ENHANCING NURSES’ CAPACITY TO PROVIDE CONCURRENT MENTAL HEALTH AND SUBSTANCE USE DISORDER CARE: A QUASI-EXPERIMENTAL INTERVENTION STUDY

Abstract

Background

Patients experiencing concurrent disorders (i.e., co-occurring mental health and substance use disorders) are prevalent in mental health settings and their health and social outcomes are often poor. This reflects persistent stigma as well as inadequate preparatory training or continuing education for healthcare professionals, including nurses.

Objective

To explore the impacts of the 1-day ‘Enhancing Concurrent Disorder Care Intervention’ on nurses’ and student nurses’ capacity to deliver care, grounded in current evidence, to patients with concurrent disorders in inpatient mental health settings.

Design

A Quasi-experimental intervention design was used with pre- and postt-test components, guided by the STROBE checklist for observational studies.

Settings

Five acute mental health units across two hospitals in British Columbia, Canada, as well as two schools of nursing representing students completing clinical practicum rotations within these settings.

Participants

Seventy-six nurses (Registered Nurses and Registered Psychiatric Nurses) and student nurses practicing in inpatient mental health care.

Methods

This educational intervention was informed by a pilot study, which included content validation from international concurrent disorder experts, and further refined through collaborative processes with lived experience and nurse partners. Intervention impacts were examined using online surveys conducted prior to the intervention and within two weeks post-intervention. Surveys assessed knowledge and attitudes about concurrent disorders using a validated instrument and questions developed by the study team. Descriptive statistics alongside paired and independent t-tests and two-way ANOVAs were used to compare survey scores before and after the intervention.

Results

Findings indicate that the intervention was effective in improving participants’ knowledge and attitudes toward patients with concurrent disorders across participant groups.

Conclusions

Enhancing care and outcomes for patients with concurrent disorders is a global priority. Brief educational interventions aimed at nurses can provide an effective, low-barrier mechanism to address knowledge gaps that contribute to harmful care and adverse outcomes.

1. INTRODUCTION

Within the mental health field, the term concurrent disorder (CD), often used interchangeably with ‘dual diagnosis’, describes the co-existence of mental disorders and substance use disorders (SUD) (Hakobyan et al., 2020). CDs are highly prevalent. Among adult patients with persistent mental disorders, it is estimated that 30–50 % will also experience a SUD in their lifetime (Canadian Centre on Substance Abuse, 2009), compared to approximately 20 % among the general population (Statistics Canada, 2015). Despite this high degree of concurrence, the treatment of mental disorders and SUDs in many countries remains siloed, resulting in barriers for CD patients seeking to access needed care, particularly for substance use (Balhara et al., 2016). For example, it is estimated that only 7.4 % of patients with CDs in the United States will receive treatment for both disorders and over 90 % will get no treatment at all (Substance Abuse and Mental Health Services Administration, 2020). This fragmentation of care, alongside persistent stigma and discrimination toward people with mental and/or SUDs and limited educational preparation among healthcare providers, contributes to poorer health and psychosocial outcomes among patients with CDs (El-Guelbaly, 2004; Pinderup, 2018a, Pinderup, 2018b). Indeed, patients with CDs tend to have longer hospital stays and higher readmission rates (Canadian Institute for Health Information [CIHI], 2013), increased risks for depression and suicidality, poorer treatment outcomes, and high degrees of physical health comorbidities (El-Guelbaly, 2004; Nesvåg et al., 2015; Pinderup, 2018b).

