Issues in Mental Health Nursing

ISSN: 0161-2840 (Print) 1096-4673 (Online) Journal homepage: https://www.tandfonline.com/loi/imhn20

Nursing Students’ Attitudes Towards People

Diagnosed with Mental Illness and Mental Health
Nursing: An International Project from Europe and
Australia

Brenda Happell, Chris Platania-Phung, Julia Bocking, Brett Scholz, Aine

Horgan, Fionnuala Manning, Rory Doody, Elisabeth Hals, Arild Granerud,
Mari Lahti, Jarmo Pullo, Heikki Ellilä, Vatula Annaliina, Kornelis Jan van der
Vaart, Jerry Allon, Martha Griffin, Siobhan Russell, Liam MacGabhann, Einar
Bjornsson & Pall Biering

To cite this article: Brenda Happell, Chris Platania-Phung, Julia Bocking, Brett Scholz, Aine
Horgan, Fionnuala Manning, Rory Doody, Elisabeth Hals, Arild Granerud, Mari Lahti, Jarmo Pullo,
Heikki Ellilä, Vatula Annaliina, Kornelis Jan van der Vaart, Jerry Allon, Martha Griffin, Siobhan
Russell, Liam MacGabhann, Einar Bjornsson & Pall Biering (2018) Nursing Students’ Attitudes
Towards People Diagnosed with Mental Illness and Mental Health Nursing: An International
Project from Europe and Australia, Issues in Mental Health Nursing, 39:10, 829-839, DOI:
10.1080/01612840.2018.1489921

To link to this article: https://doi.org/10.1080/01612840.2018.1489921

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ISSUES IN MENTAL HEALTH NURSING
2018, VOL. 39, NO. 10, 829–839
https://doi.org/10.1080/01612840.2018.1489921

Nursing Students’ Attitudes Towards People Diagnosed with Mental Illness and
Mental Health Nursing: An International Project from Europe and Australia
Brenda Happell, RN, RPN, BA (Hons), Dip Ed, B Ed, M Ed, PhDa, Chris Platania-Phung, BA (Hons), PhDb,
Julia Bocking, B Phil (Hons), B Soc & Comm Stud (Community Development), Consumer academicb,
Brett Scholz, BHSci (Hons), PhDb , Aine Horgan, PhD, MSc, BNS, PGCert T&L, RPNc, Fionnuala Manningc,
Rory Doody, B. Soc. Sc. (Hons)c, Elisabeth Hals, MAd, Arild Granerud, PhDd, Mari Lahti, MNSc, PhDe ,
Jarmo Pulloe, Heikki Ellil€a, RN, MN.Sc, PhDe, Vatula Annaliina, BAe, Kornelis Jan van der Vaart, BN, MScif,
Jerry Allonf, Martha Griffin, H. Dipg, Siobhan Russell, BS.c RPN, PhDg, Liam MacGabhann, BSc, MSc, DrNursScig,
Einar Bjornssonh, and Pall Biering, PhDh
a
School of Nursing and Midwifery, the University of Newcastle, Callaghan, New South Wales, Australia; bSynergy: Nursing and Midwifery
Research Centre, University of Canberra, Faculty of Health, and ACT Health, WODEN, Australia; cSchool of Nursing and Midwifery, University
College Cork, Cork, Ireland; dFaculty of Health and Social Sciences, Inland Norway University of Applied Sciences, Hedmark, Norway; eTurku
University of Applied Sciences, Turku, Finland, Faculty of Medicine, Department of Nursing Science, Turku University, Turku, Finland;
f
Institute for Nursing Studies, University of Applied Sciences Utrecht, Utrecht, the Netherlands; gSchool of Nursing and Human Sciences,
Dublin City University, Dublin, Ireland; hDepartment of Nursing, University of Iceland, Reykjavik, Iceland

ABSTRACT
The stigma associated with a diagnosis of mental illness is well known yet has not reduced signifi-
cantly in recent years. Health professionals, including nurses, have been found to share similar nega-
tive attitudes towards people with labelled with mental illness as the general public. The low uptake
of mental health nursing as a career option reflects these stigmatised views and is generally regarded
as one of the least popular areas of in which to establish a nursing career. The aim of the current
project was to examine nursing students’ attitudes towards the concept of mental illness and mental
health nursing across four European countries (Ireland, Finland, Norway and the Netherlands), and
Australia, using the Opening Minds Scale and the Mental Health Nurse Education survey. The surveys
were distributed to students prior to the commencement of the mental health theory component.
Attitudes towards mental health nursing were generally favourable. Differences in opinion were
evident in attitudes towards mental illness as a construct; with students from Australia and Ireland
tending to have more positive attitudes than students from Finland, Norway and the Netherlands.
The future quality of mental health services is dependent on attracting sufficient nurses with the
desire, knowledge and attitudes to work in mental health settings. Understanding attitudes towards
mental illness and mental health nursing is essential to achieving this aim.

