In order to capture different perspectives in the nursing industry and effectively collect data from different levels and regions, this study used convenience sampling to select nurses who volunteered to participate in this study from five hospitals in Jinzhou and Dalian, Liaoning Province. 1) Affiliated Hospital of Jinzhou Medical University; 2) Jinzhou Kangning Hospital; 3) Wafangdian Central Hospital; 4) Wafangdian city women and Children’s Hospital and 5) Wafangdian city fourth hospital between March 2021 and June 2021. A total of 657 questionnaires were distributed, all of which were recovered. Among them, 628 were deemed valid, resulting in an effective recovery rate of 95.59%.

Inclusion criteria: 1) possess a nursing qualification certificate 2) volunteers for the study.

Exclusion criteria: 1) currently on vacation 2) Non-clinical frontline work.

This study used an online and offline method to collect data. Before distributing the questionnaire, the purpose and significance of the questionnaire were explained to the nurses, and the precautions for filling in the questionnaire were informed. After obtaining the consent of the nurses, the questionnaires were distributed to the nurses on site, and the nurses completed the questionnaires independently. The time for filling in the questionnaire was 5 to 10 minutes. After the questionnaires were completed, they were collected on the spot to check whether there were any omissions or errors. The nurses confirmed and modified them in time to ensure the integrity and quality of the questionnaires. The scales selected in this study have good reliability and validity, which can ensure the accuracy of the measurement. The researcher herself was responsible for the distribution and collection of the questionnaires, ensuring that the questionnaires were filled in within the specified time and independence during the filling process. In the process of collecting the questionnaires, the integrity of the questionnaires was checked, and the missing options were communicated and checked with the research subjects in time to ensure the integrity of the questionnaires. After the questionnaires were collected, the quality of the questionnaires was checked, and the questionnaires with a completion rate of less than 80% were deleted to ensure the scientific nature of the research. When entering the data, two people checked, and if there were any differences, the original data was found in time for verification to ensure the accuracy of the data.

Epidata Entry Mac version 13.0 was used for data entry and data documentation, SPSS for Mac version 26.0 was used for statistical analysis, and Sociodemographic data and stigma assessment scores, social distance scores, and mental health knowledge scores were statistically analyzed using the mean, standard deviation, frequency and component ratio. The Z-score was used to standardize and classify the stigma scores to explain the variability within the sample. T-test was used for comparison between two groups, one-way ANOVA was used for comparison of multiple groups, and multiple linear regression was used for analysis of influencing factors. Pearson’s two-tailed test was used to analyze the relationship between social distance from mental ill health, mental health and mental health knowledge among clinical nurses. To explore the mediating effect of social distance between mental health knowledge and stigma of mental ill health, the process bootstrap method was used, with a=0.05 as the test criterion.

Ethical approval will be obtained from the Institutional Review Board (IRB) or relevant ethics committee prior to data collection. Informed consent will be obtained from all participants, and steps will be taken to ensure the confidentiality and anonymity of their responses. Participants will be informed of their right to withdraw from the study at any time without consequences.

The study involved 628 nurses, consisting of 589 females (93.79%) and 39 males (7.21%). Regarding age distribution, young adults aged 20 to 39 comprised 77.1%, those aged 40 to 49 comprised 20.4%, and those aged 50 or older made up only 2.5%. The univariate analysis results indicate that, among sociodemographic factors, the willingness to become a psychiatric nurse is a significant factor influencing nurses’ stigma toward mental illness (P<0.0001). Further details can be found in Table 1 .

