Perry 2020

Social Science & Medicine 255 (2020) 112974
Contents lists available at ScienceDirect
Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed
Review article
Stigmatisation of those with mental health conditions in the acute general T

hospital setting. A qualitative framework synthesis
Amanda Perry, Vanessa Lawrence, Claire Henderson∗
Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
A R T I C LE I N FO A B S T R A C T
Keywords: Rationale: Patients with long-term mental health conditions often have complex physical, mental, and social
Stigmatisation needs. They are frequent users of the acute general healthcare system, but can experience stigmatising attitudes
Discrimination and behaviours, and structural discrimination. We wished to improve understanding of stigmatisation in the
Mental health acute healthcare setting, to target areas for future intervention.
Acute healthcare
Objective: A synthesis of qualitative literature was undertaken in order to understand how patients with long-
Emergency care
term mental health conditions are stigmatised, or otherwise treated, within the acute healthcare system.
Qualitative synthesis
Critical realist Method: A theory-driven framework approach was implemented. Existing stigma theory was used to outline a
framework for categorizing stigmatising and non-stigmatising phenomena within the acute healthcare system.
Results: A systematic literature search of qualitative studies identified a sample of 51 studies that would inform
the framework. Using data in these studies, a final theoretical ‘best fit’ framework was developed. In this fra-
mework there is an overarching pattern of labelling and stereotyping, plus five ways in which patients with
mental health conditions are stigmatised in the acute healthcare system: devaluation, social control, avoidance,
rejection, and failure to act. In addition, the framework outlines positive attitudes and behaviours – valuing,
adjustment, responding, legitimising, and positive action – which contrast with the stigmatisation patterns.
Conclusions: The study offers a framework for identifying stigmatisation and positive treatment of those with
mental health conditions in an acute health setting. This framework is of potential value in targeting areas for
improved quality of care and may have utility beyond this setting and stigmatised group.
1. Background for physical problems, and not for problems directly related to their
mental health condition (Dorning et al., 2015).
People with long term mental health conditions are high users of the It is therefore concerning that patients with mental disorders report
acute general healthcare system (Dorning et al., 2015). Many with negative attitudes and discrimination in the acute healthcare setting
psychotic disorders, personality disorders, mood and anxiety disorders, (Clarke et al., 2007). Studies have shown stigmatising attitudes towards
and drug and alcohol use disorders have poor general health, with in- this group among acute care staff (Clarke et al., 2014; Henderson et al.,
creased risk of developing long term physical conditions (Hert et al., 2014), while interview- and survey-based studies of health profes-
2011; Thornicroft, 2011; BMA, 2014; Woodhead et al., 2014). Their sionals indicate that stigma may affect decision-making (Hert et al.,
overall life expectancy is considerably reduced - by one to two decades 2011; McCormack et al., 2013; Clarke et al., 2014). Furthermore,
in higher income countries such as the UK, Scandinavia and Australia, quantitative disparities in acute clinical care for patients with mental
and three decades in, for example, rural Ethiopia (Chang et al., 2011; health conditions have been widely described (Mitchell et al., 2009).
Hayes et al., 2011; Wahlbeck et al., 2011; Fok et al., 2012; Lawrence Does stigmatisation therefore lead to lower quality of care, and
et al., 2013; Nordentoft et al., 2013; Fekadu et al., 2015; Olfson et al., worse outcomes, for those with mental health conditions in the acute
2015). Patients with such mental health conditions are more likely to healthcare setting? The situation is not straightforward, due to the
attend the emergency department, and to be subsequently admitted, complexities of presentation and high social needs of such patients, who
than those without (Keene and Rodriguez, 2007; Dorning et al., 2015). are often seen as challenging (Happell et al., 2012; Shefer et al., 2014).
In a 2015 report, 81% of such admissions in English NHS hospitals were Stigmatising practices might also be mitigated by professional ethos,
∗
Corresponding author. Health Services and Population Research Department P029, David Goldberg Centre, King's College London Institute of Psychiatry,
Psychology and Neuroscience, De Crespigny Park, London SE5 8AF, UK.
E-mail address: claire.1.henderson@kcl.ac.uk (C. Henderson).
https://doi.org/10.1016/j.socscimed.2020.112974
Received 23 September 2019; Received in revised form 26 February 2020; Accepted 29 March 2020
Available online 28 April 2020
0277-9536/ Crown Copyright © 2020 Published by Elsevier Ltd. All rights reserved.
A. Perry, et al. Social Science & Medicine 255 (2020) 112974
perceived duties of care, and compassion (McCormack et al., 2013). Another useful theme of critical realism is ‘emergence’, in which
Disentangling these factors is key to ensuring that this patient group social entities can be regarded as stratified. Patterns of stigmatisation
receive high quality of care – care that is safe, effective, patient-centred, might ‘emerge’ at intrapersonal, interpersonal and structural levels.
timely, efficient and equitable (Knaak et al., 2015). This aligns with the individual and structural forms of stigmatisation, as
This study was undertaken to synthesise the qualitative literature, to described by Corrigan (2000).
better understand how patients with mental health conditions are The critical realist perspective thus allows mapping of partial reg-
stigmatised, or otherwise, in the acute healthcare system. ularities across qualitative sources of different designs, and from dif-
ferent settings, at different sociological levels. This is carried out in the
1.1. Stigmatisation current study by systematic synthesis, using ‘judgemental rationality’.
Through a critical realist lens, there is also an acknowledgement
Stigma, a ‘spoiled identity’, was originally described by Goffman that concepts such as stigmatisation are value-laden, and that in-
from an interactionist perspective (Goffman, 1963) and early stigma vestigation of stigmatisation has something to say about values (‘ethical
theory emphasised the effects of stigma on the individual. While this naturalism’). There is a dialectical aspect to social ills such as stigma,
enabled a sophisticated understanding of the effects of stigma, it hin- and identifying instances where such ills are overcome is a key step in
dered recognition of stigmatisation as a ‘doing-to’ action, and the dif- moving toward transformation (Bhaskar, 2008). To fully understand
ferential treatment of vulnerable groups may have passed un- stigmatisation, it must therefore be necessary to identify positive atti-
challenged. tudes and behaviours as well as stigmatisation, while being mindful of
More recently there has been a shift toward approaching stigma setting up a falsely dichotomous view of ‘good’ and ‘bad’ care. This
from a critical viewpoint, focusing on the individual or structure ‘doing’ might then help in understanding complexities of care, and how alter-
the stigmatising. From this perspective, stigmatisation has been aligned natives to stigma may translate to everyday practice, and thus aid in
with concepts of prejudice, discrimination and oppression (Phelan at design of a transformative approach via staff- and organisational-level
al., 2008; Scambler, 2009; Holley et al., 2012). Defining stigma as co- interventions.
occurrence of its components, of labelling, stereotyping, separation,
status loss, and discrimination, Link and Phelan (2001) assert that for 2. Methodology
stigmatisation to occur, power must be exercised. This ‘stigma power’
(Link and Phelan, 2014) is seen as a form of ‘symbolic power’, a concept 2.1. Aim
introduced by Bourdieu (1989). Proposed functions of stigma power are
to keep out-groups ‘down’, or dominated/exploited; to keep them ‘in’, The aim of this study was to identify patterns of stigmatisation in
in order to maintain social norms, and to keep them ‘away’, a process qualitative studies that focus on the care of those with mental health
characterised by patterns of avoidance (Phelan et al., 2008; Link and conditions in the acute healthcare setting.
Phelan, 2014).
In the current study we wished to maintain this critical viewpoint 2.2. Scope
and apply it to a group of people identified by a mental health condi-
tion. The Weiss et al. (2006) formulation provides a working definition The synthesis involved qualitative studies. It excluded a body of
of health-related stigma which aligns with a critical perspective: quantitative literature addressing inequalities of acute healthcare for
those with mental disorders (Mitchell et al., 2009) because many such
Stigma is typically a social process, experienced or anticipated, char-
studies are from the US, where intricacies of the health system com-
acterized by exclusion, rejection, blame or devaluation that results from
plicate analysis and interpretation. Furthermore, these studies generally
experience, perception or reasonable anticipation of an adverse social
do not illuminate the processes that lead to inequalities: there is rarely
judgment about a person or group. This judgment is based on an enduring
any distinction made, for example, between patients who were not of-
feature of identity conferred by a health problem or health-related con-
fered a procedure, and those who declined a procedure, nor whether
dition, and the judgment is in some essential way medically unwarranted.
informed choices were made, and appropriate adjustments considered.
The latter part of this definition, ‘medically unwarranted’, is perti- Qualitative studies permit deeper exploration of issues, and were
nent to the acute healthcare setting, and helps distinguish the social deemed more useful in developing a theory-based model.
process of stigmatisation from ‘ordinary’ categorisation, clinical deci-
sion-making, everyday frustrations and pragmatics of acute patient 2.3. Study design
care.
The current study also differentiates stigmatising attitudes from Methodologies for qualitative synthesis are diverse. Most are based,
stigmatising behaviours, as proposed by Thornicroft et al. (2007a,b). like the primary literature they aim to synthesise, on inductive tech-
Within ‘stigmatising attitudes’ we include emotional responses, which niques. Since we wished to use existing stigma theories to drive the
Link et al. (2004), added to their earlier stigma conceptualisation. synthesis, however, we chose a deductive ‘best fit’ framework approach
to synthesis, that utilises and expands on an a priori conceptual model
1.2. Critical realism (Carroll et al., 2011). As a variation of this approach, stigma theory was
used to define the preliminary framework.
This study was designed within a critical realist paradigm (Bhaskar, Existing theoretical models of stigma were used to construct an a
2013) which has been proposed as a useful metatheoretical approach to priori framework (Table 1). This framework incorporated the ‘down’,
qualitative synthesis (Brannan et al., 2017). ‘in’ and ‘away’ stigma functions described by Phelan et al. (2008). The
The components of critical realism are ontological realism, epis- framework also distinguished stigmatising attitudes from stigmatising
temic relativism, judgmental rationality and a cautious ethical nat- behaviours (Thornicroft et al., 2007a,b), and individual and structural
uralism (Archer et al., 2016). Critical realism regards constructs such as forms of stigmatisation (Corrigan, 2000). Also incorporated were
stigmatisation as reflecting an underlying social reality (‘ontological ‘contra-stigmatising’ attitudes and behaviours.
realism’) – however, epistemologically we cannot ‘know’ this reality.
We need to be aware of this limitation (‘epistemic relativism’), and 2.4. Search strategy
social processes like stigmatisation need to be interpreted contextually
and relatively. We can, however, identify partial regularities that help The search strategy was designed to keep the total yield manageable
to understand ways in which stigmatisation operates. (see Table 2). Only English language studies from 1996 to 2019 were
2
Table 1
A priori analytic framework matrix'.
STIGMATISATION CONTRA-STIGMATISATION
Professional attitudes Professional behaviour Structural/organisational behaviour Professional attitudes Professional behaviour Structural/organisational behaviour
Keeping ‘down’/Devaluation Valuing

