Jones, Lathlean, Higgins, and McMillan (2009) assert that the relationship between nursing staff and students must not be undervalued; it is the most important influence on nursing students’ learning. The present study determined that the clinical placements that were viewed as autonomy-supportive facilitated a significant decrease in students’ stigma post-placement, as well as a significant difference between the students who engaged in a more balanced setting. Again, this has implications for nursing clinical placement preceptors and nurse facilitators. Reeve (2009) states that people in a leadership or authority position (e.g. nurse facilitator) tend to adopt a style that is more controlling and not autonomy-supportive. If a more autonomy-supportive style was adopted, stigma could be reduced, resulting in a nurse graduate who shows less discrimination – ideally, no discrimination – towards those in their care. Yet another interesting finding of the present study was that students in the Balanced/Neutral group reported a significant increase in stigma from pre-placement to post-placement. An increase in stigma is associated with a person that is more stigmatising, and as discussed previously, may lead to poor care and mistrust of consumers (Corrigan, Mittal et al., 2014). Further to these barriers to treatment services, stigma can seriously influence how consumers view themselves. Overton and Sondra (2008) contend that the experience of stigma often results in consumers seeing themselves in a negative light, sacrificing their confidence and self-esteem. They can also experience feelings of loneliness, a loss of control, and a lack of acceptance. Their self-efficacy is also diminished, as the perceptions and expectations of those around them lead them to believe they are not capable of even the most basic functions of daily living. The findings from this study also suggest that a non-traditional setting, such as therapeutic recreation-based clinical placement might reflect an autonomy-supportive learning climate, whereby

Table 2 Differences between groups (Autonomy-Supportive and Balance/Neutral) pre-and-post clinical placement. Treatment (I)

AS Pre-test AS Pre-test B/N Pre-test AS Post-test

Treatment (J)

AS Post-test B/N Pre-test B/N Post-test B/N Post-test

Mean Diff. (I-J)

2.750 −.010 −1.804 1.488

Std. Error .488 .212 .843 .072

Sig.

.000** .962 .037* .000**

95% Conf. Interval Lower Bound

Upper Bound

1.769 −.430 −3.497 1.346

3.731 .410 −.111 1.631

Note. *p ≤ .05; **p ≤ .01. AS; Autonomy-Supportive, B/N; Balanced/Neutral.

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students are offered a greater sense of control and opportunities to share their perspectives (Patterson et al., 2016). This supports research by Moxham et al. (2016) which found that nursing students who participated in a non-traditional clinical placement, supportive of strengths-based, holistic care, reported less stigma post-placement, relative to a group who attended a traditional clinical placement in a hospital setting. As a result of increased contact with both consumers and facilitators, students in the nontraditional clinical placement had less desire for distance between themselves and people with lived experiences of mental illness. While further research in this area is recommended by the authors, developing innovative ways to educate nursing students in the clinical setting may assist in reducing stigmatising attitudes (Moxham et al., 2016). 6. Relevance to clinical practice Realistically, most if not all nursing students – no matter their chosen area of specialisation – will care for people living with mental illness. Therefore, whether or not they choose to specialise in mental health nursing, these findings have significant implications for the future nursing workforce. Autonomy-supportive clinical placements can reduce stigma. This is important, given that Ross and Goldner (2009) reviewed the literature and determined that nurses who hold stigmatising beliefs tend to partake in demeaning behaviour and hostile attitudes toward consumers. Less regard is given to holistic care, health promotion, and advocacy, and instead the focus is on more ‘interesting’ tasks of the job. This is entirely discrepant with a recovery-oriented approach, which is the standard expected by the Australian government in the Roadmap for National Mental Health Reform 2012–2022 (Council of Australian Governments, 2012).

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which foster positive outcomes for said students. Further, given the serious negative impact of stigma on people living with mental illness, often perpetuated by health professionals, it is essential to explore how to decrease stigmatising attitudes amongst future health professionals. The findings of the present study demonstrate that clinical placements perceived as autonomy-supportive can result in a decrease in stigma for undergraduate nursing students. Further, controlling settings can increase reported stigma. In order to best educate the future health workforce, facilitators should emphasise autonomy support and promote an environment of choice and control for their students. Ethical statement The authors confirm that any aspect of the work covered in this manuscript that has involved human patients has been conducted with the ethical approval of all relevant bodies and that such approvals are acknowledged within the manuscript. Name of ethics committee: University of Wollongong Human Research Ethics Committee. Approval number: HE16/060. Date of approval: 07/02/2018. Funding There is no funding to report. Declaration of Competing Interest All the authors state that there is no conflict of interest. Acknowledgements

7. Limitations This study is not without its limitations. First, surveys were self-report measures, which runs the risk of socially desirable responding, whereby participants respond in a way that reflects favourably on their image (Van der Mortel, 2008). To avoid this, surveys were not administered by nursing staff known to the students, but instead members of the research team with education and psychology expertise. Thus, students should have felt less pressure to conform to what is ‘expected’ of them, and instead were asked to respond openly and honestly given the confidential nature of the surveys. Second, despite statistically significant differences in LCQ and SDS scores pre-and-post clinical placement, it should be noted that these differences were numerically small. It is therefore difficult to determine whether these differences would result in meaningful changes in practice. In addition, due to the study’s pre-test post-test design, the authors cannot infer any persisting changes in nursing student attitudes over time. Third, the Social Distance Scale was utilised in the present study because it is short and provides an all-encompassing picture of participants’ stigmatising attitudes. Stigma may be explored further in future research, by looking at students’ attitudes specifically as they relate to healthcare. The Learning Climate Questionnaire measured how autonomy-supportive or controlling each student believed their clinical placement to be. Future research may benefit from the addition of qualitative methods to determine exactly what aspects of the clinical placement influenced the educational setting. 8. Conclusion Given the influence of clinical placements on nursing student learning, it is imperative to understand the educational settings

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Please cite this article in press as: Perlman, D., et al. Mental health stigma and undergraduate nursing students: A self-determination theory perspective. Collegian (2019), https://doi.org/10.1016/j.colegn.2019.08.001