Nurse Education Today 52 (2017) 95–102

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Nurse Education Today

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Why is psychiatric nursing not the preferred option for nursing students:
A cross-sectional study examining pre-nursing and nursing
school factors
Hui Lin Ong a,⁎, Esmond Seow a, Boon Yiang Chua a, Huiting Xie b, Jia Wang b, Ying Wen Lau a,
Siow Ann Chong a, Mythily Subramaniam a
a
Department of Research Division, Institute of Mental Health, Singapore, Singapore
b
Nursing Training, Department of Nursing Administration, Institute of Mental Health, Singapore, Singapore

a r t i c l e i n f o a b s t r a c t

Article history: Background: There is a shortage of nurses working in the mental health field globally. The aim of the present study
Received 26 October 2016 was to examine Singapore nursing students' attitudes towards specializing in psychiatric nursing by examining
Received in revised form 8 February 2017 the pre-nursing and nursing school factors as well as attitudes towards psychiatry and personality traits.
Accepted 20 February 2017 Methods: A cross-sectional online survey was conducted with 500 nursing students from four nursing institutions
in Singapore. Students' attitudes towards psychiatry (ATP-18), perception of psychiatric nursing career aspects
relative to other fields, and personality traits (mini-IPIP) were assessed. The main outcome measure was likeli-
Keywords:
Education
hood of specializing in psychiatric nursing. Logistic regression was used to examine the combined effect of factors
Mental health upon the outcome.
Psychiatric nursing Results: Twenty-six students (5.2%) rated “definitely decided to do” psychiatric nursing. Pre-nursing school fac-
Nursing students tors associated with choosing psychiatry included ethnicity, current education, parents' wishes, having person-
Singapore al/family experience of mental illness, prior work experience, interest in psychiatric nursing and psychology
module taken prior to current school admission. Nursing school factors such as teaching methods and clinical ex-
posure were not associated with choosing psychiatric nursing. Positive attitudes towards psychiatry, perception
of better career aspects in psychiatric nursing relative to other fields, and the personality traits of extraversion
and intellect/imagination were associated with likelihood of choosing psychiatric nursing. Logistic regression re-
vealed Malay (OR: 1.90, 1.14–3.16, p = 0.013) and Indian ethnicity (OR: 2.56, 1.32–4.96, p = 0.005), interest in
psychiatry (OR: 22.56, 8.22–61.92, p b 0.001), psychology module prior to current school admission (OR: 2.31,
1.28–4.17, p = 0.005), better perceived job prospects in psychiatric nursing than other fields (OR: 1.91, 1.21–
3.04, p = 0.006), extraversion (OR: 1.09, 1.02–1.17, p = 0.012) and positive attitude towards psychiatry (OR:
2.72, 1.75–4.23, p b 0.001) as factors associated with students choosing psychiatric nursing.
Conclusions: The selection of psychiatry as a specialty by nursing students was affected by pre-nursing school fac-
tors. Taking these factors into consideration may improve recruitment and alleviate the shortages in the psychi-
atric nursing field.
© 2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
Psychiatric or mental health nursing is concerned with the preven-
tion, treatment and nursing care of people of all ages who are suffering
from mental illness and its effects. Over the years, there has been a
shortage of nurses choosing to specialize or work in mental health set-
tings (Browne et al., 2013; De Kock and Pillay, 2016; Olfson, 2016).
Moreover, past studies have examined attitudes of nursing students
⁎ Corresponding author at: Research Division, Institute of Mental Health, Buangkok
Green Medical Park, 10 Buangkok View, Singapore 539747, Singapore.
E-mail address: Hui_Lin_ONG@imh.com.sg (H.L. Ong).
towards psychiatric nursing and found that the majority of nursing stu-
dents were not interested to specialize or work in mental health settings
(Muldoon and Reilly, 2003; Surgenor et al., 2005). In a recent systematic
review conducted by Happell and Gaskin (2013), mental health was
rated as one of the least preferred areas of nursing for a potential career.
Other studies also showed that psychiatric nursing had been ranked by
students as one of the least preferred career options (DeKeyser Ganz
and Kahana, 2006; Stevens et al., 2013). Various reasons such as nega-
tive attitudes towards people with mental illness (Happell, 1999), neg-
ative experiences specific to the course or the type of work (Stevens and
Dulhunty, 1997), and lack of exposure to someone with mental health
disorder (Surgenor et al., 2005) were associated with negative attitudes