Keeping ‘in’/Social Control Tolerating/Making Positive Adjustments
Keeping ‘away’/Avoidance Responding
included. Criteria were grouped in columns and search words in each Forwards chaining was undertaken by identifying papers that had cited
column searched simultaneously (eg Mental OR Schizophren* OR Bi- those in the sample, in order to identify more recently published papers
polar OR …). Initially, the group combinations shown in the table were of significance. Abstracts and full texts were screened by the primary
searched for in Titles only. Study design was then added as a further reviewer (AP) according to the screening sheet in Fig. 1.
constraint, focus terms searched within Titles, and remaining terms
searched within Titles and Abstract.
2.6. Study selection
{FOCUS AND (Setting OR Comorbidity) AND (Perspective OR
Differential OR Decisions)} [Titles]
After appraisal of the full text by the primary reviewer (AP), studies
OR were selected on the basis of two further criteria: if they were relevant
to the aim of the current study, and if they had internal validity.
FOCUS [Titles] AND {(Setting OR Comorbidity)[Titles/Abstract) AND
Perceived quality of a study was not used as a criterion as we believed
(Perspective OR Differential OR Decisions) [Titles / Abstract) AND
that studies of relatively low quality might still contain useful findings.
(Study design) [Titles / Abstract}
Care was also taken to ensure widest possible variation of features in-
The searches were initially undertaken in 2016 for years cluding study type, subgroup of patients studied, geographical setting,
1996–2016, and repeated in August 2019 for years 2016–19 only. The and type of participant.
following databases were searched: Medline/Pubmed/Google Scholar/ Study relevance was regarded as any of: direct exploration of
Embase/Psycharticles/Psychinfo/HMIC/Social Policy and Practice/Global stigma; examination of professionals’ attitudes; reports or investigation
Health/Web of Science/Social Science (Proquest)/British Nursing/Applied of differential care and naturalistic studies of the acute healthcare of
Social Sciences Index & Abstracts/Cumulative Index to Nursing and Allied those with mental health conditions. Where this was a clear central
Health Literature/King's College London Library/Cochrane/Public Health/ feature of the study, this study was deemed to have strong relevance to
King's Fund/Picker Institute/Healthwatch/National Institute for Health and the synthesis.
Care Excellence (NICE)/Social Policy Research Unit. An example search is Internal validity was judged using criteria of consistency and logic:
illustrated in the Appendix. that is, the aims and objectives, the methods of data collection and the
analyses and presentation of findings were derivable from the metho-
2.5. Sampling strategy dology. For narrative pieces such as case reports, there needed to be a
sequential account of events, rather than simply description and opi-
Due to the theory-driven aims of the study and the divergent subject nion. Logical consistency was judged by the primary reviewer (AP) and
matter, a closed ‘set’ of studies for inclusion in the review was not papers of uncertain internal validity were discussed within the group
sought. Like previous authors of syntheses (Dixon-Woods et al., 2005), monthly alongside those of debatable relevance.
we used sampling techniques derived from primary qualitative re- After discussion, the studies were divided into two groups: the
search, including purposive sampling, maximum variation and snow- primary sample for analysis and a secondary sample. The secondary
balling, to identify the literature sample. In our approach, we generated sample consisted of studies that fulfilled inclusion criteria only to a
a large sampling frame from an initial broad search, using varied search limited extent (for example, where much of the study was quantitative
terms and large number of databases. Inclusion and exclusion criteria in design), or that were only tangentially relevant, or that were from
were used to narrow the sample (see Table 3). In complex studies that ‘grey’ (unpublished) sources such as doctoral theses. Reviewers con-
met both inclusion and exclusion criteria, studies were retained for sidered the possibility that these studies might contain patterns of
further appraisal. stigmatisation that would be overlooked in the framework. These stu-
Snowballing was used to expand the sample by backwards and dies were therefore maintained to ensure completeness and check va-
forwards chaining. Backwards chaining was achieved by appraising lidity of the framework after it was developed (see below).
studies drawn from the references within the literature sample.
Table 2
Search strategy in which columns are combined, initially within titles, and then, constraining by study design group, within titles/abstracts.
SETTING FOCUS COMORBIDITY PERSPECTIVE DIFFERENTIAL DECISIONS DESIGN
Acute Mental Trauma Experience Equity Decision-making Qualitative
Emergency Schizophreni* Coronary Satisfaction Inequity Rationing Interview*
Medical Bipolar Cardiac Empower* Inequality Priorit* Focus Group*
Hospital Personality Disorder Heart Perspective Fairness Triage Ethnograph*
Homeless Myocardial View* Stigma Resuscitation Observation*
Addict* Respiratory Perceived Discrimination Delay
Substance Chest Attitude* Prejudice Diagnostic overshadowing
Depression Abdominal Perception Stereotype
Eating Disorders Musculo-skeletal Futility Inclusive
Self-harm Stroke Disparity
Self-poisoning Neurological Marginalised
Injury
3
Table 3
Inclusion and exclusion criteria.
PARTICIPANTS SUBJECT FOCUS SETTING OR SPECIALISM TYPE OF STUDY
INCLUDED Health professionals Severe mental disorder including Acute healthcare (Emergency Department; Acute Qualitative
Patients substance use disorder wards) Primary studies
Carers
EXCLUDED Students Common mental disorders Primary care Purely quantitative (including
Non-healthcare Dementia Outpatient care psychometric measures)
professionals Intellectual disability Elective (non-urgent) care Interventions
Cancer care Evaluations
Specialist mental health care Reviews
Off-site focus e.g. interviews with staff in a non-professional Syntheses and meta-analyses
context, or patients about their general life experience
Fig. 1. Screening sheet.
2.7. Data extraction 2.8. Framework development
Data extracted from studies were any that were considered as stig- Data were fitted, where possible, into the a priori framework by the
matisation after appraisal and, where necessary, group discussion. This primary reviewer (AP). Primary data and descriptions of findings that
might describe a professional's attitude - either cognitive or emotional - did not appear to belong in the matrix were recorded separately. At
professional behaviour, or organisational structure. The Weiss et al. monthly meetings, the emerging matrix was reviewed, and fitting of
(2006) definition of stigma above was considered in identifying re- data within categories was critiqued, with reference to original papers
levant data. Specifically, stigmatisation was identified if attitudes, be- to provide context where necessary. Decisions to leave data out of the a
haviours or structures appeared to arise from an adverse social judg- priori matrix were critically challenged, and this data was set aside.
ment based on the presence of a mental health condition, and if that Non-fitting data were discussed as ‘deviant cases’ and commonal-
judgment was medically unwarranted. In some instances, where the ities were sought. New categories were proposed to the group, with
text did not make some of these aspects clear, discussion among re- reattempts to fit the data into these categories. This continued until the
viewers was used to decide whether a particular instance should be expanded framework was considered to encompass all identified pat-
considered stigmatisation. terns of stigmatisation of those with mental health conditions in the
Data were extracted from the results sections of individual papers sample pool, as well as contrasting examples of positive treatment.
and included descriptions of primary data, and examples of primary The final framework was applied to the secondary sample to ensure
data (usually quotations). saturation of concepts and validity of the framework. This technique
corresponds to that described by Lincoln and Guba (1985) as ‘refer-
ential adequacy’. It also served to overcome any issues of reliability,
4
Fig. 2. Sampling strategy and framework development flowchart.
where individual appraisers might differ as to the relevance of the stigmatisation had not become identifiable since the original search. A
study, as less relevant studies were maintained in the second sample. An flowchart for this study (Fig. 2) is included to provide an idea of the
updated search sample for the years 2016–2019 was also checked iterative processes involved.
against the final framework, to ensure that further patterns of
5
3. Results 3.3. Patterns of stigmatisation
3.1. Literature sample 3.3.1. Labelling and stereotyping

