Stigma continues to surround mental health nursing, but practitioners are ideally placed to challenge this and change the views of fellow nurses and the public
In this article…
- The concept of courtesy stigma
- Misconceptions about mental health nursing
- Challenging misconceptions and stigma
Inga Heyman is lecturer, School of Nursing and Midwifery, Robert Gordon University, Aberdeen.
Heyman I (2012) Challenging misconceptions about mental health nursing. Nursing Times; 108: 27, 16-17.
There is continuing stigma surrounding mental ill health and mental health nursing. This article examines perceptions of mental health nurses and outlines how one university is working to challenge stigma in the field.
Keywords: Mental health nursing/Stigma/Discrimination
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Files’ section of this page
5 key points
- Misconceptions of mental ill health continue to fuel stigma and discrimination
- The mental health nursing profession is also the subject of many misconceptions
- These misconceptions are found among both the public and fellow nursing professionals
- The mental health nursing profession would benefit from enhancing its “brand”
- The responsibility for challenging misconceptions lies with each member of the mental health nursing community
Stigma and misconceptions are still common among marginal groups; mental ill health continues to be a widely misunderstood phenomenon.
Many researchers have explored the source of mental ill health stigmatisation and how to combat it. Angermeyer et al (2003) argued that a significant contributor to the poor public image of mental illness is the “unequal acceptance or status of mental and somatic illness” - that is, physical and visible illnesses are far easier to understand and sympathise with than mental illnesses. Sharac et al’s (2010) study found that “members of the public would prefer to see care for people with physical health problems safeguarded than that for those with mental health problems”. Yang et al (2010) found that mental ill health is matched only by HIV/Aids in terms of public stigmatisation.
All this begs the question: how can such stigma be overcome? Charities such as Mind (www.mind.org.uk) and See Me (www.seemescotland.org) have used education to combat stigma. Creating opportunities for members of the public to meet people with mental ill health is another strategy for enhancing understanding and acceptance (Corrigan and Watson, 2002).
It is my view that health professionals who work with mental health service users have long been the subject of misconceptions in the public sphere and among peers. I also believe mental health nurses - the vast majority of whom are at the front line, challenging stigma on a daily basis - are ideally placed to join, and even lead, the campaign against stigma.
While the effects of stigma on those experiencing mental ill health have been studied for decades, relatively little is known about the effects on those treating them (Ng et al, 2010; Angermeyer et al, 2003; MacRae, 1999). A useful model in explaining these effects is the concept of “courtesy stigma”, that is, stigma by association.
Courtesy stigma is said to exist as there is “a tendency for stigma to spread from the stigmatised individual to his [sic] close connections” (Goffman, 1963). These people “are obliged to share some of the discredit of the stigmatised person to whom they are related” (Goffman, 1963).
In her study of courtesy stigma and the relatives of those with Alzheimer’s disease, MacRae (1999) described the ability of certain people to reject stigma by accessing “strategic resources”. As an example, she stated that interpreting “a potentially stigmatising condition as a legitimate medical illness is one strategic resource” (MacRae, 1999). As such, it may be that the medical model of mental health treatment affords professionals the “strategic resource” they need to distance themselves from the “first-degree stigma” that service users experience and the courtesy stigma that those closest to them experience.
Certainly, when thinking of “the psychiatrist”, for example, one thinks of science, professionalism and prestige. However, I would argue that this does not extend in full to mental health nurses. It may be that there is something about the therapeutic model of mental health treatment interventions that brings them closer to stigmatisation.
Box 1. A former student’s view (on challenging stigma)
Daniel Warrender, 29, studied mental health nursing at Robert Gordon University. He now works in an adult acute admission ward at Royal Cornhill Hospital, Aberdeen.
“Throughout my studies and career so far it has been clear there are still many misconceptions of mental health nursing and patients - the expectation of violence as a daily feature of my job is still, without a doubt, a strong one. In my spare time I practise kung fu and during one training session received a black eye; I was surprised by how many people assumed I’d received the injury at work.
“I think the most powerful tool we have in changing these misconceptions is challenging stigma as it arises. Advertising campaigns are all very well, but it’s in conversation with the general public that, as professionals, we can address these misconceptions and negative stereotypes.”
Perceptions of mental health nurses
In higher education and healthcare it is widely recognised that mental health nursing is one of the most challenging in terms of recruitment. Appreciation of the roles and skills of mental health nurses is relatively low, as is their media profile.
