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Safety Promotion & Neonatal Abstinence Syndrome

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Safety Promotion & Neonatal Abstinence Syndrome

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In the vulnerable moments of labour, delivery and postpartum, we as nurses should provide compassionate and non-stigmatizing care no matter what. Many babies who's mother used substances during pregnancy end up being born with neonatal abstinence syndrome. These babies are experiencing withdrawal symptoms after experiencing these substances (usually opioids) in utero. These symptoms may include tremors, irritability, respiratory issues, and seizures. As nurses we need to ensure the safety of the child, while also ensuring there is no stigmatization towards the mother. We can educate each other and the mother about NAS, and create a supportive and trusting relationship with the mothers. We can ensure safe withdrawal management, safe discharge planning, trauma informed care, and parental involvement/bonding with the baby. The safety of the baby is the most important aspect of these situations.

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I chose the ways of knowing in nursing as a topic, as they are always a priority in nursing care. Barbara Carper created the ways of knowing to acknowledge that nursing practice also depends on empathy, ethics, self-awareness, and social justice. By utilizing the ways of knowing in nursing practice, it provides holistic care and ensures empathetic and respectful care is taking place. The ways of knowing remind us as nurses to form human connections, make ethical decisions, and understand ourselves as nurses, our biases and personal beliefs. We should always advocate for our patients, provide holistic care, and provide evidence for patient care such as vitals. Carper's ways of knowing include: empirical, ethical, sociopolitical and empirical. Throughout my 12 weeks of clinical rotation, I found myself using all of the ways of knowing consistently with all of my patients, and it guided my practice.

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I chose relational inquiry as it is applied to all types of nursing and the care a patient is given. Relational inquiry focuses on relationships, enhancing the capacity and power of people to live meaningful lives, and encourages empowerment both intrapersonal and interpersonally. As we learned in this class, relational inquiry rests on the premise that effective, competent, high quality nursing care is oriented to the living experience of people and families. We can recognize that we are all unique beings living lives in our own contexts, acknowledge that decisions of treatment will depend on personal meaning and beliefs, and know that each person will approach their health and care in different ways. We as nurses can look beyond the clinical setting to understand further what has brought the patient to where they are today. We can analyze their well being in all parts of life, including socially, emotionally and culturally. In both of my placements this semester, relational inquiry was specifically important. I was constantly caring for people in a vulnerable state, and tried to understand their life and how to make them feel comfortable as much as possible.

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I chose this video for my first artifact as it explains the proper care and safety techniques for a baby with neonatal abstinence syndrome. It shows how we as nurses can provide physical safety and commitment to ensuring the baby's health. We need to also input relational techniques in our nursing care, especially for mothers and babies of NAS, as they are a vulnerable population. This video does not adequately addresses the importance of parental involvement and bonding between a baby and their mother, as skin to skin is a well known coping mechanism for NAS. I would suggest that every nurse watch this video as it provides information on NAS and withdrawal in general.

Group, N. (2017). Treating neonatal abstinence syndrome. In YouTube. https://www.youtube.com/watch?v=VkI59skjn88

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“Tree of Life", representing the placenta and it's life sustaining role- Aesthetic Knowing

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I created this piece to reflect my most impactful placement day on the labour and delivery unit, where I witnessed both a vaginal birth and a C-section. I helped analyze the placenta after each, observing its size, completeness, and abnormalities. The nurse I worked with showed me the three-vessel cord (one vein and two arteries) and how the vein spread like branches across the placenta. She called it the tree of life, both for its appearance and its function. I added flowers to my painting to show the deep connection between human life and nature.

The aesthetic way of knowing is reflected in using art to show this experience in my nursing journey, as well as by seeing the tree of life in the placenta and appreciating it as a natural work of art.

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I chose this quote as an artifact as it shows the power of ethical knowing in nursing. Ethical knowing is understanding what is right and what is wrong in nursing. It is choosing to listen instead of always fix, to pause, and to ensure we offer judgement free care. We can sure we always respect autonomy and choose not to coerce. An example of this quote stating that power resides in what we don't do, is in mental health regarding restraints. If we don't advocate for our patients and their autonomy, they may end up in restraints for as long as the doctors order states. This shows a power dynamic where the healthcare team has power over the patient even if it is not ethical. The least restraint policy shows power in what we do as well as what we don't do. Taking restraints off in mental health when they are not needed. This is an example of choosing what is right over what is easy or expected.

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I chose this photo of a nurse taking vitals as my third artifact, as it shows empirical knowing in nursing. This type of knowing includes the objective evidence, facts and knowledge, and is considered the science of nursing. Throughout this 12 week semester, I became very comfortable with taking vitals and performing assessments on both adults and babies. This type of knowing allows for us to measure, test and have concrete evidence of a patient's health status. Throughout the term I developed my empirical knowledge through inquiry and experiment by performing vitals such as blood pressure, temperature, SpO2, respiratory rate and heart rate. Empirical knowing is important for many things in health care, including prescribing medications, and the return to a baseline state.

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"Using ways of knowing in nursing to develop educational strategies that support knowledge mobilization"

Swift, A., & Twycross, A. (2020). Using ways of knowing in nursing to develop educational strategies that support knowledge mobilization. Paediatric and Neonatal Pain, 2(4), 139–147. https://doi.org/10.1002/pne2.12037

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Using ways of knowing in nursing to develop educational strategies that support knowledge mobilization

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There are continued challenges in achieving effective pain management for children and young people (CYP). Research has found several barriers to effective CYP pain management, which include, but are not limited to, deficiencies in knowledge among…

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"How Nurses Apply Patterns of Knowing in Clinical Practice: A Grounded Theory Study"

Rafii, F., Nasrabadi, A., & Tehrani, F. (2021). How nurses apply patterns of knowing in clinical practice: A grounded theory study. Ethiopian Journal of Health Sciences, 31(1), 139–146. https://doi.org/10.4314/ejhs.v31i1.16

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How Nurses Apply Patterns of Knowing in Clinical Practice: A Grounded Theory Study

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Nurses require a great deal of knowledge to provide a comprehensive and effective nursing care. A number of patterns have been put into place to help nurses acquire this knowledge. The aim of this study was to describe the core variable in the…