Findings suggested that patients with mental health conditions in
The initial search yielded 2345 papers, with the updated the acute care system were seen as different. Even when presenting
(2016–2019) search adding a further 889 papers. 153 abstracts that met with physical problems, these patients were not always absorbed into
inclusion criteria were screened. The full texts of these papers were the day-to-day work of the emergency department, but were identified
analysed for exclusion criteria, and 89 papers that met criteria were as a particular, and often problematic, group.
selected for a snowballing approach using backwards and forwards A significant part of the work of the acute healthcare system lies in
chaining. Backwards chaining was achieved by selecting relevant stu- the appropriate sorting of patients, and in setting priorities via triage. It
dies from the references within the paper, and forwards chaining using is a time-pressured, process-driven system, where categorisations, in-
the ‘cited by’ function of Google Scholar. A pool of 199 papers were cluding medical diagnoses, are necessary for pattern recognition and
then appraised in full, and 51 papers were sub-divided into a main patient profiling. In the study sample, however, negative associations
sample (26 papers) and a secondary sample (25 papers). The main such as ‘demanding’, ‘challenging’, ‘difficult’ or ‘aggressive’ were fre-
sample consisted of 26 papers of relevance published between 1996 and quently attached to those with mental health diagnoses. There were
2016 (Malone, 1996, 1998; Hopkins, 2002; Decoux, 2005; Liggins and negative stereotypes of subgroups of patients – alcoholics, or the
Hatcher, 2005; Kerrison and Chapman, 2007; Clarke et al., 2007; Hume homeless, for example. Simply having any psychiatric diagnosis might
and Platt, 2007; Henderson et al., 2008; Hadfield et al., 2009; Hall be enough to affect care.
et al., 2011; Marynowski-Traczyk et al., 2011; Muzaffer et al., 2011;
‘Once you have been labelled as having a psychiatric illness, it's very
Gerdtz et al., 2012; MacNeela et al., 2012; Doran et al., 2013, 2014;
difficult to put that label to one side’. (Doctor, Van Nieuwenhuizen
Paterson et al., 2013; Van Nieuwenhuizen et al., 2013; Chapman and
et al., 2013).
Martin, 2014; Jackson et al., 2014; Morgan, 2014; Shefer et al., 2014;
Ackerman et al., 2015; Giandinoto and Edward, 2015; Renker et al., Negative labels were written into the patient's record, and lists kept
2015). These contributed the data for the framework development. The in the emergency department of ‘disruptive’ or ‘drug-seeking’ patients.
secondary sample consisted of unpublished works (4 studies); published Labels could remain with that patient and be presented as shorthand
works of lower relevance (10 papers), and papers from an updated information while handing over patients: for example, ‘abusive’, or
search, from 2016 to 19 (11 papers) (Chandler, 1997; Dodier and ‘difficult historian’.
Camus, 1998; Solar, 2002; Mondragon et al., 2008; Nugus, 2009; Van
‘If the pigeon-holing of the patient into ‘drug-seeking’ happens at triage,
Den Tillaart et al., 2009; Lau et al., 2012; Sivakumar et al., 2011; Blay
then I think it's difficult to get that patient out of that niche.’ (Doctor,
et al., 2012; Crowe, 2012; Knowles et al., 2012; Jelinek et al., 2013;
Henderson et al., 2008).
McCormack et al., 2015; O'Carroll, 2015; Owens et al., 2016; Brunero
et al., 2017; Noblett et al., 2017; Parkman et al., 2017; Wise-Harris
et al., 2017; Yap et al., 2017; Digel Vandyk et al., 2018; Thomas et al.,
2018; Carusone et al., 2019; Collom et al., 2019; Fleury et al., 2019). 3.3.2. Devaluing. Social judgement and attitudes
The studies are listed in the supplementary online appendix. In the literature sample, there were occasional examples of explicit
The full sample comprised interview and focus group studies (28 denigration of patients with mental health conditions. In one older
studies), ethnographies (8 studies), case reports (4 studies) and 11 study, frequent users of the emergency department – a vulnerable po-
mixed or other studies. The studies addressed: acute physical pre- pulation with a high population of patients with mental illness, drug
sentations to hospital in those with mental disorders (3 studies); the and alcohol dependence – were described as ‘animals’ or ‘subhuman’ by
acute general healthcare of those with mental disorders (16 studies); nurses (Malone, 1996). In more recent studies, patients with mental
tangential socially-defined groups in the acute hospital setting (the health conditions were described as weak, with lack of self-direction,
homeless; frequent attenders; violent patients) where those with mental expectation or ability to cope. They were perceived as a drain on re-
disorders featured significantly (11 studies); those with substance or sources - material resources, staff, and space - and as a burden on the
alcohol use disorder and physical health needs in the acute hospital Emergency Department. Staff felt their time could be better spent on
setting (10 studies); those with an acute presentation related to self- other patients:
harm (5 studies); those with a physical presentation and co-existing
‘ … they are taking you away from being with someone who is in crisis
mental disorder who declined intervention (4 studies); and un-
and really needs you.’ (Nurse, Paterson et al., 2013).
categorised relevant studies (2 studies). Sources of primary data were
healthcare professionals (23 studies), patients (13 studies), and mixed
or other sources, including ethnographies (15 studies).
3.3.3. Devaluing. Professional behaviour
3.2. Remodelling of a priori framework In the emergency department, although there were protocols for
mental health conditions, the triage system was felt to work better for
Extracted data were fitted into the starting framework. Following those with straightforward physical problems. Patients with complex
discussion, it was agreed that the data from the sample did not com- needs or communication difficulties were compromised by the brevity
pletely map to the a priori matrix. Three further categories of stigma- of triage, with nurses struggling to carry out the type of assessment they
tisation were proposed to best fit the findings: ‘rejection’, ‘failure to act’ felt was necessary.
and an overarching ‘labelling and stereotyping’.
‘With mental health, there is a time factor. I know that out in triage that I
The manifestations of mental health stigma identified in the acute
don't have the time.’ (Nurse, Marynowski-Traczyk and Broadbent,
healthcare setting were therefore: devaluation; social control; avoid-
2011).
ance; rejection, and failing to act, plus labelling and stereotyping as an
overarching concept. These patterns of stigmatisation were identified in Once admitted to the department, clinical assessment was also often
the attitudes of health professionals, in their behaviour, and in the unsatisfactory. Targets to rapidly dispatch patients deterred clinicians
structure and organisation of acute care. Positive attitudes and beha- from detailed history-taking, from seeking the views of carers, or from
viours were also identified that operated as antitheses to these patterns doing full investigations – particularly problematic for patients with
of stigmatisation. The iterated framework is outlined in Table 4. complex presentations.
6
Table 4
Iterated framework.
PATTERNS OF STIGMATISATION STEREOTYPING AND LABELLING (OVERARCHING)
DEVALUATION SOCIAL AVOIDANCE REJECTION FAILURE TO ACT

