Mental Health Nurses’ Attitudes on Consumers with Dual Diagnosis: A Thematic Analysis

Figures & data

Table 1. Key findings from scoping review of the literature.

It has been reported that clinicians have a negative attitude toward patients, treatment options, and society as a whole (Carey et al., 2000).

To serve consumers with dual diagnoses better, more facilities and services are needed (Kavanagh et al., 2000).

Educating clinicians on drugs can be beneficial. A discussion of attitudes and beliefs regarding illegal drug use and mental health problems should be included in the training (Barry et al., 2002).

Nurses exhibited adequate knowledge of alcohol and other drug use, as well as adequate problem-solving skills. There is a modest level of competency in dealing with consumers who abuse drugs and alcohol (Happell et al., 2002).

In terms of attitudes toward the abuse of drugs and substances, mental health professionals possess a positive attitude, and this constructive attitude should lead to nurses providing essential care to consumers (Pinikahana et al., 2002).

Contrary to other groups of community mental health professionals, forensic nurses tend to have a less favourable attitude toward substance misuse among forensic consumers (Foster & Onyeukwu, 2003).

The postgraduate curriculum can contribute to the development of positive attitudes and treatment optimism among clinicians who are working with substance abusers (Richmond & Foster, 2003).

It was evident from the results that staff were confident in their ability to work with consumers who use certain substances (Graham, 2004).

It is common for health professionals to have negative experiences and attitudes toward consumers with dual diagnosis (Deans & Soar, 2005).

Through the training, clinicians working with dual diagnosis consumers were able to develop more effective therapeutic attitudes (Munro et al., 2007).

According to clinicians, the frequency of dual diagnosis was generally accepted as being a common phenomenon (Phillips, 2007).

Clinicians acknowledge that dealing with consumers with dual diagnosis is more challenging than dealing with consumers with one mental illness or substance abuse problem (Cleary et al., 2009).

Consumers who sustained substance abuse were viewed negatively by nursing staff, whereas those who had overcome their drug abuse were viewed as more positive by the nursing staff (Ralley et al., 2009).

No matter the length of clinical experience or the type of work setting, staff who had received training had fewer negative attitudes toward users of illicit substances (Howard & Holmshaw, 2010).

In comparison with other consumer groups, staff attitudes toward working with drug users were lower (Gilchrist et al., 2011).

There was a significant improvement in attitudes following previous informal training, indicating the necessity of a more intensive training program (Moore, 2013).

There was a high level of therapeutic attitude and motivation among clinicians toward working with consumers with comorbid conditions (Wheeler et al., 2014).

'Multifaceted vigilance’, the act of being watchful, can be regarded as a power that allows nurses to reflect caring values and safeguard the health of consumers (Johansson & Wiklund-Gustin, 2016).

Mental health clinicians’ attitudes can be improved through training. As a result, the clinician’s role adequacy, role legitimacy, role support, motivation, self-esteem, and job satisfaction increased (Pinderup, 2017).

Generally, clinicians’ knowledge and attitudes changed as a result of the training (Pinderup, 2018).

Table 2. Semi-structured interview questions used to explore mental health nurses’ attitudes toward consumers with dual diagnosis.

Q1	Please tell me about yourself, your work, and experience.
Q2	What does co-existing mental health and drug and alcohol problems or dual diagnosis mean to you?
Q3	Do you feel you have enough knowledge to be able to provide comprehensive care for consumers with dual diagnosis problems?
Q4	What is your knowledge of the availability of the services to these people and how accessible are these services for these consumers?
Q5	What motivates you to work with these consumers?
Q6	In terms of getting support from your managers, fellow workers, and others, do you feel finding it is easy to get support from them?
Q7	How satisfied are you working with consumers with dual diagnosis? What could make things better?
Q8	How confident are you in completing certain tasks related to caring for people with dual diagnosis?
Q9	Can you provide an example of a situation with these consumers that you think the nurses you work with would be confident or not confident in?
Q10	While observing other nurses’ attitudes, how would you describe their views or opinions to these consumers? Can you provide examples of when other nurses have displayed their attitudes toward these consumers?

