I attached the article to be used in the previous comment. Also 2-3 pages of APA format
a).Introduction
Establishes purpose of paper
Captures attention of readerb)Article SummaryStatistics to support significance of the topic to mental health careKey points of the articleKey evidence presentedExamples of how the evidence can be incorporated into your nursing practicec)Article CrtiquePresent strengths of the articlePresent weakness of the articleDiscuss if you would/would not recommend this article to a colleagued)ConclusionProvides analysis or synthesis of information within body of the textSupported by ides presented in the body of the paper is clearly written Archives of Psychiatric Nursing 32 (2018) 802–808
Contents lists available at ScienceDirect
Archives of Psychiatric Nursing
journal homepage: www.elsevier.com/locate/apnu
Stigma towards people with mental disorders: Perspectives of nursing
students
T
⁎
Ellaisha Samari , Esmond Seow, Boon Yiang Chua, Hui Lin Ong, Edimansyah Abdin,
Siow Ann Chong, Mythily Subramaniam
Research Division, Institute of Mental Health, Singapore
Stigma towards people with mental disorders is highly prevalent
and often leads to negative impact on their lives (Alonso et al., 2008;
Corrigan and Watson, 2006). According to The World Health
Organization (2001), stigma signifies a ‘mark of shame, disgrace, or
disapproval’. The negative consequences of stigmatizing attitudes include ‘being rejected, discriminated against and excluded from participating in a number of different areas of society’. Furthermore, being
stigmatized not only affects the psychological well-being and development of people with mental disorders, but also acts as a significant
barrier to seeking, accessing and adherence to treatment (Link and
Phelan, 2006).
Prior research studies have generally revealed continued misconceptions about mental disorders amongst various populations. In
their review of population studies, Angermeyer and Dietrich (2006)
found that a significant proportion of the public were unable to recognize specific mental disorders and their respective causes. They also
perceived people with mental disorders as unpredictable and dangerous. These perceptions contributed to increasing desire to distance
themselves from people with mental disorders. Notably, research has
also shown the presence of a hierarchy of stigma within mental disorders diagnoses where more stigmatizing attitudes are directed towards people with schizophrenia as compared to other mental disorders
such as mood or anxiety disorders (Griffiths et al., 2006).
Stigmatizing attitudes towards people with mental disorders are not
restricted to only uninformed members of the general public.
Healthcare professionals also endorse stereotypical beliefs about people
with mental disorders (Jorm et al., 1999; Ross and Goldner, 2009).
These stigmatizing attitudes amongst mental healthcare professionals
can act as barriers to those seeking treatment and hence need to be
broken down. Essentially, healthcare professionals, especially nurses,
play a key role in the mental healthcare system (Harborne and Jones,
2008). Being on the frontline of healthcare, they are responsible for the
bulk of direct care for patients (Baker, Richards, and Campbell, 2005)
and have a profound effect on the therapeutic relationship as well as
treatment outcomes of patients with whom they interact. Furthermore,
given their high contact and experience with patients, nurses are well
positioned to ameliorate stigmatizing attitudes amongst the public
⁎
(Happell, 2005). Harbouring negative views towards people with
mental disorders may thus be challenging as these would influence the
way nurses view their patients and the nature of their work itself
(Enarsson, Sandman, and Hellzen, 2007), which may not only affect
their role as an advocate in reducing stigma, but also hinder the development of therapeutic relationship with patients (Kameg, Mitchell,
Clochesy, Howard, and Suresky, 2009).
Therefore, nursing education and placements carry great responsibilities in shaping the attitudes that are held by nursing students towards people with mental disorders. By providing enough depth and
exposure to theoretical and practical knowledge, a more positive attitude towards mental health nursing could be expected. This would
subsequently prepare them for a nursing profession in the mental health
field (Happell, 1999). Whether nursing students eventually pursue a
career in psychiatric nursing or other areas of nursing, they would most
likely encounter patients with mental disorders. Being on the practice
front, it is thus imperative that nurses have a positive attitude towards
patients who have mental disorders. Furthermore, discovering the extent of stigma is fundamental to gaining insights into the current stereotypes that could subsequently be addressed and further clarified
during nursing education and placements. Ultimately, an understanding
of nursing students’ attitudes would aid in shaping nursing education.
Singapore has twenty-one accredited nursing programmes as of
December 2015 (Singapore Nursing Board, 2016), including degree in
nursing, diploma in nursing, and others. Mental health nursing curriculum differs across programmes based on the objectives they have set
out for their students. Nonetheless, nursing students across these programmes are required to complete a mental health module and subsequently undergo a clinical placement in a mental health facility. Nursing students typically undergo their placements in a tertiary
psychiatric hospital for a span of two weeks in an inpatient ward setting
– acute care or long stay ward.