Introduction
Stigmatised attitudes towards people diagnosed with mental
illness are well known, pervasive and longstanding (Ezell,
Choi, Wall, & Link, 2018; Oexle & Corrigan, 2018; van der
Maas et al., 2018). Indeed, stigmatising views have been
found within the health professionals at rates similar to the
general public (Bingham & O’Brien, 2018; Gras et al., 2015;
Griffiths, 2011; Morgan, Reavley, Jorm, & Beatson, 2016;
Ozer, Varlik, Ceri, Ince, & Delice, 2017; Reavley,
Mackinnon, Morgan, & Jorm, 2014), including amongst
those working in mental health settings (Byrne, Roper,
Happell, & Reid-Searl, 2016; Scholz, Gordon, & Happell,
2017). Nurses have also been found to hold negative
attitudes to people with mental illness diagnosis (Bingham &
O’Brien, 2018; de Jacq, Andreno Norful, & Larson, 2016;
Happell, Bennetts, et al., 2015; Schafer, Wood, &
Williams, 2011).
The adverse impacts of stigma have been noted in the lit-
erature (Livingston & Boyd, 2010). Anti-stigma campaigns
have been introduced internationally with the aim of
reducing the subsequent discrimination stemming from
stigmatised beliefs and therefore enhancing quality of life
(Gronholm, Henderson, Deb, & Thornicroft, 2017; Stuart,
2016; Stuart et al., 2014a, 2014b). Within the health care
system, negative attitudes of health professionals have been
associated with poorer health outcomes (Knaak, Mantler, &
Szeto, 2017; Knaak, Patten, & Ungar, 2015). Nurses consti-
tute the largest professional group within the mental health
workforce (Australian Institute for Health and Welfare,
2018; Department of Health, 2017; Kakuma et al., 2011),
and therefore have an important role in the provision of
health care and the reduction of stigma.
The education of students for nursing practice facilitates
socialisation into the culture of the nursing profession

CONTACT Brenda Happell brenda.happell@newcastle.edu.au School of Nursing and Midwifery, University of Newcastle, University Drive, Callaghan, New
South Wales, 2308, Australia.
ß 2018 Taylor & Francis Group, LLC
830 B. HAPPELL ET AL.
(Dimitriadou, Pizirtzidou, & Lavdaniti, 2013; Mariet, 2016)
and influences development of the qualities and attributes
students will bring to their professional practice (Baldwin,
Bentley, Langtree, & Mills, 2014; Jack, Hamshire, &
Chambers, 2017). The setting therefore provides an excellent
opportunity to explore student attitudes towards people
with a diagnosis of mental illness (Bingham & O’Brien, 2018;
Millar, 2017), and foster graduate nurses with the knowledge,
skills and attributes required to provide high quality and
respectful care to people accessing mental health services.
Each country in this project differed in their educational
offerings. Nursing education in Ireland prepares graduates
for specialist mental health nursing practice, with students
selecting their chosen field of specialty practice at the com-
mencement of their programme (Department of Health,
2012). This is not the case in Australia and other European
countries. The other sites position undergraduate nursing
education as a potential way of enhancing interest in mental
health nursing as a potential career option to ensure future
workforce demands for mental health nurses are met
(Delaney, 2017; Happell & McAllister, 2014; Ong et al.,
2017). Comprehensive nurse education is now the approach
adopted in many countries throughout the world, replacing
the specialist undergraduate programmes which prepared
graduates for practice in specific fields of nursing, such as
mental health nursing (Edward et al., 2015; McCann,
Moxham, Usher, Crookes, & Farrell, 2009; Mental Health
Nurse Education Taskforce, 2008). Comprehensive education
is designed to prepare students for beginning level practice
across a broad range of health care settings, including
mental health, with specialisation expected to occur at
postgraduate level, although this is not always mandatory
(Mental Health Nurse Education Taskforce, 2008).
Comprehensive programmes have been broadly criticised
for not providing sufficient exposure to the theory and prac-
tice of mental health nursing (Happell & Cutcliffe, 2011;
Happell & Gaskin, 2013; Stevens, Browne, & Graham, 2013).
Research suggests inadequate numbers of students enter
nursing programmes with the intention of pursuing a career
in the mental health field (Happell, Byrne, Platania-Phung,
et al., 2014; Happell & Gaskin, 2013; Stevens et al., 2013).
Research conducted in Australia, the United States,
Singapore, the Middle East, the United Kingdom and
Croatia suggests mental health nursing generally remains
unpopular as a career choice (Bingham & O’Brien, 2018;
Happell, Byrne, Platania-Phung, et al., 2014; Happell &
Gaskin, 2013; Itzhaki, Meridan, Sagiv-Schifter, & Barnoy,
2017; Millar, 2017; Ong et al., 2017; Stevens et al., 2013;
Thongpriwan et al., 2015). While increased interest in this
field has been evident at the completion of some nursing
programmes (Happell, Byrne, Platania-Phung, et al., 2014;
Stevens et al., 2013; Thongpriwan et al., 2015), the extent to
which this occurs is influenced by the amount and quality
of both theoretical and clinical education (Happell &
Gaskin, 2013; Thongpriwan et al., 2015).
Involving people with lived experience of being diagnosed
with mental illness and related service use (hereinafter
referred to as Experts by Experience) in the education of
nurses has been identified as a strategy to reducing stigma-
tised attitudes of nursing students towards people with such
a clinical diagnoses (Happell, Byrne, McAllister et al., 2014).
Personal contact with people who are in recovery from
‘mental illness’ in conjunction with education are demon-
strated to be the two strongest influences in mitigating
against negative attitudes (Corrigan, Morris, Michaels,
Rafacz, & R€ usch, 2012). The inclusion of Experts by
Experience in the education of nurses combines both strat-
egies enhancing the likelihood of attitudinal change.
This perspective has been substantiated by evaluations
of Expert by Experience involvement in the education of
nurses (Happell, Byrne, McAllister, et al., 2014; Schneebeli,
O’Brien, Lampshire, & Hamer, 2010; Simons et al., 2007).
Such involvement has assisted students to overcome fear
and reduce anxiety (Happell, Byrne, Platania-Phung, et al.,
2014), challenge misconceptions about mental illness (Byrne,
Happell, Welch, & Moxham, 2013b; Happell, Bennetts,
et al., 2015) and develop a more multi-dimensional under-
standing of people with a mental illness diagnosis as individ-
uals first and foremost (Byrne, Happell, Welch, & Moxham,
2013a). Furthermore, involving Experts by Experience has
enhanced a greater appreciation of the value and importance
of mental health nursing practice and increased interest
in mental health nursing as a potential career (Happell,
Byrne, Platania-Phung, et al., 2014). However, despite these
positive evaluations, systematic involvement of Experts by
Experience in the education of nurses has not been widely
adopted (Happell, Platania-Phung, et al., 2015; Horgan et al.,
2018). The potential for Experts by Experience in education
to reduce clinical pessimism, develop more positive attitudes
towards people diagnosed with a mental illness and mental
health nursing requires further research attention.
An international project involving collaboration between
seven universities, Co-produced Mental Health Nursing
Education (COMMUNE) was undertaken to evaluate the
impact of Expert by Experience involvement in mental
health nursing education. The aim of this paper is to
examine the attitudes of nursing students to mental illness
diagnoses and mental health nursing and increase our
understanding of these important topics. To date very lim-
ited research has been undertaken in the European context,
highlighting the value of this international collaboration.
Methods
Study design
This was quantitative cross-sectional research on nursing
students’ attitudes towards mental illness and mental health
nursing. Multiple self-report measures were completed by
nursing students across six sites in Europe and Australia.
Setting
Data for this component of the project was collected from
undergraduate nursing students from six universities across
five countries: Ireland (two universities), Finland, Norway,

