The influencing factors of stigma towards people with mental illness among nursing students: a mixed‐method systematic review

ABSTRACT

The stigma of nursing students towards people with mental illness (PMI) creates significant barriers to diagnosis, treatment, and recovery for those with PMI. It can also have a significant impact on the future career choices of nursing students in the field of psychiatry. Current research has found various influencing factors, including personal characteristics and educational influences. However, a comprehensive analysis that encompasses all aspects is lacking. The aim of the study was to conduct a convergent mixed‐method systematic review to synthesize the influencing factors of the stigma of nursing students towards PMI according to Framework Integrating Normative Influences on Stigma (FINIS) at micro, meso, and macro levels. PubMed, Web of Science, Cochrane Library, EMBASE, CINAHL and PsycINFO were searched from 1990 to 31 December 2023. The reference lists of the included literature were further checked to identify potentially relevant articles. Two authors independently screened all titles, abstracts, and full-text articles and extracted data. Study quality was assessed by two authors using the Mixed Method Appraisal Tool (MMAT). A total of 4865 articles were initially retrieved, and 73 of these articles were included. The results suggested that the stigma towards PMI by nursing students was influenced by micro, meso and macro levels. At each FINIS level, the most frequent influencing factors are personal characteristics, the treatment system and media images. Numerous interconnected factors exert an influence on the stigma towards PMI among nursing students. Our research can be used to identify barriers and facilitators to nursing students’ stigma towards PMI and to provide supporting information for interventions designed to reduce this stigma.

Introduction

Globally, mental health conditions or addiction disorders affect over one billion individuals, constituting roughly 16% of the global populace. In the year 2016, mental and addictive disorders resulted in a global loss of 162.5 million Disability Adjusted Life Years (DALYs), representing 6.8% of the total DALYs lost during that period [1]. The different dimensions of stigma associated with mental health pose obstacles in delivering the most effective healthcare system interventions. People who experience stigmatization often suffer direct and indirect harm, which can worsen their symptoms and exacerbate the difficulty of seeking help and continuing treatment [2,3]. According to the Mental Illness Stigma Framework (MISF), stereotyping, prejudice, and discrimination are identified as the primary forms of stigma. Prejudice can be defined as a negative attitude towards someone, solely based on their association with a particular group that is distinguished by unfavorable characteristics. This unfavorable attitude such as pity or anger [4] entails making hasty judgments without considering the relevant facts. Discrimination is a behavioral consequence of prejudice, such as refusing to hire someone with mental illness or not supporting government funding for mental health services. Stereotypes are beliefs about groups of people learned while growing up in a particular circumstance, such as ’ PMI are unpredictable and can be violent [5]. ’

The stigma of mental illness affects PMI and the people associated with them in many ways. First, PMI may exhibit a negative inclination towards their mental illnesses (self-stigma). The prevalence of self-stigma among PMI is 31.3%, with the highest prevalence in individuals with schizophrenia (35.8%). PMI often internalize stereotypes about themselves, leading them to doubt their ability to meet the demands of various tasks.

Second, PMI are subjected to prejudicial attitudes and discriminatory behavior by the general population (public stigma). Public prejudice poses significant challenges for PMI in finding satisfied jobs, decent housing, and even equal health care [6]. A survey conducted across 27 countries highlighted the pervasive stigma encountered by PMI. Nearly half of the patients experienced prejudice when attempting to establish friendships, and 43% of them encountered discrimination from their family members. Additionally, they faced challenges in forming intimate relationships (27%), securing employment (29%), and maintaining their jobs (29%).

Third, they are subject to societal-level conditions, cultural norms, and organizational policies that limit their opportunities, resources, and well-being (structural stigma) [7]. This encompasses the obligation for individuals to disclose their mental health condition during job interviews, and exclusion from consideration for employment after disclosure [8]. Therefore, the majority of PMI (72%) feel it necessary to conceal their mental illness diagnosis [9].

