Elsevier

Psychiatry Research

Volume 206, Issue 1, 30 March 2013, Pages 81-87
Psychiatry Research

Mental Illness: Clinicians' Attitudes (MICA) Scale—Psychometric properties of a version for healthcare students and professionals

https://doi.org/10.1016/j.psychres.2012.09.028Get rights and content

Abstract

There are currently no published scales to assess the attitudes of students and professionals across a wide range of healthcare disciplines towards people with mental illness. Secondary analysis from a randomised controlled trial (RCT) of anti-stigma interventions was carried out to test the reliability, validity and acceptability of the Mental Illness: Clinicians' Attitudes (MICA) v4 scale, a modification of the MICA v2 scale in a sample of 191 nursing students. The MICA v4 was found to have good internal consistency (α=0.72) and item-total correlations. Principal component analysis produced a five-factor structure and the scale had acceptable convergent validity. A group of students and professionals within the healthcare discipline (n=5) reported that the MICA v4 had good face validity and suggested its use with students and professionals working in non-mental health settings. The scale had low rates of missing data, good readability and took less than 4 min to complete. The MICA v4 scale was found to be a reliable, valid and acceptable measure of foundation year nursing students' attitudes towards mental illness. It has the potential for use with students and qualified staff across a range of healthcare professions and is available for use from the authors.

Introduction

Stigma can be conceptualised as an overarching term that encompasses problems of knowledge such as inaccurate myths about mental illness, negative attitudes towards people with mental health problems and discriminatory behaviour towards this group (Thornicroft et al., 2007). These stigmatising attitudes may vary according to different socio-demographic characteristics such as gender (Angermeyer and Dietrich, 2006), ethnicity (Silton et al., 2011) and knowing someone or having a personal experience of mental illness (Corrigan et al., 2003). Staff studying or working within the healthcare disciplines often come into contact with people with a mental illness. However, despite the vital role they play in the provision of both physical and mental healthcare, health professionals tend to hold negative attitudes towards individuals with mental illness (Chaplin, 2000, Hugo, 2001, Bjorkman et al., 2008, Volmer et al., 2008, Rao et al., 2009, Horsfall et al., 2010). Practitioners, including general practitioners, psychiatrists and clinical psychologists, have reported more negative ratings of individuals with a mental illness than the general public (Jorm et al., 1999, Nordt et al., 2006) and also expressed a greater desire for social distance (Feret et al., 2011). Other studies have found the attitudes reported among physicians and nursing staff to be equally stigmatising and comparable to that of the general public (Bjorkman et al., 2008, Hori et al., 2011). Moreover, a questionnaire survey of hospital staff and medical students has reported negative attitudes, with nursing staff holding the most negative views (Arvaniti et al., 2009). Pharmacists have also been found to view people with mental illness as having an unrealistically poor long-term prognosis (O'Reilly et al., 2010).

It has been shown that health professionals may contribute to the development and maintenance of stigma through the use of stigmatising terms (Sartorius, 2007) and psychiatric labelling (Schulze, 2007). Patients have also reported feeling stigmatised in their relationship with mental health professionals by a lack of interest shown towards them (Schulze, 2007). This can have negative consequences for individuals with a mental illness, having an effect on their recovery (Horsfall et al., 2010) and ultimately the relationship between patients and professionals (Feret et al., 2011). Many researchers have highlighted the importance of health professionals having an awareness of how their attitudes and potentially stigmatising views towards individuals with mental illness might have potential detrimental consequences on both patients and the public (Caldwell and Jorm, 2001, Jorm et al., 1999, O'Reilly et al., 2010).

There has been a wealth of research carried out on the attitudes of health professionals towards people with mental illness (Arvaniti et al., 2009, Jorm et al., 1999, Schafer et al., 2011). However, there appears to be an absence of an appropriate scale which may be used to assess the attitudes of students and professionals across a wide range of healthcare disciplines as :each existing scale tends to be limited to its original intended group (Baker et al., 2006, Kassam et al., 2010, Svensson et al., 2011). We know of only one other scale for use with health professionals and this is currently unpublished. Previous research has employed a number of scales to assess the attitudes of health professionals towards individuals with mental illness, but many of these were not originally developed for use with clinical populations (Arvaniti et al., 2009, Schafer et al., 2011, Svensson et al., 2011).

For example, the Community Attitudes towards the Mentally III (CAMI) scale has been used to investigate the attitudes of student nurses towards people with mental illness (Chambers et al., 2010, Schafer et al., 2011). The CAMI has also been recently validated among a group of student nurses (Hogberg et al., 2008) and a modification of the scale has been found to be suitable for use with European professional nurses (Morris et al., 2012). However, as the authors of the modified version concluded, the overall validity of the scale in accessing nurses' attitudes towards people with mental illness remains questionable as the scale was originally developed for use with the general public (Kassam et al., 2010, Morris et al., 2012). The same is true for the Opinions about Mental Illness (OMI) scale (Arvaniti et al., 2009, Cohen and Struening, 1962, Pankhurst, 2010). In addition, the OMI scale has several subscales reporting a range of internal consistencies for the different factors ranging from 0.21 to 0.89 (Kassam et al., 2010, Nickerson et al., 1994). Furthermore, the overall internal consistency of the OMI is yet to be established (Kassam et al., 2010).