Table 1. Participant background (n ¼ 424).
N (%)
Age
18–29 339
30–39 58
40–49 9 2.1
50 or older 4 0.9
Missing 14
Gender
Female 344
Male 65
Missing 15
Country
Australia 117
Ireland 67
The Netherlands 53
Finland 69
Norway 118
Unlike other countries, Ireland represented by two universities
(University College Cork, Dublin City University).
the Netherlands and Australia. Students from the two Irish
universities undertake a 4-year undergraduate programme
specialising in mental health, at the completion of which
they register as a mental health nurse. Students from the
Australian, Finnish, Norwegian and Dutch universities
undertake programmes based on the comprehensive
approach. These students undertake a mental health nursing
component as part of the broader programme. On gradu-
ation, they become registered nurses, licenced to practice at
entry level in a variety of settings.
Participants
Participants were nursing students completing a nursing
programme at one of the participating universities. As pre-
sented in Table 1, most participants were between 18 and
29 years of age, and female. Norway and Australia had the
largest number of participants (around 28% each). While
these figures are for the overall baseline sample, it should be
noted that one participant did not complete the MHNES
and a different participant did not complete the OMS—
hence, the descriptive statistics that follow are based on 423
participants.
Materials
Data were collected using the Mental Health Nurse
Education Survey (MHNES) (Hayman-White & Happell,
2005) and Opening Minds Scale (OMS) (Modgill, Patten,
Knaak, Kassam, & Szeto, 2014).
Mental health nurse education survey
The Mental Health Nurse Education Survey (MHNES) was
designed to measure students’ attitudes to mental illness and
mental health nursing. The domains included measuring the
sense of preparedness to work within mental health care,
interest in mental health nursing as a career, importance of
mental health nursing skills and general attitudes to mental
illness (e.g. ‘people with mental illness are unpredictable’)
(Happell & Gough, 2009). The questionnaire has been
ISSUES IN MENTAL HEALTH NURSING 831
applied in evaluating changes in attitudes as a function of
incorporating lived experience in recovery-based education
(Happell & Gough, 2007; Happell, Moxham, & Platania-
80.0
13.7
Phung, 2011). In the MHNES, participants are asked to rate
28 statements on level of agreement using a seven-point
Likert scale, ranging from “strongly disagree” (at 1) to
3.3
“strongly agree” (at 7). The final section of the MHNES
81.1 requests demographic information with categorical response
15.3 options (gender, age).
3.5
27.6
15.8 Opening minds survey
12.5
16.3 The Opening Minds Survey (OMS) was created to estimate
27.8 attitudes towards mental illness among health care providers
and the impact of a range of anti-stigma interventions
(Modgill et al., 2014). The underlying aim was to reduce
stigma, especially through pedagogies led by people with
lived experience of a mental illness diagnosis (Kassam,
Papish, Modgill, & Patten, 2012; Stuart et al., 2014a, 2014b).
While developed in a Canadian context, the survey is argued
to be relevant to anti-stigma work internationally (Modgill
et al., 2014). The OMS measures attitudes towards mental
illness, the role and capacity of health care providers in care,
openness to inclusion of people with a mental illness diag-
nosis (e.g. in the workplace), and views about self-disclosure
to others (e.g. ‘If I had a mental illness, I would tell my
friends’). A five-point rating scale is used ranging from
‘strongly disagree’ to ‘strongly agree’. The current research
utilises the 20 item version for health care providers
(Kassam et al., 2012).
Procedure
Nursing students were provided with a verbal and written
explanation of the research at the commencement of their
unit; and that the module would be delivered by Experts by
Experience. If agreeable to participate, students were asked
to complete the questionnaires. In some sites (Ireland,
Finland), participants were also asked to provide separate
written consent due to local ethics requirements.
Research ethics
The research was approved to proceed after review by the
University of Canberra Human Research Ethics Committee
at the University leading the research. In each of the partner
sites, local ethical approval or approval to gain access to the
students was sought. Potential participants were informed of
the voluntary conditions for participation and that no indi-
vidual names would be disclosed in any reporting of find-
ings. This information was relayed to participants verbally
and in writing. Students were encouraged to ask questions
and seek clarification before proceeding. Submission of the
completed questionnaire was taken as evidence of consent
to participate in Australia, Norway and the Netherlands,
where separate written consent was obtained in Ireland
and Finland.
832 B. HAPPELL ET AL.
Analytic approach
Data analyses were conducted using the SPSS, Version 25.
