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Issues in Mental Health Nursing
ISSN: 0161-2840 (Print) 1096-4673 (Online) Journal homepage: https://www.tandfonline.com/loi/imhn20
Battling Associative Stigma in Psychiatric Nursing
Candice Waddell, Jan Marie Graham, Katherine Pachkowski & Heather
Friesen
To cite this article: Candice Waddell, Jan Marie Graham, Katherine Pachkowski & Heather
Friesen (2020): Battling Associative Stigma in Psychiatric Nursing, Issues in Mental Health Nursing
To link to this article: https://doi.org/10.1080/01612840.2019.1710009
Published online: 01 May 2020.
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Battling Associative Stigma in Psychiatric Nursing
Candice Waddell, MPN, PhD candidate
a
, Jan Marie Graham, MN
b
, Katherine Pachkowski, MSc
a
, and
Heather Friesen, PhD
c
a
Department of Psychiatric Nursing, Faculty of Health Studies, Brandon University, Brandon, Manitoba, Canada;
b
Department of Nursing,
Faculty of Health Studies, Brandon University, Brandon, Manitoba, Canada;
c
Institutional Research & Effectiveness, Abu Dhabi University,
Abu Dhabi, United Arab Emirates
ABSTRACT
Psychiatric nurses often experience associative stigma. Associative stigma may impact psychiatric
nurses’views of their professional identity which ultimately impacts the health care of individuals
experiencing mental health concerns. Very little research has been conducted on associative
stigma in the western Prairie Provinces, including Manitoba. The authors conducted a secondary
analysis on the results of an explanatory sequential mixed methods research study to determine if
psychiatric nurses in Manitoba are influenced by associative stigma. Three themes were identified
through this analysis, specifically: (1) the perception that RPNs are not “Real”Nurses; (2) lack of
recognition of specialized training; and (3) working with a stigmatized population. Associative
stigma was intertwined in all of the participants’narratives indicating a need to dismantle associa-
tive stigma. Strategies to enhance the public perception of psychiatric nursing and decrease asso-
ciative stigma within the profession are described.
Sometimes I don’t know what is worse, living in a state of panic
or living with other people’s attitudes about it. (Healthy
Place, 2018)
As the quote suggests, detrimental societal reactions often
either overshadow or aggravate the symptoms associated with
mental illness among many individuals. Harmful societal mes-
saging, such as: (1) people with mental illness are violent, (2)
mental illness is an excuse for bad behavior, and (3) people
with mental illness are to be blamed for their condition
(Horsfall, Cleary, & Hunt, 2010) are predominant and have an
impact on how people are treated within the health care sys-
tem and society in general. These statements are an example
of what is otherwise known as stigma. Stigma may be defined
as “negative attitudes and beliefs about a group of people due
to their circumstance in life”(Government of Canada, 2018,
para. 2).
Stigma causes disastrous effects on individuals’abilities to
live full, complete and satisfying lives (Canadian Mental
Health Association, 2018; Corrigan, Morris, Michaels, Rafacz,
& Rusch, 2012). To compound the problem, in some situa-
tions and settings professionals—including those who provide
care to this population—have been influenced by these nega-
tive misconceptions, which directly impact the treatment they
provide to individuals with mental illness (Halter, 2008;
Nakash, Nagar, & Levav, 2015). Psychiatric nurses have the
education and the experience to be pivotal members of the
interdisciplinary team, positioned to work against societal
stigma and to convey positive attitudes toward people experi-
encing mental illness (Happell & Gaskins, 2012).
The invisible practice
While there is an obvious and defined need for psychiatric
nursing care, some geographical locations are struggling to
train and retain psychiatric nurses in the mental health sys-
tem (Happell & Gaskins, 2012; Hercelinskyj, Cruickshank,
Brown, & Phillips, 2014; Jansen & Venter, 2015; Ng et al.,
2010). Psychiatric nursing is consistently described as the least
attractive and the least respected field within nursing (Happell
& Gaskins, 2012; Jansen & Venter, 2015; Molloy, Lakeman, &
Walker, 2016).
