Nurses’ stigmatizing attitudes toward patients with substance use disorders and their impact on care quality

Abstract

Background

Stigmatizing attitudes among nurses toward patients with substance use disorders (SUDs) and Opioid Use Disorder (OUD) represent a significant and pervasive barrier to equitable, patient-centered care. Despite growing recognition of addiction as a chronic, relapsing brain disease, nurses across diverse healthcare settings continue to exhibit negative perceptions, moralistic judgments, and stigmatizing language that compromise care quality, therapeutic relationships, and patient outcomes.

Methods

A scoping review was conducted following the Arksey and O’Malley framework, refined by Levac and colleagues, and reported in accordance with PRISMA-ScR guidelines. Four electronic databases PubMed, Scopus, ScienceDirect, and CINAHL were searched from January 2018 to January 2026. Following systematic screening and full-text assessment, 12 peer-reviewed primary studies were included and synthesized thematically.

Results

Five overarching themes were identified: (1) the pervasiveness of nursing stigma across individual, professional, organizational, and structural levels; (2) knowledge deficits and negative professional socialization as primary antecedents of stigmatizing attitudes; (3) the direct impact of stigma and clinical language on care quality, with person-first documentation language independently associated with a fivefold increase in the odds of a documented OUD treatment plan (AOR = 5.21; 95% CI: 2.28–11.89); (4) patient-reported experiences of dehumanization, eroded trust, and treatment avoidance; and (5) evidence-based educational interventions demonstrating significant improvements in nursing attitudes and clinical role adequacy.

Conclusions

Nursing stigma toward patients with SUDs is a systemic, structurally embedded problem with measurable adverse consequences for care quality. Effective mitigation requires a multilevel response integrating addiction education reform, person-first language standards, implicit bias training, institutional-level policy and electronic health records reform to ensure equitable, evidence-based care for this vulnerable population.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12912-026-05067-z.

Introduction

Substance Use Disorders (SUDs) pose a significant and enduring global public health challenge. They contribute markedly to morbidity, mortality, and the burden on the healthcare system worldwide. Individuals with SUDs often face complex physical, psychological, and social consequences. These challenges require multidisciplinary and sustained healthcare support [1]. Although there has been progress in conceptualizing addiction as a chronic, relapsing medical condition, stigma remains pervasive within healthcare systems. This stigma continues to impede effective treatment and patient engagement [2].

Stigma directed toward individuals with SUD is widely recognized as a major barrier to quality care. This stigma includes negative stereotypes, prejudicial attitudes, and discriminatory behaviors. These factors marginalize individuals and undermine therapeutic relationships [3]. In healthcare settings, stigma leads to delayed treatment, diminished patient trust, premature discharge, and avoidance of care. This ultimately worsens health outcomes [3, 4]. Additionally, SUD is consistently ranked among the most stigmatized medical conditions. This further intensifies disparities in care delivery and access [5].

Nurses hold a central and influential role in caring for patients with SUD, often serving as the initial point of contact and taking responsibility for ongoing clinical management, patient education, and emotional support. Their attitudes and perceptions play a critical role in shaping patient experiences and outcomes [2]. However, evidence shows that nurses, like other healthcare professionals, may have stigmatizing attitudes toward this population. Studies among nursing and nursing student populations indicate that 20% to 51% hold negative beliefs or feelings toward people with SUD, leading to diminished empathy, avoidance behaviors, or compromised care practices [1, 6, 7]. Recent studies among undergraduate nursing students and nursing assistant students have documented negative attitudes, knowledge gaps, and limited preparedness in caring for patients with SUD, particularly in acute and maternity settings [6, 7].

Multiple factors contribute to the development of stigmatizing attitudes. These include insufficient education, limited clinical training in addiction care, cultural beliefs, and previous experiences with patients [6]. Many nurses report they feel unprepared to manage SUD-related conditions. This can result in frustration, fear, and negative perceptions during patient interactions [7]. High-intensity environments, such as emergency departments, intensify these challenges. Time constraints, safety concerns, and systemic pressures in such settings may reinforce negative attitudes and biases [7].

Nurses’ stigmatizing attitudes have impacts that extend beyond interpersonal interactions. They directly influence the quality of care provided. Higher levels of nursing stigma have been linked to inadequate pain assessment and management, avoidance of therapeutic communication, and suboptimal treatment planning. In inpatient settings, nurses have described an internal ethical conflict around pain management and reported that stigma contributes to diagnostic overshadowing and fragmented care coordination [8, 9]. Negative perceptions can also cause diagnostic overshadowing, delayed interventions, and fragmented care coordination. This further jeopardizes patient safety and recovery [6]. Patients who perceive stigmatization from healthcare providers often report feelings of dehumanization and reduced trust. They may also avoid seeking future care, creating a cycle of poor health outcomes and disengagement from healthcare [4].

Despite increased attention to this problem, research remains fragmented. Studies vary by design, setting, and measured outcomes. While some focus on certain healthcare groups, we still need an overall review of nurses’ stigma and its impact across settings. A scoping review is needed to summarize current evidence and show gaps in the research.

This scoping review will examine nurses’ stigma toward people with SUD and how it affects care quality. By gathering current evidence, the review aims to guide research, training, and policy to reduce stigma and improve fair, patient-centered care.

Methods

Study design and objective

This study was conducted as a scoping review to systematically map the available evidence regarding nursing-related attitudes, perceptions, stigmatizing language, and educational interventions in the context of substance use disorders (SUDs), with a particular focus on opioid use disorder (OUD). The methodology followed the framework developed by Arksey and O’Malley and was further refined using the guidance of Levac [10, 11]. This review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis - Extension for Scoping Review (PRISMA-ScR) guidelines [12].

The primary objective was to synthesize and map the breadth of available evidence on nurse-related factors, including stigmatizing attitude, knowledge deficits, perceptions, and educational interventions - that influence the quality of care delivered to individuals with SUDs and OUD across diverse healthcare settings. The secondary objective was to identify evidence-based implications for nursing practice, education, and healthcare policy, with the ultimate goal of improving patient centered outcomes for this population. This review was guided by the following research question: “What is the nature and scope of evidence regarding nursing attitudes, perceptions, stigmatizing language, and educational interventions aimed at improving care for individuals with substance use and opioid use disorders?”

