Literature Review

https://doi.org/10.1177/1078390319878773

Journal of the American Psychiatric Nurses Association 2020, Vol. 26(3) 250 –261 © The Author(s) 2019 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1078390319878773 journals.sagepub.com/home/jap

Original Research

Introduction

Known as a dual diagnosis, an estimated one third to one half of adults diagnosed with a mental illness also have a substance use disorder (Antai-Otong, Theis, & Patrick, 2016; Drake, Mueser, & Brunette, 2007; European Monitoring Centre for Drugs and Drug Addiction [EMCDDA], 2015; Petrakis, Robinson, Myers, Kroes, & O’Connor, 2018). Also referred to as having a concurrent disorder or a co-occurring disorder (EMCDDA, 2015), individuals in this subgroup face many challenges includ- ing being more likely to have added health problems (Drake et al., 2006; Rosenberg, Drake, Brunette, Wolford, & Marsh, 2005) as well as being at increased risk for adverse outcomes, including treatment nonadherence and suicide (Beeber & Stein, 2015; Cosci & Fava, 2011; Czobor et al., 2015; Drake, O’Neal, & Wallach, 2008; Greenberg & Rosenheck, 2014; Jacobs et al., 2010; Krausz et al., 2013; Montes, Maurino, de Dios, & Medina, 2013; Roque, Findlay, Okoli, & El-Mallakh, 2017; Sendt, Tracy,

& Bhattacharyya, 2015). The frequency of emergency room visits as well as hospital readmission rates and length of stay are significantly higher for patients with a dual diagnosis than for those with either a mental illness or a substance use disorder alone (Antai-Otong et al., 2016; Cosci & Fava, 2011; Drake et al., 2008; Jacobs et al., 2010). Service use by this population is thus relatively

878773 JAPXXX10.1177/1078390319878773Journal of the American Psychiatric Nurses AssociationOuld Brahim et al. research-article2019

1Lydia Ould Brahim, MSc, RN, Ingram School of Nursing, McGill University, Montreal, Quebec, Canada 2Cezara Hanganu, MSc, RN, Ingram School of Nursing, McGill University, Montreal, Quebec, Canada 3Catherine Pugnaire Gros, MSc, RN, McGill University, Montreal, Quebec, Canada; Centre Intégré Universitaire de Santé et de Services Sociaux de l’Ouest-de-l’Île-de-Montréal; Douglas Mental Health University Institute, Verdun, Quebec, Canada

Corresponding Author: Lydia Ould Brahim, Ingram School of Nursing, McGill University, 680 Sherbrooke Street West, Suite 1800, Montreal, Quebec H3A 2M7, Canada. Email: [email protected]

Understanding Helpful Nursing Care From the Perspective of Mental Health Inpatients With a Dual Diagnosis: A Qualitative Descriptive Study

Lydia Ould Brahim1 , Cezara Hanganu2, and Catherine Pugnaire Gros3

Abstract BACKGROUND: An estimated 30% to 50% of people with a mental illness also have a substance use problem. Referred to as having a dual diagnosis, these patients experience high levels of unmet needs, poor health outcomes, and require specialized care during psychiatric hospitalization. Research on nursing inpatients with a dual diagnosis is limited and patient perceptions of helpful care during hospitalization are unknown. AIMS: What nursing interventions, attitudes, actions, and/or behaviors are perceived as helpful by patients with a dual diagnosis during psychiatric hospitalization? METHODS: A qualitative-descriptive design was used. Twelve adult inpatients with a dual diagnosis were recruited using purposive sampling. Individual, semistructured interviews were conducted, and interview data were analyzed using content analysis. RESULTS: Helpful nursing occurred across three themes: (1) promoting health in everyday living, (2) managing substance use in tandem with mental illness, and (3) building therapeutic relationships. CONCLUSIONS: Specific examples of helpful interventions and their reported outcomes reinforce the critical role that nurses play in the health and recovery of inpatients with a dual diagnosis. The importance of collaborative, strengths-based approaches is highlighted, and expanding the nurse’s role to include evidence-based responses to substance use is recommended.

Keywords dual diagnosis, patient experience, nursing role, substance abuse, acute hospital

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high, particularly with respect to inpatient treatment. Inpatient settings typically provide continuous around-the- clock nursing care, combined with interprofessional exper- tise and multifaceted approaches such as family support and therapy, pharmacotherapy, psychotherapy, detoxifica- tion, and crisis intervention (Seitz et al., 2012; Stensland, Watson, & Grazier, 2012). Despite these efforts, the reported level of unmet needs for the population remains high (Beeber & Stein, 2015; Lawrence-Jones, 2010; Rush, Urbanoski, Bassani, Castel, & Wild, 2010).

