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

Abstract

Background

The issue of dual diagnosis continues to be a global health concern. There is a lack of empirical research on mental health nurses’ attitudes toward consumers with dual diagnosis.

Objective

This study aimed to answer the following research question: How do mental health nurses describe their attitude toward consumers with co-existing mental health and drug and alcohol problems?

Design

This qualitative study employed purposive sampling to recruit participants. Semi-structured interviews were conducted to explore mental health nurses’ attitudes toward consumers with dual diagnosis.

Setting

This study focused on mental health nurses employed in mental health settings. It placed a particular emphasis on mental health nurses who had experience in caring for consumers with dual diagnosis. Seventeen mental health nurses participated in the interview.

Methods

Interviews were transcribed verbatim and coded using NVivo™ 12 Plus software. Thematic analysis was used to generate codes and themes inductively.

Results

Three major themes with a total of eight sub-themes were identified: (1) satisfaction and connection, with three subthemes; (2) combating negativity in others, with two subthemes; and (3) working to improve outcomes, with three subthemes.

Conclusions

Participants were concerned about their peers’ sense of fear and frustration, stigmatized language, and lack of consistency in providing dual diagnosis training for mental health nurses. There is a need to investigate effective strategies to address mental health nurses’ stigmatized attitudes, fear, and frustration toward consumers with dual diagnosis.

1. Introduction

Mental, neurological, and substance use disorders affect almost one billion people worldwide (World Health Statistics, 2022). As of 2019, this accounts for 10% of the global burden of disease and 25% of the number of years lived with disability. Substance use is a major contributor to ill health and death worldwide settings (WHO, 2019). Co-occurring mental health and drug and alcohol problems or dual diagnosis is a term used to describe simultaneous alcohol/drug problems and mental health problems within psychiatric/mental health settings (WHO, 2019). Approximately 10% of the global disease burden is attributed to dual diagnosis, while 30% is attributed to non-fatal diseases (WHO, 2022).

The prevalence of consumers with dual diagnosis is high (De Ruysscher et al., 2019), and caring for these consumers can be complex and challenging (de Waal et al., 2019; Lopes & Freitas, 2022; Toftdahl et al., 2016). The prevalence of mental disorders among Australians aged 16–85 years is estimated to be over two-in-five (43.7% or 8.6 million people) (AIHW, 2022). In Australia, an estimated 4.2 million individuals (21.4%) experience mental disorders at some point during their lifetime in 2020–2021 and 3.3% of those aged 16–85 (650,800 people) had a substance use illness within the past 12 months (AIHW, 2022). It was reported that there is an influx of emergency admissions of consumers to Australian hospitals in 2014–2015 was due to psychological and behavioral problems caused by illegal substance use (AIHW, 2018).

Consumers with dual diagnosis exhibit higher health and social risks, including homelessness, illegal behavior, homicide, and suicide (Hamdan-Mansour et al., 2018; Iheanacho et al., 2020; Priebe et al., 2018). Moreover, these consumers have many health concerns and complex needs (Ortega & Ventura, 2013). Due to their complex social and health care needs, people with substance use disorders frequently present in the health services settings (WHO, 2022). Although effective and brief treatments are available and recommended, they are not widely covered (WHO, 2022) and these consumers also tend to experience more stigma than individuals with any other health problem (Livingston et al., 2012).

Nurses generally are the largest professional group within the healthcare system (Garrod et al., 2020). Mental health nurses portray a crucial part in providing care to consumers with dual diagnosis (Chicoine et al., 2023; Smyth et al., 2019). To provide such care, there is a need for mental health nurses to be well-prepared to provide care to consumers with dual diagnosis (Russell et al., 2017; Worley, 2019). Moreover, the attitudes of mental health nurses toward these consumers can affect the consumers’ involvement in treatment and recovery (Estreet & Privott, 2021; Peters et al., 2017). According to Farley-Toombs (2012), nurses’ attitudes and stigma surrounding consumers with dual diagnosis influence therapeutic relationships. In addition, discriminating in providing nursing care to these consumers can have long-term consequences, affecting consumers’ life goals, community relations, and support (Lucksted & Drapalski, 2015). It is essential to provide specialized treatment for consumers with dual diagnosis; for this to be successful, mental health nurses must have adequate knowledge, skills, attitudes, empathy and self-efficacy. It can be argued that a lack of positive attitudes, empathy, and low self-efficacy may lead to poor nurse-consumer therapeutic relationships and poor therapeutic outcomes.