While a recent population-wide study explored the extent of stigmatizing attitudes towards people with mental disorders in Singapore
(Subramaniam et al., 2016), there is no previous study that compared
attitudes amongst nursing students across different types of mental
disorders and examined the extent of stigma amongst nursing students
Corresponding author at: Research Division, Institute of Mental Health, Buangkok Green Medical Park, 10 Buangkok View, 539747, Singapore.
E-mail address: Ellaisha_SAMARI@imh.com.sg (E. Samari).
https://doi.org/10.1016/j.apnu.2018.06.003
Received 5 June 2017; Received in revised form 19 March 2018; Accepted 2 June 2018
0883-9417/ © 2018 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Archives of Psychiatric Nursing 32 (2018) 802–808
E. Samari et al.
3 = neither agree nor disagree, 4 = disagree, 5 = strongly disagree).
Higher scores suggest a more stigmatizing attitude. Cronbach’s α for the
personal stigma scale was 0.647.
The Social Distance Scale (SDS) (Link, Phelan, Bresnahan, Stueve,
and Pescosolido, 1999) was used to assess respondents’ self-reported
willingness to have contact with the person depicted in the vignette.
Specifically, respondents rated their willingness to 1. move next door to
the person in the vignette; 2. spend an evening socialising with the
person; 3. make friends with the person; 4. work closely on a job with
the person; and 5. have the person marry into the family. Ratings for
each item were measured on a 4-point scale (1 = definitely unwilling,
2 = probably unwilling, 3 = probably willing, 4 = definitely willing).
Lower scores suggest greater social distance desired by respondents.
Cronbach’s α for this scale was 0.827.
A similar vignette-based approach and measurement tool was used
in a previous population-based study conducted by Subramaniam et al.
(2016) in Singapore. Factor analysis done on these measurement tools
suggested a two-factor structure of the depression stigma scale (‘weaknot-sick’ and ‘dangerous-unreliable’), consistent with a study done by
Yap, Mackinnon, Reavley, and Jorm (2014), and a one-factor structure
for social distance scale (‘social distance’). The first dimension ‘weak
not sick’, comprised three items (PS1–PS3). These items describe the
problem which the person depicted in the vignette is experiencing as a
form of personal weakness that is within his/her control as opposed to
it being a medical condition. The subsequent four items (PS4, PS5, PS6
and PS8) formed the second dimension ‘dangerous/unpredictable’.
These items describe the person depicted in the vignette as one who is
dangerous and whom is best avoided. The third dimension ‘social distance’ comprised all the five items from the social distance scale
(SD1–SD5) which loaded strongly into a single factor. Following the
aforementioned population-based study, the total score for each of the
three dimensions were calculated by summing all the items in each
dimension. For ‘dangerous/unpredictable’ dimension, item (PS7) ‘if I
had a problem like [vignette] I would not tell anyone’ was excluded
from the calculation. All 5 items from the ‘social distance’ factor were
reversed coded before they were summed together. Higher scores for
each dimension represent more stigmatizing attitudes towards mental
illness.
in Singapore towards people with mental disorders. Furthermore, a
limited number of studies have examined nursing students’ attitudes
towards people with mental disorders across various types of mental
disorders in Asia. This study could thus contribute to the dearth of this
research in this region.
Using a vignette approach, the present study aims to (i) examine the
extent of overall stigma towards people with mental disorders (depression, obsessive compulsive disorder (OCD), schizophrenia, dementia and alcohol abuse) as well as to (ii) examine factors that correlate with the stigma dimensions amongst the nursing student
population in Singapore.
Methodology
Design and sample
In this cross-sectional study, an online web survey tool
QuestionPro® was used to collect data from a sample of nursing students in Singapore. Ethical approval was granted by the National
Healthcare Group Domain Specific Review Board in Singapore. The
target population included students from four public nursing institutions in Singapore. Once permissions were granted from the corresponding institutions, mass email invitations were sent to these nursing
students to invite them to partake in the study. Enclosed in the email
was a link that directed potential participants to an online portal where
screening questions were asked to assess their suitability for the study.
These included participants’ course of study, nationality, academic year
and institution. Participation quota was based on institutions and academic years. In order to be eligible for the study, participants had to be
nursing students who were enrolled in a public nursing institution in
Singapore during the recruitment period (April 2016 to July 2016) and
be a Singapore citizen or permanent resident. Those who did not meet
the inclusion criteria received an automatic email notifying them of
their ineligibility for this study. Those who met the inclusion criteria
were directed to the online consent form. Participation was voluntary.
