Stigma of nursing students towards people with mental illness: Protocol of a mixed‐method systematic review

Abstract

Aims

To synthesize the influencing factors of the stigma of nursing students towards people with mental illness (PMI).

Background

The stigma of nursing students towards PMI may affect their career choices and negatively impact people seeking health services. While many studies have examined the educational aspects of mental health, they often overlook the multiple dimensions of possible factors influencing nursing students' perceptions.

Design

A mixed‐method systematic review using the Framework Integrating Normative Influences on Stigma (FINIS).

Methods

We will search six databases, including PubMed, Web of Science, Cochrane Library, EMBASE, CINAHL and PsycINFO. The reference list of the included literature will be thoroughly examined to identify if any additional studies meet the criteria. Two authors will independently screen all titles, abstracts, full text and extract data. The Mixed-method Appraisal Tool will be used to assess quality. The extracted data will be disposed to different levels, including micro (demographic characteristics, disease characteristics), meso (social networks, treatment systems) and macro (media images, national context) to comply with the FINIS.

Expected results

This systematic review aims to comprehensively analyze the influencing factors of the stigma of nursing students towards PMI, providing a reference basis for anti-stigma intervention measures.

Prospero registration number: CRD42022374419.

1. Introduction

In recent years, there has been a notable increase in the incidence of mental health conditions. In 2019, Approximately 970 million individuals worldwide, representing one-eighth of the global population, were affected by a mental disorder, with anxiety and depression being the most prevalent. In addition, COVID-19 has had a more significant impact on the economy, work, and life, which increased the psychological burden and aggravated mental health problems. The pandemic has caused tremendous distress in society, with anxiety and major depression rates increasing by 26% and 28%, respectively [1], and the trend might continue [2].

Goffman defined stigma as “an attribute that is deeply discrediting, but it should be seen that a language or relationships, not attributes, is really needed” [3]. The concept of stigma encompasses both public stigma and self-stigma. Public stigma describes the phenomenon of social groups embracing stigma and acting against people with mental illness (PMI). On the other hand, self-stigma refers to the loss of self-esteem and self-efficacy when public stigma is internalized [4]. The stigmatization of PMI can be characterized as an individual perceiving and treating them negatively due to their mental health illness [5]. Stigma in mental health is not a novel concept, and it is conceptualized as stereotypes, prejudice and discrimination [6]. Typically, mental illness is associated with a comparable degree of social stigma as HIV/AIDS, and is often perceived to carry a greater sense of shame than physical disability [7]. In the UK, 86.7% of mental health service users have experienced stigma in the past, and 74.0% of people may choose to withhold disclosure of their mental health problems from others because of discrimination [8]. PMI experience both the challenge of managing their illness and the mental health stigma. Most people regard patients as dangerous and unpredictable, and some people are even reluctant to communicate with patients [9]. Common forms of discrimination are encountered within family, social circles, and societal interactions [8]. To avoid the stigma associated with mental illness, people do not want to be diagnosed with a mental illness or be seen as seeking treatment for a mental illness [10], and the avoidance behavior may result in a loss of confidence in challenging stigma [11]. Stigma, including shame or negative social judgement, has become a significant barrier to help-seeking and care-seeking [12,13].

Part of the stigma experienced by PMI is perpetuated through interactions between mental health professionals. Negative experiences include inadequate and delayed treatment, extended waiting periods, and other similar frustrations [14]. The attitudes of mental health professionals towards mental illness can hinder the recovery of PMI [15]. Conversely, establishing a positive relationship with mental health professionals can significantly enhance patients' willingness to seek and use mental health services [16]. Studies have shown that mental health nurses' attitudes toward mental illness mirror those of the general public, exhibiting more negative attitudes toward patients with schizophrenia [17]. Additionally, emerging evidence suggests that nursing students, as future nurses, may express stigma toward their patients [18]. Nursing students with high levels of stigma often experience discomfort, anxiety, and fear when providing care for PMI. Despite understanding the need for assistance for PMI, nursing students may still attempt to avoid interacting with them [19,20], potentially influencing their perception of psychiatric nursing as a future career choice [21].

A systematic review of nursing students' attitudes and stigma toward PMI has been published, which found that mental health education and training improved nursing students’ perceptions of mental health [22]. However, the article did not pay attention to diverse dimensions of possible factors influencing nursing students' stigma towards PMI. Therefore, the protocol aims to synthesize the influencing factors of stigma towards PMI among nursing students.

1.1. Theoretical framework

Researchers decided to use the Framework Integrating Normative Influences on Stigma (FINIS) to guide the synthesis of the evidence [23]. FINIS was a conceptual framework derived from Goffman's notion that understanding stigma required the language of social relations, emphasizing that individuals did not socially interact without influence and motivation. The FINIS framework focused on several different levels of social life - the micro (social and illness characteristics, recent social psychological and cognitive insights), meso (social networks, the treatment system) and macro levels (media images, the national context). Based on the FINIS, researchers will explore the micro, meso, and macro influence factors on the stigma of nursing students towards PMI.