Search strategy

A comprehensive and systematic search was conducted across four electronic databases: PubMed, Scopus, ScienceDirect, and CINAHL, covering the period from January 2018 to January 2026. The search strategy was developed iteratively by the research team to ensure maximal sensitivity and specificity. To ensure full transparency, the complete search for all databases, along with the method used to develop them, are provided in supplementary Tables S1 and S2.

Search terms combined keywords using Boolean operator, including: (“nursing interventions” OR “nurse-led” OR “nursing education” OR “nursing attitudes” OR “nursing perceptions” OR “nursing care”) AND (“substance use disorder” OR “opioid use disorder” OR “dual diagnosis” OR “concurrent disorders”) AND (“stigma” OR “bias” OR “language” OR “patient outcomes” OR “quality of care” OR “educational intervention”).

The final search was conducted in January 2026 to identify additional eligible studies not captured through database searches, hand searching of reference lists from all included studies and relevant systematic reviews was performed. Forward and backward citation tracking was conducted using Google Scholar and Web of Science. Consistent with PRISMA-ScR guidance, prospective registration of the review protocol was not required.

Eligibility criteria

Exclusion criteria

Studies were excluded if they: (1) were not focused on nursing professionals or nursing students as a primary population; (2) lacked a clearly identifiable SUD- or OUD-related component; (3) were non-peer-reviewed, editorial commentary without empirical data, letters to the editor, or conference abstracts without full-text availability; or (4) were published in languages other than English.

In accordance with PRISMA-ScR Guidelines, no formal assessment of methodological quality or risk of bias was applied, consistent with the scoping review’s objective to map the breadth of evidence rather than appraising study quality for meta-analytic synthesis. This scoping review evaluated sources’ credibility based on study design rigor and peer-review status. Both reviews and primary studies were included without quantitative analysis so conceptual overlap is not a major concern.

Study selection and data extraction

Two independent reviewers (O.A. and S.D.) conducted a two-stage screening process. In the first stage, titles and abstracts were screened for relevance against the eligibility criteria. In the second stage, full-text articles of potentially eligible studies were retrieved and assessed in detail. Discrepancies between reviewers at either stage were resolved through discussion and consensus. Where consensus could not be reached, a third reviewer was consulted. The selection process is detailed in the PRISMA-ScR flow diagram (Fig. 1). Data were extracted using a standardized form that captured the following: author, purpose, setting, sample size, study design, and main findings (Table 1). A completed PRISMA-ScR reporting checklist is provided in Supplementary Table S1.

Fig. 1.

PRISMA-ScR flow diagram. PRISMA: Preferred reporting items for systematic reviews and meta-analysis - extension for scoping review

Table 1.