Finally, the pervasiveness of stigma often leads to stigma for relatives, close friends [10], and healthcare professionals (HCPs) working in psychiatry (stigma by association) based on a working relationship [11]. The perception of mental health among medical students can be influenced by the stigma of association. As a result, they may perceive mental health as lacking a scientific foundation and view work as both disheartening and unproductive. Additionally, they may consider it a field that necessitates interaction with individuals who are deemed mentally unstable and potentially hazardous [12].

The attitudes and conduct of HCPs towards PMI hold profound importance. HCPs act as influential figures in the field of mental health. They serve as pillars of support and sources of understanding for individuals in need [13]. However, stigma toward PMI is prevalent among HCPs, posing a significant barrier to the processes of diagnosing, treating, and recovering from PMI. PMI experience negative treatment including inadequate and delayed provision of healthcare services, as well as prolonged waiting periods [14]. Furthermore, it is noteworthy that stigma attitudes among nurses might result in a lower quality of care for individuals diagnosed with mental illness compared to those without mental health illness [15]. Nursing students, as future nurses, share similar misconceptions about PMI as the general public. They tend to hold stigmatizing attitudes toward PMI and exhibit low levels of empathy [16]. Additionally, nursing students often display avoidance, anxiety, and fear when they encounter PMI, which can result in providing insufficient care to promote recovery from PMI [17]. These misconceptions and attitudes can negatively impact the career choices of nursing students.

In consideration of the above, there is a need to understand from scientific studies what factors influence the stigma of PMI among nursing students. Previous research has systematically analyzed studies related to the effect of theoretical education and/or clinical placement in changing the stigma of PMI among nursing students [18]. However, no research has conducted a comprehensive analysis of the influencing factors by 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). Therefore, a systematic search of the literature was conducted to summarize the different factors associated with the stigma of PMI among nursing students.

Aim

This study aims to synthesize and analyze the influencing factors of the stigma of nursing students towards PMI.

Method

This review was designed in adherence to the JBI Manual for Evidence Synthesis. This systematic review was prospectively registered in PROSPERO on 9 December 2022.

Conceptual model

We used the Framework Integrating Normative Influences on Stigma (FINIS) as the guiding theoretical model [19]. FINIS is an intellectual framework based on Goffman’s idea that understanding stigma requires using terms related to social connections. Goffman also argues that social interactions are always influenced by these connections. The FINIS framework summarizes the various levels of social interaction – 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).

Search strategy

All potentially relevant articles were identified through the following six electronic databases: PubMed, Web of Science, Cochrane Library, EMBASE, CINAHL and PsycINFO. A research librarian was consulted to assist in the creation of searches. The database search terms consisted of MeSH headings and appropriate keywords. The following terms were used: (‘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 selected search period, ranging from 1990 to 31 December 2023, was based on the gradual ascent of multidisciplinary research on stigma since the 1990s. Moreover, during this period, various international organizations have commenced expressing concern and undertaking anti-stigma actions related to mental illness [20,21]. Specific search strategies are shown in Supplemental Appendix III. Additionally, we examined the references of the included articles.

Inclusion and exclusion criteria

Eligible articles were identified by using specific inclusion and exclusion criteria.

Inclusion criteria: (a) studies that evaluated nursing students’ stigma attitudes towards PMI, (b) studies that analyzed the factors influencing the stigma of nursing students (c) articles published in English, (d) quantitative, qualitative or mixed studies.

Exclusion criteria: (a) editorial opinions, reviews, letters to editor, opinion articles, conference abstracts, (b) repeated publication.

Study selection

Records found during database searches were imported into the document management software and duplicate records were removed. Two authors (Author 1 and Author 2) independently screened titles and abstracts of all included studies. The full texts of the studies included after the initial screening were examined by the same two authors (Author 1 and Author 2) according to the inclusion and exclusion criteria. Authors resolved differences through discussion. An overview of the search and screening process was provided by using the PRISMA 2020 flowchart [22].

