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Running head: STIGMA CONCEPT MATURITY Maturity of Stigma as a Concept in Nursing Discipline Laila Al-Daken Ghadeer al Dweik Abla Habeeb Allah Hana' abu Snieneh Ruba al Ajarmeh Faculty of Nursing University of Jordan 1 Stigma a Concept in Nursing Discipline 2 Table of Contents Abstract ......................................................................................................................................................... 3 Introduction ................................................................................................................................................... 3 Definitions of Stigma ..........................................................................Ошибка! Закладка не определена. Stigma In Nursing Discipline........................................................................................................................ 4 Methods ...................................................................................................................................................... 10 Findings ...................................................................................................................................................... 10 Epistemological....................................................................................................................................... 10 Logical .................................................................................................................................................... 13 Pragmatical ............................................................................................................................................. 15 Linguistical ............................................................................................................................................. 20 Conclusion .................................................................................................................................................. 21 References ................................................................................................................................................... 22 Stigma a Concept in Nursing Discipline 3 Abstract Purpose: The purpose of this paper is to evaluate the level of maturity of stigma as a concept in the nursing discipline. Method: The four principles of Morse and his colleagues were used to evaluate the Maturity level of stigma concept: epistemological, logical, pragmatical, and linguistical. Findings: This evaluation suggests that the concept of stigma is immature, deﬁned inconsistently, and measured with varied instruments. Conclusion: Stigma is an important concept for nursing and public health, further development and clarifications for stigma concept are needed. Clinical Implication: How stigma is deﬁned can assist the nurse to improve the assessment of the patients health and to identify patients and their families needs. In addition, the nurse will be able to increase the public awareness about the stigmatization phenomenon which may influence positively to change health care policies and public awareness. Introduction Nursing concepts are relatively abstract, but they differ in their abstraction level (Waltz, Strickland, & Lenz, 2010). As a feature of many chronic illnesses; health professionals and the general population gave more attention toward the concept of stigma. Health professionals therefore have substantial interests in recognizing and analyzing the impact of stigma as both an aspect and a cause of many health problems (Weiss, Ramakrishna & Somma, 2006). The negative influence of stigma on people’s lives creates a negative self-concept and causes individuals to be socially distance from the society (Parcesepe & Cabassa, 2012). The concept of stigma has been well documented and is associated with people who suffer from Stigma a Concept in Nursing Discipline 4 specific health problems as Human Immunodeficiency Virus (HIV), cancer, mental illness, and disability. Furthermore, ethnic minorities are particularly more vulnerable to stigmatization than other people (Copel & Al-Mamari, 2015). How stigma is deﬁned or understood is important for health professionals, patients, and general population. Literature and research address the influence of stigma towards diseases; however, systematic conceptual analysis to identify the maturity level of stigma concept is still lacking (Copel & Al-Mamari, 2015, Parcesepe & Cabassa, 2012). The purpose of this paper is to evaluate the maturity level of the stigma concept as used in nursing and health discipline based on the four principles of Morse et al. (1996), epistemological, logical, pragmatical, and linguistical. This will help nurses and health