Issues in Mental Health Nursing, 30:705711, 2009 Copyright Informa Healthcare USA, Inc.

. ISSN: 0161-2840 print/ 1096-4673 online DOI: 10.3109/01612840903131792

Attitudes of Jordanian Mental Health Nurses Toward Mental Illness and Patients with Mental Illness
Ayman M. Hamdan-Mansour, RN, MSN, PhD
Associate Professor, Department of Community Health Nursing, Faculty of Nursing, University of Jordan, Amman, Jordan

Lina A. Wardam, RN, MSN

Lecturer, Department of Community Health Nursing, Faculty of Nursing, University of Jordan, Amman, Jordan

The purpose of this study was to examine Jordanian mental health nurses attitudes toward mental illness and patients with mental illness. A descriptive correlational design was utilized to collect data from 92 mental health nurses in Jordan. Data was collected on nurses attitudes toward mental illness and patients with mental disorder and their satisfaction with nursing care delivery. The Jordanian mental health nurses who participated in this study had negative attitudes toward mental illness and toward patients with mental disorders. About 60% of the mental health nurses had perceived patients with mental illness to be dangerous, immature, dirty, cold hearted, harmful, and pessimistic. In only two descriptionsbeing polite and adultdid nurses have positive perception about patients with mental illness. Mental health nurse were not satised with nursing care delivery. More than 70% of nurses were proud to be a mental health nurse. Age and gender were signicant inuential factors in forming the nurses attitudes or satisfaction. Immediate intervention is needed to improve the quality of patient care provided by mental health nurses.

BACKGROUND Mental health nurses face numerous challenges, such as increased patient acuity, decreased length of stay, and changing patient expectations (Cleary, Walter, & Hunt, 2005) that may burden nurses and negatively affect nursing quality of care. While mental health nurses attempt to provide a safe environment, they struggle to provide therapeutic care (OBrien & Cole, 2003). The changes in mental health services impact the role and practice of mental health nursing (Cleary, Walter, & Hunt, 2005). According to Rey, Walter, and Giuffrida (2004), mental health professionals reported that patients with mental illnesses are more demanding, acute, and disturbed. Incidents of aggres-

Address correspondence to Ayman M. Hamdan-Mansour, University of Jordan, Faculty of Nursing, Amman, 11942 Jordan. E-mail: a.mansour@ju.edu.jo

sion and substance abuse in the inpatient psychiatric units were reported to be common and of increased concern among mental health professionals (MacGabhann, Baker, & Dixon, 2002). These increased demands require increased effort by mental health nurses. There is limited data available on mental health nursing in regard to nurses attitudes toward mental illness and patients with mental illness. In addition, there are scarce data related to the impact of mental health nurses attitudes toward acute mental illness on the quality of patient care provided. Studying nurses attitudes is essential for mental and psychosocial health. Attitudes include cognitive, affective, and behavioral components activated due to exposure to stimulus or object (Baker, Richards, & Campbell, 2005). Attitudes of mental health nurses toward patients with a mental illness are considered an inuential factor of the quality of mental health nursing care provided (Baker, 2000). Recently, and due to the importance of having a positive attitude toward mental illness, the United States, New Zealand, the United Kingdom, and India launched a campaign to change the negative attitudes toward mental health problems (Royal College of Psychiatrists, 2001; World Psychiatric Association, 2001). It has been found that negative attitudes are mostly displayed by mental health nurses toward patients who are disturbed, and this usually occurs for patients at an acute level of mental illness (Read & Harre, 2001). Negative attitudes, as a result, have inuenced nurses interactions with patients and the quality of nursing care provided (Baker, 2000). Mental health services in Jordan are not well recognized or understood, and many Jordanians lack knowledge about psychiatric illnesses and treatments (El-Islam, 1994). Therefore, psychiatric illness is still stigmatized among Jordanians; this is one barrier to seeking treatment through professional institutions. Another barrier is the lack of mental health services. Access to these services is limited due to a shortage of mental health staff and centers. Mental health services in Jordan are provided by two public hospitals (390 beds), one military unit (20 beds), and one private hospital (40 beds).

