Healthcare Workers’ Attitudes Towards Patients Diagnosed with a Mental Illness

Alexandra W. Moore
Edson College of Nursing and Health Innovation, Arizona State University

Author Note
Alexandra W. Moore is a registered nurse at Phoenix Children’s Hospital in the
perioperative unit.
She has no known conflict of interest to disclose.
Correspondence should be addressed to Alexandra W. Moore, Edson College of Nursing
and Health Innovation, Arizona State University, Health North Suite 301, PO Box 873020,
Tempe, AZ, 85287. Email: alwhitne@asu.edu

Abstract
Healthcare workers may have poor attitudes, bias or feel unprepared when caring for
patients with mental illness in the pediatric intensive care unit (PICU) setting. The aim of this
project was to resolve these biases using education to increase quality of care for pediatric
mental health patients using Rossworm and Larabee’s change model. The Questionnaire on
Stigmatizing Attitudes Towards Children with Emotional and Behavioral Disorders (EBD) was
completed by voluntary participants at pretest, posttest and at a one month follow up. Between
pretest and posttest, participants engaged in three educational modules regarding mental health.
Participants were voluntary, anonymous staff members at a pediatric hospital currently employed
in the PICU. Results of the questionnaires pre M= 23 post M=11 and follow up M=9.5 indicates
education improves attitudes, and decreases bias in PICU staff. Recommendation to obtain larger
population of study with trial implementation. Recommend adding educational modules to
annual education or to new hire orientation.
Keywords: mental health, healthcare worker, attitudes, bias, patient care

Healthcare Workers’ Attitudes Toward Mental Health Patients
Hospital staff members often feel uncomfortable caring for patients with psychiatric
disorders. The attitudes could be due to inexperience, bias, stigma, or lack of preparedness.
Recognition of personal bias and management of one’s emotions is important for the patient and
their family members. Stigma interferes with managing mental health disorders (Centers for
Disease Control and Prevention [CDC], n.d.). Depending on the severity of the psychiatric
disorder, healthcare workers may encounter physical aggression and violent acts, which can add
to the emotional involvement and increase the need for education to reduce harm and improve
patient safety. Unfortunately, the lack of preparedness and education can lead to incidents of
staff injuries and patient restraints.
Background and Significance
Problem Statement
Mental health has a significantly high prevalence, with one in five adults developing a
mental health problem in any given year (Morgan et al., 2018). Poor and undesired outcomes are
associated with those diagnosed with mental illness and co-occurring medical illness (Loeb et al.,
2012). Biases are likely to influence treatment, levels of care, and diagnosis (FitzGerald & Hurst,
2017). Implicit biases occur from a group attribute to a negative evaluation and manifest in
behaviors toward an individual (FitzGerald & Hurst, 2017). Even discussions about the mental
health specialty receive judgmental responses (Flaskerud, 2018). These attitudes lead to failure to
treat the whole patient, and ignoring the psychiatric aspect. It is easy to focus on acute healthcare
concerns and disregard the patient’s mental health in a medical unit. This happens because it is
known, less discussed, and more challenging. A consultation is often required to manage mental

health symptoms or a new diagnosis from psychiatry, psychology, or social work, rather than
merely treating the physical medical problems.
One-third of primary care patients are diagnosed with depression; according to Loeb et al.
(2012), this adds to the complexity of primary care provider’s workload and knowledge base.
Mental health complaints are commonly encountered first at a primary care visit, requiring the
primary care provider to address the complaint and determine if it requires a referral to a
psychologist, a psychiatric provider, or treatment at their current visit. Medical providers require
specialized training for psychiatric disorders to care for their patients properly. This care comes
with requirements to recognize personal bias and manage the provider’s emotions, the patient,
and family members.
Purpose and Rationale
Mental health issues can affect anybody, and they do not discriminate. Patients with
mental health symptoms could be placed in any hospital unit, not solely in a psychiatric unit.
Any patient being cared for may have suffered from psychiatric illness or have a history of a
mental health diagnosis. Therefore, every health care worker requires the knowledge for proper
interactions and care of a patient with a mental health disorder. Results from a survey to better
understand attitudes toward mental illness show greater than 80% of individuals agreed that
treatment for mental health is sufficient; however, 35%-67% reported the health care workers as
sympathetic and caring (CDC, n.d.). By understanding the attitudes toward the mental health
population, the care given can improve, which will improve patient outcomes.
Mental disorders are associated with an increased risk for violence and aggression
(Richter & Whittington, 2006). In addition to attitude, physical violence is an aspect that is
required to address and manage in healthcare. Depending on the severity, healthcare workers

