How did the perceptions of healthcare providers change within the mental health care

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The combined experience of working through the pandemic and managing their homelife against the emotional background of the lockdown, prompted the study participants to reflect at a more abstract level about the meaning of their profession, and this was the third theme to emerge from the analysis.

In particular, it led them to reflect on what it means to be a healthcare worker in critical care, particularly because the media portrayed a certain image with which some caregivers did not identify.

We do it with our heart and soul. Why are there medals now? The medal is all year long. Indeed, the pandemic led some participants to reflect on the values they hold, as some reported that what they experienced in the workplace during the crisis went against the values they personally held dear.

The experience of the crisis prompted some participants to reflect on what humanity means to them. There you go , it was… we have a lot of deaths in the ICU ordinarily , but not in conditions like that , not dying one after the other , not having to triage , to choose.

Since the pandemic focused the media spotlight on the profession of critical care health workers, many participants felt that the profession as a whole should capitalize on this positive media attention to achieve a new level of recognition for their profession, for example by raising the status of critical care nurses to the same degree of professional qualification as that accorded to other nursing specialties. All the participants were amazed by the outpouring of generosity from the public, and they reported, for example having received enormous amounts of free meals, gifts, and services from local businesses, shops, restaurants, schools and residents.

Finally, two minor themes also emerged from the interviews in this study. Firstly, there was a raised awareness of the importance of local businesses, eating locally produced produce, and behavioural interactions with people in the local environment.

Secondly, most participants noted that their experienced of the crisis always played out against the national background, namely the management of the pandemic by the government, the measures implemented at national level, etc. This qualitative study investigating the sources and repercussions of the psychological distress suffered by healthcare workers during the COVID pandemic, provides novel insights into the perceptions and experiences of ICU staff, and how this affected them in their daily personal and professional lives.

There is paucity of data on this topic, yet the health of these professionals seems to be in jeopardy, with a level of psychological stress that has been cumulating over the course of pandemic, and reports of a fear of dying and an elevated risk of suicide [ 2 ]. Reports to date about the mental health in healthcare professionals have mainly relied on quantitative data, with wide heterogeneity across studies due to the large number of different scales and tools used.

As a result, comparisons are difficult, and it is difficult to draw conclusions about the individual effects of various factors in generating anxiety, depression or post-traumatic stress disorder [ 1 — 3 , 6 ].

Our study therefore aimed to explore the individual consequences of the psychological distress perceived by healthcare workers during the pandemic in France, exploring both their personal and professional lives, and to put these consequences in perspective with literature data and avenues for instigation of mental health support services. Our findings underline that the personal and professional domains are intricately linked, and difficult to dissociate. The respondents reported their fear of carrying contamination from the workplace to the home and family.

This fear was compounded by the national lockdown, which forced families to reduce contacts outside the home, with children on home-schooling. Some, but not all were able to count on the presence of a spouse or other family member to help out in the home. Many of these fears have been shared by healthcare workers worldwide since the beginning of the crisis, notably with the first reports from China soon after the onset of the pandemic [ 9 , 10 ].

These studies identified the feeling of uncertainty and insecurity as being problematic, with healthcare workers afraid of being contaminated in the workplace, and also afraid that they would in turn contaminate their entourage [ 11 ].

This fear is even greater for healthcare workers who have vulnerable individuals in their entourage, such as family members with a chronic disease, and this may translate into symptoms such as insomnia or anxiety [ 12 ]. The COVID infodemic, with its abundance of information on all the media outlets and social networks, may have engendered fear, or even panic, inciting forms of suspicions, discrimination and stigmatization due to the risk of contamination [ 14 ].

All these circumstances have had direct repercussions on the personal lives of healthcare workers [ 15 — 17 ]. The scientific advisory board advising the French government through this crisis was quick to recommend the implementation of psychological support units in hospitals nationwide in collaboration with the existing network of medico-psychological emergency units, usually mobilized to help victims of large-scale events such as terrorist attacks or natural disasters [ 19 — 21 ].

Other ad hoc solutions also emerged, notably the recognition that mental health services should be provided for the family and friends of people affected by the COVID crisis [ 22 ]; the online delivery of psychotherapy or psycho-educational services, or the use of internet and social media to share strategies for coping with psychological stress [ 7 , 8 , 23 ].

