More than 450 million people suffer from mental disorders worldwide (1, 2), but stigmatizing attitudes toward people with mental disorders (PWMD) are prevalent in the global population (3–6). This is also evident in Chinese culture (7–10). Stigma is “the situation of an individual disqualified from full social acceptance” (11). It reflects an individual’s negative attitude/behavior toward mental disorders (12) and is often divided into personal and perceived stigma. Personal stigma is generally the negative attitudes formed by negative perceptions and emotional experiences of PWMD. Meanwhile, perceived stigma is the derogatory behavior toward and rejection of PWMD by others (13). PWMD can be perceived as dangerous, unpredictable, intellectually disable (3), or personally weak (9, 14–16). Stigmatizing attitudes of PWMD may negatively affect their treatment-seeking behavior, education, social activities, work, and mental health (17). Stigma associated with mental disorders is a significant barrier to accessing mental health services and timely treatment (18–20).

Stigma is common among medical caregivers (19, 21, 22). Such stigmatizing attitudes create severe barriers to good patient-provider communication and quality therapeutic care (19, 23, 24), thereby resulting in delayed help-seeking (24), treatment interruptions, safety concerns (19), and poor prognosis (25, 26). Negative attitudes resulting from caregivers’ lack of experience and knowledge about mental disorders can negatively affect patient interactions and the quality of care (19, 27). Stigma can also negatively affect caregivers’ willingness to seek help or disclose mental health problems (19), and nurses’ stigmatizing attitudes may affect other members of the team and future practitioners (28, 29).

The vital link between stigmatizing attitudes, substance use, and suicidal behavior cannot be ignored, such as cannabis being a relevant risk factor linked to suicidal attempts and behaviors (30).

Medical personnel have the closest contact with patients, and they often encounter patients with mental health problems or psychological crises (31). Fewer than 5% of patients see a psychiatrist first, and more than 70% see a non-mental health professional in general hospitals first (32). Due to these factors, non-mental health nurses in general hospitals are highly likely to come into contact with PWMD and play an essential role in the timely referral of patients to psychiatrists (33). However, nurses cannot better provide appropriate assistance to this population because of their negative attitudes toward mental disorders, lack of identification of PWMD, or lack of skills to assist (34, 35), which further affects the effective treatment, early diagnosis, and effective referral rate of this group of patients, thereby resulting in more extended hospital stays, and patients with mental problems being more prone to doctor-patient disputes (36).

Most published studies have focused on the general public’s attitudes toward mental disorders and people with lived experiences (21). However, there is less research on the extent of stigmatization of people with clinically common anxiety and depression by NMHNs in general hospitals. An Australian study comparing the attitudes of health professionals with those of members of the general community showed that health professionals’ stigmatizing attitudes were comparable to those of members of the general community (37). In addition, a study on the attitudes of Finnish nurses showed positive attitudes (38). A recent study of medical students in 65 countries showed that women and medical and nursing students showed more positive attitudes toward PWMD (22). Meanwhile, a survey of healthcare professionals in Qatar showed that nurses had higher levels of stigma than doctors (25). Moreover, studies in Saudi Arabia and Poland showed that stigmatizing attitudes toward PWMD were common among physicians in tertiary care hospitals (39, 40).

Furthermore, a study in Iran showed that stigmatizing attitudes were higher among internal medicine and cardiology departments than among residents in psychiatry (41). Recently, a Greek study showed that healthcare professionals’ willingness to interact with psychiatric patients is relatively poor, and the prejudice against them is high (42).

In addition, screening for depression in general hospitals can improve the accuracy of detecting depressed patients (43) and the overall treatment of patients (44). Nurses are essential in screening, identification, and referral programs for depression in general hospitals’ physical disease management teams (45, 46). A nurse-based model for early screening of depression in patients with physical illness in general hospitals has been proposed in Korea (46), and there are a few reports on such aspects in China.