The needs of patients with a dual diagnosis are complex and delivering effective care calls for specialized knowl- edge, novel approaches, and clinical skills specific to this population (EMCDDA, 2015; McCallum, Mikocka- Walus, Gaughwin, Andrews, & Turnbull, 2016; McGovern, Lambert-Harris, Gotham, Claus, & Xie, 2014; Petrakis et al., 2018). Acquiring and developing these competencies requires further staff education, standardized training, and professional support (Antai-Otong et al., 2016; Delaney & Lynch, 2008; McGovern et al., 2014; Petrakis et al., 2018; Van Boekel, Brouwers, Van Weeghel, & Garretsen, 2013). Many also argue in favor of an integrated care model, in which the management of substance use is incorporated as an integral part of mental health services. As such, the aim of organizational systems and clinical staff is to address co-occurring disorders simultaneously, rather than sepa- rately or sequentially (Edwards, 2008; Gallagher & Scott, 2008; McGovern et al., 2014).

Educational resources aimed at advancing the care of clientele with a dual diagnosis include several national and international guidelines (Canadian Centre on Substance Abuse, 2015; EMCDDA, 2015; World Health Organization [WHO], 2013). While these frameworks offer edvience-based information and general direction for clinicians, none are specifically designed for nurses and place little emphasis on hospital-based care. Consequently, their use for guideling inpatient nursing practice is limited.

Helpful Nursing Care From the Perspective of Mental Health Inpatients With a Dual Diagnosis

Despite the importance of experiential expertise in improving health care services (Petersen, Hounsgaard, & Nielsen, 2008), patient perspectives are underrepresented in the literature (Cleary, Hunt, Horsfall, & Deacon, 2012). Little is known about how inpatients with a dual diagnosis perceive their care, and the specific interventions they find helpful have yet to be explored. Studies investigating the perceptions of psychiatric inpatients as a whole reveal that their primary concerns involve issues related to informa- tion, communication, activities, the physical environment, autonomy, and relationships with nurses (Hughes,

Hayward, & Finlay, 2009; Sebergsen, Norberg, & Talseth, 2016; Selvin, Almqvist, Kjellin, & Schröder, 2016; Stewart et al., 2015; Voogt, Goossens, Nugter, & van Achterberg, 2015; Walsh & Boyle, 2009; Zolnierek, 2011).

An extensive literature search conducted by two grad- uate students in collaboration with a resource librarian retrieved one article that examined nursing care from the perspective of inpatients with a dual diagnosis. In this interpretive phenomenological study, research partici- pants (n = 10) perceived the inpatient care environment as controlling, which was found to negatively affect their relationships with clinicians. However, the findings also demonstrated that the impact of this negative perception of the environment could be mitigated through nonjudg- mental approaches to care and staff communication styles (Chorlton, Smith, & Jones, 2015). This study highlighted that themes of rejection, power, and compassionate care are particularly important for inpatients with a dual diag- nosis. However, examples of specific nursing interven- tions of value were not elaborated.

Previous research on patient perceptions of helpful nursing is limited to two descriptive studies focused on suicide care across diverse pediatric settings. The first was conducted with suicidal adolescents (n = 6; Gros, Jarvis, Mulvogue, & Wright 2012; Gros, Wright, Mulvogue, & Jarvis, 2011), and the second involved chil- dren (n = 5) and their parents (n = 5; Montreuil, Butler, Stachura, & Gros, 2015). Overall, helpful interventions focused on building relationships, managing illness, and creating therapeutic environments. While the results highlight the critical role nurses play in the quality and outcomes of care, these findings pertain to children and cannot be generalised to the adult population.

In sum, research into how mental health inpatients with a dual diagnosis view their care is limited (Lawrence- Jones, 2010) and the specific nursing interventions they find helpful have not been explored. Specifically, the research question we aim to answer is, “What actual and/ or potential nursing interventions, attitudes, actions, or behaviors are perceived as helpful by psychiatric inpa- tients with a dual diagnosis?” This is the first empirical study on this topic to date. It aims to contribute to the development of care by identifying the interventions, atti- tudes, actions, and behaviors that are of benefit to this population.

Conceptual Framework

This study was designed and conducted using a concep- tual framework known as the McGill model of nursing (Allen & Warner, 2002; Gottlieb & Ezer, 1997; Gottlieb & Rowat, 1987). This person/family-centered approach is consistent with recovery-oriented mental health practices

252 Journal of the American Psychiatric Nurses Association 26(3)

(Anthony, 1993). It emphasizes working in collaborative partnership (Gottlieb & Feeley, 2005; WHO, 2013) and reflects the principles of strengths-based care (Gottlieb & Gottlieb, 2013). Used primarily in the clinical realm, the model also serves as a framework for nursing research. It is rooted in a philosophy of learning and continuous inquiry involving exploration, dialogue, and mutual dis- covery (Gros & Ezer, 1997; Gros & Young, 2007) in which the nurse (or researcher) focuses on learning from the patient (or participant) who is considered the expert in matters concerning their own health (Gros & Young, 2007).