The Scale for Assessing the Stigma of Mental Illness in Nursing yielded total scores of 58.96 ± 9.38 points for nurses, 58.86 ± 9.33 points for general nurses, and 59.41 ± 9.58 points for psychiatric nurses. Specifically, the scores for violence and danger were 22.68 ± 5.71 points, for ability deficiency were 14.64 ± 3.54 points, and for irresponsibility and lack of ability were 21.64 ± 3.83 points (refer to Table 2 for specifics). To evaluate nurses’ levels of mental ill health stigma, the total stigma score for each subject was converted to a Z score. Stigma levels were categorized into four tiers: no stigma, mild stigma, moderate stigma, and severe stigma. With an average Z value of 0 and a general range of -3 to 3, a Z score below -1.5 indicated severe stigma, -1.5 to 0 indicated moderate stigma, 0 to 1.5 indicated mild stigma, and above 1.5 indicated no stigma. The analysis revealed that out of the sample, 69 cases (10.99%) exhibited no stigma, 281 cases (43.47%) showed mild stigma, 248 cases (39.49%) had moderate stigma, and 38 cases (6.05%) displayed severe stigma (refer to Table 3 for detailed breakdown).

According to Pearson correlation analysis, the mental ill health stigma score of the nursing staff was negatively correlated with social distance (P<0.0001), negatively correlated with mental health knowledge (P<0.0001), and positively correlated with social distance and mental health knowledge (P<0.01). That is, the degree of mental illness stigma of nursing staff is positively correlated with social distance, and the degree of mental illness stigma is negatively correlated with mental health knowledge. All three are correlated; therefore, this information can be used to analyze the mediating effect. For detailed statistics, please refer to Table 4 .

Structural equation modeling (SEM) was used to test complex relationships between multiple variables simultaneously, including direct and indirect effects. Utilizing the theoretical framework of Knowledge-Attitude-Practice Model, a structural equation modeling was constructed, where mental health knowledge served as the independent variable (X), social distance from mental ill health as the dependent variable (Y), and stigma of mental ill health among nurses as the mediating variable (M), while controlling for sex, age, and education level. The findings revealed significant paths: a=0.599 ((P<0.0001)), b=-0.194 ((P<0.0001)), and c’=-0.007 (P=0.078). These results underscore the pivotal role of stigma as the primary mediating factor. Moreover, they indicate that mental health knowledge influences social distance from mental ill health predominantly through the mediation of mental ill health stigma. For comprehensive statistics, please refer to Tables 5 , 6 .

The findings of this study offer valuable insights into the dynamic interrelationships among mental health knowledge, stigma, and social distance within the cohort of clinical nurses in Liaoning, China. This research underscores the pivotal role that mental health knowledge plays in influencing nurses’ attitudes and behaviors toward individuals with mental illnesses. Importantly, the mediating effect of stigma on the relationship between knowledge and social distance highlights the intricate challenges involved in addressing mental health care disparities in clinical practice. By examining these factors within the nursing profession, the study contributes to an expanding body of evidence that underscores the significance of targeted educational interventions and stigma-reduction strategies. These strategies are essential for enhancing mental health care delivery and promoting a more inclusive clinical environment.

Regarding stigma among clinical nurses, findings from this study indicated an average stigma rating of 58.96 ± 9.38 among nursing staff, with 45.54% (286 cases) from the total sample exhibiting moderate to severe stigma. These results align with those of numerous previous studies (39), indicating a prevalent stigmatized attitude among nursing staff toward individuals with mental illness. Surveys of nursing students (40, 41) revealed similarly negative attitudes toward mental illness. Notably, these attitudes were observed to be more negative in comparison to those documented in a stigma survey involving 192 caregivers, as reported by Jin Xinxia (42). This discrepancy may be attributed to variations in the timing of measurement, given that Jin Xinxia’s study focused on clinical nurses at an earlier stage in their careers. Previous research has indicated that age serves as an independent factor influencing the stigma associated with mental illness among nursing professionals, with younger individuals exhibiting more positive attitudes (43, 44).