Quality assessment and risk of bias

The same two authors were involved in the critical appraisal process by using MMAT [23]. The MMAT is a critical appraisal tool designed for the appraisal phase of a systematic mixed research review. When there is disagreement, Author 3 resolved it through discussion with the two authors.

Data extraction

Author 1 developed a data extraction table based on the PRISMA checklist. The following information was extracted: author’s name, publication year, study design, study objective, number of participants, grade, assessment instruments used, data source and influence factors. Data were collected by two authors (Author 1 and Author 2) independently. Any inconsistencies in the extraction of information are addressed through discussion.

Data synthesis

According to JBI [24], the convergent synthesis method was used. The convergent synthesis refers to the process of combining data extracted from quantitative research (including data from the quantitative part of a mixed methods study) and qualitative research (including data from the qualitative part of a mixed methods study). The quantitative data in the study and the quantitative component of the mixed-methods study ‘qualitised’ as textual descriptions through narrative interpretation. The data were synthesized by using the framework synthesis approach. It has been widely used in mixed-method systematic reviews [25]. The framework synthesis approach has five stages [26]: familiarization, framework selection, indexing, charting, mapping and interpretation.

Familiarization: Authors became acquainted with current issues and perspectives on the topic.

Framework selection: The FINS framework which brought together theories from micro-, meso- and macro-level studies was considered appropriate. Influencing factors were identified and ranked according to the levels of FINS.

Indexing: Checking the fit of the data to the categories in FINS.

Charting: Performing a tabular analysis in Excel where columns and rows reflected the study as well as the associated categories.

Mapping and interpretation: Data were interpreted and synthesized by using charts and graphs. Data were extracted and analyzed by two authors (Author 1 and Author 2). When there was disagreement, it was resolved by the third author. Ultimately, we used the FINS to categorize the findings.

We identified influencing factors on the stigma of PMI among nursing students and marked them as ‘barriers’ or ‘facilitators’. For illustrative purposes, the ‘+’ and ‘-’ symbols represent the facilitators and barriers to eliminating nursing students’ stigma. In many cases, an article explored barriers and facilitators for each factor (e.g., if gender was a facilitator for females and a barrier for males, gender would be counted as an influential facilitator and barrier for each factor). In addition, if there was no significant association between certain factors in the article, we used ‘0’ to indicate the results.

Results

Characteristics of included studies

Figure 1 shows the stage of the review process. A total of 4865 articles were identified in the research process, and 69 articles met the inclusion criteria, furthermore, 4 articles that met the criteria were included by viewing references. As shown in Table 1, 58 quantitative studies (19 cross-sectional surveys and 38 quantitative nonrandomized studies and a cross-sectional study), 6 qualitative studies, and 9 mixed-method studies were included in the 73 papers. The year of publication of the literature ranged from 1991 to 2023, with the majority of studies published after 2015 (n = 52). Europe had the highest number of publications (n = 22), followed by Oceania (n = 18) and Asia (n = 14). The four countries with the highest number of publications were Australia (n = 16), Turkey (n = 9), the United States (n = 12), and France (n = 7). Details of the included studies are in the Supplemental Appendix I.

Figure 1.

PRISMA flow diagram.

Table 1.

Characteristic of the included studies.

Characteristics	Number of studies
Year of Study
Before 2000	3
2001–2005	3
2006–2010	7
2011–2015	8
2016–2020	27
After 2020	25
Study design
Quantitative	58
Qualitative	6
Mix-method	9
Region
Asia	14
Africa	1
Europe	22
North America	13
Oceania	18
Multi regions	4
South America	1

In quantitative studies, sample sizes ranged from 15 (a pilot study) to 605 [27]. The most used measurement instrument was the Psychiatric/Mental Health Clinical Placement Survey for First Day of Placement (PMHCPS preplacement) and it was used nine times. The second and third most used measurement tools are the Community Attitudes Toward the Mentally Ill Scale (CAMI) and Opinions of Mental Illness Scale (OMI) with 8 and 5 occurrences respectively.