Applying these concepts in a research contextoffers an alternative to more traditional approaches to inquiry that are problem-oriented and deficits-based. By exploring helpful, as opposed to unhelpful care, this study seeks to understand what works well, and focuses on identifying possibilities, potentials, and possible avenues for change. Moreover, research aimed at learning about nursing best practices from patients reflects concepts of collaborative, strengths-based practice in which the expertise of patients is valued and their input actively sought.

Definition of Terms

For the purposes of this study, a person with a dual diag- nosis is defined as having both a diagnosed mental illness and a history of nonprescribed drug use as documented in the medical record. Drug use is defined here as any past or present use of alcohol and/or illicit substances as docu- mented in the medical record. The term “helpful nursing” is defined as the nursing practices, actual or potential, that participants report as being beneficial. These practices include any strategies, techniques, actions, approaches, activities, attitudes, or behaviors implemented or offered by nursing staff on inpatient mental health units. The ben- eficial effects of helpful nursing refer to the positive changes or useful outcomes described by participants as a result of helpful nursing care.

Methods

Study Design

This study was conducted using a qualitative descriptive design as outlined by Sandelowski (2000, 2010). Data were analyzed using a conventional approach to content analysis (Hsieh & Shannon, 2005). As detailed below, semistruc- tured interviews were conducted with participants.

Our reporting adheres to the Consolidated Criteria for Reporting Qualitative Research guidelines (Tong, Sainsbury, & Craig, 2007). As mentioned above, the approach to inquiry was guided by a person-centered, strengths-based philosophy in which patients are considered experts in their

own care (Allen & Warner, 2002; Gottlieb & Feeley, 2005; Gottlieb & Gottlieb, 2013). The methods of data collection and analysis used throughout were consistent with the study purpose and were focused on foregrounding participants’ ideas, needs, perspectives, and experiences (Letts et al., 2007; Polit & Beck, 2012).

Research Team

The project was carried out by three investigators. The project supervisor was an associate professor, clinical nurse specialist in mental health, and an experienced nurse researcher with expertise in strengths-based care (registered nurse, female). The other two investigators were master’s level student nurse researchers (SNRs, both female) interested in mental health who conducted this study as a program requirement.

Setting

The study took place at the Douglas Mental Health University Institute, a 270-bed psychiatric hospital located in Montreal, Quebec, Canada. The facility ser- vices individuals with a variety of mental illnesses. Specialized therapies for drug addiction or dependency are not offered, and there is no care unit specifically designed for clientele with a dual diagnosis. Patients with a mental illness and substance use disorder are thus admitted to a treatment program based on their psychiat- ric diagnosis alone. The researchers worked in close col- laboration with clinical partners to identify the units where adult patients with a dual diagnosis could be accessed. Three different inpatient units were confirmed as the sites for study recruitment: psychosocial rehabilita- tion, acute psychosis, and mood disorders.

Sample and Recruitment Process

Participant enrollment was determined according to the following inclusion criteria: currently hospitalized on a study unit; 18 years of age or older; fluent in spoken English or French; documented history of substance use; able and willing to sign a consent form; granted permis- sion to the SNRs to access their medical record; and agreed to participate in an audio-recorded interview. Recruitment took place over a 4-month period. Throughout this time, the SNRs maintained regular contact with the registered nurses and inter-professional staff from each unit who played a key role in recruitment.

Staff’s contribution included identifying current inpa- tients with a dual diagnosis who were deemed capable of participating and introducing them to the study. To facili- tate this process, the researchers prepared written sum- maries of the project for staff and developed information

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pamphlets for distribution to selected patients. The SNRs were notified of patients who were interested in receiving further information and who agreed to meet with an SNR for this purpose. Potential participants were identified by staff on a rolling basis and were not known to the SNRs prior to this initial meeting. The SNRs introduced them- selves to potential participants as students completing their master’s degree in Nursing and explained that the project was being undertaken as part of their studies.

Approaches to purposive sampling (Sandelowski, 1995) included tracking the sample demographics over time and maximizing diversity with regard to mental health diagnoses, gender, age, types of substances used, and inpatient units. The total number of eligible patients who were deemed appropriate and were approached by staff for potential inclusion in the study is unknown. A total of 12 patients agreed to be contacted by an SNR and, after meeting to discuss the project, all 12 chose to enroll in the study.