Recent research has indicated the Eye Movement Desensitization and Reprocessing EMDR and cognitive behavioural therapy may be efficacious for reducing the symptoms of post-traumatic stress disorder [ 24 , 25 ]. However, it is not unreasonable to consider that the services provided are likely insufficient, in the face of such a monumental pandemic. A more holistic approach to mental health at work is needed, with institutional support for resilience, and a hierarchy that takes account of emotional distress, as well as organisational and relational difficulties among the caregiving staff [ 26 ].

Within the workplace, the reorganisation of care delivery in terms of structure and human resources was sometimes viewed in a positive light, with extra staff brought in to help, and more relaxed rules greater presence of management, additional supplies etc. Lost opportunities for care due to a shortage of ICU beds were rapidly identified by many healthcare workers as possible major issue for the pandemic, leading the French Intensive Care Society to issue recommendations about admission criteria to the ICU for the pandemic context as well as recommendations for allowing family visits in the ICU www.

Healthcare workers received a good degree of recognition from the public during the first wave of COVID infections, and in France, there was applause in public places every evening at 8pm.

It has been reported that social support can help build resilience and promote recovery after stressful encounters [ 28 , 29 ]. As underlined by Chen et al. The development of preventive strategies is also necessary to support healthcare workers continuing to care for severely ill patients, thereby protecting a resource that is increasingly precious in this ongoing crisis [ 30 , 31 ].

Some healthcare workers use this as a coping strategy in the face of stress and demanding situations. Indeed, experiencing positive emotions promotes resilience, and reinforces certain cognitive functions, such as attention, creativity and flexibility [ 3 , 19 , 26 , 28 ]. This study has some limitations. First, the questions asked during the interview may not have covered all the aspects of the crisis, or the full spectrum of repercussions that the pandemic may have had on all areas of their personal and professional lives.

Lastly, only French healthcare workers were included, and the experiences of front-line workers in other countries would undoubtedly be different. The healthcare workers in this qualitative study expressed their personal concerns and perceptions of the COVID crisis, as experienced during the first wave of the pandemic.

Positive effects, such as renewed motivation for their work, closer team spirit, and greater resilience, were also mentioned. Impact studies, both in the prevention and treatment of mental health issues among healthcare workers could be useful to avoid long-term psychological distress due the ongoing pandemic in this category of professionals.

Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field. Abstract Background Intensive care unit ICU staff have faced unprecedented levels of stress, in the context of profound upheaval of their working environment due to the COVID pandemic. Conclusion In this qualitative study investigating the experiences and perceptions of healthcare workers caring for critically ill patients during the first COVID wave in France, the participants reported that the crisis had profound repercussions on both their personal and professional lives.

Introduction The worldwide pandemic caused by the SARS-CoV-2 virus has put intensive care units ICUs around the world under unprecedented pressure, as they provide front-line care for the most severely ill individuals, notably those with acute respiratory distress requiring mechanical ventilation.

Download: PPT. Fig 1. Conceptual framework describing the main themes and the relations between them. Conditions in the workplace The second major theme concerned the working conditions during the pandemic. The meaning of the profession The combined experience of working through the pandemic and managing their homelife against the emotional background of the lockdown, prompted the study participants to reflect at a more abstract level about the meaning of their profession, and this was the third theme to emerge from the analysis.

Discussion This qualitative study investigating the sources and repercussions of the psychological distress suffered by healthcare workers during the COVID pandemic, provides novel insights into the perceptions and experiences of ICU staff, and how this affected them in their daily personal and professional lives.

Conclusion The healthcare workers in this qualitative study expressed their personal concerns and perceptions of the COVID crisis, as experienced during the first wave of the pandemic. References 1. A Cross-Sectional Study. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID pandemic: A systematic review and meta-analysis.

Brain Behav Immun. Ann Intensive Care. Psychological experience of patients 3 months after a stay in the intensive care unit: A descriptive and qualitative study.

J Crit Care. Can qualitative research play a role in answering ethical questions in intensive care? Ann Transl Med. J Psychiatr Res. Int J Biol Sci. Depression after exposure to stressful events: lessons learned from the severe acute respiratory syndrome epidemic.

