IMAGES OF MENTAL ILL AMONG NURSES

ILLNESS AND THE MENTALLY IN A DEVELOPING COUNTRY* MICHAEL MlCKLrNt

Battelle Human Affairs Research Centers, Seattle. WA, U.S.A.

and CARLOS A. LEON Universidad de1 Valle. Cali. Colombia

Abstract-While a number of recent studies have attempted to assess the quality and the significance of nurses’ orientations toward the mentally ill. these investigations suffer from a number of inadequacies in scope and method. Utilizing less formal techniques, this study examines a variety of views on mental illness for a random sample of 114 Colombian nurses. Emphasis is placed on definitional and identifying criteria, perceived differences between persons suffering from more and less serious forms of mental disorder and several beliefs about persons suffering from mental illness. These nurses’ images tend to be relatively uncrystallized and eclectic although behavioral and psychological perspectives are slightly more predominant. Variations in terms of position in the nursing division of labor and personal characteristics are minimal. Results are interpreted to indicate the lasting influence of ‘cultural norms. on the one hand and the relatively minor influence of occupational socialization. on the other. Several directions for future research are suggested.

In recent years considerable attention has been given to analysis of nurses’ orientations toward mental illness and the mentally ill. Results from a number of studies suggest that professional nurses hold more sophisticated and humanitarian views than do health workers of lower status with less formal training [lIO]. Another general conclusion is that psychiatric experience, primarily through formal training sessions, leads to the development of more positive attitudes toward the mentally ill [l l-l 71. Additional studies have indicated further bases of differentiation in psychiatric attitudes among nurses including class and cultural backage C9.1S]. social ground [2,9, 191 and the nature of ‘the work setting [ZO]. Informative as these studies may be. however. there are yet many deficiencies and lacunae in existing research that must be overcome before an accurate appreciation of the relationship between the nursing role and orientations toward mental illness is possible. Perhaps the greatest single deficiency lies in the fact that the vast majority of studies have been conducted * This research was supported by the Tulane UniversityUntversidad de1 Valle International Center for Medical Research. Grant AI 10050 from the Institute for Allergy and Infectious Disease. The final version was written while the first author was affiliated with the MRC Social Psychiatry Unit. Institute of Psychiatry. London. supported by: Research Grant MH 24677 from the Center for Epidemiologic Studies. National Institute of Mental Health. U.S. Public Health Service. Assistance in data collection and analysis was provided by Lida Victoria. Joan McMullen and Joanne Lowery. Julian Leff provided helpful comments on an earlier version of this paper. + Current address: Population Study Center. Battelle Human Affairs Research Centers. 4000 NE. 41st Street. Seattle. Washington 98105. U.S.A.

in highly industrialized countries having a common cultural heritage. Many important influences may be overlooked by such an emphasis. For example it is widely recognized that nursing is largely a female role [21,22] and its occupants are thus senstive to the status of women in society and the ideological climate surrounding familial organization [23,24]. The less industrialized countries are generally more restrictive regarding the social control of female activities [25] and thus nursing roles in these societies may be patterned quite differently than in more developed areas. The significance of societal variations in the structure of social inequality for a wide variety of role behaviors is well documented [26] although consequences for nursing, and health workers generally, have yet to be investigated in any detail. It is clear, however, that the organization of health care services in developing nations is somewhat distinct and highly variable [27]. Finally, cultural belief systems regarding the nature of illness differ considerably from one society to another as well as among sub-cultural units within societies [Zl, 28,291. In short, the prevailing focus of research on nursing orientations toward relationships with the mentally ill has been largely limited to advanced industrial societies, thus restricting the possible range of observations and generalizations. Another deficiency results from the fact that research has been concentrated on psychiatric nurses or nursing students undergoing psychiatric training. This is a curious limitation, given the widespread recognition that the traditional role of the nurse generally has involved meeting the emotional needs of the patient [21,22.30] and even recent changes in the organization of nursing roles would not appear to have altered this expectation [24]. Also. given that general practice studies indicate a wide range of psychological problems among non-psychiatric

441

MICHAEL MICKLIN AND CARLOS A. LEON

43’

patients [31], it is likely that nurses. too. must encounter and deal with comparable issues. The point is that all varieties of nurses are. in carrying out their everyday roles. subjected to patients exhibiting psychiatric symptoms and their orientations toward mental illness thus constitute an important focus of research from both practical and theoretical points of view. A third limitation of existing research stems from the limited range of questions used to ascertain nurses’ views regarding mental illness. Frequent use has been made of attitude scales such as the CM1 [3] and the OMI [ 1.21 with results reported in terms of factor or scale scores. While such procedures are methodologically defensible. responses to individual items may often be even more informative. Alternately, openended questions, while more difficult to evaluate, may provide a more accurate representation of the nurse’s subjective position. Even psychiatric nurses have been shown to have relatively uncrystallized and eclectic orientations toward mental disorder and its treatment [32] and thus premature closure through the use of highly structured methods of data collection should be avoided. The foregoing comments suggest the need for more broadly based studies of nursing orientations toward mental illness. The study reported here is designed to contribute toward this end. More specifically, it is focused on a sample of nurses working in an urbanized area of Colombia. a Latin American country currently experiencing the turmoil of social change and development. A variety of orientations toward mental illness and the mentally ill are examined for nurses with varying levels of training and practical experience. The purpose of this article is to describe these orientations and to assess patterns of variation according to selected respondent characteristics.

