Journal of Psychiatric and Mental Health Nursing, 2014, ••, ••–••

Psychometric evaluation of the Korean version of the attitudes toward acute mental health scale M. GANG1 1 3

RN

Ph D,

Y. S O N G 2

RN

Ph D,

S . - Y. P A R K 3

Ph D

& S . YA N G 4

Ph D

2

Assistant Professor, Associate Professor, College of Nursing, Chungnam National University, Daejeon, and Assistant Professor, 4Associate Professor, Department of Social Welfare, Kyonggi University, Suwon, Korea

Keywords: acute hospital,

Accessible summary

culture/ethnicity, nursing education, scales and assessment



Correspondence: Y. Song College of Nursing Chungnam National University Daejeon 301 747 Korea E-mail: [email protected] Accepted for publication: 19 April 2014

• •

doi: 10.1111/jpm.12164



The Attitudes Toward Acute Mental Health scale (ATAMHS) was translated into Korean with attention to linguistic and content equivalence. Nine items were eliminated from the Korean version because of low correlations with the overall scale due to differences in clinical nursing environments and culture between South Korea and English-speaking countries. The results of this study showed that the Korean version of the ATAMHS (ATAMHS-K) is a reliable and valid scale for measuring attitudes toward mental illness in nurses and nursing students in an acute mental care setting. Factor analysis of the 24-item ATAMHS-K revealed three factors: (1) professional perspective; (2) semantic differentials; and (3) positive attitudes. The final analysis revealed that the three factors accounted for 39.5% of the variance. In addition, the ATAMHS-K was shown to have strong concurrent validity due to its strong positive correlations with the Community Attitudes Toward the Mentally Ill – Korean version (CAMI-K) scale. This study was the first attempt to adapt the ATAMHS for use in South Korea and to validate it with Korean nurses and nursing students.

Abstract The purpose of this study was to adapt the Attitudes Toward Acute Mental Health Scale (ATAMHS) into the Korean language and culture and then to determine the reliability and validity of it by administering it to a sample of Korean nursing students and nurses. We conducted a psychometric evaluation that included a two-step item analysis (analysis and reanalysis), exploratory factor analysis and concurrent validity. The ATAMHS was translated into Korean by bilingual nurses. Then, 429 participants (224 undergraduate nursing students and 205 nurses, all with psychiatric experience) completed the translated version of the ATAMHS. The item analysis revealed that nine items correlated poorly with the rest; thus, they were deleted from the scale. The final Korean version of the scale, which we refer to as the Korean version of the ATAMHS (ATAMHS-K), contains 24 items. The ATAMHS-K showed good internal consistency. Exploratory factor analysis revealed three factors (professional perspective, semantic differentials and positive attitudes) that explained 39.5% of the variance. The ATAMHS-K had strong correlations with the Korean version of the Community Attitudes towards the Mentally Ill Scale, thus confirming the concurrent validity. Therefore, the ATAMHS-K demonstrated acceptable psychometric properties as a measure of attitudes toward acute mental health in Korean nursing students and nurses.

© 2014 John Wiley & Sons Ltd

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Introduction More than 450 million people suffer from mental health problems [World Health Organization (WHO) 2001] worldwide. The South Korean government reported that approximately 30% of adults have experienced some form of mental illness at least once in their lives (Ministry of Health & Welfare 2006). In general, mental health care in South Korea is delivered using a wide variety of facilities such as mental health outpatient facilities, day treatment facilities, community-based psychiatric inpatient units and hospitals, depending on the severity of the consumers’ illness and the decisions of psychiatrists. Day treatment facilities provide comprehensive and tailored services to people with mental illness who can attend every day or a few times a week. Community-based psychiatric inpatient units refer to residential treatment centers designed for consumers who require psychosocial recovery. Psychiatric nurses working in the mental health-care system in South Korea receive comprehensive training broken down into three levels: (1) training through their hospital’s uncertified education system; (2) a 1-year certificated programme for mental health nursing, offered in community settings, that does not provide a master’s degree but results in their certification as psychiatric mental health nurse practitioners; and (3) a master’s degree programme in psychiatric nursing practice for clinical settings, which results in their attaining certification as mental health professionals (MHPs). However, despite this intensive training, they and other MHPs, along with the general public, often have negative attitudes toward mental illness (Seo & Kim 2010). Although these negative attitudes and stigmas attached to mental illness exist around the world, they seem far more prevalent in non-Western countries (Ng 1997, Leong & Lau 2001, Zane & Yeh 2002). In South Korea, mental illness is thought to be due to faulty genes, family misfortune or lack of willpower (Park & Bernstein 2008). The notion of mental illness being a medical disease is not widely accepted, and South Korean families who have mentally ill members tend to keep these family members out of public, and seek aid only within their close social networks (Bernstein 2007). This can delay effective treatment, increasing the duration and severity of the illness (Leong & Lau 2001). It is especially problematic when health professionals hold such negative attitudes and stigmas toward mental health because it negatively affects the quality of care, service range and therapeutic relationships that professionals can provide (Hugo 2001, Aydin et al. 2003, Happell 2005). It is particularly important that we understand the attitudes of nurses because they stand at the front lines of care. Nursing students must receive attention as well, as 2