Compr Psychiatry. Diabetes Metab Syndr. COVID a novel coronavirus and a novel challenge for critical care. Intensive Care Med. Psychiatry Res. Moghanibashi-Mansourieh A. Asian J Psychiatr. Med Sci Monit. Prevalence of self-reported depression and anxiety among pediatric medical staff members during the COVID outbreak in Guiyang, China. Oulehri W, Rolling J. Revue de neuropsychologie. View Article Google Scholar The Lancet P. Isolation and inclusion. Lancet Psychiatry.

Perlis RH. J Trauma Stress. Interventions for posttraumatic stress disorder symptoms induced by medical events: A systematic review. J Psychosom Res. Fredrickson BL. The broaden-and-build theory of positive emotions.

Admission criteria and management of critical care patients in a pandemic context: position of the Ethics Commission of the French Intensive Care Society, update of April Resilient individuals use positive emotions to bounce back from negative emotional experiences. In recent years, recovery-oriented practices have shifted towards being more individual-focused and centred around helping people lead meaningful lives [ 4 ].

However, there has yet to be a consensus on what the term means, as evinced by a review that suggested that there are differing views among persons with mental illnesses PMI , caregivers, and service providers on what recovery entails [ 5 ]. Likewise, the literature suggests that there are also differing opinions on the factors that impact the recovery of PMI [ 6 — 8 ]. One of the most widely studied barriers to recovery is the stigma towards mental illness. There is compelling evidence in the literature evincing that stigma often affects the recovery of the service users [ 10 , 11 ].

For instance, stigma may discourage an individual from seeking help due to the fear of being labelled with a mental illness diagnosis [ 12 ]. Even amongst individuals who have sought treatment, their recovery may also be compromised by self-stigma [ 10 , 13 ]. In mental health settings, therapeutic pessimism is defined as the inclination to believe that PMI are difficult to treat or immune to treatment [ 14 ]. Additionally, a corollary to stigma is the reduced opportunities available to consumers and greater social exclusion [ 16 ].

In recent years, there is a growing interest in associative stigma experienced by healthcare professionals in mental health settings, whereby these professionals are judged with similar stigmatising stereotypes as their patients [ 17 ].

This was largely explored in a qualitative study by Vayshenker and colleagues, postulating that associative stigma experienced by these healthcare professionals can lead to severe consequences in the quality of care provided to PMI [ 18 ]. To be more specific, the established link between emotional exhaustion, job dissatisfaction, and associative stigma might lead to diminished empathy towards PMI [ 18 ].

For example, the study revealed that factors such as job devaluation e. These stereotypes associated with mental health professionals not only devalues the role these individuals play in treatment and recovery but also underplay the needs of PMI in the healthcare system.

In addition, these stereotypes can further aggravate stigmatising beliefs about mental health conditions [ 15 ]. Other studies have similarly found that stigmatisation by association influences professional burnout, depersonalisation, lower job satisfaction, and emotional exhaustion among healthcare professionals working with PMI [ 20 , 22 — 24 ]. PMI also described higher self-stigma and decreased satisfaction in healthcare institutions when their healthcare professionals experience more associative stigma [ 17 ].

Extensive literature has also exhibited the link between work stress and performance, indicating that stress in the workplace because of stigmatisation influences interpersonal performances, such as reduced sensitivity toward PMI and increased disregard of individual differences among PMI [ 20 ].

Thus, they may be less likely to provide quality services to their clients, serving as a barrier to recovery [ 18 ]. Despite the role of healthcare professionals in understanding mental health stigma and its impact on recovery, a look into current literature reveals a pattern of investigating stigma and recovery from the standpoint of service-users and the general public, with a scarcity of research done to address the perspectives of healthcare professionals working in mental health settings [ 25 , 26 ].

This is surprising in many respects, considering that PMI regularly interact with these healthcare professionals [ 18 ]. There are certain advantages to understanding stigma and barriers to recovery through the perspectives of healthcare professionals. Secondly, although PMI are the most important individuals to discuss barriers and facilitators to recovery, they may sometimes also possess poor insight towards their mental illness such as a lack of awareness of their symptoms, significance, and severity of their illness, which may be associated with poorer perceptions of experienced stigma [ 28 — 30 ].

Furthermore, a study by Happell and colleagues reported that consumers felt that their recovery was hindered when healthcare professionals prioritised treating them according to symptoms instead of their individual needs [ 31 ]. Most importantly, healthcare professionals are often present in situations where they can witness significant breakthroughs and outcomes in patients which surpasses expectations [ 27 , 32 ].