Table 3. Attitude interview sample characteristics (n = 17).

Variable	n	%
Gender
Female	9	53%
Male	8	47%
Age group
30–39	4	23%
40–49	4	23%
50–59	4	23%
60–69	5	29%
Work setting
Acute mental health	5	29%
Community mental health	9	53%
Emergency department	1	6%
Nursing workforce	1	6%
University sector	1	6%
Countries worked
Australia	5	29%
Australia and one other country	8	47%
Australia and two other countries	4	24%
Qualification
Bachelor’s degree in nursing	5	29%
Master’s degree in nursing	7	41%
Postgraduate diploma	3	18%
PhD in nursing	1	6%
Unknown	1	6%
Experience (years)
10–19	7	41%
20–19	7	41%
30+	3	18%
Position
Mental health nurse	5	29%
Associate nurse unit manager	6	35%
Senior clinician	2	12%
Clinical nurse consultant	2	12%
Nursing educator	2	12%

Table 4. Themes and subthemes.

Themes and subthemes	Files coded (n = 17)	Coding references
Theme 1: Satisfaction and connection
Enjoying collaborating with the marginalised community	16	27
Fascinated to see consumer recovery	17	21
Listening to the whole story	13	23
Theme 2: Combating negativity in others
Fear and frustration	12	32
Stigmatised language	15	44
Theme 3: Working to improve outcomes
Difficult to treat	17	46
Limited services	16	56
Dual diagnosis training needs	16	28

Figure 1. Mental health nurses’ attitudes to consumers with dual diagnosis.

Carey, K. B., Purnine, D. M., Maisto, S. A., Carey, M. P., & Simons, J. S. (2000). Treating substance abuse in the context of severe and persistent mental illness: Clinicians’ perspectives. Journal of Substance Abuse Treatment, 19(2), 189–198. https://doi.org/10.1016/S0740-5472(00)00094-5

 PubMed Web of Science ®Google Scholar

Kavanagh, D. J., Greenaway, L., Jenner, L., Saunders, J. B., White, A., Sorban, J., & Hamilton, G. (2000). Contrasting views and experiences of health professionals on the management of comorbid substance misuse and mental disorders. The Australian and New Zealand Journal of Psychiatry, 34(2), 279–289. https://doi.org/10.1080/j.1440-1614.2000.00711.x

 PubMed Web of Science ®Google Scholar

Barry, K. R., Tudway, J. A., & Blissett, J. (2002). Staff drug knowledge and attitudes towards drug use among the mentally ill within a medium secure psychiatric hospital. Journal of Substance Use, 7(1), 50–56. https://doi.org/10.1080/14659890110110365

 Google Scholar

Happell, B., Carta, B., & Pinikahana, J. (2002). Nurses’ knowledge, attitudes and beliefs regarding substance use: A questionnaire survey. Nursing & Health Sciences, 4(4), 193–200. https://doi.org/10.1046/j.1442-2018.2002.00126.x

 PubMedGoogle Scholar

Pinikahana, J., Happell, B., & Carta, B. (2002). Mental health professionals’ attitudes to drugs and substance abuse. Nursing & Health Sciences, 4(3), 57–62. https://doi.org/10.1046/j.1442-2018.2002.00104.x

 PubMedGoogle Scholar

Foster, J. H., & Onyeukwu, C. (2003). The attitudes of forensic nurses to substance using service users. Journal of Psychiatric and Mental Health Nursing, 10(5), 578–584. https://doi.org/10.1046/j.1365-2850.2003.00663.x

 PubMedGoogle Scholar

Richmond, I., & Foster, J. (2003). Negative attitudes towards people with co-morbid mental health and substance misuse problems: An investigation of mental health professionals. Journal of Mental Health, 12(4), 393–403. https://doi.org/10.1080/0963823031000153439