By clicking on the ‘agree’ button, participants indicated their willingness to participate in this study. Upon completion, participants were
reimbursed with an inconvenience fee.
Participants were randomly assigned to one of five vignettes describing a person with a mental disorder – (i) alcohol abuse, (ii) dementia, (iii) depression, (iv) OCD or (v) schizophrenia. Vignettes were
adapted from those used in prior studies – ‘depression’ and ‘schizophrenia’ vignettes were adapted from Jorm et al. (1997) while ‘alcohol
abuse’, ‘dementia’ and ‘OCD’ vignettes were adapted from
Subramaniam et al. (2016). Participants were then asked to indicate
their attitudes towards the person described in the assigned vignette
using two different scales – the personal and perceived scale of Depression Stigma Scale (DSS) (Griffiths et al. 2004) and the ‘Social Distance Scale’ (SDS) (Link, Phelan, Bresnahan, Stueve, and Pescosolido,
1999).
Statistical analyses
IBM SPSS Statistics Version 23 was used to conduct all statistical
analyses in this study. Mean and standard error of mean were calculated for continuous variables while frequencies and percentages were
calculated for categorical variables. For descriptive analyses, items on
the personal and perceived stigma scale were recoded and grouped into
three categories; agree, neither agree nor disagree and agree (items
‘agree’ and ‘strongly agree’ were combined into ‘agree’ while ‘disagree’
and ‘strongly disagree’ were combined into ‘disagree’), while items on
the social distance scale were recoded as binary responses; willing and
unwilling (items ‘definitely willing’ and ‘willing’ were combined into
‘willing’ and ‘definitely unwilling’ and ‘unwilling’ were combined into
‘unwilling’).
T-tests and one-way ANOVA tests were conducted to identify differences in mean scores on all three stigma dimensions across these
variables: gender, ethnicity, education level, monthly household income, clinical placement experience, lectures on psychiatry, type of
vignette administered and whether family or friends ever had problems
similar to the person described in the vignette. Multivariate linear regressions were also conducted to examine the associations of the
aforementioned variables with each of the stigma dimensions towards
people with mental disorders. Listwise deletion was used to handle
missing data. All statistically significant results were reported at
p < 0.05.
Instruments
The Depression Stigma Scale (DSS) (Griffiths, Christensen, Jorm,
Evans, and Groves, 2004) which has two subscales (personal and perceived stigma) was developed to measure stigma towards people with
mental disorders. Each subscale has nine items and asks respondents
about their own (personal stigma scale) or their beliefs about others'
attitudes (perceived stigma scale) towards the person who was described as having depression in the vignette. Although originally designed to measure stigma towards depression, the scale can also be used
to measure stigma towards other disorders as described in the relevant
vignettes. Eight out of the nine items of the personal stigma scale were
used in this study, excluding one item “I would not vote for a politician
if I knew they had a mental disorder”. Ratings for each item were
measured on a 5-point Likert scale (1 = strongly agree, 2 = agree,
803
Archives of Psychiatric Nursing 32 (2018) 802–808
E. Samari et al.
Table 1
Sociodemographic characteristics of the study sample
Table 2b
Item endorsement of the Social Distance Scale – social distance.
n
Age
Gender
Ethnicity
Current education
Average monthly household income per
capita over the past 1 year
Clinical placement experience
Lectures
Vignette Type
Family or close circle of friends ever had
problems similar to person described
in the vignette
Mean = 20.1 years
SD = 3.1
Male
Female
Chinese
Malay
Indian
Others
Degree
Diploma and others
Below SGD2000
SGD2000 – 5999
SGD6000 and
above
Yes
No
Yes
No
Depression
OCD
Alcohol abuse
Dementia
Schizophrenia
Yes
No
‘Social distance’ dimension
%
83
417
287
134
60
19
100
400
158
248
94
16.6
83.4
57.4
26.8
12.0
3.8
20.0
80.0
31.6
49.6
18.8
303
197
424
76
100
100
100
100
100
125
375
60.6
39.4
84.8
15.2
20.0
20.0
20.0
20.0
20.0
25.0
75.0
SD1. How willing would you be to move next door to
X?
SD2. How willing would you be to spend an evening
with X?
SD3. How willing would you be to make friends with
X?
SD4. How willing would you be to have X start
working closely with you on a job?