http://dx.doi.org/10.1016/j.nedt.2017.02.014
0260-6917/© 2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
96 H.L. Ong et al. / Nurse Education Today 52 (2017) 95–102
or lack of interest in pursuing psychiatric nursing as a career or
specialty.
A number of studies have examined the different factors associated
with nursing students' choice of selecting psychiatric nursing as a spe-
cialty (Happell, 2008b; Hunter et al., 2015; Thongpriwan et al., 2015).
In a recent study conducted by Thongpriwan et al. (2015) among junior
and senior nursing students, students with no experience in theoretical
or clinical setting held greater negative stereotypes of persons with
mental illness and expressed more anxiety about mental illness. Inter-
estingly in the same study, students with prior mental health experi-
ence were more interested in a future career in mental health nursing
than those who did not. More favourable attitudes towards psychiatric
nursing were found when undergraduate nursing students received
more hours of theoretical preparation and undertook longer clinical
placement (Happell, 2008b). Increasing amount of time in clinical set-
ting, adding psychology-specific content particularly the importance
of psychiatric mental health nursing and effects of stigma to the curric-
ulum were associated with recruiting and retaining psychiatric mental
health nurses (Hunter et al., 2015).
According to the Singapore Nursing Board Annual Report 2015,
there were a total of 639 nurses who were registered as Registered
Nurses — Psychiatric (RNP). A total of 20 RNPs were registered as
RNPs only with the remaining 619 RNPs concurrently registered on at
least one other register. Of the 639 nurses, 573 were currently working
(553 full-time, 20 part-time) and 495 were in the public sector. In Sin-
gapore, there were a total of 21 formal nursing programmes accredited
in 2015 and as of December 2015, 59 clinical facilities which include
public and private hospitals and long-term care nursing homes etc.
were accredited for clinical nursing education (Singapore Nursing
Board, 2015).
There is limited literature reporting on the attitudes of nursing stu-
dents towards psychiatry and their reasons for choosing psychiatric
nursing as a career in Asian countries especially in Singapore. As efforts
are being made by the policy makers to attract students and nurses to
work in the mental health field, it is important to examine the attitudes
and factors that are associated with students' choice of selecting psychi-
atric nursing as a future career choice. Therefore, the purpose of this
study is to identify the pre-nursing and nursing school factors as well
as attitudes towards psychiatry, perception of psychiatric nursing career
aspects relative to other fields, and personality traits that are associated
with the likelihood of choosing psychiatric nursing as a specialty choice.
2. Methods
2.1. Design and Sample
This cross-sectional study used an online web survey to collect data
on Singapore nursing students' likelihood of choosing psychiatric nurs-
ing as a specialty and examined their attitudes towards persons with
mental illness. The study was approved by the relevant ethics commit-
tee (National Healthcare Group's Domain Specific Review Board, Singa-
pore). The target population included all nursing students who were
enrolled in public nursing educational programmes in Singapore at
the time of the study. Students who were Singapore residents (Singa-
pore Citizens or Permanent Residents) were eligible to participate in
the study. Approval was sought from every institution. A representative
from each institution sent an email broadcast to invite its students to
participate in the study. Participants were required to go through an on-
line informed consent before they could proceed to complete the
survey.
2.2. Instruments
All instruments were administered in English language only. The in-
struments used in the present study comprised a self-report online
questionnaire which included questions on socio-demographic
information.
2.3. Pre-nursing School Factors
To measure pre-nursing school factors, questions enquired about the
sources of information which helped the students in the process of
choosing their specialty preference (e.g. parents' wishes, portrayal of
doctor/nurses in books, television and the media, prior work experience
etc.), pre-nursing school qualifications (e.g. General Certificate of Edu-
cation (GCE) Ordinary (O)/Normal Academic (NA) or Normal Technical
(NT)/Advanced levels (A) etc.), prior modules of study (e.g. Economics,
Psychology, and Sociology, etc.), and their interest in psychiatric nursing
prior to current school admission (refer to Appendix A for the full list of
modules studied in previous school).
2.4. Nursing School Factors
Students were asked to answer “Yes” or “No” for teaching methods
and enrichment activities such as whether they had attended any type
of psychiatry or mental health related activities. These include curricu-
lum-based modules, psychiatry electives, optional courses/modules/
electives, e-learning modules, etc. (refer to Appendix B for the full list
of teaching and enrichment activities).
Subjects studied at current nursing school were queried and stu-
dents were given the option of the following subjects: Behavioural Sci-
ences, Philosophy, Psychology, Ethics, Communication skills, Sociology,
Neuroscience, and other psychiatry and mental health related subjects.
Other nursing school influences and clinical exposure factors included
sources of information from school advisors or tutors and academics
or lectures and self-reported highest level of responsibility for patient
care during nursing school placement.
2.5. Other Factors
2.5.1. Attitudes Towards Psychiatry (ATP-18)
The scale consists of 18-items which were derived from verbatim
comments by students in a pilot study conducted by Wilkinson et al.
(1983) and is rated on a five-point Likert scale with scores ranging
from 1 (strongly agree) to 5 (strongly disagree). Questions on attitudes
towards psychiatry included e.g. “Psychiatrists are often merely failed
physicians” and “Within medicine, psychiatry is one of the least impor-
tant specialties” etc. Nine of the 18 items (2, 5, 6, 7, 11, 13, 14, 15, 17)
which expressed positive views were reverse scored items (Wilkinson
et al., 1983). The original ATP-30 had good internal consistency in
other studies ranging from 0.77 to 0.87 (Parikh et al., 2014; Reddy et
al., 2005) however, no Cronbach's alpha coefficient was calculated for
ATP-18 (Wilkinson et al., 1983). ATP-18 had a Cronbach's alpha coeffi-
cient of 0.57 in the present study.
2.5.2. Perception of Psychiatric Nursing Career Aspects Relative to Other
Fields
Perception of psychiatric nursing career aspects relative to other
fields was measured using 12 individual factors namely academic op-
portunities, research opportunities, work-life balance, perception of
competency, job satisfaction etc. Participants were asked to rate each
criteria based on whether they considered psychiatric nursing to be
“better”, “worse”, or “similar/unsure” relative to other fields.
2.5.3. Personality Traits
Personality traits were measured using the Mini-International Per-
sonality Item Pool (mini-IPIP), a five-point Likert scale with scores rang-
ing from 1 (very inaccurate) to 5 (very accurate) (Donnellan et al.,
2006). This model includes the following 5 traits i.e. Extraversion,
Agreeableness, Conscientiousness, Neuroticism, and Intellect/Imagina-
tion. This model consists of 20 items which is the short version of the
 H.L. Ong et al. / Nurse Education Today 52 (2017) 95–102 97