Summary of 12 studies included in this review

Author /years	Purpose	Settings	Sample size	Study design	Main findings
Ginther & McNally (2024) [13]	To review the consequences of addiction stigma and identify strategies nurses can adopt to reduce bias against patients with substance use disorders (SUDs), using a case-based scenario as a pedagogical tool	United States (US)	N/A	Continuing education article / narrative review with empirical evidence synthesis	Nurses frequently exhibit stigmatizing attitudes and use pejorative language (e.g., “junkie,” “addict”) when caring for patients with SUDs. Knowledge deficits are a major driver of stigma. Person-first, medically appropriate language, and implicit bias training are recommended as core strategies for stigma reduction. A systemic, multilevel approach, inclusive of nursing curriculum reform and continuing education, is required to achieve meaningful change.
Vottero, Schüler & Kratovil (2023) [15]	To develop a conceptual model, the Substance Use Disorder Nursing Attitude Model (SUDNAM), which explains the antecedents of nursing attitudes and perceptions toward patients with SUD and their effect on patient care outcomes	US	691 nurses	Mixed-methods analytical cross-sectional study	Negative nursing attitudes toward patients with substance use disorders are driven by inadequate education and prior personal or professional experiences, as described in the SUDNAM model (context, internalization, behavioral outcomes, and patient outcomes), with nurses who have personal SUD experience showing greater empathy and emphasizing the necessity of integrated SUD sensitivity training combining addiction science and empathy-based approaches to reduce stigma and improve patient outcomes.
Bertrand & Morvillers (2025) [16]	To explore psychiatric and mental health (PMH) nurses’ perceptions of the illness trajectories of patients with co-occurring psychiatric and substance use disorders in psychiatric settings in France	Public psychiatric hospitals, including community mental health centers (CMHCs) and inpatient wards, in the Paris metropolitan area, France	11 PMH nurses	Exploratory qualitative study	The core category identified was “waiting for a patient’s will to change to emerge.” Nurses balanced two care priorities: clinical stabilization and preservation of the therapeutic relationship. Feelings of powerlessness and diminished agency were common among patients in the pre-contemplative stage. Long-term trusting relationships facilitated collaboration. Training in motivational interviewing and collaborative recovery-oriented approaches was identified as an essential practice need.
Jenkins et al. (2022) [17]	To examine the impact of a one-day educational intervention, the Enhancing Concurrent Disorder Care Intervention, on nurses’ and student nurses’ capacity to care for patients with concurrent disorders (co-occurring mental health and substance use disorders) in inpatient mental health settings	Five acute mental health units across two hospitals in British Columbia, Canada, and two regional schools of nursing	76 nurses and student nurses (paired pre-post data)	Quasi-experimental	The intervention produced statistically significant improvements in knowledge and attitudes toward patients with concurrent disorders across all participant groups. The largest effect was observed in Role Adequacy (Cohen’s d = 1.10). Student nurses demonstrated greater improvements than practicing nurses on most measures. Brief, evidence-informed educational interventions integrating patient lived experience are effective and feasible mechanisms for addressing knowledge and attitudinal gaps among nurses.
Lewis & Jarvis (2019) [18]	To examine undergraduate nursing students’ experiences and attitudes toward patients with opioid use disorder (OUD) in clinical settings, and to assess their perceptions of educational preparedness for this population	Clinical rotations across multiple inpatient settings, predominantly maternity units, at a public university in New England, United States	11 senior undergraduate nursing students	Qualitative content analysis	Six themes emerged: (1) navigating ethical dilemmas, (2) gaining comfort with time and experience, (3) avoiding the “elephant in the room,” (4) learning from real-world scenarios, (5) witnessing discriminatory care, and (6) recognizing bias and stigma. Students felt most unprepared in maternity settings and most frequently encountered OUD there. Nurse role modeling had a powerful, both positive and negative, influence on students’ attitudes. Students expressed a readiness to learn and a desire to provide empathetic, non-judgmental care.
McCurry et al. (2023) [14]	To identify stigma, barriers, and facilitators experienced by members of the opioid use disorder (OUD) community when seeking healthcare, with specific attention to nurses’ roles	US	10 individuals (persons with OUD, family caregivers, and support group leaders)	Qualitative exploratory design	Eight thematic domains were identified: (1) stigmatizing language, (2) being labeled, (3) inequitable care, (4) OUD as a chronic illness, (5) insurance barriers, (6) stigma associated with medications for OUD (MOUD), (7) community resources, and (8) nursing knowledge and care. Stigma manifests at structural, public, and internal levels. Participants identified nurses as key to facilitating or impeding access to care. Person-first language, framing OUD as a chronic illness, and warm care transitions were identified as critical facilitators.
Balmuth et al. (2024) [19]	To explore the perspectives of hospitalized patients with SUDs on positive and negative aspects of their hospital care, consequences of care, and recommendations for improvement	US	15 hospitalized patients with a confirmed SUD diagnosis	Qualitative descriptive study	Patients identified perceived clinical and emotional proficiency, partnership, and individualized care as core components of positive experiences. Perceived bias, stigmatizing assumptions (e.g., “drug-seeking” labels), clinical inefficiency, and inhumane treatment characterized negative experiences. Such experiences profoundly affected patients’ trust, emotional well-being, and willingness to engage in care. Recommendations included promoting compassionate partnership, individualizing care, educating providers, and actively supporting recovery.
Horner et al. (2019) [8]	To assess the attitudes, perceptions, and training needs of inpatient nurses caring for patients with comorbid opioid use disorder (OUD)	US	22 inpatient nurses	Qualitative grounded theory study	Six themes were identified: (1) stigma, (2) safety and security concerns, (3) challenges in assessing and treating pain, (4) communication between providers, (5) feelings of burnout, and (6) opportunities for change. Nurses described an internal ethical conflict, “a war with yourself,” around pain management. Stigma was rooted in inadequate education and organizational culture. Nurses unanimously expressed willingness to learn. An organizational culture shift accompanied by structured education, role support, and standardized protocols was recommended.
Quaye, Alatrash, & Metoyer (2020) [20]	To examine differences in SBIRT (Screening, Brief Intervention, and Referral to Treatment) knowledge, attitudes, and beliefs in BSN students after completing SBIRT education and clinical practice in a community home health setting	US	488 undergraduate nursing (BSN) students	Single-group pretest–posttest design	SBIRT knowledge and negative attitudes toward patients with alcohol and drug use significantly improved post-intervention. Specific gains were observed in knowledge of standard drinking limits and in knowledge of brief intervention steps. Seventeen of 25 negative attitude items improved significantly. No significant differences were found based on gender, race, or ethnicity. Integrating SBIRT into home-based community health clinical education was identified as a novel and effective approach to improving student competency and reducing stigma in pre-licensure nursing programs.
Isbell et al. (2023) [21]	To develop a comprehensive, data-driven model of the challenges and care dynamics experienced by emergency department (ED) physicians and nurses when caring for patients with psychiatric conditions and/or SUDs, and to identify factors affecting patient care quality	US	86 ED healthcare providers (45 physicians, 41 nurses)	Preplanned topical analysis of grounded theory data	A cyclical model of challenging care dynamics was identified: emotional (burnout, frustration), diagnostic (premature closure, diagnostic overshadowing), and logistical challenges interact with pre-existing negative attitudes and biases toward patients with psychiatric conditions and SUDs. These processes adversely affected the quality of patient care and the well-being of ED staff. Systemic change, including healthcare policy reform, expanded community resources, and localized provider-level interventions, was deemed essential to disrupting these cycles.
Carpenter et al. (2023) [9]	To determine how inpatient physicians describe patients with OUD in discharge summaries and to examine associations between the language used and clinical outcomes along the OUD continuum of care	US	328 hospitalized patients with OUD and infectious complications of injection drug use	Retrospective medical record review	Potentially stigmatizing language (predominantly “abuse”) was found in 68% of discharge summaries; best-practice person-first language (“use disorder”) appeared in only 23%. Use of non-stigmatizing language was significantly associated with increased odds of having a documented OUD treatment plan (AOR 5.21; 95% CI: 2.28–11.89) and addiction-specific follow-up referral (AOR 2.47; 95% CI: 1.36–4.47). Provider language in clinical documentation reflects attitudes that directly influence the quality of addiction care delivered.
Hirshman et al. (2025) [22]	To understand the nature and frequency of stigmatizing and affirming language used by healthcare providers in electronic health records (EHR) of hospitalized patients with OUD with long hospital stays, using an interdisciplinary social constructivist lens	US	48 patients (96 admission and discharge notes reviewed)	Retrospective qualitative chart review	Stigmatizing language was identified nine times more frequently than affirming language (434 vs. 47 occurrences). Eighty-nine of 96 notes (92.7%) contained stigmatizing language. The most common stigmatizing categories were “drug abuse language” (n = 154) and “identity-first language” (n = 83). One-third of stigmatizing language was system-generated (EHR dropdown menus and ICD-10 codes), indicating the need for structural EHR reform. Both provider education and institutional-level changes to diagnostic codes and EHR fields are necessary to reduce stigmatizing language and improve patient care.