People’s attitudes are determined by their opinions of acceptable or unacceptable behavior (Maio & Haddock, 2012). As a result of one’s attitude, one may respond positively or negatively to an object, person, institution, or event (Ajzen & Fishbein, 1980). Different attitudes and traits influence an individual’s specific behaviors (Ajzen & Fishbein, 1980). It is possible to evaluate attitudinal behaviors whether it is positive or negative (Ajzen & Fishbein, 1980). The present study explored the nature of those behavior-related factors—namely, the attitudes of mental health nurses regarding consumers with dual diagnosis, based on the Theory of Planned Behavior (TPB) (Ajzen & Fishbein, 2005). The TPB predicts and rationalizes human behavior in selected circumstances.

Before conducting this study, a scoping review of the literature was undertaken. The scoping review followed the Joanna Briggs Institute approach to scoping studies (Peters et al., 2015). The scoping review identified twenty studies for final reporting. Key finding is provided in Table 1. Studies reported in the scoping review had multiple gaps. Study designs were unbalanced, selection bias existed, attrition rates were high, and there were very low response rates and mental health nurses were underrepresented. Further, the attitudes of mental health nurses toward consumers with dual diagnosis have not been validated in follow-up studies, and most studies were conducted over a decade ago. The literature needs to provide a well-rounded picture of mental health nurses’ attitudes toward consumers with dual diagnosis. It is crucial to ensure that mental health nurses provide equal and unbiased care to all consumers with dual diagnosis, regardless of mental health status. It is socially and economically detrimental to neglect the well-being of these consumers (WHO, 2020).

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).

2. Study aim

This study aimed to answer the following research question: How do mental health nurses describe their attitude toward consumers with co-existing mental health and drug and alcohol problems?

3. Methods

There were multiple gaps in the studies reported in the scoping review. There is a need to provide a comprehensive picture of mental health nurses’ attitudes toward consumers with dual diagnosis. This qualitative study used an essentialist approach (Braun & Clarke, 2006) because little is known about mental health nurses’ attitudes toward consumers with dual diagnosis. This research was guided by an essentialist epistemology that informs how data are interpreted and meaning derived from them. It is possible to theorize motivations, experiences, and purpose using an essentialist approach.

3.1. Data collection

This study was conducted in accordance with the Declaration of Helsinki. Ethical approval for this study was obtained from the Federation University Australia Human Research Ethics Committee (Approval number: A19-026). Purposive sampling, whereby participants were carefully chosen based on their knowledge and experience of the topic being studied (Lopez & Whitehead, 2013), allowed this study to collect valuable information while optimizing available resources (Etikan et al., 2016). The study recruited mental health nurses who had experience working with consumers with dual diagnosis. This enabled the researchers to obtain meaningful perspectives from participants with relevant expertise. This study used maximum variation sampling to ensure the representativeness and diversity of individual mental health nurses and mental health settings. This study also used snowball sampling. This approach involved collecting data from initial participants and using their connections to introduce the research to other potential participants (Lopez & Whitehead, 2013). This approach helped to expand the sample size and diversity. Information-rich cases may be interpreted more deeply than empirical generalizations (Etikan et al., 2016; Lopez & Whitehead, 2013).