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There are no psychiatric beds in the university hospitals. There are 50 psychiatrists in the country and only three psychiatric nurses and two psychiatric nurse practitioners (World Health Organization, 2003). A previous Jordanian study (Wardam & Dawani, unpublished) investigated perception of mental health among the general Jordanian population, including nursing students and general nurses, and found that there is a negative attitude toward patients with mental illness and a lack of understanding of the causes of mental illness. However, no previous study conducted in Jordan has examined this issue among mental health nurses and no studies have been conducted to explore mental health nurses experience and satisfaction about nursing care delivery. Therefore, this study addresses an important neglected sector in the Jordanian health care system. The purpose of this study was to examine Jordanian mental health nurses attitudes toward mental illness and patients with mental illness. The specic aims were: 1. To examine Jordanian mental health nurses attitudes toward mental illness and patients with mental illness; 2. To investigate the differences in Jordanian mental health nurses attitudes toward mental illness and patients with mental illness in relation to selected demographic and personal characteristics; 3. To investigate the mental health nurses satisfaction with nursing care delivery and their experience being mental health nurses. METHODS Design This descriptive correlational study was conducted in Amman, Jordan. Data were collected using self-reported questionnaires from all mental health nurses in governmental and private sectors in Jordan. Sample and Setting The target sample included 105 registered and associate nurses, representing all nurses working at the acute and chronic inpatient and outpatient mental health agencies in the governmental and private health care sectors in Jordan. A total of 105 questionnaire packages were sent out and 92 were returned, providing an 88% response rate. A total of 79% (n = 73) of the responding nurses were from the governmental sector and 21% (n = 19) represented the private sector. Data Collection Procedure Prior to data collection, ethical approval from the Academic and Scholarship Committee at the Faculty of Nursing, University of Jordan, was obtained. Then a package of two selfreported questionnaires and an author-developed demographic survey was distributed to all registered and associate mental health nurses in all acute and chronic mental health care agencies in the governmental and private health care sectors in Jordan.

Nursing managers served as liaisons, and facilitated access to and the return of the questionnaires. The questionnaire package contained all instruments and included a cover page explaining the purpose of the study, its signicance, and informing the participants that the study is anonymous. The cover page also included information about the contact person and instructions for returning the questionnaires. The whole package was translated into Arabic. Participants were assigned an identication number at the beginning of the study and all information was kept condential by the investigators. All les were kept in locked cabinets at the Faculty of Nursing, University of Jordan. The electronic versions of the project and its data were kept in the primary investigators computer. Measures For the purpose of this study, instruments were translated into Arabic language. All original norms were applied for the translated scales. Translation was done from English into Arabic by a professional English language translator. Then a back translation into English was carried out by another professional English language translator. Finally, the two English forms (the original and the translated forms) were compared, and pilot testing using a sample of ten nurses was conducted to evaluate the readability and comprehension of the instruments. The scales also were checked for cultural variation. An author-developed demographic prole was used in addition to measurement scales to gather additional data. The Attitudes toward Acute Mental Health Scale (Baker, Richards, & Campbell, 2005) was used to examine attitudes and knowledge of nurses toward mental illness and patients with mental health problems. The scale is formed of 33 items in which the rst 25 items are measured on a 7-point Likert scale. Responses ranged from (1) strongly disagree to (7) strongly agree. Items 2633 were measured on a semantic differential that ranged from 010. For the purpose of this study, the semantic scale was dichotomized into positive perception (>5) and negative perception (<5). The scale takes approximately 1520 minutes to complete. The scale has good reliability; Cronbachs alpha equals .72 (Baker, Richards, & Campbell, 2005). In this study Cronbachs alpha was .70. Nurses satisfaction with mental health care delivery was measured using an adapted scale of 11 items developed by Cleary, Walter, and Hunt (2005). The survey asks nurses to rate their responses in relation to nursing care delivery in their work setting, the quality of nursing care, how satised they were with it, their sources of satisfaction and dissatisfaction, and how difcult that system of care delivery was. The scale has good reliability in this study with Cronbachs alpha equal to .83. Background information, including participants age, gender, details about their nursing education, number of years in nursing, most frequent place of work, and primary work duties, job titles, length of employment on the current ward, and length of employment in the nursing profession, was obtained using an author-created survey.