 Google Scholar

Graham, H. L. (2004). Implementing integrated treatment for co-existing substance use and severe mental health problems in assertive outreach teams: Training issues. Drug and Alcohol Review, 23(4), 463–470. https://doi.org/10.1080/09595230412331324581

 PubMed Web of Science ®Google Scholar

Deans, C., & Soar, R. (2005). Caring for clients with dual diagnosis in rural communities in Australia: The experience of mental health professionals. Journal of Psychiatric and Mental Health Nursing, 12(3), 268–274. https://doi.org/10.1111/j.1365-2850.2005.00830.x

 PubMedGoogle Scholar

Munro, A., Watson, H. E., & Mcfadyen, A. (2007). Assessing the impact of training on mental health nurses’ therapeutic attitudes and knowledge about co-morbidity: A randomised controlled trial. International Journal of Nursing Studies, 44(8), 1430–1438. https://doi.org/10.1016/j.ijnurstu.2006.07.024

 PubMed Web of Science ®Google Scholar

Phillips, P. A. (2007). Dual diagnosis: An exploratory qualitative study of staff perceptions of substance misuse among the mentally ill in northern India. Issues in Mental Health Nursing, 28(12), 1309–1322. https://doi.org/10.1080/01612840701686468

 PubMedGoogle Scholar

Cleary, M., Hunt, G. E., Matheson, S., & Walter, G. (2009). Views of Australian mental health stakeholders on clients’ problematic drug and alcohol use. Drug and Alcohol Review, 28(2), 122–128. https://doi.org/10.1111/j.1465-3362.2008.00041.x

 PubMed Web of Science ®Google Scholar

Ralley, C., Allott, R., Hare, D. J., & Wittkowski, A. (2009). The use of the repertory grid technique to examine staff beliefs about clients with dual diagnosis. Clinical Psychology & Psychotherapy, 16(2), 148–158. https://doi.org/10.1002/cpp.606

 PubMed Web of Science ®Google Scholar

Howard, V., & Holmshaw, J. (2010). Inpatient staff perceptions in providing care to individuals with co-occurring mental health problems and illicit substance use. Journal of Psychiatric and Mental Health Nursing, 17(10), 862–872. https://doi.org/10.1111/j.1365-2850.2010.01620.x

 PubMed Web of Science ®Google Scholar

Gilchrist, G., Moskalewicz, J., Slezakova, S., Okruhlica, L., Torrens, M., Vajd, R., & Baldacchino, A. (2011). Staff regard towards working with substance users: A European multi-centre study. Addiction, 106(6), 1114–1125. https://doi.org/10.1111/j.1360-0443.2011.03407.x

 PubMed Web of Science ®Google Scholar

Moore, J. (2013). Dual diagnosis: Training needs and attitudes of nursing staff. Mental Health Practice, 16(6), 27–31. https://doi.org/10.7748/mhp2013.03.16.6.27.e801

 Google Scholar

Wheeler, A., Crozier, M., Robinson, G., Pawlow, N., & Mihala, G. (2014). Assessing and responding to hazardous and risky alcohol and other drug use: The practice, knowledge and attitudes of staff working in mental health services. Drugs: Education, Prevention & Policy, 21(3), 234–243. https://doi.org/10.3109/09687637.2013.864255

 Web of Science ®Google Scholar

Pinderup, P. (2017). Training changes professionals’ attitudes towards dual diagnosis. International Journal of Mental Health and Addiction, 15(1), 53–62. https://doi.org/10.1007/s11469-016-9649-3

 Web of Science ®Google Scholar

Pinderup, P. (2018). Improving the knowledge, attitudes, and practices of mental health professionals regarding dual diagnosis treatment: A mixed methods study of an intervention. Issues in Mental Health Nursing, 39(4), 292–303. https://doi.org/10.1080/01612840.2017.1398791

 PubMed Web of Science ®Google Scholar