The sample sizes of the qualitative studies ranged from 12 to 76. Of the six qualitative studies, two employed the method of focus group interviews, one utilized a questionnaire, two performed textual analysis on the gathered texts, and the remaining study relied on an in-depth interview.

Quality appraisal

Numerical scores were not given for each study because MMAT prefers a more detailed presentation of the scores for each criterion to better understand the quality of the included studies [23]. All studies were included after quality assessment. The studies included in this review used qualitative methods (n = 6), quantitative methods (n = 58), and mixed methods (n = 9). For qualitative studies, 100% reported data sources relevant to addressing the research questions. Sources of bias included inadequate citations (quotes) used to demonstrate themes. For quantitative studies, sources of bias for non-randomized studies included not considering confounding factors in the design and analysis (25/38; 65.79%) and not having complete outcome data (12/38; 31.58%). For cross-sectional studies, sources of bias were mainly from lack of representativeness of the sample target population (4/19; 21.05%), and a higher risk of non-response bias (7/19; 36.84%). Detailed information on the quality assessment was provided in Supplemental Appendix II.

Convergent qualitative synthesis

We referred to the FINIS framework for data synthesis. Stigma exists at the intersection of community and individual factors. The FINIS framework centers on the core theorem that there are multiple levels of social life – from the psychological and sociocultural level (micro) to the social network and organizational level (meso), and finally to the society-wide level (macro). The influencing factors were ranked according to the frequency of studies reporting them (see Table 2).

Table 2.

Taxonomy and frequency counts of nursing students’ stigma towards PMI barriers and facilitators from multiple perspectives.

Level description of factors			Frequency counts
			-	+	0
The micro level
	Personal Characteristics (n=23)	Gender	8	8	5
		Personal psychiatric history	7	8	1
		Age	4	4	6
		Grade	4	4	3
		Country of birth	3	3
		Ethnicity	1	1	3
		Emotional intelligence	1	1
		Branches of nursing	2	2
		Degree	1	1
		Health-related qualification			1
		Employment	1	1
		Religion	1	1
		High self-determination		1
		Substance use	1	1
	Perceptions of mental health	Willingness to work in a mental health clinic	4	4
	(n=5)	Interesting in a mental health externship			1
The meso level
	Social Networks	Prior contact with mental illness	12	12	4
	(n=15)	Parent education	1	1	1
		Parents’ country of birth	1	1
		Family income	1	1	1
		Knowing someone who had experienced discrimination	1	1
	The Treatment System (n=53)	Theoretical course and practice training		18	2
		Practical training		16	5
		Theoretical course		14
		Standardized Patient-based Simulation		2
		Anti-stigma program		5	2
The macro level
	Media Images		2	3
	(n=3)
	The National Context		1	1
	(n=1)

The degree is either an Associate Degree in Nursing or a Bachelor of Science in Nursing.

The micro level

The micro level refers to the intra-personal level, the characteristics associated with nursing students and how they combine to predict stigma reactions.

Personal characteristics

Twenty-three studies considered the demographic characteristics of nursing students (e.g., gender, age, grade level, education, branch of nursing, emotional intelligence) and examined the relationship between these personal characteristics and discrimination against PMI. Studies found that female, senior students who have received theoretical education or training, higher emotional intelligence scores, Associate Degree in Nursing (ADN), the mental health branch of nursing rather than adult nursing or child health nursing, employed nursing students, addictive substance use (i.e., alcohol or cannabis use), nursing students with high self-determination or personal history of mental illness had a more positive attitude towards PMI. Besides, the country of birth, ethnic groups and religious beliefs could also have an impact on stigma.