they develop many of their attitudes and beliefs about mental health during their clinical placements, attitudes that they often retain in their nursing careers (Boyle 2010). Some studies have measured the attitudes of nurses and nursing students toward mental health through instruments meant to assess attitudes in the public (Murray & Steffen 1999, Mukherjee et al. 2002, Chambers et al. 2010). These scales include the Opinions about Mental Illness scale and the Community Attitudes Towards Mental Illness (CAMI) scale, which have mainly been used as measurement tools in community settings (Struening & Cohen 1963, Taylor et al. 1979, Taylor & Dear 1981). Other scales – such as the Mental Illness Attitudes scale (Yuker et al. 1960) and the Attitudes Towards Mental Illness scale (Weller & Grunes 1988) – have been developed but lack appropriate validation for health-care providers (Morris et al. 2012). The CAMI is suitably up to date and is a well-validated tool (Morris et al. 2012) that has been used for comparing non-professionals’ and professionals’ attitudes toward mental health in community settings (Jorm et al. 1999, Caldwell & Jorm 2000). The acute mental health delivery system in South Korea has been reorganized according to the mental health-care reform enacted in 1995. Currently, both general and university hospitals are much more involved in caring for consumers with severe mental illness than before the 1995 Act. Despite the increasing importance of understanding the attitudes of medical staff toward consumers with acute mental illness, many studies have measured these attitudes using only instruments designed for the public, such as the CAMI scale, because of a lack of Korean versions of more suitable tools (Jee & Wang 2006). Thus, accurate measurement of clinicians’ attitudes requires a culturally appropriate and easy-to-administer tool. One such tool would be the Attitudes Toward Acute Mental Health scale (ATAMHS; Baker et al. 2005). The ATAMHS was developed in the UK as a selfadministered tool for examining nurses’ attitudes toward mental illness (Baker et al. 2005, Munro & Baker 2007). So far, the ATAMHS has been used in research across the world (See Table 1), having been translated and validated in populations in the UK (Baker et al. 2005), Palestine (Ahmead et al. 2010), Fiji (Foster et al. 2008) and Jordan (Hamdan-Mansour & Wardam 2009), but not in South Korea. These previous studies (Baker et al. 2005, Munro & Baker 2007, Hamdan-Mansour & Wardam 2009) demonstrated that the ATAMHS is a useful and reliable tool for assessing the attitudes of health professionals, including nurses, toward mental illness. In recent years, South Koreans are beginning to accept a medical disease model of mental illness requiring medical treatment. Subsequently, families have begun taking their © 2014 John Wiley & Sons Ltd

© 2014 John Wiley & Sons Ltd

North of England

North west of England

Fiji

Jordan

Palestine

Baker et al. (2005)

Munro & Baker (2007)

Foster et al. (2008)

Hamdan-Mansour & Wardam (2009)

Ahmead et al. (2010)

ATAMHS, Attitudes Toward Acute Mental Health Scale.

Country

Study

Table 1 Evidence of the ATAMHS used in studies worldwide

Acute and chronic inpatients and outpatient mental health agencies N = 92 All nurses Psychiatric hospital N = 78 Psychiatrists, social worker, psychologist, nurses, occupational therapist and administrative staff

Acute mental health units N = 140 Qualified and unqualified nurses Major in-patient mental health-care setting N = 71 Nursing staffs and medical orderlies

Mental health units N = 251 All nurses

Sample ATAMHS Cronbach’s alpha = 0.72

ATAMHS Cronbach’s alpha = 0.72

ATAMHS modified

ATAMHS – Arabic version Cronbach’s alpha = 0.70

ATAMHS – Arabic version

To answer the positive and negative or neutral response of mental health illness To survey mental health worker’s attitude toward mental illness