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Rafii, F., Nasrabadi, A., & Tehrani, F. (2021). How nurses apply patterns of knowing in clinical practice: A grounded theory study. Ethiopian Journal of Health Sciences, 31(1), 139–146. https://doi.org/10.4314/ejhs.v31i1.16

Swift, A., & Twycross, A. (2020). Using ways of knowing in nursing to develop educational strategies that support knowledge mobilization. Paediatric and Neonatal Pain, 2(4), 139–147. https://doi.org/10.1002/pne2.12037

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I chose this infographic for the topic of safety promotion and neonatal abstinence syndrome, as it provides helpful information on how to assess a newborn baby for this. This infographic provides essential information on signs we should quickly assess for and that we should quickly intervene on. We can see how safety promotion is essential in caring for infants in general, and specifically for those with NAS. Each one of these complications is an opportunity for nurses to promote safety through clinical care, education, and advocacy. Safety promotion is not just about preventing harm, but creating a protective and empowering environment for both the infant and their caregivers, grounded in relational inquiry and trauma-informed care.

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I chose this artifact of a patient's room that is nicely decorated with things that make them feel comfortable. Comfort is a large piece of relational inquiry, as it provides patients with a space that supports their safety, dignity and connections with others. We as nurses can consider how much an environment effects a patient's well being, and how we can increase their well being so easily by making their environment more comfortable and personalized. For example, in the mental health unit the rooms are very sterile and bare, and may feel triggering for some people. We can provide comfort while also ensuring safety by offering things such as blankets, access to light, or offering some personal items if allowed. In my personal practice on the children's psychiatric unit I had a 14 year old patient who was staying in the hospital for at least a month, and I found her room to be very bare and lonely. During my shift, we sat together and coloured many colouring sheets and hung them on her walls to personalize her room. As soon as we did this, the patient seemed much happier with being in her room, and an increased feeling of comfort in the setting. This collaboration and interpersonal communication showed the patient respect, and strengthened our nurse-patient therapeutic relationship. Relational inquiry transforms providing a comfortable room into an intentional, ethical, and human-centered form of practice.

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I chose this quote by Maya Angelou as my second artifact for relational inquiry. This quote emphasizes how our presence, empathy and connections with patients have a lasting impact on their health and well being. In the mental health placement I found myself taking part in relational inquiry often by just being present with patients. There were many times where they just needed an outlet, someone to talk to and share their feelings with, and I ensured that I was there and present. I was always intentional, creating a space of respect, trust, and also calmness. In the maternal child unit, I ensured to always ask about the mother's emotional well being, but also the father's. It is always good to check in on both parents and analyze how they are doing with their new baby. This quote relates to relational inquiry as nurses show an intentional presence and ethical engagement with patients, and the patients remember this holistic care. Just like the quote states, your patients will remember how you made them feel, especially in such vulnerable moments such as those they are facing in the healthcare setting.

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"Be Curious: Advancing the Nursing Profession Through Clinical Inquiry"

I chose this youtube video as my third artifact, as it shows how nurses can be so involved in their patients care by furthering their knowledge using relational and clinical inquiry. Nurses involved in scientific inquiry raise questions about their clinical practice, challenge out of date or poorly functioning policies, and work with an interdisciplinary team to solve pressing nursing problems. This video shows us that curiosity is the foundation of nursing inquiry, and holistic, person-centered care. Relational practice includes not only how we care for individuals, but also how we engage with systems, power structures, and outdated ways of thinking in healthcare. Relational inquiry encourages nurses to ask those questions related to their patients' care, and find out how they can contribute to improving care. An example of using relational inquiry to question care could be related to ethics in the mental health unit. Restraints are used on patients when needed but only as a last resort, and may be traumatic for the patient. Relational inquiry helps nurses to question the use of restraints and encourage a least restraint policy where comfort and safety of the patient is the key goal.

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Be Curious: Advancing the Nursing Profession Through Clinical Inquiry

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"Relational inquiry approach for developing deeper awareness of patient suffering"

Younas, A. (2020). Relational inquiry approach for developing deeper awareness of patient suffering. Nursing Ethics, 27(4), 096973302091252. https://doi.org/10.1177/0969733020912523

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Relational inquiry approach for developing deeper awareness of patient suffering - PubMed

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To practice compassion, the recognition, understanding, and alleviation of patient suffering are of utmost importance. Nursing literature provides ample guidance about the nature and meaning and patients’ views about compassion and physical and psychological suffering. However, missing is the discus …

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"In-hospital interventions to promote relational practice with families in acute care settings: A scoping review"

Emmamally, W., Erlingsson, C., & Brysiewicz, P. (2022). In-hospital interventions to promote relational practice with families in acute care settings: A scoping review. Health SA Gesondheid, 27. https://doi.org/10.4102/hsag.v27i0.1694

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In-hospital interventions to promote relational practice with families in acute care settings: A scoping review

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Relational practice is characterised by genuine interaction between families and healthcare professionals that promotes trust and empowerment. Positive clinical outcomes have been associated with relational practice. To assess and examine…

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Emmamally, W., Erlingsson, C., & Brysiewicz, P. (2022). In-hospital interventions to promote relational practice with families in acute care settings: A scoping review. Health SA Gesondheid, 27. https://doi.org/10.4102/hsag.v27i0.1694

Johns Hopkins Medicine. (2021). Be curious: Advancing the nursing profession through clinical inquiry. In YouTube. https://www.youtube.com/watch?v=nxYE_t-uy2k

Younas, A. (2020). Relational inquiry approach for developing deeper awareness of patient suffering. Nursing Ethics, 27(4), 096973302091252. https://doi.org/10.1177/0969733020912523

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I chose the topic of stigma related to mental health as it is prevalent in the community, but also with care providers in healthcare settings. It is found that many patients do not receive help for their mental health because they feel stigmatized or embarrassed by others. As nurses it is our job to find ways to decrease stigma in the community and in the workplace, and normalize receiving help for mental health support. People who receive help for mental health often feel stereotyped, excluded, face discrimination, and develop poor self esteem. Stigma contributes to delayed help seeking, decrease in health outcomes, low self-esteem and self-worth, social isolation, and unequal access to services and support. As nurses we have a job to challenge stigma, use first person language, provide trauma informed care, support patient autonomy, and reflect on our own biases. We need people who struggle with their mental health to feel welcome in the healthcare setting, and to want to receive help, and that is why this is a main topic that I am highlighting in my podcast.