50-item International Personality Item Pool by Goldberg (1999). 3. Results

Questions include, “Am the life of the party”, “Have a vivid imagination”,
“Feel others' emotions” and “Seldom feel blue”. Details of the scoring of
the items are available in the article by Donnellan et al. (2006).
2.6. Likelihood of Specializing in Psychiatric Nursing
The primary analysis was to examine the likelihood of choosing psy-
chiatric nursing as a specialty. This variable was developed by Feifel et
al. (1999) and was originally used to assess the attitudes of medical stu-
dents towards various medical specialties. The scale was measured on a
5-point Likert scale ranging from “no way”, “unlikely”, “possible/unsure
yet”, “seriously considering” and “definitely decided to do”.
2.7. Data Collection
Data were collected electronically using QuestionPro®. The invita-
tion email included a web link to the survey form. The survey began
with screening questions to check for citizenship and institution that
the respondent was currently enrolled in. Students who were eligible
to participate would proceed to the informed consent form. After
going through the informed consent and agreeing to participate in the
study, participants went through the series of survey questions.
2.8. Statistical Analysis
All statistical analyses were performed using the Statistical Package
for the Social Science (SPSS) version 23.0. The frequency and percentage
of subjects were calculated for categorical variables, and mean and stan-
dard deviation were calculated for continuous variables. All statistically
significant results were reported at p ≤ 0.05.
For the purpose of analysis, the outcome variable was reduced to a
dichotomous outcome variable in the present study, with students ei-
ther being “unlikely” to specialize in psychiatric nursing when they
chose the options (“no way”, “unlikely”, and “possible/not sure yet”)
and students being “likely” to specialize in psychiatric nursing when
they chose the options (“seriously considering” and “definitely decided
to do”). Reasons for reducing the scale were reported in a previous arti-
cle by Farooq et al. (2014) who had conducted a similar study to identify
factors influencing psychiatry career choice among medical students.
Chi-square tests were conducted separately for each of the following
factors: teaching methods and enrichment activities, subjects studied at
pre-nursing school, subjects being studied at the current nursing school,
nursing school influences and clinical exposure factors as these factors
are measuring separate variables which may affect the outcome vari-
able differently.
ATP-18 was categorized into a binary outcome variable (positive at-
titude and negative attitude). A higher scoring indicated greater positive
The socio-demographic profile of the participants is presented in Table
1. The sample consisted of 500 nursing students recruited from 4 institu-
tions in Singapore. Respondents had a mean age of 20.1 years (SD = 3.1,
range = 16–35). Majority of the students were Singapore Citizens (N =
479, 95.8%), females (N = 417, 83.4%) and of Chinese ethnicity (N =
287, 57.4%). Overall, 363 (72.6%) nursing students reported taking psychi-
atry or mental health related curriculum-based modules and 303 (60.6%)
nursing students reported clinical placement, but only 171 (34.2%)
expressed an interest in choosing psychiatric nursing as a specialty. Twen-
ty-six (5.2%) of the students rated “definitely decided to do” psychiatric
nursing as a specialty while 145 (29.0%) rated it as “seriously considering”.
Significant differences were found for ethnicity and current education
using the Chi-square test. Compared to those of Chinese ethnicity (25.4%),
those of Malay (42.5%), Indian (55.0%), and Other (42.1%) ethnicity were
more likely to choose psychiatric nursing as a specialty. Moreover, stu-
dents who were currently pursuing Technical Education (46.0%) and Di-
ploma (34.0%) were more likely to specialize in psychiatric nursing than
students who were pursuing undergraduate nursing education (23.0%).
3.1. Likelihood of Specializing in Psychiatric Nursing
Fig. 1 shows the ranking of nursing specialties by the students. This
ranking was calculated based on the percentage of “definitely decided
to do” rating by students for each specialty. The top 3 “definitely decided
to do” specialties listed by nursing students were Accident and Emer-
gency medicine (15.2%), Surgical Nursing (10.4%), and Paediatrics
(10.0%). Psychiatric Nursing was ranked 4th (5.2%) followed by General
Practice/Primary Care (4.6%), Obstetrics and Gynaecology (3.6%) and
General Internal Medicine (3.4%).
3.2. Pre-nursing School Factors Associated with Choosing Psychiatric
Nursing
Tables 2 and 3 show the pre-nursing school factors in relation to
choosing psychiatric nursing. Three factors were found to be significantly
associated with the likelihood of specializing in psychiatric nursing: par-
ents' wishes (p = 0.040), personal/family experience of a mental illness
(p = 0.009), and prior work experience (p = 0.045) (Table 2). Students
who rated “yes” for parents' wishes were more likely to choose psychiat-
ric nursing than those who rated “no” (45.7% vs. 32.3%). Those who rated
“yes” for personal/family experience of a mental illness were more likely
to choose psychiatric nursing than those who rated “no” (50.9% vs.
Table 1
Socio-demographic profile of participants and likelihood of choosing psychiatric nursing
as a specialty (n = 500).