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RESULTS Demographics The sample consisted of 92 nurses with ages ranging from 22 to 51 years (Mean = 32.7, SD = 7.3). Among those, 72% (n = 66) were female and 28% (n = 26) were males. There were three (3.3%) registered nurses with a masters degree, 57 (62%) registered nurses with a bachelors degree, and 32 (35%) nurses with an associates degree. A total of 79% (n = 73) of the nurses came from the governmental sector and 21% (n = 19) came from the private sector. Among all the nurses, only 21% (n = 19) had specialized training in the eld of psychiatric and mental health nursing. Attitudes Toward Mental Illness As shown in Table 1, mental health nurses in general have negative attitudes toward mental illness. The reports in Table 1 show that nurses had more than 70% agreement on nine items that are categorized as negative attitudes toward mental illness. The highest among all the negative attitudes was the nurses disagreement (95%) on item-1, Psychiatric illness deserves as much attention as physical illness, indicating that mental

health nurses value physical health over mental and psychiatric health. The second highest negative attitude was for item 2, The manner in which you talk to patients affects their mental state, which infers that nurses do not value the positive effects of using therapeutic verbal communication skills with the patient. Nurses also had negative attitudes toward the patients ability to control their environment and psychosocial stressors. Nurses had more than 80% agreement on items 35, which indicate that nurses connected mental illness with an individuals ability to control him- or herself. Nurses perceived mental illness as a loss of control of the self, emotions, and behaviors. However, mental health nurses had positive attitudes for ve items. The highest two positive attitudes were related to causes of mental illnesses. Mental health nurses disagreed that people are born vulnerable to mental illness, although they agreed that mental illnesses are genetic in origin. These results suggest some inconsistency in nurses attitudes. Attitudes Toward Patients with Mental Illness Mental health nurses had negative attitudes toward patients with mental illness in six of the eight descriptions used in the study. About 60% of mental health nurses perceived patients

TABLE 1 Attitudes Toward Mental Illness and Patients with Mental Health Problems (n = 92) Item # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Agree Attitude Psychiatric illness deserves as much attention as physical illness. The manner in which you talk to patients affects their mental state. Mental illness is the result of adverse social circumstances. Alcohol abusers have no self-control. Mentally ill patients have no control over their emotions. Many normal people would become mentally ill if they had to live in a very stressful situation. Patients with chronic schizophrenia are incapable of looking after themselves. People are born vulnerable to mental illness. Mental illnesses are genetic in origin. It is difcult to negotiate care plans with patients in acute environments. Those who attempt suicide that leaves them with serious liver damage should not be given treatment. It is hard to help patients who are emotionally disturbed. Psychiatric drugs are used to control disruptive behavior. Depression occurs in people with a weak personality. % 1.1 5.4 87.0 84.8 84.8 16.3 78.3 17.4 76.1 73.9 17.4 26.1 70.7 68.5 n 1 5 80 78 78 15 72 16 70 68 16 24 65 63 Disagree % 94.6 93.5 12.0 8.7 13.0 81.5 19.6 78.5 18.5 22.8 70.7 70.7 20.7 26.1 n 87 86 11 8 12 71 18 72 17 21 65 65 19 24 Implication of Attitudes Negative Negative Negative Negative Negative Positive Negative Positive Negative Negative Positive Positive Positive Negative