Data Collection

Individual, face-to-face, semistructured interviews with a randomly assigned SNR were conducted in a private space, within the familiar setting of each participant’s unit. A semistructured interview guide, developed by the researchers, was designed for the purpose of exploring the practices and outcomes of helpful nursing. Exploratory, open-ended questions and follow-up prompts focused on eliciting the “positive” or therapeutic aspects of care. The aim was to capture each participant’s unique perspectives, thoughts, ideas, and suggestions to generate rich, narrative descriptions as well as concrete examples (see Table 1 for sample questions).

Following each interview, the SNRs gathered supple- mentary information from the patient’s medical record and wrote reflective field notes. These notes documented their thoughts, feelings, and observations about key fac- tors, including the context or physical environment, par- ticipant behaviors, and the main topics explored (Morse & Field, 1995). Each interview was transcribed verbatim

by the SNR involved, and the was data shared with the research team. Individual transcripts were not returned to the participant for verification or review.

Throughout the data collection period, the SNRs held regular debriefings to identify emerging questions and challenges. Ongoing feedback, guidance, and input was provided by the project supervisor. Concerns related to the interview process that required focused attention were addressed as a team in brainstorming and problem-solv- ing sessions.

Data Analysis

The researchers engaged in in-depth review, analysis, and discussion of each transcript. The SNRs held regular debriefings and received guidance and input from the project supervisor throughout. Data were analyzed using a conventional approach to content analysis. This involved an ongoing, iterative process of constant com- parison, beginning with the first interview and adding subsequent data over time (Hsieh & Shannon, 2005).

The researchers used an inductive approach to analysis and worked as a team to identify categories and themes in the transcripts (Kondracki, Wellman, & Amundson, 2002). Open coding, in which relevant segments of data were iden- tified and their meaning captured by assigning keywords or phrases, was used (Kondracki et al., 2002; Lockyer, 2004). Categories that cut across data sets were subsequently iden- tified and grouped into meaningful themes and subthemes (Hsieh & Shannon, 2005). Each transcript was analyzed by both SNRs according to the coding scheme until interrater reliability was achieved (first three interviews). Thereafter, transcripts were analyzed separately, followed by a com- parison and discussion of findings.

Ethical Considerations

This study was approved by a scientific review commit- tee at McGill University and the Douglas Mental Health University Institute research ethics board provided final approval to conduct the study (#14-30). By engaging unit

Table 1. Sample Questions From Semistructured Interview Guide.

1. Could you tell me what a typical day here is like for you? 2. What types of things do nurses do here to help or support you? 3. Do you have a favorite nurse? If so, could you please tell me about them.

a. What is it that you like about that nurse? 4. What would you say is the most helpful thing about the nursing care you have received?

a. Could you give me an example? b. What difference did this make?

5. Is there anything else the nurses could do that would be helpful? 6. If you could give nurses one piece of advice about helping people who have mental illness and use drugs/have addictions,

what would it be?

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staff in the identification of potential participants, the researchers sought to avoid potential conflicts of interest related to the recruitment process. Prior to beginning each interview, participants were informed of their rights, including the option to withdraw their participation at any time and the choice to respond, or not, to any questions asked. Participant anonymity was respected using an identification code number and all data were stored securely and treated confidentially. Following the inter- view, each participant was offered a 20-dollar gift card in appreciation for their contribution.

Findings

According to Letts et al. (2007), an acceptable sample size has been reached when redundancy or saturation of the data is achieved. This represents “the point in data collection and analysis when new information produces little or no change to the codebook” (Guest, Bunce, & Johnson, 2006, p. 65). The researchers aimed to conduct interviews until data saturation was reached (Guest et al., 2006), and the research team decided that this had been achieved after 12 interviews as no further modifications to the coding scheme were needed at this point (Guest et al., 2006; Letts et al., 2007). The final 12 interviews were conducted with patients of various ages (mean = 33.6 years, SD = 11.4, range 19-61), the majority of whom identified as male (n = 7, 58%; see Table 2 for further demographic information).

Each participant was interviewed once. The duration of the interviews ranged from 20 to 80 minutes. The pro- cess of eliciting data about helpful nursing was not straightforward. In many instances, responses to inter- view questions described practices that were unhelpful. Throughout the interview process, participants were offered ample time to share these stories and feelings. Follow-up questions aimed to elicit insight on what help- ful nursing in these situations might look like, and what the outcomes of this care could be. For example, SNRs used prompts such as: “How might the nurse have been more helpful to you in that situation?” or “what could the nurse have done differently?” or “what difference would that have made for you?” Resulting descriptions of help- ful care and its outcomes were included for analysis.