Descriptive information was calculated for each full set of
items for the Nurse Education Survey and Opening Minds
Scale, including statistical estimates such as standard
deviation, and three indicators of central distribution (mean,
median and mode). Spearman correlations were analysed to
examine the magnitude, direction and statistical significance
of relationships between age, gender and attitudes. To
explore country differences in attitudes, given the ordinal
categorical type data derived from survey responses,
chi-square (v2) tests were applied, with inspection of contin-
gency tables used to identify differences. As chi-square tests
require at least five cases per category, to have sufficient
frequencies by sub-group, recoding of the data was applied.
Specifically, the five-level scale of Opening Minds was
collapsed to three categories (“disagree”, “neither disagree
nor agree”, and “agree”) and the seven-level scale of the
Nurse Education Survey collapsed to three levels (“disagree”,
“mid-point”, and “agree”). Given the number of chi-square
tests to be conducted (48), a Bonferroni correction was applied,
with the new alpha level being .001. For cases of a significant
chi-square statistic, thereby suggesting country differences in
student attitudes, the pattern of adjusted standardised residuals
was examined to identify country-specific deviations from
expected frequencies, especially those 2.5 or over.
Results
Results are reported for each survey separately, starting
with overall response patterns for each country, followed by
differences in terms of country, age and gender.
Mental health nurse education survey
Table 2 presents the percentage of responses to the MHNES
based on the recoding (disagree, mid-point, agree), informa-
tion on the distribution based on the original rating
(e.g. range, median) and v2 overall statistic for country,
with country differences shown where there was statistical
significance for the overall model (determined as p < .001),
and the location of differences, based on large standar-
dised residuals.
Overall responses
As suggested by the variety of median estimates, overall
responses to the MHNES were generally positive, with
medians veering to the “strongly agree” end of the scale
for positively worded items and veering to the “strongly
disagree” end for negatively worded items. The percentages
suggest a strong positive level of attitude to the efficacy of
mental health nursing; for instance, that this type of care
can “assist people with mental illness in their recovery”
(item 8), only 2% disagreed, compared to 87% agreement.
Perceived level of understanding of the role, however, was
more evenly distributed (see item 4), where the percentages
Figure 1. Response distribution for intention to pursue MHN as a
career (n þ 355).
ranging from disagree to agree were 29%, 24% and 47%
respectively.
Attitudes towards people with a diagnosis of mental
illness were more variable. For some items respondents
were positive; for instance, 78% agree that “when a person
develops a mental illness it is not their fault” (item 22). In
comparison, for “I am concerned I may be harmed by a
person with mental illness”, 56% disagreed, 22% were mid-
way between disagree and agree, and 21% agreed (item 11).
Figure 1 below presents the frequency of responses to
a key item of interest: the intention to pursue mental
health nursing as a career. For this item, there were no
responses for Ireland, as students representing the two
universities there were all in a specialist mental health
nursing stream (i.e. already engaged in a trajectory to men-
tal health nursing). Of remaining respondents (n ¼ 355),
45.4% were in the “disagree” range of the response scale,
28.2% were at the mid-point, while 26.5% were at the
“agree” end of the scale. Twenty-seven students (7.6% of
the 355) strongly agreed with this statement about pursu-
ing a career in mental health nursing. Based on medians,
Australia and Norway were at the mid-point of the
response scale, while Finland and the Netherlands fell in
the “disagree” spectrum of the scale.
Between-country variations in responses
Table 2 shows statistically significant variations between
countries for ten of the 28 items. For some of these there
were several differences – for instance, for ‘I am familiar
with the needs of people with mental illness’ (item 20),
Australia and Ireland tended to agree relative to overall
patterns, while Norway and Finland tended to disagree.
There were also multiple significant variations in perceived
understanding of the mental health nurse role (item 4), with
Ireland tending to indicate more understanding, and Finnish
and Dutch students less so. In terms of overall patterns
where there was statistical significance, students from
Australia and Ireland were more positive on attitudes, those
from Finland less positive, and for Norway and the
Netherlands it seemed to depend more on specific statements.
Table 2. Response patterns for the Nurse Education Survey (n ¼ 423).
Response (%) (highest