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with mental illness as being dangerous, immature, cold hearted, harmful, and pessimistic and as having poor physical hygiene. The highest negative attitude was related to the physical hygiene of the patient (67.4%, n = 62). About 50% (n = 47) of the respondents perceived patients with mental illness to be adults and polite. This indicates that patients may have used positive manners with the nurses that made the nurses perceive them as polite and adult. Another explanation is that nurses may overestimate their patients behaviors and manners, and therefore, they were more attentive to positive behaviors than negative ones. This may have positively inuenced nurses attitudes and contributed to their positive perception of the patients as polite and adults. Differences in Attitudes Related to Demographics The analysis using Mann-Whitney U test showed that nurses age was a signicant factor in the differences in attitudes toward patients with mental illnesses, especially in regards to the nurses perceptions of patients as adults versus children and as caring versus cold hearted (p < .05). Chi-square analysis showed that male and female mental health nurses were significantly different in item 2, Patients with chronic schizophrenia are incapable of looking after themselves, ( 2 = 4.61, p = .035). Male and female nurses also had signicant differences in their attitudes regarding their perception of patients as

polite versus rude (chi-square = 7.07, p = .03), with female nurses more frequently perceiving mental health patients to be polite than male nurses did. Female nurses had higher positive scores than male nurses did, which indicates that female nurses perceive patients more positively than male nurses do. On the other hand, male and female mental health nurses had marginal non-signicant differences in items 24, The manner in which you talk to patients affects their mental state, and 13, Those with a psychiatric history should never be given a job with responsibility, ( 2 = 5.42, p = .052; 2 = 4.54, p = .051, respectively). The results, in general, indicate that gender does not play a signicant role in determining the mental health nurses attitudes toward mental illness and patients with mental illness. Regarding the relationship between the other selected demographic characteristics and attitudes (see Table 2), the analysis showed that nurses attitudes have been largely inuenced by their place of work (the employer; governmental versus private) and whether they had received specialized training in psychiatric nursing. Marital status, job title, and level of education had minimal contribution to the differences in nurses attitudes. Satisfaction of Mental Health Nurses The third research question of this study was concerned with exploring mental health nurses satisfaction with nursing

TABLE 2 Demographics and Attitudes toward Mental Illness and Patients with Mental Illness (n = 92) Chi-square Variables Have Special Training in Psychiatric Nursing (yes versus no) Attitude Members of society are at risk from the mentally ill. Acute wards are little more than prisons. Mental illnesses are genetic in origin. The manner in which you talk to patients affects their mental state. Deliberate self-harm more often happens when other people are around. Acute wards are little more than prisons. Mental illnesses are genetic in origin. Perception of patients with mental illness as caring versus cold hearted. Those who attempt suicide leaving them with serious liver damage should not be given treatment. Deliberate self harm more often happens when other people are around. Patients with mental illnesses are more likely to harm someone else than themselves. Violence mostly results from mental illness. Psychiatric illness deserves as much attention as physical illness. Test Statistics 4.12 6.16 6.8 21.49 10.79 9.83 14.80 10.86 7.22 8.97 5.05 7.09 11.26 p-value .048 .019 .050 .007 .016 .045 .013 .037 .030 .008 .028 .039 .013

Employer (private versus governmental)

Job Title (registered versus associate nurse) Marital Status (married versus single)

Level of Education (masters versus bachelor versus associate)