Abbreviations: AOR – Adjusted Odds Ratio; BSN – Bachelor of Science in Nursing; CI – Confidence Interval; CMHCs – Community Mental Health Centers; ED – Emergency Department; EHR – Electronic Health Record; ICD-10 – International Classification of Diseases, 10th Revision; MOUD – Medications for Opioid Use Disorder; OUD – Opioid Use Disorder; PMH – Psychiatric Mental Health; SBIRT – Screening, Brief Intervention, and Referral to Treatment; SUD – Substance Use Disorder; SUDNAM = Substance Use Disorder Nursing Attitude Model, US – United States

The search across the four electronic databases (PubMed, Scopus, ScienceDirect, and CINAHL) yielded a total of 428 records (n = 428). Following the removal of duplicate records (n = 96), a total of 332 records underwent title and abstract screening (n = 332). Of these, 260 records were excluded as not relevant to the study objectives (n = 260), yielding 72 reports sought for full-text retrieval (n = 72). Of these, 8 reports could not be retrieved (n = 8). Full-text assessment for eligibility was conducted for 64 reports (n = 64), of which 52 were excluded (n = 52) for the following reasons: not focused on nursing professionals as a primary population; not directly addressing stigma or nurse-patient attitudes toward SUD/OUD; wrong study population (non-SUD patients); or not primary research (e.g., editorials, letters, non-peer-reviewed commentaries). Ultimately, 12 studies (n = 12) were included in the final scoping review.

Characteristics of included studies

The 12 included studies comprised heterogeneous research designs, consistent with the breadth-mapping objective of scoping review methodology. Study designs included qualitative studies employing grounded theory and thematic content analysis; a quasi-experimental pre-post intervention design; a retrospective cohort study; a qualitative focus-group study; a mixed-methods/practice-focused article; and a continuing professional development article with empirical evidence synthesis. Studies were conducted across multiple countries and healthcare settings, including academic medical centers in the United States, a public psychiatric hospital in France, acute mental health units in Canada, and community-based healthcare settings in the United States.

Sample sizes ranged from small purposive qualitative samples (n = 10 to n = 22 participants) to larger retrospective cohort studies involving chart reviews of hospital admissions. One included study is a peer‑reviewed continuing education article with empirical evidence synthesis rather than a primary research study [13]. It was retained on the basis of its peer‑reviewed status, clinical relevance, and alignment with scoping review methodology’s broader evidence‑mapping objectives. Two additional studies examined nursing-adjacent populations in inpatient clinical documentation and patient-reported experiences of nursing care, respectively [9, 14].

Although nurses were not the primary study participants in these studies, their findings directly reflect nursing behaviors, documentation language, and the patient experience of nursing care. Their inclusion is consistent with the scoping review’s objective to map the breadth of evidence on how nursing-related factors influence care quality for patients with SUDs and OUD.

Inclusion criteria

Studies were included if they met all of the following criteria:

1. Focused on nursing attitudes, perceptions, stigma, knowledge, or educational interventions related to patients with SUDs or OUD.

2. Involved registered nurses, psychiatric nurses, student nurses, or advanced practice nurses as primary participants or subjects of the intervention; OR examined nursing-related clinical behaviors, documentation practices, or patient-reported experiences of nursing care that directly pertain to nurses’ roles and responsibilities in caring for patients with SUDs or OUD.

3. Reported measurable outcomes pertaining to nursing practice, nurse-patient interactions, clinical documentation, or patient-reported experiences of nursing care.

4. Published in English between January 2018 and January 2026.

5. Peer-reviewed primary research studies, including qualitative, quantitative, and mixed-methods designs.

Results

Overview of included studies

The 12 included studies were published between 2019 and 2026, predominantly originating from the United States (n = 10), with one study conducted in France [16] and one in Canada [17]. Study designs were heterogeneous, encompassing qualitative approaches (grounded theory, qualitative content analysis, exploratory focus groups, retrospective chart review), a quasi–experimental pre–post–test design, a retrospective cohort study, and a narrative review with empirical evidence synthesis. Sample sizes ranged from 10 participants [14] to 691 nurses [16].

Thematic synthesis

Thematic synthesis of the 12 included studies yielded five overarching themes, as conceptually illustrated in Fig. 2: (1) the pervasiveness and multidimensional nature of nursing stigma toward patients with SUDs/OUD; (2) antecedents and contextual drivers of stigmatizing attitudes; (3) the impact of stigma and language on clinical outcomes and care quality; (4) patient perspectives on stigmatized care; and (5) educational and organizational interventions for stigma reduction. Critically, when stigma is effectively mitigated through educational interventions, language reform, and systemic organizational change, the model posits that the downstream consequence is Improved Care Quality manifested through equitable treatment access, enhanced therapeutic relationships, person‑centered clinical practices, and improved patient outcomes [9, 13, 17, 20, 22].

Fig. 2.

Conceptual synthesis of stigma impact on care quality and patient outcomes

Theme 1: Pervasiveness and multidimensional nature of nursing stigma

Stigmatizing attitudes toward patients with SUDs and OUD were identified as a consistent and pervasive finding across the included studies. Nurses across diverse clinical settings demonstrated negative perceptions, moralistic judgments, and avoidance behaviors toward this population [8, 13, 15]. Stigma was documented at multiple levels simultaneously, individual, professional, organizational, and structural, and manifested through interpersonal behavior, clinical decision-making, and the language embedded in clinical documentation [9, 22]. Table 2 provides a cross-study overview of the settings, populations, and documented forms of stigma identified in Theme 1.

Table 2.