may encounter physical aggression and violent acts. This can add to the emotions involved in
caring for patients with psychiatric disorders. It also increased the need for education to reduce
harm and improved safety to patients and staff. Unfortunately, lack of preparedness and
education can lead to incidents of staff injuries and patient restraints.
Epidemiological Data
Healthcare Workers
Responses from nurses to mental health patients, specifically borderline personality
disorder, were found to have counter-therapeutic reactions with the patients (Dickens et al.,
2016). In addition to attitudes, healthcare workers also have a bias, whether conscious or
subconscious. Evidence from a study by FitzGerald and Hurst (2017) indicated that healthcare
professionals and the wider population exhibit similar implicit bias levels.
Education and Preparedness
Medical education exists to reduce bias. These bias-focused educational programs
increased healthcare workers’ knowledge and comfort levels in caring for specific populations
(Morris et al., 2019). The biases held by healthcare workers are known to affect patient care,
including assessment findings, treatment plans, and quality (Morris et al., 2019). Negative
communication may take place due to bias. The educational programs evaluated in this study
effectively improved health care workers’ knowledge regarding the population and treatment
(Morris et al., 2019). In addition to the knowledge improvement, healthcare workers’ comfort
levels increased in caring for the vulnerable population after education was provided (Morris et
al., 2019). Healthcare students and workers can become aware of personal biases, and by
increasing their awareness and knowledge, they will improve patient outcomes and reduce health
disparities (Morris et al., 2019). A study of a tool to evaluate mental health education and

training was performed in England with the NHS Workforce Development Confederations.
According to Brooker and Curran (2006), the national continuous quality assurance tool was
developed and found to provide a useful framework allowing assessment of the quality mental
health education and recommended implementation into the system. Brooker and Curran (2016)
discuss a specific tool developed to assist in educational implementation.
Current Training
Because mental illness is the leading cause of disability worldwide (Tyerman et al.,
2020), healthcare workers' preparedness is vital. Hospitals have standard orientation for new
hires, which includes specific training for the various staff. It is known that the specialty of
mental health needs increased workers as the volumes of individuals requiring assistance
continue to grow. Psychiatric nursing has not been an area of focus that nursing professionals are
encouraged to enter. The focus has been to have nursing students start in medical surgical
nursing. Nurse residency programs focus and specialize in areas other than mental health, such as
emergency nursing, medical/surgical nursing, and critical care (Nadler & Loucks, 2011).
Because any patient in the hospital may have a mental health disorder, there should be a focus on
this population.
Future State
Various interventions to assess education and improve knowledge with decreased stigma
have been researched, such as implementing mental health first aid training (MHFA). A systemic
review by Morgan et al. (2018) found MHFA training improves mental health first aid
knowledge, recognition of mental disorders, the confidence of the healthcare worker, and
improvements in the amount of help provided to the patient (Morgan et al., 2018). There is a
relationship between burnout in healthcare professionals and poor-quality care (Tawfik et al.,

2019). This can be avoided by proper training and education. Developments and applications of
psychiatric care have been behind other areas of care (Kilbourne et al., 2018). It is known that
mental health care requires improvement, which can start in the hospital setting with education.
The barriers of stigma can be addressed and reduced by specialized training education to bridge
the gap for appropriate care (Kohrt et al., 2018). According to Giacchero Vedana et al. (2017),
training in mental health may improve attitudes and emotional competencies required for
patients.
Internal Evidence
The pediatric intensive care unit (PICU) manager brought forward concern from
administration surrounding staff attitudes and patient sitters’ interactions with patients.
Unfortunately, the communication between mental health patients and staff members is not
always constructive and therapeutic. The staff members will try to ‘parent’ the patients and set
their own rules. After discussion with the staff in a PICU, the general staff attitudes were brought
to attention. Staff members have been observed making negative comments regarding their
assignments of mental health patients. The staff who interact this way require specific training,
preparation, and education to improve the outcome. The healthcare staff face burnout and have
their own bias, whether it is subconscious or conscious.
PICOT
This inquiry has led to the PICOT question, for hospital staff caring for pediatric patients
in the intensive care unit with mental health diagnoses, does providing mental health education
affect bias, attitudes, and preparedness to impact outcomes for patients and healthcare workers
compared to current hospital training?