Subsequent analyses identified variations in attitudes toward mental illness across different demographic groups. The willingness of nurses to pursue a career in psychiatric nursing can significantly influence the prevalence of mental illness stigma among nursing professionals. Nurses who express a readiness to specialize in psychiatric nursing tend to exhibit lower levels of stigma, a finding corroborated by numerous studies. These studies suggest that an interest in psychiatric nursing is often linked to more positive attitudes and reduced stigma toward mental illness. For example, a study examining the stigmatizing attitudes of nurses and nurse managers toward mental illness found that those who actively supported and assisted patients with mental health conditions exhibited lower levels of stigma (45). This suggests that nurses inclined toward psychiatric nursing roles may have a greater capacity for understanding and empathizing with individuals experiencing mental illness, thereby reducing stigma. Moreover, another study investigated the impact of psychiatric nursing courses on students’ perceptions of mental illness and the field of psychiatric nursing. The results indicated that exposure to psychiatric nursing education significantly reduced negative beliefs about mental illness while fostering more positive attitudes toward psychiatric nursing as a profession (46). These findings highlight the crucial role of education in shaping nurses’ attitudes toward mental health, emphasizing the need for targeted training programs to reduce stigma and enhance mental health care. The results of this study showed that individuals who were willing to become psychiatric nurses usually showed lower stigmatization of mental illness, which may be related to their interest in psychiatric nursing and professional education background. This pathway of action is consistent with the hypothesis of this study. Therefore, further strengthening mental health education and professional training, especially targeted courses and practice opportunities for clinical nurses, may be an effective strategy to reduce stigma, improve nursing quality, and enhance patient outcomes.

Notably, psychiatric nurses demonstrate lower levels of mental health stigma compared to their non-psychiatric counterparts (47). This observation is consistent with the results of this study, although there was no statistically significant difference in the level of stigma between general nurses and psychiatric nurses. These results imply that professional background and roles may play a crucial role in shaping mental illness stigma. The frequent exposure of psychiatric nurses to mental illness cases in their professional environment may contribute to this reduced stigma. Existing quantitative research (48) and qualitative studies (49) support the “contact hypothesis.” However, contradictory evidence exists, such as studies indicating that family caregivers may display high levels of mental stigmatization despite their close interactions with patients. This phenomenon could be attributed to the substantial emotional, psychological, and social stress experienced by family caregivers in their caregiving roles, although the specific mechanisms warrant further investigation.

The results of this study underscore the persistent high degree of mental ill health stigma among nurses, emphasizing the urgency to address, adapt, and ameliorate these stigmatizing attitudes to enhance nursing care quality.

The results of this cross-sectional investigation illuminate the complex interplay between mental health knowledge and social distancing behaviors within the realm of clinical nursing, placing particular emphasis on the intervening role of stigma associated with mental ill health. Employing mediation model analysis and Pearson correlation, our study unveiled a significant correlation between the degree of mental ill health stigma among nurses and both their mental health knowledge and social distancing behaviors. Notably, diminished levels of stigma among clinical nurses were found to correspond with heightened mental health knowledge and closer interpersonal proximity. These findings are in consonance with prior research (50), which echoes the theoretical framework linking knowledge acquisition to belief formation and consequent behavioral change, underlining the critical importance of promoting health literacy to cultivate affirmative attitudes and conduct (51). The theoretical model of Knowledge-Attitude-Practice Model (KAP) (52) is one of the models for changing human health-related behaviors, used to understand and analyze the behavior change process. It divides the change in human behaviors into three continuous processes: acquiring knowledge, generating beliefs and changing behaviors. Knowledge is the foundation, belief is the driving force, and behavior change is the goal. Through learning of knowledge, people acquire health knowledge and skills, form health beliefs and attitudes, and finally promote the creation of healthy behaviors (53). The model provides a structured approach to analyze the interaction among the three and identify gaps in education and intervention needs.

However, studies have also hinted at a discrepancy, indicating that despite possessing extensive mental health knowledge, nurses may still harbor negative attitudes toward mental ill health—a phenomenon observed across various healthcare professions (32, 54). In recent years, mental ill health has gradually received attention from society. Mental health knowledge is now disseminated through multiple channels that provide basic psychological knowledge, but does not go deep enough to encourage society to readily accept people with a mental health condition.