To examine Jordanian mental health nurses’ attitudes toward mental health illness

To assess the attitude of professional attitudes towards mental illness

Instrument & internal consistency

To develop and validate ATAMHS

Goal

Items: 33, Components: 5 (Care or control, semantic differentials, therapeutic perspective, hard to help, positive attitude) Account for 42% of the variance The higher levels of positive attitude in 11 items were observed No validity test Alcohol abuse, lack of self-control, lacking control over their emotion and medication were the negative expressed items No validity test Participants had negative attitude toward mental illness and patients with mental disorders No validity test Participants revealed more negative attitude in relation to alcohol misuse, medication, patient’s ability to control their emotions and genetic predisposition to mental illness No validity test

Results

Validation of ATAMHS, Korean version

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M. Gang et al.

mentally ill loved ones to hospitals and clinics. Lee (2012) reported that the rate of mental health service use by Koreans increased from 11.4% in 2006 to 17.5% in 2011. Many South Koreans experiencing psychiatric symptoms (either by suffering such symptoms themselves or indirectly in witnessing a loved one fall ill) may perceive mental illness to be a curse or disaster rather than an illness analogous to a physical disease (Le Meyer et al. 2009). However, mental illnesses are biopsychosocial in nature and can be treated with physical and psychological treatments (Pilgrim 2002). Nevertheless, mental illness remains a prevalent stigma even among health professionals (Seo & Kim 2010). Therefore, in order to improve mental health care in South Korea, researchers must develop methods for altering these negative attitudes; in order to develop these methods, researchers require appropriate instruments for accurately measuring negative attitudes. Until now, there has been no adaptation of the ATAMHS for use with Korean health professionals, nor have the psychometric properties of this instrument been explored with this population. The purpose of the present study is therefore to adapt the ATAMHS into the Korean language and culture, and to evaluate the reliability and validity of Korean version of the ATAMHS (ATAMHS-K) for use with Korean nursing students and nursing professionals.

Methods Study design Our research design was a cross-sectional survey, which is a useful method of obtaining information for establishing the validity of any psychological scale in a given population. The survey design included translation of the ATAMHS into Korean followed by four steps of data analysis to explore the psychometric properties of the ATAMHS-K. First, a systematic translation process was used to assure the semantic and content equivalence of the ATAMHS and the ATAMHS-K. Subsequent analyses examined the reliability, construct and concurrent validity of the ATAMHS-K (please see the data analysis section for a more comprehensive description). The validated and reliable ATAMHS-K will help in the assessment of the attitudes toward acute mental health in acute care settings of psychiatric nurses and nursing students.

Sample Convenience sampling was used to recruit 429 participants (224 undergraduate nursing students and 205 registered nurses). Inclusion criteria for the study were as follows: (1) undergraduate nursing students in their third or fourth year 4

of professional training who had experience working in a psychiatric unit in university hospitals; and (2) registered nurses who had worked at the psychiatric unit in general hospitals or university hospitals. The required sample size was determined by calculating the ratio of study participants to the number of items in the scale, ensuring that the ratio exceeded 10:1 (Costello & Osborne 2005). Because there were 33 items in the ATAMHS, a minimum of 330 was needed for adequate factor analysis. The total sample size for the study was 429, meaning that our sample size far exceeded these requirements.