Mental health nurses who wanted to take part in the research were contacted via email and phone calls. Further, the study was advertised on the website of the Australian College of Mental Health Nurses Inc. (The Australian College of Mental Health Nurses Inc. is Australia’s peak mental health nurses’ association.) and social media. In the invitation letter and plain language statement, it was clearly stated that this study would only recruit mental health nurses with experience working with consumers who have co-occurring mental health and drug and alcohol problems. It was confirmed with the interviewees before the interview process began. A total of 33 mental health nurses agreed to participate in the interview. However, due to COVID 19 restrictions, 17 nurses were interviewed over the telephone. Participants were not provided with any incentives. Data collection took place from 17 July 2020 to 6 October 2020. A detailed information on the research was provided to participants. A semi-structured interview schedule was used (see Table 2). The interviews lasted between 30 and 60 min. Participants were encouraged to share their opinions and experiences regarding consumers with dual diagnosis. Data collection ceased once data saturation was reached.

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?

3.2. Data analysis

A six-step thematic analysis method was utilized (Braun & Clarke, 2006). In step one, all interviews were digitally recorded and transcribed verbatim via NVivo™ 12 Plus Version (QSR International, 2018). To protect participants’ privacy, their names were encoded using pseudonyms. The transcripts were reviewed again to ensure their accuracy. In step two, we generated initial codes via an auto-coding method using NVivo™ 12 Plus. Large amounts of data can be quickly analyzed, and themes identified with NVivo’s automated tools. By importing files automatically, nodes can be created for entire files. The term “node” refers to a collection of references related to certain topics, places, people, or other areas of interest (NVivo™). From interview transcripts, nodes were gathered for this study. The Auto Code Wizard options were used to accomplish this. In step three, 40 auto-coded items were collected, and a search was conducted for potential themes based on these codes. In step four, three major themes were identified. We identified 71 aggregated codes for the first theme, 76 for the second theme, and 130 for the third theme. In step five, the themes were refined and named. In step six, themes were reported and arranged as per the research questions and prior literature. Inductive approaches were incorporated into the theme-building process. All data were stored securely according to university policy. Two researchers proficient in qualitative research examined interview transcriptions and themes, and any inconsistencies were resolved through several discussions.

We followed the guidelines outlined in Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) (Tong et al., 2012).

4. Results

4.1. Participant characteristics

Participants’ demographic characteristics are presented in Table 3. All participants had at least 10 years of experience working in the area. Participants worked in a range of mental health settings (e.g. acute and community mental health units, emergency departments, homeless services, people with HIV, forensic mental health, youth, adults, adolescents, generalist hospitals, geriatrics, brain disorders units, drug and alcohol units, medically supervised injecting clinics).

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%

5. Themes

Three main themes and eight subthemes emerged from the data (see Table 4): (1) satisfaction and connection, with three subthemes; (2) combating negativity in others, with two subthemes; and (3) working to improve outcomes, with three subthemes. These themes and subthemes are discussed below.

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

5.1. Satisfaction and connection

This theme describes participants’ knowledge about dual diagnosis, their job satisfaction, and how they therapeutically engage with consumers with dual diagnosis. This theme had three subthemes: enjoying collaborating with the marginalized community, fascinated to see consumer recovery, and listening to the whole story.

5.1.1. Enjoy collaborating with the marginalized community

This subtheme describes participants’ work satisfaction and confidence when treating consumers with dual diagnosis. Participants stated that they are confident and enjoy working with these consumers, even though it can be challenging at times:

I feel confident with working with people [consumers with dual diagnosis] who present with significant drug and alcohol issues or mental health issues. I prefer working people who have at least hope, the most chaotic, the most challenging, the most difficult clients because I think the bar for improvement is very low. (Austin)

According to participants, addressing the needs of these consumers has proven to be a fulfilling and enriching experience. This is despite the gradual pace of progress. Any improvement, no matter how small, is viewed as a noteworthy achievement and a source of immense gratification for caregivers:

I am very satisfied, especially if I can help them [consumers with dual diagnosis]. I was able to settle them down, settling their emotions or mood, providing the care, is rewarding for me. (Luca)

Participants also reported that their job satisfaction depends on collaborative teamwork and their ability to partner with allied health services available to consumers:

I have the best team in the world… It took us [the team] a couple of years to break the ice, to get people to feel confident in what we are doing and our recommendations. (Georgia)

