A Case-Based Approach to Ethical Decision-Making and Stigma Reduction in Nursing Education

As the opioid epidemic has grown in scale in the past decades, its impact on mothers with substance use disorder (SUD) can result in significant stigma when seeking healthcare (Renberg, 2024). This stigma by healthcare providers can be amplified by concerns for the well-being of their children, resulting in workers to express bias in providing care (Barnett et al., 2021). Thus, these patients can face barriers to accessing supportive care.

Providing care to vulnerable populations such as mothers with SUD presents unique challenges for experienced nurses and undergraduate nursing students. Developing the skills to recognize and address personal biases, and provide ethical, patient-centered care, is important in improving health outcomes. For nursing students in particular, early exposure to these situations is helpful in shaping attitudes and fostering more empathetic, non-stigmatizing care.

Objective

The aim of this pilot study was to examine the feasibility of reducing stigma toward mothers with SUD among undergraduate nursing students through case studies informed by firsthand accounts, as measured by the OM-PATOS scale.

Methods

A convenience sample of BSN nursing students from a Miami University was used, including students across all levels of the nursing major. Interviews were conducted with 27 mothers with a history of SUD to identify patterns of stigmatized care, which informed the development of case studies. Students participated in weekly, online, case-based online learning sessions over seven weeks, with facilitated group discussions focused on ethical decision-making. The Opening Minds Provider Attitudes Toward Opioid Use Scale (OM-PATOS) was administered to a cohort of 36 students in fall 2024 to assess stigma.

The OM-PATOS is a 15-item questionnaire which includes an 5-point Likert scale to evaluate stigma among healthcare providers, with lower scores indicating less stigmatizing attitudes and total scores ranging from 15 to 95. A certified nurse instructor developed the case studies based on real patient experiences. Students worked in small groups of four to five, followed by larger group discussions, with group compositions rotating weekly. Survey data was collected and analyzed using IBM SPSS Statistics, with feasibility assessed through qualitative feedback.

Results

Results indicated a significant effect of time on OM-PATOS scores (β = −2.90, SE = 0.22, z = −13.47, p < .001), sjowing that stigma scores decreased across the seven-week period by an average of approximately 2.9 points per week. Descriptive statistics supported this trend, with mean scores declining from 46.07 (SE ≈ 1.28) in Week 1 to 28.40 (SE ≈ 1.15) in Week 7. Because lower OM-PATOS scores reflect less stigmatizing attitudes toward individuals with opioid use disorder, these findings show substanial improvements in participant attitudes over time.

A sensitivity analysis including only participants who attended five or more sessions produced nearly identical results (β = −2.93, SE = 0.22, p < .001), indicating that reductions in stigma were not due to participant attrition. At the individual level, 75% of participants showed reductions of at least five points on the OM-PATOS scale. Overall, these findings show a consistent reduction in stigmatizing attitudes across the case studies, suggesting that the case study intervention contributed to measurable shifts in stigma of nursing students.

Discussion

The Opening Minds Provider Attitudes Toward Opioid-Use Scale scores decreased ~17–18 points, with changes emerging by Week 3 and sustained through Week 7, suggesting significant reduction in stigma. These findings exceed typical small to moderate effects reported in prior OM-PATOS interventions, suggesting the enhanced impact of our approach, which included iterative cycles of critical reflection and discourse. Multiweek, reflective engagement facilitated deeper, sustained attitude change. Although the majority of participants showed meaningful improvement, these results are limited by self-report, no control group, and need for behavioral outcome validation.

Conclusion

Overall, this pilot study showed that stigma toward mothers with SUD decreased over time with the use of case-based learning. These findings suggest that this approach may be a useful way to help nursing students develop more empathetic and less judgmental attitudes.

The following is an image of poster presented at the 2026 Undergraduate Research Forum

References

Barnett, E. R., Knight, E., Herman, R. J., Amarakaran, K., & Jankowski, M. K. (2021). Difficult binds: A systematic review of facilitators and barriers to treatment among mothers with substance use disorders. Journal of substance abuse treatment, 126, 108341. https://doi.org/10.1016/j.jsat.2021.108341

Renbarger K. M. (2024). Factors Influencing Maternal Substance Use and Recovery in the Perinatal Period. Western journal of nursing research, 46(9), 725–737. https://doi.org/10.1177/01939459241266736

NACE Career Readiness Competencies

I developed critical thinking by analyzing data and interpreting changes in stigma scores over time. I strengthened my communication skills by presenting ideas my ideas through the above research poster. I improved my teamwork by collaborating with others throughout the research process.

Research Compliance Protocols

This study was approved by the Institutional Review Board (IRB) at Miami University, and all participants provided informed consent prior to participation of the study. Participant confidentiality was maintained throughout the study.

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