professionals to understand the concept of stigma properly. Definitions of Stigma Historically, stigma as a term goes back to the ancient Greece where criminals, slaves, and traitors were identified by using tattoos on their bodies. People with illness or abnormal behaviors have been socially discriminated and avoided (Engebretson, 2013). Later in Christian time, the word stigma used for the interpretation of bodily physical features as an indicator either for holy grace and/or physical disorder (Goffman, 1963). In the past, stigma was used in medical texts to refer to pathological markings on the skin such as petechia or lesions that are associated with specific diseases (Weiss, Ramakrishna, & Somma, 2006). The English Oxford dictionary defined stigma as “Feelings of disapproval that people have about particular illnesses or ways of behaving” (Oxford Dictionary, 2016). Stigma a Concept in Nursing Discipline 5 Goffman (1963), who is a well-known sociologist defined stigma as “The phenomenon whereby an individual with an attribute which is deeply discredited by his/her society is rejected as a result of the attribute. Stigma is a process by which the reaction of others spoils normal identity” (Lim & Tan, 2014, p. 2). Goffman considered stigma as a relation between attribute and stereotype where the stigmatized person is moved from the normal and usual to the deviant and discounted one, also identified three types of stigma, body (physical), character (personal), and tribal (social). Goffman’s effort is considered as seminal work and has inspired research on stigma in social science and social psychology (Omori, Mori, & White, 2014). Link and Phelan (2001) claimed that as a result of vast increase of social science research on stigma especially in social psychology, the definition of stigma became too vague and individualized. As response, they constructed a definition of stigma as “the co-occurrence of its components–labeling, stereotyping, separation, status loss, and discrimination–and further indicate that for stigmatization to occur, power must be exercised” (Link & Phelan, 2001, p. 363). Weiss and colleagues (2006), proposed a formulation of concept of stigma for public health to enhance action-oriented research on health-related stigma. They defined stigma as “a social process, experienced or anticipated, characterized by exclusion, rejection, blame, or devaluation that results from experience or reasonable anticipation of an adverse social judgment about a person or group” (p. 280). Stigma a Concept in Nursing Discipline 6 Stigma In Nursing Discipline Not until 1963 when Erving Goffman described the concept of stigma in his pioneer work (Stigma: Notes on the Management of Spoiled Identity). He identified Sigma in its social context as visible and invisible attributes and characteristics in an individual, group, or society that cause discrediting, devaluation and stereotyping for them (Omori, Mori, & White, 2014). In 2011, Bos, Pryor, Reeder and Stutterheim identified four types of interrelated and integrated stigma: public stigma, self-stigma, stigma by association, and structural stigma (Bos, Pryor, Reeder, & Stutterheim, 2013). Nursing discipline has been concerned with the study of Stigma as a concept. It has been widely used in nursing research in relation to three domains; psychiatric and mental illness, infectious diseases such as HIV and Hepatitis C, and in chronic illness such as diabetes (Butt, 2008; Florom-Smith & Santis, 2012; Oliveira, Carvalho, & Esteves, 2016). Though, it has been over fifty years for the definition of stigma concept by Goffman; the concept of stigma in nursing literature remains unclear (Florom-Smith & Santis, 2012), inconsistent, and there is an overlap in conceptual and operational definitions (Oliveira, Carvalho, & Esteves, 2016; Kato, Takada, & Hashimoto, 2014; Zelaya, Sivaram, Johnson, Srikrishnan, Suniti, & Celentano, 2012). However, most of nurses based their derived definitions of Stigma on the seminal work of Goffman (Pinto-Foltz & Logsdon, 2008; Brunton, 1997) .This indicates lack of a specific nursing definition of stigma concept in nursing. Some nursing studies have focused on stigma as a general attribute, while other studies have elaborated on the different types of stigma. Furthermore were inconsistent when they referred to the types, such as (Oliveira, Carvalho, & Esteves, 2016; Omori, Mori, & White, 2014; Stigma a Concept in Nursing Discipline 7 Florom-Smith & Santis, 2012). Examples of definitions of Stigma concept in nursing discipline are presented in Table 1. Stigma a Concept in Nursing Discipline 8 Table 1. Definitions of Stigma concept, and Stigma Types Used in Nursing Discipline Author Oliveira, Carvalho, & Esteves, 2016 Zelaya, Sivaram, Johnson, Srikrishnan, Suniti, & Celentano, 