A wide variety of helpful nursing practices were identi- fied. These were described in association with different care needs, which were categorized according to three main themes: (1) promoting health in everyday living, (2) managing mental illness in tandem with substance use, and (3) building a therapeutic relationship. The themes representing each care need together with the correspond- ing sub-themes are described below. Selected examples of helpful nursing associated with each category are included.

Theme 1: Promoting Health in Everyday Living

These interventions helped clients successfully meet the fundamental needs and “basic” requirements of daily life.

Subtheme 1: Promoting Physical Health. This included help- ful strategies meeting physical needs, such as nutrition, hygiene, or mobility. One participant expressed apprecia- tion when a nurse offered to help push his wheelchair (A16, M, 61); another focused on a time when a nurse helped him eat outside (J10, M, 33). The relationship between helpful care aimed at meeting everyday patient needs and key mental health outcomes is illustrated by the following participant, who reported increased feel- ings of self-worth when a nurse took the time to make sure he got his preferred meal choice: “. . . with every- thing going on around here and all the people with major issues and stuff, it actually made me feel important” (O28, M, 31). For another participant, receiving help to meet basic care needs represented a significant first step in transitioning to a “new life.”

So we eat . . . we take a shower . . . it helps me a lot because we all need this, it’s our fundamental needs, Maslow’s pyramid. . . . It’s a new life . . . especially when you’re using [drugs or alcohol] and you have a hard time making a pyramid. . . . It’s like a handful of sand that falls apart all the time, you don’t know how to make your pyramid. (S26, F, 30)

Table 2. Sample Characteristics.

n %

Gender Male 7 58.3 Female 5 41.7 Age 18-29 3 25 30-39 7 58.3 40-65 2 16.7 Diagnosis Psychotic disorder 6 50.0 Mood disorder 4 33.3 Mixed (psychotic and mood disorder) 2 16.7 Suicidal ideation or attempts 5 41.7 Type of drug used (categories non-exclusive) Alcohol 9 75.0 Tetrahydrocannabinol (THC) 10 83.3 Cocaine 5 41.7 Other 4 33.3 Unit of hospitalization Intensive rehabilitation 4 33.3 Psychotic disorders 3 25.0 Mood disorders 5 41.7

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While nursing care aimed at meeting basic needs may be considered “low priority” within an illness-oriented hos- pital environment, the above data highlight the relevance of these interventions for patients with a dual diagnosis.

Subtheme 2: Promoting Psychosocial Well-Being. Rather than referring to actual care experiences, most of the data in this category were suggested or potential interventions. Helpful strategies aimed at promoting psychosocial health included offering structured experiences and pro- viding resources. Of potential help were pastimes to relieve boredom and offer recreation: “There’s no activi- ties that are done. . . . There’s other stuff that the patients can be doing with their time other than smoking ciga- rettes and walking up and down [the unit]” (J20, M, 25). Six respondents described the need to be distracted or kept “busy” and suggested that nurses could help by coor- dinating more recreational activities.

Several participants described helpful nursing inter- ventions related to supporting family relationships. These included facilitating visitation or contact, providing fami- lies with information, and helping resolve family issues. Reported outcomes included increased well-being, feel- ing adequately supported by staff, and feeling reassured as the following quote suggests:

You see that there are healthcare professionals who . . . try to fix things with family . . . it’s reassuring, it’s a good feeling, it’s like love . . . you have help around you to make it out, to do something with your life. (S26, F, 30)

Theme 2: Managing Mental Illness in Tandem With Substance Use

Subtheme 1: Addressing Illicit Drug and Alcohol Use. Four participants described nurses’ interventions pertaining to hospital rules prohibiting drugs and alcohol as being helpful. In addition to feeling safer as a result of this enforcement, five participants described the rules as help- ful for someone who was an “ex-drug addict” (A16, M, 61) or currently trying to quit using drugs or alcohol. However, three respondents noted discomfort regarding the drug searches performed by nurses.

Several participants stressed the need for helpful care related to providing information about drugs and alcohol, their side effects, and their impact on mental health: “[The nurse should] inform of the dangers of addiction . . . of the side effects” (S26, F, 30). Another participant shared simi- lar advice for nurses:

A lot of us are doing [drugs and alcohol] just generally because our meds aren’t working . . . and we’re trying to self-medicate . . . . Obviously it doesn’t work . . . [Nurses should] explain the pros and cons of self-medication. (A24, F, 32)

Nurses may be ideally positioned to offer insight into the complex relationships between drug and alcohol use and mental health outcomes.