SD5. How willing would you be to have X marry into
your family?
Unwilling
Willing
n
%
n
%
126
25.2
374
74.8
137
27.4
363
72.6
59
11.8
441
88.2
151
30.2
349
69.8
330
66.0
170
34.0
more participants agreed that ‘people with a problem like X’s are unpredictable’ (PS6–47.0%). However, participants were less likely to
agree that the person described in the vignette was dangerous to others
(PS4–18.6%) and should be best avoided in order to avoid contracting
the same disorder (PS5–5%). They were also less likely to agree that
they would not tell someone if they had a similar problem (PS7–21.4%)
and would not employ someone with such a problem (PS8–18.4%).
‘Social distance’ dimension and its pattern of endorsement
Table 2b reports the endorsement of stigmatizing statements in the
‘social distance’ dimension. It reports the percentage of participants
who were either ‘willing’ or ‘unwilling’ to make social contact with the
person described in the vignette for each item on the scale. In general, a
larger percentage of participants were willing to have social contact by
saying that they were willing to: move next door to (SD1–74.8%), spend
an evening with (SD2–72.6%), make friends with (SD3–88.2%) and
work closely on a job with someone who has a mental disorder
(SD4–69.8%). However, the social interaction that participants were
most unwilling to engage in was having the person with a mental disorder marry into their family (SD5–66% were unwilling).
Results
500 nursing students (83 male, 417 female) aged between 16 and
35 years old (M = 20.1, SD = 3.1) completed the study. Table 1 presents the sociodemographic characteristics of the participants.
‘Weak not sick’ dimension and its pattern of endorsement
As seen in Table 2a, percentage difference between participants who
‘agree’ and ‘disagree’ to each item within the ‘weak not sick’ dimension
shows that a larger number of participants endorsed stigmatizing attitudes on items ‘PS1’ as compared to items ‘PS2’ and ‘PS3’. Specifically,
more participants agreed that ‘people with a problem like X could get
better if they wanted to (PS1–77.2%). However, participants were less
likely to agree that ‘a problem like X is a sign of personal weakness
(PS2–23%) and ‘X’s problem is not a real medical illness' (PS3–17.2%).
Stigma dimensions
Descriptive values of the three established dimensions of stigma –
‘weak not sick’, ‘dangerous/unpredictable’ and ‘social distance’ – across
sociodemographic groups are reported in Table 3. Higher mean scores
denote higher level of stigma for all three dimensions.
Multivariate linear regression analyses reported in Table 4 shows
the correlates of variables predicting the three factors of stigma mentioned above. Participants who were Malay (β = 0.578, p < 0.05),
received the ‘depression’ (β = 0.597, p < 0.05) or ‘alcohol abuse’
(β = 0.759, p < 0.05) vignette were significantly associated with
higher ‘weak not sick’ scores while those pursuing a degree in nursing
‘Dangerous/unpredictable’ dimension and its pattern of endorsement
Table 2a also shows that a larger number of participants endorsed
stigmatizing attitudes on items ‘PS6’ as compared to the rest of the
items within the ‘dangerous/unpredictable’ dimension. Specifically,
Table 2a
Item endorsement of the Depression Stigma Scale – personal stigma.
Disagree
Neither agree nor disagree
Agree
n
%
n
%
n
%
‘Weak not sick’ dimension
PS1. People with a problem like X could get better if they wanted to.
PS2. A problem like X's is a sign of personal weakness.
PS3. X's problem is not a real medical illness.
47
219
282
9.4
43.8
56.4
67
166
132
13.4
33.2
26.4
386
115
86
77.2
23.0
17.2
‘Dangerous/unpredictable’ dimension
PS4. People with a problem like X's are dangerous to others.
PS5. It is best to avoid people with a problem like X's so that you don't also get this problem.
PS6. People with a problem like X's are unpredictable.
PS7. If I had a problem like X's I would not tell anyone.
PS8. I would not employ someone if I knew they had a problem like X.
261
412
107
232
227
52.2
82.4
21.4
46.4
45.4
146
63
158
161
181
29.2
12.6
31.6
32.2
36.2
93
25
235
107
92
18.6
5.0
47.0
21.4
18.4
804
Archives of Psychiatric Nursing 32 (2018) 802–808
E. Samari et al.
Table 3
Descriptive statistics of stigma dimensions by sociodemographic factors.