Evidence Synthesis
Search Strategy
An extensive review of three databases was performed to answer the PICOT question.
These included ProQuest, PubMed, and CINAHL. These three were specifically selected for
their relevance to psychiatric, mental health, health care, medical field, and nursing. The PICOT
keywords were addressed in all three of the databases which included: attitudes, education,
mental health patient, bias, improved outcomes, hospital staff, ICU, and health care workers.
Similar PICOT words searched included staff, mental illness, mental disorder, psychiatric
illness, stereotype, inpatient, ward, and nursing. Terms for the outcome searched included
patient outcome, training, compassion fatigue, preparedness, and readiness. Filters applied
included the publication date within the past five years (2016-2021), peer-reviewed journal
articles, English language, systematic reviews, and full text. MESH and Boolean terms were
used to expand the search. The titles and abstracts were assessed.
ProQuest
The initial yield of ProQuest included key terms attitudes, mental health patient, and
healthcare worker. This resulted in 239 results; on the next search, ICU was added, limiting the
results to two results. The wording was altered with each search moving forward, including
education, bias, hospital staff, nursing, and improved outcomes, resulting in 69, two, 21, then
one result.
PubMed
The initial search with PubMed included mental health patient and attitude resulting in
311 results. When the term bias was used instead of attitude, the results increased to 496.
Compassion fatigue and nursing were added to mental health patient, with only one result.

Healthcare worker and education were added to mental health patient, and 64 resulted. Other
key terms used in PubMed were education, training, staff, and patient outcome; other results
included 12 and ended with 38.
CINAHL
The initial CINAHL search included mental health/mental illness/mental illness/mental
disorder/psychiatric illness and biases/bias/stereotype/attitudes and nursing. Due to the ability
to include numerous key terms to be interchangeable, this resulted in 4,224. The following
searches included healthcare workers/medical workers/preparedness/education/training to
narrow the search results, including 598, 172, 1,733, 1,705, 66, and 968.
Exclusion criteria included articles before 2016, articles that were not relevant to the
PICOT, and that did not address health care. Reviewing the titles and abstracts assisted in
yielding relevant studies to the PICOT question. Higher levels of evidence were preferred over
articles. Rapid critical appraisals were conducted, then limited to 10 articles for further
evaluation.
Critical Appraisal and Synthesis of Evidence
Melnyk & Fineout-Overholt (2019) developed the rapid critical appraisal process, which
is used to determine overall quality. Two categories of articles that went through the rapid
critical appraisal process included qualitative (see Appendix A, table 2) and quantitative (see
Appendix A, table 1). The quality of research articles remains high. There is a wide range of
research found and discussed (see appendix A table 3). A combination of qualitative and
quantitative studies were included in these synthesis tables to provide support toward healthcare
workers having a bias, opinion, or certain attitude toward patients with mental health problems

which is a barrier to proper care and positive patient outcomes. They are supportive of the
PICOT.
The research articles referenced in the table include discussion surrounding attitudes
toward mental health patients, or attitudes/bias toward patients in the health care setting. The
studies took place in various countries. The importance of patient outcomes, proper and adequate
care, and burnout are brought up. Poor quality care is addressed. A few of the studies had limited
reviews while the others were more successful.
Conclusion
The evidence of potential bias, poor attitude, or judgment toward patients with mental
health issues or diagnosed disorders is present and proven. The evidence also suggests various
outcomes to combat the problem at hand. There may be a requirement of time and low cost to
implement learning modules, a course upon hire, or an annual refresher course provided at the
hospital for all staff. By implementing this change practice into the training regulations, staff will
be as prepared as possible, self-aware of any potential bias, and improve patient outcomes.
Theoretical Framework and Implementation Framework
Theory Application
Education, preparedness, self-reflection, and awareness can prevent unintended
outcomes, or poor treatment for patients with mental health illnesses or diagnoses. The theory of
self-transcendence has a background in understanding developmental processes of overall wellbeing (Reed, 2008). This theory aims to promote well-being regardless of challenges or difficult
life situations (Reed, 2008), (see Appendix B table 1).
The theory can directly apply as it was encouraged to be formulated in child and
adolescent psychiatric mental health care. By assisting well-being, the theory can increase the