CONTROL
Social judgement about patients with Lower worth Deviant Unwelcome Not urgent Unable to be helped
mental health conditions Not ‘real’
Not deserving
Attitudes Denigration Disapproval Discomfort Blaming Frustration
Disallowing
Professional behaviour Compromised care Shaming Physical avoidance Diagnostic overshadowing Inaction
Bargaining Emotional Requests withheld Failure to consider legal options
Confronting detachment
Organisational behaviour Lower priority group Segregation Abdication of Exclusion Absence of structural mechanisms to
Insufficient resources for Surveillance responsibility Ejection assess capacity or risk to self because
complexity of need Restraint of mental state
Unsuitable environment Law enforcement
Low training priority
Counter-judgement Valued, equal Accepted Welcomed Legitimate Meriting positive action
Positive treatment Prioritisation Tolerance Responsiveness Inclusion Active care
Equity of care Adjustments Acting in best interests of one who
lacks decision-making capacity
3.3.4. Devaluing. Organisational behaviour Potential disruption by patients added a weight of responsibility and
The environment of the Emergency Department was noisy, over- an extra burden of duty as the health professional tried to maintain
crowded and distracting, and lacked privacy. Often designed purely for social boundaries and avoid exacerbating undesired behaviour.
physical injury and illness, it was seen as a ‘poor fit’ for those with Clinicians that allowed patients to behave outside the accepted norm
mental disorders (Marynowski-Traczyk and Broadbent, 2011). This, were seen as complicit.
coupled with long waits, predisposed some with mental health condi-
‘We condone bad behaviour by giving (pain) meds to verbally and
tions to leave before being seen, or against medical advice.
physically abusive people.’ (Healthcare professional, Renker et al.,
‘You'd be waiting … sitting there all night and then by the morning I 2015).
suppose … it's more important like to get some drink into you than the
{chest} pains that you had the night before.’ (Patient, O’Carroll, 2015).
3.3.6. Social Control. Professional and organisational behaviour
Staff training priorities were reported to de-emphasise mental Healthcare professionals used a number of strategies to achieve
health conditions and associated problems like homelessness. social conformity. These included bargaining with patients, trying to
Furthermore, personnel that might aid healthcare for this patient group, ‘outwit’ them, being firm or shaming them. There was often an element
such as a liaison psychiatry service, drug and alcohol advisers, patient of coercion:
advocates and social workers, were frequently either unavailable
‘You have to stay in bed, and you will have to behave or else we will put
during off-peak hours - often a peak time for mental health admissions -
this back on.’ (Healthcare Professional, MacNeela et al., 2012).
or not available at all.
Anticipated disruptive behaviour was deterred or circumvented by
‘So the time when we need [the crisis team] is usually at three in the
making patients wait longer before being seen, by physical segregation
morning on Sunday or Saturday night, and they don't come to work until
or by instigating surveillance. Patients were searched, or continuously
Monday’. (Healthcare Professional, Jackson et al., 2014).
watched by staff or by security. Disruptive behaviours were often
managed by the use of physical or chemical restraints, or by legal
3.3.5. Social control. Social judgement and attitudes structures.
One proposed function of stigma is to maintain social norms (Phelan
et al., 2008; Link and Phelan, 2014). There were many examples in 3.3.7. Avoiding. Social judgement and attitudes
which patients with mental health conditions were perceived as be- In a few studies, staff conveyed disgust or discomfort towards those
having outside the norm. Behaviours poorly tolerated by emergency with mental health conditions. This was sometimes on behalf of other
department staff included patients being verbally or physically de- patients.
monstrative, swearing, smoking inappropriately or endangering their
‘Just a bloke sitting there muttering to himself in an incoherent fashion
own healthcare by not complying with medical advice.
wouldn't worry me but if you're sitting (in the waiting room) six foot from
Anticipation of disruptive behaviour might arise from previous ex-
him for an hour and half it's fairly uncomfortable … to have to sit there
perience of a patient, particularly in the case of frequent attenders, but
and tolerate it … it isn't very nice for them.’ (Healthcare Professional,
could also follow from group stereotyping:
Knowles et al., 2012).
‘My past experiences or when I hear about other staff's past stories …
negative stories about IV drug users, I always suspect the worst.’
3.3.8. Avoiding. Professional behaviour
(Healthcare Professional, Giandinoto and Edward, 2015).
Discomfort around those with mental health conditions could
Escalation of danger to healthcare staff, the public, or the patient manifest as avoidance of their psychological needs. Staff feared getting
was also anticipated. ‘too involved’, overwhelmed by emotional outpourings, or having their
own sanity challenged. Asking questions about patients' past lives was
‘High medication schizophrenics disorders - they look at you like they are
avoided because staff found some morally uncomfortable.
just about to stab you and it's scary.’ (Nurse, Brunero et al., 2017).
‘{He} told me that he had molested a child and I said, ‘Oh god, I don't
7
think I can take care of this man anymore’’. (Nurse, Crowe, 2012). Some patients were seen as ‘scamming’ - presenting a proxy com-
plaint for secondary gains which were not themselves regarded as le-
Patients might also be avoided physically due to fear of violence.
gitimate. These might be basic needs, such as shelter, food, clothing,
‘I won't go back near the patient … you don't want the patient kicking off showers, pain control, or social contact.
and getting angry’ (Nurse, Van Nieuwenhuizen et al., 2013).
‘And they just come here – change of scenery, ride across town, maybe
Professionals would sometimes avoid undressing patients for as- some food … Medicine for aches and pains is, like, secondary.’ (Nurse,
sessments, or might make fewer clinical observations, or interact for Malone, 1998).
shorter periods with the patient. Communication between staff and
Scammers could also, according to acute care staff, be misusing
patients would be limited to what was considered essential, deliberately
medication. Behaviour such as ‘clock watching’, requesting analgesia at
maintaining emotional distance.
the shortest prescribed interval, or asking for medication by name,
‘By having a set protocol, you're removing any thoughts about the patient could suggest that the patient was a ‘drug seeker’. Others, once labelled
yourself.’ (Doctor, Hadfield et al., 2009). with a mental health condition, were interpreted as faking physical
symptoms or exaggerating pain. Self-harmers were accused of lacking
Conversation about the patient's mental state was thus evaded,
serious intent.
particularly if there was a coexisting physical problem.
‘If they have taken a small amount of a drug that is harmless, I see it as
‘I haven't really got training to sit and talk to them about, you know, their
attention-seeking and such behaviour should not be rewarded by giving
problems and counsel them, so I tend to leave them alone after they have
more attention.’ (Healthcare Professional, Chapman and Martin,
been medically treated.’ (Nurse, Hopkins, 2002).
2014).
Lastly, certain behaviours of those with mental health conditions
3.3.9. Avoiding. Organisational behaviour were regarded as morally ‘bad’, and thus non-legitimate, if patients
At the organisational level, avoidance was often achieved through were seen to have caused or contributed to the presenting problem.
transfer of care to the mental health service. Although one of the Clinicians would resent the care that was given to these ‘undeserving’
functions of the Emergency Department is to divert patients toward patients. This was particularly the case for those who had self-harmed,
specialty assessments, studies suggested that, for mental health referral, and those with substance and alcohol use disorders.
transfer of responsibility was more abrupt and more absolute.
‘Once you are in psychiatry you don't go back to medical.’ (Patient, 3.3.11. Rejecting. Professional and organisational behaviour
Liggins and Hatcher, 2005) Non-legitimate patients could be rejected by confrontation and
reprimand:
This created friction between professional teams. Both would try to
avoid full responsibility, the mental health service requesting that pa- ‘This is the fourth time in two weeks you've been here. What's wrong with
tients were first ‘medically cleared’, and the emergency service creating you?’’ (Junior doctor, Malone, 1996).