This perception has contributed to psychiatric nurses con-
ducting a so-called “invisible practice”(Fourie, McDonald,
Connor, & Bartlett, 2005). This invisible practice stems in part
from the reality that a majority of psychiatric nurses struggle to
identify or articulate the knowledge and the skills that underlies
their practice (Fourie et al., 2005; Santangelo, Procter, &
Fassett, 2018). The skills that are paramount in psychiatric
nursing, such as developing a trusting therapeutic relationship,
providing support and providing client education are deemed
by professionals both within and outside of psychiatric nursing
to be “soft skills”or invisible skills (Ng et al., 2010). One could
argue that psychiatric care itself is fragmented by a physical/
psychiatric binary, which is paralleled by the distinction
between the technical, “hard”skills associated with medical
practice, and the “soft skills”associated with psychiatric prac-
tice. Soft skills are thought to require less knowledge then more
technical skills (Happell, Welch, Moxham, & Byrne, 2013;Ng
et al., 2010). Thus, many nurses attribute higher value to
CONTACT Candice Waddell waddellc@brandonu.ca Brandon University, 270 18th Street, Brandon MB R7A 6A9, Canada.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/imhn.
ß2020 Taylor & Francis Group, LLC
ISSUES IN MENTAL HEALTH NURSING
https://doi.org/10.1080/01612840.2019.1710009
technical skills, and often the psychiatric component of client
care is devalued and ignored (Ross & Goldner, 2009). The per-
petuation of this fragmentation, and the internalization of these
values by psychiatric nurses, appears because of a lack of know-
ledge and insufficient clinical support in mental health and
addictions (Ross & Goldner, 2009). The fact that non-specialist
nurses with little to no experience in mental health often end
up teaching in psychiatric programs and providing clinical
supervision to psychiatric nurses in training (Happell, 2014)
minimizes the importance of the psychiatric nurse and the spe-
cialized skills associated with the practice. This reality in nurs-
ing education is misaligned with research that suggests the
most important characteristic of psychiatric nurses is a broad
knowledge base that is focused on holistic care and a thorough
understanding of the mental health needs of individuals
(Brimblecombe, Tingle, Tunmore, & Murrells, 2007; Halter,
2008;Happell,2019).
Stigma by association
The low status associated with the profession of psychiatric
nurses may also be attributed to the fact that many of the
same traits and characteristics that are falsely believed about
people with lived experience of mental illness are also
believed about the individuals that work with this popula-
tion (Gouthro, 2009). In fact, many of the stereotypes asso-
ciated with the stigma of the population are redirected at
the professionals that work within the system (Gouthro,
2009; Natan, Drori, & Hochman, 2015). For instance, psy-
chiatric nurses are perceived as neurotic, inefficient, un-
skilled and there is a tendency for people to believe that
those who work in mental health are also inflicted with
mental illness (Natan et al., 2015). Stigma by association is
often referred to as “associative stigma”and “courtesy
stigma”in the literature. These terms are used interchange-
ably (Bladon, 2018; Delaney, 2012; Gouthro, 2009; Ng et al.,
2010; Ross & Goldner, 2009; Verhaeghe & Bracke, 2012).
Verhaeghe and Bracke (2012) define associative stigma as
“stigma that mental health professionals experience because
they are associated with persons who belong to a stigmatized
category in society, namely, people with mental health prob-
lems”(p. 18). Stigmatizing beliefs regarding mental health
nurses devalue the contribution made by these professionals
and simultaneously discredit the needs of individuals receiv-
ing care within these services (Gouthro, 2009).