According to Slade et al. To our knowledge, there are limited publications in the literature about the topic of recovery in Singapore [ 33 , 34 ], a country in Southeast Asia where the lifetime prevalence of mental illness is reported to be approximately Mental health services in Singapore are delivered both in hospitals and at the community level. The Institute of Mental Health IMH is the only state-run psychiatric hospital comprising in-patient and out-patient services.

Public and private hospitals deliver inpatient and outpatient mental health services also but in small-scale capacities [ 36 ]. In the community, mental health services are delivered by primary care physicians in state-run clinics i. A nationwide survey reported considerable stigma towards PMI in Singapore among the general public [ 35 ], and stigma has also been surmised to be a contributor to the wide treatment gap in Singapore.

Treatment gap is defined as the absolute difference between the prevalence of a particular mental disorder and those who had received treatment for that disorder [ 37 ].

Anationwide study revealed that more than three-quarters of individuals Qualitative evidence in Singapore also indicates that PMI do experience discrimination and prejudice due to stigma [ 38 ]. Even though stigma possesses ubiquitous features across contexts, the specific experiences and manifestations of stigma may be localised and vary according to the cultural context [ 39 , 40 ].

This study aims to utilise a qualitative approach to investigate how stigma affects the recovery of PMI through the lens of HP working in mental health settings in Singapore. Since stigmatising processes operate on multiple levels, the study adopted Logie et al. This qualitative study is part of a larger research project that examined the concept of mental illness stigma in Singapore from the perspectives of five stakeholder groups — the general public, PMI, caregivers of PMI, HP in mental health settings, and policymakers [ 42 — 44 ].

As the primary objective of the present study was the provision of actionable knowledge, it therefore adopted a pragmatic approach in health services research and did not assume any specific methodological orientation [ 45 ]. The study was approved by the National Healthcare Group Domain Specific Review Board, and written informed consent was obtained from all participants before initiating study-related procedures. Participants were recruited from March to July through direct email invitations.

These individuals were identified through purposive and snowball sampling based on their experience of working with PMI, to represent a range of professions from different organizations. The inclusion criteria for this study comprised 1 being a Singapore citizen or Permanent Resident; 2 being aged 21 years and above; 3 a healthcare professional currently working with persons with mental illness 4 willingness to allow the interview to be audio recorded.

Healthcare professionals in our study included professional care providers providing care to PMI in Singapore e. Semi-structured interviews SSI were conducted with a total of 17 health care professionals in mental health settings. Refer to Table 1 for other sociodemographic information. Before the start of the SSI, background information i. Each SSI was conducted by two study team members — one of whom would be the interviewer and the other a note-taker — and lasted between 1 and 1.

Participants were assured of confidentiality and that there were no right or wrong opinions during the written informed consent process. To ensure that information was captured accurately, the SSIs were audio-recorded and then transcribed verbatim by a member of the study team. As this study is part of a larger research project, the study team developed a topic guide see Additional file 1 consisting of open-ended questions which mainly pertained to the stigma of mental illness.

The larger research project aimed to explore the concept of stigma from various stakeholder perspectives, to gain a more in-depth understanding of this complex phenomenon in Singapore. Building on existing quantitative research in Singapore relating to stigma, it delved further into specific existing gaps in current knowledge.

The study, therefore, sought to identify both specific reasons for stigmatising attitudes, as well as interventions that may help reduce the stigma, which in turn will be used to help inform future anti-stigma initiatives and ultimately reduce stigma towards mental illness.

The team developed the questions in the topic guide utilizing the recommendations by Krueger et al. Team members conceptualised potential questions pertaining to the objectives of the study, and one study team member drafted the questioning route, reordered, and paraphrased the questionnaire to generate a logical flow.

This draft was subsequently circulated among the team members and suggestions were included. Decisions to exclude questions were based on their relevance in eliciting responses to the research objective and all final decisions for the questions were made by the lead investigator MS.

Can you tell us more about it? All interviewers in the study utilised this topic guide comprising the final questions to ensure a uniform approach to data collection. The data were analysed using inductive thematic analysis, which includes the familiarization of the data, coding, generating themes, reviewing themes, and defining and naming themes [ 48 ]. During this preliminary analysis of SSI transcripts, study team members familiarised themselves with the data and highlighted quotes of relevance in the transcripts which could be grouped into axial codes, before proposing themes representative of an abstract concept which their axial codes could be classed under.