1.2. Research purpose

• (1)Describe the research methods and assessment instruments used to explore nursing students' stigma against PMI.
• (2)Synthesize the influencing factors of stigma in nursing students.

2. Method

The systematic review will be reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [24]. Researchers will synthesize the evidence using the JBI Manual for Evidence Synthesis [25]. The systematic review was registered on PROSPERO on September 12, 2022.

2.1. Search strategy

A systematic review will be conducted using the following databases: PubMed, Web of Science, Cochrane Library, EMBASE, CINAHL and PsycINFO. The following terms were used for the search of titles and abstracts: ((“student” OR “undergraduate” OR “college” OR “university” OR “education”) and “Nurs*”) and (“mental health” OR “health mental” OR “Mental Hygiene” OR “hygiene mental” OR “psyc*” OR “mental ill*” OR “mental disorder”) and (“stigma*” OR “discrimin*” OR “negative attitudes” OR “attitude*” OR “prejudice” OR “stereotype” OR “feeling*” OR “perception” OR “opinion*” OR “thought*”). The search will be limited to studies published from 1990 to 2022. The researchers will also screen the references of the included literature to identify if additional eligible literature exists.

2.2. Data management

Reference management software will be used to document the process and screen duplicate papers.

2.3. Inclusion and exclusion criteria

Inclusion criteria: (a) studies that evaluated nursing students’ stigmatizing attitudestowards PMI, (b) studies with influencing factors of stigma in nursing students, (c) studies published in English, (d) studies retrieved from the database from 1990 to 2022 (e) quantitative, qualitative or mixed studies.

Exclusion criteria: (a) editorial opinions, reviews, letters to the editor, opinion articles, and conference abstracts, (b) studies that only discussed attitudes towards mental health or mental health nursing, (c) repeated publication, (d) studies did not explore the influencing factors, (e) the study combined outcomes for medical students without distinguishing nursing students separately.

2.4. Study selection

Two authors (ZY and PT) will screen titles and abstracts independently. Full-text articles will also be reviewed separately by both authors. If there is a discrepancy between the two authors, it will be discussed with the third author (HYQ). Articles that do not meet the inclusion criteria will be rejected, and the reasons for this will be recorded. An overview of the search and screening process will be provided by using the PRISMA 2020 flowchart in Fig. 1 [24].

Fig. 1.

Flow diagram.

2.5. Quality assessment

Two authors (ZY and PT) will independently assess study quality using the Mixed-method Appraisal Tool (MMAT) and categorize them as low, medium, or high quality by customizing the cut-off value. Disagreements between authors will be resolved through discussion with a third author (HYQ).

2.6. Data extraction

Two authors (ZY and PT) will independently extract data according to a pre-designed table. The following information will be collected from each study: author's name, publication year, study design, study objective, number of participants, assessment instruments, methodology, and results.

2.7. Data synthesis

According to JBI [25], the convergent synthesis method will be used in the study. The convergent synthesis refers to combining data extracted from quantitative research (including data from the quantitative part of a mixed-method study) and qualitative research (including data from the qualitative part of a mixed-method study). The quantitative data in the study and the quantitative component of the mixed-method study will be “qualitised” as textual descriptions through narrative interpretation. These data will then be assembled along with the qualitative data extracted from the qualitative study and the qualitative component of the mixed-method study. The authors will follow the steps of the thematic analysis, including familiarization with the data, initial coding, searching for themes, reviewing themes, naming, and reporting in part to summarize the qualitative data [26].

2.8. Ethical approval and consent to participate

This mixed-method systematic review will not include empirical data or human experimentation; therefore, ethical approval will not be sought.

3. Discussion

The stigma associated with mental illness can appear in all areas of life [27]. However, it is particularly concerning to observe stigma among nurses who closely interact with patients, as this may adversely affect individuals seeking health services during their most vulnerable times, leading to a reduction in help-seeking attitudes among mental health consumers and fostering negative help-seeking behaviors [28]. Hence, it is crucial to examine the stigma held by nurses and nursing students towards PMI. Understanding the factors influencing stigma by nursing students can inform the development of targeted interventions to address stigma effectively [29,30]. Therefore, this systematic review will extract relevant articles from six databases to synthesize the influencing factors of stigmatization among nursing students.

Funding sources

This work was supported by the Teaching Reform and Practice in General Higher Hunan Province Universities (Grant ID HNJG-2022-0449) and the Graduate Education and Teaching Reform Project of Central South University (Grant ID 2022YJSKS026).

Data availability

All data analyzed during this study are included in the article.

CRediT authorship contribution statement

Yi Zeng: Conceptualization, Writing – original draft, Writing – review & editing. Ting Pan: Conceptualization, Formal analysis, Methodology, Writing – original draft, Writing – review & editing. Yuqing He: Data curation, Methodology. Mei Sun: Funding acquisition, Supervision, Writing – review & editing.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.