Weak not sick
Mean
Overall
Gender
Male
Female
Ethnicity
Chinese
Malay
Indian
Others
Average monthly household income per capita over the past 1 year
Below SGD2000
SGD2000–5999
SGD6000 and above
Current education
Degree
Diploma and others
Clinical placement experience
Yes
No
Attended psychiatry lecture
Yes
No
Vignette type
Depression
OCD
Alcohol abuse
Dementia
Schizophrenia
Family or close circle of friends ever had problems similar to person described in the vignette
Yes
No
a
a
S.E.
9.010
0.096
8.840
9.040
0.220
0.110
8.690
9.679
9.267
8.211
Dangerous/unpredictable
p value
Mean
a
S.E.
p value
Social distance
Meana
S.E.
11.226
0.117
p value
10.320
0.119
0.452
10.482
10.288
0.319
0.128
0.545
10.759
11.319
0.291
0.127
0.075
0.126
0.171
0.286
0.527
0.000
10.216
10.634
10.017
10.632
0.161
0.214
0.354
0.636
0.342
11.307
10.873
11.250
12.421
0.160
0.202
0.351
0.520
0.082
9.171
9.105
8.468
0.169
0.130
0.247
0.025
10.304
10.456
9.989
0.216
0.166
0.280
0.351
10.867
11.492
11.128
0.201
0.170
0.265
0.058
7.920
9.277
0.242
0.100
0.000
9.860
10.435
0.244
0.135
0.053
11.070
11.265
0.241
0.133
0.506
9.109
8.848
0.121
0.158
0.185
10.528
10.000
0.160
0.173
0.030
11.436
10.904
0.150
0.185
0.026
9.045
8.789
0.099
0.312
0.342
10.276
10.566
0.130
0.300
0.383
11.210
11.316
0.125
0.325
0.746
9.200
8.860
9.560
8.610
8.800
0.234
0.195
0.206
0.233
0.196
0.015
9.680
9.000
11.270
10.700
10.950
0.229
0.246
0.287
0.247
0.254
0.000
10.710
10.530
11.760
11.030
12.100
0.270
0.246
0.239
0.252
0.269
0.000
8.584
9.147
0.222
0.104
0.011
9.808
10.491
0.238
0.137
0.013
10.304
11.533
0.243
0.130
0.000
Higher mean scores denote higher level of stigma.
stigmatizing attitudes for every item in the ‘weak not sick’ dimension as
compared to Singapore's general population (PS1–89.4%; PS2–50.8%;
PS3–38.5%), based on percentage of those who ‘agree’ to each item in
the scale. In the ‘dangerous/unpredictable’ dimension, the nursing
student population (PS4–18.6%; PS5–5.0%; PS6–47.0%; PS7–21.4%;
PS8–18.4%) were less likely to endorse stigmatizing attitudes on all
items except ‘PS7 (If I had a problem like X's I would not tell anyone) as
compared to Singapore's general population (PS4–35.7%; PS5–10.6%;
PS6–62.5%; PS7–21.4%; PS8–45.3%). In the ‘social distance’ dimension
(Supplementary Table 2), the nursing student population (SD1–25.2%;
SD2–27.4%; SD3–11.8%; SD4–30.2%; SD5–66.0%) were more willing
to have social contact with people who have a mental disorder as
compared to Singapore's general population (SD1–32.4%; SD2–22.4%;
SD3–18.2%; SD4–42.8%; SD5–70.2%), with the exception of item ‘SD2
(How willing would you be to spend an evening with X?)’.
While previous studies have shown that nursing students hold diverse views and attitudes about mental disorders, they were found to be
generally positive in various studies such as those conducted in New
Zealand (Surgenor, Dunn, and Horn, 2005), Hong Kong (Callaghan,
Shan, Yu, Ching, and Kwan, 1997) and across several countries in
Europe (Chambers et al., 2010). However, results of some studies are
contrary to current results. For example, a study in Sweden found that
nursing students did not demonstrate a positive attitude towards persons with mental disorders as compared to their general population
(Ewalds-Kvist, Högberg, and Lützén, 2012).
Taking into consideration participants' age range of 16 to 35 years in
this study, it could perhaps reflect a growing knowledge and understanding about mental disorders amongst the younger age group.