Themes for the preliminary codebook were then generated via an iterative process of grouping axial codes with similar concepts into themes based on their common properties, while axial codes with the distinct concept were grouped to form separate themes. Finally, consensus on any disagreements regarding codes and themes was reached through discussions and iterative review, and the preliminary codebook was thereby developed.

The codes were specified with the following: label, definition, inclusions and exclusions, and typical and atypical exemplars from the raw data. Using the preliminary codebook, three members of the study team GTHT, CMJG, WJO independently coded three similar transcripts, and held separate meetings after coding of each transcript to discuss their findings i.

The codebook was updated after each meeting, and the final revised codebook was established after the third coding, when team members agreed themes were useful and accurate representations of the data, no new themes could be derived from the data and had no difficulties coding with the current existing themes. To promote understanding and consistency across the team, the final codebook included definitions and example quotes under each theme.

Upon achieving a satisfactory Kappa score of 0. The results of this study are based on secondary data analysis of the transcripts. Although the main topic explored pertains to stigma, the study team noticed that discussions about the impact of stigma on recovery recurred in all the interviews, which led to the formulation of the research question in this study.

All analysis and inter-rater reliability tests were performed using Nvivo V. QSR International. NVivo Computer software. The results of this study were organised into three overarching multilevel categories, which also comprised themes and subthemes refer to Fig. To ensure that standard usage of English is maintained, minimally corrected verbatim quotes are presented.

Stigma-related factors that affect recovery organised in a multilevel structure. So, they hope to get friends or even relationships, and I think they fear that they will be rejected. They know themselves that they are in a manner disadvantaged, and that greatly reduces their self-esteem. That greatly reduces their self-esteem in being able to get to where they could have achieved, you know, even better.

The results also revealed that mental-health-related stigma is embedded in the community and social norms meso level. The participants highlighted instances of dismissing, shaming, and excluding PMI and people associated with the stigmatised group i. Where have you gone? So, to them every day is a struggle, every day is a battle you know. All they get is all these mixed… sometimes wrong impression on the people that they work with.

Two subordinate themes were identified pertaining to how stigma by association experienced by HP is a major contributor to feelings of burnout and compassion fatigue that subsequently hinders treatment and recovery of PMI.

Participants revealed that often the value of their profession is minimised by the general public and peers. These concerns were particularly addressed by psychiatrists who disclosed that they were constantly compared to their peers i. Comparably, psychiatry is deemed a less reputable career choice. Individuals were also less encouraged to pursue psychiatry in medical school. You know as a medical student, there is a stigma against psychiatry.

Nobody ever encouraged us to take up psychiatry. These responses illustrated the presumed notion that caring for PMI meant that one is more susceptible to mental illnesses, that mental illnesses are contagious, and that PMI are aggressive, therefore HP often have their safety questioned at work — such assumptions can contribute to feelings of frustrations at having to explain the misconceptions about their profession, further escalating job stress.

While not directly affecting recovery, negative perceptions about their profession can spill over to the therapeutic work that HP conduct with PMI. How is the environment like? The patients there all Participants highlighted that PMI experience discrimination and exclusion within healthcare providers and other systems such as employment and legal systems macro-level.

Three sub-themes were identified under macro-level factors, namely stigma within the healthcare settings, cultural norms within the Singapore society, and structural stigma. Five subordinate themes were derived pertaining to how stigma within the healthcare settings results in suboptimal treatment for consumers. Several participants provided accounts that alluded to the existence of diagnostic overshadowing in Singapore.

Participants were asked to opine on the extent of recovery possible for PMI, and only a minority of the participants gave responses that indicated that full recovery for service users is possible. Others had a less optimistic outlook on recovery, remarking that not everyone can recover and that recovery is contingent on the type of illness, indicating that therapeutic pessimism is prevalent in the healthcare system in Singapore.

There are some conditions that are chronic and even with the best of treatments you will still be having that condition with the symptoms and impacts on your life. PMI are often misrepresented in many media avenues, and as a result, professionals too are not immune to influence from this misinformation. Another avenue was through peer influence from fellow professionals in the field who have had encounters with PMI.

When fellow peers share stories of negative experiences with PMI, healthcare professionals may experience anxiety that such an experience would occur to them which in turn results in them being fearful of PMI. So, when the person declares that they have mental illness, it gets their attention and they have to be… they are very wary, they will try to be careful.