In recent years, acute mental health services have come under great pressure to deliver care to patients with CDs (CIHI, 2013), a responsibility that many health professionals working in these settings feel poorly equipped to manage (Hughes et al., 2007). While the reasons for this are varied, a lack of educational preparation in CDs is commonly identified as a substantial barrier (Garrod et al., 2020; O’Gara et al., 2005). For example, Brems and colleagues note that “most training programs fail to incorporate curricula dedicated to assessing, treating, and managing comorbid clients” (2002, p. 110). Indeed, Balhara and colleagues conclude from their review of training and treatment services for CDs across four countries that significant gaps remain and “efforts to address training needs, clinical services and research on [CDs] have been inadequate at best…” (2016, p.252). These educational gaps can limit healthcare professionals’ clinical skillsets for working with patients experiencing CDs and are also associated with moralistic and potentially stigmatizing attitudes toward this patient population (Garrod et al., 2020; Richmond and Foster, 2003). Promisingly, these negative attitudes appear to improve with training focused on CDs (Garrod et al., 2020; Howard and Holmshaw, 2010), underscoring the potential for educational interventions in supporting health professionals to serve this patient group more compassionately and equitably.

Research on nurses, specifically, indicates that many feel they lack the knowledge and skills to provide effective care to patients experiencing CDs Garrod et al., 2020; Copello et al., 2012). In the absence of appropriate training and supports, nurses working with this patient population have reported feeling less prepared to provide care that is responsive to the complexity of CD patients’ illness presentation, which often includes significant physical and psychosocial comorbidity (Chicoine et al., 2020). This has been identified as contributing to low job satisfaction, and feelings of powerlessness and frustration among nurses and has also been shown to translate into harmful attitudes toward patients with CDs, impacting care experiences and outcomes (Howard and Holmshaw, 2010; Rani and Byrne, 2012). While research exploring knowledge and attitudes toward CD care among nursing students is limited, the broader mental and SUD literature suggests that this group likely experiences similar challenges to those of practicing nurses. Specifically, like practicing nurses, nursing students have also been found to espouse stigmatizing attitudes and low levels of empathy toward people with mental and/or SUDs (Abuhammad et al., 2019; Schuler and Horowitz, 2020) and may perceive this patient population as dangerous (Slemon et al., 2018). Moreover, as noted by Harling and Turner (2012), nursing students receive minimal formal training or engagement with patients experiencing SUDs, which likely contributes to negative attitudes reinforced by broader societal views. In other research, this limited training has been characterized as highly distressing to nursing students who describe entering the training environment with great empathy and compassion and recount witnessing stigmatizing and nontherapeutic clinical encounters (Slemon et al., 2018). Promisingly, however, when exploring predictors of nursing student attitudes toward patients with mental disorders, Abuhammad et al. (2019) found that prior experience working with this population contributed to more positive attitudes and perceptions. In summary, despite these well-documented consequences, there remain critical gaps in educational preparation pertaining to CDs in both basic nursing programs and continuing education training (Garrod et al., 2020; Howard and Holmshaw, 2010; Hughes et al., 2007).

As the largest professional group working in acute psychiatric settings (Adams, 2008; Barry et al., 2009), nurses are well positioned to lead much-needed efforts to enhance care and associated outcomes for patients with CDs. Importantly, nurses spend the greatest amount of time providing direct care to patients and are trained to be highly proficient in assessment and illness management for patients with complex needs (Canadian Nurses Association, 2015; International Council of Nurses, 2013). Further, nurses receive intensive educational preparation in establishing therapeutic relationships (Miles et al., 2014) – a critical skillset for managing the complexities of CD illness presentation. Indeed, building nursing capacity for CD care has been identified internationally as a health system priority (Mental Health Commission of Canada, 2012; National Institute for Health and Care Excellence, 2016). Responsive to this demand, the aim and objective of this study was to conduct an exploratory examination into the impacts of a brief evidence-informed educational intervention on nurses’ and student nurses’ capacity to deliver care to patients with CD receiving treatment in inpatient mental health settings.

2. METHODS

2.1. Context

This study was conducted within the acute mental health care setting in British Columbia (BC), Canada. Within this region, two of the central, publicly funded health service providers were engaged, facilitating the inclusion of nurses working in acute mental health units across five major hospitals in a densely populated urban centre. Collectively, these hospitals deliver care through 192 mental health-designated beds, with a high proportion of patients experiencing CDs. This study also included student nurses from two regional schools of nursing who were completing clinical practicum rotations within these hospital settings at the time of the study.