attitude towards psychiatry. Those who scored higher than the median Factor Unlikely Likely P-valuea
score of 64 were labelled as having a “positive attitude”, while those
N % N % N %
who scored 64 and below were labelled as having a “negative attitude”.
Age M = 20.09 M = 20.29 M = 19.73 0.052
Association of ATP-18 in relation to likelihood to choose psychiatric
SD = 3.06 SD = 3.13 SD = 2.90
nursing was assessed using the Chi-square test. Citizenship Singapore 479 95.8 315 65.8 164 34.2 1.000
Personality traits were measured by summing the raw score of each Citizen
trait. A higher score for questions in mini-IPIP implied that the students Permanent 21 4.2 14 66.7 7 33.3
associated themselves with that trait. Association of the 5 personality Resident
Gender Male 83 16.6 54 65.1 29 34.9 0.977
traits and the likelihood of choosing psychiatric nursing were per-
Female 417 83.4 275 65.9 142 34.1
formed using the independent t-tests. Ethnicity Chinese 287 57.4 214 74.6 73 25.4 b0.001⁎
Binary logistic regression model was employed in the current study. Malay 134 26.8 77 57.5 57 42.5
To avoid the overloading of the regression model, the analysis only in- Indian 60 12.0 27 45.0 33 55.0
Others 19 3.8 11 57.9 8 42.1
cluded significant and close to significant variables derived from the ini-
Current Undergraduate 100 20.0 77 77.0 23 23.0 0.003⁎
tial Chi-square tests and independent t-tests. Similar to the study Education Diploma 300 60.0 198 66.0 102 34.0
conducted by Farooq et al. (2014), a backwards selection procedure Technical 100 20.0 54 54.0 46 46.0
(Wald) was employed. This procedure allows the elimination of non- ⁎ p ≤ 0.05.
significant variables one at a time, based on the probability of the a
Chi-square test for citizenship, gender, ethnicity, and current education and Inde-
Wald statistic, until only the statistically significant variables remained. pendent t-test for age.
98 H.L. Ong et al. / Nurse Education Today 52 (2017) 95–102

Nursing Specialties
16.0%
15.2%

14.0%

12.0%

10.4%
10.0%
10.0%

8.0%

6.0%
5.2%
4.6%

4.0% 3.6% 3.4%

2.0%

0.0%
Accident and Surgical Nursing Paediatrics Psychiatric Nursing General Practice/ Obsterics and General Internal
Emergency Medicine Primary Care Gynaecology Medicine

1st 2nd 3rd 4th 5th 6th 7th

Fig. 1. Nursing specialties ranking by students: “definitely decided to do”.

32.1%). Students who had prior work experience were less likely to
choose psychiatric nursing than those who did not (27.6% vs. 37.2%).
No significant association was found between students' qualifications
before entering nursing school and their decision to specialize in psychi-
atric nursing (p N 0.05). Students who reported psychiatric nursing as the
specialty that they were most interested in or decided upon prior to cur-
rent school admission were more likely to specialize in psychiatric nurs-
ing than those who chose other specialties (88.6% vs. 28.9%, p b 0.001)
(Table 3). Among all the modules taken prior to nursing school (refer to
Appendix A), nursing students who had taken psychology module prior
to current school admission were more likely to choose psychiatric nurs-
ing as a specialty choice (45.6% vs. 32.1%, p = 0.028).
psychiatric nursing. Among all the subjects studied at the current nurs-
ing school, nursing students who took ethics were less likely to choose
psychiatric nursing (28.3% vs. 40.2%, p = 0.007). Nursing school influ-
ences and clinical exposure factors were not associated with likelihood
of choosing psychiatric nursing (Table 4). Although not significant,
those who were given responsibility for patient care during psychiatry
clinical placement (i.e. asked opinion, conducted structured activities,
and assessed risk) were more likely to choose psychiatric nursing than
students with no responsibility. Students who conducted structured ac-
tivities during placement were likely to choose psychiatric nursing com-
pared to those who were given no responsibility during placement,
39.8% vs. 20.8%.