In some previous studies, females had more tolerant and sympathetic attitudes towards PMI [28]. Women had higher social empathy [29] and sensitivity to the pernicious effects of stigma [30], and were more positive in building interpersonal relationships compared to males [31].

Nursing students with mental illness or a history of mental illness had more positive attitudes toward PMI, which emphasized the effect of personal experiences of mental illness in reducing stigma [32].

Four studies [33–36] found lower stigma performance in higher years of study, and researchers hypothesized that students would receive training in psychiatry and mental health modules in higher grades, with a reduction in stigma.

Three studies have shown that the level of stigma for nursing students varies between countries [37]. Happell [38] examined the attitudes of nursing students towards PMI in four European countries (Ireland, Finland, Norway, and the Netherlands) and Australia, and found that there were significant differences in the attitudes of students towards mental health care between countries. This was probably because of the disparity between various cultures within a country, as well as differences in educational backgrounds. Millar [39] proposed that individuals from distinct cultural backgrounds may possess unique viewpoints on the management of mental illnesses such as Asia tended to favor pro-social restrictions.

There have been relatively few studies of the influences of religion and ethnicity in this area. Only one study found a statistically significant difference in mean CAMI scores between the white group and the black or black British group [40]. Three studies did not find statistical significance between ethnicity [35,41,42]. Regarding religion, one study found a significant or critically significant difference in attitudes between students who believed in religion and those who did not [33].

Perceptions of mental health nursing

Studies discussed the impact on mental health perceptions, nursing students who had a willingness to work in psychiatry [28,43] and interested in a mental health externship might have more positive attitudes toward PMI.

The meso level

The meso level was at the interpersonal level, which referred to the ‘contact’ based influences. Scholarly efforts have predominantly focused on this domain, acknowledging its pivotal role in shaping attitudes and behaviors. It was debatable that the influence of acquaintances (psychiatric history of family or friends) or interactions with individuals suffering from mental illness. Furthermore, educational approaches also played an important role.

Social networks

Fifteen studies have focused on the connection between social networking and stigma. Among the interpersonal dimensions, family income, parents’ level of education, and parents’ place of birth may have an impact on nursing students’ discriminatory attitudes.

Researchers focused on nursing students who had friends or family members with mental illness or had early contact with PMI manifested notably more favorable perspectives [28,43]. Personal experiences of mental illness in friends or family members were also a key factor in nursing students’ decisions to choose a mental health nursing career. After observing the unjust stigma endured by their own family members, certain nursing students opted to pursue a career in psychiatry as their primary choice. However, there are also nursing students who did not choose it as a career because of the relative emotional burden it created, which nursing students described as ‘they are stigmatized from the beginning. They are isolated, which is very difficult. It’s hard to even imagine the difficulties they go through. That’s why working with them exhausts me’ [44]. Personal experiences of mental illness in friends or family members enhanced nursing students’ familiarity to PMI, and intergroup contact usually reduced intergroup bias. A meta-analysis that combined 696 samples showed that increased intergroup engagement correlated with a decrease in prejudiced attitudes [45].

The treatment system

In the last two decades, many researchers have tried different anti-stigma measures such as theoretical teaching combined with practical training, volunteer activities, anti-discrimination programs and digital storytelling, etc. Most nursing students’ negative attitudes or stereotypes towards PMI have changed to some extent after interventions.

Theoretical course

A total of fourteen studies examined the relationship between theoretical education and the stigma of nursing students, finding that nursing students who received more hours of mental health nursing education demonstrated significantly more favorable views and attitudes toward mental health [28] and even the distance education also proven to yield positive outcomes in shaping student attitudes [46]. Expert by experience (EBE) involvement in the mental health theoretical course was prevalent, and EBE involvement is used to provide nursing students with an in-depth understanding of the expectations of the mental health consumer perspective and to foster the person-centered perspective. EBE fostered a more equitable dynamic between nursing students and PMI, achieving dual benefits: it reduced the nursing students’ negative attitudes and deepened nursing students’ understanding of nursing. Moreover, this approach promoted mental health nurses as a more desirable career choice for nursing students [47].