Documented forms and clinical manifestations of nursing stigma across included studies

Study	Setting	Population	Documented Form of Stigma	Clinical Manifestation
Ginther & McNally (2024) [13]	Acute care / nursing practice (USA)	Nurses (narrative review)	Labeling, pejorative language, identity-first terminology	Dismissal of patient pain; use of terms “junkie,” “addict,” “drug-seeking” in documentation and verbal communication
Vottero et al. (2023) [15]	Multiple inpatient settings (USA)	691 registered nurses	Attitudinal stigma at individual, professional, and institutional levels	Reduced empathy; avoidance behaviors; compromised care practices; embedded in professional culture
Horner et al. (2019) [8]	Inpatient medical center (USA)	22 inpatient nurses	Moral judgment; safety concerns; therapeutic avoidance	Internal ethical conflict (“a war with yourself”); inadequate pain assessment; labeling patients as “manipulative” or “drug-seeking”
Lewis & Jarvis (2019) [18]	Clinical rotations – maternity and inpatient settings (USA)	11 undergraduate nursing students	Internalized bias; witnessed discriminatory care from supervisors	Avoidance of OUD discussion; replication of supervising nurses’ stigmatizing behaviors; strongest in maternity settings
Isbell et al. (2023) [21]	Emergency departments (USA)	86 ED clinicians (41 nurses)	Premature clinical closure; diagnostic overshadowing; emotional burnout	Self-perpetuating cycle: negative attitudes → emotional exhaustion → diagnostic errors → reinforced stigma
Carpenter et al. (2023) [9]	Inpatient medical services, 4 academic health systems (USA)	328 hospitalized patients with OUD	Stigmatizing documentation language	“Abuse” used in 68% of discharge summaries; “use disorder” in only 23%
Hirshman et al. (2025) [22]	Tertiary academic medical center (USA)	48 patients with OUD (96 EHR notes)	Provider-generated and system-generated stigmatizing language in EHR	434 stigmatizing vs. 47 affirming language occurrences (9:1 ratio); “drug abuse language” (n = 154), identity-first language (n = 83)
Bertrand & Morvillers (2025) [16]	Public psychiatric hospital (France)	11 PMH nurses	Therapeutic passivity; perceived futility	Withdrawal of therapeutic engagement; “waiting for patient’s will to change to emerge” as central care orientation

Abbreviations: ED – Emergency Department; EHR – Electronic Health Record; OUD – Opioid Use Disorder; PMH – Psychiatric Mental Health; USA – United States of America

Theme 2: Antecedents and contextual drivers of stigmatizing attitudes

The included studies consistently identified knowledge deficits and inadequate clinical education as the primary antecedents of stigmatizing attitudes among nurses and nursing students. Ginther & McNally (2024) [13] emphasized that nurses frequently hold the common misconception that addiction is a moral failing or a matter of personal choice rather than a complex chronic brain disease and that this misunderstanding is perpetuated by a lack of formal addiction education in nursing curricula. Vottero et al. (2023) [15] operationalized this finding within the Substance Use Disorder Nursing Attitude Model (SUDNAM), which positions contextual factors, including the type and depth of prior education and both professional and personal experience with addiction, as the foundational antecedents of nursing attitudes. Nurses who had personal or familial experience with SUD demonstrated markedly higher levels of empathy toward patients, suggesting that experiential proximity to addiction can attenuate stigmatizing tendencies.

Negative professional socialization and peer modeling were identified as additional drivers of stigmatizing attitudes, particularly among student nurses. Lewis & Jarvis (2019) [18] documented that undergraduate nursing students frequently absorbed pejorative language and dismissive behaviors from supervising registered nurses in clinical settings, normalizing stigma as an acceptable component of professional culture. Horner et al. (2019) [8] similarly noted that the organizational culture of inpatient units characterized by inadequate protocols, limited role support, and minimal addiction-specific training created an environment in which stigmatizing attitudes were reinforced rather than challenged. In emergency department settings, Isbell et al. (2023) further identified systemic and logistical pressures, including overcrowding, high patient acuity, time constraints, and limited access to psychiatric and addiction consultation resources, as powerful contextual factors that amplified pre-existing negative biases [21]. In the psychiatric context, Bertrand & Morvillers (2025) [16] found that Psychiatric and Mental Health Nurses (PMH) nurses experienced profound feelings of powerlessness and therapeutic futility when caring for patients with co-occurring disorders who were in pre-contemplative stages of change, a form of learned helplessness that may contribute to withdrawal of care engagement and, by extension, stigmatizing dynamics.

Theme 3: Impact of stigma and clinical language on care quality and patient outcomes

Converging evidence across the included studies demonstrated that nursing stigma has direct, measurable adverse consequences for the quality of clinical care delivered to patients with SUDs and OUD. Stigmatizing attitudes were linked to a range of suboptimal clinical behaviors, including inadequate pain assessment and management, avoidance of therapeutic communication, premature discharge, and failure to engage patients in addiction-specific treatment planning [8, 9, 21] (Table 3).

Table 3.

A structured synthesis of the clinical and outcome-level consequences of stigma and language documented across the included studies

Study	Type of Stigma / Language Behavior	Outcome Measured	Key Finding	Statistical Evidence
Carpenter et al. (2023) [9]	Non-stigmatizing (“use disorder”) vs. stigmatizing (“abuse”) language in discharge summaries	OUD treatment plan documentation; addiction-specific follow-up referral	Use of person-first language associated with significantly higher odds of treatment planning and referral	OUD treatment plan: AOR = 5.21 (95% CI: 2.28–11.89); Addiction referral: AOR = 2.47 (95% CI: 1.36–4.47)
Hirshman et al. (2025) [22]	Stigmatizing vs. affirming language in EHR admission and discharge notes	Frequency and type of language categories across 96 clinical notes	Stigmatizing language overwhelmingly predominated; one-third system-generated	434 stigmatizing vs. 47 affirming occurrences; 92.7% of notes contained stigmatizing language
Horner et al. (2019) [8]	Stigmatizing attitudes and organizational culture	Pain management quality; therapeutic communication; nurse burnout	Stigma produced internal ethical conflict, inadequate pain assessment, and clinical avoidance	Qualitative 6 themes including “a war with yourself” around pain management
Isbell et al. (2023) [21]	Stigma-driven care dynamics in the ED	Diagnostic accuracy; care coordination; clinician well-being	Cyclical model: stigma → emotional exhaustion → premature closure → reinforced negative attitudes	Qualitative grounded theory cyclical model of challenging care dynamics
Bertrand & Morvillers (2025) [16]	Therapeutic passivity in the face of patient ambivalence	Therapeutic relationship quality; care engagement	Nurses’ passive stance led to disengagement from care and loss of therapeutic opportunities	Qualitative core grounded theory category: “waiting for a patient’s will to change to emerge”
Balmuth et al. (2024) [19]	Perceived bias, labeling, and inhumane treatment from providers	Patient trust; willingness to engage in care; emotional well-being	Stigmatizing care profoundly eroded patients’ trust and desire to seek future care	Qualitative/ descriptive: 4 dimensions of negative care experience identified
McCurry et al. (2023) [14]	Stigmatizing language and labeling by nurses	Patients’ perceived care quality; treatment engagement; access to services	Nurses identified as key gatekeepers; stigmatizing language reported as a major barrier to care	Qualitative focus group 8 thematic domains; labeling and inequitable care most prominent