a sense that the patient did not belong to them and was in the wrong Care could be deliberately cursory. Requests, for example for
place. Passing patients around from service to service, with decisions painkillers, might also be rejected.
made serially, prolonged assessment and delayed intervention.
‘If I asked for pain relief [I] was treated like a junkie, they wouldn't up
‘This chap had taken quite a large overdose. {The emergency doctor's} the dose’. (Patient, Blay et al., 2012).
attitude was … ‘I'm not getting involved. Psych need to come and deal
with him.’ And psychiatry were like, ‘Well he's not been medically ‘Non-legitimate’ claims to Emergency Department resources by
cleared. We can't get involved …. ’ Unfortunately, the guy died on our those with mental health conditions resulted in patients being made to
clinical decisions unit.’ (Healthcare Professional, Shefer et al., 2014). wait longer, being excluded from the Emergency Department, or being
prevented from admission to hospital.
‘They told me in the A&E that they couldn't take me in because I was a
3.3.10. Rejecting. Social judgement and attitudes
drug addict and I made my own choices.’ (Patient, O’Carroll, 2015).
Rejection was a new category in the expanded framework. It was
associated with a judgement of non-legitimacy, in which a patient was
deemed not to be a valid patient, deserving of healthcare. 3.3.12. Failing to act. Social judgement and attitudes
The idea of non-legitimacy could be expressed in various ways. The Emergency Department is regarded as a place of critical care
There was a common perception among healthcare professionals that where patients come to be rescued, and, if possible, ‘fixed’. Those with
mental disorders themselves were not ‘real’. Clinicians distinguished mental health conditions were seen as a threat to this perspective. There
‘genuine’ physical problems from psychosocial problems, and patients was an apparent intractability of the problems for this group that re-
were presumed not to have a real problem, even when they had phy- sulted in frustration and threat of professional failure. Patients were
sical symptoms. seen as not looking after, or investing in their own health, as exhibiting
self-destructive behaviour and in not heeding previously given advice.
‘I wasn't taken seriously … there was nothing wrong with you, it's all in
They left the Emergency Department prematurely or with unmet needs,
your head.’ (Patient, Liggins and Hatcher, 2005).
and staff felt their own skillset was inadequate, that they had not done
This phenomenon, referred to as diagnostic overshadowing, could their job properly, or that their interventions were futile.
result in clinical deterioration and sometimes death, and there were
I've actually almost reached the point where I've given up a little. (Doctor,
many examples of such scenarios where physical diagnoses were in-
Doran et al., 2014).
itially missed.
A problem could also be ruled as inappropriate if it was interpreted Frequent attenders could also bring healthcare professionals to a
as ‘not an emergency’. Those attending with needs related to long term sense of hopelessness and helplessness, as strategies they had tried
health conditions, or with vague and ambiguous symptoms, were par- previously seemed to have failed.
ticularly perceived as inappropriate users of the emergency department.
‘You feel like you're spinning your wheels and you're like … I don't feel
This was even more the case for frequent attenders who could, over
I'm making a difference in your life.’ (Healthcare Professional, Doran
time, lose their claim to legitimacy.
8
et al., 2014). There were many examples where staff did not feel the need to ‘fix’
patients but saw their duties of care as simply to listen, to understand,
to comfort, to calm, and to ensure that patients left happy. Professionals
3.3.13. Failing to act. Professional and organisational behaviour
were concerned not to judge or treat people differently because of their
The behaviour, in this form of stigmatisation, was ‘giving up’.
personal histories.
Ongoing attempts at addressing patient's needs were, for example,
curtailed: My job is not to investigate their life and find out whether they're in-
nocent or guilty … It changes your opinion and you don't need to do that.
‘At some point I just try less hard … I just think they're not going to do it.’
(Nurse, Crowe, 2012).
(Doctor, Henderson et al., 2008).
Care might be interpreted as no more than providing a bed, or a
A special case of ‘failure to act’ occurred when patients declined
sandwich, and so such patients could be ‘easy’. Healthcare professionals
medical intervention. Tests of capacity were not necessarily employed
felt useful and rewarded, while patients appreciated staff ‘being nice’
or interpreted correctly, and failure to assess the decision-making ca-
and begun to reveal needs that they hadn't previously admitted. Instead
pacity of patients who refused to engage with professionals resulted in
of transferring responsibility to the mental health services, some gen-
delayed or abandoned care. Use of a legal framework to act in the pa-
eral clinicians tried to meet all their needs, physical, mental and social.
tient's best interests was an option either not considered, or, seemingly,
Staff appreciated the learning experience that these patients provided.
not properly understood.
3.4.4. Legitimising
3.4. Positive attitudes and behaviour Some health professionals took care not to miss physical diagnoses
that might otherwise be overlooked, or misinterpreted as ‘not-physical’.
Positive attitudes and behaviours were fitted into framework cate- They also recognised that what may be perceived as non-urgent or
gories that were antithetical to the five types of stigmatisation. ‘social’ problems might be matters of significance to the patients, who
had come to the emergency department because they had nowhere else
3.4.1. Valuing to turn. Staff saw a role for the emergency department as a primary
In contrast to devaluing those with mental health conditions, some healthcare service; a pathway to recovery; a safe haven; a sobering
staff made an effort to treat all patients equitably as part of their wider centre; a temporary shelter; a rehousing centre, a short-term provider of
duty of care. food, warmth and washing facilities, and as having a function in re-
‘I come here to work and this is not about me, it's about caring for this ducing social isolation. ‘Scamming’ was understood as a necessary
person.’ (Nurse, Liggins and Hatcher, 2005). means to subvert the system to get authentic needs met.
In a few examples, patients with mental health conditions were ‘It's kind of sad that you actually have to scam, you know.’ (Nurse,
prioritised above others, and staff observed that when they devoted Malone, 1998)
extra time to those with complex mental and physical health needs, Substance users’ requests for painkillers were believed as genuine,
they uncovered underlying conditions that had previously been over- and nurses advocated on their behalf to doctors. Those who self-harmed
looked. Doctors sometimes gave priority admission to those with were perceived as in genuine need of care.
chaotic lives, to ensure treatment was successful.
Staff would work hard to convince patients to stay for treatment, 3.4.5. Positive action
recognising a duty to keep the patient safe. Professionals also welcomed Lastly, rather than submitting to ‘futility’, healthcare professionals
opportunities to include mental health conditions in their training and could take action. This involved believing that recovery and change
professional development. were not only possible, but could be partially achieved in the emer-
gency department.
3.4.2. Adjustment
‘If I don't make them feel that, (a) what they have done is important, and
Instead of judging lifestyle and behaviour as deviant, some staff
(b) something can be done about it and that there are other forms of help
tried to understand the reasons for a behaviour, putting themselves ‘in
that they can get to avoid this happening again, then this {episode of self-
the patient's shoes', considering their social background, and reframing
harm} is blatantly not going to be an isolated incident.’ (Doctor)
aggressive behaviour as rooted in anxiety. Healthcare staff might also
(Hadfield et al., 2009).
break the rules themselves, providing unauthorised care, or slipping a
patient a cigarette, or a sandwich, or giving away their own lunch. Thus, patients were referred to ‘quit smoking’ classes, social services
and in-house support teams. Healthcare professionals persuaded pa-
‘I would rather do something to help somebody and lose my nursing li-
tients to undergo tests that they were otherwise refusing and, when this
cense than to sit back and say ‘Well it's not within my scope.’ (Nurse,
approach failed, there were examples where staff utilised mental health
Morgan, 2014).
and capacity legislation to secure treatment in patients' best interests.
3.4.3. Responding 3.5. Secondary sample