2012 Kato, Takada, & Hashimoto, 2014 Type of Stigma Internalized stigma (self-stigma). Stigma Self-stigma: (internalized stigma) Definition of Stigma The process in which a person internalizes stigmatizing beliefs about mental illness, accepting and applying the negative stereotypes to oneself Is a social process, discrediting and devaluing individuals or groups with an attribute that is either feared or sanctioned by society as immoral or deviant A stigma that is experienced by individuals who have negative Attitudes towards themselves as a result of their condition And/or characteristics Represents negative reactions of the general public towards a group Based on stereotypical attributes that distinguish that group in society Florom-Smith & Santis, 2012 Public stigma (social stigma) Stigma AIDS related Stigma (Public Stigma) Felt stigma (Internalized stigma, self-stigma) Enacted stigma - Erving Goffman (1963): an attribute or characteristic that is profoundly discrediting to the individual possessing the attribute or characteristic. - Herek (2002): a lasting, negatively valued circumstance, status, or characteristic that discredits and disadvantages individuals. Stigma directed at people living with HIV/AIDS (PLWHA) and/or associated with PLWHA. A fear of disclosure of HIV serostatus, in anticipation of resultant discrimination Discrimination in the forms of rejection, verbal insults, and ostracism perpetrated by family members and friends, and was manifested as avoidance related to fears of infection, judgment, and an inability to understand why spouses or caregivers would choose to remain with people living with HIV. Stigma caused by an association with an individual living with a stigmatizing condition) was experienced by participants’ family and children via avoidance by friends and family members because of unfounded fears of infection. Stigma a Concept in Nursing Discipline 9 Omori, Mori, & White, Self-Stigma in Schizophrenia: A Concept Analysis, 2014 Courtesy stigma (Stigma by association) Stigma Self-stigma Link and Phelan (2001): the term “Stigma” should be applied “when elements of labeling, stereotyping, separation, status loss, and discrimination co-occur in a power situation that allows the components of stigma to unfold” (p. 367). Stereotyping, prejudice, and discrimination toward oneself Stigma a Concept in Nursing Discipline 10 Methods The evaluation of the maturity level of stigma as a concept in nursing discipline was guided by the four principles recommended by Morse et al. (1996); epistemological, logical, pragmatical, and linguistical. Stigma related literatures were retrieved by searching the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via Ebesco and MEDLINE via PubMed, in addition to Google Scholar. Search terms used were: stigma, stigma concept, health-related stigma, concept analysis, and nursing. Initial search was restricted to include published literatures from 2006 to 2016 with full text and presented in English. Some literature before 2006 were also considered since it included seminal studies and definitions. Findings Epistemological It is the first premise in the principle-based concept analysis method in which concept should to be clearly identified and well distinct from other concepts in order to be evaluated as a mature concept (Penrod & Hupcey, 2005). Previous studies in psychology and the social sciences have extended to Goffman’s theory to reveal on the nature, sources and consequences of stigma in order to investigate the wide variation in defining and conceptualizing the concept of stigma (Omori, Mori, & White, 2014; Brinkley-Rubinstein, 2015; Butt, 2008; Engebretson, 2013). Stigma as a concept remains uncertain, due to the diverse stereotypes and interactive characteristics that belong to the different health conditions among minorities (Omori, Mori, & White, 2014). Furthermore, concept of stigma was often discussed in separation from its multiple forms and intersectional Stigma a Concept in Nursing Discipline 11 exploration, thus, leading to a substantial burden that there is no consensus in the literature on what the definition of stigma constitutes (Brinkley-Rubinstein, 2015). It is important to highlight that the meanings of stigma change across cultures or over time. For instance, epilepsy has been perceived as demon possession, a neurological disorder, as well it was perceived as spiritual gift from God in the book “The Spirit Catches You and You Fall Down” which described the struggels between the Hmong culture and the American culture (Fadiman, 1997). Link and Phelan (2001) Reported that stigma is constantly changing trajectory of human being behavior, thus, definitions of stigma vary with the context in which it is studied in. Goffman (1963) in