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I chose this art piece for my first artifact as it states "you are not your mental illness". Stigmatization in mental health many times makes people feel belittled, like they are not good enough, and as though their mental health defines them as a person. These statements are not true. As nurses, we can use relational inquiry to understand the whole picture and dive deeper into patients lives, as well as what brought them to where they are today. We can provide them holistic care, and acknowledge our own personal biases. We can create safe, non judgemental spaces, validate patient experiences, engage in active listening, and challenge stigma. People deserve to feel seen, understood, and that they should be able to receive care. Everyone deserves to feel welcomed in an environment, especially in healthcare where everyone is there to receive some sort of help.

**Artist is unknown.

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I chose this quote by Bill Clinton, as it emphasizes that mental illness is not a moral failing or personal weakness, but a health condition, just like diabetes or heart disease. What causes the worst harm isn't the illness, but the stigma and prejudice that surrounds it. Society is known to treat individuals who struggle with mental health differently, silencing them, discrimination, and showing judgement. Mental health stigmatization is prevalent in healthcare systems in many ways such as these patients not receiving care as quickly or being taken as seriously. This stigma that takes place in healthcare is most times formed by personal biases that healthcare providers hold. These biases go against the duty of a nurse which is to provide ethical and compassionate care to everyone. Healthcare workers and people in general should ensure they are acknowledging their biases and work towards being more welcoming to everyone.

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"Mental Health Stigmas Explained"

I chose this as my third artifact, as it shows how what people around you think, greatly influences the way you feel. Stigma against mental health works in the same way. If you are always hearing poor things about mental illness or about the people who struggle with mental illness, you might feel poorly about it too. This video acknowledges the lack of awareness and understanding that people have, and the conflict it creates at home, with friends, in the workplace, and more. These barriers have powerful impacts on people with mental illness, as our society does not often promote acceptance and inclusion. People with mental illness many times develop “self-stigma” and as a result do not receive the necessary help. This video explains how we need to speak properly about mental health and illness, and encourage people to think openly about it. We need to advocate for people with mental illness, and ensure they are receiving the help they need.

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"Understanding and Addressing Mental Health Stigma Across Cultures for Improving Psychiatric Care: A Narrative Review"

Ahad, A., Gonzalez, M., & Junquera, P. (2023). Understanding and addressing mental health stigma across cultures for improving psychiatric care: A narrative review. Cureus, 15(5), 1–8. https://doi.org/10.7759/cureus.39549

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Ahmed A. Ahad aahad004med.fiu.edu ✉Corresponding author.

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Understanding and Addressing Mental Health Stigma Across Cultures for Improving Psychiatric Care: A Narrative Review

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Stigma, characterized by negative stereotypes, prejudice, and discrimination, is a significant impediment in psychiatric care, deterring the timely provision of this care and hindering optimal health outcomes. Pervasive in all aspects of psychiatric…

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"A Systematic Review of the Effect of Stigmatization on Psychiatric Illness Outcomes"

Chukwuma, O. V., Ezeani, E. I., Fatoye, E. O., Benjamin, J., Okobi, O. E., Nwume, C. G., & Egberuare, E. N. (2024). A systematic review of the effect of stigmatization on psychiatric illness outcomes. Cureus, 16(6). https://doi.org/10.7759/cureus.62642

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Abstract

A significant proportion of individuals with psychiatric disorders face dual challenges such as managing the symptoms and disabilities of their conditions and enduring stigma arising from misconceptions about mental illness. This stigma denies them quality-of-life opportunities, such as access to satisfactory healthcare services, better employment, safer housing, and social affiliations. This systematic review aims to evaluate the effect of stigmatization on psychiatric illness outcomes, particularly its influence on treatment adherence, treatment-seeking behavior, and care outcomes. We conducted a systematic review of 39 studies published between 2010 and 2024, focusing on the effects of stigmatization on psychiatric illness outcomes. The review utilized robust methodology following Cochrane guidance and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, including studies from 2010 to 2024 obtained from databases such as PubMed, Embase, Google Scholar, Web of Science, and SCOPUS. The quality of the included studies was assessed using the Appraisal Tool for Cross-Sectional Studies, with most studies rated as moderate to high quality. The findings indicate that stigma in psychiatric illness is closely associated with several factors, including illness duration (mean effect size = 0.42, p < 0.05), frequency of clinic visits (mean reduction = 2.3 visits/year), and diagnosis of psychotic disorders (OR = 1.78, 95% CI: 1.20-2.65). Stigma manifests through misinformation, prejudice, and discrimination, leading to significant barriers to accessing and adhering to psychiatric treatment, thereby worsening health outcomes. It leads to delays in accessing healthcare, poor adherence to medication and follow-up, and negative psychiatric health outcomes, including disempowerment, reduced self-efficacy, increased psychiatric symptoms, and decreased quality of life. Also, stigma extends to caregivers and healthcare professionals, complicating care delivery. This review highlights the need for effective interventions and strategies to address stigma, emphasizing the importance of educational interventions to mitigate the adverse effects of public stigma. Understanding the multifaceted nature of stigma is crucial for developing targeted approaches to improve psychiatric care outcomes and ensure better mental health services for individuals with mental illnesses.