Thus the literature indicates that stigma is intricately and
explicitly intertwined with the role and the identity of psychi-
atric nurses. Much of the research pertaining to associative
stigma has been conducted in countries other than Canada
(Ebsworth & Foster, 2017; Harrison, Hauck, & Ashby, 2017;
Natan et al., 2015). The information that has arisen from
Canada indicates that associative stigma is an issue within our
borders with mental health nurses (Ng et al., 2010). However
there has been little to no research conducted in the western
prairie provinces of Canada. The training and regulation of
psychiatric nurses differs vastly between jurisdictions across
the country. Manitoba, Saskatchewan, Alberta and British
Columbia are unique to the rest of the country as there is
specialized training for registered psychiatric nurses in under-
graduate programs—a similar model to practice in the United
Kingdom and much of Europe. In Eastern Canada, mental
health nurses are trained as registered nurses and they may or
may not have additional training in mental health—a similar
model to that in the United States, Australia, and New
Zealand. Additionally, psychiatric nurses in Manitoba,
Saskatchewan, and Alberta have their own distinct profes-
sional regulation bodies (College of Registered Psychiatric
Nurses of Manitoba, Registered Psychiatric Nurses
Association of Saskatchewan and the College of Registered
Psychiatric Nurses of Alberta).
Methodology
This article reports on a secondary analysis that was con-
ducted on the data collected in a mixed methods research
study focused on the scope of practice, roles, responsibilities,
and unique characteristics of registered psychiatric nurses in
Manitoba (Graham, Waddell, Pachkowski, & Friesen, 2020).
Primary study methods
The original study consisted of a 14-item online survey
administered electronically to 94 practicing registered psychi-
atric nurses (RPNs). The online survey was designed to deter-
mine information about the participants employment settings,
common activities performed in the workplace and the align-
ment of the common activities with the participants’percep-
tions of their roles as psychiatric nurses. Additionally,
participants were asked to reflect on their beliefs regarding the
unique knowledge and skills that they possess as psychiatric
nurses. The survey was reviewed by three practicing RPNs, a
RN with significant experience in mental health and a statisti-
cian to ensure validity. Lastly, participants were offered an
opportunity to participate in one of two follow up focus
groups to expand on their responses from the survey. The
focus groups were offered in a larger city center and a rural
location to accommodate participants varying employment
locations. The focus groups consisted of semi-structured inter-
view questions developed to expand on the information pro-
vided in the survey. Both focus groups were moderated by the
same researcher and research assistant to ensure consistency.
Ethical approval for this research was obtained from Brandon
University Research Ethics Committee (#21915).
Primary study participants
Letters of invitation were distributed to over 1,000 RPNs by
the College of Registered Psychiatric Nurses of Manitoba.
Ninety-four RPNs responded to the survey from a broad
range of practice environments. The participants had bacca-
laureate degrees or diplomas in psychiatric nursing and
graduated between 1973 and 2017. Seven RPNs participated
in the focus groups. Although numerous participants con-
firmed for both focus groups sites, six participants attended
the larger city center location and only one participant
attended the rural location focus group. The single
2 C. WADDELL ET AL.
participant wanted to be included and participate in the
research project, so the exact same questions were asked in
this individual interview as was asked in the focus group to
allow the transcripts to be analyzed together.
Primary study analysis
Data analysis for the closed-ended questions was completed
using Statistical Package for the Social Sciences. To ensure
inter-rater reliability and consistency of findings, the narra-
tive responses to the open-ended questions within the survey
and the focus group transcripts were themed independently
by three research team members (O’Reilly & Kiyimba,
2015). Axial coding was used by the three researchers in col-
laboration to establish the final themes (Ravitch & Carl,
2016). The findings from this mixed methods research study
indicated that the unique characteristics included specialized
knowledge in mental health, mental illness and addictions as
the central theme that contributed and influenced psychi-
atric nurses’practice. The subthemes were therapeutic rela-
tionship, holistic approach, recovery, stigma reduction and
advocacy for system change. It was concluded that “to be
most effective in practice, psychiatric nurses must have com-
prehensive knowledge plus the values, beliefs, and attitudes
that support the positive application of therapeutic relation-
ship, holistic approach, recovery orientation, stigma reduc-
tion and advocacy.”(Graham et al., 2020).