which described stigma as a process in which self identity is flawed by the social reaction of others. Since, there is an agreement that stigma is a complex and socially constructed phenomenon experienced by individuals with various diseases in varying contexts; this necessitates further investigations toward a distinctive definitions for this concept (Weiss, Ramakrishna, & Somma, 2006). Several contextual variables and health conditions might induce similar and dissimilar attributes of stigma (Omori, Mori, & White, 2014). Literature showed different experiences and perceptions of stigma among different individuals with different health conditions (Butt, 2008; Brinkley-Rubinstein, 2015; Omori, Mori, & White, 2014). Distinction of stigma concept from its various stances like its definition and reasons of episode in the lives of people is a matter of challenge (Link & Phelan, 2001). Hence, stigmatized individuals have been recognized to have several negative attributes, and subsequently they are treated differently by members of society (Link & Phelan, 2001), it is crucial to review the uncertainty in conceptualizing the concept of stigma and its impact on the individuals’ conditions. Extending the concept of stigma will help those offering healthcare practices to provide better care for stigmatized individuals (Link & Phelan, 2006). Therefore, a Stigma a Concept in Nursing Discipline 12 comprehensive understanding for the complexities linked with the sociocultural, conditional and structural attributes that influence the experience of stigma should be taken into account for better differentiation of the concept of stigma (Butt, 2008). Despite the labeling of a chronic illness as a disease, cultural and social meanings are still attached to certain diseases to include negative meanings (Engebretson, 2013). Stigma can be experienced by individuals in many chronic health conditions; such as psychiatric illnesses and certain sexually transmitted diseases like HIV, however, the response of society to such diseases and conditions may lead to stigmatization (Engebretson, 2013; Parkera & Aggleton, 2003). Investigating the universality of stigma and examination of the social perceptions associated with this process can unify its meaning and promote health behaviors among vulnerable persons regardless variety of their conditions (Engebretson, 2013). While Moreover, concepts that are related to stigma have been studied for clarification and specification. For instance, the concept of “self-stigma” has been examined and was distinguished from public stigma, particularly among individuals with psychiatric illnesses (Omori, Mori, & White, 2014). Stereotyping, prejudice, and discrimination are considered as the basic facets for concept of stigma as well as self stigma (Link & Phelan, 2001), whereas, selfstigma characterized by harmfulness to self-identity (Pinto-Foltz & & Logsdon, 2008) selfstigma can be resulted fron internalized Sociatal stigma (Vogel, Wade, & Hackler, 2007). Many psychological studies examined perceived self-stigma, perceived public-stigma, and social distance as common types of stigma (Vogel, Wade, & Hackler, 2007; Evans-Lacko, Brohan, Mojtabai, & Thornicroft, 2012; Link, 1987 ; Rayan & Jaradat, 2016). Perceived public-stigma is the extent to which individuals expect that other persons will devalue or discriminate against Stigma a Concept in Nursing Discipline 13 persons who are mentally ill, while social distance scrutinizes individuals’ willingness to communicate with persons who are mentally ill ( Vogel, Wade, & Hackler, 2007; Link, 1987). Stigma can be both externally imposed and internally perceived in a process of self-stigma (Engebretson J. , 2013). Logical It is the second premise in the principle-based concept analysis method refers to the integration of the concept with related concepts. It also determines whether the conceptual boundaries are kept through logical and theoretical integration with other concepts (Penrod & Hupcey, 2005). Stigma is a broad and complex social phenomenon; therefore several dimensions of stigma were discussed by psychologists to include perspectives of: visibility, course and perceived danger, controllability, and perceived stigma (Green, 2009). In addition, three types of stigma were recognized by Goffman to include: physical defect; personality blemish; and prejudice (Goffman, 1963). These aspects need rigorous investigation to permit proper and logical integration of stigma with other concepts. Social psychologists conceptualized stigma as the co-incidence of: labeling, stereotyping, separation, and emotional reactions, those often lead to status loss and discrimination (Link & Phelan, 2001). In the Oxford Dictionary of Sociology, the definition of discrimination is linked not