Abbreviations: AOR – Adjusted Odds Ratio; CI – Confidence Interval; ED – Emergency Department; EHR – Electronic Health Record; OUD – Opioid Use Disorder

Theme 4: Patient perspectives on stigmatized nursing care

Two studies examined the experiences of patients with SUDs and OUD from the recipients’ perspective, providing critical insights into the human consequences of healthcare stigma. Balmuth et al. (2024) [19], in a qualitative descriptive study of 15 hospitalized patients with confirmed SUD diagnoses, identified three core components of positive care experiences: perceived clinical and emotional proficiency, therapeutic partnership, and individualized care, alongside four dimensions of negative care experiences: perceived bias, stigmatizing assumptions (including labeling as “drug-seeking”), clinical inefficiency, and inhumane treatment. Patients described being dismissed, dehumanized, and emotionally harmed by providers’ negative attitudes, with these experiences directly eroding trust and willingness to engage in future care.

McCurry et al. (2023) [14], in a qualitative focus group study with 10 individuals from the OUD community, including persons in recovery, family caregivers, and peer support leaders, identified eight thematic domains of care experience, among which stigmatizing language, labeling, and inequitable care were the most prominently reported barriers to treatment engagement. Participants explicitly identified nurses as occupying a pivotal position in either facilitating or impeding access to quality care and expressed that nurses’ use of person-first language and non-judgmental communication was perceived as a meaningful marker of respect and competence. Both patient-centered studies underscore that the consequences of provider stigma are experienced directly and acutely by patients, contributing to treatment avoidance, self-stigmatization, and disengagement from healthcare systems.

Theme 5: Educational and organizational interventions for stigma reduction

A subset of included studies examined evidence-based interventions aimed at reducing stigmatizing attitudes and improving nurses’ capacity to deliver quality care to patients with SUDs and OUD. Table 4 provides a structured comparison of the interventions evaluated, their target populations, key components, and outcomes.

Table 4.

Educational and organizational interventions for stigma reduction among nurses and nursing students

Study	Intervention	Target Population	Setting	Key Components	Primary Outcome	Key Result
Jenkins et al. (2022) [17]	Enhancing Concurrent Disorder Care Intervention (1-day educational workshop)	76 nurses and student nurses	5 acute mental health units + 2 nursing schools, British Columbia, Canada	Didactic sessions + patient lived experience integration	Knowledge, attitudes, and role adequacy in caring for patients with concurrent disorders	Significant improvement in all domains; largest effect in Role Adequacy (Cohen’s d = 1.10); student nurses improved more than practicing nurses
Quaye et al. (2020) [20]	SBIRT education + community home health clinical practice (4-hour online module + family assessment)	488 undergraduate BSN students	Community home health settings + California State University, Fullerton	SBIRT training, motivational interviewing, AUDIT-10 screening, clinical application	SBIRT knowledge (SBIRT Knowledge Instrument) and negative attitudes (SAAS)	Significant increase in SBIRT knowledge (t = 5.24, p < .001; Cohen’s d = 0.28); significant reduction in negative attitudes (t = 3.30, p < .001); improvements consistent across all demographic groups
Ginther & McNally (2024) [13]	Multilevel stigma mitigation framework (narrative review with evidence synthesis)	Nursing students and practicing nurses	Nursing education and clinical practice (USA)	Person-first language, implicit bias training, addiction neurobiology education, case-based learning	Reduction of stigmatizing language and behaviors; improvement in person-centered care	Evidence-based multilevel approach recommended; language reform and implicit bias training identified as immediately implementable, high-impact strategies
Vottero et al. (2023) [15]	SUDNAM model-guided SUD sensitivity training (conceptual framework for intervention design)	Registered nurses across practice settings	Multiple inpatient settings (USA)	Cognitive (addiction science) + affective (empathy-building, patient narratives) components	Nursing attitudes and patient care quality (via SUDNAM model)	Integrated training addressing both knowledge deficits and empathic dimensions required; nurses with personal SUD experience showed greater empathy, informing curriculum design
Horner et al. (2019) [8]	Organizational culture change + structured addiction training (recommendations)	Inpatient nurses	Urban academic medical center (USA)	Addiction consults services, standardized pain protocols, role support structures	Nursing attitudes, pain management quality, care coordination	Organizational environment identified as a key determinant of stigma; structural and cultural reform necessary alongside individual education

Abbreviations: AUDIT-10 – Alcohol Use Disorders Identification Test (10-item version); BSN – Bachelor of Science in Nursing; SAAS – Substance Abuse Attitude Survey; SBIRT – Screening, Brief Intervention, and Referral to Treatment; SUD – substance use disorder; SUDNAM – Substance Use Disorder Nursing Attitudes Model; USA – United States of America