Subtheme 2: Managing Mental Illness. All participants identified nursing interventions related to managing their mental illness as helpful. Offering prescribed medication was perceived as beneficial when a patient was in crisis or having a “bad day” (M18, F, 49). One participant con- firmed that when in crisis nurses gave him a “PRN . . . and it calmed [him] down” (J10, M, 33). Conversely, an overreliance on medication provision was also empha- sized, and was seen by some as having replaced other helpful interventions: “they can [do something helpful] but they just give me medication and then wait for the doctor to do something, that’s it” (N30, F, 23).

This reinforces the idea that helpful care related to symptom management goes beyond administering medi- cation to include considering alternative or additional interventions. When discussing the need for information concerning his mental illness, one participant stated:

Everyone should get some kind of education before they leave [the hospital] about their problem . . . not just given drugs like . . . about the diagnosis about . . . what’s the best way of dealing with it. (J20, M, 25)

Theme 3: Building a Therapeutic Relationship

Subtheme 1: Ways of Being. Demonstrating love and human caring was identified as helpful in 11 of 12 inter- views, with participants noting repeatedly that they “need care” (J22, M, 36) or that nurses could “show more love and care” (F12, M, 34). Moreover, nurses’ presence, availability, and attentiveness combined with “ways of being” that are empathetic, supportive, and understand- ing were reported to contribute to positive patient out- comes such as feeling loved and reassured: “when I feel supported well yes it’s reassuring, it’s a good feeling, it’s like love, you know, when you don’t have any, it’s rare” (S26, F, 30).

Subtheme 2: Ways of Knowing. Getting to know the patient was emphasized as helpful by all participants. Respon- dents stated that they wanted nurses to “know [them] more” (N30, F, 23). “Paying attention” to how patients are feeling through ongoing observation, exploration, and accompaniment, was identified as a helpful way for nurses to learn about the person, and thereby develop an understanding of each patient’s situation and experi- ences. One participant found it helpful when, on a “hard day,” nurses “paid quite a bit of attention to the way [he] was feeling” (A24, F, 32). Another participant advised nurses to: “talk about how [patients] feel, be open to

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them, have a good time with them, and spend time with them” (N30, F, 23).

Several respondents identified attentive listening as being a particularly helpful way for nurses to increase their knowledge and deepen their understanding of the person: “I think this is the most important, listening” (S26, F, 30). The beneficial outcomes associated with lis- tening were also clearly described: “[When nurses listen to me and understand me] it helps because I feel less iso- lated . . . less apart from others . . . less bizarre, because we already feel judged because we are in mental health” (S26, F, 30). Spending time engaged in attentive listening is thus an important nursing practice associated with out- comes such as reducing stigmatization and decreasing feelings of social isolation.

Subtheme 3: Ways of Doing. The humane and humanizing way in which nurses carry out their practice is an impor- tant aspect of helpful care. For example, being treated “as a human” (M18, F, 49) was reported as being crucial and “precious” (M18, F, 49). Moreover, one respondent pointed out that nursing care offered in a personal and human way results in patient feelings of positive self- worth: “[When nurses] look at me as . . . a human being . . . you feel like you’re not alcohol, drug abuse, mental illness, whatever . . . you feel yourself as a human” (A24, F, 32). Furthermore, providing individualized care was stated to be valuable. The importance of recognizing that “every patient is different” (J20, M, 25) and so nursing care must be “different” (J20, M, 25) was highlighted as helpful by a number of participants. Finally, the process of “trying to relate to a person . . . to determine who and how a person is and accommodate them” (A24, F, 32), represented an essential aspect of helpful nursing care.

Discussion

In large part, the helpful interventions described by study participants are consistent with professional knowledge and beliefs about the nursing practices viewed by clini- cians as being of benefit. While the interventions identi- fied by the participants may not be ‘new,’ the extent to which these data validate clinicians’ understanding of helpful care is a key finding. Moreover, the detailed examples provided by participants serve to link specific interventions to outcomes and outline the meaning and importance of these outcomes experienced as a result. The meaning and power of a wide variety of interventions is also evident in the data. In particular, the findings underscore the potent changes brought about through the use of simple, “everyday” strategies and “basic” nursing practices.