Measurements Attitudes Toward Acute Mental Health Scale (ATAMHS) The ATAMHS consists of 33 items measuring the attitudes of psychiatric clinical staff toward their patients with mental health problems (Baker et al. 2005). The first 25 items are scored using a 7-point Likert-type scale ranging from 1 (‘strongly disagree’) to 7 (‘strongly agree’), with a score of 4 being the neutral midpoint. The last eight items use a semantic differentials scale format, where participants answer by choosing a point on a scale of 0 to 10 ranging from ‘dangerous’ to ‘safe,’ respectively (point 5 was the midpoint, and anything below represented more negative attitudes toward mental illness). The original ATAMHS had five factors: (1) care or control (12 items; e.g. ‘Alcohol abusers have no self-control’); (2) semantic differentials (seven items; e.g. marking on a line from 0 to 10 about how ‘dangerous’ or ‘safe’ nurses considered mentally ill patients to be in general); (3) therapeutic perspectives (six items; e.g. ‘Psychiatric treatments cause patients to worry too much about their symptoms’); (4) hard to help (four items; e.g. ‘Mental illnesses are genetic in origin’); and (5) positive attitudes (four items; e.g. ‘People are born vulnerable to mental illnesses’). Negatively worded statements were reverse scored; thus, higher scores indicated more positive attitudes toward mental health. The Cronbach’s alpha for the ATAMHS was 0.72 (Baker et al. 2005). Community Attitudes Toward the Mentally Ill (CAMI) scale To assess the concurrent validity, we calculated correlations with another measure of attitudes toward the mentally ill, the CAMI scale. The CAMI scale was originally designed to measure attitudes in the general population (Taylor & Dear 1981), but it has been used in several studies to assess the attitudes of MHPs, including nurses and psychiatrists, for identifying the general public’s attitude toward mental illness (Sevigny et al. 1999, Chambers et al. 2010). The CAMI scale has been translated into Korean (CAMI-K) and is widely used to assess Korean health-care professionals. A © 2014 John Wiley & Sons Ltd

Validation of ATAMHS, Korean version

number of studies have demonstrated the reliability of the CAMI-K, with Cronbach’s alphas ranging from 0.70 to 0.71 (Noh et al. 2001, Jee & Wang 2006, Seo & Kim 2010). The CAMI scale has 40 items that participants rate on 5-point Likert scales, ranging from 1 (‘strongly disagree’) to 5 (‘strongly agree’). The scale taps four dimensions of attitudes toward the mentally ill: (1) authoritarianism (e.g. mentally ill persons are somehow inferior and must be controlled); (2) benevolence (e.g. items reflecting a sympathetic view of mentally ill people); (3) social restriction (e.g. the mentally ill should be isolated because of the danger they pose to the rest of the community); and (4) community mental health ideology (e.g. items corresponding to how mentally ill patients should be accepted into the wider community). When the CAMI scale was developed by Taylor & Dear (1981), the Cronbach’s alpha ranged from 0.68 to 0.88 for each subscale.

Translation process In order to validate the ATAMHS and adapt it to the Korean culture, we needed first to translate the original English version (Baker et al. 2005) into Korean. To establish semantic equivalence, the translation of the ATAMHS took place in three steps. First, the scale was translated into Korean by a pair of bilingual nurses. Second, a second pair of bilingual nurses back translated the scale into English. Finally, the ATAMHS and this back-translated version were compared. In order to establish content equivalence (i.e. the cultural equivalence of the translation) during the translation process, we considered cultural differences and any minor disagreements were discussed until consensus was achieved. To enhance content validity, we continually checked the item wording, response formats and instructions. In general, content validity is established mainly through procedures within the initial stages of scale development (Netemeyer et al. 2003). The translated version of ATAMHS was administered to the samples as a self-report questionnaire.

Data collection Data were collected between the 1 and 28 of February from seven hospitals (both general and university) and four universities located in metropolitan area of South Korea. We visited hospital nursing departments and nursing schools that had previously agreed to participate in this study and explain the protocol in detail. Convenient sampling was used by contacting head nurses at each hospital and professors from the nursing department who served as gatekeepers to recruit nurses for participation. Once the gatekeepers granted permission and access, they allowed attending the © 2014 John Wiley & Sons Ltd

classes, conferences and meetings, where we explained the study’s purposes and procedures to potential participants. Consenting and eligible participants completed questionnaires on the same day the study was presented. Each structured questionnaire used a paper-and-pencil format and was self-administered. The questionnaire was distributed to 450 people (225 undergraduate nursing students and 225 nurses) who met the eligibility criteria. Out of the 450 nurses who received the questionnaire, 429 (205 nurses and 224 nursing students) were returned and included in the data analysis. The total response rate was 95.5%.

Ethical consideration The Chungnam National University College of Nursing Institutional Review Board approved all study procedures (No. 2012-52) before data collection. Furthermore, all participants provided their written informed consent before participation. We explained to all participants the purpose, procedure and anonymity policy of the study. A pen and envelope were provided along with the survey questionnaire and instructions that the completed survey should be sealed in the provided envelope to ensure that the survey information would be kept confidential as it was returned to the researchers.