Practical training

Twenty-one studies noted the role of practical training on mental health in improving stigma. sixteen investigations concluded that practical training reduced stigma in nursing students, with the duration and contextual diversity of placements yielding varied impacts on the students’ attitudes and understanding. A study indicated that students with placements of more than 15 days had more positive attitudes towards PMI [48]. In addition, the educational environment of clinical mental health placements plays a vital role in developing the knowledge and skills that nursing students needed to provide quality mental health services [28]. Clinical practice in a mental health setting was more likely to reduce stigma attitudes among nursing students compared to a non-mental health setting [49]. A more open and autonomous practicum environment was associated with a significant decrease in nursing student stigma, while a balanced/neutral practicum environment was associated with a significant increase in stigma [50]. Similarly, therapeutic recreation (TR) based clinical placements were more successful in improving the attitudes than students who participated in typical mental health clinical placements [51]. The TR-based clinical placement was a five-day immersive, experiential mental health clinical learning program that facilitated a therapeutic relationship between nursing students and PMI by working together. It has also been found that mental health clinical placement settings in the community significantly changed negative attitudes whereas those in hospital settings did not [52]. However, certain studies have observed no marked reduction in nursing students’ stigma after practical training. This discrepancy might stem from students’ encounters during clinical placements, which at times led to diminished optimism regarding recovery prospects for PMI, reinforcing unfavorable viewpoints [53] Another plausible explanation lies in the influence of negative attitudes prevalent among clinical nurses. Students’ close collaboration with them during placements often exposed them to adverse perspectives, impacting their attitudinal development negatively [54].

Theoretical course and practice training

An emerging trend in the literature reveals a preference for integrated approaches that blend theoretical instruction with practical application. A case in point is a study conducted in Turkey, where their psychiatric program was 18 hours in total completed over 14 weeks, and consisted of 6 hours of theoretical sessions and 12 hours of practical sessions. The theoretical part of the course was taught using a variety of teaching methods such as lectures, discussions, film analysis, role plays and case studies. The practical component took place in a psychiatric clinic for 13 weeks (lasting one and a half days per week), and all students worked with PMI [55]. The duration and structure of such programs displayed variations across different academic institutions, with some opting for extended internship durations.

Standardized patient-based simulation

Standardized Patient-based Simulation (SP simulation) has been used to prepare and familiarize with a variety of diagnoses, procedures, and communications for nursing students to enhance their knowledge and skills. During the SP simulation, undergraduate nursing students were asked to effectively assess patients and respond appropriately. Kameg [56] found that nursing students’ attitudes related to social stigma improved after exposure to SP simulation scenarios.

Anti-stigma program

Many researchers have launched anti-stigma projects. For instance, İnan [57] orchestrated an exhaustive 32-hour anti-stigma project, encompassing modules on stigma awareness, execution of anti-stigma campaigns, debates, in-depth discussions, and screenings of documentaries. Şengün [58] adopted a peer-led education strategy, wherein clusters of 10 to 12 nursing students assumed the role of educators for their peers. The course content included computer demonstrations, documentary screenings, and group discussions, totaling 90 minutes. In a peer education program, students changed their original thoughts that PMI were dangerous, but the effectiveness of peer education declined after six months.

Some studies utilize patient stories as educational materials. Cho, M. K. selected 10 storybooks featuring individuals with schizophrenia [59]. Linz explored the use of digital storytelling as an intervention, wherein psychiatric patients, aided by nursing students, created digital narratives about their journeys of recovery from mental health challenges, but no statistical significance was found in the results [27].

Contact-based interventions were also employed, where volunteers with mental illness shared their experiences of mental health challenges, treatment, and recovery with nursing students [60]. This approach helped enhance nursing students’ attitudes and behaviors toward patients with mental illness. Additionally, apart from direct contact, academics have explored interventions using the photography website SNAP. SNAP offers firsthand accounts of the lived experiences of mental illness, making it a potential indirect social contact intervention [61].