Relational Interventions: Making the Invisible Visible

The majority of helpful nursing practices described by the participants in this study pertained to relational care interventions. These findings are consistent with previ- ous research by Chorlton et al. (2015) in which the com- passionate care was highlighted as being of particular importance to mental health inpatients with a dual diag- nosis. Similarly, the importance of relational care was a prominent theme in both studies exploring helpful nurs- ing from the perspective of pediatric clientele (Gros et al., 2011; Gros et al., 2012; Montreuil et al., 2015). Taken together, these findings indicate that the thera- peutic relationship represents an area of primary impor- tance to mental health clientele across age groups and care settings. Moreover, all three studies on helpful care clearly demonstrate the wide variety of potent health outcomes that result from relational interventions. These ideas are also reflective of the general literature in which “soft” skills such as listening to, talking to, and being reassuring are valued, and not viewed as inferior to skills that are more technical, practical, or procedural in nature (DeFrino, 2009; Hopkins, Loeb, & Fick, 2009; Stickley & Freshwater, 2006).

The importance of supportive relationships is well established (Gilburt, Rose, & Slade, 2008; Haron & Tran, 2014; Hopkins et al., 2009; McCallum et al., 2016; Schön, Denhov, & Topor, 2009), and strong, therapeutic relation- ships with staff, in particular nurses, are considered a cor- nerstone of mental health care (Cleary et al., 2012; Hopkins et al., 2009; Rydon, 2005; Sweeney et al., 2014). These relationships have been linked to improvement in the course of treatment, maintenance of recovery, and reduced patient perceptions of stigmatization (Ball, Carroll, Canning-Ball, & Rounsaville, 2006; Day et al., 2005; Denhov & Topor, 2012; Schön et al., 2009).

As mentioned, patients place high value on these rela- tionships (Gilburt et al., 2008; Hopkins et al., 2009; Sweeney et al., 2014) and appreciate empathetic, warm, honest, and caring nurses (Dziopa & Ahern, 2009; Haron & Tran, 2014; Moreno-Poyato et al., 2016). Helpful nurs- ing interventions identified by study participants such as demonstrating respect, recognizing patient individuality, providing active listening, and being present are also noted in earlier research (Dziopa & Ahern, 2009; Moreno- Poyato et al., 2016; Stenhouse, 2011). Frequently addressed within the literature and our own findings is the importance patients place on being treated with respect and as “humans” not as problems or illnesses (Bee et al., 2008; Gros et al., 2012; Haron & Tran, 2014; Mistry, Levack, & Johnson, 2015; Montreuil et al., 2015).

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In sum, participants detailed descriptions of relational strategies that serve to make these interventions more concrete, thus increasing their visibility. Moreover, by linking these interventions to specific outcomes, the results of this study highlight the meaning and value of relational care practices for patients with a dual diagnosis and contribute to their application and development in clinical practice. As identified by participants, and as reflected in previous work on this topic, helpful nursing involves providing collaborative, strengths-based, patient-centered care across dimensions of need (Gros et al., 2011; Gros et al., 2012; Montreuil et al., 2015). Helpful nursing must therefore be whole person care.

Responding to Dual Diagnosis: Integrating Mental Illness Care and Substance Use Care

In terms of the specialized care needs unique to this popu- lation, our findings highlight the important role inpatient nurses can play in responding to mental illness and sub- stance use concurrently. This includes developing the ability to respond to patient needs for information regard- ing the influence of illicit drugs and alcohol on their men- tal illness as well as helping patients understand how these substances interact with prescribed and nonpre- scribed medications. The importance of the nursing role in addressing dual diagnosis in an integrated and compre- hensive manner has been highlighted in the literature (Antai-Otong et al., 2016; Edwards, 2008; Gallagher & Scott, 2008; Howard & Holmshaw, 2010; McGovern et al., 2014; Petrakis et al., 2018). For example, as pro- posed by Lawrence-Jones (2010), and as indicated by the participants in this study, the opportunity to address sub- stance use issues and mental illness with the same clini- cian is of potential benefit, provided that this clinician has expertise in both areas. However, despite the high inci- dence of mental illness co-occurring with substance use, these health issues tend to be addressed as distinct, spe- cialty areas of clinical practice (Edwards, 2008). As the findings of this study illustrate, when services for mental health and substance use are not integrated at the level of clinical care, one or the other tends to be neglected (Gallagher & Scott, 2008).

Study Limitations

A number of limitations should be taken into account when considering our findings. Eligible patients were limited to those judged by clinicians as “stable enough” and “appropriate” to participate, which may have intro- duced bias in selection. Furthermore, participants were asked about nursing care generally. The questions posed did not attempt to differentiate the care offered in terms of nurses’ level of the experience or education; nursing

assistants and nurses with technical diplomas or univer- sity degrees were all present on the study units. Study rigor could have been improved by returning the tran- scripts to participants for review and verification. Moreover, the study participants were recruited from a single mental health facility. While the study results pro- vide in-depth examples of helpful nursing practices, these data represent the experiences and perspectives of indi- viduals with a dual diagnosis and are thus not transferable to the care of this population at large.