Keywords: discrimination, prejudice, stereotyping, social stigma, psychiatry, mental disorders, negative attributes, stereotypes, stigmatization, stigma

Introduction and background

Erving Goffman's work, "Stigma: Notes on the Management of Spoiled Identity," published in 1963, inspired researchers to study the causes and outcomes of stigma more extensively [ 1]. Stigma can be defined as the simultaneous occurrence of status loss, labeling, trivialization, and discrimination or segregation in a given situation [ 2]. Despite significant advancements in mental health care over the past five decades, efforts to reduce psychiatric stigma have been insufficient [ 3]. The stigma associated with psychiatric disorders, including within healthcare systems and among healthcare providers, remains a significant barrier to better treatment outcomes and recovery, resulting in poor quality of care for psychiatric patients [ 4, 5]. Stigma negatively affects the willingness of patients and healthcare providers to seek and provide treatment, respectively, leading to poorer health outcomes and increased healthcare costs [ 5, 6]. Severe psychiatric disorders often lead to significant behavioral changes, posing risks to patients, their families, and healthcare providers [ 7]. These emergencies, though secondary to the psychiatric illness, can lead to fear, prejudice, anger, and exclusion. Common psychiatric emergencies include severe depressive and manic episodes, impaired judgment, substance intoxication, aggressive agitation, withdrawal crises, and severe self-neglect [ 7]. Effective management of these situations can help reduce or prevent the perpetuation of stigma.

Psychiatric illnesses are among the most widely stigmatized disorders globally, despite evidence that they result from neurochemical imbalances rather than moral failings or witchcraft, as often perceived by the public [ 8]. Stigmatizing attitudes and labeling of psychiatric illnesses are widespread [ 9]. The complex nature of mental health stigma is attributed to public misunderstanding, misperception, and lack of information about mental illnesses [ 10]. Stigma in psychiatric illness involves five key issues: negative attitude, labeling, status loss, discrimination, and segregation [ 11]. Consequently, the public often views individuals with mental illness as incompetent, dangerous, irresponsible, less human, and unpredictable [ 10, 12].

The effects of stigmatization on individuals with mental illness can be severe, leading to treatment avoidance, incomplete treatment, job insecurity, low self-esteem, and rejection in marriage by families [ 13- 15]. The prevalence of stigma has been noted to vary from one country to another, with the estimated prevalence rates in Canada, Nigeria, and Ethiopia being 24.4%, 22.5%, and 83.5%, respectively [ 10- 15]. Moreover, factors that include poverty, educational status (inability to write and read), poor social support, psychiatric disorder duration of less than one year, lack of employment, substance abuse and use, as well as type of psychiatric illness have been acknowledged to worsen stigmatization among mentally ill persons [ 7, 9, 10- 14]. Still, stigma creates barriers to recovery and positive treatment outcomes. Recent studies have highlighted perceived stigma as a critical factor undermining patients' self-esteem, prompting self-isolation and social withdrawal, and deterring individuals from seeking mental health treatment [ 13, 14, 16, 17]. Stigma also extends to caregivers, including family members and healthcare providers, known as associative stigma [ 10, 17, 18]. Associative stigma refers to negative attitudes toward individuals not because of their characteristics but due to their association with someone with a mental illness [ 19]. Initially applied to family members, this concept now includes mental health professionals due to growing evidence of stigma toward them [ 10, 20, 21]. Factors contributing to associative stigma among healthcare professionals include overestimation of coercion in mental health services, public ignorance about mental illness, indistinct boundaries between normality and abnormality in psychiatry, and oversimplification of psychiatric issues [ 22].

Globally, mental health services are often neglected and under-resourced, especially in developing nations [ 23]. In developed countries, high levels of stigmatization persist, with nearly 90% of individuals with mental illness reporting experiences of stigma [ 24, 25]. In some Asian countries, cultural values, fear of shame, and strong family values restrict the pursuit of psychiatric treatment [ 26]. Current research indicates that no country is free from the stigmatization of psychiatric illness [ 27]. Additionally, projections suggest an increase in psychiatric disorders, including depression, and associated costs worldwide by 2030, highlighting the need for more effective interventions to reverse these trends [ 28, 29]. We conducted a systematic review of existing literature, specifically highlighting studies that explored the consequences of stigmatization on psychiatric illness outcomes.

Review

Materials and methods

To collect relevant research and peer-reviewed studies published in English, we conducted an in-depth search of various online medical databases, including PubMed, Embase, Google Scholar, Web of Science, and SCOPUS, covering 2010 to 2024. The selected articles included epidemiological studies, health assessment studies with de-identified data, multicenter studies, and published review articles. We identified duplicate data sources by comparing different articles and studies from similar population years. The literature search employed keywords such as stigma, stigmatization, stereotypes, negative attributes, mental disorders, psychiatry, social stigma, stereotyping, prejudice, and discrimination. This search yielded a total of 988 articles.

Inclusion and exclusion criteria

After removing duplicates, we selected relevant articles through a three-phase process. In the first phase, we screened the titles and abstracts. The second phase involved excluding irrelevant articles. In the third phase, we conducted a thorough full-text examination of the selected articles to confirm relevance. Three independent reviewers conducted the article screening process, and any discrepancies were resolved through consultation and consensus.

The inclusion criteria required original studies, such as crossover design studies, randomized controlled trials, and prospective cohort studies, that met the following criteria: scientific publication of original research findings, published in reputable peer-reviewed journals from 2010 to 2024, and written in English. The studies must have investigated stigmatization in psychiatric illness and included individuals with mental illnesses, focusing on the effects of stigma on psychiatric treatment and health outcomes.

We excluded sponsored clinical trials, editorials, and narrative reviews. We also excluded studies that did not use standard tools to assess stigmatization in mentally ill persons or those that assessed stigmatization without relevance to the target populations. Articles that were inaccessible or had unsound materials and methods were also excluded. Following these criteria, 965 articles were excluded.

For this systematic review, we extracted pertinent data from the qualified articles. We collected general study attributes, including the authors' names, the study year, the year of publication, and the sampling methodologies used. Additionally, we gathered study population attributes such as race, sample size, participants' gender and age, and follow-up information. We also documented the type of intervention employed, the intervention duration, and the measures used in weight assessment. Finally, we noted the main findings of each study.

We conducted the study selection process using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The initial database search retrieved 988 article records. After screening, 578 duplicates were removed, and 207 articles were found ineligible through automation. Another 130 records were excluded for various reasons, including misalignment with our study objectives and animal-based studies. Dissertations and studies published in non-peer-reviewed journals were also excluded. We excluded studies initially published in languages other than English, opinion pieces, articles by non-academics, scoping reviews, secondary studies, and non-primary research types.