The macro level

In the FINIS model, stigma was embedded in a larger cultural context that shaped social acceptance of different groups as well as stereotypes. Stigma is indeed a universal cross-cultural phenomenon, but norms also vary between countries. A country’s overall concepts and attitudes determine how stigmatized groups are defined and treated. The larger context, such as economic models, social structures, and cultural traditions, sets the norms for how we deal with stigma and also determines which groups are susceptible to stigma and how they can escape this label [19]. For instance, in Latino culture, discussions surrounding mental health issues are markedly taboo, particularly among males. The societal expectation for men to embody traits of strength and masculinity contributes to the stigmatization of mental health disorders, often construed as manifestations of cowardice or weakness. Similarly, within the cultural contexts of Asian countries, mental health issues are met with disapproval, likely attributable to the perception of mental health as a concept rooted in Western ideologies. Consequently, a pervasive stigma regarding mental health persists among many olds [62].

Media images were community-based social networks that acted as a mechanism to change larger cultural stereotypes and provided advice and assistance to PMI. Media [34] have had an impact on individuals’ perceptions of PMI [63]. Negative portrayals of PMI were frequently depicted in various forms of media, including stories and movies [34]. Research has underscored how media narratives reinforce public stigma by hastily associating PMI with incidents of violence or personal failure. It has been noted that news reporting on mental health is often biased, tending to focus disproportionately on depictions of violence [64].

However, certain nursing students contend that familiarity with celebrities’ encounters with mental illness could reduce the stigma surrounding PMI. For instance, upon learning of Anthony Bourdain’s suicide in a hotel, many were struck with a sense of sorrow and bewilderment. Nonetheless, this event may have imparted the realization that mental health disorders can afflict individuals across all socioeconomic strata, regardless of wealth, age, or social standing [62].

A systematic review [65] that included 22 studies concluded that mass media interventions may have a small to moderate effect on reducing prejudice. In general, groups with a better understanding of mental illness are less likely to support discriminatory views, and education focused on providing accurate information can improve positive attitudes toward PMI [66]. Therefore, digital technology also has the potential to be a powerful tool aimed at making truthful information widely available so that nursing students can make more intelligent decisions and judgments about mental illness.

Discussion

Among the quantitative studies, self-report questionnaires were mostly used, with four of them having large sample sizes of over 500 participants. The sample sizes of the selected qualitative studies were relatively small compared to the quantitative studies, with only three studies having sample sizes of 50 or more, and the smaller sample sizes were convenient for focus group or interview research methods. Regarding the methodology used in the evaluated studies, focus interviews were the most commonly used method.

We examined the factors influencing nursing students’ stigma towards PMI at the FINS level. The included studies covered all three levels of FINS, with a greater emphasis observed on the micro-level and meso-level investigations. At each FINS level, the most frequent influencing factors were gender, personal psychiatric history, prior contact with mental illness, theoretical courses, and practical education. The results of this study were similar to other studies. In a systematic review [67] assessing medical students’ attitudes towards psychiatry in the Eastern Mediterranean Region (EMR), it was found that factors influencing medical students’ attitudes towards psychiatry included their own mental health status, having friends with mental illness, and exposure to psychiatry traineeships/teaching.

It can be observed that most of the research focuses on influences at the educational intervention, particularly clinical practice training. They were based on contact theory, which was developed from the study of racial prejudice and focuses on contact and its effects on prejudiced attitudes. The theory suggested that intergroup contact can reduce prejudice across a wide range of groups and contexts [45]. Contact was thought to provide individuals with opportunities to encounter stigmatized group members who did not conform to the negative expectations of the individual’s stereotype. Some studies have found that contact was more effective than theoretical education in reducing the stigma of adults, and that contact with PMI leads to greater improvements in improving public stigma. However, some studies suggested that more than a certain amount of contact may actually produce less favorable outcomes, and thus there may be an optimal ‘dose’ of contact [68,69]. Furthermore, scholars have debated the notion that the cultivation of favorable attitudes was predominantly observed in instances of voluntary interaction. If contact was compulsory, it can lead to negative effects instead.

