Illuminating Emergency Nurses’ Perceptions of Stigma, Attribution, and Caring Behaviors Toward People With Mental Illness Through the Lens of Individualized Care: A Cross-sectional Study

Abstract

Introduction

Emergency nurses’ negative attitudes and lack of caring have been identified as factors affecting the experience of individuals with mental illness in emergency departments. This study examined the relationships between emergency nurses’ perceptions of stigma, attribution, caring behaviors, and individualized care toward people with mental illness.

Methods

A cross-sectional study was conducted among 813 nurses working in United States emergency departments. Data were collected using a demographic questionnaire; the Mental Illness: Clinicians’ Attitudes Scale-4; the Attribution Questionnaire; 24-Item Caring Behaviors Inventory; and the Individualized Care Scale-Nurse version. Data analyses consisted of descriptive and correlation statistics and multiple linear regression.

Results

The findings from the final regression analysis revealed that caring had a significant relationship with individualized care (version A: β = 0.70, P < .001; Version B: β = 0.73; P < .001). Stigma and attribution had significant inverse relationships with individualized care (β = −0.07, P < .01; β = −0.06, P < .05, respectively).

Discussion

The results of this study indicated that emergency nurses’ perception of individualized care toward people with mental illness is mostly associated with the nurses’ level of caring behaviors toward this population. Stigma and attribution had little to no effect. Findings from this study reinforce nurses’ altruistic and caring qualities. The findings suggest the need for a possible paradigm shift from antistigma training to trainings that prioritize caring behaviors toward mental illness. This could ultimately improve health equity, safety, and overall outcomes for people with mental illness.

Introduction

People with mental illness experience significant health disparities and inequites. It is reported that people with serious mental illness die on average 25 years earlier from treatable medical conditions as compared to the general population.¹ The emergency department is often the point of entry into the health care system for people with mental illness, particularly those experiencing crisis. From 2017 to 2019 in the United States, there were 52.9 ED visits per 1000 adults per year with a diagnosis of a mental health disorder.² The high prevalence of ED usage by people with mental illness is caused partially by limited resources and access to mental health services.3, 4, 5 Nonetheless, emergency nurses experience significant and unique challenges impeding their ability to deliver quality and safe care to this population.⁴

An essential component of care quality, person-centered care, and overall health outcomes is individualized care.6, 7, 8, 9 Individualized care is defined as nursing care delivery that considers the patient’s personal characteristics in their clinical situation, personal life situation, and preferences, while promoting their participation and decision making in care.¹⁰ Van Servellen¹¹ further added that individualized nursing care translates standard nursing procedures and tasks into care that is personally designed to meet each patient’s uniqueness. Growing evidence suggests that people with mental illness experience health inequities,3, 4, 5 which are defined as systemic differences in opportunities that affect people’s ability to achieve optimal health, thereby leading to avoidable and unfair health outcome disparities.¹²

Emergency nurses have identified inadequate educational preparation, lack of support, staffing and material resources, concerns of safety, the physical design of the environment, crowding, organizational culture, personal biases, stigma, and attribution as contributing barriers to delivering quality care to people with mental illness in the emergency department.13, 14, 15, 16, 17, 18, 19 Individuals with mental illness experience extended ED lengths of stay that can be up to 4 times longer than the general population.² This is often exacerbated by barriers with admission to inpatient psychiatric settings and community resources.

Of great concern are the experiences of stigma reported by emergency nurses19, 20, 21 and care recipients.22, 23, 24, 25 According to Link and Phelan,²⁶ stigma exists in power situations where there is co-occurrence of labeling, stereotyping, separation, status loss, and discrimination. Moreover, the emotional responses that shape behavior toward a person who experiences stigma is defined as attribution.^27,28 For example, when it is perceived that mental illness is caused by weakness, bad character, or free will, then endorsement of stigmatizing attitudes, discrimination, and social distance ensues.

Recipients of care with mental illness in the emergency department have described that the negative experiences in the emergency department often result in feelings of anxiety and have worsened their presenting symptoms.22, 23, 24, 25 These experiences also have led to self-harming behaviors and substance use to self-medicate in effort to avoid ED visits.²⁹ It has been predicted that the COVID-19 pandemic is contributing to and exacerbating our nation’s ongoing mental health crisis.³⁰ As such, the effects of the COVID-19 pandemic will likely contribute to the already existing health care challenges and inequities for individuals with mental illness, particularly in the emergency department.

Extensive research has been done on the care of people with mental illness in the emergency department. However, most were undertaken in international settings and were of qualitative designs. Owing to possible cultural and structural differences, their generalizability and transferability may be limited to settings in the United States. In addition, the findings of these studies are incongruent with the caring nature of nurses in that they report emergency nurses display negative attitudes toward people with mental illness, which has resulted in harm to care recipients.19, 20, 21, 22, 23, 24, 25

Although the conceptualization of stigma (and attribution) has been widely used and tested, they have not been tested with emergency nurses. Moreover, despite its significance in the promotion of quality care and overall health outcomes, individualized care has yet to be researched in the context of mental illness. A careful examination of the associations between emergency nurses’ perceptions of individualized care, stigma, attribution, and caring toward people with mental illness may help in the development of interventions to advance health equity and decrease health disparities for people with mental illness. Therefore, the purpose of this study was to determine the relationships between emergency nurses’ perceptions of stigma, attribution, caring behaviors, and individualized care toward people with mental illness in the United States.

Owing to the incongruence in the literature with the innate caring characteristics of nurses, Swanson’s³¹ Theory of Caring was used as a theoretical framework for this study. According to Swanson,³¹ caring is “a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility”³¹ (p. 162). The fundamental and universal component of quality nursing care is caring for a person’s biopsychosocial and spiritual well-being.³¹ The Theory of Caring has 5 caring processes that lead to the intended outcome of client well-being: maintaining belief, knowing, being with, doing for, and enabling. The intended outcome of well-being is one that promotes dignity, respect, empowerment, and empathy for the care recipient.^31,32