Discussion

Principal findings in context

This scoping review synthesized evidence from 12 peer-reviewed studies published between 2019 and 2025, identifying a robust and consistent body of literature that documents the pervasiveness, antecedents, and clinical consequences of nursing stigma toward patients with SUDs and OUD. The principal finding of this review is that stigmatizing attitudes are not incidental or isolated phenomena but rather deeply embedded features of nursing culture, professional socialization, and healthcare organizational structures, with tangible, measurable adverse consequences for the quality of care that this population receives. This pattern is consistent with the broader literature on health professional stigma toward patients with substance use disorders, which has documented stigmatizing attitudes across nursing, medicine, and allied health professions internationally. More recently, Idrees et al. (2026) reported persistent stigma and structural barriers in the context of opioid use disorder among cancer patients, further underscoring the systemic nature of stigma across different clinical populations and settings [23]. The convergence of evidence from qualitative and quantitative studies across diverse healthcare settings, including emergency departments [21], inpatient medical units [9, 22], psychiatric facilities [16], and academic nursing programs [17, 18, 20], indicates that the problem is systemic and not confined to any particular clinical specialty or country. The cross-national nature of these findings, spanning studies from the United States, France, and Canada, suggests that healthcare stigma toward patients with SUDs reflects broader sociocultural and professional norms that transcend individual healthcare systems, a conclusion that underscores the urgency of a coordinated, system-level response.

Nursing stigma as a structural and cultural problem

The evidence synthesized in this review challenges simplistic conceptualizations of nursing stigma as a product of individual moral failings or personality traits and instead positions it as a structural and cultural phenomenon rooted in systemic knowledge deficits, negative professional socialization, and inadequate institutional supports. Vottero et al. (2023) [15], through the development of the SUDNAM model, provided a theoretically grounded framework for understanding how contextual factors, particularly the type and quality of prior addiction education and the nature of professional experiences, shape nursing attitudes in predictable and modifiable ways. This model offers an important conceptual contribution establishing that stigma is not immutable, but is instead a product of specific antecedents, that are amenable to targeted intervention. The role of negative professional socialization in perpetuating stigma is particularly well-evidenced in this review. Lewis and Jarvis [18] demonstrated that undergraduate nursing students acquired stigmatizing attitudes and behaviors through direct observation of supervising nurses in clinical settings, representing a concerning intergenerational transmission of a professional stigma culture. This finding resonates with Ginther & McNally (2024) [13], who drew attention to the role of implicit, hidden, and null curricula in nursing education and informal messages about values and norms conveyed by faculty and clinical preceptors constitute a key mechanism through which stigmatizing attitudes become embedded in professional identity. These dynamics carry significant implications for nursing education, suggesting that addressing stigma requires not only explicit curricula reform but also a fundamental transformation of clinical learning cultures. Structural stigma manifested through system-generated EHR language, ICD-10 diagnostic codes, and institutional policies represents an underappreciated but critically important dimension of the problem documented in this review [9, 19]. The finding that one-third of all stigmatizing language identified in patient medical records was generated automatically through EHR dropdown menus and diagnostic coding fields [19] is particularly striking, as it suggests that even providers who are personally committed to person-first communication may inadvertently perpetuate structural stigma through routine EHR use. This calls for institutional-level advocacy directed at EHR vendors, professional medical associations, and health ministries to revise and modernize the language embedded within clinical informatics infrastructure.

Language as a mediator of stigma and care quality

One of the most significant contributions of this review is the accumulation of evidence linking provider language directly to patient outcomes, thereby demonstrating that language is not merely a symbolic consideration but a clinically consequential behavior. The dose-response relationship identified by Carpenter et al. (2023) [9], wherein the use of person-first language was independently associated with a five-fold increase in the odds of a documented OUD treatment plan (AOR = 5.21; 95% CI: 2.28–11.89) and a 2.5-fold increase in addiction-specific follow-up referrals (AOR = 2.47; 95% CI: 1.36–4.47), provides compelling empirical evidence that language both reflects and shapes clinical practice. Hirshman et al. (2025) [22] further extended this evidence base by demonstrating that stigmatizing language overwhelmingly predominates in the clinical documentation of hospitalized patients with OUD, with 434 stigmatizing occurrences compared to only 47 affirming occurrences across 96 reviewed notes.

These findings are theoretically coherent with the social constructivist framework employed by Hirshman et al. (2025) [22], which posits that language is integral to the construction of social reality and identity. When patients with OUD encounter identity-first language such as “addict” or “drug abuser” in their own medical records, as now required under the 21st Century Cures Act (2020), the psychological harm is compounded: stigma is experienced both in live interpersonal interactions and through the permanent written record of those interactions. McCurry et al. (2023) [14] and Balmuth et al. (2024) [19] corroborated this experience from the patient perspective, documenting that stigmatizing language and labeling were among the most potent determinants of patients’ perceptions of care quality, their level of trust in providers, and their willingness to engage in ongoing treatment. The collective weight of this evidence suggests that language reform represents a high-leverage, low-barrier intervention point within a broader strategy for stigma reduction.

Educational interventions: evidence, limitations, and opportunities

The evidence reviewed in this study supports the efficacy of educational interventions in improving nursing knowledge and reducing stigmatizing attitudes toward patients with SUDs and OUDs, with several important qualifications. Jenkins et al. (2022) [17] and Quaye et al. (2020) [18] both demonstrated significant and measurable improvements in knowledge and attitudes following structured educational programs. The quasi-experimental study by Jenkins et al. (2022) reported particularly large effect sizes for gains in role adequacy (Cohen’s d = 1.10) [17], while Quaye et al. (2020) documented significant reductions in negative attitudes across 17 of 25 SAAS (Substance Abuse Attitude Survey) items among 488 BSN students [20]. The consistency of these findings across pre-licensure and practicing nurse populations indicates that educational interventions have broad applicability across career stages. However, several limitations temper the strength of these conclusions. Most educational intervention studies included in this review used single-group pretest–posttest designs without control groups, limiting causal attribution. The long-term durability of attitude change following brief educational interventions also remains insufficiently studied. Vottero et al. (2023) [15] noted that purely knowledge-based approaches are insufficient in isolation and must be complemented by affective and empathy-based components to achieve meaningful and durable attitudinal change. Additionally, Lewis & Jarvis [18] identified the maternity clinical setting as the point of greatest vulnerability and inadequate preparation, suggesting that educational interventions should be delivered prior to first clinical exposure to OUD populations and should include practical communication strategies, simulation-based practice, and explicit preparation for the ethical dilemmas most commonly encountered in these contexts.