5.1.2. Fascinated to see consumer recovery

This subtheme describes participants’ motivation toward treating consumers with dual diagnosis. Participants are motivated to provide high standards of care and treatment, regardless of consumers’ economic status. Participants believe that those with dual diagnosis can improve over time. Therefore, it is crucial to provide these individuals with high-quality services to aid in their recovery:

When they [consumers with dual diagnosis] get discharged, and then, we see that, they are happy and then they have got some independence, then how they move on to their life. (Felicity)

Participants reported that recovery can sometimes be a slow process and consumers often pass through different stages of change before the desired outcome is achieved:

I have seen people improve over time, it might be the first few times of detox, but eventually they do get something from it and make changes to their lifestyle. (Crystal)

5.1.3. Listening to the whole story

This subtheme describes participants’ direct interaction with consumers with dual diagnosis. Participants used an open communication strategy to obtain as much information as possible when interacting with these consumers:

It is our responsibility to personally engage with the person [consumer with dual diagnosis] and help them feel comfortable and build a trusting relationship, so, they tell us as much information as possible. (Henry)

Participants noted that it was very important to listen to the whole story of a consumer to fully understand the reasons for their current circumstances:

I have met different people [consumers with dual diagnosis]. The problem is, when we look at substances, we think it is their choice to use substances, but sometimes it is not. I am willing to listen to the whole story. I try and say, ‘Look, we have an issue up here’. Until this is resolved, they will always go back to alcohol or to cannabis and sort of things, or whatever issues they are having. (Isabella)

Participants reported that interactions with consumers with dual diagnosis could be challenging. These consumers sometimes use insulting language and threatening behavior, and nurses can struggle with this, affecting nurses’ care and attitude:

Their [consumers with dual diagnosis] behavior is erratic until we get them settled down with their medication regime. This is the chance to talk to somebody about their drug usage and how it impacts their mental health. Just explanation and communication are the best way to go. (Crystal)

5.2. Combating negativity in others

This theme describes participants’ views on what they perceive to be the negative attitude of some nurses toward consumers with dual diagnosis. Participants claimed that nurses need to be more helpful, and some are not looking at the whole picture of consumers’ illness. It is possible that nurses do not see illness as a result of the consumer’s psychosocial environment. This theme had two subthemes: fear and frustration, and stigmatized language.

5.2.1. Fear and frustration

Participants expressed dissatisfaction with managing consumers who have a dual diagnosis. They were concerned that managing such consumers could prove difficult, especially if they were under the influence of drugs or alcohol during their first referral:

There is a good element of fear, the good element of frustration is there. We can see there is a lack of empathy. I cannot say everyone [nurses] is like that, but some of them are like that. (Emma)

Participants stated that most nurses they work with know about recovery-based services. However, there seems to be a struggle when it comes to consumers with dual diagnosis:

When consumers are angry or upset, nurses take that on board personally, straight away, instead of asking the consumers why they are angry and disappointed. (Nolan)

Participants reported seeing junior mental health nurses get anxious when working with consumers with dual diagnosis:

Nurses take it a little bit personally if somebody [consumers with dual diagnosis] has a slip, most of the time, they [nurse] are little bit avoidant of wanting to deal with the issues of the drug and alcohol. There is a little bit of avoidance. (Tiana)

Participants stated that some nurses are frustrated, judgmental, and fearful of working collaboratively with consumers with dual diagnosis, especially when the consumer has a forensic history:

I have come across some of my fellow nurses coming and telling me, ‘Could you avoid allocating this particular client for me today?’ That particular nurse would be afraid to engage with those kinds of clients. (Nora)

5.2.2. Stigmatized language

This subtheme describes nurses’ judgmental attitudes toward consumers with dual diagnosis. During handovers, nurses may use confrontational, belittling, and disparaging language toward these consumers:

If they [consumers with dual diagnosis] ask for medication, they [nurses] talk about drug-seeking behavior. You can still hear people saying, ‘Oh, he is just another drug seeker!’ (Henry)

Participants reported that nurses’ stigmatizing language and opposing attitudes during handover can be degrading at times:

Especially at the beginning of the shift allocation, some staff says, ‘I do not want to look after that patient’, because many of these dual diagnosis patients can be challenging. The staff politely refuse to look after them. (Jordan)