Secondary analysis
Associative stigma was identified as an outlier. Although
participants did not explicitly name it as a unique character-
istic of psychiatric nursing practice, it was alluded to with
regularity in the survey narratives and focus group tran-
scripts. The recurrence of the theme was sufficiently strong
to motivate the research team to undertake a secondary ana-
lysis of the primary data, in order to answer the question:
how is the unique identity of RPNs in Manitoba impacted
and influenced by associative stigma?
Secondary analysis on primary data sets in qualitative
research is a method of reusing one’s own data set to answer
supplementary or additional questions that were not
explored in the primary research (Bishop & Kuula-Luumi,
2017;O’Reilly & Kiyimba, 2015). Sorting relevant infor-
mation from a complete data set to selectively limit topics
is common in secondary analysis (Long-Sutehall, Sque,
& Addington-Hall, 2011).
Two research team members independently reviewed the
narrative responses from the survey and the focus group
transcript coding specifically for language and concepts
related to associative stigma. The independent analyses were
then compared until consensus was reached regarding evi-
dence of associative stigma.
Findings
After secondary analysis was completed, three main topics
emerged in relation to associative stigma from the survey
narratives and the focus group transcript, specifically: (1)
the perception that RPNs are not “Real”Nurses; (2) lack of
recognition of specialized training; and (3) working with a
stigmatized population.
Perception that RPNs are not “Real”Nurses
In the participant’s narratives, the idea that psychiatric
nurses aren’t“real nurses”was mentioned in relation to the
skills and duties that RPNs typically perform. For instance,
one participant reflected that she has heard in the past,
Oh, she’s a psych nurse, oh, so not a real nurse. Right, it’s that
kind of thing, and of course they are not personally attacking
me, but it’s like they sort of refer to psych in kind of negative
way. I think, the thought is there because they do all of these
technical things. They do all of these skills, that’s what
differentiates a real nurse and a RPN, and I totally disagree. I
think that those are skills that anybody can do, if you’re taught
to do it. Inserting a naso-gastric tube is not rocket science, it
really isn’t. (Focus Group Participant)
Another stated,
…you have this sense that you’re not legit, your competency is
kind of down there. Well the RN has to do it right? (Focus
Group Participant)
In addition to skills and duties, there was consensus
among many participants that the RPN role is ambiguous
and that the sheer volume of RNs versus RPNs causes RPNs
to have trouble defining themselves. For instance, one par-
ticipant voiced,
There are still a lot of grey areas around being a psychiatric nurse
that I don’t know. You know we’re not the majority of the people
on the floor we’re just sort of like white blood cells floating
around sort of filling in the gap. (Focus Group Participant)
Additionally, the idea that RPNs are not real nurses was
challenged when a participant indicated:
That’s the same thing with RNs though to, because an RN who
works in the community would have a hard time going back
into a hospital setting because the skill set is different. I think
we have to respect that. I’d rather be more proficient at certain
skills then sort of like a little bit good at everything but maybe
I’m not completely competent. (Focus Group Participant)
Lack of recognition of specialized training
Stigma is generated when mental health is not recognized as a
specialized field. In many cases there is no specialized training
provided to individuals working within certain mental health
environments. One participant brought this up as an issue in
relation to her identity as a psychiatric nurse by stating,
[In the place I work] they are also discussing allowing LPNs
[Licensed Practical Nurses] to work in psychiatry. I was an LPN
and we took an intro to psychology and an intro to sociology
class and that’s basically it. An RN [Registered Nurse] is not
given a whole lot of study in mental health either. From what I
know and what I’ve been told it’s maybe 3 to 5 days, where they
actually work in mental health. To me that does not justify, nor
is it enough for that person to decide to go ahead and work on
an acute psychiatric floor and be qualified to do that type
of work.
ISSUES IN MENTAL HEALTH NURSING 3
Another participant expanded on this sentiment by stating,
…why have the training, why have the distinction of RPN? We
go through a 4-year curriculum in order to learn the skills to be
a psychiatric nurse and it’s not recognized in some ways
because it just seems like anybody with a degree can also apply
for my position. But yet I can’t apply for an RN position, I can’t
apply for a social worker position. There is something kind of
wrong with that.