Ultimately, 73 eligible articles underwent screening, and 14 were excluded. The remaining 59 articles were sought for retrieval, but 20 were not retrieved. Thus, 39 articles underwent evaluation for eligibility, leading to the exclusion of 16 articles after full-text screening for reasons such as irretrievable full text (four articles), protocol issues (five articles), and failure to report limitations (seven articles). The article selection process is presented in the PRISMA flow diagram in Figure 1.

Figure 1. PRISMA flow diagram indicating the study selection process for the studies included in this systematic review.

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Quality assessment

We assessed the quality of the included studies in this systematic review using the Appraisal Tool for Cross-Sectional Studies, a 20-item critical appraisal tool designed for cross-sectional studies [ 30]. Three authors independently evaluated each study, and two additional authors confirmed the assessments. We resolved any potential disagreements through group discussions. Each study received a score of 1 (yes), 0 (no), or "don't know" for items that were not applicable. Overall, the quality of the included studies ranged from moderate to high, with three studies rated as moderate quality and the remaining 10 as high quality.

Data extraction

We developed a data extraction form to extract pertinent data from the included studies. We collected data on the reviewed studies' attributes, including the authors' names, publication year, location, sample size, findings, stigma prevalence, research design, correlates, stigmatization areas, and impacts on the health outcomes of individuals with mental illness. Three authors independently extracted these data, and we resolved any discrepancies through group discussions.

Discussion

Erving Goffman first described stigmatization in psychiatric health in 1963, identifying it as any attribute or characteristic that taints, devalues, discredits, and brings shame to a mentally ill individual [ 1, 32]. Goffman's work has profoundly influenced subsequent studies in this field, leading to explorations of stigmatization across various contexts and cultural backgrounds. Stigmatization in psychiatric health is strongly influenced by contextual and cultural value systems, which vary across contexts and over time. However, many researchers agree with Goffman's basic description of stigma in psychiatric health, which includes stereotyping, prejudice, social isolation, labeling, ignorance, rejection, discrimination, low self-esteem, marginalization, status loss, and low self-efficacy [ 37- 39]. Therefore, stigmatization in psychiatric health is defined as the social disapproval, disgrace, and social discrediting of mentally ill individuals [ 40, 41].

Professional stigmatization occurs when healthcare professionals exhibit stigmatizing attitudes toward mentally ill patients. These attitudes stem from fear and misunderstanding of psychiatric disorders' causes and symptoms, as well as experiences of stigmatization from the general public and other healthcare professionals due to their association with mentally ill individuals [ 37]. Professional stigmatization is particularly concerning as it can affect the treatment and care provided to mentally ill patients, including treatment for physical illnesses, thereby impacting patients' well-being and recovery [ 37].

Within mental healthcare, stigma remains a significant concern for mentally ill individuals and their families. Several studies reveal that stigmatization in psychiatric illness hinders access to appropriate and professional psychological and mental treatment, potentially worsening patients' conditions and leading to multiple hospital admissions [ 16, 51, 52]. Patients often describe the stigma and prejudice they experience as being as detrimental as their psychiatric disorder symptoms, affecting both their public and private lives [ 53]. Stigma also impacts the families of patients and healthcare providers working in psychiatric units [ 15, 54- 56]. Reducing stigma in mental healthcare is crucial for improving psychiatric outcomes and should be a public health priority. Future research should focus on developing and evaluating interventions to mitigate stigma and its effects on mental health.

Self-stigma, the internalization of stigma, significantly decreases the interest of mentally ill individuals in seeking help for their psychiatric disorders [ 61, 62]. Studies indicate that self-stigma negatively impacts recovery by reducing self-worth and self-esteem, diminishing hopes for recovery, impairing social relationships, and worsening psychiatric symptoms [ 54, 63]. Self-stigma also increases avoidant coping and suicide ideation risks while reducing vocational functioning and treatment adherence [ 15, 55]. For instance, a 2019 study revealed that more than 17% of individuals with AUD and other substance use disorders did not seek treatment due to concerns about negative opinions from their communities and neighbors [ 15, 34]. Additionally, painful experiences of prejudice and discrimination within healthcare contexts are major causes of treatment-seeking avoidance among individuals with mental disorders. The stigma surrounding AUD and substance abuse disorders is internalized, causing ongoing shame and distress, leading to further substance abuse [ 64].

Several studies that we assessed in this systematic review explored the effects of stigma in psychiatric illness on treatment duration and reported mixed outcomes [ 71- 74]. For example, a study on veterans from the Afghanistan and Iraq wars found that higher degrees of perceived stigma were linked to, but did not predict, the number of outpatient psychiatric visits made by participants who registered for treatment [ 72]. However, higher perceived stigma predicted the likelihood of completing a significant treatment episode, especially in patients with post-traumatic stress disorder (PTSD) and depression [ 72]. Another study found that higher stigma scores forecasted a greater likelihood of completing eight or more PTSD-associated psychotherapy visits in 260 veterans who began psychotherapy [ 73]. Conversely, a study of 103 participants in a residential substance use therapy program found that higher levels of self-stigma resulted in longer hospitalization durations in treatment facilities [ 74].

Stigma's effects have also been evaluated in relation to the quality of life and functioning of mentally ill individuals. Several studies in this review addressed the issue of stigma and its impact on quality of life and functioning, indicating a negative correlation between stigmatization and these outcomes. For example, a study of outpatient and inpatient psychiatric health service users in Germany found that higher levels of stigma experienced by patients predicted poorer mental health outcomes nine months later [ 76]. Another study disclosed that in individuals with schizoaffective disorders and schizophrenia, baseline stereotype endorsement ratings significantly predicted changes in vocational functioning at five months, as evaluated using the Quality of Life Scale's Instrumental Functioning subscale [ 77]. Greater stereotype endorsement was linked to reduced improvements in functioning [ 55]. A study focusing on mental health service users with major mood disorders and schizophrenia with higher self-stigma rates at baseline found that increased stigma levels were linked to lower quality of life scores [ 78]. However, since the study sample was selected based on higher reported self-stigma levels, it is unclear if the findings are generalizable to the broader population of mentally ill individuals.