I think they just try to be careful. Participants also mentioned the lack of adequate training among healthcare professionals in mental health settings with regards to working with and providing services for PMI. Inadequate training of these professionals, especially new professionals in the field, affects their perceived and actual self-efficacy and knowledge. As such, these professionals tend to be anxious, fearful, and less confident when interacting with PMI, holding onto their preconceived negative notions about PMI.

Because you know our training as a student nurse… And during the 3 years, 2 years, they may not have a lot of encounters with people with mental illness. But I cope with it what! She thought it was it just puberty yeah, so that to me was the discrepancy that was mentioned. A few participants also discussed how cultural influences confers a notion of shame to mental illness which discourages help-seeking. This is especially pertinent in the Chinese culture, where an individual may feel discouraged to seek help to avoid bringing shame upon the family.

The same participant also cited how cultural ideologies of masculinity can impart shame on males wishing to seek help. They feel more embarrassed about seeking help than to admit that they do have a mental condition. On the contrary, individuals who are more infused with western cultures tend to be more indifferent towards the stigma associated with help-seeking, as highlighted by a participant, further accentuating the negative influence that Eastern culture has on help-seeking.

The attribution of mental illness to supernatural or religious etiological causes was also brought up by participants as a factor that results in the deferment of service users receiving appropriate professional mental health care. Maybe these are those to me that think people with mental health issues need not see a doctor, really they should just seek spiritual help and improve their spirituality and then they will be alright.

Structural stigma is the last theme identified under macro factors. Participants mainly mentioned three structural level stigmas that compound the recovery for PMI. And even if the said PMI does end up getting hired, they might be passed up for promotion or unfairly paid because of their illness. No high er up , no employer will pay them that full rate, if they declare they have a mental illness. So, does that mean I can never be covered? The last has to do with the stigma associated with IMH which could deter patients from seeking help at IMH, even though IMH is the only tertiary mental health hospital and arguably provides the most affordable psychiatric services in Singapore.

I am not a mad man. To them IMH equivalent to? These themes were categorised into different levels to better conceptualize a model that elucidates mental health stigma in our findings see Fig. While the outcomes of this study may not be completely unique, given that certain features of stigma are ubiquitous, there are some salient points worth discussing.

A systematic review of 14 studies sheds light on some of the effective features of interventions that reduce self-stigma, such as empowering PMI and improving their self-esteem, both of which are key components of recovery-oriented practice [ 55 , 56 ]. The findings of this study also observed the detrimental effect of cultural influences in Singapore on recovery. As elaborated by participants of this study, cultural influences associate mental illness with shame, which inhibits the help-seeking intentions of the consumer.

This finding is consistent with a previous local study by Tan et al. According to the study, this cultural factor is also reflected in the devaluation of the field of psychiatry, with Chinese medical students expressing that the field of psychiatry is often undervalued, and poorly taught and that psychiatric facilities are often underdeveloped [ 58 ].

Cultural influences may also compound the recovery process for PMI on an interpersonal level. Participants in this study mentioned the attribution of mental illness to personal weaknesses or supernatural causes both of which are linked to culture by the people close to the PMI, which may result in the PMI facing greater resistance to seeking professional psychological help. Consequently, there is a delay in receiving formal treatment, and studies have shown that a greater treatment gap is associated with adverse outcomes [ 59 — 61 ].

Our findings suggest that stigma also permeates the healthcare settings in Singapore, as reported by our participants who had witnessed instances of diagnostic overshadowing by other HP. This corroborates the evidence from a previous study that documented the stigma experienced by PMI in Singapore, where PMI opined that their opinions were often disregarded by the HP [ 38 ].

In line with our findings, the literature suggests that diagnostic overshadowing is a global occurrence, which could delay consumers from receiving proper treatment and increase the risk of further health complications [ 53 , 54 ]. Therapeutic pessimism is another manifestation of healthcare stigma identified in this study, with many participants intimating that PMI will not be able to fully recover.

This aligns with studies conducted overseas, suggesting that it is not an uncommon form of stigma [ 11 , 62 , 63 ]. Participants highlighted the issue of inadequate training in the mental health field, whereby many HP are thrust into the field without having adequate support. Some stated that when first joining the field, they had low perceived and actual self-efficacy, and a lack of knowledge with regards to PMI.