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TABLE 3 Ratings of Satisfaction with Nursing Care Delivery (n = 92) Item 1 2 3 4 5 6 7 8 9 10 11 Nursing teamwork Continuity and consistency of nursing work Interdisciplinary collaboration Time available to spend with patients and their families Nursing status within the interdisciplinary team Continuity of care for patient Training and ongoing nursing education Ratio of nurses to patient The number of permanent mental health nurses in the ward Information technology education and training Information technology resources Percentage Satised 68 48 45 33 29 27 23 23 20 11 9

care delivery. The analysis (see Table 3) showed that mental health nurses were not satised about the delivered nursing care. Analysis showed that nurses had fair satisfaction only about nursing teamwork with 68% of the respondents being in agreement. In all other areas, nurses had low to very low levels of satisfaction with rates ranging from 948% agreement rates. The results indicate that mental health nurses had general dissatisfaction about the delivered nursing care. In examining the relationship between nurses attitudes and their satisfaction, Kendalls tau b showed that item #9 (Patients with mental illnesses are more likely to harm someone else than themselves) had signicant negative correlation with nurses satisfaction with nursing teamwork (.23, p = .013), while items #27 (Adult-child) and 31 (Polite-rude) had signicant positive correlation with nurses satisfaction with nursing teamwork (.22, p = .019; and .18, p = .028). Eta has been used to examine if gender has a role in nurses satisfaction rate. The analysis showed that male and female nurses were not signicantly different in the total satisfaction score. In relation to items of satisfaction, male and female nurses were signicantly different only in relation to their satisfaction with interdisciplinary collaboration ( 2 = 5.83, p = .016) despite their low satisfaction rate. In all other items, nurses were not signicantly different. In relation to mental health nurses experiences, the results were controversial. While 30% (n = 28) of nurses would recommend mental health nursing for their colleagues and nursing students, 40% (n = 37) will not choose to work in mental health nursing if they could go back to when they started nursing. Moreover, only 25% (n = 23) were not proud to be mental health nurses compared to 20% (n = 18) who were slightly proud, 24% (n = 22) who are proud, and 29% (n = 27) who are very proud to be mental health nurses.

DISCUSSION The purpose of this study was to explore mental health nurses attitudes toward mental illness and patients with mental illness. In addition, the study aimed at exploring nurses satisfaction with nursing care delivery and their experiences of being mental health nurses. The factors explored have implication for nursing practice and patient care. The high response rate (88%) of all mental health nurses in Jordan supports our conclusions and generalizability of the ndings. The ndings related to mental health nurses attitudes toward mental illness and patients with mental illness indicate that mental health care in Jordan is facing challenges and in need of extensive reform. The results infer that nurses have negative attitudes toward mental illness and patients with mental illness. Mental health patients were perceived as dangerous, pessimistic, immature, cold hearted, harmful, and as having low physical hygiene. This raises the issue of the sense of safety nurses have (or dont have) in the work place. Feeling safe in ones working environment and in performing nursing practices is compromised with such reports. With 60% of the nurses having negative attitudes toward patients with mental illness, the quality and priorities of nursing care provided to those patients is in question. Although physical hygiene is a nursing responsibility, nurses perceived patients as having poor physical hygiene. In addition, psychiatric illness was perceived at a lower priority level than physical illness, verbal communication was perceived as useless, causes of mental illnesses were rationalized in negative and non-scientic ways, and patients with mental illness were considered powerless and hopeless in terms of their ability to control their behaviors and expressions. These attitudes may interfere with the quality of nursing care delivery, and as a result, patients with a mental illness may be deprived from receiving appropriate nursing care. As this study is the rst in Jordan, there is no previous study to allow comparison. However, international studies emphasized the importance and connection between attitudes of nurses toward mental illness and nursing care delivery. Baker (2000) noted that attitudes of mental health nurses toward inpatient mental health inuence the quality of mental health nursing care provided, and negatively inuence nurses interaction with patients. This study corresponds with this conclusion that quality of nursing care, and therefore quality of mental health care in general, is inuenced by the negative attitudes of mental health nurses in Jordan. One explanation might be connected to a cultural stigmatization of mental illness among the Jordanian population; this corresponds with results of a previous national study (Al-Krenawi, Graham, & Kandah, 2000). In this context, nurses might be inuenced by their culture, and therefore, stigmatize their patient with mental illness. According to Sartorius (2002), stigma against mental illness is considered the biggest barrier in the development of effective mental health care. Another explanation could be related to the lack of training among mental health nurses. The results showed that nurses who received specialized training in psychiatric nursing were more satised and were more

