Auditory Hallucination Simulation and Mental Health Stigma Among Nursing Students: How Clinical Practicum Experience Differentiates the Predictive Contributions of Knowledge, Attitudes, and Behaviours.

Abstract

Stigmatising beliefs towards people with mental health disorders impede treatment-seeking and recovery. This study examined how the predictive contributions of knowledge, attitudes, and behaviours to stigmatising beliefs towards people with mental health disorders differed by clinical practicum experience among nursing students exposed to auditory hallucination simulation. A non-randomised comparative cross-sectional design was employed (Strengthening the Reporting of Observational Studies in Epidemiology guidelines). Nursing students (n = 363) from four Korean universities were allocated to groups with (n = 175) and without (n = 188) clinical practicum experience based on academic progression. All participants completed an auditory hallucination simulation programme followed by questionnaires measuring knowledge, attitudes, behaviours, and stigma. Stepwise multiple regression analyses revealed that among students without clinical experience, knowledge (β = -0.435, p < 0.001), attitudes (β = -0.259, p < 0.001), and behaviours (β = -0.144, p = 0.020) predicted stigma (Adjusted R² = 0.419). Among students with clinical experience, only knowledge (β = -0.455, p < 0.001) and attitudes (β = -0.287, p < 0.001) predicted stigma (Adjusted R² = 0.478); behaviours did not reach significance despite a stronger bivariate correlation in the experienced (r = -0.390) than inexperienced group (r = -0.332). This paradoxical pattern-a stronger zero-order association losing independent variance in the multivariate model-suggests clinical experience integrates the three stigma components such that behaviour's effect becomes fully mediated through knowledge and attitudes. These findings support a stage-sensitive model: direct behavioural strategies are most effective pre-practicum, while post-practicum intervention should prioritise cognitive-affective integration via structured debriefing.