level of understanding for the process of development (Reed, 2008). Due to this finding,
healthcare workers should be able to learn and better comprehend the patient and their needs
regardless of their mental health state or diagnosis.
Implementation Framework
Rosswurm and Larrabee’s change model fits because it focuses on assessing the need for
change through each step throughout implementation. Regarding this project, there is a need to
change to the current process. Staff, patients, and administration will benefit. Rosswurm and
Larrabee will assist in the steps to guide this new practice (see Appendix B figure 2).
The primary investigator formulates plans following the step to step process necessary to
finalize and perfect the phases. The model adapts to the individual issues addressed to produce
an efficient change process. This type of quality improvement goal fits into the steps provided by
the Rosswurm and Larrabee model, if the project requires changes or revision, the model will
seamlessly allow for it (Rosswurm & Larrabee, 2007). At the fifth step, it is decided if the
change in practice will adapt, adopt or even reject the proposed practice change (Rosswurm &
Larrabee, 2007). In the final step to the model, the outcomes and processes will be monitored
and evaluated, which will be performed in this change project. The model aligns with this
doctorate project.
Implications for Practice Change
The evidence found during research leads the project to provide additional education
regarding personal bias and mental health patients. The population of mental health patients
requires the same care from healthcare workers as other populations being treated regardless of
their history or background. Healthcare workers will have higher satisfaction rates in their job
and improve patient outcomes with the proper preparedness. The work environment will be able

to provide this education either during the hiring process, specific training, or annual refresher
educational classes. It would also benefit the healthcare workers if specialty classes were offered
throughout the year by the employer. An assessment was performed to rate healthcare workers’
baseline understanding and attitudes toward this patient population before implementation.
The stakeholders include patient care technicians, nurses, behavioral health technicians,
respiratory therapists, child life specialists, patients, patient family members, physical therapists,
occupational therapists, speech therapists, nurse practitioners, and physicians. Data collected
includes a questionnaire regarding staff attitudes, understanding of mental health patients, what
type of learning intervention healthcare workers would prefer, and the intervention’s outcome.
The intervention selected to assist with this gap was a learning module via PowerPoint. A pre,
post and one month follow up questionnaire were used to measure outcomes.
Methods
Ethical Considerations and Human Subject Protection
If any staff members become upset or feeling as if they need to speak with somebody due
to the nature of the project contact they were encouraged to reach out to the PI or contacts given
in the consent form. IRB approval was received from both Arizona State University as well as
the hospital site IRB (see Appendix C).
Population and Setting
Population of this project includes current PICU staff members at a pediatric hospital in
the greater Phoenix area in the state of Arizona.
Change to be Achieved and Expected Impact
The hope was to create a change of attitude toward mental health patients in the PICU
setting with education. When it comes to the PICU and how healthcare workers treat mental

health patients, the staff would greatly benefit from further education about individual’s mental
state, including their own. With this cost-effective implementation of education to the staff, the
workplace saw a change in culture, patient outcomes, and overall satisfaction. Without
awareness, education, and understanding, there can be no change or growth.
The PICU providers care for various patients with mental health problems during the
most critical phase of illness. A patient may be admitted to the PICU with an attempted suicide
or may have an acute or chronic medical condition with a co-morbid mental health disorder.
Regardless of the reason for admission, the patient’s mental health care is vital. The patient’s
well-being is the standard of care and an important aim of this project.
Project Description and Timeline
The project’s intention was to provide current employees with education and resources in
order to assist preparedness and confidence in treating patients with mental health issues. Project
outcomes included improved preparedness, confidence, knowledge, and attitude. The project
timeline was about a month and a week.
The DNP project information posted into ‘PICU Pals’ Facebook group took place to offer
the opportunity to participate. The post explained the general project. Individuals emailed an
inquiry. If interested, these individuals were given the project purpose, terms and consent to
complete to move forward. Participants had time to review information, ask questions and clarify
participation to be comfortable with participating before signing consent to participate. At this
time the participants provided consent and completed a demographics survey followed by the
pre-survey. The demographics survey included length of employment, age, current role and
gender and took approximately two minutes. The attitudes survey measured how strongly the
participant agreed or disagreed to the statement and took approximately five minutes. The