Limitations

This systematic review has several limitations, primarily due to the heterogeneity in the description of stigma in mental illness, as well as variations in contexts, methodologies, and reported findings. This diversity complicates comparable data extraction. Only a limited number of the reviewed articles reported longitudinal outcomes, and few studies were conducted within psychiatric rehabilitation clinics or centers. Additionally, a significant proportion of the included articles (12 articles) focused on self-stigma, suggesting that other forms of stigma might also have wide-ranging effects on psychiatric illness outcomes. However, the emphasis on self-stigma in this review provides a detailed understanding of the effects of stigmatization on individuals with mental illnesses.

Conclusions

This systematic review provides a thorough examination of the concept of stigma and its implications within the domain of psychiatric illnesses. This knowledge is vital for developing effective interventions and strategies to improve psychiatric care outcomes for individuals with mental illnesses. The literature review presented has revealed that regardless of the progress made in understanding the dimensions of stigma associated with psychiatric illnesses and the processes through which public stereotypes and prejudices translate into discriminatory behaviors, stigma in psychiatric disorders remains widespread globally, significantly affecting mental healthcare outcomes. Mental stigma is particularly prevalent among younger individuals, the unemployed, females, single individuals, those residing in rural areas, and those with lower socioeconomic and educational levels. Stigma in psychiatric illness correlates with the duration of illness, number of clinic visits or hospital admissions, and diagnosis of a psychotic disorder. It also leads to delays in accessing healthcare, poor medication adherence, and follow-up issues, all of which impact the recovery process and duration. Effective interventions to address stigma are critical for improving mental health services and outcomes. Educational interventions are essential to prevent the adverse effects of public stigma on psychiatric illness.

Disclosures

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:

Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.

Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.

Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Author Contributions

Concept and design: Okelue E. Okobi, Obinna V. Chukwuma, Esther I. Ezeani , Evelyn O. Fatoye, Janet Benjamin, Chuka G. Nwume, Esther N. Egberuare

Acquisition, analysis, or interpretation of data: Okelue E. Okobi, Obinna V. Chukwuma, Esther I. Ezeani , Evelyn O. Fatoye, Janet Benjamin, Chuka G. Nwume, Esther N. Egberuare

Drafting of the manuscript: Okelue E. Okobi, Obinna V. Chukwuma, Esther I. Ezeani , Evelyn O. Fatoye, Janet Benjamin, Chuka G. Nwume, Esther N. Egberuare

Critical review of the manuscript for important intellectual content: Okelue E. Okobi, Obinna V. Chukwuma, Esther I. Ezeani , Evelyn O. Fatoye, Janet Benjamin, Chuka G. Nwume, Esther N. Egberuare

Supervision: Okelue E. Okobi

References

Articles from Cureus are provided here courtesy of Cureus Inc.

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A Systematic Review of the Effect of Stigmatization on Psychiatric Illness Outcomes

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A significant proportion of individuals with psychiatric disorders face dual challenges such as managing the symptoms and disabilities of their conditions and enduring stigma arising from misconceptions about mental illness. This stigma denies them ...

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I chose this topic as non birthing parents want to be involved and support their partners in breastfeeding but may feel left out and helpless. In many studies with fathers, it was found that they want specific and accessible information about the benefits of breastfeeding, strategies to encourage and support their partner alongside support for themselves during this time. We as nurses must involve, include and support fathers as well as non birthing parents in recognizing their importance in the breastfeeding relationship. I experienced this in my maternal child placement where a father was in the room while the mother was trying to breastfeed, and it was more of a struggle since the baby was tongue tied. The father stated that he felt useless, and wished he could help, but did not know how. We encouraged him to watch the teaching of placement of the baby, so he could assist his wife in ensuring their newborn was in the right place that was most effective once they arrived home.

We can encourage the non birthing parent of the child to help hand express the breast milk if needed while the mother holds the baby in place, they can also help to ensure the mother is comfortable, and watch for any cues that the baby is feeding or not. It is important to provide patient and family centered care whenever possible, and include the non birthing parent in such a special moment of their life.

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"How dads and partners can be more involved in breastfeeding"

I chose this video as my first artifact, as it is a good educational video that supports fathers in the process of learning how to better support the mother of their child. It provides ways that non birthing parents can feel included and needed, even when the mother of the baby has such a large role in that child's life. This video shows how parents can improve their connection with their newborn, share responsibilities, and take part in family centered care. By using relational inquiry, it also promotes equity, presence, and engagement in the early postpartum period. This video reflects an awareness of how gender roles, systemic barriers, and family dynamics affect postpartum care. We as nurses can continuously provide education to non birthing parents, and encourage their participation in as much as they can.

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Parent Club: How dads and partners can be more involved in breastfeeding

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I chose this quote as an artifact as it shows the importance of support from the non birthing parent, and how appreciated it is. This quote states truly that what the mother of the child needs most is love and support. When a father actively supports and cares for his partner, he is also nurturing the emotional and physical environment in which the child is raised. Breastfeeding is physical and emotionally demanding on a mother, so any form of help is greatly appreciated by the mother. Showing forms of emotional reassurance to the mother such as "you are doing great" is also a great way to express love and ensure a stable environment. This relational support nurtures a positive and loving family culture.

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I chose this art piece as my final artifact, as it displays the love of a family when a new baby comes and how they are interconnected with each other. The non-birthing parent can be present in many ways of the child's life, and support the mother continuously. In this art piece the father is hugging both the mother and the baby, offering a form of support, protection, and presence. The mother is connected intimately with the baby, showing the bond formed by breastfeeding. The colours and smooth line throughout the art piece may be interpreted as warmth, emotions flowing, and show the intimate connection that breastfeeding forms for both parents. This art piece also shows that breastfeeding is a team effort, and that the non birthing parent's support is greatly appreciated and helpful.