in the type and extent of training received. Graduate nurses. including those with M.S.. B.S. and general nursing degrees. received extensive university training in three areas: maternal and infant care. psychiatry and mental health, and surgical nursing. Additional training is received in planning. administration and research methods, as well as the biological and social sciences. Auxiliary nurses must have a minimum of two years of high school and complete a three-year program of nurse training. 18 months of coursework and 18 months of practical experience. The coursework is centered around patient care as well as understanding of family and community problems. The third group, nurse aides, must have completed the primary level of school (5 yr) and receive 18 months of on-the-job training. Thus, the three groups are distinct from one another in terms of the amount of schooling and formal nursing education received as well as their exposure to principles of behavioral science. It is to be expected, then, that they will differ in their knowledge about and orientations toward mental illness. Selected characteristics of the three samples are presented in Table 1. Age differences are evident in that auxiliary nurses are somewhat younger than the other two groups. All three samples consist largely of females, with the few males located among the nondegree nurses. In all three groups roughly two-thirds of the respondents are not married (including those Table

1. Selected

characteristics of nurses status*

by occupational

METHODS AND MEASURES

Wring

and

samplr. The data reported here are taken from a more inclusive study of medical and paramedical personnel recently conducted in Cali. Colombia. This city of nearly one million inhabitants provides a wide range of modern medical facilities and is generally known as one of the more progressive centers for health care in Latin America. A comprehensive roster of selected types of health care workers in Cali was compiled from professional directories, lists of employees from medical care institutions, customer records from drug companies and the telephone directory. As part of the larger study, independent random samples of three categories of nurses were selected in the following proportions: Xl”,; of graduate nurses and lo”/, of auxiliary nurses and nurse aides [33]. Interviews were ultimately conducted. by two specially trained social workers, with 26 graduate nurses, 33 auxiliary nurses and 55 nurse aides. The larger proportion of graduate nurses is due to their relatively small representation in the total population of nurses in Cali at the time of the study, which included 141 graduates. 346 auxiliaries and 554 aides. Two graduate nurses and 1 auxiliary refused to be interviewed. The three categories of nurses differ considerably

* Deviations from total Ns of 26 (Graduate Nurses). 33 (Auxiliary Nurses), and 55 (Nurse Aides) are due to lack of information on certain characteristics. Percentages are rounded due to the small numbers of respondents involved.

Mental

illness among

nurses

single, separated and widowed). Given the differing educational requirements for the three types of nurses, it was assumed that each represented a distinct level of social status within the nursing profession. This assumption is borne out by the differences seen in the three status indicators presented in Table 1. While all of the graduate nurses for whom data are available locate themselves in the middle or upper class, this is true of only 59”,, of the auxiliaries and 46”/, of the nurse aides. In terms of place of residence. while 87?; of the graduate nurses live in middle or upper class barrios (neighborhoods), relatively few respondents among the other categories of nurses are equally situated. The barrios of Cali have been ranked by the municipal planning office according to a variety of characteristics of socioeconomic status. These were averaged and a ninestep scale of barrio statuses constructed. For purpose of this analysis the top four and bottom five levels have been separated as “upper” and “lower” categories. Finally. the three groups are differentiated as to the status of the areas of the city in which they are employed. Eighty-eight per cent of the graduate nurses and 76”b of the nurse aides work in higher status barrios, but this is true for only 527, of the auxiliaries. Data analysis. During the course of the interview respondents were presented a number of questions designed to reflect their views on mental illness and the mentally ill. First, they were asked, “What is a loco?” (mentally ill person) [34]. A second category of questions was aimed at ascertaining the characteristics respondents attributed to persons who were /oco. including the means by which they could be identified, their best “qualities.” and their worst “defects.” A third objective was to determine whether respondents thought there were differences between locos and nervous persons and if so what these were. Finally. a set of questions regarding miscellaneous attributes of mental illness and the mentally ill asked whether all locos behave in the same manner. whether locura can be cured. whether the mentally ill are dangerous and whether persons who commit suicide are mentally ill. Codes for open-ended questions were initially derived by two Colombian research assistants and subsequently refined b> the authors. In the analysis that follows. emphasis IS placed on comparisons among the three groups of nurses as well as within-group comparisons according to selected respondent characteristics. RESULTS T/w &finitio~~

