In brief
In a survey of 112 nursing students, attitudes toward suicide did not predict confidence or skill in helping patients with mental health problems or self-harm; instead, only moderate confidence levels overall pointed to a curriculum gap that the author recommends addressing with mandatory suicide-prevention training.
What this article is about
Quick Answer
In a survey of 112 nursing students, attitudes toward suicide did not predict confidence or skill in helping patients with mental health problems or self-harm; instead, only moderate confidence levels overall pointed to a curriculum gap that the author recommends addressing with mandatory suicide-prevention training.
Student takeaways
Key Takeaways
- Among 112 nursing students, none of the four Spearman's rho correlations between attitude toward suicide (ATTS) and mental health training confidence/skill (MHTCQ) reached statistical significance (all p > .5).
- Confidence in helping someone with a mental health problem showed essentially no relationship with attitude toward suicide (rs = .01, p = .909).
- Perceived skill and confidence scores on the MHTCQ averaged in a moderate range (3.16 to 3.37 out of 5), with only about 45-47% of students reporting high confidence or skill.
- A large majority of students expressed constructive general attitudes toward suicide (e.g., 75% agreed a suicide attempt is a cry for help; nearly 69% agreed suicide can be prevented).
- Both instruments used, the Attitude Toward Suicide scale and the Mental Health Training and Confidence Questionnaire, showed acceptable to excellent reliability in this sample (Cronbach's alpha of .71 and .91, respectively).
Student summary
Why This Research Matters
Suicide is a leading cause of death, and nurses are often among the first professionals to encounter someone who is suicidal or engaging in deliberate self-harm. This 2021 Walden University doctoral dissertation by Beverly A. Burton asked a focused question: does a nursing student's personal attitude toward suicide affect how confident and skilled they feel helping someone with a mental health problem or an episode of deliberate self-harm?
Burton used a quantitative, descriptive correlational survey design grounded in Pender's health promotion model, a theory that links personal behaviors and existing conditions to health-related actions. She recruited nursing students online through SurveyMonkey, drawing mainly from two baccalaureate nursing programs in Iowa and a broader pool of medical majors who identified as nursing students. After removing incomplete responses, the final analyzed sample was 112 nursing students, the large majority female (94.6%), spread across a wide range of ages, with the largest single age group being 18 to 24 years old. About 61% identified as White and 28% as Black or African American.
Participants completed two instruments: the Attitude Toward Suicide (ATTS) scale, a 35-item measure of general attitudes toward suicide, and the 4-item Mental Health Training and Confidence Questionnaire (MHTCQ), which asks how confident and skilled someone feels helping with a mental health problem or deliberate self-harm. Both instruments showed solid reliability in this sample (Cronbach's alpha of .71 for the ATTS and .91 for the MHTCQ). Burton then used Spearman's rho, a statistical test for ranked or ordinal data, to look for relationships between overall attitude scores and each of the four confidence/skill questions.
None of the four relationships reached statistical significance. Attitude toward suicide was not meaningfully correlated with confidence in helping with a mental health problem (rho = .01, p = .909), confidence in helping with deliberate self-harm (rho = -.04, p = .678), perceived skill in helping with a mental health problem (rho = -.05, p = .589), or perceived skill in helping with deliberate self-harm (rho = -.06, p = .549). In plain terms, how a nursing student personally feels about suicide as a topic did not predict how confident or skilled they felt handling it clinically.
What did stand out was the descriptive picture of confidence itself. On the MHTCQ, average confidence and skill scores clustered in a middling range (roughly 3.16 to 3.37 on a 5-point scale), and only about 45% of students said they felt "extremely" or "quite a bit" confident helping someone with a mental health problem, with about 47% saying the same about their skill level. Burton points out that in most grading systems, scoring below 60% would be considered a failing performance, framing this moderate confidence level as a curriculum gap rather than a reassuring finding.
Interestingly, students' general attitudes toward suicide leaned constructive: about 75% agreed that a suicide attempt is a cry for help, nearly 69% agreed suicide can be prevented, and large majorities rejected the ideas that suicide is "none of our business" or a topic that "shouldn't be talked about." So the gap isn't attitude, it's training and confidence.
Burton concludes that the lack of statistical significance does not diminish the value of the study; instead, it shifts the spotlight toward the lack of confidence itself as the more meaningful problem. Her core recommendation is that nursing curricula should build in specific, mandatory suicide-prevention and self-harm content, rather than leaving it as an optional add-on within general mental health coursework, in the hope that doing so may support future nurses' confidence and, ultimately, patient safety.