Ng et al (2010) argued that courtesy stigma is a reality among mental health nurses - not by their association to those with mental illness but by association to society’s view of mental illness in general. Drawing on the research of others, they suggested mental health nurses are often viewed by the public as corrupt, evil and mentally abnormal.
The researchers also observed misconceptions of the profession among their nursing peers, namely that:
- It is a less desirable career choice compared with other sectors;
- It is not seen as a specialty with a complex knowledge and skill base;
- The knowledge and skills required to practise are “soft”;
- There is little opportunity for future professional growth;
- It should be left to the end of a nurse’s career after gaining specialised skills and rewarding experiences in other sectors (Ng et al, 2010).
While I would challenge the perception of mental health nurses as “corrupt” and “evil”, I would support the findings about our reputation among our peers. Is it time for a complete rebranding of mental health nursing?
There is evidence of support at governmental level to boost the public image of the nursing profession. For example, the Extraordinary, Everyday initiative aims to promote an aspirational image of 21st-century nursing and midwifery (NHS Education for Scotland, undated).
While such initiatives help, I believe the responsibility for brand boosting and raising awareness of the profession lies predominantly at the level of individual practitioners. This sentiment is reflected in the most recent standards for pre-registration nursing, which identified that “sometimes the public image of nursing fails to reflect the full range and complexity of current nursing work” (Nursing and Midwifery Council, 2010).
The new standards outlined clear competencies for contemporary health practice. Many of these directly address the ways in which mental health nursing, among other fields, can better meet people’s health needs today and in the future (NMC, 2010). A number of these standards seek to rectify the areas where nursing is open to criticism and stigma arises.
In the section directly relating to the specific competencies of mental health nursing - of which there are 22, compared with the nine field-specific competencies of adult nursing - the NMC (2010) stated that:
- Practitioners must “promote mental health and wellbeing, while challenging the inequalities and discrimination that may arise from or contribute to mental health problems”;
- They must “help raise awareness of mental health, and provide advice and support in best practice in mental health care and treatment to members of the multiprofessional team and others working in health, social care and other services and settings”.
This sends a clear signal to all that measurable change in the misconceptions surrounding mental health and its related professions is only achievable if everyone does their bit. For mental health professionals, this means fostering positive, therapeutic relationships with patients, their families and friends, plus members of the public.
At Robert Gordon University we seek opportunities wherever possible to weave this into the fabric of our programmes. The following are a few examples of current activities within our nursing, midwifery and schools engagement programmes:
- We work with pre-registration mental health students to bolster themselves against discrimination and look at strategies to challenge patient and staff stigma;
- We conduct regular school visits and host “aspire days” to give pupils an insight into the breadth of mental health nursing responsibilities and the environments in which practitioners work;
- Our nursing summer and autumn schools offer young people the chance to meet mental health nursing practitioners and service users in real-life settings;
- We have designed an innovative “hub and spoke” placement programme, which allows students to follow the patient journey and enhances their holistic understanding of mental ill health and patient experience.
I believe mental health nurses should be standing shoulder to shoulder with activists and academics, creating a wider appreciation of mental health conditions and the people behind them. It is by challenging the stigma of mental ill health that we will change the misconceptions of the profession.
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Angermeyer MC et al (2003) Courtesy stigma. A focus group study of relatives of schizophrenia patients. Social Psychiatry and Psychiatric Epidemiology; 38: 593-602.
Corrigan PW, Watson AC (2002) Understanding the impact of stigma on people with mental illness. World Psychiatry; 1: 1, 16-20.
Goffman E (1963) Stigma. Englewood Cliffs, NJ: Prentice Hall.
MacRae H (1999) Managing courtesy stigma: the case of Alzheimer’s disease. Sociology of Health and Illness; 21: 1, 54-70.
Ng S et al (2010) Growing practice specialists in mental health: addressing stigma and recruitment with a nursing residency programme. Nursing Leadership; 23: 101-112.
NHS Education for Scotland (undated) Nursing and Midwifery. Extraordinary, Everyday.
Nursing and Midwifery Council (2010) Standards for Pre-Registration Nursing Education.
Sharac J et al (2010) The economic impact of mental health stigma and discrimination: a systematic review. Epidemiologia e Psichiatria Sociale; 19: 3, 223-232.
Yang LH et al (2010) Stigma of mental illness. In: Patel V et al (eds) Mental and Neurological Public Health: A Global Perspective. London: Elsevier.