Similarly, previous research studies showed that people from the
younger age group tend to be less stigmatizing when compared to the
ones from the older age groups (Chong et al., 2007; Hayward and
Bright, 1997; Subramaniam et al., 2016). Furthermore, as nursing
(β = −1.175, p < 0.05) and those whose family or close circle of
friends ever had problems similar to person described in the vignette
(β = −0.457, p < 0.05) were significantly associated with lower
‘weak not sick’ scores. Participants pursuing a degree in nursing
(β = −0.639, p < 0.05) and those who had attended psychiatry lectures (β = −0.916, p < 0.05) had lower ‘dangerous/unpredictable
scores’. Male participants (β = −0.711 p < 0.05), those who received
the ‘dementia’ vignette (β = −0.817, p < 0.05) and those whose family or close circle of friends ever had problems similar to the person
described in the vignette (β = −1.003, p < 0.05) were significantly
associated with lower social distance scores. Interestingly, participants
who were presented with either the ‘depression’ (β = −1.072,
p < 0.05; β = −1.019, p < 0.05) or ‘OCD’ vignette (β = −1.879,
p < 0.05; β = −1.495, p < 0.05) were associated with lower ‘dangerous/unpredictable scores’ and ‘social distance’ scores, participants
who had attended clinical placements (β = 0.822, p < 0.05;
β = 0.730, p < 0.05) were associated with significantly higher dangerous/unpredictable and social distance scores.
Discussion
The main purpose of this study was to examine the extent of overall
stigma towards people with mental disorders (depression, OCD, schizophrenia, dementia and alcohol abuse) and factors that were significantly correlated with the stigma dimensions amongst the nursing
student population in Singapore. In general, results from this study are
encouraging as it showed evidence of a relatively low endorsement of
stigmatizing attitudes towards people with mental disorders within the
nursing student population. In fact, when compared against the larger
Singapore population (Subramaniam et al., 2016) as shown in supplementary table 1, the nursing student population in Singapore
(PS1–77.2%; PS2–23.0%; PS3–17.2%) were less likely to endorse
805
Archives of Psychiatric Nursing 32 (2018) 802–808
E. Samari et al.
Table 4
Multivariate linear regression analyses for variables predicting stigma dimensions.
Weak not sick
Gender
Male
Female
Ethnicity
Malay
Indian
Others
Chinese
Average monthly household
income per capita over the
past 1 year
Below SGD2000
SGD2000–5999
SGD6000 and above
Current education
Degree
Diploma and others
Clinical placement experience
Yes
No
Attended psychiatry lecture
Yes
No
Vignette type
Depression
OCD
Alcohol abuse
Dementia
Schizophrenia
Family or close circle of friends
ever had problems similar
to person described in the
vignette
Yes
No
Dangerous/unpredictable
Social distance
β
95% confidence interval
p value
β
95% confidence interval
p value
β
95% confidence interval
p value
−0.206
Ref
−0.698
0.286
0.412
0.092
Ref
−0.510
0.694
0.764
−0.711
Ref
−1.307
−0.115
0.020
0.578
0.305
−0.636
Ref
0.131
−0.289
−1.596
1.025
0.899
0.323
0.011
0.313
0.193
0.221
−0.560
0.338
Ref
−0.326
−1.287
−0.837
0.769
0.167
1.513
0.428
0.131
0.572
−0.525
−0.356
1.158
Ref
−1.067
−1.076
−0.005
0.017
0.363
2.321
0.058
0.331
0.051
0.166
0.167
Ref
−0.380
−0.335
0.711
0.669
0.551
0.513
0.086
0.345
Ref
−0.582
−0.270
0.754
0.960
0.801
0.271
−0.367
0.287
Ref
−1.028
−0.322
0.294
0.895
0.276
0.355
−1.175
Ref
−1.676
−0.674
0.000
−0.639
Ref
−1.253
−0.026
0.041
−0.452
Ref
−1.058
0.155
0.144
0.404
Ref
−0.036
0.845
0.072
0.822
Ref
0.283
1.361
0.003
0.730
Ref
0.197
1.264
0.007
−0.159
Ref
−0.756
0.437
0.600
−0.916
Ref
−1.646
−0.186
0.014
−0.719
Ref
−1.442
0.004
0.051
0.597
0.107
0.759
−0.027
Ref
0.010
−0.465
0.186
−0.610
1.184
0.678
1.331
0.555
0.046
0.714
0.010
0.927
−1.072
−1.879
0.308
−0.032
Ref
−1.790
−2.579
−0.394
−0.745
−0.354
−1.180
1.009
0.681
0.004
0.000
0.389
0.930
−1.019
−1.495
−0.272
−0.817
Ref
−1.730
−2.187
−0.966
−1.523
−0.308
−0.803
0.422
−0.112
0.005
0.000
0.442
0.023
−0.457
Ref
−0.889
−0.025
0.038
−0.521
Ref
−1.050
0.008
0.054
−1.003
Ref
−1.526
−0.479
0.000
lead to changes in attitudes, beliefs and stigma towards them. A literature review done by Couture and Penn (2003) found both personal
and professional contact to be associated with positive attitudes to
mental disorders. In a similar vein, research studies comparing the level
of stigma amongst nursing students before and after psychiatric clinical
placements found that clinical placements helped to foster positive attitudes towards mental health nursing (Happell and Gaskin, 2012) and
that this platform facilitated the demystification of preconceived ideas
and stereotypes that students have towards mental disorders (Schafer,