Implications for Nursing Practice

In line with existing research and guidelines that stress the importance of using patient expertise to inform care (Hopkins et al., 2009; WHO, 2013), the attitudes, actions, and approaches identified as helpful by study participants are directly transferable to nursing practices involving inpatient clientele with a dual diagnosis. For example, the findings underscore the importance of relational care inter- ventions and illustrate the potent outcomes associated with basic strategies, attitudes, and approaches such as listen- ing, demonstrating respect, and being honest, as well offer- ing small gestures that convey kindness and compassion.

Helpful interventions related to promoting learning and education for clientele with a dual diagnosis include sharing knowledge and information in response to the questions and concerns raised by patients. The develop- ment of these interventions requires specialized knowl- edge and skills in areas such as addiction and substance use in the context of mental illness. Helpful practices include sharing information on various drugs and their effects on behavior, mood, and daily functioning as well as on the pharmacological interactions that occur when taking prescribed medications while consuming alcohol and/or illicit drugs.

Helpful nursing care includes broad based approaches as well as practices of specific relevance to clients with a dual diagnosis. Without exception, the examples pro- vided reflected principles of human caring and compas- sion and were consistent the use of a collaborative, strengths-based approach to clinical nursing practice. As such, helpful nursing care involves understanding the unique needs, priorities, and preferences of each individ- ual and responding in ways that are tailored, timed, and adjusted to fit each situation.

Priorities aimed at advancing helpful nursing practices include fostering nurses’ knowledge and understanding of collaborative, strengths-based philosophies and develop- ing the relational skills that enable nurses to apply these philosophies throughout the course of their interactions with patients. In addition, staff education and clinical sup- port with experts in substance use and addictions care enables clinicians to formulate accurate assessments of

258 Journal of the American Psychiatric Nurses Association 26(3)

patient physical and mental status, and to intervene in ways that ensure client health and safety and to help clien- tele with a dual diagnosis learn to manage the health issues of particular concern to them. Increased collaboration with interprofessional addictions treatment teams and agencies is also needed for mental health nurses to main- tain up-to-date knowledge and to offer evidence-based interventions in a complex and rapidly changing field.

This study demonstrates that inpatient clientele with a dual diagnosis have the capacity to communicate the nurs- ing interventions that are helpful to them. Viewing patients as experts in their own care and actively engaging them in the process of exploring and describing what helpful nurs- ing means to them and working to shape care accordingly is consistent with collaborative, strengths-based approaches; assessment, intervention, planning, and eval- uation are determined in partnership with clientele. For instance, the exploratory research questions used in this study can readily be implemented in clinical practice. Examples include the following: What nursing practices are most helpful to you or your family at this time? What nurse qualities or actions are most important to you? Can you provide specific examples of these actions, attitudes, and approaches? What difference do these practices make to you? What changes do you notice as a result?

Conclusion

This study involved participants from a population that is often excluded from the research process. The findings highlight the scope, complexity, and value of nursing for inpatients with a dual diagnosis and provide specific examples of the broad range of therapeutic interventions that occur across multiple dimensions of care. The results of this study offer a novel perspective on nursing inter- ventions, many of which are well known but whose com- plexity and therapeutic value are often underestimated. In sum, this study highlights the critical role that clientele with a dual diagnosis play in the process of identifying, reinforcing, and developing the nursing practice they find helpful.

Acknowledgments

The authors sincerely thank the participants who shared their stories, experiences, and perspectives in this study. The authors gratefully acknowledge the assistance and support of Gérard Lebel, RN, MPS, MAdm, as well as the involvement of clinical collaborators, unit managers, and all nursing staff at the study site; and Dr. Antonia Arnaert and Dr. Margaret Purden and for their supervision and guidance.

Author Roles

All authors conceived the study and worked on developing the methodology. LOB and CH collected the data with coaching

and input from CPG. LOB and CH transcribed the data, which were then analyzed by all three authors. LOB and CH conducted the literature review and prepared the first draft of the paper. Thereafter, all authors contributed to editing, reviewing, and approving the final manuscript prior to its submission for publication.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial sup- port for the research, authorship, and/or publication of this arti- cle: This research was funded by the Nursing Directorate of the Douglas Mental Health University Institute and the RQSHA Quebec Network on Suicide, Mood Disorders, and Related Disorders.

Ethical Approval

This research was approved by the Research Ethics Committee of the Centre Intégré Universitaire de Santé et de Services Sociaux de l’Ouest-de-l’Île-de-Montréal; CIUSSS-ODIM; Douglas Mental Health University Institute, and all participants provided informed consent and signed consent forms.

ORCID iD

Lydia Ould Brahim https://orcid.org/0000-0003-1638-4953

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