Concerns were raised regarding specialized education
programs but there was also recognition that there are many
similarities between RPNs and other health care professio-
nals. There was indication that the specialized training of
mental health skills needs to be more fully recognized. One
expressed, “we may not have the medical background to be
able to do the more advanced nursing skills. We deal with
people all the time and add the human element. We’ve
learned to be the calm presence and how to recognize cer-
tain things that may be off with somebody and to look into
that. It is important to rule out the medical but there is also
a psychiatric component and they all need to function
together”(Focus Group Participant). Another indicated:
“Psychiatric nurses are nurses first, with extra skills and
training in mental health with a focus on holistic patient
care and caring for the whole person, not just their medical
or mental health needs”(Survey Narrative).
Working with a stigmatized population
Our participants, as strong advocates for mental health and
mental illness, made many comments about the stigma asso-
ciated with mental illness, and the importance of psychiatric
nurses addressing that added burden. For instance, one par-
ticipant stated,
RPNs give humanity. They approach patients as people and
relate to them as just another human being. RPNs remind other
team members and patients that we are all people dealing with
something and it is our job to understand all sides and create
care for one another with that in mind”(Survey Narrative). This
idea of global mental health, holistic care and treating people
the same regardless of their diagnosis resonated with other
participants, “psychiatric nurses have a greater compassion for
those with mental illness including the ability to provide care
with significantly less stigma then other health care
professionals. (Survey Narrative)
The stigma associated with mental illness was also identi-
fied as a burden to appropriate health care. For instance one
participant recognized that “psychiatric clients are stigma-
tized in the sense that they are not trusted in making their
own decisions”(Survey Narrative). In addition, one partici-
pant elaborated on situations prevalent within health care
when mental health clients are involved. For instance, “A lot
of times in emergency people have these predisposed
thoughts or have labeled somebody. Sometimes [our clients]
feel the non-verbal reaction of the staff. Then [our
clients] may get problematic because of the way they were
treated when they first came in”(Focus Group Participant).
Many participants also spoke about what is needed to
provide adequate care for clients with mental illness.
Participants alluded to the impatience of other health care
providers regarding the increased length of time care provi-
sion sometimes required for people with mental health
problems. One stated: “I know that sounds kind of odd but
I find a lot of medical people think they are there to solve
somebody’s problem as opposed to working with the person
and deciding what that person wants to do. The thinking is
more problem centered rather than client centered”(Focus
Group Participant). Another indicated, “I think RPNs bring
a greater strength in listening to the client’s perspective and
engaging clients in finding places to start to effect change
rather than directing clients to make changes”(Survey
Narrative). A focus group participant stated, “The ability to
be able to empower that person to do as much as they can
for themselves, and I think as psychiatric nurses we’re a lit-
tle bit unique in that. We don’t just do something for some-
one. We kind of help guide them along because we know
how good it feels to be able to be able to do it yourself”
(Focus Group Participant).
Another summarized the concept when stating,
I think it’s just in the language and the way that a person is
approached. Body language and just welcoming somebody into
a place means a lot. Where a nurse is trained, educated and
employed plays a significant role in how they welcome
somebody. Some people are very task orientated. They’re
actually doing things, and whirling around the person trying to
get stuff organized for them and the person is just sitting there.
Whereas, somebody else who comes from a psychiatric nursing
background would approach it in a very different way. I think
the silence is important, just taking your time, not just jumping
in there. I see a lot of people rescuing, it’s all about I’ve got to
do this for them and I’ve got to do that and I have to make
everything okay, how can I help this person or what can I do
for them? And really they should be asking, what does this
person want? What does this person feel they need? (Focus
Group Participant)
There was also acknowledgement from participants that
working in a career that focuses on clients with mental ill-
ness is not a popular career choice, a focus group partici-
pant acknowledged “I think going into this profession you
recognize that not everybody wants to do this type of work.