Data analysis Four steps were involved in testing the psychometric properties of the translated ATAMHS and the final ATAMHS-K. The first step was an item analysis, which included calculating the internal consistency reliability (Cronbach’s alphas) and the corrected item–total correlations. In particular, we checked the value of each item–total correlation to determine whether each item was within the acceptable limit of >0.30 (Nunnally & Bernstein 1994). The purpose of this step was to evaluate whether each item was sufficiently reliable; unreliable items were eliminated. After item elimination, we proceeded to the second step, which entailed reanalyzing the reliability and corrected item–total correlation to ensure that our results were robust for the shortened scale. Third, we calculated the Kaiser–Meyer–Olkin (KMO) index, which is a comparison of the magnitude of the measured correlation coefficients with the magnitude of the partial correlation coefficients (Nunnally & Bernstein 1994). The KMO index is used to assess the adequacy of correlation matrices for factor analysis. Values between 0.5 and 1.0 indicate that factor analysis is appropriate. In our study, the KMO value was 0.8, indicating that it was suitable for factor analysis. Then, we conducted an exploratory factor analysis (EFA) of the ATAMHS-K to assess the 5

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construct validity. EFA is a multivariate statistical method that examines the correlations among a set of observed variables to explore the underlying structure. EFA is a common, highly useful approach to assessing the construct validity of self-report scales (Nunnally & Bernstein 1994). We used principal axis factoring with a direct oblimin rotation because this method effectively identifies the component parts of a scale according to the correlations between factors (Costello & Osborne 2005). Factors were initially extracted if they had an eigenvalue >1.0 (Thompson & Daniel 1996), and a scree plot was then created to check the ‘elbows’ on the scale. After rotation, we selected items with loadings above 0.32, and ensured that there were no items with crossloadings of over 0.20 on more than two factors (Costello & Osborne 2005). Through this process, we confirmed whether the ATAMHS-K accurately measured the construct that it was intended to measure. Finally, in the fourth step, we determined the concurrent validity of the ATAMHS-K by calculating Pearson’s correlation coefficients between ATAMHS-K and CAMI-K scale scores. If scores on the ATAMHS-K were highly correlated with those of the CAMI-K, then the ATAMHS-K would be considered to have high concurrent validity. SPSS version 20 (SPSS Inc., Chicago, IL, USA) was used for data analyses. Significance was set at 5% (Fig. 1).

Results Demographics About half of the participants were registered nurses (52.2%), with an average of around 10 years of clinical experience. Nursing students had all completed a 4-week long psychiatric rotation on an inpatient unit. The majority of participants (92.1%) were women. The mean duration

Step 1

• Item analysis and scale reliability test • Reanalysis of reliability and corrected item–total

Step 2

Step 3

Step 4

correlation test • Exploratory factor analysis

• Concurrent validity test

Figure 1 Data analysis procedure

6

of clinical experience among the 205 psychiatric nurses was 128 months (SD = 92.2), ranging from 2 to 348 months.

Item analysis and internal consistency Table 2 shows the item–total score correlations and Cronbach’s alphas for all items of both the translated ATAMHS and the final ATAMHS-K. According to Netemeyer et al. (2003), corrected item–total correlations refer to the extent to which any one of the items of a set under consideration is correlated with the remaining items. In the current study, nine items had corrected item–total correlations that were either negative or less than 0.3; correlations less than 0.3 indicated that participants who scored higher on a particular item also tended to score lower on all other items. Thus, items that had less than 0.3 on the corrected item–total correlations were dropped. These nine items were 1, 19, 21, 22, 25, 27, 30, 32 and 33. The label ‘Revised’ in Table 2 denotes the corrected item– total correlations after the exclusion of these items. The ATAMHS-K consisted of 24 items and had a Cronbach’s alpha of 0.89, suggesting high reliability.

Construct validity The construct validity refers to the ability of an instrument to assess what it has been designed to measure (Haynes et al. 1995). Before assessing the construct validity using the EFA, we calculated the KMO value to assess the adequacy of the sample for factor analysis. The value of the KMO was 0.88, which was deemed acceptable for proceeding with the EFA. Table 3 shows the results of the EFA. Three factors were extracted: (1) ‘professional perspective’ (eigenvalue: 6.35); (2) ‘semantic differentials’ (eigenvalue: 1.85); and (3) ‘positive attitude’ (eigenvalue: 1.29). According to the Kaiser criterion (Kaiser 1960), factors with an eigenvalue of greater than 1 can be retained. Following Tabachnick & Fidell’s (2001) guidelines, items that had factor loadings greater than 0.40 on one factor and less than 0.20 on the others were considered good indicators of an underlying factor. None of the items on any of the three factors needed to be dropped. The ‘professional perspective’ factor contained 17 items, with factor loadings ranging from 0.41 to 0.66. The item, ‘Acute wards are little more than prisons’ explained 66.4% of the variance in ‘professional perspective.’ The average percentage of variance explained by the ‘professional perspective’ factor was 26.4%. Four items (e.g. ‘Patients are more safe than dangerous’) were loaded onto the ‘semantic differentials’ factor, with factor loadings ranging from 0.56 to 0.74. The item, ‘Patients are slightly more mature than immature’ accounted for 73.8% of the variance in ‘seman© 2014 John Wiley & Sons Ltd