Implications for nursing practice, education, and policy

The findings of this scoping review yield several clear and actionable implications across the domains of nursing practice, education, and healthcare policy. For nursing practice, the evidence supports the immediate adoption of person-first, medically appropriate language as a minimum standard of professional conduct in all clinical communication and documentation [9, 13]. Nurses should be encouraged to engage in ongoing implicit bias awareness training, to adopt the brain disease model of addiction as the foundational conceptual framework for caring for patients with SUDs, and to utilize evidence-based screening and intervention tools, such as SBIRT in their clinical assessment practices [20]. The qualitative evidence from Horner et al. (2019) [8] and Balmuth et al. (2024) [19] further supports the integration of patient-centered, individualized, and partnership-based approaches as essential components of competent and ethical nursing practice with this population.

For nursing education, the evidence points strongly to the need for comprehensive, mandatory, and longitudinal SUD education in both pre-licensure and post-licensure nursing curricula [13, 17, 18]. Educational programs should incorporate diverse modalities, including simulation, patient narrative presentations, case-based learning, and clinical placements in addiction treatment settings to address both the cognitive and affective dimensions of stigma [15]. Faculty and clinical preceptors must also be considered as intervention targets, given the well-documented influence of role modeling on students’ professional socialization [18].

For healthcare policy and systems, the structural dimensions of healthcare stigma identified in this review demand responses that exceed the scope of individual behavioral change. Healthcare institutions should audit and reform their EHR systems to remove or replace stigmatizing default language in dropdown selections [22]. Professional bodies and health ministries should advocate for revision of ICD-10 diagnostic language to align with contemporary person-first language standards. The establishment of addiction consult services, development of standardized OUD management protocols, and removal of punitive structural policies are further recommended on the basis of the evidence reviewed [8, 14, 21].

Strengths and Limitations

This scoping review has several notable strengths, including the systematic application of the Arksey and O’Malley (2005) framework refined by Levac et al. (2010) [10, 11], adherence to PRISMA-ScR reporting guidelines, a comprehensive four-database search strategy covering the period from January 2018 to December 2025, and the inclusion of methodologically diverse studies that provide a multidimensional picture of the review topic. However, consistent with scoping review methodology, no formal risk-of-bias appraisal was conducted. The predominance of studies from the United States (n = 10 of 12) limits the geographic generalizability of the findings. The majority of qualitative studies employed small purposive samples, precluding statistical generalization, and the heterogeneity of study designs precluded quantitative meta-analytic synthesis. Furthermore, the review identified only 12 studies meeting the eligibility criteria, representing a relatively limited body of primary evidence. This small number of included studies constrains the breadth of synthesis and limits the generalizability of the conclusions that can be drawn. Accordingly, the findings of this review should be interpreted as a preliminary mapping of the evidence landscape rather than definitive conclusions, and the broad thematic patterns identified herein require confirmation through future primary research with larger, more diverse samples.

Directions for future research

Priority areas for future research include longitudinal studies assessing the durability of attitudinal improvements from educational interventions and their translation into observed clinical practice change; randomized controlled trials of stigma-reduction interventions with active control conditions and long-term follow-up; research conducted in non-Anglophone and lower-resource healthcare systems to assess the cultural specificity or universality of the patterns documented; and intervention studies specifically evaluating the impact of EHR language reform on provider attitudes and patient-reported outcomes.

Conclusion

This scoping review demonstrates that nurses’ stigmatizing attitudes toward patients with substance use disorders (SUDs) and opioid use disorder (OUD) are pervasive, multidimensional, and rooted in knowledge deficits, negative professional socialization, and structural factors, leading to measurable impairments in care quality and patient outcomes. While these findings are derived from a limited body of 12 studies, they reveal consistent patterns that warrant urgent attention from nursing educators, clinicians, and policymakers. Thematic synthesis of 12 studies revealed consistent evidence that person-first language in clinical documentation is associated with significantly higher odds of OUD treatment plans (AOR 5.21, 95% CI 2.28–11.89) and referrals, underscoring language as a modifiable mediator of stigma. Educational interventions, such as SBIRT training and brief workshops, effectively reduce negative attitudes. However, multilevel strategies, including curriculum reform, EHR redesign, and policy changes, are essential for sustainable stigma mitigation and equitable care.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

AOR

Adjusted odds ratio

BSN

Bachelor of science in nursing

CI

Confidence interval

ED

Emergency department

EHR

Electronic health record

ICD-10

International Classification of Diseases, 10th Revision

MOUD

Medications for opioid use disorder

OUD

Opioid use disorder

PMH

Psychiatric and mental health

PRISMA-ScR

Preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews

SAAS

Substance abuse attitude survey

SBIRT

Screening, brief intervention, and referral to treatment

SUD

Substance use disorder

Author contributions

O.A. contributed to conceptualization, methodology, formal analysis, data curation, writing of the original draft, supervision, validation, and project administration. S.D. contributed to methodology, supervision, validation, and writing – review and editing. F.H. contributed to conceptualization, methodology, and writing – review and editing. M.D. contributed to writing – review and editing, project administration, and supervision. L.G. contributed to writing – review and editing. M.H. contributed to writing – review and editing. P.T. contributed to writing – review and editing. All authors read and approved the final manuscript.

Funding

This scoping review received no specific funding from any public, commercial, or not-for-profit funding agency.

Data availability

No primary datasets were generated or analyzed during the current scoping review. All data used in this study were extracted from previously published articles included in the review.

Declarations

Ethics approval and consent to participate

Ethics approval was not required for this scoping review, as it was based entirely on previously published literature and did not involve direct participation of human subjects. Therefore, consent to participate was not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.