Usually people have some sort of motivation for going into
it. Maybe we have history our self or history in our family”
(Focus Group Participant).
Discussion
Associative stigma was alluded to and reflected on by survey
respondents and focus group participants. This is not a new
phenomenon. Molloy et al. (2016) reported that the lowly
status of psychiatric nursing has been an issue for decades.
Numerous academics globally, have studied associative
stigma (Ebsworth & Foster, 2017; Flaskerud, 2018; Harrison
et al., 2017; Natan et al., 2015; Verhaeghe & Bracke, 2012).
The participants within our study were proud to be psychi-
atric nurses and they were able to clearly articulate what
makes their profession unique. The negative impacts of asso-
ciative stigma were the external beliefs of other health care
professionals and the public. This is a similar finding to
what researchers in other jurisdictions have found in regard
to the perception of psychiatric nurses from other health
4 C. WADDELL ET AL.
professionals (Crowther & Ragusa, 2011; Harrison
et al., 2017).
A strategy that increases the public perception of RPNs
within health care would decrease the associative stigma that
occurs within this population. Strategies to rectify this would
be to: redefining “soft skills”as essential skills in RPN prac-
tice; spreading the message through promotion and educa-
tion; and embedding the concepts that decrease associate
stigma into educational programs.
Redefining “soft skills”as essential skills in
RPN practice
It is quite apparent that more work needs to be done to honor
and celebrate the unique skills that make psychiatric nurses a
valuable part of the therapeutic health care team. There is rec-
ognition among health care professionals that are not confi-
dent within mental health that they do not have the skills or
the knowledge to work with clients with mental illness (Ross
& Goldner, 2009). Yet, there is a continued perpetuation that
these same skills are not as difficult to master as the technical
medical skills, and that they are less important (Natan et al.,
2015; Ross & Goldner, 2009; Sercu, Ayala, & Bracke, 2014).
Some authors have gone as far to indicate that these skills are
“invisible skills”or “soft skills”(Fourie et al., 2005; Happell
et al., 2013; Ng et al., 2010).
Reiterating that skills such as empathetic listening, devel-
oping therapeutic rapport, de-escalation techniques, fostering
recovery and advocating for client and system are not soft-
skills and reframing these as essential skills within psychi-
atric nursing practice will shift perceptions. The recovery of
individuals within the mental health system relies on psychi-
atric nurse’s ability to value and make space for these skills
within this type of caring engagement (Delaney, 2012).
Devaluation of psychiatric nurses because of an inability to
perform technical skills is a fundamental devaluation on
what our foremothers wanted for nursing, first and foremost
an emphasis on client care and the therapeutic relationship
(Peplau, 1997).
Spreading the message through promotion
and education
Suggestions on how to minimize stigma of association are
already apparent in the literature. For instance, Bladon
(2018) suggests that mental health nurse’s first need to iden-
tify their own areas of uniqueness then celebrate this
uniqueness through public means. The participants within
the primary research project were able to clearly articulate
the unique characteristics of RPNs in Manitoba (Graham
et al., 2020). The unique characteristics were that psychiatric
nurses use specialized knowledge in mental health, mental
illnesss, and addictions as the central theme that influences
the use of the therapeutic relationship, holistic approach,
recovery, stigma reduction, and advocacy for system change.
These unique characteristics could be used as the foundation
for promotion of the profession and education of other
health professionals.
Even when alluding to the associative stigma that they
experience, our participants were still able to maintain pride in
the profession and an acknowledgement that their work is valu-
able. Nihart (2016b) states “part of the reason that others do
not know what we do is that we do not speak up for ourselves.
We cannot tolerate that level of ignorance. We must speak up!
Not defensive and apologetic, but rather with pride!”(p. 243).