of‘Loc0. Previous reports on concepTable

2. Definition

in a developing

443

country

tions of mental illness in Latin America have indicated that views of both the general public and many health workers tend to be rather vague [34-371. This is only slightly less true of the nurses considered here. Forty-five per cent define the concept of loco in terms of psychological attributes such as disturbances in cognition and intelligence. anxiety. worrying. anguish and irritability while another 24’j, focus on behavior problems such as aggression, destruction. and a general lack of control in social relationships [3X]. Fourteen per cent are unable to define this concept, 9’lb respond with a popular synonym (e.g. a ‘nut.” one who is “off his tracks” or “has a screw loose”). 7’;/, provide an approximation of a technical psychiatric definition of a psychotic [39] and 2 per cent base their detimtton on some type of organic disorder. Clearly, these nurses’ images of the loco are premised upon a broad- concept of mental illness rather than one specifically oriented toward psychosis [40]. Differences among the three groups are minimal and not statistically significant (see Table 2). Ths most evident, and perhaps expected, variation is the decreasing reference to technical definitions among graduates. auxiliaries and nurse aides, in that order. Definitional variations within the three groups are also minor although greater use of behavioral definitions is evident for auxiliary nurses whose class identification is working or lower class (p = 0.07, Fisher’s Exact Test (41)). Characteristics of the Loco. From the foregoing analysis of definitions of the concept of loco one might expect that when asked for the primary characteristic by which locos can be identified. the nurses would continue to emphasize psychological and behavioral criteria. However, this is not the result obtained. While 58:); indicate that locos are to be identified by their behavioral characteristics, only 13% cite psychological attributes. Twenty-two per cent of these nurses state that the primary identifying feature of a loco is his physical state. including facial expression, the look of the eyes, the condition of the brain or nervous system and his general appearance. in sharp contrast to the previously mentioned lack of emphasis on definitional criteria of a physical or organic nature. Negligible proportions of respondents (3% or less) mention the loco’s relationship to his environment. his general “abnormality,” or his lack of contact with reality as primary identifying characteristics [42]. It is also interesting to note that while 16 of these nurses are unable to define the concept of loco, all but 2 are able to provide a primary identifying feature. This may be due to the fact that the

of loco by occupational

status

(in percentages)*

Graduate hYT.eS

15

8

”

42

19

15

AuxiliarV Nurses

9

9

3

42

28

9

(33)

9

2

47

21

2

(55)

xurse

Aides

16

* Percentages total horizontally. Deviations from loo”, are due to rounding. i Definition reflects popular or folk terminology. : Definition in terms of technical psychiatric terminolog) stressing lack of contact

(26)

with realit!.

44-l

MICHAEL MICKLIN A&D CARLOS .A.

definitional question was asked first while later questions allowed respondents more time to think about the topic in question. On the other hand. this difference in response frequency may suggest that the status of loco is more easily conceived in terms of specific characteristics rather than a more generic definition. Several differences are evident among the three groups of nurses (see Table 3) although none is statistically significant. The largest of these suggests that physical features are somewhat more important for both of the lower status groups. It should also be noted that only the graduate nurses mention characteristics reflecting a technical definition of the loco. Variations in respondent characteristics associated with features employed to identify locos show only two differences that approach statistical significance. Older (30 yr or more) graduate nurses are more likely to indicate behavioral characteristics (p = 0.10. Fisher’s Exact Test) and unmarried auxiliaries more frequently employ psychological features (p = 0.07. Fisher’s Exact Test). Respondents were also asked their opinions regarding the best qualities and worst defects of locos. With respect to qualities, fully 65% of these nurses cannot name any. Another 177; say locos are quiet and affectionate while 99’, suggest that their best quality is a spontaneous and outgoing nature. Four per cent of the nurses indicate that locos are gifted and extraordinarily intelligent and the remaining 7% mention an assortment of miscellaneous qualities [43]. Regarding the defects of locos. only 29% of the respondents interviewed did not name any. The largest number (41%) indicate physical defects such as brain damage. unpredictable body movements and a generally poor appearance. Thirteen per cent mention emotional or affective handicaps, 80,: suggest that tacos’ worst defect is seen in their troublesome behavior and interpersonal relationships, another 3% focus on immorality and 2Y.imention various clinical (technical) symptoms. Finally, 69; of these nurses name other miscellaneous defects and 4p/; say that locos have no defects [44]. Although the small number of nurses indicating qualities of the loco and the variety of defects mentioned prohibit more detailed anatysis, it is interesting to note that all three groups of nurses are clearly more likely to mention defects than qualities and the nurse aides are least likely to specify either. Only one within-sample difference is statistically significant. indicating that auxiliary nurses who work in lowcr status barrios are more likely to enumerate qualities of the loc~o (p = 044. Fisher’s Exact Test). Table

3. Primary

characteristic “AbnO~liCy”