Therefore, this study primarily aimed to examine the attitudes and frequency distribution of NMHNs toward PWMD and mental disorders among demographic and occupational characteristics in Chinese general hospitals. Secondly, the study aimed to explore factors associated with morbidity stigma and investigate the current use of depression screening by NMHNs, to provide a basis for further intervention studies.

This study found that NMHN in Chinese general hospitals have stigmatized attitudes toward patients with mental disorders. Factors associated with stigma and sources of acquiring knowledge about mental disorders inform the next steps in developing interventions to provide a better quality of care for patients.

This study explored the stigmatization of PWMD in Chinese general hospital NMHNs. In this study, the mean DSS-Personal Scale score of Chinese general hospitals NMHNs was (17.24 ± 6.700) (Table 2), which was higher than the scores of Chinese medical students (13.71 ± 5.350) (10) and Portuguese community adults (12.71 ± 5.520) (53). This finding suggests that the stigma of personal mental disorders is higher in Chinese general hospital NMHNs.

In addition, the survey analysis found that the detection rate of stigma for mental disorders among the nurses interviewed was significantly lower than in studies related to the stigma of patients and families attending outpatient clinics in Chinese domestic community hospitals (21.5%) (54). However, Swedish nurses’ attitudes toward PWMD are similar to those of the general public (55). A study by Cattell showed that nurses had higher negative attitudes toward PWMD than physicians (25), which may indicate a global phenomenon. Media portrayals of mental disorders may influence nurses toward seeing patients as potentially dangerous, unpredictable, violent, or weak (56).

The findings showed an effect of stigma of mental disorders among nurses interviewed between ages 30–39 years [OR = 1.427 (1.154–1.764), p = 0.001], which is inconsistent with a study on the stigma of depression in the general population in Canada (57).

In the present study, a bachelor’s degree was also an independent influence on the morbid stigma of mental disorders [OR = 0.742 (0.647–0.851), p < 0.001], which is generally consistent with a Greek study (42). Higher levels of education are associated with less stigmatizing attitudes toward PWMD. However, our study showed that having a master’s degree or higher was not an independent influence on the stigma of mental disorders [OR = 0.595 (0.306–1.159), p = 0.127]. However, univariate analysis showed that the prevalence rate of stigma gradually decreased with the increase of education level (7.40% for master’s degrees and higher, 12.10% for bachelor’s degrees, and 15.60% for college and lower). Those with a master’s degree had the lowest detection rate of stigma.

Years of work experience is another critical variable in our data. The highest OR for stigma was found among the nurses surveyed with 11–15 years of work experience [OR = 1.714 (1.247–2.356), p < 0.001] in a U-shape. Moreover, in the univariate analysis, the stigma prevalence rate was highest among the surveyed nurses with 11–15 years of work experience (16.20%). This may be because most undergraduate medical education programs in China are rarely designed with mental health-related course credit hours (58).

In this study, no independent influences on the stigma of mental disorders were found in the department for NMHNs. However, a study in Qatar showed that stigma was highest among emergency department nurses (25). Individuals requiring acute mental disorder care are initially assessed in the emergency department. Thus, nurses’ attitudes can severely impact the quality of patient care (25). A patient’s physical discomfort may be overlooked and attributed to their mental disorder in the emergency department. This diagnostic masking is a high risk for worsening morbidity and potential mortality. It is a significant barrier to help-seeking behavior and may lead to delays in receiving necessary help (25). A Swedish study showed that staff in inpatient units had more negative attitudes than staff in outpatient departments (21). Greater exposure to mental disorders and higher knowledge of mental disorders predicted lower personal stigma and social distance (59).

This study showed that Chinese NMHNs’ overall mean SDS score was (10.34 ± 3.154). Results also found that the willingness to interact with patients with mental illness was highest among young respondents, those with only a few years of experience, those with low education and title, and who were working in secondary hospitals. Interestingly, we found that the willingness to interact with patients with mental illness was lower for head nurses than for nurses. However, stigma prevalence rates were higher for nurses than for nurse leaders. This finding suggests that a high level of contact with patients with mental illness is not necessarily associated with sufficient willingness to interact with these patients, nor does it decisively reduce existing bias (42, 55).