Bagus Prakoso. (2025). Continuous one line drawing of a happy family. mother, father and baby. vector illustration. Vecteezy. https://www.vecteezy.com/vector-art/24053897-continuous-one-line-drawing-of-a-happy-family-mother-father-and-baby-vector-illustration

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Ahad, A., Gonzalez, M., & Junquera, P. (2023). Understanding and addressing mental health stigma across cultures for improving psychiatric care: A narrative review. Cureus, 15(5), 1–8. https://doi.org/10.7759/cureus.39549

Chukwuma, O. V., Ezeani, E. I., Fatoye, E. O., Benjamin, J., Okobi, O. E., Nwume, C. G., & Egberuare, E. N. (2024). A systematic review of the effect of stigmatization on psychiatric illness outcomes. Cureus, 16(6). https://doi.org/10.7759/cureus.62642

Mental health stigmas explained. (2020, June 29). Www.youtube.com. https://www.youtube.com/watch?v=lXYP3kdWSEw

x x. (2021, August 13). Mental health - end the stigma. Pinterest. https://ca.pinterest.com/pin/381961612157050756/

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"The role of paternal support in breastfeeding outcomes: a meta-analytic review"

Zhou, S., Lu, J., Qin, A., Wang, Y., Gao, W., Li, H., & Rao, L. (2024). The role of paternal support in breastfeeding outcomes: A meta-analytic review. International Breastfeeding Journal, 19(1). https://doi.org/10.1186/s13006-024-00694-1

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The role of paternal support in breastfeeding outcomes: a meta-analytic review - International Breastfeeding Journal

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Background The advantages of breastfeeding for maternal and child health have been widely acknowledged on an international scale. However, there is a paucity of research regarding the effectiveness of paternal support in breastfeeding. This study aimed to systematically review the impact of paternal support interventions on breastfeeding and to contribute additional evidence to inform current breastfeeding practices. Methods A systematic search was conducted across multiple databases, including China National Knowledge Infrastructure (CNKI), Wanfang Data, the VIP Database, the Chinese Biomedical Literature Service System (SinoMed), PubMed, EMBASE, the Cochrane Library, and Web of Science, for randomized controlled trials (RCTs) related to breastfeeding and paternal support interventions, covering the period from the inception of the databases to June 2024. In accordance with the predefined inclusion and exclusion criteria, two researchers independently screened the literature and performed a meta-analysis via RevMan 5.4.1 software. The choice between fixed or random effects models was determined by the outcomes of the heterogeneity test, and relative risks (RR) along with 95% confidence intervals (CI) were computed. Results A comprehensive search yielded 3065 studies, of which eight were included in the meta-analysis. These studies involved a total of 2531 participants, with 1306 in the intervention group and 1225 in the control group. The studies conducted across the United Kingdom, Australia, Canada, and China encompassed a variety of interventions, including breastfeeding education, consultations led by specialists, distribution of informational materials, utilization of educational media, facilitation of interactive discussions, provision of online support through phone or WeChat, dissemination of public account messages, training in breastfeeding techniques, postpartum social support, and guidance on maternal and newborn care. The meta-analysis results indicated that the rate of exclusive breastfeeding was significantly higher in the intervention group compared to the control group at various time points: within one week postpartum (RR 1.28; 95% CI 1.16, 1.42); at 30–42 days postpartum (RR 1.12; 95% CI 1.02, 1.23); and at three months postpartum (RR 1.35; 95% CI 1.21, 1.50). These findings suggest that paternal support interventions effectively enhance breastfeeding practices. Conclusions The findings suggest that current evidence supports the efficacy of paternal support interventions in both the initiation and maintenance of breastfeeding.

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"Impact of Paternal Breastfeeding Interventions on Exclusive Breastfeeding Rates and Attitudes of Fathers Towards Breastfeeding: A Systematic Review"

Hosking, T., Cassidy, S., & Louie. (2025). Impact of paternal breastfeeding interventions on exclusive breastfeeding rates and attitudes of fathers towards breastfeeding: A systematic review. Current Nutrition Reports, 14(1). https://doi.org/10.1007/s13668-024-00603-2

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Impact of Paternal Breastfeeding Interventions on Exclusive Breastfeeding Rates and Attitudes of Fathers Towards Breastfeeding: A Systematic Review - PubMed

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A systematic review was conducted following the 2020 PRISMA guidelines, searching PubMed, CINAHL, and Medline databases for randomized controlled trials and quasi-experimental studies published after December 2017. Nine studies met the inclusion criteria. Six out of seven studies measuring breastfee …

# data[].attributes.body
Bagus Prakoso. (2025). Continuous one line drawing of a happy family. mother, father and baby. vector illustration. Vecteezy. https://www.vecteezy.com/vector-art/24053897-continuous-one-line-drawing-of-a-happy-family-mother-father-and-baby-vector-illustration

Hosking, T., Cassidy, S., & Louie. (2025). Impact of paternal breastfeeding interventions on exclusive breastfeeding rates and attitudes of fathers towards breastfeeding: A systematic review. Current Nutrition Reports, 14(1). https://doi.org/10.1007/s13668-024-00603-2

Scottish Government. (2023, February 28). Parent club: How dads and partners can be more involved in breastfeeding. YouTube. https://www.youtube.com/watch?v=N3xZbgfARYk

Zhou, S., Lu, J., Qin, A., Wang, Y., Gao, W., Li, H., & Rao, L. (2024). The role of paternal support in breastfeeding outcomes: A meta-analytic review. International Breastfeeding Journal, 19(1). https://doi.org/10.1186/s13006-024-00694-1

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For artifact 3, I chose a photo of a baby uncontrollably crying, a major sign of NAS. Babies with NAS often cry a lot, shake, are easily upset, and react strongly to touch or light. The baby in this image may be showing signs of overstimulation, discomfort from withdrawal and trouble calming down. These are all common signs of NAS and need careful attention and support from nurses. When a baby is showing signs such as inconsolable crying we need to ensure safety by using assessment tools and taking vitals. We need to also input comfort measures such as skin to skin contact, swaddling, a quiet environment, and minimal interactions. To keep a baby with NAS stable and comfortable, we need to input non pharmacological interventions, and possibly some pharmacological interventions. Relational inquiry is necessary for providing holistic care to both the babies and mothers in this situation.

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"Neonatal Abstinence Syndrome"

Anbalagan, S., Mendez, M. D., & Falkowitz, D. M. (2024, April 1). Neonatal abstinence syndrome. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK551498/

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Substance abuse during pregnancy is on the rise, resulting in a hidden epidemic of neonatal abstinence syndrome (NAS). This is especially true for both prescribed and illicit opioid use. NAS is a multisystem disorder that results from the infant’s abrupt cessation of exposure to a substance used or abused by the mother during pregnancy. Central nervous system (CNS), gastrointestinal (GI), and autonomic manifestations predominate in terms of clinical presentation. The pathophysiology of this condition is not well understood, but multiple neonatal and maternal factors affect the expression of symptoms, including gestational age, gender, genetics, and maternal substance abuse.