3.3. Nursing School Factors Associated with Choosing Psychiatric Nursing

3.4. Other Factors
3.3.1. Teaching Methods, Enrichment Activities, Nursing School Influences
and Clinical Exposure Factors 3.4.1. Attitudes Towards Psychiatry (ATP-18)
No association was found between teaching methods and enrich- Table 5 shows the ATP-18 scores in relation to the likelihood of spe-
ment activities (refer to Appendix B) and the likelihood of choosing cializing in psychiatric nursing. Students who had a higher mean score
in ATP-18 (M = 65.17, SD = 6.19) were more likely to choose psychiat-
ric nursing than those who had a lower mean score in ATP-18 (M =
Table 2 63.33, SD = 5.27, p b 0.001) (Table 5). After reducing ATP-18 into a bi-
Pre-nursing school factors influencing the choice to study psychiatric nursing.
nary outcome variable using the median as cut-off, the Chi-square test
Factor Category Unlikely Likely P-valuea revealed that those with a positive attitude (N64) were more likely to
N % N % consider psychiatric nursing than those who had a negative attitude
(≤64), with 43.0% vs. 27.1% (p b 0.001).
Parents' wishes No 291 67.7 139 32.3 0.040⁎
Yes 38 54.3 32 45.7
Wider family and friends' advices No 263 67.8 125 32.2 0.104
Yes 66 58.9 46 41.1
A trusted doctor/nurse who has No 273 66.6 137 33.4 0.504 Table 3
close contact (family or close Yes 56 62.2 34 37.8 Interest in psychiatric nursing and psychology module taken prior to current school
friends) with you admission.
Portrayal of doctors/nurses in books, No 250 67.2 122 32.8 0.308
television and the media Yes 79 61.7 49 38.3 Factor Category Unlikely Likely P-valuea
Personal/family experience of a No 241 66.2 123 33.8 0.834
N % N %
physical illness Yes 88 64.7 48 35.3
Personal/family experience of a No 302 67.9 143 32.1 0.009⁎ Interest in psychiatric nursing prior No 324 71.1 132 28.9 b0.001⁎
mental illness Yes 27 49.1 28 50.9 to admission Yes 5 11.4 39 88.6
Prior work experience No 216 62.8 128 37.2 0.045⁎ Psychology module prior to No 286 67.9 135 32.1 0.028⁎
Yes 113 72.4 43 27.6 admission Yes 43 54.4 36 45.6
⁎ p ≤ 0.05. ⁎ p ≤ 0.05.
a a
Chi-square test. Chi-square test.
 H.L. Ong et al. / Nurse Education Today 52 (2017) 95–102 99

Table 4 Table 6
Nursing school influences and clinical exposure factors and relation to likelihood of choos- Perception of psychiatric nursing career aspects relative to other fields and relation to like-
ing psychiatric nursing. lihood of choosing psychiatric nursing.

Factor Category Unlikely Likely P-valuea Factor Category Unlikely Likely P-valuea