For nursing students reading this study, the takeaway is not that attitudes don't matter, but that goodwill alone doesn't translate into clinical readiness. Confidence and skill have to be built deliberately through structured coursework and practice, not assumed to follow naturally from having a compassionate outlook toward people in crisis. For Canadian nursing students and educators the transferable lesson holds even though the specific numbers are U.S.-based: entry-to-practice competencies in Canada likewise expect new nurses to recognize and respond to mental health crises, so suicide-prevention capability is something a program has to teach rather than presume. As a dissertation obtained through ERIC (ED665754) and Walden University's ScholarWorks repository, this study's findings are best treated as one data point rather than a definitive national picture, given its sample was concentrated in two Iowa programs plus an online convenience pool.
Source abstract
Study Overview
The mental health training of nursing majors may play a role in their levels of confidence in attending to suicide patients as working professionals. The purpose of this quantitative study was to explore what impact, if any, attitudes toward suicide had on nursing majors' levels of confidence in their mental health training. Pender's health promotion theory was the theoretical framework. A descriptive correlational survey was used to explore individuals majoring in nursing confidence and perceived skills in mental health training. The 4 research questions asked the relationship between the level of confidence in helping someone with a mental health problem and deliberate self-harm and attitudes to suicide, and between the level of perceived skill in helping someone with a mental health problem and deliberate self-harm and attitudes to suicide. SurveyMonkey was used to collect data from 110 nursing student participants who completed the Attitude Toward Suicide instrument and Mental Health Training and Confidence Questionnaire. The Software Statistical Package for Social Science was used to analyze the reliability, as tested with Cronbach's alpha. Descriptive statistics and Spearman's rho were used. The predictor variable attitude toward suicide was less meaningful than the lack of confidence in mental health training. The lack of significance in the findings of the research questions did not compromise the value of the study. Recommendations include incorporating specific suicide prevention education and training in nursing education curricula. Addressing the public health problem of suicide in all areas of nursing curricula may bolster nurses' confidence in their ability to care for such patients effectively, leading to positive social change. [The dissertation citations contained here are published with the permission of ProQuest LLC. Further reproduction is prohibited without permission. Copies of dissertations may be obtained by Telephone (800) 1-800-521-0600. Web page: http://www.proquest.com/en-US/products/dissertations/individuals.shtml.]
Evidence appraisal
Main Findings
- Among 112 nursing students, none of the four Spearman's rho correlations between attitude toward suicide (ATTS) and mental health training confidence/skill (MHTCQ) reached statistical significance (all p > .5).
- Confidence in helping someone with a mental health problem showed essentially no relationship with attitude toward suicide (rs = .01, p = .909).
- Perceived skill and confidence scores on the MHTCQ averaged in a moderate range (3.16 to 3.37 out of 5), with only about 45-47% of students reporting high confidence or skill.
- A large majority of students expressed constructive general attitudes toward suicide (e.g., 75% agreed a suicide attempt is a cry for help; nearly 69% agreed suicide can be prevented).
- Both instruments used, the Attitude Toward Suicide scale and the Mental Health Training and Confidence Questionnaire, showed acceptable to excellent reliability in this sample (Cronbach's alpha of .71 and .91, respectively).
Practice transfer
Clinical Relevance
- Moderate self-reported confidence scores suggest nursing curricula may need dedicated, mandatory suicide-prevention and self-harm training rather than folding it into general mental health content.
- Because attitude did not predict confidence, programs should not assume that students with compassionate views toward suicide are automatically prepared to intervene clinically; skill-building content is still needed.
- Given the moderate confidence levels reported, new graduates may benefit from structured mentorship or simulation-based practice specific to suicide risk assessment and self-harm response before independent practice.
- Because attitudes toward suicide varied by demographic factors in the broader literature Burton reviewed, suicide-prevention curricula and training should account for cultural, age, and gender differences among learners.
- Nursing leadership, regulators, and accreditation bodies (e.g., U.S. state boards of nursing, and in Canada provincial nursing colleges and CASN accreditation standards) are positioned to mandate standardized suicide-prevention competencies, since attitude alone is not shown to close the confidence gap.