Similarly, rather than avoiding conversations about mental health
and social needs, some staff saw themselves as ‘counsellors’, ‘social Following framework development, data extracted from the sec-
workers’ and mediators of behavioural change. Some expressed warmth ondary sample was ‘fitted’ to the iterated matrix (see Table 4). This
towards those with mental health conditions, and found them inter- confirmed that the five patterns of stigmatisation could be identified in
esting. Relationships between staff and patients became meaningful. studies outside the main sample. It also demonstrated that all relevant
data could be fitted to the iterated framework without requiring further
‘For some reason, I'm attached to them like they're my family or some-
categories.
thing.’ (Nurse, Malone, 1996).
Professionals ‘cut them some slack’ (Malone, 1996). Staff acquired 3.6. Heterogeneity
intimate knowledge of patients' lives and felt that they were able to
make a difference. They were personally affected by the death of a Almost all the papers in this study contained examples of both
patient with whom a caregiver relationship had been formed. stigmatising and non-stigmatising attitudes and/or behaviours. There
9
was no obvious relationship with professional role or length of pro- patients in the emergency department into ‘good’ and ‘rubbish’ (Jeffery,
fessional experience. Particular mental health conditions did not appear 1979). Microrationing around low status patients has been observed
to be specific targets of stigmatisation: all five patterns of stigma to- (Vassy, 2001) and levels of social control in the emergency department
gether with examples of positive treatment, could be identified across were found to be maintained by gatekeeping, redirection and deprior-
patient subgroups. However, as described above (under Rejection), itisation (Hillman, 2014).
those who had self-harmed and those with substance and alcohol use The finding that stigmatisation can take many forms was also an-
disorders may have been more likely to be regarded as morally un- ticipated. Concepts around stigma were used in constructing the a priori
deserving of healthcare. matrix - and findings were, of course, partly constrained by this matrix.
Likewise, stigmatisation was not confined to healthcare organisa- Nevertheless, it was felt that the identified forms of stigmatisation in
tions or geographical areas, although there was a suggestion that in- this study did usefully distil into the attitudinal, behavioural (profes-
dividual attitudes could influence those of the entire setting, particu- sional) and structural (organisational) categories, defined a priori from
larly from a leadership position. The public safety-net departments in the work of Thornicroft et al. (2007a,b), Corrigan et al. (2004) and
the US also seemed to have a particularly inclusive ethos. others.
The a priori matrix included subdivisions that aligned with the
4. Discussion ‘down’, ‘in’ and ‘away’ typology characterised by Phelan et al. (2008).
The iterated matrix added two further processes, ‘rejection’ (perhaps an
4.1. Summary of findings ‘out’ process), and ‘failure to act’ (a ‘null’ process). Devaluation, social
control, avoidance, rejection and failure to act might thus be abbre-
This study puts forward a framework for describing stigmatisation viated, respectively, to ‘down’, ‘in’, ‘away’, ‘out’ and ‘null’. The over-
towards those with mental health conditions in an acute healthcare arching concepts of labelling and stereotyping were not included a
setting (see Table 4). It offers a tool for critical analysis of attitudes, priori, but were also key parts of Link and Phelan's conceptualisation of
individual behaviours and structural discrimination in this, and po- stigma and serve as preconditions for stigmatising processes (2001).
tentially wider, settings. There are also interesting parallels between the five patterns of
Five patterns of stigmatisation were characterised: devaluation; stigmatisation and Young's Five Faces of Oppression (2005) which, in a
social control; avoidance; rejection, and failure to act. Those with critical realist sense, may suggest ways in which stigma may ‘emerge’ at
mental health conditions may be devalued in terms of access, assess- macro-levels of society, or ways in which cultural oppression of a group
ment and care – and in terms of service design, environmental structure can emerge at organisational and individual levels (see Table 5).
and professional knowledge. They may be subject to social control Lastly, by identifying positive care as well as negative, the current
measures based on anticipated behaviour. Some make staff feel un- study highlights the struggle between stigmatisation and benevolence
comfortable; many are transferred into the care of mental health teams in the acute healthcare setting. Ballatt and Campling (2011) introduced
early, with physical conditions being overlooked. They may be seen as the term ‘intelligent kindness’- for what might be termed counter-
undeserving of care, with problems that are ‘not real’, faked, in- stigmatising behaviour. According to them, intelligent kindness, or
appropriate, presented too often, or self-imposed. Clinicians grow fru- professional compassion, is lacking in the modern, over-industrialised,
strated; there is a perceived futility around the treatment of this patient healthcare system. Particularly at risk are those stigmatised groups ‘on
group, and staff may abandon their input. the edges of kinship’ such as those with mental health conditions.
The framework (Table 4) is also potentially transformative, as it Ballatt and Campling (2011) discuss how opposing pressures on
identifies the type of care that might be expected if stigmatisation did healthcare professionals might both elicit, and discourage, intelligent
not exist. In this scenario, patients with mental health conditions are kindness toward such groups. A recent extended case study of a
treated respectfully. The system is equitable, and adjustments are made homeless, alcohol-dependent frequent user of the Emergency Depart-
for their difficulties. The environment is adapted to their needs, staff are ment illustrates the precarity of such a dichotomy, and the profound
tolerant, and distress is met with respect and understanding. Patients impact of the positive and negative attitudes and behaviours on in-
are recognised as deserving of healthcare, and where they are them- dividual lives (Salhi, 2020). The findings from the current study provide
selves ambivalent, time is taken to understand their perspective, and act a framework for further analysing these antagonistic processes from a
according to their wishes or in their best interests. The sampled lit- sociological perspective.
erature demonstrates that this type of care is possible, and likely to be
everyday behaviour for many health professionals within the acute care 4.3. Limitations
system.
Indeed, stigmatising attitudes, differential behaviour and structural Although critical realist synthesis has been advocated by Brannan
discrimination appear to be interwoven with positive treatment of those et al. (2017), there are disadvantages of using a qualitative literature
with mental health conditions in the acute care setting. The framework sample to spot the ‘partial regularities’ that might provide an insight
derived in this study (Table 4) offers a means of disentangling this into ontological reality. Each study will lack some contextual in-
complex juxtaposition. formation, and extraction of data from even that limited information
removes further context.
4.2. Relevance to existing literature Methodological limitations included the fact that study selection
and data extraction was largely performed by one reviewer (AP),
Methodologically, this qualitative synthesis aligns with the process overseen by the other two authors. Associated problems of reliability
of critical realist synthesis outlined by Brannan et al. (2017) who ad- and bias were mitigated to some extent by monthly in-depth group
vocate for this approach to meta-analysis. discussion and the use of techniques (after Lincoln and Guba, 1985)
The finding of stigmatisation in acute general healthcare was un- including referential adequacy and review of deviant cases.
surprising. Studies have previously implicated healthcare professionals The assignation of data to categories of stigmatisation sometimes
in stigmatisation of those with mental ill health (Thornicroft et al., demanded a judgement about the meaning behind an attitude or be-
2007a; Henderson et al., 2014) while quantitative studies have sug- haviour – a meaning that may have been lost in the interpretation of
gested disparities of acute healthcare toward this group (Mitchell et al., primary data away from context. There is also a risk of shoehorning
2009). Furthermore, a body of sociological literature has revealed the data into categories, mitigated again by discussion between authors,
acute healthcare setting as somewhere where stigmatisation might and by the iterative development of the framework.
occur. Ethnographic studies describe categorisation by clinicians of A related risk is that the framework (Table 4) sets up a view of
10
polarised attitudes and behaviour as either stigmatising or benevolent,