N % N % N % N %

School advisors or tutors No 194 65.8 101 34.2 1.000 Academic opportunities Better 114 57.3 85 42.7 0.005⁎
Yes 135 65.9 70 34.1 Worse 19 73.1 7 26.9
Academics or lectures No 147 65.6 77 34.4 1.000 Similar/unsure 196 71.3 79 28.7
Yes 182 65.9 94 34.1 Research opportunities Better 149 61.6 93 38.4 0.138
Senior clinicians during No 243 64.3 135 35.7 0.252 Worse 15 65.2 8 34.8
placements Yes 86 70.5 36 29.5 Similar/unsure 165 70.2 70 29.8
Junior clinicians during No 274 65.4 145 34.6 0.758 Competition for training places Better 95 58.3 68 41.7 0.048⁎
placements Yes 55 67.9 26 32.1 Worse 32 69.6 14 30.4
Other students in the No 253 66.1 130 33.9 0.914 Similar/unsure 202 69.4 89 30.6
same course Yes 76 65.0 41 35.0 Flexible working Better 95 58.3 68 41.7 0.044⁎
Weeks of psychiatry ≤5 weeks 254 64.6 139 35.4 0.442 Worse 41 71.9 16 28.1
training 6–10 weeks 28 68.3 13 31.7 Similar/unsure 193 68.9 87 31.1
11 + weeks 36 73.5 13 26.5 Job prospects Better 96 54.2 81 45.8 b0.001⁎
Ethics No 147 59.8 99 40.2 0.007⁎ Worse 46 78.0 13 22.0
Yes 182 71.1 72 28.3 Similar/unsure 187 70.8 77 29.2
Clinical placement No 134 68.0 63 32.0 0.455 Likelihood of suffering Better 71 56.8 54 43.2 0.003⁎
Yes 195 64.4 108 35.6 emotional drain/burnout Worse 135 75.0 45 25.0
Seen acutely unwell No 196 67.4 95 32.6 0.442 Similar/unsure 123 63.1 72 36.9
inpatients Yes 133 63.6 76 36.4 Salary/pay Better 125 61.6 78 38.4 0.238
Seen people with chronic No 200 66.9 99 33.1 0.596 Worse 23 71.9 9 28.1
symptoms Yes 129 64.2 72 35.8 Similar/unsure 181 68.3 84 31.7
Level of responsibility No responsibility 19 79.2 5 20.8 0.068 Prestige among general public Better 65 52.0 60 48.0 0.001⁎
during placement Asked opinion 18 62.1 11 37.9 Worse 77 73.3 28 26.7
Conducted 124 60.2 82 39.8 Similar/unsure 187 69.3 83 30.7
structured activities High status among medicine Better 59 50.0 59 50.0 b0.001⁎
Assessed risk 34 77.3 10 22.7 Worse 53 80.3 13 19.7
Similar/unsure 217 68.7 99 31.3
⁎ p ≤ 0.05.
a Work-life balance Better 77 55.4 62 44.6 0.005⁎
Chi-square test.
Worse 56 75.7 18 24.3
Similar/unsure 196 68.3 91 31.7
Perception of competency Better 85 54.5 71 45.5 0.001⁎
3.4.2. Perception of Psychiatric Nursing Career Aspects Relative to Other Worse 52 78.8 14 21.2
Similar/unsure 192 69.1 86 30.9
Fields
Job satisfaction Better 108 54.3 91 45.7 b0.001⁎
Ten out of twelve individual factors were found to be associated with Worse 40 81.6 9 18.4
students' likelihood of choosing psychiatric nursing using the Chi- Similar/unsure 181 71.8 71 28.2
square test (Table 6). Across the 10 factors (i.e. academic opportunities, ⁎ p ≤ 0.05.
competition for training places, flexible working, job prospects, likeli- a
Chi-square test.
hood of suffering emotional drain/burnout, prestige among general
public, high status among medicine, work-life balance, perception of
competency, and job satisfaction), students who rated these 10 factors 3.5. Logistic Regression
as “better” in psychiatric nursing than the other fields were more likely
to choose psychiatric nursing. Logistic regression was conducted to examine the effect of multiple
factors that were significant from previous tests upon the likelihood of
choosing psychiatric nursing as a specialty (Table 8). Results from the
3.4.3. Personality Traits multivariate logistic regression revealed that six factors remained sig-
Three out of five personality traits were not associated with the like- nificantly associated with nursing students being likely to choose psy-
lihood of choosing psychiatric nursing (Table 7). Extraversion and Intel- chiatric nursing as a specialty.
lect/Imagination were associated with the likelihood of choosing Compared to students of Chinese ethnicity, Malay students were
psychiatric nursing. Students who scored higher in extraversion about two times (OR: 1.90, 95% CI 1.14–3.16, p = 0.013) and Indian stu-
(M = 12.4, SD = 3.3) and in intellect/imagination (M = 14.4, SD = dents were about three times more likely to consider psychiatric nurs-
2.7) were more likely to choose psychiatric nursing as a specialty than ing as a specialty (OR: 2.56, 95% CI 1.32–4.96, p = 0.005). Those who
students who scored lower (Extraversion: M = 11.7, SD = 3.0, p = rated psychiatric nursing as the specialty that they were most interested
0.028; Intellect/Imagination: M = 13.7, SD = 2.7, p = 0.005). in or decided on prior to current school admission were 23 times more

Table 5
ATP-18 scores in relation to likelihood of choosing psychiatric nursing. Table 7
a
Personality traits and likelihood of choosing psychiatric nursing.
Factor Category Unlikely Likely P-value
Personality trait Unlikely Likely P-valuea
N % N %
Mean SD Mean SD
ATP scoreb M = 63.33 SD = M = 65.17 SD = b0.001⁎
5.27 6.19 Extraversion 11.7 3.0 12.4 3.3 0.028⁎
ATP score Negative attitude 202 72.9 75 27.1 b0.001⁎ Agreeableness 15.4 2.4 15.8 2.6 0.052
Positivec attitude 127 57.0 96 43.0 Conscientiousness 13.5 2.6 13.2 2.7 0.178
Neuroticism 11.8 2.7 11.8 2.8 0.971
⁎ p ≤ 0.05.
a Intellect/Imagination 13.7 2.7 14.4 2.7 0.005⁎
Chi-square test.
b
Mean (M) and standard deviation (SD) reported. ⁎ p ≤ 0.05.
c a
Positive attitude defined as score N 64. Independent t-test.
100 H.L. Ong et al. / Nurse Education Today 52 (2017) 95–102