questionnaire was called Questionnaire on Stigmatizing Attitudes Towards Children with
Emotional and Behavioral Disorders (see Appendix D). Statements surround attitudes toward the
pediatric population who have emotional/behavioral disorders. Once the pre survey and
demographics survey were completed the participant completed modules one, two, and three.
This took place via PowerPoint. Modules took approximately 15-20 minutes to complete in total.
Total project time requirement was up to 60 minutes. After completion of educational modules
the participants completed the attitude measurement survey which included the same questions
as the pre-survey. One month following the education completion, participants completed a
follow up post-survey of the Questionnaire on Stigmatizing Attitudes Towards Children with
Emotional and Behavioral Disorders with the same questions. Data received from all pre, post
and one month follow up post survey were uploaded to Intellectus Statistics to run statistics and
data modeling to determine if the education on mental health influenced health care workers’
attitudes toward mental health patients in the PICU.
Analysis
Descriptive statistics was performed to describe the sample, outcome variables and
explain the clinical significance of the findings. Intent to treat was utilized for this project.
Budget
No funding or budget obtained or needed.

Results
Outcomes and Significance
The average age of the subjects was 31 (SD= 5.29). The ages range from 27 to 37 years.
All participants were female and Registered Nurses (RN). Years of work ranged from 3 to 7+.
The pre questionnaire had an average score of 23 (SD = 7.81) The pre scores ranged from
18 to 32. The post questionnaire had an average of 11.33 (SD = 5.03). The post scores ranged
from 6 to 16. The follow up questionnaire had an average of 9.50 (SD = 7.50. Follow up scores
ranged from 2 to 17.
The participant with length of work of 3-5 years had the largest improvement from a
score of 19 during the pre survey to 2 at the follow up timeframe.

Means of Attitudes Toward Mental Illness
25

Attitude Mean Score

20

15

Means

10

5
T1TS

T2TS
T1-Pre Attitude T2-Post Attitude T3-Follow Up

T3TS

Impact of Project
The attitudes improved overall from pre, post to the follow up survey. Educational
modules implemented improved attitudes over time.
Sustainability
This project intervention can be sustained and implemented at the hospital. Education
modules can be implemented with new hires, new graduate hires, annual competencies or with
unit education in services.
Discussion
Summary and Conclusion
Education improves healthcare worker attitudes toward mental illness. Education is cost
effective, easily implemented, and evaluated, and is sustainable. The questionnaire has a max
negative score of 70 and a minimum score of 0 for most positive attitude. The mean attitude
score decreased from a mean of 23 down to a 9.5 for the one month follow up which suggests an
improvement of attitudes toward mental health after education was implemented to staff.
Limitations and Barriers
Strong interest in project and outcomes, yet limited participation was noted. Limited
participants in the study are noted of n=3. Recruitment strategy may need to be looked into in
order to obtain a substantial number of participants for a larger number of results for data
analysis. Another possible barrier may be current burnout levels of healthcare staff in PICU
related to the COVID 19 pandemic.
Literature Relation and Recommendations for Future
The educational modules utilized in this project improved attitudes, similarly to what was
found during literature review. Education has been proven to improve preparedness, attitudes and

bias. With the results obtained from the questionnaires, this project is suggested to be related to
literature that exists and was researched prior to this project study. Measuring attitudes on a
larger population of study will be beneficial in the future. Trialing educational modules in
hospital training to evaluate sustainability and attitude improvements is recommended.

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Appendix available upon request.