losing understanding of the complex and nuanced attitudes and beha-
Inaction; creating a culture of

viours that are possibly more representational of the healthcare setting.
Our argument would be that the framework aids understanding of these
complexities, providing that such rigid polarised attributions are re-
FAILURE TO ACT
sisted in its application.

Powerlessness
Where possible, we distinguished stigmatisation from medically

incapacity
warranted treatment, and professional frustrations (which may not in

themselves be stigmatising) from the organisational bases for these
frustrations (which sometimes are). Sometimes it was not clear that
attitudes and judgements were in response to knowledge that a patient
did have a mental health condition – for example, there may be an
immediate emotional response on being confronted with a disturbed
Blaming, reprimanding,
patient. In the context of the Emergency Department, it is likely that a

degree of pre-judgement and stereotyping takes place even without a
diagnostic label, but in the sample this was not always explicit.
REJECTION
eliminating
The screened literature was heavily slanted toward studies from

Violence
higher income countries, and the sample pool reflected this.

Stigmatisation might be expressed differently in lower income coun-
tries, where the structure of the healthcare system and local culture
would impact on the findings. Additionally, of the papers included in
Confining to the edges of a social
the study, 80% were based on interviews, focus groups, and other re-
ports of attitudes/behaviour, rather than naturalistic observation. The
question thus arises whether behaviours and, to a lesser degree, orga-
nisational structures, would have been enacted if observations had been
Marginalisation
done naturalistically. This opens an avenue for future research.