# data[].attributes.body
"Neonatal abstinence syndrome"

Lee, K. G. (2016). Neonatal abstinence syndrome: MedlinePlus medical encyclopedia. Medlineplus.gov. https://medlineplus.gov/ency/article/007313.htm

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Neonatal abstinence syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother's womb.

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"What's in a name? The ethical implications and opportunities in diagnosing an infant with neonatal abstinence syndrome (NAS)"

Oei, J. L., Blythe, S., Dicair, L., Didden, D., Preisz, A., & Lantos, J. (2022). What’s in a name? The ethical implications and opportunities in diagnosing an infant with neonatal abstinence syndrome (NAS). Addiction, 118(1), 4–6. https://doi.org/10.1111/add.16022

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What’s in a name? The ethical implications and opportunities in diagnosing an infant with neonatal abstinence syndrome (NAS) - PubMed

# data[].attributes.attachment_link.description
What’s in a name? The ethical implications and opportunities in diagnosing an infant with neonatal abstinence syndrome (NAS)

# data[].attributes.body
Anbalagan, S., Mendez, M. D., & Falkowitz, D. M. (2024, April 1). Neonatal abstinence syndrome. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK551498/

Group, N. (2017). Treating neonatal abstinence syndrome. In YouTube. https://www.youtube.com/watch?v=VkI59skjn88

Lee, K. G. (2016). Neonatal abstinence syndrome: MedlinePlus medical encyclopedia. Medlineplus.gov. https://medlineplus.gov/ency/article/007313.htm

Oei, J. L., Blythe, S., Dicair, L., Didden, D., Preisz, A., & Lantos, J. (2022). What’s in a name? The ethical implications and opportunities in diagnosing an infant with neonatal abstinence syndrome (NAS). Addiction, 118(1), 4–6. https://doi.org/10.1111/add.16022

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Part 4: Safety Promotion & Neonatal Abstinence Syndrome

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Part 4: Safety Promotion & Neonatal Abstinence Syndrome

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Part 5: Non-Birthing Parent & Feeding Support

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Part 5: Non-Birthing Parent & Feeding Support

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References

Ahad, A., Gonzalez, M., & Junquera, P. (2023). Understanding and addressing mental health stigma across cultures for improving psychiatric care: A narrative review. Cureus, 15(5), 1–8. https://doi.org/10.7759/cureus.39549

Anbalagan, S., Mendez, M. D., & Falkowitz, D. M. (2024, April 1). Neonatal abstinence syndrome. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK551498/

Bagus Prakoso. (2025). Continuous one line drawing of a happy family. mother, father and baby. vector illustration. Vecteezy. https://www.vecteezy.com/vector-art/24053897-continuous-one-line-drawing-of-a-happy-family-mother-father-and-baby-vector-illustration

Chukwuma, O. V., Ezeani, E. I., Fatoye, E. O., Benjamin, J., Okobi, O. E., Nwume, C. G., & Egberuare, E. N. (2024). A systematic review of the effect of stigmatization on psychiatric illness outcomes. Cureus, 16(6). https://doi.org/10.7759/cureus.62642

Emmamally, W., Erlingsson, C., & Brysiewicz, P. (2022). In-hospital interventions to promote relational practice with families in acute care settings: A scoping review. Health SA Gesondheid, 27. https://doi.org/10.4102/hsag.v27i0.1694

Group, N. (2017). Treating neonatal abstinence syndrome. In YouTube. https://www.youtube.com/watch?v=VkI59skjn88

Hosking, T., Cassidy, S., & Louie. (2025). Impact of paternal breastfeeding interventions on exclusive breastfeeding rates and attitudes of fathers towards breastfeeding: A systematic review. Current Nutrition Reports, 14(1). https://doi.org/10.1007/s13668-024-00603-2

Johns Hopkins Medicine. (2021). Be curious: Advancing the nursing profession through clinical inquiry. In YouTube. https://www.youtube.com/watch?v=nxYE_t-uy2k

Lee, K. G. (2016). Neonatal abstinence syndrome: MedlinePlus medical encyclopedia. Medlineplus.gov. https://medlineplus.gov/ency/article/007313.htm

Mental health stigmas explained. (2020, June 29). Www.youtube.com. https://www.youtube.com/watch?v=lXYP3kdWSEw

Oei, J. L., Blythe, S., Dicair, L., Didden, D., Preisz, A., & Lantos, J. (2022). What’s in a name? The ethical implications and opportunities in diagnosing an infant with neonatal abstinence syndrome (NAS). Addiction, 118(1), 4–6. https://doi.org/10.1111/add.16022

Rafii, F., Nasrabadi, A., & Tehrani, F. (2021). How nurses apply patterns of knowing in clinical practice: A grounded theory study. Ethiopian Journal of Health Sciences, 31(1), 139–146. https://doi.org/10.4314/ejhs.v31i1.16

Scottish Government. (2023, February 28). Parent club: How dads and partners can be more involved in breastfeeding. YouTube. https://www.youtube.com/watch?v=N3xZbgfARYk

Swift, A., & Twycross, A. (2020). Using ways of knowing in nursing to develop educational strategies that support knowledge mobilization. Paediatric and Neonatal Pain, 2(4), 139–147. https://doi.org/10.1002/pne2.12037

x x. (2021, August 13). Mental health - end the stigma. Pinterest. https://ca.pinterest.com/pin/381961612157050756/

Younas, A. (2020). Relational inquiry approach for developing deeper awareness of patient suffering. Nursing Ethics, 27(4), 096973302091252. https://doi.org/10.1177/0969733020912523

Zhou, S., Lu, J., Qin, A., Wang, Y., Gao, W., Li, H., & Rao, L. (2024). The role of paternal support in breastfeeding outcomes: A meta-analytic review. International Breastfeeding Journal, 19(1). https://doi.org/10.1186/s13006-024-00694-1