to stigma but to prejudice and sexism (Marshall, 1998). Prejudice, in turn, is described as ‘‘an unfavorable attitude towards a group or its individual members’’ (p. 522). In contrast, Sociologist perceived discrimination in the early era as an expression of ethnocentrism, it is cultural phenomenon of ‘‘dislike of the unlike’’ (Marshall, 1998). Recently, sociologists’ analyses of discrimination perceived it as a pattern of dominance and oppression, and a struggle Stigma a Concept in Nursing Discipline 14 for power and opportunity” (Marshall, 1998). Persons who are stigmatized are seen as unsafe and scare others, they are unwanted in the social hierarchy and they are discriminated at their institutions (Link & Phelan, 2001). Stigma is linked to the expression of social inequality issues of stigmatization and discrimination in the case of HIV and AIDS related stigma (Parkera & Aggleton, 2003). Psychologists concluded that the concept stigma has conceptual adequacy and relevancy for multiple conditions and circumstances of stigmatized groups (Link & Phelan, 2001; Parkera & Aggleton, 2003). It was noted that labeling can be classified from attitude, appearance, and even from medical diseases (Green, 2009). Since stereotyping is one of the basic elements of stigma it includes a connection to classify labeled individuals (Link & Phelan, 2001). The concept of stigma succeed to ‘embraces its boundaries’ when it is correlated with other related concepts in some occasions (Evans-Lacko, Brohan, Mojtabai, & Thornicroft, 2012; Parkera & Aggleton, 2003; Vogel, Wade, & Hackler, 2007). The stigmatizing and the stigmatized persons both are interchangeably used terms to describe the interactive aspects of stigma (Pinto-Foltz & & Logsdon, 2008). Stigmatizing attitude is shaped by public responses to discredited people, while stigmatized person was defined as someone expected to be rejected in social activities and devalued as less trustworthy, intelligent, and competent by socially intact persons (Anglin, Link, & Phelan, 2006). Theoretical definition of stigma incorporated logical integration and connectedness with other related terms like self- stigma, public stigma; internalize stigma, and explicit stigma (Vogel, Wade, & Hackler, 2007; Evans-Lacko, Brohan, Mojtabai, & Thornicroft, 2012; Link, 1987; Pinto-Foltz & & Logsdon, 2008; Goffman, 1963). Stigma a Concept in Nursing Discipline 15 Pragmatical The third premise in the principle-based concept analysis method is the applicability and usefulness of the concept and it also determines how it is operationalized (Penrod & Hupcey, 2005). Clearly defined any concept with clinical usefulness is never fully completed because the concept is dynamic and change over time. Concepts are influenced by history, clinical care and treatment, and the occurrence of innovative health conditions and diseases (Florom-Smith & Santis, 2012). Stigma has enormous definitions and applications, which have inconstancies agreed on it and often remains unrecognized by nurses within themselves and others; unrecognized stigma is an obstacle to understand patient behavior (Pinto-Foltz & Logsdon, 2008). Stigma concept was measured based on variety of populations and mainly measured using self-report indicators and self-measurement which were specific for particular populations or groups. However, the term stigma is used to describe both concepts—stigma and self-stigma—it was found that the definition of stigma is varied in literature (Omori, Mori, & White, 2014). There are many operational definitions for stigma in nursing literature and many instruments and questionnaires have been developed to measure specific stigma, thus definitions of specific stigma related to disease varies from study to study (Florom-Smith & Santis, 2012). Examples of well-established and most widely used instruments in nursing research include Ritsher, Otilingam, and Grajales (2003) who developed “Internalized Stigma in Mental Illness (ISMI)” instrument. This is a 29-item tool rated on a four points Likert scale (1 strongly disagree to 4 strongly agree). The internalized stigma was defined as " inner subjective experience and its psychological effects, including alienation, stereotype endorsement, perceived discrimination, social withdrawal, and stigma resistance'' p32. Stigma a Concept in Nursing Discipline 16 Another commonly used measure is The Self-Stigma of Mental Illness Scale (SSMIS) which was developed by Corrigan et al., (2006). This scale has four subscales (stereotypeawareness, stereotype agreement, stereotype self-concurrence, and self-esteem decrement) with 40 items; each item is rated on a nine-point agreement scale. The Japanese version of the Self-Stigma Scale (SSS-J) is another example that contains 39 items allows responses in 