Faculty notes
Educational Relevance
This 2021 Walden University PhD dissertation by Beverly A. Burton (Public Policy and Administration) investigates whether nursing students' attitudes toward suicide predict their self-reported confidence and skill in helping patients with mental health problems or deliberate self-harm. The study is framed by Pender's (1984) health promotion model and uses a quantitative, descriptive correlational survey design, useful for instructors teaching research methods, as it illustrates a clean single-predictor correlational design with four parallel research questions and matched null/alternative hypotheses.
Data were collected via SurveyMonkey (July 2020) from nursing majors recruited primarily through two Iowa baccalaureate programs, supplemented by a broader medical-major sample screened for nursing status. After exclusions for incomplete responses, N = 112 nursing students remained, overwhelmingly female (94.6%), with meaningful representation across age brackets and roughly 61% White, 28% Black/African American participants. Instrumentation combined the 35-item Attitude Toward Suicide (ATTS) scale (Renberg & Jacobsson, 2003) with the 4-item Mental Health Training and Confidence Questionnaire (MHTCQ; Robinson et al., 2008). Reliability was acceptable-to-excellent (ATTS alpha = .71; MHTCQ alpha = .91).
Spearman's rho tested four RQs pairing overall ATTS scores against each MHTCQ item. All four hypotheses failed to reject the null: confidence helping with a mental health problem (rs = .01, p = .909), confidence with self-harm (rs = -.04, p = .678), perceived skill with a mental health problem (rs = -.05, p = .589), and perceived skill with self-harm (rs = -.06, p = .549). This is a useful teaching case for discussing the distinction between statistical significance and practical significance: Burton argues the null findings do not undercut the study's value, because the descriptive statistics revealed the more actionable problem, moderate rather than strong confidence levels (MHTCQ means 3.16-3.37 of 5), with only 45-47% of students reporting high confidence or skill.
Burton also notes a limitation worth flagging for students: aggregate ATTS scores muted item-level relationships, and she reports that analyzing single ATTS items (rather than a composite mean) revealed at least one significant negative association with self-harm skill, suggesting mean-score aggregation may obscure real effects, a good discussion point on measurement of attitudinal constructs. Recruitment control was also imperfect (no way to verify how many students received the survey link, and no geographic capture), which she partially addressed by broadening the sampling frame.
For classroom use, this dissertation supports discussions of curriculum policy advocacy: Burton recommends mandatory, dedicated suicide-prevention and self-harm content in nursing curricula (theoretical and clinical), rather than folding it into general mental health coverage, and calls for future research on state nursing board policy levers (a lever that, in the Canadian context, maps onto provincial nursing colleges and CASN accreditation standards rather than U.S. state boards). Instructors should note this is unpublished dissertation-level evidence (ProQuest/ERIC ED665754), single-institution-weighted, U.S.-based, and correlational, appropriate for illustrating research design and appraisal skills, not for citing as generalizable clinical guidance.
Critical appraisal
Limitations
- The sample (112 nursing students) was drawn largely from two baccalaureate programs in Iowa plus a broader online convenience sample, limiting geographic and program-type generalizability.
- The sample was heavily skewed female (94.6%), and cultural/ethnic representation was uneven, so findings may not generalize across all nursing student populations.
- Recruitment was not fully controlled: the researcher could not verify how many students actually received the survey invitation, and no location indicator was collected.
Classroom use
Discussion Questions
- Why might a nursing student's general attitude toward suicide fail to predict their confidence in helping a patient with a mental health problem or deliberate self-harm?
- What does it mean that all four null hypotheses in this study were not rejected, and why does the author argue this does not diminish the study's value?
- How should nursing programs interpret a finding that only 45-47% of students report high confidence or skill in mental health helping behaviors?
- What are the strengths and weaknesses of using Spearman's rho versus Pearson correlation for data like the ATTS and MHTCQ in this study?
- How might aggregating a 35-item scale into a single mean score obscure meaningful relationships, as the author suggests happened with the ATTS?
- In what ways does Pender's health promotion model justify including suicide-prevention content within a broader nursing curriculum?
- What curriculum changes would you propose based on the recommendation for mandatory, dedicated suicide-prevention and self-harm training?
- How might cultural, age, or gender differences among nursing students shape the design of an effective suicide-prevention training module?
- What are the risks of generalizing findings from a sample weighted toward two Iowa baccalaureate programs to nursing education nationally?
- How could future researchers address this study's limitation regarding uncontrolled survey distribution and unknown response rate?