Furthermore, our investigation underscores the nuanced role of stigma in mediating the relationship between mental health knowledge and social distancing behaviors among nurses. While mental health literacy serves as a cornerstone for fostering empathy and comprehension toward people with a mental health condition (55), the presence of stigma may impede the translation of this knowledge into supportive actions. Our findings underscore stigma’s function as a barrier, obstructing nurses’ full engagement in social distancing practices when tending to people with a mental health conditions. This underscores the imperative of addressing stigma within healthcare settings to cultivate environments conducive to equitable and compassionate care provision.

The implications of our findings for nursing practice are profound. Recognizing the influence of mental health knowledge on social distancing behaviors, healthcare institutions can institute targeted educational interventions (56) aimed at augmenting nurses’ comprehension of mental health issues and mitigating stigma. Equipping nurses with training programs (57) focused on fostering empathy, cultural sensitivity, and effective communication skills (58) can empower them to navigate intricate patient interactions with confidence and professionalism, ultimately elevating the caliber of care dispensed.

It’s crucial to stress the significance of providing insights into interventions aimed at enhancing mental health literacy and reducing stigma among clinical nurses. This discussion delves into potential avenues for intervention:

Firstly, implementing targeted education (59) and training programs (60) tailored to the specific needs of clinical nurses can significantly bolster their mental health literacy. These programs should encompass various aspects of mental health, including common disorders, symptoms, treatment modalities, and communication strategies. Utilizing methods such as case studies (61), direct patient interaction (62), role-playing exercises, and interactive workshops (63) can foster active learning and skill development among nurses.

Moreover, developing evidence-based practice guidelines specific to mental health care can furnish clinical nurses with clear protocols and best practices for assessing, managing, and supporting individuals with mental health concerns. It’s imperative to regularly update these guidelines to reflect advances in research and clinical practice, ensuring nurses have access to the most current information and recommendations.

Encouraging interdisciplinary collaboration between clinical nurses and mental health professionals is another pivotal strategy (64). Facilitating regular meetings, case consultations, and joint training sessions can promote knowledge sharing, skill exchange, and mutual support, enabling nurses to learn from experts in the field and access specialized resources and expertise (65).

Establishing peer support networks within healthcare organizations can provide clinical nurses with a safe and supportive space to discuss challenges, share experiences, and seek guidance related to mental health care (66). These networks can help reduce feelings of isolation, normalize discussions around mental health, and foster a culture of empathy and understanding among nurses.

Launching targeted anti-stigma campaigns aimed at raising awareness, challenging stereotypes, and promoting positive attitudes toward mental ill health can effectively combat stigma among clinical nurses. Leveraging various mediums such as posters, seminars, social media (67), and workshops can disseminate accurate information, challenge misconceptions, and encourage empathy and compassion toward individuals with mental health conditions.

Creating a supportive organizational culture that prioritizes mental health awareness and inclusivity necessitates strong leadership commitment (68). Hospital administrators and nursing leaders should actively champion initiatives to improve mental health literacy and reduce stigma, allocating resources (69), providing training opportunities, and acknowledging efforts to promote positive change within the organization.

Regularly evaluating the effectiveness of interventions to improve mental health literacy and reduce stigma among clinical nurses is crucial for identifying areas of improvement and refining strategies over time (70). Collecting feedback from nurses, monitoring key performance indicators, and conducting periodic assessments can help gauge the impact of interventions and inform future initiatives.

Furthermore, it’s noteworthy that while more knowledge about mental ill health doesn’t necessarily equate to increased stigma, studies have indicated a desire for more education and experiences related to mental ill health among participants (71). Therefore, broadening the scope and depth of mental health knowledge among nurses and teaching effective patient interaction strategies may help mitigate stigma. Additionally, nurses should be equipped with appropriate coping strategies for their mental health, as the well-being of healthcare professionals can significantly impact staff and patient safety.