for identifying E%yaical State

Lrou

Colttrusts hrnrerrt Locos nttd “17erz.o~~~” prrsorrs. The data presented thus far suggest that these nurses have a fairly broad and amorphous concept of the loco. Nevertheless. only 3 of those Interviewed (I auxtliary and 1 nurse aide) fail to indicate differences between a loco and a person who could be characterized as nervous [35]. When asked for the principal criterion by which these two conditions could be differentiated. respondents are again somewhat vague and unsystematic. They frequently provide pairs of attributes that are not substantively comparable. e.g. “the loco is incurable while the nervous person does not behave differently than normal people”. While all respondents recognizing differences are able to mention at least one attribute of the loco. 3”” are unable to identify a corresponding attribute of the nervous person [46]. Overall. 454; of the total sample indicate that. as opposed to nervous persons. locos have lost contact with reality. Another 17”d mention behavioral symptoms and 134; suggest that locos feel apathetic. mdifferent. or depressed. Of the other differentiating features attributed to the loco. including the permanence or seriousness of the disturbance. the need for remedial action. the organic basis of the symptoms, problems in communication and relatively low social acceptability. none is mentioned by more than 49; of the respondents [47]. Views on the distinguishing features of nervous persons are distributed somewhat more evenly. Thirty-eight per cent of these nurses suggest that people who are nervous. as opposed to the loco. are in contact with reality while 227” say that they suffer from emotional problems. Another 12’;, distinguish those who are nervous by their lack of behavioral symptoms and 1lo, emphasize the temporary nature of this disorder. The lack of any need for remedial action is mentioned by 7’2 of the nurses and the few remaining responses suggest that nervous persons have less difficulty in communication and suffer from less serious dtsturbances that are not organically based [48]. Differences among the three groups of nurses are not statistically significant but are substantively interesting. First, the view that contact with reality is a distinctive feature of nervous persons is increasingly evident as occupational status decreases while the contrasting view. that lack of contact with reality is distinctive of the loco. is relatively constant among the three groups. Second. only the auxiliary nurses fail to indicate the importance of affective symptoms and this evaluation is true only with regard to the loco. Finally. the opinion that the presence of hehava Loco

Psvchological

by occupational Behavior

z.tace

status

(m percentages)’

neiarion CO Technical

Tocal

Enviranmenr Oef‘nitio”

N

Graduate NYrSeS

4

12

12

54

8

1:

(26)

Auxiliary NUT?...

0

27

18

54

D

0

(33)

Nurse AL&t

2

23

11

62

2

0

(571

* Percentages total horizontally. Deviations from ICO’~, are due to rounding. +The two nurse aides who could not specify a primary identifying characteristic from this table.

are omitted

445

Mental illness among nurses in a developing country

A&/iti~~~uIopirrions. These nurses show little variation regarding all but one of the other images queried. Ninety per cent agreee that the mentally ill are not dangerous, 99% feel that locos do not all behave similarly, and 93% do not believe that locuru is a permanent condition [SO]. When asked whether people who commit suicide are mentally ill, however, only 657: agree and some differences in opinion are apparent (see Table 5). Nurse aides are considerably less likely to respond affirmatively to this question (x’ = 6.93, 0.05 > p > 0.02) while within-group differences are minimal.

ioral symptoms is distinctive of the loco while their absence characterizes the nervous person is unique to nurse atdes and the view that nervousness is a temporary disorder is apparent only for auxiliary nurses. Several variations in the bases for differentiating between locos and nervous persons are evident within the three types of nurses. The view that locos are out of contact with reality is greater among younger graduates 0, = 0.04. Fisher’s Exact Test). Married graduates are more likely to differentiate [ocos by the need for remedial action @ = 0.10) and nervous persons by the lack of necessity for such intervention @ = 0.04. Fisher’s Exact Test). Another method for examining these distinctions between locos and nervous persons focuses on the degree of interpretation involved. On the one hand, some responses are purely “descriptive” in that they simply reflect a recognition of symptoms characterizing the disorder in question, including organic, affective. behavioral and communicative attributes. On the other. a second group of responses may be designated as “evaluative” in that they suggest more specific knowledgeof the impact or consequences of the disturbance. These include references to the permanence or seriousness of the condition, its social acceptability, the need for remedial action and whether or not the person afflicted is in contact with the realities of normal social life. The pattern of response for the combined samples shows a strong preference for the use of evaluative criteria, 647; for the loco and 62% for the nervous person [49]. Several differences are evident, however. when the three groups of nurses are contrasted (see Table 4) although they fail to reach an acceptable level of statistical significance. Auxiliaries are more likely to use evaluative criteria in distinguishing the loco, followed by graduates and nurse aides respectively. For descriptive criteria. the order of preference is of course just the reverse. Differentiation of nervous persons in evaluative terms is greatest among nurse aides although auxiliary nurses and graduates are not far behind. The range of \,Mrltion among the three groups is somewhat greatel ior the loco. It should also be noted that only with the nurse aides are evaluative criteria thought to be more important for distinguishing nervous persons than for locos. Differcnces within significant.

the three

groups

Tabir

AND

DISCUSSION

Overall patterns. As a group these nurses show several tendencies and a few inconsistencies in their images of mental illness. In this respect they appear to be uncommitted to any particular psychiatric orientation, similar to the psychiatric nurses studied by Strauss and his colleagues [32]. When asked to define the concept of loco in the abstract, nearly half offer a psychologically based interpretation and about one-quarter indicate a definition couched in behavioral terms. Only 2% of those interviewed suggest that the loco should be defined according to physical or organic criteria. However, when requested to name the primary characteristics by which locos may be identified, fully 60% emphasize behavioral attributes while the proportion of psychologically based responses decreases to 13% and the proportion of a physical or organic nature increases to 22%. These inconsistencies suggest a differential basis for abstract as opposed to more concrete images of the loco. The abstract notion is probably associated with a tendency, common among health workers as well as with the general public, to refer to persons whose acts violate cultural and situational norms as “mentally” disturbed or ill. Concrete images, however, are more likely based upon linguistic descriptions or direct observations of what such a person actually does, i.e. of the very activities by which he is defined as deviant. It is not surprising, then, that the identifying characteristics of the loco are more typically represented in hehavioral terms. The generally stigmatized view of the loco is evident in that the proportion of nurses willing or able to indicate his worst defect is twice that naming his best quality although this discrepancy is much less than

statistically

4.