percentage in bold font) Country differences (N/A: tables with insufficient cell counts)
Mean (Standard
Statement Disagree Midpoint Agree Range Deviation) Median v2 statistic & p-value Differences (only those where overall v2 was p < .001)
1. I feel well prepared for my psychiatric placement 42.6 23.4 34.0 1–7 3.83 (1.48) 4 47.81, p¼.000 - Australia more likely to agree
- Norway more likely to disagree and more likely to agree
- Ireland more likely to agree and less likely to disagree
2. Psychiatric/mental health nursing makes a positive contribution 1.9 9.5 88.6 3–7 5.81 (1.03) 6 N/A
to people experiencing a mental health problem
3. I am anxious about working with people experiencing 55.0 17.1 28.0 1–7 3.37 (1.60) 3 34.31, p¼.000 - Finland more likely to agree, less likely to disagree
a mental problem
4. I have a good understanding of the role of a 28.9 23.9 47.2 1–7 4.36 (1.46) 4 72.09, p¼.000 - Finland less likely to agree, more likely to disagree
psychiatric/mental health nurse - The Netherlands less likely to agree, more likely
to disagree
- Ireland more likely to agree, less likely to disagree
5. I am uncertain how to act towards someone with a mental illness 47.0 26.0 27.0 1–7 3.62 (1.47) 4 28.86, p¼.000 - Norway less likely to disagree
- Ireland more likely to disagree, less likely to agree
6. I will apply for a Graduate programme in psychiatric/mental 50.6 27.7 21.8 1–7 3.27 (1.76) 3 22.27, p¼.001
health nursing
7. I feel confident in my ability to care for people experiencing 30.9 26.8 42.3 1–7 4.14 (1.39) 4 42.06, p¼.000 - Norway more likely to disagree, less likely to agree
a mental problem - Ireland less likely to disagree, more likely to agree
8: Psychiatric/mental health nursing can assist people with a 2.4 10.2 87.4 2–7 5.87 (1.08) 6 57.91, p¼.000 - Australia more likely to agree, less likely to be at mid-point
mental illness in their recovery - Norway less likely to agree, more likely to be at mid-point
9. People with mental illness are unpredictable 35.2 38.7 26.1 1–7 3.86 (1.31) 4 21.91, p¼.005
10. Mental illness is not a sign of weakness in a person 7.3 5.2 87.5 1–7 5.98 (1.42) 6 N/A
11. I am concerned I may be harmed by a person with mental illness 56.5 22.0 21.5 1–7 3.29 (1.49) 3 20.91, p¼.007
12. The theoretical component of psychiatric/mental health 30.5 28.8 40.7 1–7 4.11 (1.49) 4 90.19, p¼.000 - Australia more likely to agree, less likely to be at
nursing has prepared me well for my clinical placement mid-point or disagree
- Ireland more likely to agree, less likely to disagree
- Norway less likely to agree, more likely to be at mid-point
- The Netherlands less likely to agree, more likely to disagree
13. People with mental illness are more likely to be violent 55.7 30.7 13.6 1–7 3.23 (1.28) 3 12.56, p¼.128
14. This clinical placement in psychiatric/mental health nursing 2.9 7.4 89.8 1–7 6.03 (1.13) 6 N/A
will provide valuable experience for my nursing practice
15. I intend to pursue a career in psychiatric/mental health nursing 45.4 28.2 26.5 1–7 3.52 (1.79) 4 21.60, p¼.001
16. If I developed a mental illness, I wouldn't tell people 50.6 18.5 30.9 1–7 3.54 (1.75) 3 10.03, p¼.263
unless I had to
17. My course has prepared me to work as a graduate nurse in a 6.3 22.3 71.3 1–7 5.21 (1.20) 5 N/A
medical-surgical graduate programme
18. Mental illness can affect people from all walks of life 1.4 3.1 95.0 2–7 6.48 (0.92) 7 N/A
19. My course has prepared me to work as a graduate nurse in a 26.9 31.6 41.5 1–7 4.23 (1.37) 4 9.31, p¼.054
psychiatric/mental health graduate programme
20. I am familiar with the needs of people with mental illness 33.7 27.1 39.2 1–7 4.03 (1.44) 4 73.19, p¼.000 - Australia more likely to agree, less likely to disagree
- Ireland more likely to agree, less likely to disagree
- Norway less likely to agree, more likely to disagree
- Finland more likely to disagree
21. Someone I know has experienced a mental health problem 10.2 5.5 84.3 1–7 5.89 (1.64) 7 N/A
22. When a person develops a mental illness it is not their fault 7.6 14.3 78.1 1–7 5.69(1.64) 7 N/A
23. Mental health services provide valuable assistance to people 1.2 8.9 90.0 1–7 6.00 (1.04) 6 N/A
experiencing a mental health problem
24. I will work in a medical-surgical setting for at least a year 30.4 28.9 40.7 1–7 4.14 (1.93) 4 90.03, p¼.000 - Australia more likely to agree, less likely to disagree
before considering a career in mental health nursing - Ireland less likely to agree, more likely to disagree
25. People with mental illness can’t handle too much responsibility 59.7 25.7 14.6 1–7 3.12 (1.44) 3 26.37, p¼.001
26. I feel safe about this psychiatric/mental health placement 26.9 20.7 52.4 1–7 4.49 (1.63) 5 91.71, p¼.000 - Finland more likely to agree, less likely to disagree
- Ireland more likely to disagree
27. The way people with mental illness feel can be affected 3.1 8.8 88.1 1–7 5.96 (1.16) 6 N/A
by other people's attitudes towards them
28. People with mental illness are more likely to commit 57.2 27.3 15.6 1–7 3.14 (1.42) 3 27.80, p¼.001
ISSUES IN MENTAL HEALTH NURSING