It’s worth noting that only three studies dealt with the impact of the social dimension, and future studies could consider designing questionnaire development with the social factors obtained from the qualitative study.

The increasingly important role of media such as the Internet and video in people’s lives also makes it possible to use the media to reduce stigma, and it may serve as a tool for conveying anti-stigma messages and promoting help-seeking behaviors [70,71]. The media is an effective way to provide rich interactive content that better represents the person and his or her actual experiences and helps to reduce social distancing from PMI [72]. Prior studies have suggested that interventions of mass media (e.g., interactive computer education programs via the Internet, articles via the Web, educational advertisements via e-mail, video apps, etc.) may have the potential to diminish prejudice, Yang has used SNAP the Stigma website interaction to reduce stigma [61]. However, a lack of sufficient evidence to determine their long-term effect [65]. And more exploration is needed about media tools interventions in nursing.

It was worth noting that most of the researches were conducted in developed countries, with less information from studies in middle- and low-income countries. More than 85% of the world’s population lives in low- and middle-income countries, and more than 80% of PMI inhabit these countries. Nearly five-sixths of low-income countries, four-fifths of Southeast Asian countries, and half of Eastern Mediterranean countries have fewer than just one psychiatric nurse per 100,000 people. However, 75% of high-income countries have 10 or more psychiatric nurses per 100,000 people [73]. Lower middle-income countries have more PMI and fewer medical resources, thus there is a need for more attention to be paid to psychiatric nursing and nursing students in low- and middle-income countries groups.

Furthermore, most of the studies were pre- and post-intervention comparisons and lacked data on long-term follow-up (e.g., the absence of data on three- or six-month follow-up), which were relevant to whether the intervention has long-term effectiveness. It has been suggested that anti-stigma measures such as peer education programs should be incorporated into the psychiatric nursing curriculum system and repeated on a periodic schedule to prevent a decrease in the effectiveness of stigma education [58].

Limitations

The literature search was limited to English, meaning grey literature or studies in other languages have been missed. In this study, we did not perform a meta-analysis of quantitative studies due to the high heterogeneity of findings. Additionally, we assessed the methodological quality of the studies using MMAT, but were still included in this review regardless of outcome according to MMAT criteria.

Conclusion

This review provides an overview of the factors associated with nursing students’ stigma of PMI, which may have an impact on nursing students’ future career choices and patients’ healthcare experiences. Based on the available studies, diverse factors (such as personality traits, perceptions of mental health, social connections, educational intervention methods and settings and social media) influenced the stigma of nursing students, but the findings are controversial. The findings can be used to guide teaching institutions and researchers in formulating relevant policies. Further research is required to address the problems found in this review.

Relevance to clinical practice

There is a gap in the current research on mental health stigmatization, and existing systematic reviews provide a multilevel perspective on the education of nursing students about stigmatization. To reduce the stigma of mental health among nursing students, we recommend an integrated approach to introducing mental health nursing in university nursing education.

Authorship statements

Yi Zeng: Conceptualization, methodology, formal analysis, writing – original draft.

Ting Pan: Methodology, formal analysis, writing – review and editing.

Mei Sun: formal analysis, writing – review and editing.

All authors have read and agreed to the published version of the manuscript.

Funding Statement

This work was supported by the Hunan Provincial Philosophy and Social Science Fund [Grant ID 23YBA010]; Independent Exploration and Innovation Programme for Postgraduate Students at Central South University [Grant ID 2024ZZTS0897]; Research project on graduate education and teaching reform at Central South University [Grant ID 2024JGB098].

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/10872981.2024.2376802