Therefore, results in Figure 1 indicate that people between the ages of 30–39, with 11–15 years of work experience, with college degrees or less, who believe they have sufficient knowledge and are fully capable of assisting people with anxiety and depression, and who do not believe it is necessary to acquire the skills to identify anxiety and depression, can be the focus of future stigma education and training implementation in the region.

This study is the first for NMHNs in China, and results reveal a critical public health issue. Therefore, we innovatively used the stigma detection rate method to explore and analyze the factors that influence the stigma of mental disorders in NMHNs, opening up new research ideas in this field. Second, the sample size of this investigation was relatively large for this type of study. However, this study also has its limitations. First, this study was a national online cross-sectional survey. Although 8,254 nurses from all provinces of mainland China responded, the sample was small and disproportionately distributed compared to the number of nursing staff in China, which may affect the validity and generalizability of our findings. Second, no causal relationship can be inferred from the current study, and future longitudinal studies are needed. Third, in the research analysis, the categories of absolute and possible unwillingness for each item in the SDS scale were not combined; this research will be conducted later. The investigation was conducted during the COVID-19 pandemic. Therefore, we could not assess whether or not personal mental health problems and occupational exhaustion affected participants’ responses. Fourth, the current study analyzed self-reported data from NMHN, which may pose a potential risk to the validity of the measurements. However, based on the critical influencing factors of stigma identified in this research, it may provide meaningful guidance for future efforts to improve intensive education on attitudes toward mental disorders appropriate for NMHNs in Chinese general hospitals.

In clinical practice, biased perceptions may negatively affect how patients with mental illness are treated during hospitalization (42, 65). Nurses are the frontline healthcare workers with the most access to patients; thus, they are the most proportional and widespread force in the healthcare workforce and can play an essential role in anti-stigma efforts (66), more so as healthcare workers. Therefore, appropriate educational programs can improve perceptions of mental illness and of patients (67, 68). Our findings suggest that using stigma detection rate methods can detect people at high risk for stigmatizing attitudes and focus on giving targeted interventions based on this. The construction of the mental health system is a significant public health, livelihood, and social issue related to economic and social development and the physical and mental health of the people in China. The reform of China’s mental health system should not only focus on technology and infrastructure but also on improving the way and attitude of providing services to each patient to meet current mental health service needs.

This study identified a high stigma toward and social distance from mental disorders among NMHNs in Chinese general hospitals and found various associated factors. There were more stigmatizing attitudes among such respondents who were between 30 and 39 years old, had been working for 11–15 years, had a bachelor’s degree, self-identified as having sufficient knowledge of psychology, and thoroughly understood how to communicate with people suffering from anxiety and depression.

The current study also found that anxiety and depression were the most common mental disorders encountered by nurses interviewed, and radio and television were the most common sources of mental health knowledge. The most frequent options for willingness to use the scale to screen for anxiety and depression were facilitating good patient psychological care, improving treatment adherence, and promoting early recovery. In addition, the most frequent reason for being unwilling to use the scale was being too busy at work to do it. The number of people willing to use the scale to screen for anxiety and depression was much higher than those who were not willing to do so. These findings guide the development and implementation of effective interventions for stigma to reduce problems in clinical services in the future.

The raw data supporting the conclusions of this article will be made available by the authors without undue reservation.

The studies involving human participants were reviewed and approved by The Ethics Committee of Xiangya Nursing School of Central South University approved this study on April 20, 2022 (No. E202255). Informed consent was obtained from all participants. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

LL and YL participated in the conception and design of this study. CX organized the database. LL performed the statistical analysis and wrote the first draft of the manuscript. SL revised the manuscript. YL and SL provided advice on the statistical analysis and interpretation of the results and reviewed the manuscript draft. All authors contributed to the article and approved the submitted version.

This study was supported by the National Natural Science Foundation of China (No. 81873806) and Major Scientific and Technological Projects in Hunan Province (No. 2020SK2085).

The authors declare that the study was conducted without any commercial or financial relationship, which may be considered a potential conflict of interest.

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