Evaluative vs descriptive criteria for differentiating between locos and nervous persons by occupational status (in percentages)*

Graduate

N”me6

Auxiliary Nurse

are not

SUMMARY

N”r*eS Aides

63

37

57

43

(24)

76

24

62

38

(31)

57

43

65

35

(52)

* Percentages total horizontally within each major category. Omitted are those respondents who saw no difference between locos and nervous persons as well as the few whose responses were ambiguous and therefore not codable. For the loco category. combining graduate nurses and auxiliaries. Q = 0.028. /1 = 24&I.p > 0.20. For the Nervous category. Q = -0.11. x2 = 0.33. p > 0.20.

346

MICHAELIMICKLIYAND CARLOS.-\. LEOX

Table 5. Opinion as to whether people who commit suiill by occupational status (in cide are mentally percentages)*

Graduate Nurses

77

23

(26)

AuxiliaryNurses

76

24

(33)

Nurse Aides

53

47

(55)

* Percentages total horizontally. Combining graduate nurses and auxiliaries, Q = 0.48. %I = 6-93. 0.05 > p > 0.02.

is evident for the general public. Of the qualities that are mentioned. the majority center around personal characteristics that would contribute to ease and efficiency in nurse-patient relationships. Defects tend to be more variable, but it is interesting to note that 5X”,, are said to be of a physical or organic nature, This tendency may be associated with the popular belief that mental illness is Iargely due to hereditary or organic factors [51]. Its significance resides in the nurse’s view of her role as “healer” [23]. To the extent that treatment of physical and organic problems is beyond the nurse’s capacity, then such conditions inhibit this aspect of her role performance and may thus be defined as “defects” of the patient. Given the wide range of conditions and characteristics these nurses attribute to locura, it is perhaps surprising that all but two of those interviewed recognize that this condition is distinct from nervousness although the specificity of the question asked may have created a bias toward a response not commensurate with actual knowledge. The fact that some respondents give inconsistent and illogical contrasts also supports this contention. In contrast to their criteria for defining and identifying locos, 45% of these nurses differentiate the loco by his lack of contact with reality while other psychological and behavioral symptoms are mentioned much less frequently, and physical symptoms hardly at all. Nervous persons are distinguished primarily by their being in contact with reality, followed by the presence of emotional or affective problems, the lack of behavioral symptoms and the fact that the disturbance is temporary and does not require remedial action. While it is clear thdt the loco is recognized to be suffering from a more disturbing and problematic condition, it is also evident that the two labels sympolize overlapping symptoms for many of these nurses. Examination of the locc+nervous differences in terms of the evaluative-descriptive dichotomy indicates that just over 60:/; of those interviewed make evaluative distinctions for both conditions. This suggests a slight tendency to think of both locura and nervousness in terms of their impact on personal and social functioning rather than isolated symptomatic characteristics. Such a position may reflect a degree of personal concern for the disturbed person’s welfare. a likely consequence of the “motherroles surrogate” aspect of traditional nursing

althou_ph it should be pointed out that the general public IS little different in this regard. More than 90”,, of these respondents indicate that the mentally ill are not dangerous. that all /OCYLS do not behave alike and that loctrw need not be permanent. They are more divided on the question of whether suicide implies mental illness. with but 65”,, in agreement. This latter result is hardly surprising given that even psychiatrists and behavioral scientists disagree on this issue. Occupatior7al cariatiom. It would be expected. @ten the differences in formal and specialized traming among the three groups. that greater sophistication in images of mental disorder would be exhibited by the graduate nurses. followed by the auxiliaries and nurse aides. respectively. According to a statistical significance criterion. results do not support this expectation although several images show some differentiation by occupational status and warrant brief discussion. That graduate nurses are most likeI\ to utilize “lack of contact with reality” as the primary definitional and identifying characteristics of the loco suggests that they tend to identify locura with psychosis to a greater extent than auxiliaries or aides although the proportion doing so is relatively small. Graduate nurses also stand apart in that they are much less likely to identify the loco in terms of physical or organic characteristics or to mention “contact with reality” as the primary differentiating feature of nervous persons. The latter concept may well be viewed as a cIichC. masking the more essential features of nervousness. by this more highly educated group. Auxiliary nurses’ images are the most diverse, some distinct and others more in accord with members ol one of the other two groups. This pattern probably reflects their middle rank in terms of formal nursing education. Thus, auxiliaries stand between graduates and aides regarding the use of reality contact as a definitional criterion of the loco and the evaluative differentiation of the nervous person. They are closer to the graduates in terms of their association of suicide with mental illness and to the aides with respect to identification of locos by physical characteristics and the use of contact with reality to differentiate nervousness. However, auxiliaries are distinguished by their greater use of behavioral definitions and mention of psychological identify,ing features in characterizing the [oco, their recogmtlon that nervousness is more likely a temporary disorder and their more frequent use of evaluative characteristics in differentiating the loco. Perhaps these nurses present more diverse and sometimes conflicting images of mental Illness due to the dual intluence of a minimal amount of formal training and the popular notions inherent in their cultural background. Nurse aides are least likely to utilize lack of contact with reality to define the loco, most likely to identify and differentiate this condition in terms of behavioral disorders. least likely to see either qualities or defects in the loco. least likely to see nervous persons as manifesting behavioral problems and most likely to differentiate such persons evaluatively. and least like11 to associate suicide with mental illness. Only with regard to the differentiation of locos in terms of evaluative characteristics do they share a perspective