4-point anchored Likert scale: strongly disagree, disagree, agree, and strongly agree. The responses are afforded a score of 0, 1, 2, and 3, respectively. The complete scores have a range of 0 to 117; a higher score signifies a higher level of self-stigma (Kato, Takada, & Hashimoto, 2014). The concept of HIV-related stigma is well-documented in the research literature; however, there are gaps related to the utility of this concept. In addition, the definitions and specific components that focuses on of stigma different from study to study (Nyblade, 2006). Each different instrument measures components of HIV-related stigma, but none of the current instruments measure all components of this concept. Consequently none of the instruments is valuable in measuring this concept across all populations. Therefore, lack of clinical utility of the concept of HIV-related stigma is obvious (Oliveira, Carvalho, & Esteves, 2016). The concept of HIV related stigma is not clearly defined, not consistently measured, and remains too abstract for clinical use. The concept of stigma cannot be useful clinically because of its abstract nature (FloromSmith & Santis, 2012). More theoretical and empirical works are needed for clarifying the concept, which will improve the operational definition of the concept. Examples of applications and instruments used in nursing research are presented in Table 2. Stigma a Concept in Nursing Discipline 17 Table 2. Application of Stigma Concept in Nursing Researches Author And year Title Purpose Target population Conceptual definition of stigma Operational definition of stigma Term used to reflect stigma Stigma dimensions measured Rayan & Jaradat, 2016 Stigma of Mental Illness and Attitudes Toward Psychological Help-seeking in Jordanian University Students To examine the level of stigma toward mental illness and its association with attitudes toward psychological help-seeking in Jordanian university students. 519 undergraduate university students Not explicit The 6-item Social Distance (SD) Scale, The Percieved DevaluationDiscrimination (DD) Scale, and the Attitudes Toward Seeking Professional Psychological Help Scale (ATSPPHS Perceived public stigma and social distance Perceived public stigma toward mental illness, Attitudes toward mental illness, and attitude toward psychological help-seeking. Oliveira, Carvalho, &Esteves, 2016 Internalized stigma and quality of life domains among people with mental illness: the mediating role of selfesteem To propose a theoretical model in which selfesteem mediates the effects of internalized stigma on the multidimensional domains comprising quality of life Psychiatrist participants inpatients and outpatients Theoretical model in which selfesteem mediated the relationship between internalized stigma and Quality of life domains. Internalized Stigma of Mental Illness scale (ISMI). The Rosenberg SelfEsteem scale (RSES). World Health Organization Quality of Life Bref–WHOQOL Internalized Stigma Internalized Stigma on the multidimensional domains comprising quality of life Kato, Takada, & Hashimoto, 2014 Reliability and validity of the Japanese version of the Self-Stigma Assessed the psychometric properties of a Japanese version of the Self- People with type 2 diabetes Not explicitly mentioned SSS-J scale. The Rosenberg Self-Esteem Scale. The General SelfEfficacy Scale. Self-stigma public stigma Negative reactions stereotypical attributes that distinguish that group in society Stigma a Concept in Nursing Discipline 18 Scale in patients with type 2 diabetes Stigma Scale (SSS-J) in patients with type 2 diabetes. The nine-item depression module of the Patient Health Questionnaire (PHQ-9) McGonagle & Barnes-Farrell, 2014 Chronic Illness in the Workplace: Stigma, Identity Threat and Strain To examine work-related chronic illness stigma, identity threat and strain from the perspective of the individual worker through an application and empirical test of an established theoretical model 350 workers with various chronic illnesses Theoreticall y based model of stigmarelated identity threat and strain using survey responses Non-illness-related survey items. fivepoint response scale was used for all survey items, ranging from (1) Strongly disagree to (5) Strongly agree. A situational factor. a personal characteristic and metaperceptions of devaluation each related to identity threat perceptions, which in turn related to both strain and work ability Boundary flexibility, job self-efficacy, and metaperceptions of devaluation strain and work ability Molina, Choi, Cella, & Rao, 2013 The Stigma Scale for Chronic Illnesses 8-Item Version (SSCI-8): Development, Validation and Use Across Neurological Conditions To collect data on the psychometric properties of new instrument, examine its factor structure