Validation of ATAMHS, Korean version

Table 2 Item analysis of the ATAMHS-K Corrected item–total correlation Items

Revised

% of negative attitude

0.200 0.448 0.461 0.448 0.458 0.440 0.393 0.548 0.575 0.604 0.439 0.382

– 0.447 0.435 0.427 0.482 0.458 0.390 0.578 0.584 0.640 0.463 0.411

81.8 62.9 63.4 50.8 28.0 29.1 27.5 30.8 33.6 21.0 24.5 42.4

0.577 0.489

0.602 0.529

21.9 10.7

0.552 0.513 0.357 0.546 0.080 0.347 0.279 0.098 0.472 0.533 0.005 0.373 −0.078 0.422 0.268 −0.148 0.300 −0.113 0.131 0.844

0.573 0.505 0.379 0.588 – 0.339 – – 0.524 0.580 – 0.376

23.8 43.4 18.4 21.2 59.2 37.3 56.2 37.8 31.0 30.8 39.2 66.7 35.2 65.5 78.8 27.5 58.3 40.6 66.7

Translated

1 Alcohol abusers have no self control 2 Patients with chronic schizophrenia are incapable of looking after themselves. 3 Members of society are at risk from the mentally ill 4 Mentally ill patients have no control over their emotions 5 Staff should not talk to patients about their delusions 6 Deliberate self-harm more often happens when other people are around 7 Depression occurs in people with a weak personality 8 The cause of psychological problem is bad nerves 9 Patients with mental illnesses are more likely to harm someone else than themselves. 10 Acute wards are more little more than prisons 11 Mental illness is the results of adverse social circumstances 12 Many normal people would become mentally ill if they had to live in a very stressful situation 13 Those with a psychiatric history should never be given a job with responsibility 14 Those who attempt suicide leaving themselves with serious liver damage should not be given treatment 15 Violence mostly results from mental illness 16 Psychiatric patients are generally difficult to like 17 Patients who abuse substances should not be admitted to acute wards 18 Psychiatric treatments cause patients to worry too much about their symptoms 19 It is difficult to negotiate care plans with patients in acute environments 20 It is hard to help patients who are emotionally disturbed 21 Psychiatric drugs are used to control disruptive behaviour 22 Mental illnesses are genetic in origin 23 Psychiatric illness deserves as much attention as physical illness 24 The manner in which you talk to patients affects their mental state 25 People are born vulnerable to mental illness 26 Safe ∼ dangerous (range 0–10) 27 Adult ∼ child (range 0–10) 28 Mature ∼ immature (range 0–10) 29 Optimistic ∼ pessimistic (range 0–10) 30 Cold hearted ∼ caring (range 0–10) 31 Polite ∼ rude (range 0–10) 32 Harmful ∼ beneficial (range 0–10) 33 Clean ∼ dirty (range 0–10) Cronbach’s alpha

0.425 – – 0.321 – – 0.887

ATAMHS, Attitudes Toward Acute Mental Health Scale.

tic differentials’. Finally, three items made up the ‘positive attitude’ factor, with factor loadings ranging from 0.85 to 0.61. The proportion of variance explained by ‘positive attitude’ of the three factors was 5.3%.

spective’ and the CAMI-K scale score was strong (r = 0.55, P < 0.001); for ‘semantic differentials,’ the correlation was statistically significant, but still low (r = 0.28, P < 0.001); and finally, for ‘positive attitude,’ the correlation was strong and statistically significant (r = 0.51, P < 0.001).