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positive in their attitudes than those who did not. These ndings do not support a previous study conducted in Turkey (Aydin, Yigit, Inandi, & Kirpinar, 2003) that found that the least trained and educated mental health nurses had more positive attitudes. These results could be used to urge mental health care reform in Jordan, including mental health nursing. In general, the results do not correspond with a previous study (Munro & Baker, 2007) that reported that Australian mental health nurses had general positive attitudes toward mental illness and patients with mental illness. Interestingly, mental health nurses in Jordan and Australia had the highest satisfaction rate related to nursing teamwork. This highlights the global agreement on the value and importance of the relationship among nurses and with other members of the mental health team. On the other hand, and corresponding with Addison and Thorpe (2004), gender did not have a signicant role in forming the nurses attitudes. The age of the nurses also had limited effect on nurses attitudes. This supports Addison and Thorpes (2004) conclusion that focusing on genderand here we can add age is misleading and that nurses attitudes are inuenced by a wide range of factors. The data showed that two thirds of the mental health nurses in Jordan are satised with nursing teamwork, and about half of the nurses were satised with continuity and consistency of nursing care and interdisciplinary collaboration. About one third of the nurses were satised with the time available to spend with patients and their families, the status of nursing within the interdisciplinary team, the continuity of care for patients, the opportunities for training and ongoing nursing education, the ratio of nurses to patient, and the number of permanent mental health nurses in the ward. Moreover, about 90% of the nurses were dissatised with information technology education and training and information technology resources. The ndings showed that the age and gender of mental health nurses had very limited correlation with nurses satisfaction rates. The ndings highlight many hurdles that mental health nurses in Jordan face in their daily practice. Working environment is one major factor that inuences nursing satisfaction. Again, receiving specialized training and the place of work (the type of employer) played signicant role in determining the nurses level of satisfaction. The nurse-patient ratio, in light of nursing shortages, affected continuity of nursing care, interdisciplinary collaboration, and quality of nursing care delivery. Unlike the results of this study, a previous study (Cleary, Walter, & Hunt, 2005) found that mental health nurses were almost satised with nursing care delivery. The ndings support the notion that there is a discrepancy between the ideals of mental health practices and the realties of a clinical setting (Cleary, 2003, 2004; Moyle, 2003). Mental health nursing practice is given little attention and the role of nurses in mental health settings is ambiguous, therefore, mental health settings are not attractive to well educated and qualied nurses. Mental health nurses, then, may struggle for the development of therapeutic unit culture and innovative mental nursing health care practices.