Knowledge check
Quiz
1. What was the primary purpose of Burton's 2021 dissertation study?
- To evaluate nursing faculty teaching methods for mental health content
- To explore what impact, if any, attitudes toward suicide had on nursing majors' levels of confidence in mental health training
- To compare suicide rates between nurses and the general population
- To develop a new instrument for measuring suicide risk in patients
Rationale: The abstract states the purpose was 'to explore what impact, if any, attitudes toward suicide had on nursing majors' levels of confidence in their mental health training.'
2. Which theoretical framework guided this study?
- Watson's theory of caring
- Bandura's self-efficacy theory
- Pender's health promotion model
- Orem's self-care deficit theory
Rationale: The dissertation states: 'Pender's health promotion theory was the theoretical framework' and later 'The theoretical framework used to guide this study was Pender's (1984) health promotion model (HPM).'
3. How many nursing student participants made up the final analyzed sample?
- 70
- 89
- 112
- 363
Rationale: The dissertation states the final data set contained 112 nursing students after removing four participants who did not complete the MHTCQ.
4. Which two instruments did participants complete?
- PHQ-9 and GAD-7
- Attitude Toward Suicide (ATTS) instrument and Mental Health Training and Confidence Questionnaire (MHTCQ)
- Beck Depression Inventory and Columbia Suicide Severity Rating Scale
- Maslach Burnout Inventory and Nursing Stress Scale
Rationale: The abstract states participants 'completed the Attitude Toward Suicide instrument and Mental Health Training and Confidence Questionnaire.'
5. What statistical test did the researcher use to examine the relationships in the four research questions?
- Independent samples t-test
- Chi-square test of independence
- Spearman's rho
- One-way ANOVA
Rationale: The dissertation states: 'Descriptive statistics and Spearman's rho were used' and 'I tested the RQs and hypotheses with Spearman's rho.'
6. What was the overall result of the four hypothesis tests in this study?
- All four null hypotheses were rejected, showing strong relationships
- None of the four null hypotheses were rejected; all relationships were statistically non-significant
- Two of four null hypotheses were rejected
- The results could not be calculated due to missing data
Rationale: The dissertation reports p-values of .909, .678, .589, and .549 for the four research questions, each concluding 'the null hypothesis was not rejected.'
7. According to the study, what was 'less meaningful' than the lack of confidence in mental health training as a predictor?
- Age of the participant
- Attitude toward suicide
- Years of nursing experience
- Type of nursing program attended
Rationale: The abstract states: 'The predictor variable attitude toward suicide was less meaningful than the lack of confidence in mental health training.'
8. What was the Cronbach's alpha reliability coefficient for the Mental Health Training and Confidence Questionnaire (MHTCQ)?
- .38
- .71
- .91
- .55
Rationale: The dissertation states: 'The internal consistency for the 4-item MHTCQ was excellent (α = .91).'
9. What is the primary recommendation Burton makes based on the study's findings?
- Eliminate mental health content from nursing curricula
- Incorporate specific suicide prevention education and training into nursing education curricula
- Require all nursing students to complete a psychiatric residency
- Replace the ATTS instrument with a new attitude scale
Rationale: The abstract states: 'Recommendations include incorporating specific suicide prevention education and training in nursing education curricula.'
10. What limitation did the researcher note regarding the ATTS instrument's use as a composite mean score?
- It could not be scored using SPSS
- Aggregating items into a single mean score produced a false nonsignificant relationship, masking a significant item-level association
- It was not validated for use with nursing students
- It required more than 200 participants to be reliable
Rationale: The dissertation states the ATTS items 'grouped together, when analyzed using inferential statistics, showed a false nonsignificant relationship... The findings showed a significant negative relationship for one of the ATTS items' when analyzed separately.
Study cards
Flashcards
What was the primary purpose of Beverly Burton's 2021 dissertation?
To explore what impact, if any, attitudes toward suicide had on nursing majors' levels of confidence in their mental health training.
What research design did Burton use?
A quantitative, descriptive correlational survey design.
What theoretical framework guided the study?
Pender's (1984) health promotion model (HPM).
How many nursing students made up the final analyzed sample?
112 nursing students, after four incomplete responses were removed.
What platform was used to collect survey data?
SurveyMonkey, an online survey and data collection tool.
What instrument measured attitudes toward suicide?