offences or crimes
Note: Students in the Netherlands did not respond to these items. Students in Ireland did not respond to this item.
833
834 B. HAPPELL ET AL.
Age and gender
There were few observed relationships between either age or
gender and responses to the MHNES that reached statistical
significance. In cases where they did, the size of correlation
was low. Older participants tended to agree more with the
following statements: “I will work in a medical-surgical set-
ting for at least a year before considering a career in mental
health nursing” (r ¼ .13, p < .01), and “I am familiar with
the needs of people with mental illness” (r ¼ .11, p < .05).
Female students tended to agree more that “Someone I
know has experienced a mental health problem” (r ¼ .10,
p < .05), and disagree more than male students that “My
course has prepared me to work as a graduate nurse in
a psychiatric/mental health graduate programme” (r ¼ .13,
p < .05), and “I feel safe about this psychiatric/mental health
placement” (r ¼ .13, p < .05).
Opening minds scale
For the OMS, overall percentages, descriptive statistics
and v2 results for country variations are presented in
Table 3 below.
Overall responses
There was a general pattern of students having positive atti-
tudes towards people with a mental illness diagnoses; inclu-
sion, the capacity for care provision to be helpful and
advocacy. For items to do with a capacity to help people
with mental illness, ratings leaned to the positive end – such
as 79% disagreeing that “there is little I can do to help peo-
ple with mental illness” (item 13). Sixty-one per cent dis-
agreed that “the best treatment for mental illness is
medication” (item 16). Sixty-two per cent disagreed that
“Healthcare providers do not need to be advocates for peo-
ple with mental illness” (item 18) and around 79% agreed
“It is the responsibility of health care providers to inspire
hope” (item 11).
In terms of social distancing, there tended to be positive
ratings in relation to settings within and outside of the
workplace. For example, there was a median response of
“agree” that “I would not mind if a person with a mental ill-
ness lived next door to me” (item 19), and of “agree” to “If
a colleague with whom I work told me they had a managed
mental illness, I would be just as willing to work with him/
her” (item 3), with around 87% agreeing with this statement.
Responses suggest a willingness to disclose having a mental
illness diagnosis and seeking related help. For instance, 68%
agreed that “If I had a mental illness, I would tell my
friends” (item 10). However, reluctance featured more
strongly in the workplace, with 32% disagreeing, 35% neu-
tral and 33% agreeing that “If I were under treatment for a
mental illness I would not disclose this to any of my
colleagues” (item 4). Like the MHNES, perceived dangerous-
ness was more varied—26% disagree, 40% neutral and 34%
agreed that “people with mental illness seldom pose a risk
to the public” (item 15).
Between-country variations in responses
Table 3 reports statistically significant variations by country
for ten of the twenty items of the OMS. Students in Ireland
tended to disagree more with negative statements about
mental illness (e.g. that “there is little I can do to help peo-
ple with mental illness”, item 13), suggesting more positive
attitudes than the other countries. This was not uniform—
for instance, those in Ireland were less likely to disagree (as
well as those in the Netherlands) that “It is the responsibility
of health care providers to inspire hope in people with men-
tal illness” (item 11), while those in Finland were more
likely to agree. Norwegian students rated a higher comfort
in “helping a person who has a physical illness”, compared
with people with mental illness diagnosis (item 1), and Irish
students had the opposite orientation. Several differences
were found for the view that “Healthcare providers do not
need to be advocates for people with mental illness” (item
18). Students from Australia and the Netherlands were more
likely to disagree, while those in Norway were less likely to
disagree. Disclosure of mental illness to friends “if I had
a mental illness” (item 10) was endorsed more often for the
Netherlands and less so for Australia.
Age and gender
Only one OMS item was associated with age: those who
were older were very slightly more likely to agree with the
following statement: “I would see myself as weak if I had
a mental illness and could not fix it myself.” (r ¼ .12,
p ¼ .014, p < .05). Small statistically significant correlations
were observed for the relationship between gender and three
OMS items. Females, compared to males, were more likely
to disagree that “I struggle to feel compassion for a person
with mental illness” (r ¼ .10, p¼.035, p < .05), more likely
to agree that “I would not mind if a person with a mental
illness lived next door to me” (r ¼ .10, p ¼ .039), and agree
with “I would be more inclined to seek help for a mental
illness if my treating healthcare provider was not associated
with my workplace” (r ¼ .10, p ¼ .049, p < .05).
Discussion
This project contributes to the growing international
research base pertaining to nursing students’ attitudes
towards people diagnosed with mental illness (Gonzales,
Davidoff, Nadal, & Yanos, 2015; Schomerus, Matschinger, &
Angermeyer, 2014; Schomerus et al., 2012), in particular, the
viewpoints of those employed in or entering the health care
workforce (de Jacq, Norful, & Larson, 2016; Del Olmo-
Romero et al., 2018; Itzhaki et al., 2017; Linden &
Kavanagh, 2012).
Literature reviews examining the trends in attitudes
towards mental illness diagnoses from the general public,
have found some incongruent beliefs. The importance the
public places on health care for the well-being of people
experiencing symptoms of a mental illness has increased.
Despite this, there is no evidence of improvement, in fact a
Table 3. Response patterns for the Opening Minds Survey (n ¼ 423).
Response (%) (and mode in bold font) Country differences