Finally, it is reassuring to know that two thirds of mental health nurses in Jordan are satised with nurse teamwork. This may indicate that nurses interpersonal relationships do not form a hurdle in the nursing care delivery. Considering that age and gender of nurses were not contributing factors in forming nurses satisfaction or attitudes, and that training and place of work were strong contributing factors, reforming mental clinical settings will require emphasizing personal, interpersonal, and environmental components. In addition, 75% of the nurses were slightly to very proud of being mental health nurses. This may reect the nurses commitment and willingness to change in the future if appropriate mechanisms established. CONCLUSION The results of the study have implications for decision makers and mental health professionals at all levels. Factors such as nurse training and place of work affected nurses satisfaction. This indicates that continuing education and training programs will help change nurses negative attitudes, increase satisfaction, and develop their therapeutic abilities to interact with patients. The nurse-patient ratio is another issue that negatively affects quality mental health nursing care. Decision makers and health professionals need to emphasize the importance of specialization in mental health and support interdisciplinary efforts to form strategic planning for mental health reform in Jordan. Another important area that needs more attention is nursing education at undergraduate and graduate levels. Attitudes and professional behaviors have to be emphasized and integrated in the nursing curricula to reect national and international standards of care for patients with mental illness. In addition, there is an urgent need to give more attention to mental health practices by developing policies and protocols of mental health care and nursing practices, in particular. Future research investigating the educational and training needs of mental health nurses may help to shed light on areas in which nurses need more training in order to be able to provide quality of mental nursing care. Declaration of interest: The authors report no conicts of interest. The authors alone are responsible for the content and writing of the paper. REFERENCES
Addison, S. J., & Thorpe, S. J. (2004). Factors involved in the formation of attitudes towards those who are mentally ill. Social Psychiatry and Psychiatric Epidemiology, 39, 228234. Al-Krenawi, A., Graham, J. R., & Kandah, J. (2000). Gendered utilization differences of mental health services in Jordan. Community Mental Health Journal, 36(5), 501511. Aydin, N., Yigit, A., Inandi, T., & Kirpinar, I. (2003). Attitudes of hospital staff toward mentally ill patients in a teaching hospital, Turkey. International Journal of Social Psychiatry, 49, 726. Baker, S. (2000). Environmentally friendly, patients views of conditions in psychiatric wards. London: Mind. Baker, J. A., Richards, D. A., & Campbell, A. (2005). Nursing attitudes towards acute mental health care: Development of a measurement tool. Journal of Advanced Nursing, 49(5), 522529.

JORDANIAN MENTAL HEALTH NURSES ATTITUDES Cleary, M. (2003). The challenges of mental health care reform for contemporary mental health nursing practice: Delivery of nursing care. International Journal of Mental Health Nursing, 12, 213222. Cleary, M. (2004). The realities of mental health nursing in acute inpatient environments. International Journal of Mental Health Nursing, 13, 5360. Cleary, M., Walter, G., & Hunt, G. (2005). The experience and views of mental health nurses regarding nursing care delivery in an integrated, inpatient setting. International Journal of Mental Health Nursing, 14, 7277. El-Islam, F. M. (1994). Cultural aspects of morbid fears in Qatari women. Social Psychiatry and Psychiatric Epidemiology, 29(3), 137140. MacGabhann, L., Baker, S., & Dixon, P. (2002). Prevention and management of violence: Implementing clinically effective practice. Mental Health Practice, 6, 813. Moyle, W. (2003). Nursepatient relationship: A dichotomy of expectations. International Journal of Mental Health Nursing, 12, 103109. Munro, S., & Baker, J. A. (2007). Surveying the attitudes of acute mental health nurses. Journal of Psychiatric and Mental Health Nursing, 14(2), 196202. OBrien, L., & Cole, R. (2003). Close-observation areas in acute psychiatric units: A literature review. International Journal of Mental Health Nursing, 12, 165176.

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Read, J., & Harre, N. (2001). The role of biological and genetic causal beliefs in the stigmatization of mental patients. Journal of Mental Health, 10(2), 233335. Rey, J., Walter, G., & Giuffrida, M. (2004). Policy, structural change and quality of psychiatric services in Australia: The views of psychiatrists. Australasian Psychiatry, 12, 118122. Royal College of Psychiatrists. (2001). Mental illness: Stigmatization and discrimination within the medical profession, Council report CR91. London: Author. Sartorius, N. (2002). Iatrogenic stigma of mental illness. British Medical Journal, 324, 14701471. Wardam, L., & Dawani, H. (unpublished). Perception of Jordanian population toward mental illness. Unpublished manuscript, University of Jordan at Amman. World Health Organization, Regional Ofce for the Eastern Mediterranean. (2003). Mental health in Jordan. Retrieved April 12, 2009, from http://www.emro.who.int/MNH/WHD/CountryProle- JOR.htm World Psychiatric Association. (2001). The WPA global program to reduce the stigma and discrimination because of schizophreniaan interim report. Geneva: Author.