Participants argued that nurses use language like “clean” (i.e. drug free), whether people are “abstinent” or “dirty” (i.e. currently drug using), and label them as “criminals” and “junkies.” Nurses stigmatizing consumers with dual diagnosis can leave these consumers without hope:

It is quite difficult working with other people [nurses] who are stigmatizing and punishing toward a client [consumers with dual diagnosis]. (Nolan)

There is a culture of judgmental attitude among nurses working in the dual diagnosis area, and nurses who work in this area tend to become disillusioned:

It is another time, another druggie. Why can the police not just lock them up? (Isabella)

You know, sort of saying, ‘Oh, this is the pure drug and alcohol, they [consumers with dual diagnosis] are not mental health’. (Crystal)

Participants also stated that some nurses were resistant to dealing with drug and alcohol problems:

One of my colleagues does not have a good attitude toward consumers [consumers with dual diagnosis], who [nurse] would call ‘drug users’. That particular nurse would lose interest or refuse to even engage with the client. If at all that nurse engages, would have that kind of attitude toward client. Interaction will be negative all the time negative. (Nora)

5.3. Working to improve outcomes

This theme describes the challenges of treating consumers with dual diagnosis. Providing quality mental health services is a crucial aspect of healthcare, and this theme underscores the need for continuous improvement in this area. This theme also highlights the importance of addressing mental health nurses’ educational needs. This is to equip them with the skills and knowledge required to deliver adequate and appropriate services for consumers with dual diagnosis. This theme had three subthemes: difficult to treat, limited services, and dual diagnosis training needs.

5.3.1. Difficult to treat

This subtheme describes participants’ opinions about consumers with dual diagnosis’ complexities and difficulties. According to participants, consumers who are referred to mental health services with drug and alcohol issues face significant challenges:

One of the big grey areas will be when there is any violence involved, it can be tricky. (Christopher)

So, in my experience, working with dual diagnosis, [I] find that very complicated. To be honest with you, it is difficult. (Isabella)

Participants stated that most of their consumers with dual diagnosis commenced the use of drugs and alcohol early in life due to trauma or family issues. Participants noted that most of their consumers engage in the use of drugs to escape family issues:

They [consumers with dual diagnosis] use [illicit drugs] as self-medicating, and of course, that goes oppositely. A lot of people who have diagnosed mental illnesses also use drugs and alcohol as a preference to using antipsychotic medications, which can exacerbate the whole situation. (Crystal)

5.3.2. Limited services

Combined with consumer complexities, this subtheme describes the difficulties staff and consumers face. According to participants, more public services should draw from other specialties:

The public service is heavily underfunded and quite often restrictive with their criteria, making it quite hard for people to access their services. People want to look at rehab, especially residential rehab. There are limited places, and COVID-19 has further limited that. (Austin)

Other issues preventing adequate service delivery include a medical model of care, a need for more customer self-referrals, and an absence of integrative treatments. These consumers may not receive relevant or appropriate assessments. Inaccurate assessments may adversely affect consumer outcomes. Participants believe hospital admission is heavily focused on stabilizing consumers on psychotropic medications:

The mental health service often focuses on the psychotic symptoms, keeping people [consumers with dual diagnosis] out of the hospital, the medications, some therapy. (Benson)

Participants are worried about these consumers’ ongoing contact with drug and alcohol facilities after they have been discharged from mental health facilities:

I have noticed when we [hospital] discharge them [consumers with dual diagnosis] from our facility, that is when they relapse, maybe because they do not get enough support in the community. (Lily)

Regarding the availability of services, participants have a distinct concern and reported that there are not many youth-specific services. Participants believed that young people cannot navigate through the arduous triage process. Moreover, getting into a drug detox program is complex, and drug rehabilitation programs are not user-friendly:

Look, they [mental health service] are accessible, but the problem with these services is that they are set up more for middle-class sort of people as well as via appointments. (Nolan)