Neither agree Mean (Standard Median Differences (only those where

Statement Disagree nor disagree Agree Deviation) (label) v2 statistic & p value overall v2 was p<.001)
1. I am more comfortable helping a person who has a physical illness 39.0 31.0 30.0 2.83 (1.10) 3 Neither agree 54.71, p¼.000 - Norway more likely to agree, less likely to disagree.
than I am helping a person who has a mental illness nor disagree - Ireland less likely to disagree, more likely to agree.
2. If a person with a mental illness complains of physical symptoms 64.5 23.8 11.7 2.32 (0.91) 2 Disagree 16.96, p¼.031
(e.g., nausea, back pain or headache), I would likely attribute this to
their mental illness
3. If a colleague with whom I work told me they had a managed 4.3 8.3 87.4 4.30 (0.85) 4 Agree 30.44, p¼.000 - Norway less likely to agree, and more likely to ‘neither
mental illness, I would be just as willing to work with him/her agree nor disagree’
- Ireland less likely to ‘neither agree
nor disagree’
4. If I were under treatment for a mental illness I would not 32.0 35.1 32.9 3.00 (0.99) 3 Neither agree 13.87, p¼.085
disclose this to any of my colleagues nor disagree
5. I would be more included to seek help for a mental illness if my 16.0 20.2 63.8 3.63 (1.02) 4 Agree 32.27, p¼.000 - The Netherlands more likely to disagree
treating healthcare provider was not associated with my workplace - Finland more likely to disagree
- Norway less likely to disagree
6. I would see myself as weak if I had a mental illness and 55.7 20.1 24.2 2.56 (1.11) 2 Disagree 39.77, p¼.000 - Finland more likely to agree, less likely to disagree
could not fix it myself - Ireland less likely to agree, more likely to disagree
7. I would be reluctant to seek help if I had a mental illness 59.8 19.3 21.0 2.43 (1.09) 2 Disagree 22.63, p¼.004
8. Employers should hire a person with a managed mental 3.8 13.1 83.1 4.21 (0.83) 4 Agree 36.03, p¼.000 - Norway more likely to ‘neither agree nor disagree’,
illness if he/she is the best person for the job and less likely to agree
- The Netherlands less likely
to ‘neither agree nor disagree’, and more likely to agree
9. I would still go to a physician if I knew that the 5.9 20.7 73.4 3.93 (0.89) 4 Agree 24.47, p¼.
physician had been treated for a mental illness The Netherlands
002
10. If I had a mental illness, I would tell my friends 10.2 22.2 67.6 3.77 (0.95) 4 Agree 30.95, p¼.000 - Australia more likely to disagree less likely to agree
- The Netherlands more likely to agree
11. It is the responsibility of health care providers to inspire 4.3 16.2 79.5 4.14 (0.88) 4 Agree 59.66, p¼.000 - Finland more likely to agree
hope in people with mental illness - The Netherlands more likely to disagree and
‘neither agree nor disagree’ and less
likely to agree
- Ireland more likely to disagree
12. Despite my professional beliefs, I have negative 83.0 10.9 6.1 1.83 (0.89) 2 Disagree 25.22, p¼.001
reactions towards people who have mental illness
13. There is little I can do to help people with mental illness 79.1 14.5 6.4 1.95 (0.90) 2 Disagree 38.22, p¼.000 - Finland less likely to disagree and more likely to ‘neither
agree nor disagree’
- Ireland more likely to disagree and
less likely to ‘neither agree nor disagree’
14. More than half of people with mental illness don't try hard 64.0 29.4 6.6 2.17 (0.92) 2 Disagree 24.79, p¼.002
enough to get better
15. People with mental illness seldom pose a risk to the public 25.7 40.4 34.0 3.08 (0.96) 3 Neither agree 25.01, p¼.002
nor disagree
16. The best treatment for mental illness is medication 61.4 33.6 5.0 2.23 (0.86) 2 Disagree 23.91, p¼.002
17. I would not want a person with a mental illness, even 55.8 30.7 13.5 2.44 (1.00) 2 Disagree 86.96, p¼.000 - Finland more likely to agree and less likely to disagree
if it were appropriately managed, to work with children - Ireland more likely to disagree and less likely to ‘neither
agree nor disagree’
18. Healthcare providers do not need to be advocates for 62.2 26.8 10.9 2.22 (1.01) 2 Disagree 126.74, p¼.000 - Australia more likely to disagree, and less likely to
people with mental illness disagree or ‘neither agree nor disagree’
- Norway less likely to disagree and more likely
to agree, or ‘neither agree nor disagree’
- The Netherlands more likely to disagree and less
likely to agree or ‘neither agree nor disagree’
19. I would not mind if a person with a mental illness lived 7.8 16.8 75.4 4.00 (0.96) 4 Agree 18.6, p¼.017
ISSUES IN MENTAL HEALTH NURSING

