Stereotyping by nurses and nursing students: a critical review of research

Attitude to personality disorder among prison officers working in a dangerous and severe personality disorder unit

BACKGROUND

It is well established that staff attitudes to personality disordered patients are commonly negative, characterised by pessimism and rejection. A recent study in forensic psychiatric hospitals has described the psychological and social factors underlying positive attitudes, and suggested that staff with more positive attitudes perform better and are less stressed.

AIM

To assess whether it is possible to predict which staff will adjust positively to working with personality disordered people. More specifically to confirm links between attitude to personality disorder and: job performance; perception of managers; personal well-being; burnout; and interaction rates with inmates.

METHODS

The opening of a new Dangerous and Severe Personality Disorder unit within a UK prison allowed a longitudinal study of prison officers to be performed, in which a number of measures, including the Attitude to Personality Disorder Questionnaire (APDQ), were collected at three fixed points (at baseline, eight and sixteen months after the opening of the unit).

RESULTS

Attitude to Personality Disorder varied over the course of the study, and changes in attitude were linked to events experienced by individual officers. More positive attitude to personality disorder was associated with improved general health and job performance, decreased burnout, and favourable perception of managers.

CONCLUSIONS

Attitude to Personality Disorder has important outcomes, and is responsive to the psychosocial environment. Its measurement is not useful for staff selection, because of low stability over lengthy time periods. The APDQ has been demonstrated to be valid measure of attitude to PD, and potentially useful for outcome studies, or benchmarking between units.

Dangerous and severe personality disorder: an ethical concept?

Most clinicians and mental health practitioners are reluctant to work with people with dangerous and severe personality disorders because they believe there is nothing that mental health services can offer. Dangerous and severe personality disorder also signals a diagnosis which is problematic morally. Moral philosophy has not found an adequate way of dealing with personality disorders. This paper explores the question: What makes a person morally responsible for his actions and what is a legitimate mitigating factor? How do psychiatric nurses working with this client group understand the awful things some clients do? What concepts do they need, if they are to know how to explain and how to react? It is suggested that dangerous and severe personality disorder is best regarded as a moral category, framed in terms of goodness, badness, obligation and other ethical concepts. It seems plausible that in important ways the dangerous and severe personality disordered client does not understand morality or understands it differently. The peculiar position of the dangerous and severe personality disordered individual in our system of moral responsibility stems from his apparent inability to see the importance of the interests of others. It might be more helpful to regard personality disordered clients as we do children: partially but not fully reasonable for their actions. We might regard the dangerous and severe personality disordered client responsible for those actions which he most clearly understands, such as causing others physical pain, but not for those with which he is only superficially engaged, such as causing emotional pain. The paper concludes by suggesting that the dangerous and severe personality disordered individual does not fit easily into any conventional moral category, be it criminal, patient, animal or child, and thus an assessment of his moral accountability must take into consideration his special circumstances.

Changes in attitudes to personality disorder on a DSPD unit

BACKGROUND

Psychiatric professionals tend to have poor attitudes towards people who suffer from personality disorder. Previous studies suggest that such attitudes are influenced by sufferer behaviours, organizational factors and the characteristics of individual professionals, but do similar considerations apply outside health services?

AIM

To identify what events, experiences and factors in the course of daily work with personality-disordered people influence the attitudes and beliefs of prison staff.

METHOD

Semi-structured interviews were conducted with prison officers working in a pilot "Dangerous and Severe Personality Disorder" Unit within a UK prison. Open questions were asked about any changes in their attitudes to or beliefs about personality-disordered inmates.

RESULTS

Positive influences on attitude were: development of greater understanding of personality disorder and prisoners as individuals; improvement in inmate behaviours; education; the staff counselling programme; staff sharing support and skills; the challenge and purpose of the new role and having their views listened to. Negative influences were: delays in establishing the treatment programme; some inmate behaviours; fear and concern over their new roles and negative portrayal as a profession in the media.

CONCLUSIONS

In order to maintain a high overall positive attitude among staff to working with people with personality disorder, units should have: consistency of direction and timely implementation of anticipated developments; clear philosophy and treatment regime; substantial investment in staff training programmes and effective programmes for the provision of clinical supervision to frontline staff.