5.3.3. Dual diagnosis training needs

This subtheme describes dual diagnosis training needs for mental health nurses. According to participants, nurses working with consumers with dual diagnosis need encouragement and training in recovery-focused language. Participants indicated that nurses’ confidence could be improved through in-service training; however, participants reported that no consistent education packages were delivered to upskill nurses across various mental health settings:

There is one online package through [mental health service], we do it online once, you know, and that is it! You do not have to do it again through your whole career. (Tiana)

Mental health nurses reported that dual diagnosis training improves nurses’ attitudes, but working in multiple mental health settings also boost the nurses’ attitude and confidence, as they are capable to provide care in a range of settings:

The nurse education team deals particularly with the inpatient unit, the graduate nurses and upskilling them. Once somebody transitions into the community, they [nurses] have to get the skills on the job. Their capacity to learn how to navigate the system and learn what is out there is dependent on the expertise of their colleagues. (Georgia)

As well as being aware of trauma-informed care, mental health nurses need regular debriefings and the opportunity to learn from consumer experiences through consumer-led meetings:

I think the other one is learning from the people who have had some lived experience, whether through the work we do or having people with experience come in and teach us. (Henry)

6. Discussion

This qualitative study explored mental health nurses’ attitudes toward consumers with dual diagnosis. Three major themes with a total of eight sub-themes were identified.

The study’s identified themes indicated the importance of nurses feeling satisfied and connected at work, combating negativity in others, and working toward improving the outcomes of the work environment.

The findings show mental health nurses are satisfied and enjoy working with consumers with dual diagnosis. Participants were knowledgeable about caring for consumers with dual diagnosis. Happell et al. (2002) reported that nurses are knowledgeable about alcohol and other drug use, as well as possess adequate problem-solving skills. Previous studies have also reported that nurses’ job satisfaction is related to their experience, knowledge, and skills (Takano et al., 2015).

The current study found mental health nurses’ lack of enthusiasm and harmful attitudes toward consumers with dual diagnosis. Researchers have reported that clinicians have a negative attitude toward consumers, treatment options, and society at large (Carey et al., 2000; Deans & Soar, 2005; Foster & Onyeukwu, 2003; Gilchrist et al., 2011; Ralley et al., 2009). It is worth noting that mental health nurses reported witnessing fear, frustration, and stigma among their colleagues. In addition, participants reported many difficulties and complexities when caring for consumers with dual diagnosis, including frustration, fear, and difficulties coping. Previous studies found similar results (Houghton et al., 2021; Zarea et al., 2013).

Participants stated that derogatory language is a culture ingrained in their profession; thus, they emphasized that mental health nurses must recognize consumers’ needs and use effective communication strategies when treating consumers. Participants reported that the negative attitudes of nurses can contribute to feelings of helplessness among consumers. To achieve a therapeutic relationship with consumers, mental health nurses must maintain an open dialogue with them. Other studies have reported that staff members’ opposing attitudes may be related to their struggles with developing a therapeutic relationship with consumers (Petersén et al., 2021). This study also identified areas by which to improve outcomes in caring for consumers with dual diagnosis. Participants acknowledged that consumers with dual diagnosis can be challenging to treat, and treatment pathways can sometimes be complex. Cleary et al. (2009) reported that consumers with dual diagnosis are more challenging to treat than consumers with one mental illness or substance abuse issue. Brekke et al. (2018) and Cilia Vincenti et al. (2022) reported similar issues. It is necessary to develop effective strategies to manage issues that arise during consumer communication.

According to participants in this study, nursing confidence and attitude are improved by education and practical experience on the ward, as well as working with senior nurses. Previous studies have reported that regular training programs can address stigmatized attitudes, fears, and frustrations (Van Boekel et al., 2014) and reinforce staff confidence in providing superior consumer care (Horner et al., 2019). Regular education can also change attitudes over time (Bielenberg et al., 2021; Wright et al., 2022). It is beneficial to educate clinicians about drugs and alcohol issues (Munro et al., 2007; Pinderup, 2018). However, Barry et al. (2002) recommend that training include a discussion of attitudes and beliefs regarding drug use and mental health problems. Taking training increases clinicians’ motivation, self-esteem, and job satisfaction because they feel more appropriate, legitimate, and supported (Pinderup, 2017). The current study indicates that dual diagnosis training remains necessary. Moore (2013) suggests intensive training programs as a means of achieving this.