Concurrent validity Concurrent validity reflects the degree to which different measures of the same construct are correlated (Netemeyer et al. 2003). In this study, the Cronbach’s alpha for the CAMI-K was 0.88. The correlations between the scores of the ATAMHS-K and those of the CAMI-K scale were calculated to assess concurrent validity. The analysis indicated a strong relationship between the two measures (see Table 4). Pearson’s correlations indicated a significant positive relationship between the total scores of the two measures (r = 0.61, P < 0.001). We then determined the relationships among the three factors of the ATAMHS-K and the CAMI-K scale total score: the correlation between ‘professional per© 2014 John Wiley & Sons Ltd

Discussion While the ATAMHS has been used internationally to measure MHPs’ attitudes toward people with mental illness and mental illness in general, this was the first attempt to adapt the instrument for use in South Korea and to validate it with Korean nurses and nursing students. In this study, the ATAMHS-K, which contains 24 items, demonstrated good reliability and validity as a tool for assessing the attitudes of Korean nurses and nursing students. The internal consistency of the ATAMHS-K was slightly higher than that found in other studies with this instrument (Baker et al. 2005, Munro & Baker 2007, 7

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Table 3 Factor analysis of the ATAMHS-K Factors Items

1

10 Acute wards are more little more than prisons 9 Patients with mental illnesses are more likely to harm someone else than themselves 8 The cause of psychological problem is bad nerves 15 Violence mostly results from mental illness 13 Those with a psychiatric history should never be given a job with responsibility 18 Psychiatric treatments cause patients to worry too much about their symptom 14 Those who attempt suicide leaving them with serious liver damage should not be given treatment 16 Psychiatric patients are generally difficult to like 5 Staff should not talk to patients about their delusions 6 Deliberate self-harm more often happens when other people are around 11 Mental illness is the results of adverse social circumstances 4 Mentally ill patients have no control over their emotions 3 Members of society are at risk from the mentally ill 7 Depression occurs in people with a weak personality 2 Patients with chronic schizophrenia are incapable of looking after themselves 17 Patients who abuse substances should not be admitted to acute wards 20 It is hard to help patients who are emotionally disturbed 28 Mature ∼ immature 29 Optimistic ∼ pessimistic 26 Safe ∼ dangerous 31 Polite ∼ rude 23 Psychiatric illness deserves as much attention as physical illness 24 The manner in which you talk to patients affects their mental state 12 Many normal people would become mentally ill if they had to live in a very stressful situation Eigenvalue Proportion of variance: total 39.513% of variance Mean ± SD (Total 104.2 ± 20.0) Cronbach’s alpha = 0.887

2

3

0.664 0.659 0.633 0.616 0.614 0.603 0.590 0.528 0.520 0.505 0.502 0.486 0.483 0.478 0.468 0.465 0.413 0.738 0.688 0.639 0.563

6.346 26.442 75.2 ± 14.8 0.877

1.852 7.715 15.9 ± 5.5 0.776

0.846 0.835 0.605 1.285 5.355 13.1 ± 4.7 0.840

Factor 1, professional perspective; Factor 2, semantic differential; Factor 3, positive attitudes. ATAMHS, Attitudes Toward Acute Mental Health Scale.

Table 4 Correlation between the ATAMHS-K with the CAMI-K

CAMI-K

ATAMHS-K

Professional perspective

Semantic difference

Positive attitude

r = 0.606 P < 0.001

r = 0.551 P < 0.001

r = 0.281 P < 0.001

r = 0.511 P < 0.001

ATAMHS-K, Korean version of the Attitudes Toward Acute Mental Health Scale; CAMI-K, Korean version of the Community Attitudes towards the Mentally Ill scale.

Hamdan-Mansour & Wardam 2009). As the Cronbach’s alpha must be at least 0.70 for self-report instruments to be reliable, the high value we received indicates that the ATAMHS-K is considerable reliable. Particularly, the ‘positive attitudes’ factor, consisting of three items, sported the highest internal consistency when compared with the other factors. In addition, this factor had higher factor loadings than those found in the original ATAMHS (Baker et al. 2005) and other language versions (Hamdan-Mansour & Wardam 2009), a finding that suggests that these three items sufficiently reflect positive attitudes toward mental illness in Korean nursing students and nurses. The factor analysis of the ATAMHS-K supported three factors that explained 39.5% of variance including: (1) professional perspective; (2) semantic differentials; and (3) positive attitudes. Other studies reported five factors that explained 42% of the variance in an English-speaking 8