Effect of a psychiatric diagnosis on nursing care for nonpsychiatric problems

This study was designed to test how patients' psychiatric diagnoses would affect nursing care for medical problems. Sixty nurses were randomly assigned to three groups in this posttest-only experiment. Control group nurses read a vignette describing a man admitted with a possible myocardial infarction (MI). Nonpsychotic group nurses also read that the person was on alprazolam. Psychotic group nurses read that the person was on haloperidol, benztropine, lorazepam, trazadone, fluoxetine, and lithium. Psychotic group nurses estimated a decreased probability that the patient was having an MI and were less likely to respond to additional possible MI symptoms. An increased awareness of the potential to stereotype medical patients with a history of psychosis might assist nurses when providing care.

How much does physical appearance say about the psychological adjustment of competent and dysfunctional children?

Presents a study in which three sets of photographs of socially competent, aggressive, and anxious preschoolers were rated by college students (n = 150 raters per set), blind to the children's group membership. This was done to assess the extent to which adults are able to make valid and reliable evaluations of children's psychological adjustment on the basis of physical appearance alone. Sets 1 and 2 were photographs of different children taken under the same conditions and providing both facial and nonfacial cues. Sets 2 and 3 were of the same children taken under conditions that varied as to the amount of nonfacial cues they provided. Results showed that (a) socially competent children were judged to be better adjusted than their dysfunctional peers (i.e., more competent, less aggressive, less anxious, and less likely to have emotional or behavioral problems); (b) within the dysfunctional group, aggressive and anxious children were distinguished in ways that correspond closely to what is known about them from behavioral and clinical research; (c) irrespective of group membership, girls and boys were generally distinguished in ways that reflect normative beliefs about gender differences from social and developmental research; (d) group differences in ratings of psychological adjustment were generally comparable across photograph sets and could not be accounted for by differences in the children's perceived physical attractiveness; and (e) raters reported that they relied mainly on the children's expression, eyes, and posture to make their judgments of adjustment. These results replicate and extend earlier findings based on 1 of the 3 photograph sets (Serketich & Dumas, 1997). They suggest that when first impressions matter, competent children are at an advantage and their dysfunctional peers at a disadvantage even before their actual behavior comes to confirm or to invalidate these impressions. Theoretical and clinical implications of the findings are discussed.

Nursing student-patient relationship: a review of the literature from 1984 to 1998

AIM AND BACKGROUND

The aim of this review is to examine the research of the nursing student-patient relationship for planning an empirical study in this area.

METHODS

A literature search was made focusing on relationship from student and patient perspectives. The sample included 104 articles from 1984 to 1998. The articles were analysed using an inductive analysis of the literature.

RESULTS

The review shows that there has been an increasing research interest in the issue since the 1980s, with the main focus on nursing students. Most of the studies were of a descriptive nature, using both qualitative and quantitative approaches. It seems that the relationship with a patient is an important part of a meaningful learning process, teaching nursing students about the patient's individualised care and promoting their personal and professional growth, confidence and self-esteem. Patients are willing to participate in students' learning process and they tend to benefit from therapeutic and social interaction with students. Instruction has the effect of changing students' attitudes and improving their interaction skills, but it does not affect their feelings of anxiety in novel situations.

CONCLUSIONS

In future empirical research should be based more firmly on theory-based illuminations of the student-patient relationship.

Patients' images in nursing magazine advertisements

Images of patients in advertisements can reflect and influence readers. Since studies have shown discrimination against women and minorities in health care, images of patients in nursing practice magazine advertisements (n=446) were assessed for their reflection of reality. More male than female images were found. Men were shown more frequently as critically ill or with cardiac disease than women. Most patients were Caucasian and under 65 years old. These findings, at variance with reality, may influence nursing care. Nursing magazine readers may perceive women as less critically ill and with less heart disease than men. The underrepresentation of minorities and the elderly negates their health care presence.