In that case, HP at the nascent stage of their career are likely to be oblivious to their preconceived negative beliefs and attitudes towards mental illness. Moreover, they are also more susceptible to misinformation and misconceptions about mental illness from their peers and the media as compared to their more veteran peers as they are less likely to have developed the tools and first-hand experiences to counter misattributions.

This was especially seen among professions whereby their training programmes do not allow for experiences with PMI — for instance, responses revealed that nursing programmes do not have mental health training before their posting to mental health services.

The lack of proper training often leads to HP not being adequately prepared to interact with PMI or debunk negative attitudes and myths - these issues often lead to anxiousness and fear when interacting with PMI, resulting in a tendency to avoid PMI and desire for a greater social distance towards PMI [ 11 ]. As a result, this ultimately jeopardises the therapeutic relationship, adherence to treatment for PMI, and ultimately recovery [ 26 ].

The study also explored associative stigma experienced by HP from the perspective of hindering recovery among PMI. Salient issues highlighted were the negative assumptions the public have about HP, and a general pattern of job devaluation experienced by HP.

Similar studies have addressed this issue, whereby HP working closely with PMI are often viewed as less skilled and less competent than their counterparts [ 19 , 21 , 67 ]. This is akin to some of our participants suggesting that they were discouraged from joining psychiatry during medical school. A recent Singaporean study revealed that while doctors in mental health settings were more likely to experience moderate stigma, nurses were more likely to experience both moderate and high associative stigma [ 70 ].

Negative perceptions about these HP might spill over to their jobs and increase job stress [ 20 , 71 ]. Previous studies have emphasised the connection between associative stigma and burnout, dissatisfaction, and compassion fatigue, which negatively affects the way practitioners interact with PMI, jeopardizing the quality of care [ 18 ].

Lastly, our findings also unearthed practices at a structural level that HP perceived as discriminatory, and exacerbating the challenges that PMI face in their recovery.

Perhaps a difficulty that insurance companies face in providing PMI with coverage for physical health problems is that people with serious mental illness are associated with a higher risk of physical comorbidity and a shorter lifespan [ 76 ].

However, for insurance companies to exclude PMI who have sustained recovery and are otherwise physically healthy from getting insurance plans that provide physical coverage or to charge them higher premiums would be inequitable. As such, to mitigate this particular barrier to help-seeking, there may be a need for policymakers to press for legislative changes in the realm of insurance. For instance, insurance companies could shift towards a case-by-case basis to evaluate applications from PMI and be more transparent about their underwriting process, instead of rejecting PMI without providing concrete reasons.

Such a shift could reduce stigma on a structural level and promote equity for PMI, concomitantly sending across a message that recovery is possible and that PMI are not markedly different from the lay public.

An interesting finding that our study came across is the stigma associated with IMH the state mental hospital which could potentially deter individuals from seeking help, or more specifically seeking help from IMH. An earlier local study showed similar results, where it was reported that for individuals with non-schizophrenia disorder, greater stigma was associated with being treated by IMH as compared to being treated in a university hospital [ 78 ].

In contrast, individuals with schizophrenia in that study reported a greater degree of stigmatisation in general hospitals as compared to at IMH. Chee and colleagues [ 78 ] posited that their finding might be attributable to the fact that there are disease-specific and institution-specific aspects of stigma because the proportion of patients with schizophrenia only comprises a fairly small percentage in the general hospital and so the demographic of psychiatric patients in the general hospital is more heterogeneous, whereas IMH comprises largely patients with schizophrenia as it caters to most of the persons with schizophrenia in the country.

Another plausibility for this aversion towards IMH could be the fact that a general hospital treats a variety of health conditions, and one could better conceal their mental health condition by seeking treatment at a general hospital [ 81 , 82 ].

Nonetheless, it is recommended that more studies be carried out to affirm the hypotheses of this finding, as well as research for effective strategies to eradicate such stigma.

To attenuate the impact of healthcare stigma identified in this study, there is a need to also focus anti-stigma efforts on HP, and we postulate that it would be helpful to take reference from the work by Knaak and colleagues [ 84 ]. Knaak et al. Such forms of social contact are likely to increase empathy and diminish fear of PMI.

Conceivably, the reduction of stigma would also lead to a decrease in instances of diagnostic overshadowing or the tendency for HP to reject working with PMI.