447

Mental illness among nurses in a developing country

nurses while the few views corresponding to those of the auxiliaries have already been mentioned. Of the three groups of nurses interviewed, the aides only minimally affected by experience and training in nursing care probably most clearly reflect the views of the general public. The ir$uence qfpersonal characteristics. At the outset of this study it was expected that the images examined would show within-group variation associated with the nurses’ age, marital status, subjective social class identification and the general status of the area in which they work. The cultural status of age differentiation in Latin America has an important bearing on attitudes and personal conduct [X-54]. Older persons generally are accorded considerable prestige and status and their views are respected and listened to. Younger persons, on the other hand. are more hesitant to express definitive opinions, knowing that they may be “overruled” by their elders. Age is of additional significance in the present context in that older nurses are more likely to have more experience in treating and caring for those who are ill and thus should have formed more concrete views on the nature of illness. Marital status is an especially salient factor, given that the large majority of these nurses are women and considering the strength of the family as a social institution in Latin America [55-573. Marriage is a normative expectation and goal for women and once married. they are not expected to work outside the home [SS] although some variation is found by ethnic and social status and level of urbanization [59]. Thus. unmarried nurses, especially the older ones, occupy a deviant cultural status, which should influence their orientation toward occupational role performance as well as beliefs about illness. Another important consideration, mentioned earlier, is the “mother-surrogate” aspect of traditional nursing roles, which may be more salient for those who are married. Colombia, like other Latin American countries, is characterized by a rigid system of social stratification based upon family prestige, education. wealth and occupation [60-611. Research has shown that nursing is viewed as a relatively desirable occupation by Colombian women [58] and that it is ranked relatively highly in terms of prestige value by the general public [62]. Nevertheless the auxiliaries and nurse aides studied show some variation in social class identification (see Table 1). which may help to explain some of the differences in their orientations toward illness and patient care. Related research has shown striking differences by social class in the general population [63]. Urban neighborhoods in Latin America tend to be more or less homogeneous in class composition and thus the relative status of the area in which a nurse is employed should influence the types of illness encountered and the resulting images developed. Such a consequence has been pointed out in a study of general practitioners in London [31]. with the graduate

In spite of the theoretical importance of these personal and social factors. their actual impact on the nurses’ orientations toward mental illness appears to be relatively, small although slightly more evident among graduate nurses and auxiliaries, than nurse aides. Furthermore. no systematic pattern emerges

from an examination

of those differences that are sta-

tistically significant. In short, the anticipated effects of social position and occupational socialization are not found among these samples of Colombian nurses. CONCLUSIONS

AND IMPLICATIONS

FURTHER

FOR

RESEARCH

The data presented here suggest that these Colombian nurses have somewhat vague and eclectic images of mental illness and the mentally ill. Although these imagescannot be characterized in terms ofany particular psychiatric perspective, it is apparent that they are heavily psychological when approached in abstract terms and become more behavioral and organic when specific characteristics of the loco are called for. Oniy when asked to distinguish between locos and people who are nervous does a recognition of the significance of “contact with reality” emerge as an important component of this imagery. It is also evident that these nurses do not hold rigid stereotypes of mental illness. Although they more readily enumerate the defects of the loco, qualities are recognized as well. All but two of the nurses interviewed recognize that low-a and nervousness are characterized by different symptoms and the vast majority indicate that mental illnesses vary in terms of duration, symptomatic behavior and degree of danger to others. Only about two-thirds agree that there is an association between suicide and mental illness. Images show only minimal differences according to status in the nursing division of labor as well as personal characteristics. These results suggest that the common cultural background shared by the nurses studied has shaped their views on mental illness and the mentally ill and that neither individual differences nor variations in nursing training and experience have had much influence on these orientations. It may well be that the stigma associated with mental disorder inhibits the development of concrete knowledge and attitudes regarding psychiatric problems. This issue will be examined in a later publication. Several additional lines of investigation may be proposed on the basis of these findings. First. further research should be conducted in a variety of cultural settings to more adequately determine how common cultural orientations toward mental illness are affected by nursing training and experience. Second, studies might be focused on nurses’ images of mental illness and its recognition in patients actually under nursing care. No evidence is available as to how the perception of mental disorder in a patient might influence the type of care he receives from the nurse. Third, the relationships among personal characteristics, position in the nursing division of labor and images of mental illness are still far from clear. Age, marital status and class position are characteristics of all nurses and it is important to understand how they condition images of patients and their problems and thus influence subsequent role performance. REFERENCES 1.

Cohen. J. and Streuning. E. L. Opinions about mental illness: mental hospital occupation profiles and profile clusters. Psychol. Rep. 12. 111-124. 1963.