Providing opportunities for this pride to be showcased would
highlight the profession and the unique characteristics of the
profession. This is a responsibility of our regulators, our
employers and our educators, as well as individual psychiatric
nurses. An example of this concept in practice is the College of
Registered Psychiatric Nurses of Manitoba, RPNs in Practice
profiles, which highlight the work of specific registered psychi-
atric nurses across the province (College of Registered
Psychiatric Nurses of Manitoba [CRPNM], 2019). Emphasizing
positive work within the profession may require collaboration
between the regulators, educators, and employers to showcase
and highlight the positive aspects of the profession. Making the
space and time for this type of acknowledgement not only
increases the positive identity of psychiatric nurses, it also raises
awareness for the general public regarding services and sup-
ports that are available. In addition, this type of public educa-
tion about the unique skills and role of psychiatric nurses has
the potential to improve client outcomes by reducing the stigma
associated with mental health issues and allowing psychiatric
nurses to fully advocate for patient care (Delaney, 2012).
Embedding concepts that decrease associative stigma
into education programs
As mentioned by our participants, recognizing the unique
education of psychiatric nurses is another way to combat asso-
ciative stigma. Ensuring that psychiatric nursing education is
delivered by psychiatric nurses, either RPNs or an RN with
mental health expertise, is crucial in the development of cur-
riculum that challenges stereotypes and fosters passion for the
recovery of those with mental illness or mental health con-
cerns (Happell et al., 2013). Registered psychiatric nurses as
educators are in the perfect position to tackle associative
stigma. As Nihart (2016a) suggests “I call upon you to help
redefine our image, start with these simple actions: describe
with pride your skills, teach others what you are doing, and
share how you care and how you help”(p. 324).
Another aspect of consideration is to ensure educators
are choosing appropriate placements for clinical practicums
that allow students to keep mental health at the forefront.
This requires that educators ensure that even in highly med-
ical environments students are encouraged to use their
essential skills and not only become dependent on their
technical skills (Ng et al., 2010).
Curriculum should be wrapped around the essential skills
that uniquely define the practice of registered psychiatric nurs-
ing. According to Graham et al. (2020)thefoundationalconcepts
for psychiatric nursing practice are: specialized knowledge in
mental health, mental illness and addictions which contributed
and influenced to the application of therapeutic relationship, hol-
istic approach, recovery, stigma reduction and advocacy for
ISSUES IN MENTAL HEALTH NURSING 5
system change (see Figure 1). These concepts should be inte-
grated in all aspects of psychiatric nursing curriculum.
Future research
One of the concerns raised in the literature is that associa-
tive stigma negatively impacts recruitment of future psychi-
atric nursing students globally (Ebsworth & Foster, 2017;
Molloy et al., 2016; Natan et al., 2015; Ong et al., 2017).
However, this is not the case in Manitoba where we actually
have more applicants as there are traditionally and currently
more applicants than spaces for the psychiatric nursing pro-
gram. Future research could focus on this discrepancy.
Conclusion
From the secondary analysis of the data, three themes were
extracted from psychiatric nurses’responses in the survey and
focus group that connected to associative stigma. The themes
were: (1) the perception that RPNs are not “Real”Nurses; (2) lack
of recognition of specialized training; and (3) the added pressures
of nursing a stigmatized population. Associative stigma can be
addressed through redefining “soft skills”as essential skills in
RPN practice; spreading the message through promotion and
education; and embedding the concepts that decrease associate
stigma into educational programs. By addressing these issues,
new psychiatric nurses coming into professional practice will be
equipped with knowledge and confidence to counter the com-
ment “You are not a real nurse”with “I am a real psychiatric
nurse. These are my skills and this is what I do!”
Declaration of interest
The authors report no conflict of interest. The authors alone
are responsible for the content and the writing of the paper.
Funding
This research was funded by a Faculty of Health Studies Research
Grant #2389, Brandon University, Brandon, Manitoba, Canada.
ORCID
Candice Waddell https://orcid.org/0000-0002-3013-4638
Figure 1. Unique contributions of psychiatric nurses –a framework.
6 C. WADDELL ET AL.
Jan Marie Graham https://orcid.org/0000-0002-0144-0759
Katherine Pachkowski https://orcid.org/0000-0002-4866-6747
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