AVOIDANCE
Lastly, the qualitative synthesis was constrained to a particular

setting. We would tentatively propose, however, that the framework
system
may have applicability beyond acute general healthcare to other as-

pects of healthcare and, indeed, more generalised settings.
Penalisation; perceived deviance from
4.4. Utility of the framework
Within the area of focus for this study - those with mental health
conditions in the acute hospital setting - there is potential for im-
Cultural Imperialism
mediate translation to practice. Stigmatisation might be targeted both

SOCIAL CONTROL
Five patterns of healthcare stigmatisation compared with Young’s (2005) five faces of oppression.
an imposed norm
at the level of individual attitudes and behaviours, and at a structural

level (see Table 6). The framework (Table 4) might be used as a quality
of care tool, with interventions targeted at outcomes across the quality
of care dimensions: safety, effectiveness, patient centredness, time-
liness, efficiency, and equitable care.
At professional level, this might be around staff training, which
Disfavouring of an ‘out’ group for the benefit
could be both knowledge-based or values-based, or by having staff

working alongside experts by experience, or by promoting exposure to
patient self-advocacy groups. It might include focus on reflective
practice, and quality of care measures, including monitoring of patient
feedback, audits of care, and reviews of significant incidents and serious
cases. At organisational level, the framework (Table 4) supports at-
tention to policy, training curricula, the environment, human resources
and care pathways. Finally, the framework (and the underpinning cri-
of the ‘in’ group
DEVALUATION
tical realist paradigm) illustrates how stigma might ‘emerge’ at different

Exploitation
levels. Thus, improving organisational structures might reduce profes-

sional frustration; a policy of tolerance and reasonable adjustments
might improve individual attitudes, and allowing staff the freedom to
speak out about inequities might improve the quality of care in the
organisation.
Patterns of healthcare stigmatisation
Faces of oppression (Young, 2005)
Evidently, stigmatisation of vulnerable groups in the acute health-

care setting is not confined to those with mental health problems but is
described towards the poor (Allen et al., 2014); the elderly (Deasey
et al., 2014); patients with certain conditions such as sickle cell disease
(Jenerette and Brewer, 2010) and dementia (Houghton et al., 2016);
Common features
patients with intellectual disabilities (Ali et al., 2013); people who are
(this study)
transgender (Chisolm-Straker et al., 2017; Willging et al., 2019), and so

on. Using the framework to examine attitudes, behaviours and orga-
Table 5
nisational response could be useful in mapping stigma against these

other vulnerable groups in the acute healthcare system.
11
Table 6
Potential ways to reduce structural discrimination towards those with mental health conditions in acute healthcare.
Ways to reduce stigmatisation at professional level Ways to reduce stigmatisation at organisational level
STEREOTYPES & LABELS Discourage inappropriate labelling in staff handovers Avoid group-specific discriminatory policies
Counterstereotype interventions (Lai et al., 2014) Avoid lists of problematic patients
Anti-stigma training (Henderson et al., 2014) Avoid ‘special codes’ on notes
DEVALUATION Staff training focus on vulnerable patient groups Allow longer time to triage patients with complex needs
Audits of care to ensure equity Provide low-stimulus patient waiting areas
Patient feedback and response to this Provide 24/7 advocates, advisors and specialist teams
Specific training of triage nurses about needs of those with mental health Introduce mechanisms to advise patients who wish to leave before
conditions being seen
Focus training curricula on vulnerable patient groups
SOCIAL CONTROL Exposure to patient self-advocacy groups Emphasise mediation and de-escalation techniques
Simulation training Minimise use of surveillance and security personnel
Significant incident reviews Minimise use of chemical, physical and legal restraints
AVOIDANCE Staff exposure to those with mental health conditions Parallel input from physical and mental healthcare teams
Staff participation in Schwarz Rounds (Lown and Manning, 2010) Employment of experts by experience in the acute care system
Encourage reflective practice
REJECTION Training around awareness of diagnostic overshadowing Open access policy for patients
Increase knowledge about physical health inequalities and complex needs Avoid ‘front door’ mechanisms to turn patients away
FAILURE TO ACT Increase knowledge of legal structures eg Mental Capacity Act (UK) Improve access pathways to accessory services
Serious case reviews Assess mental capacity in patients who decline treatment
Quality of Care monitoring
Finally, although this qualitative synthesis was undertaken as a health care for the poor. Milbank Q. 92 (2), 289–318.
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of stigmatisation may generalise to many other settings which Goffman critical-realism.
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A common goal of all general healthcare systems should be to tackle Chapman, R., Martin, C., 2014. Perceptions of Australian emergency staff towards pa-
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may help in developing a path to this goal. Nurs. 22 (3), 140–145.
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Acknowledgements illness from a secondary mental health care case register in London, the UK. Am. J.
Epidemiol. 173, S311.
Chisolm-Straker, M., Jardine, L., Bennouna, C., Morency-Brassard, N., Coy, L., Egemba,
Thank you to Dr Nicola Mackintosh who contributed to discussions
M.O., Shearer, P.L., 2017. Transgender and gender nonconforming in emergency
in the early phase of this project. AP was funded by the UK Economic departments: a qualitative report of patient experiences. Transgender Health 2 (1),
and Social Research Council (ESRC) through a King's-ESRC Doctoral 8–16.
Studentship. There are no competing interests. Clarke, D.E., Dusome, D., Hughes, L., 2007. Emergency department from the mental
health client's perspective. Int. J. Ment. Health Nurs. 16 (2), 126–131.
Clarke, D., Usick, R., Sanderson, A., Giles-Smith, L., Baker, J., 2014. Emergency depart-
Appendix ASupplementary data ment staff attitudes towards mental health consumers: a literature review and the-
matic content analysis. Int. J. Ment. Health Nurs. 23 (3), 273–284.
Collom, J., Patterson, E., Lawrence-Smith, G., Tracy, D.K., 2019. The unheard voice: a
Supplementary data to this article can be found online at https:// qualitative exploration of companions' experiences of liaison psychiatry and mental
doi.org/10.1016/j.socscimed.2020.112974. health crises in the emergency department. BJPsych Bull. 4, 1–6.
Corrigan, P.W., 2000. Mental health stigma as social attribution: implications for research
methods and attitude change. Clin. Psychol. Sci. Pract. 7 (1), 48–67.
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Social Science & Medicine 255 (2020) 112974

Contents lists available at ScienceDirect

Social Science & Medicine

Stigmatisation of those with mental health conditions in the acute general T

Keeping ‘down’/Devaluation Valuing

Fig. 1. Screening sheet.

2.7. Data extraction 2.8. Framework development

Fig. 2. Sampling strategy and framework development ﬂowchart.

3. Results 3.3. Patterns of stigmatisation

3.1. Literature sample 3.3.1. Labelling and stereotyping

DEVALUATION SOCIAL AVOIDANCE REJECTION FAILURE TO ACT

3.4.3. Responding 3.5. Secondary sample

polarised attitudes and behaviour as either stigmatising or benevolent,

Inaction; creating a culture of

sisted in its application.

Where possible, we distinguished stigmatisation from medically

warranted treatment, and professional frustrations (which may not in

patient. In the context of the Emergency Department, it is likely that a

The screened literature was heavily slanted toward studies from

higher income countries, and the sample pool reﬂected this.

done naturalistically. This opens an avenue for future research.

Lastly, the qualitative synthesis was constrained to a particular

may have applicability beyond acute general healthcare to other as-

4.4. Utility of the framework

mediate translation to practice. Stigmatisation might be targeted both

at the level of individual attitudes and behaviours, and at a structural

could be both knowledge-based or values-based, or by having staﬀ

tical realist paradigm) illustrates how stigma might ‘emerge’ at diﬀerent

levels. Thus, improving organisational structures might reduce profes-

Faces of oppression (Young, 2005)

Evidently, stigmatisation of vulnerable groups in the acute health-

transgender (Chisolm-Straker et al., 2017; Willging et al., 2019), and so

nisational response could be useful in mapping stigma against these

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