Different versions of the Attribution Questionnaire (AQ) have been used to assess the attitudes of psychology and nursing students (Corrigan et al., 2003) as well as mental health professionals (Pankhurst, 2010). However, it has been noted that the psychometric properties of the different versions of the AQ are not clear, warranting further research to establish its validity (Brown, 2008, Van Brakel, 2006).

More recently, the reliability of the “Changing Minds” and Fear and Behavioural Intentions (FABI) scales has been examined during assessments of the attitudes of nursing students towards individuals with mental illness (Svensson et al., 2011). The subscales of the Changing Minds questionnaire had low internal consistency with alpha coefficients ranging from 0.19 to 0.46 whereas the FABI scale was found to have high internal consistency with an alpha of 0.80 (Svensson et al., 2011). However, like the CAMI, these scales were not originally developed for use with health professionals.

Finally, the Attitude Toward Acute Mental Health Scale (ATAMHS 33) was developed to address the need for a measure of health professionals' attitudes towards mental illness in acute mental health care settings (Baker et al., 2006). The scale has been employed mainly in the UK to assess the attitudes of nursing staff (Baker et al., 2006, Munro and Baker, 2007), but studies using this scale have also included a range of professionals including psychiatrists, social workers, psychologists and occupational therapists (Ahmead et al., 2010). The scale has been found to be reliable and valid, and it has been suggested for use in evaluating change in nurses' attitudes towards mental illness following education (Baker et al., 2006). However, the application of the ATAMHS 33 scale is restricted to assessing the attitudes of health professionals towards individuals with mental illness who are acutely unwell.

To address these limitations, the Mental Illness Clinicians' Attitudes scale (MICA v2) was developed to assess the attitudes of medical students towards people with mental illness as well as the field of mental healthcare. The scale was found to be a reliable (α=0.79; test-retest=0.80) and valid measure of medical students' attitudes towards mental illness (Kassam et al., 2010). Convergent validity was assessed using the Mental Disorder Understanding Scale (r=0.17), and divergent validity was determined using the Complementary Health Beliefs Questionnaire (r=−0.08) and the Marlowe–Crowne Social Desirability Scale (r=−0.27). It also demonstrated responsiveness to change following an intervention, with a standardised response mean (SRM) of 0.4. Factor analysis yielded seven factors, indicating the need for further research to assess its internal structure (Kassam et al., 2010). Additionally, the sample sizes used for assessing the reliability and validity were small in some cases.

As an extension to the work conducted on the MICA v2 (medical student version), our research group developed a version that is suitable for use with students and professionals within any healthcare discipline (MICA version 4). The aim of the study reported in this article was to assess the psychometric properties of the MICA v4 scale with a sample of nursing students. We also aimed to present a socio-demographic profile of participants broken down by relevant categories.

Section snippets

Design

This study has a cross-sectional design and is a secondary analysis of 4-month follow-up data from a randomised controlled trial (RCT) of anti-stigma interventions (Clement et al., 2012).

Participants

Participants were nursing students in their foundation year of an English university with an intended specialty of adult, child or mental health nursing. At 4-month followup, 193 participants completed the measures (89% response rate), but, two outliers were removed and were excluded from the analyses. Of the

Scale properties

The mean score of the MICA v4 was 34.55 (S.D.=7.11, n=183), with a range of 17–54. Following the removal of two outliers, the data set had acceptable levels of skew (0.27, SE=0.18) and kurtosis (−0.26, SE=0.36) values, and visual inspection of the distribution curve indicated a normal distribution. Skewness and kurtosis values were found to be acceptable as they were within the required range of +1 to −1 (Lamping et al., 2002). However, the Kolmogorov–Smirnov test was significant (D (183)=0.09,

Discussion

The MICA v4 scale was developed to assess the attitudes of health professionals towards individuals with mental illness, and its psychometric properties have been assessed. The MICA v4 was found to have good internal consistency established by Cronbach's alpha and item-total correlations. Principal component analysis revealed a five-factor structure. The scale was also found to have satisfactory convergent and face validity with statistically significant moderate correlations between the RIBS

Conclusions

The MICA v4 scale was found to be a reliable, valid and acceptable measure of foundation year nursing students’ attitudes towards mental illness. Students and professionals within the healthcare disciplines who reviewed face validity endorsed its use with students and professionals working in non-mental health settings as well as staff working in both mental and general healthcare. The MICA v4 scale addresses the limitations of previous scales in that it was modified to include items specific

Acknowledgement

This article presents independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (No. RP-PG-0606–1053). The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. GT is also funded through a NIHR Specialist Mental Health Biomedical Research Centre at the Institute of Psychiatry, King's College London and the South London and

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