next door to me
20. I struggle to feel compassion for a person with mental illness 87.2 8.5 4.3 1.68 (0.84) 1 Strongly disagree 17.14, p¼.029
835
836 B. HAPPELL ET AL.
deterioration in attitudes and beliefs in regards to having
a mental illness diagnosis (for example people diagnosed
with mental illness are more dangerous) remains evident
(Schomerus et al., 2012). The findings from the current
project support this research, even taking account of the
variations between countries. For instance, there was more
variation in perceived dangerousness than for other areas of
attitudes and beliefs, and concerns about the dangerousness
of people with mental illness remains relatively high.
Concerns about aggression were evident, with two-thirds of
students disagreeing that “people with mental illness seldom
pose a risk to the public” and almost half agreeing they “are
more likely to be violent”.
Variations between student cohorts according to country
were evident in attitudes to clinical mental diagnoses and
mental health nursing. Australian and Irish students tended
to hold more positive attitudes around mental illness than
other cohorts. Finnish students held quite varied attitudes,
having more positive views on some areas (e.g. responsibility
for providers to inspire hope) and more negative on others
(e.g. seeing oneself as ‘weak’ if having mental illness).
Norwegian students seemed less confident and prepared to
work with people diagnosed with mental illness. To date the
research into these subjects has predominantly been under-
taken in Australia (Happell, Byrne, Platania-Phung, et al.,
2014; Millar, 2017; Stevens et al., 2013). Other countries
where such research has been undertaken includes Croatia
(Arbanas, Bosnjak, & Sabo, 2018), Singapore (Ong et al.,
2017), United States (Thongpriwan et al., 2015), the Middle
East (Itzhaki et al., 2017), the United Kingdom
(Schafer et al., 2011), and New Zealand (Bingham &
O’Brien, 2018).
One research project focussed specifically on comparing
attitudes of mental health nurses in five European coun-
tries using multivariate analysis of variance, based on the
Community Attitudes towards the Mentally Ill (CAMI)
self-report measure (Chambers et al., 2010). Ireland and
Finland were two of the countries compared in this project.
The findings suggested Irish nurses were more likely to
endorse the therapeutic value of community care, and
deinstitutionalised care as an effective model than Finnish
nurses. A similar Ireland-Finland difference was found in
relation to benevolence; defined as “a sympathetic view of
those experiencing mental health problems, based on
humanistic principles,” (p. 353) with Irish students demon-
strating higher levels of benevolence. Findings of the cur-
rent project showed more positive attitudes from Ireland
than Finland. Specifically, nursing students in Ireland self-
reported more familiarity with mental health nursing, more
sense of efficacy in this type of nursing in furthering the
recovery of people diagnosed with mental illness, greater
understanding of the needs of people experiencing symp-
toms, and less social distancing than students in Finland.
In contrast to these trends, two important factors must
be considered in interpreting these results. Firstly, the
Chambers et al. (2010) research was conducted with
registered nurses as opposed to students. Secondly, as pre-
viously discussed, the students from Ireland in the current
research are completing a specialist programme in mental
health nursing. Given students have elected to undertake
this specialty, it is logical that there is a higher prevalence
of more positive attitudes. However, given the attitudes of
the Australian nurses in the current research were similarly
positive to the Irish cohort, although Australia has adopted
a comprehensive model of education (similar to Finland),
it is likely that cultural differences in perspectives of
mental health illness account for at least some of these
differences between countries.
Attitudes to mental health nursing as a career appear
more positive than those demonstrated in other research
(Bingham & O’Brien, 2018; Happell, Byrne, Platania-Phung,
et al., 2014; Happell & Gaskin, 2013; Itzhaki et al., 2017;
Millar, 2017; Ong et al., 2017; Stevens et al., 2013;
Thongpriwan et al., 2015). It is however, important to note
that strong agreement with intention to pursue a career in
mental health nursing remains low, suggesting it is not the
first preference for the majority of students. Enhancing the
popularity of mental health nursing in countries utilising
a comprehensive education approach therefore continues to
remain problematic.
A limitation to the design of the studies in this project is
that it was fully based on self-report data. For self-report,
social desirability may potentially play a role in rating levels,
such as participants intentionally or unintentionally tending
to put more positive responses. Due to time limitations with
student participants, it was not feasible to include a ‘check’
for social desirability, such as the Marlowe-Crowne Social
Desirability Scale (Reynolds, 1982). It would be desirable
for future research studies on student attitudes to include
this type of instrument alongside the attitudinal measures.
A further limitation is that student variations in responses
by country may conflate with differences in the educational
context. For instance, nursing students in Ireland were in
a course exclusively on mental health nursing while those in
Finland were enrolled in a comprehensive programme. As
a result, it could not be definitively inferred whether the
divergences in responses reflected country-specific view-
points, or rather, reflected whether or not the degree special-
ised in the mental health area.
Conclusions
The findings from this research highlight the importance
of understanding attitudes towards people diagnosed with
mental health illness and to mental health nursing as a
speciality profession. Education has been demonstrated to
positively influence attitudes in both of these domains.
Maximising this opportunity requires an understanding of
attitudes students hold before they commence the mental
health component of their programme. The current project
also provides baseline information to measure changes in
attitudes following the introduction of content taught by an
Expert by Experience.
This project shows that most nursing students had
positive perceptions of people diagnosed with mental illness.

Nevertheless, too many hold considerable stigma before
commencing their clinical mental health placements. The
provision of high quality and effective mental health services
requires a competent workforce with the capacity to create
a therapeutic environment. Pessimistic or negative attitudes
impede this goal. Nurses are the largest professional group
within the mental health workforce and thus have a crucial
role to play. Ensuring sufficient numbers of skilled and
recovery-orientated mental health nurses can meet future
workforce demands must be a priority. Understanding
student nurses’ views of mental illness diagnoses and nursing
care is therefore essential.
Acknowledgements
The authors acknowledge and thank:
 Erasmus þ for the funding which made this innovative pro-
ject possible.
 the students who generously gave of their time to complete the
questionnaires
 Ms. Nathasha Munasinge for her assistance with coordinating data
collection from participating countries and for data entry for the
Australian component
 staff who assisted with the distribution and collection of question-
naires and with data entry
ORCID
Brett Scholz http://orcid.org/0000-0003-2819-994X
Mari Lahti http://orcid.org/0000-0002-3403-5418
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