Wood, and Williams, 2011). Other studies however found no support
for the contact hypothesis. A study amongst nursing students in Hong
Kong showed that previous contact with people with mental disorders
had no significant effect on students' attitudes towards people with
mental disorders (Callaghan, Shan, Yu, Ching, and Kwan, 1997). Another study done by Gras et al. (2014) which investigated stigmatizing
attitudes amongst mental healthcare professionals also found that
personal and work experience in mental health did not influence stigmatizing attitudes towards people with mental disorders. However,
results from our study may perhaps indicate that negative attitudes
towards people with mental disorders were developed during the
clinical placement experience or that negative preconceptions held towards people with mental disorders prior to clinical placements were
hardened during contact with them. A possible explanation for either
interpretation could be due to exposure to situations that nursing students were not fully prepared to face or deal with such as in witnessing
psychotic or violent behaviours from patients, which Fisher's (2002)
study found to contribute to negative experiences reported by healthcare students.
Having a family member or a close friend (close contact) who had
students, they are probably more familiar and knowledgeable about
treatment, causes and outcomes of mental disorders, which may have
led to less stigmatizing attitudes towards people with mental disorders.
In fact, previous research studies reported that familiarity with mental
disorders and people suffering from them was associated with positive
attitudes (Hayward and Bright, 1997; Angermeyer and Dietrich, 2006).
This would have contributed to the development of more informed
perspectives of people with mental disorders which may have decreased
the stigma surrounding mental disorders. Nevertheless, looking at the
level of knowledge alone would be insufficient to form an understanding of nursing students' attitudes towards people with mental
disorders. It is likely that knowledge has an intricate relationship with
other sociodemographic characteristics of individuals. In fact, a study
by Griffiths, Christensen, and Jorm (2008) found that that depression
literacy was inversely related to stigma after controlling for other sociodemographic variables including age and education level. Further
research exploring the relationship of sociodemographic characteristics
with knowledge and subsequently attitudes, would be beneficial in
enriching the literature.
We found that those who had clinical placement experience (professional contact) had significantly more stigmatizing attitudes towards
people with mental disorders on two stigma dimensions: ‘dangerous/
unpredictable’ and ‘social distance’. This showed that these nursing
students were more likely to perceive people with mental disorders as
dangerous and unpredictable, and wanting greater social distance from
them. Prior studies have shown mixed evidence of how contact experience, including having attended clinical placement affects attitudes
towards people with mental disorders. According to Allport's (1954)
contact hypothesis, interaction with people from a different group can
806
Archives of Psychiatric Nursing 32 (2018) 802–808
E. Samari et al.
Nursing education implications
similar problems as the one in the vignette, was significantly associated
with lower stigmatizing attitudes on two stigma dimensions: ‘weak not
sick’ and ‘social distance’. Having a family member or close friend with
a mental disorder may result in increased feelings of empathy and
greater knowledge of the mental disorder itself. Furthermore, associations with persons with mental disorders by family ties or friendships
may have resulted in similar experience of the negative consequences of
mental disorders stigma (Corrigan, Morris, Michaels, Rafacz, and
Rϋsch, 2012) which could have led to greater empathy and hence less
stigmatizing attitudes.
Participants who were presented with the ‘depression’ and ‘alcohol
abuse’ vignette were significantly more likely to perceive the person in
the vignette as ‘weak not sick’ in comparison to those presented with
the ‘schizophrenia’ vignette. Angermeyer, Matschinger, and Schomerus
(2013) found that public attitudes towards people will mental disorders
are disorder specific and there is an increasing difference between attitudes towards schizophrenia and other mental disorders including
their perceived causal attributions. Schizophrenia was more likely to be
attributed to brain disease while depression to stress and alcohol dependence was less likely to be attributed to both brain disease and
negative life events as causes. In another review, Schomerus et al.