and study the severity of stigma across condition Participants were among the 581 respondents from eight academic medical centers who comprised the second wave of a study on the quality of life for people with neurological item response theory methodologi es Stigma Scale for Chronic Illness 8-item version Psychological distress and patient performance. Enacted Stigma and Its Consequences in Neurological Populations. Internalised Stigma and Its Consequences in Neurological Populations Stigma a Concept in Nursing Discipline 19 disorders (Neuro-QOL). Dalky , 2012a Arabic translation and cultural adaptation of the stigmadevaluation scale in Jordan To translate and culturally modify the stigmadevaluation scale (SDS) into Arabic, and to test the reliability, content and construct validity of the Arabic version of the SDS 164 family Caregivers in Jordan. The study adopted the process of translation and crosscultural adaptation of an instrument as proposed by Brislin (1970), Flaherty et al. (1988) and LopezMcKee (2005). Consumers' scale and consumer families scale. Isolation, low selfesteem and discriminatio n and the difficulties associated with caregiving and holding down a job or getting married Status reduction, role restriction and community rejection Stigma a Concept in Nursing Discipline 20 Linguistical The fourth premise in the principle-based concept analysis method refers evaluate if it is the appropriately and consistently used in the context (Penrod & Hupcey, 2005). Stigma is a complex, multi-faceted construct (Webb, et al., 2016). Without knowing which concept is related to stigma, it is difficult at this point to know how these other concepts effect or impact stigma (Nyblade, 2006). Stigma is a social construct that identifies a person by virtue of a physical or social trait, resulting in negative social reactions such as avoidance and discrimination (Hassan & Wahsheh, 2011). Stigma is a universal and multidimensional concept that is experienced in all cultures and in various stages of life (Pinto-Foltz & Logsdon, 2008). But stigma is a variable from context to context and it is viewed as negative points which have different dimensions: interpersonal; intrapersonal; and structural (Butt, 2008). Despite stigma’s relevance to nursing, few have revealed on the meaning of stigma in nursing and in patient care, nurses usually seek for the help of psychiatrist and psychologist in defining stigma (Pinto-Foltz & Logsdon, 2008). Furthermore, while the role of culture on stigma in the literature is clear, few studies discussed stigma from cultural perspectives (Dalky, 2012b). Stigma concept should be continuously refined in the context in which it is used. Discussion Stigma is a complex phenomenon which can be found in many health care environments and affects the caring process toward both the individuals and the community. Although there is a large body of literature that addresses the concept of stigma, there is no consistency in the definitions, dimensions and operationalizations of stigma. Stigma concept was evaluated based on Morse et al.’s (1996) principles to assess its level of maturity. Studies showed that stigma plays a greater role among underserved populations than Stigma a Concept in Nursing Discipline 21 general populations. Most of studies were consistent in which stigma is a complex and has multi dimensions. Effective nursing care requires additional ability, awareness, and understanding of stigma concept among nurses to improve health care process. While a wide range of studies exist dealing with stigma types, definition, and measurement, several gaps remain particularly with measuring stigma and defining it (Omori, Mori, & White, 2014; Florom-Smith & Santis, 2012). Therefore, further concept development and clariﬁcation are needed. Nurses and other health care professionals should work on the deﬁnition of stigma concept and reach global consistency regarding the conceptualization and operationalization of stigma to keep it related to cultural context (Dalky, 2012b). Nurses should reach consensus regarding the deﬁnition of stigma in order to be appropriately operationalize and measure it. Conclusion Stigma has become an important topic for public health; it contributes to suffering, which leads to health deterioration, and it interferes with appropriate use of health services. How stigma is deﬁned can help the nurse to improve the assessment of the patient’s health and to identify health problems and patient’s needs. This paper highlights the stigma as a concept related to chronic illnesses, with reference to prior work in the ﬁeld; stigma is deﬁned inconsistently in nursing and other disciplines. Additional concept development and clariﬁcation is needed. 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