The Attitude Toward Suicide (ATTS) scale, a 35-item instrument developed by Renberg and Jacobsson (2003).
What instrument measured mental health training confidence and skill?
The Mental Health Training and Confidence Questionnaire (MHTCQ), a 4-item instrument developed by Robinson et al. (2008).
What was the Cronbach's alpha reliability for the ATTS?
.71, interpreted as acceptable internal consistency.
What was the Cronbach's alpha reliability for the MHTCQ?
.91, interpreted as excellent internal consistency.
What statistical test examined the relationships in the four research questions?
Spearman's rho, a nonparametric correlation test suited to ordinal data.
What was the result for RQ1 (confidence helping with a mental health problem vs. attitude toward suicide)?
No significant relationship, rs = .01, p = .909; the null hypothesis was not rejected.
What was the result for RQ4 (perceived skill helping with deliberate self-harm vs. attitude toward suicide)?
No significant relationship, rs = -.06, p = .549; the null hypothesis was not rejected.
What percentage of the sample felt extremely or quite a bit confident helping someone with a mental health problem?
About 45% of the sample.
What percentage of the sample felt extremely or quite a bit skilled helping someone with mental health issues?
About 47% of the sample.
What percentage of students agreed that a suicide attempt is a cry for help?
About 75% of respondents agreed or strongly agreed.
What was the gender composition of the final sample?
Overwhelmingly female, at 94.6%, compared to 5.4% male.
What did the researcher identify as the main limitation involving the ATTS composite score?
Aggregating the ATTS into a single mean score masked a significant item-level negative relationship with self-harm skill that appeared when items were analyzed individually.
What is Burton's central recommendation for nursing education?
Incorporate specific, mandatory suicide prevention and self-harm education into nursing curricula rather than leaving it as general mental health content.
What institution and degree program produced this dissertation?
Walden University, Doctor of Philosophy in Public Policy Administration, completed May 2021.
What is the difference between deliberate self-harm and suicide as defined in this study?
The distinction is intent: individuals who self-harm are not always suicidal, but people who attempt suicide are classified as self-harming.
Search-ready answers
Frequently asked questions
What is the main finding of Beverly Burton's study on nursing students and suicide attitudes?
The study found no statistically significant relationship between nursing students' attitudes toward suicide and their self-reported confidence or skill in helping someone with a mental health problem or deliberate self-harm. Instead, the more meaningful finding was that confidence and skill levels themselves were only moderate.
How many nursing students participated in this research?
The final analyzed sample included 112 nursing students, recruited mainly from two baccalaureate nursing programs in Iowa along with a broader online sample of medical majors screened for nursing status.
What instruments were used to measure attitudes and confidence in this study?
Researchers used the 35-item Attitude Toward Suicide (ATTS) scale and the 4-item Mental Health Training and Confidence Questionnaire (MHTCQ), both of which showed acceptable to excellent reliability in this sample.
Did nursing students in this study have negative attitudes toward suicide?
No. A large majority expressed constructive attitudes, such as agreeing that a suicide attempt is a cry for help (75%) and that suicide can be prevented (nearly 69%).
Why didn't attitude toward suicide predict confidence in this study?
All four Spearman's rho correlations were statistically non-significant (p values from .549 to .909), suggesting that how a student personally feels about suicide as a topic is a separate issue from how prepared they feel to handle it clinically, which likely depends more on specific training.
What theoretical model was used to frame this research?
Pender's (1984) health promotion model, which links personal behaviors and existing conditions to health-related actions and supports including mental health promotion, such as suicide prevention, within nursing education.
What did the study recommend for nursing curricula?
Burton recommends incorporating specific, mandatory suicide prevention and self-harm education into nursing curricula, rather than treating it as incidental content within general mental health coursework.
What were the main limitations of this dissertation?
Key limitations include a sample weighted toward two Iowa programs, an uncontrolled recruitment process with an unknown response rate, a heavily female sample, and evidence that aggregating the ATTS into a mean score may have masked a real item-level relationship.
Where can I find the full text of this dissertation?
It is indexed in ERIC under ED665754 and is openly available through Walden University's ScholarWorks repository as a 2021 doctoral dissertation.
Is this study generalizable to all nursing students?
Caution is warranted. The sample was drawn mainly from two Iowa baccalaureate programs plus an online convenience sample, was predominantly female, and used self-report data at a single time point, so findings should be treated as exploratory rather than broadly generalizable.