(2010) found that the public viewed alcohol-dependent patients as
having more responsibility for their condition and a reflection of
“weakness of character” in contrast to those who are suffering from
schizophrenia and depression. Additionally, those presented with the
‘depression’ vignette were more likely to perceive the person as ‘weak
not sick’ as compared to those presented with ‘schizophrenia’, as they
may have associated depression with psychosocial causes instead of
biological causes, thereby assuming that one could be resilient against
it. By extension, some people believe depression to be associated with a
fluctuation of mood that is within the individual's control as opposed to
it being a disorder (Schomerus, Matschinger, and Angermeyer, 2006),
seeing them as weak and responsible for their own condition (Aromaa,
Tolvanen, Tuulari, and Wahlbeck, 2010).
Participants who were presented with the ‘depression’ or ‘OCD’
vignette reported significantly lower scores on the ‘dangerous/unpredictable’ dimension as compared to those presented with schizophrenia. It was also found that those presented with the ‘depression’,
OCD’ or ‘dementia’ vignette reported significantly lower scores on the
‘social distance’ dimension as compared to those presented with the
‘schizophrenia’ vignette. Previously, Schomerus et al. (2010) found that
participants perceived persons with schizophrenia to be more dangerous and desired greater social distance from them as compared to
those with depression or anxiety disorders. Angermeyer and Dietrich
(2006) found that labels elicited the belief that those who are affected
with schizophrenia are dangerous and unpredictable, and in turn triggers negative emotional reactions such as fear and aggression. This
consequently results in increasing desire for social distance. Notably,
the vignette that participants were presented with did not confirm the
type of diagnosis, only examples of its symptomology. Thus, participants who endorsed stigmatizing attitudes may have done so on the
basis of perceiving the symptoms and behaviours of those with schizophrenia as out of the ordinary, alarming or bizarre.
Male participants were significantly associated with lower social
distance scores as compared to female participants, suggesting that they
are more likely to be willing to make social contact with persons with
mental disorders than the latter participants. Results were not consistent with the few prior studies that explored associations between
gender and stigmatizing attitudes. Some found women to be less stigmatizing than men (Angermeyer, Matschinger, and Holzinger, 1998;
Farina, 1981), while other studies found no significant gender difference (Chou and Mak, 1998). Even though this study showed that male
participants were less likely to desire social distance from people with
mental disorders, the underrepresentation of male participants in this
population is a concern as it makes it difficult to draw conclusions on
gender based differences.
Considering the negative correlation between close contact of
people with mental disorders and stigma in this study, psychiatric
nursing curriculum could focus on creating a closer contact experience
between nursing students and people with mental disorders prior to
clinical placements. Additionally, nursing schools could also review
their preparation methods for students attending clinical placements,
and include managing students' expectations of the institution they
would be attending at for their clinical placements and types of patients
they would be interacting with. This study also showed that stigma
towards mental disorders varies based on its type. Possibly, nursing
schools could effectively reduce stigma towards people with mental
disorders by addressing identified misconceptions of people with each
mental disorder i.e. people with depression or people with schizophrenia in depth rather than addressing it as a single concept i.e. people
with mental disorders.
Strengths and limitations
This study has various strengths including a relatively large sample
size and the use of standardized questionnaires to assess for responses
across multiple disorders, thus aiding to expand the dearth of research
which have analysed differences in nursing students' perception across
various mental disorders. However, the present study has a few limitations. The study is limited to analyses done based on the two scales in
the study – DSS and SDS. There may be other aspects of stigma that
persist amongst nursing students such as behavioural discrimination
that was not measured in this study. Lastly, a vignette-based approach
may not reflect respondents' actual behaviour in real life. Future research should look into conducting qualitative studies that examine
students' experience during clinical placements to explore their influence on attitudes towards mental disorders and gain a more insightful
understanding of their experiences.
Conclusion
While there is relatively low endorsement of stigmatizing attitudes
amongst nursing students in Singapore towards people with mental
disorders, efforts are still needed to address existing stigma towards
certain types of mental disorders. Further exploration into the correlation between nursing education and clinical placements are crucial to
form a better understanding of how these platforms influence the level
of stigma amongst students. Perhaps the psychiatric nursing education
could deal with stigma in a more effective way by addressing misconceptions of individual mental disorders during teaching and clinical
placements as well. Essentially, enriching students' clinical placements
experience would be vital in helping to ameliorate stigmatizing attitudes amongst nursing students.
Conflict of interest
None.
Acknowledgment
The authors would like to thank the schools for allowing us to
conduct the study amongst their students. We also want to thank the
participants for their time and efforts in the study. This research was
supported by the Singapore Ministry of Health's National Medical
Research Council under the Centre Grant Programme (Grant No.:
NMRC/CG/004/2013).
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
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Archives of Psychiatric Nursing 32 (2018) 802–808
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