Culture, age and gender: effects on quality of predicted self and colleague reactions

Ethnocentrism on the part of health care workers has been documented in the literature and has led to misdiagnosis, mistreatment and undertreatment of culturally diverse individuals worldwide. Aversive Insidious Racism and Ingroup Favoritism theories were used as the guiding framework for this study. Two hundred and sixty-eight female nurses from a large, urban, multi-service hospital in the United States were surveyed to identify those psychosocial variables (age, gender and culture status of the client) which enhanced and/or inhibited their predicted reactions with clients and which have the power to contribute to unethical decision making and less than ethical client care. The findings of this study, which is the first to examine nurses' predicted self and colleague reactions to multiple client variables concurrently, demonstrated that Client Gender as a main effect was not significant in itself when examining self and colleague predictions. Client Age as a main effect was significant for self predictions, p < 0.006, and for colleague predictions, p < 0.000. Client Culture as a main effect was significant for self predictions, p < 0.001 and for colleague predictions, p < 0.001. Many two-way and three-way interaction effects were significant. Subjects consistently predicted more favorable self reactions than colleague reactions, supporting Aversive Insidious Racism theory. Study findings did not consistently support Ingroup Favoritism theory. Subjects did not predict most favorable reactions with Caucasian female clients.

The response of women to gender stereotyping during a health interview

Gender-stereotypical responses and critical health information were examined in this posttest-only experiment. Thirty-eight university women students and staff were randomly assigned to a gender-stereotyped or a nonstereotyped health interview. Gender-biased cues were embedded in three of the five questions in the gender-stereotyped interview. Women in the gender-stereotyped interview responded with significantly more gender-stereotypical responses. However, no subjects felt affected by the gender-biased cues. Findings suggest that women affirm gender-biased questions asked in health interviews.

Smoking among low-income, pregnant women: prevalence rates, cessation interventions, and clinical implications

Smoking has a significant effect on the major causes of death and disability among women, including coronary heart disease, stroke, cancer, and osteoporosis. When pregnant women smoke, it adversely affects not only them but also the health, development, and functioning of their unborn and young children. Of the general population of pregnant women, between 20 and 45 percent smoke. Furthermore, among low-income and less educated pregnant women, the increase in prevalence of postpartum smoking relapse rates, continued smoking, and initiation of smoking underlies the need for developing effective interventions for prevention and cessation. Although self-help, stop-smoking materials demonstrated success in several trials, interventions used in conjunction with these materials were brief with little follow-up, and did not address the need for continued intervention to help maintain abstinence or cessation after birth. This article reviews the smoking cessation trials that have assessed the effects of various interventions on cessation rates among low-income pregnant women, and describes future research needs for clinic-based smoking interventions for those women and the clinical implications for health professionals.

Review of adolescent coping research: representation of key demographic variables and methodological approaches to assessment

Stressful experiences can be traced to surrounding social structures, the most encompassing of which include gender, socioeconomic status (SES), and race. An integrative review of adolescent coping research was conducted to examine the inclusion of key demographic variables and methodological approaches to the assessment of coping. Results indicated that the majority of studies investigated coping among both gender groups. However, only 46.7% reported information on SES. Coping among adolescents of lower SES and the inner city was not adequately examined. Similarly, only 53% of the studies reported information on racial composition. African-American and other minority adolescents were underrepresented in the research. To assess coping, 73.3% of the studies utilized the questionnaire format. However, instruments were not used in a consistent manner with regard to the period of time from which to recall a stressor and the context from which the stressor was selected. For those using the open-ended format for assessment, data were analyzed exclusively via the deductive approach. Our findings suggest that future research should (a) investigate coping among youth from diverse SES and racial groups, (b) examine coping over a full range of stressors, (c) utilize daily reports, and (d) assess coping by applying qualitative methods.

Gender and ethnic stereotyping and narcotic analgesic administration

The purpose of this study was to investigate whether nurses provide different amounts of narcotic analgesics to male and female patients, and different amounts to white and ethnic minority patients. A retrospective survey was conducted with the medical records of 101 male and 79 female uncomplicated adult appendectomy patients, 40 of whom were ethnic minority members. Narcotic analgesic doses for the entire postoperative period were converted to equianalgesic doses comparable to intramuscular morphine. Male patients received significantly larger initial doses than female patients. There was no gender difference in the total dose received postoperatively. White patients received significantly more total postoperative narcotic analgesics than ethnic minority patients. The gender difference provides modest external validation for prior experimental results. The ethnic difference suggests that irrelevant cues may be used in nurses' medication decisions.