448

MICHAEL

MICKLIN

CARLOS r\. LEO>

AND

2. Cohen. J. and Streuning, E. L. Opimons about mental illness: hospital differences in attitude for eight occupational groups. Psycho/. Rep. 17. 25-26. 1965. and 3. Gilbert. L. and Levinson. J. Ideology. personality institutional policy in the mental hospital. J. .4hri. Sot. Psychoi. 53. 263-271. 1956. 4. Gredt. F. Patterns of attitude similarity among psychiatric hospital staff. Inr. J. Sot. Psychiut. 4. 28s 290. 1959. Klett. C. J. and Lasky. J. J. Attitudes of hospital staff members towards mental illness and chemotherapy. Dis. ,Veru. Sysr. 23. 101-105, 1962. nurses and aides 6. Reznikoff. M. Attitudes of psychiatric toward psychiatric treatment and hospitals. &fern. Hyg. 47. 360-364, 1963. 7. Speigel. D. E.. Keith-Speigel. P. and Grayson. H. M. Behavior of the typical mental patient as seen by eight groups of hospital personnel. J. Ps.vchiar. Res. 5. 317325, 1969. and custo8. Stein, W. W. and Oetting. E. R. Humanism dialism in a Peruvian mental hospital. Hum. Oryan~. 23. 278-282, 1964. 9. Williams. J. H. and Williams. H. M. Attitudes toward mental illness, anomia, and authoritarianism among state hospital nursing students and attendants. Munt. Hyg. 45. 418-424, 1961. 10. Wright. F. H. and Klein. R. A. Attitudes of hospital personnel and the community regarding mental illness. j. Couns. Psycho/. 13. 106107. 1966. II Gelfand. S. and Ullman, L. P. Attitude changes associated with psychiatric affiliation. Nurs. Rrs. 10. ?OG204, 1961. I2 Lewis, I. L. and Cleveland. S. E. Nursing students’ attitudinal changes following a psychiatric affiliation. J. Psychiut. Nuts. 4. 223-23 I, 1966. 13 Morris. K. D. Behavioral change: a concomitant of attitude change m nursmg students. Nurs. Res. 13. 132-138. 1964: 14 Orlev. J. H. and Leff. J. P. The effect of psychiatric education on attitudes to illness among the G&da. Br. J. Psychiat. 121. 137-141. 1972. 15. Fryer. M. W.. Distefano. M. K. and Marr. L. W. Attitude changes in psychiatric attendants following experience and training. Mmt. Hyg. 53. 2533257. 1969. 16. Toomey. L. C., ReznikotI. M., Brady, J. P. and Schumann. W. D. Some relationships between the attitudes of nursing students toward psychiatry and success in psychiatric affiliation. Nurs. Rrs. 10. 165-169, 1961. 17 Toomey, L. C., Reznikoff. M.. Brady, J. P. and Schumann, W. D. Attitudes of nursing students toward psychiatric treatment and hospital. Merit. Hyy. 45. 58% 602. 1961. significance 18 Stotsky, B. A. and Rhetts, J. E. Functional of attitudes toward the mentally ill among nursing home personnel. J. Sot.. Psychol. 17, 79-85, 1967. 19 Band. R. 1. and Brody. E. B. Human elements of the therapeutic community. Arch. Cm. Psychiut. 6. 65-72. I Y62. 20 Caine. T. M. and Smail. D. J. Attitudes of psychiatric nurses to their role in treatment. Er. J. Med. Psycho/. 41. 193-197, 1968. 21 King. S. H. Perceptions of’/llnrss und Medical Practrce. Russell Sage Foundation, New York. 1962. 22. Mauksch. H. 0. Nursing: Churning for a Change’? In: Hundhook of Medicul S&ioloyy. 2nd Edn (Edited by Freeman, H. E.. Levine. S. and Reader. L. G.) pp. 206 230. Prentice-Hall, Englewood Cliffs, N.J.. 1972. 23. Schuiman. S. Basic functional roles in nursing: mother surrogate and healer. In: Puricwts, Ph~Wrum und /I/ness (Edited by Jaco. E. G.) pp. 528-537. Free Press. New York, 1958. 24. Schulman, S. Mother Surrogate--After a Decade. In:

25. 26. 2? 28. 39

30

?I

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34.