Table 8 identified. Compared to the Chinese, Malays and Indians exhibit lesser
Logistical regression factors in choosing a psychiatric nursing specialty. social distancing and social restrictiveness towards those with mental
Factora Category Odds 95% C.I. P-value illness (Yuan et al., 2016). Another study also found that Malays and In-
ratio
Lower Upper
dians endorsed less social distancing towards those with mental illness
than the Chinese and viewed mental illness as a weakness but not sick-
Age – 0.93 0.86 1.00 0.052
ness (Subramaniam et al., 2016). This difference could be attributed to
Ethnicity Chinese Ref
Malay 1.90 1.14 3.16 0.013⁎ religion and culture. In Singapore, the majority of the Malays are Mus-
Indian 2.56 1.32 4.96 0.005⁎ lims and the Islamic health practises view both physical and mental ill-
Others 2.42 0.85 6.93 0.100 nesses as a test or punishment from God, and suggest one should see it
Interest in psychiatric nursing No Ref as an atonement for their sins (Padela et al., 2012; Rassool, 2000). A
prior to admission Yes 22.56 8.22 61.92 b0.001⁎
Psychology module (previous No Ref
study conducted among rural Indian citizens found that Indians were
school) Yes 2.31 1.28 4.17 0.005⁎ generally willing to be a friend, neighbour or colleague of persons
Job prospects relative to other Better 1.91 1.21 3.04 0.006⁎ with mental illness (Kermode et al., 2009). However, they are less will-
fields Worse 0.79 0.37 1.69 0.543 ing if this involves marriage as this plays an important role in their
Similar/Unsure Ref
culture.
Personality trait Extraversion 1.09 1.02 1.17 0.012⁎
ATP-18 Negative Ref Interest in psychiatry has been reported in other studies to be asso-
attitude ciated with specialty or career choice. Alexander et al. (2015) found that
Positive 2.72 1.75 4.23 b0.001⁎ among psychiatric nurses in United States who remained in their spe-
attitudeb cialty choice, their interest developed prior to or while in nursing school,
⁎ p ≤ 0.05. personal relevance, and validation of potential were associated with
a
Backwards selection procedure, variables entered initially (Step 1): Age, Ethnicity, their career choice. In another study among final year medical students,
Current education, Parents' wishes, Personal/family experience of a mental illness, Prior
those who had a clear idea that they wanted to study psychiatry were
work experience, Psychology module (prior to current school admission), Ethics (current
school), Academic opportunities, Competition for training places, Flexible working, Job 11 times more likely to consider specializing in psychiatry compared
prospects, Likelihood of suffering emotional drain/burnout, Prestige among general public, to those who had no specialty choice when entering medical school
High status among medicine, Work-life balance, Perception of competency, Job satisfac- (Farooq et al., 2014).
tion, Extraversion, Intellect/Imagination, Agreeableness, Interest in psychiatric nursing In contrast to existing studies (Happell and Gaskin, 2013; Muldoon
prior to current school admission, and ATP-18 category.
b
Positive attitude denoted as score N 64.
and Reilly, 2003), psychiatric nursing is not listed as the least popular
choice in nursing specialties among nursing students in Singapore
(ranked 4th out of 7 specialties). Unlike other studies (Farooq et al.,
likely to consider specializing in psychiatric nursing than those who had 2014; Thongpriwan et al., 2015), the present study did not find any sig-
other or no specialty choice (OR: 22.56, 95% CI 8.22–61.92, p b 0.001). nificant association between teaching methods, enrichment activities,
Students who were exposed to the psychology module prior to current and clinical exposure factors with the likelihood of choosing psychiatric
school admission were more likely to specialize in psychiatric nursing nursing. While previous evidence suggests that nursing students who
than those who had no exposure (OR: 2.31, 95% CI 1.28–4.17, p = undergo a greater amount of clinical time in psychiatry had a greater de-
0.005). sire to pursue a career in psychiatric nursing that does not appear to be
Job prospects remained significantly associated with the likelihood the case in the present study (Adams, 1993; Happell, 2008a, 2008c;
of choosing psychiatric nursing as a specialty. Students who perceived Happell and Gaskin, 2013). Possible reasons could be due to the differ-
psychiatric nursing as having better job prospects relative to other fields ences in the psychiatry module structure across institutions and clinical
were more likely to choose psychiatric nursing than those who gave placement experience. Although students may show a positive shift in
similar or unsure ratings (OR: 1.91, 95% CI 1.21–3.04, p = 0.006). Last their attitudes towards persons with mental illnesses after psychiatric
but not least, students with a positive attitude towards psychiatric nurs- nursing clinical placement, negative clinical experience can have an ad-
ing were three times more likely to choose psychiatric nursing as a spe- verse effect on a student's view of psychiatric nursing, making it less
cialty than those with negative attitudes (OR: 2.72, 95% CI 1.75–4.23, likely that students will choose psychiatric nursing as a specialty or ca-
p b 0.001). reer choice (Hunter et al., 2015).
The results of the study suggest that pre-nursing school factors play
4. Discussion a crucial role in influencing students' likelihood of choosing psychiatric
nursing than nursing school factors. Sources of information such as par-
4.1. Main Findings ents' wishes, personal or family experience of a mental illness, and prior
work experience are likely to affect the student's decision in choosing
Consistent with a study among United Kingdom medical students psychiatric nursing. It is plausible that in an Asian setting like Singapore,
that reported high representation of ethnic minorities in the specialties parents' views are taken seriously and thus remain a big influence on
that includes general psychiatry, learning disability and old age psychi- children's career choices (Liu et al., 2015). The other two factors associ-
atry (Goldacre et al., 2004), our study found that those of Malay and In- ated with the likelihood to pursue psychiatric nursing are personal or
dian ethnicity were more likely to consider psychiatric nursing as family experience of mental illnesses and prior work experience. Ste-
compared to those of Chinese ethnicity. Few studies have reported ra- reotypes of persons with mental illness are common among the public
cial and ethnic differences in attitudes towards mental illness and this and studies reported that negative stereotypes can raise fear and anxi-
could be the reason for the disparity found in the present study (Fan, ety about working with people with mental illness (Ganzer and
1999; Jimenez et al., 2013). A separate analysis was conducted to look Zauderer, 2013). A study conducted among medical students found
at the relationship between ethnicity and attitudes towards psychiatry that prior experience with mental illness either through personal (in
(ATP-18) in the present study and we found the lowest ATP-18 mean self, family member or friend) professional experience was associated
score among Chinese nursing students and the highest ATP-18 mean with more positive attitudes towards students with mental illness
score among the Malays followed by Indian nursing students. The low (Roth et al., 2000). It is possible that having experience with mental ill-
score in ATP-18 is a plausible reason for Chinese students being less like- ness would help students to be less anxious as it would equip them with
ly to choose psychiatric nursing as a specialty compared to Malay and skills and knowledge of what to expect and to work with mentally ill
Indian students. In a recent study conducted in Singapore, significant people and develop confidence in communicating with them (Ganzer
ethnic differences in stigma towards those with mental illness were and Zauderer, 2013).
 H.L. Ong et al. / Nurse Education Today 52 (2017) 95–102 101