Comparisons between dentist ratings and self-ratings of dental appearance in an elderly population

Little is known about dental appearance in terms of the elderly population. The purpose of this paper is to compare self-reported dental appearance with dentist-rated appearance for individuals over 65. The subjects (N = 550) were participants in the Los Angeles based Medicare Screening and Health Promotion Trial. Most were female (57.3%), white (89.0%), and married (62.0%), with a mean age of 74.5 years. About one-third had incomes greater than $25,000. Results are based on a 45 minute telephone interview and onsite dental screening. Findings show that 40% of the self-ratings on a five point scale were higher than the dentist ratings, and 22% were lower. Bivariate analyses showed that both sets of ratings were related to dental status variables, self-reported health, and education. High self-ratings were also associated with being white and having a positive mental health status, while high dentist ratings were associated with patients who were younger, married, and who had higher income and social network scores. Comparison of results from two multiple regressions showed unique predictors for the self-ratings (marital status and GOHAI scores) and for the dentist ratings (sex and income). These discrepancies can raise barriers to effective treatment planning in the elderly, which could affect utilization and satisfaction.

The effect of clients' family structure on nursing students' cognitive schemas and verbal behavior

The primary purpose of this study was to investigate if nursing students stereotype clients on the basis of family status. In addition, the influence of information about the client's family status on students' predictions about the client's behavior, information sought from the client, recalled information, and verbal responses directed toward the client were examined. The participants were 83 nursing students from a large Midwestern university. They were randomly assigned to one of two groups. Brief written information about a female adult client with a vaginal discharge was provided and, after listening to an audiotaped interview between a nurse and the client, students completed a battery of questionnaires. They also responded verbally to questions asked by the audiotaped client. All information given to both groups was identical except for the client's family status. Results indicated that the client who was a married mother was perceived somewhat more positively than the unmarried mother client. Participants' perceptions were only somewhat consistent with cultural stereotypes about these family statuses. Information sought and information remembered about the client were greater when she was an unmarried mother. There were no differences in predictions of patients' behaviors and verbal responses.

Gender stereotyping and nursing care

The effect of gender stereotyping on nursing care was examined. Eight conditions were created in a posttest-only experiment by completely crossing patient gender (male/female) by memory load (low/high) by patient health status (stable/unstable). One hundred sixty nurses read the same patient vignette. The vignette differed in patient gender, memory load, and patient health status. The nurses then estimated the minutes needed for specific nursing interventions with the patient. Nurses planned significantly more ambulation, analgesic administration, and emotional support time for the male patient, despite the presence of individuating information. More accurate, effective nursing care is possible when nurses are aware of the effect of gender stereotyping on nursing care.

Children's perspective of stress and coping: an integrative review

This integrative review of children's perceptions of stressors and coping strategies contained only 14 studies published from September 1979 to March 1989. Most of these descriptive studies were theory-based research using convenience samples of children (aged 8-12 years) in urban settings. Commonly identified stressful events were fear of negative evaluation (adult or peer), parental conflict or loss, and conflict with an adult. Categories of commonly identified coping strategies were social support, physical activities, and avoidance activities. Individual studies reported that more children tended to catastrophize than to cope; normal amounts of stress may enhance a familial tendency for migraines; increased information and age tended to increase the amount of active modes of coping while in the hospital; and children given frequent and complete information about their sibling's illness tended to be more positive about their own development. Recommendations for further research are included.

Nursing students' stereotypes of married and unmarried pregnant clients

The purpose of this study was to investigate the effects of information about a pregnant client's marital status on nursing students' initial perceptions of the client, attributions of group stereotypes to the client, predictions of client behavior, data sought, and verbal responses toward the client. Forty-three undergraduate nursing students from a large Midwestern university volunteered to participate. Subjects were randomly assigned to one of two experimental groups, the "married client" or "unmarried client." Subjects viewed a videotape of a nurse interviewing a pregnant client and were administered a series of questionnaires. Following this, they were asked to respond in writing to five statements made by the videotaped client. Videotapes were identical except that one group was told they were viewing an unmarried woman and the other group was told the client was married. Results indicated that students evaluated the married client more positively than the unmarried client. Students' perceptions were consistent with several cultural stereotypes. In addition, students predicted that, if hospitalized, the unmarried client would have greater difficulty than the married client. There were no differences between groups in the information they would seek from the client or in responses towards the client.