35

36

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Brvant. 1. Heulth wd r/w Lkrcloprrrq li or/d Cornell Universitv Press. Ithaca. NY’.. 1969. Paul. Benjamin D. (Editor) Hwlrh. C’~rir~rt,C~UI/C‘CIJ~Imwr~. Russell Sage Foundation. New York. I’)!! World Health Organization. Expert Committee on Mental Health. Social Psychiatr! and Communit! Attitudes. rrchi~ict~i Rcporr SL’I.IL,)177. I 40. lY59. Habenstem. R. W. and Christ. E. ..A. P~.r)/l,\.\,o,r[r/r_r,~.. Trudiriomlixr. L:rili:er. Umversit> of Missouri. Calumbia. MO.. 1955. Shepherd. M.. Cooper. B.. Brown. A. c‘. and Kalton. G. W. Psychiutrir Illmsa 111G~~wr~r/Procrm Oxford University Press. London. 1966. Strauss. A.. Schatzman. L. B.. Bucher. R.. Ehrlich. D and Sabshin. M. Ps!~hiatric Idtwio~q~evur~tl Imrrrmccwr. Free Press. New York. 1964. There are three categories of nursing personnel rscognized in Colombia: (I) .Itrr\~,: ..,-I universlt!-trained professional. with a mmimum of three years of 0th cially approved studies that give one the capability to work with the rest of the health team in the nlannma. direction and supervision of the integral treatment Gf the individual. the family. and the community.” (2) Au\-iliar!, .Vursr: “Persons who have completed a theoretical and practical program of otlicially recognized vocational training and thus have the capabiht) to participate in the care and rehabilitation of patients. the prevention of illness and the protection and recuperation of health. under the supervision of a Nurse (as defined above).” (3) .Vursr .-lidc: “Persons who have learned some nursing techniques during the course of work in medical care institutions and u ho on occasions have received in-service training.” Source: Association Colombiana de Facultades de Medicina. Estudio dr Recwws Hwnuno.s ptrru /U S&d y la Educrtcion .vedicu ~‘II Colonihiu. Bogota. Ministerio de Salud Publica. 1970. Popular understandings of the concepts of locmtr and loco emphasize deviations from expected and acceptable cognitive and affective states as well as individual and interpersonal behaviors. To a lesser extent. there is a recognition that locwu involves a lack of contact with reality. Furthermore. there is fairly widespread recognition of significant psychological, behavioral. and. in some cases, organic differences between ioco~ and persons suffering from nervous conditions. Fabregd. H. and Metzger. D. Psychiatric illness in a small ladmo community. P.sjx’hiut. 31. 33Y-?!I. 1968. Leon. C. A. and Micklin. M. Opuuones Commumtarras sobre la Enfermedad Mental y su Tratamiento en Cali. Colombia, .-l&r Psiq~iut. Psicol. .Am. Llr. 17. 385-395. 1971. Micklin. M.. Durbin. M. and Leon. C. A. The lexicon for madness in a Colombian city. an exploration m semantic space. Am. Erhnol. I. 143. 156. . 1974. Rogler. L. H. and Hollingshead. A. B. Trapped: Fuw/iv.\ und Schixphrr~lirr. Wiley. New York. 1965. Micklin, M. and Leon. C. A. Rechazo al enfermo mental en una ciudad Sudamericana: un analisis comparativo. .4cta Psryuiur. Psicol. Amrr. Lur. 18. 321 329. 1972. Micklin. M. and Leon. C. A. Cultural bases of images of causation in psychological disorder: a Colombian survey. I,u. J. Sot. Ps!,chrut.. forthcommg. Stein. W. W. Patterns in a Peruvian mental hospital. Irlr. J. SOC. P.syc,hrur. 9. 20X 2 IJ. 1963.

Mental illness among nurses in a developing country 38. The operational

39.

40.

41. 42.

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distinction between “psychological” and “behavioral” dimensions of mental illness for this and several of the following questions is based upon the authors’ judgement as to whether other persons are directly involved in or affected by the loco’s actions. If so. the key feature of locura would appear to be the quality of social relationships engaged in and thus fall in the behavioral category. Responses lacking this social dimension. but reflecting personal, non-physical attributes of the loco were allocated to the psychological category. Admittedly. some of these decisions proved to be difficult. but then this is typically the case with aspects of human conduct that potentially overlap the fields of psychology and sociology A representative psychiatric definition of psychosis is as follows: “A psychosis is a severe form of mental disease characterized by an extensive disorganization of the personality function. In the typical psychosis the individual has lost contact with reality and reveals severe disturbance in all areas of his life. The psychotic reaction is a much more thoroughly and severely abnormal one than is the psychoneurosis.” English. 0. S. and Finch. S. M. Il~rroducrion to Psychiatry. 3rd Edn. W. W. Norton. New York. 1964. For some of the questions analyzed here, corresponding data are available for a stratified sample of 800 adult heads of household in Cali. The sample design characteristics are reported in Leon and Micklin, 1971 and Micklin. Durbin and Leon. 1974 (reference 34); Micklin and Leon. 1972 (reference 35); and Micklin and Leon. forthcoming (reference 36). Where relevant. we will contrast these public data to those for the nurses. but will not go into great detail because of space limitations and because our emphasis in this article is on internal differences in the nurse sample. More extensive comparisons will be reported in a monograph currently in preparation, With regard to the definition of loco. members of the general public emphasize organic definitions (374;). followed by popular definitions (IX”,). behavioral definit-ions (167;). and psychological definitions (1 I”,). All tests for statistical significance reported here are two-tailed. Differences between nurses and the public sample are minimal, The latter group emphasizes behavioral characteristics (59”,) followed by physical characteristics (I 9”,). 9”,, cannot provide a primary identifying characteristic. 6’,, provide a psychological characteristic and but 5”” mention a technical definition. Corresponding data for the public sample show 64vb unable to name any qualities of the loco. 16”,, say they are quiet and affectionate. 6”, mention their spontaneous and outgoing nature. 3”” indicate intelligence and giftedness. and 11”” mention other miscellaneous qualities. In contrast to the question regarding focos’ qualities, i-esponsrs for the public sample differ sharply from those of the nurses on the question of defects, Less than I”,) fail to name any. 5”,, mention physical defects. 5”