4.2. Limitations and Strengths Appendix A. Which subjects have you been exposed to before enter-
ing your current school?
This study is a cross-sectional study and thus no causal relation-
ship could be made between the factors and students' likelihood of Economics Psychology Philosophy
choosing psychiatric nursing. For example, it is possible that Sociology Modern Languages History
students who were interested in or have decided on a psychiatric Accounting/Finance/Business Art/Design Classical Languages
Chemistry Geography Information Technology
nursing career were more likely to take up the psychology module
Technology Physics Music
prior to current school admission than vice versa. We did not do a Performing Arts General Studies Mathematics
pre-post test to see if the education in psychiatry or mental health Politics Religious Studies Biology
related activities i.e. teaching methods, clinical placements, and en- English Sports Science
richment activities would affect the students' attitudes towards psy-
chiatry. It is probable that education had changed students' attitudes Appendix B. Which of the following types of psychiatry or mental
towards psychiatry, positively or negatively, but was not captured in health related activities have you had during your course of study
the current study. In the current study, the ATP-18 instrument had a in your current institutions?
relatively low Cronbach's alpha coefficient and thus, the interpreta-
tions of the findings related to attitudes towards psychiatry are lim-
Curriculum-based modules Psychiatry electives
ited. However, this is the most relevant tool that the author could
Optional courses/modules/electives Problem-based learning scenarios
find to measure students' attitude towards psychiatry. E-learning modules Simulation teaching
Notwithstanding these limitations, this study is the first that ex- Lectures/tutorials Project-based assignments
amined the above phenomena among Singapore nursing students Research experience in psychiatry Talks/sharing by special guests
Student wellness/mental health Psychiatry/mental health club
across different education levels. The sample size of 500 nursing stu-
programme
dents was relatively large and participants were recruited from all 4 Visit to Institute of Mental Health Volunteering with mentally-ill
institutions in Singapore to get a good distribution of students of dif- patients
ferent qualifications. These institutions consist of students studying Internship or work experience
for post-secondary qualifications to undergraduate qualifications
and thus provide a holistic overview of Singapore nursing students'
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