sample: professional perspective, semantic differentials, positive attitudes, care or control and hard to help (Baker et al. 2005, Munro & Baker 2007, Ahmead et al. 2010). This inconsistency in the factor structure of the ATAMHS may be due to the role of culture in the context of mental illness. For example, in the present study, three of the nine items from the ATAMHS that were excluded, were ‘Mental illness is genetic in origin,’ ‘People are born vulnerable to mental illness’, and ‘Psychiatric drugs are used to control disruptive behavior’. These three items seem to reflect the conceptualization of mental illness as a disease requiring medical attention. However, many Koreans typically believe that mental illness is caused by sins or bad deeds of committed member in question or ancestor of the mentally ill person and can be incurable (Yoo & Wood 2013). Or mental illness may reflect a lack of will power and it can be overcome by having a strong will (Griffiths et al. 2006). © 2014 John Wiley & Sons Ltd

Validation of ATAMHS, Korean version

Treatment recommendations are often non-Western medicinal treatments, and people are especially hesitant in hospitalizing or using medication to treat such illnesses (Macdonald 1996). Therefore, these excluded items may not have adequately captured the Korean culture. While nursing schools in South Korean teach about the disease model of mental illness and effective pharmacological treatment, faculty may simultaneously hold and convey more traditional Korean beliefs about mental illness. The attitudes of nurses toward mental health may reflect their exposure in training to a mix of modern medical knowledge and traditional beliefs. Another item that was excluded from the translated ATAMHS was ‘It is difficult to negotiate care plans with patients in acute environments’. This may be due to the structure of the Korean health-care system. At health settings in Korea, only medical doctors have the authority to diagnose and create the care plans for people with mental illness; not even registered nurses or nurse practitioners are allowed to change these plans, only manage them. Additionally, the absence of ‘care or control’ and ‘hard to help’ factors in the ATAMHS-K may be partly due to the lack of access to mental health services. Further study of the underlying causes of these differences in the factor structures would be useful to better understand the attitudes that Korean nurses have toward mental illness. A comparison of our study with that of Baker et al. (2005) suggests that the ATAMHS-K is roughly equivalent in validity to the original ATAMHS for measuring attitudes toward mental health among Korean nurses and nursing students. Generally, people’s attitudes are influenced by affective, cognitive and behavioural factors (Baker et al. 2005). The CAMI has been found to emphasize the affective and behavioural aspects of people’s attitudes toward mental illness for the general population as well as community health professionals, but it might not account for the professional and practical components of acute mental care settings (Baker et al. 2005, Morris et al. 2012). Nevertheless, we chose the CAMI scale to test the concurrent validity because the Korean version has been used widely in various settings across South Korea. We found that the ATAMHS-K had good concurrent validity because of its strong positive correlations with the CAMI-K scale. Thus, the ATAMHS-K could be considered a more useful tool than the CAMI-K in assessing health-care professionals’ attitudes toward mental illness in acute care settings.

References

Nevertheless, our results should be considered in the context of the following limitations. First, our use of convenience sampling of nursing students and nurses in several hospitals limits generalizability. Second, it is possible that the 24-item, three-factor structure of the ATAMHS-K was invariant because of the relative homogeneity of the sample, being drawn from only one discipline. Further study is warranted with a more diverse population that includes physicians and other mental health clinicians apart from nurses. Third, the ATAMHS was developed in the UK; thus, the scale may not capture the nuances of attitude, culture and language relevant to Korean MHPs. Lastly, although our translators were matched in academic background and educational attainment and they attempted to address the issue of culture as well as linguistic equivalence of items, there was no systematic method to assess each translator’s ability to translate the scale appropriately. Despite these potential limitations, the findings of this study have clinical and educational implications for psychiatric nurses and nurse students. First, the validated ATAMHS-K could be used to evaluate the attitudes toward acute mental health of various health-care professionals working in acute psychiatric settings in South Korea. This, in turn, would facilitate comparison in attitudes toward acute mental health between psychiatric nurses in South Korea and those in other countries. Furthermore, the scale might be used to measure changes in attitude toward mental health in nursing students and nurses as they gain clinical experience. Second, the scale we encourage exploration of the cultural nuances of attitudes toward mental health, allowing for the creation of culturally specific education programs to improve these attitudes.

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© 2014 John Wiley & Sons Ltd

Psychometric evaluation of the Korean version of the Attitudes Toward Acute Mental Health Scale.

The purpose of this study was to adapt the Attitudes Toward Acute Mental Health Scale (ATAMHS) into the Korean language and culture and then to determ...
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