Nurses’ attitudes are further guided by several factors, including their age, work experience with consumers with dual diagnosis, and work settings (Chang & Yang, 2013). In the present study, all participants had extensive work experience (minimum of 10 years) and high job satisfaction and were highly motivated at work. It is likely that the participants with more work experience were more satisfied with their job and motivated since they had more opportunities to interact with consumers with dual diagnosis and provide care to them. According to Kluit et al. (2013), role support, consistent work experience, further training, and open communication all contribute to developing a positive attitude and staff competence. Researchers reported that nurses who received training had more positive attitudes toward people who use illicit drugs regardless of their clinical experience or work setting (Howard & Holmshaw, 2010).

The study also found that there are hindrances to service provision that need to be addressed. Nurses’ attitudes may be affected by their lack of experience with successful interventions and recovery processes. More facilities and services are needed to meet the needs of consumers with dual diagnosis so that they can be served more effectively (Kavanagh et al., 2000). Providing more opportunities for consumer interaction and care may help mental health nurses develop a more positive attitude toward consumers with dual diagnosis.

7. Study limitations

This study was limited to an Australian context, which may affect the generalizability of the results. It is possible that snowball sampling could have led to sample bias and resulted in a population that represents smaller networks rather than the larger group. However, caring for consumers with dual diagnosis is a global challenge, and the results may apply to international healthcare settings.

8. Conclusion

This study explored attitudes among mental health nurses in caring for consumers with dual diagnosis. The findings suggest that mental health nurses are knowledgeable, motivated, satisfied, role-supported, and possess a variety of self-esteems specific to their roles toward consumers with dual diagnosis. It is however difficult to improve consumer care quality due to stigmatized language, fear and frustration among mental health nurses, lack of consistent dual diagnosis training packages, and limited services for consumers with dual diagnosis. In the view of the TPB, a person’s attitude, subjective norms, and perception of control determine whether or not they will engage in a particular behavior (Fishbein & Ajzen, 1975). Figure 1 illustrates mental health nurses’ demotivational factors and perceived conversational partners. It may be beneficial to address these areas in order to build a positive attitude, which is essential to the success of treatment. It may be possible to contribute to a healthier attitude among nurses by addressing fears and frustrations through consistent education and training with experienced clinicians, consumers, carers, and peer support workers. Treatment outcomes may be improved as a result.

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

Relevance to clinical practice

• The results can be used by teachers, clinicians, and administrators when designing, developing, and delivering training packages for mental health nurses in caring for consumers with dual diagnosis.

• Mental health nurses need to be trained in dual diagnosis to ensure they can adequately assess and provide efficient care to consumers with dual diagnosis.

• Mental health nurses should be given opportunity to work in multiple mental health settings so that they can familiarize themselves with the needs of these consumers with dual diagnosis.

• Mental health nurses should also be provided with access to resources, such as shared learning opportunities, to help them gain a better understanding of consumer complexities.

• Mental health nurses should be equipped with access to ongoing professional development opportunities to remain up-to-informed with the modern advances in dual diagnosis care.

• Educational programs are needed to address stigmatized language and staff fear and frustration when providing care to consumers with dual diagnosis.

• Further interventional research is needed on a larger sample of mental health nurses to assess their attitudes in caring for consumers with dual diagnosis.

Ethical approval

Ethical approval for this study was obtained from the Federation University Australia Human Research Ethics Committee (Approval number: A19-026).

Author contributions

All authors listed meet the authorship criteria in keeping with the latest guidelines of the International Committee of Medical Journal Editors, and all the authors agree with the manuscript. 

Acknowledgments

We would like to thank all the participants for participating in the research and sharing their experiences despite the difficulties associated with COVID-19.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

Roopalal Anandan was supported by the Australian Government Research Training Program (RTP) Stipend and RTP Fee-Offset Scholarship through Federation University Australia.