Knaak and colleagues also proposed emphasizing that recovery is possible and demonstrating the impactful roles that HP play in this process [ 11 , 84 ], which could alleviate some of the pessimistic views about recovery held by HP. Implementing recovery-oriented models of care would probably be another effective approach to counteract therapeutic pessimism.

This way, recovery would no longer be framed as an end state characterised by the decrease of symptoms and disabilities. Rather, when recovery is regarded as a process as in recovery-oriented practice, the aim would be to support PMI in a way to inspire hope and see beyond the illness, as well as giving more agency to the PMI in their recovery goals setting [ 4 , 55 ].

Moreover, some studies have shown that recovery-oriented practice is associated with better therapeutic alliance [ 85 , 86 ], and research has indeed evinced that better therapeutic alliance is linked to positive outcomes such as reduction of psychiatric symptoms and improvement in quality of life [ 87 ], further substantiating the advantage of implementing recovery-oriented practice.

Additionally, the vulnerability of HP working closely with PMI to associative stigma calls for implementations that address the challenges that healthcare professionals might experience. It is important that healthcare professionals, especially those new to the field, are aware of such stigma, and able to identify how it affects their job-related tasks.

Bladon suggested that one possible way of mitigating stigma is by celebrating the uniqueness of these professionals through public means [ 88 ]. Emphasising the unique and positive contributions of HP working with PMI through public education does not only increase the positive identity of these professionals but also possibly can enhance client outcomes through reducing mental illness-related stigma and giving a platform for HP to copiously advocate for patient care [ 89 ].

Even though associative stigma is experienced, it is essential that these HP still can maintain pride in the profession and acknowledge that the work that they do is valuable [ 21 ]. There are a couple of limitations pertaining to this study that need to be highlighted.

Firstly, most of the participants in this study were affiliated with IMH, and it is possible that the findings of this study would not be generalizable to HP working in other hospitals or private settings. Secondly, the sample of this study consisted of HP from various occupations, and there might be unique viewpoints from the various specific occupations which were not elucidated in this study. Furthermore, since participation was voluntary, it is probable that many of our participants are strong advocates of anti-stigma work, and they may hold views that are disparate from those who are not.

Lastly, although participants were assured of confidentiality, it is possible that they were not completely candid in their discussions and had withheld some personal views, which could be in part attributed to social desirability bias as well as a fear of expressing opinions that might have implicated other organizations or hospitals.

Based on the above limitations, it is recommended for future studies to sample only HP of a particular occupation, or to include only HP from general hospitals and private settings, to allow for a more diverse understanding of how stigma influences recovery.

These limitations notwithstanding, our study presents an early attempt to examine how stigma influences recovery from the perspective of HP, and also showcased important insights on the challenges that stigma poses toward recovery, the findings of which could inform policymakers of ways to improve the recovery of PMI.

The present study elucidated several determinants of stigma from the perspective of healthcare professionals working closely with PMI. A total of 17 themes were derived, and these were classified into a socioecological model to demonstrate stigma across micro, meso, and macro levels.

Findings from the study illustrated that some of the viewpoints articulated by healthcare professionals have been pervasive among other stakeholder groups — internalised stigma micro and cultural factors macro are factors that the general public have also illustrated as prevailing determinants of stigma [ 39 ].

SG and GTHT conducted analysis of the data, wrote the main manuscript text, and prepared tables and figures. MS provided supervision for the study and conducted critical review of the manuscript. All the authors listed have gone through the manuscript and agreed to its submission. The funding body of the study had no involvement with the design of the study, collection, data analysis, interpretation, and the writing of the manuscript.

All methods were carried out in accordance with relevant guidelines and regulations. Written informed consent was obtained from all participants before initiating study-related procedures. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Published online Jul 9. Author information Article notes Copyright and License information Disclaimer. Savita Gunasekaran, Email: gs. Corresponding author. Received Mar 22; Accepted Jun The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

Associated Data Supplementary Materials Additional file 1. Abstract Background Mental health stigma is one of the most prominent barriers to recovery, and it is widely known that stigma may manifest differentially in different cultures. Methods Semi-structured interviews were conducted with a total of 17 healthcare professionals who were working in mental health settings in Singapore. Conclusions The findings of this study gave us a greater understanding of how stigma influences recovery in Singapore, which could be used to guide the development and implementation of future policies and strategies to promote recovery.

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