2.2. Intervention

The ‘Enhancing Concurrent Disorder Care Intervention’ (hereafter, the Intervention) was informed by a preliminary intervention developed by a member of our study team (Bonnie, 2017). The preliminary intervention was based on a survey of CD learning needs among nurses working in acute mental health settings in BC and consisted of an 8-h educational intervention that was validated through consultation with a panel of international experts in CDs (see Bonnie, 2017 for further details on this pilot study). Aligned with global acknowledgement of the importance of patient-oriented research (Kaur and Pluye, 2019), the intervention was refined and contextualized for the present study in collaboration with patient and family partners with lived experience of mental disorders (n = 3). Additionally, recognizing that nurses’ practice expertise are integral to the development of interventions that are clinically relevant and impactful (Canadian Institutes of Health Research, 2019; Concannon et al., 2012), we further refined the intervention through participatory processes that included point-of-care nurses (n = 4) and nurse leaders (n = 3). This collaborative approach to research ensured that nurse and patient voices were embedded in the intervention and that it was well-grounded in both scientific and experiential knowledge.

The intervention is comprised of six learning foci: 1) neurobiology of addiction and treatment approaches; 2) trauma- and violence-informed care and practice, including how trauma and structural vulnerabilities contribute to CDs; 3) psychosocial and behavioural interventions for CDs; 4) lived experience perspectives of CDs and treatment; 5) incorporating harm reduction into CD care; and 6) the role of nurses in enhancing CD care and outcomes. These foci are inclusive of priority content as validated by the panel of international CD experts during the preliminary study as well as our lived experience and nurse partners. The intervention was delivered in November 2018 through a 1-day, in-person session to maximize nurse and student nurse participation. The intervention content was delivered by experts in the CD field who were identified in collaboration with our lived experience and nurse partners. These experts reflected diverse disciplinary and experiential backgrounds and included four nurses, one psychologist, one clinical counsellor, two physicians, three people with lived experience of mental or SUDs, and one family member of a person with lived experience of CDs. These experts provided engaging presentations that included personal stories, clinical case studies, current data and scientific findings. Each presenter facilitated space for participant questions, reflections, and dialogue. The presentation on lived experience perspectives was comprised of a moderated panel and provided opportunities for participants to gain insights into the clinical experiences of patients with CDs and to ask questions to guide their practice. Following the in-person session, the intervention content was transformed into a publicly available online continuing education course that is free to access and qualifies for a certificate of completion (Provincial Health Services Authority LearningHub, 2019).

2.3. Study design and sample size requirements

A quasi-experimental pre-post test design was used to examine the impacts of the intervention on nurse and student nurse participants. We conducted baseline and follow-up assessment of knowledge and attitudes using online surveys with a combination of knowledge assessment questions developed by the study team, a validated survey instrument assessing attitudes toward CDs, and additional questions about harm reduction. Surveys were completed prior to the intervention and within two weeks post-intervention. The STROBE checklist for observational studies was followed to guide reporting of findings.

Given the exploratory nature of this study combined with the lack of information on expected effect sizes, we examined sample size requirements assuming generic small (Cohen’s d = 0.20) and moderate effects (Cohen’s d = 0.50). Based on a small effect size, the study would require a sample size of approximately 199 participants with complete pre-post data (i.e., pairs) to achieve a power of 80 % using a significance of 5 % (two sided) to compare group means. The required sample size drops to 34 participants with complete pre-post data to detect a moderate sized effect with a power of 80 % and a significance level of 5 %. Post hoc tests associated analysis of variance models would require an additional correction for multiple comparisons, which would further increase the required sample size (Dhand and Khatkar, 2014).

2.4. Participants

Convenience sampling was used to recruit participants. All nurses working on any of the five mental health units at one of the two hospitals involved were eligible to participate. Additionally, student nurses from two schools of nursing who were completing practicum placements on these units were invited to participate. Point-of-care nurses and nurse leaders from our study team provided information on the intervention to the study sites through clinical managers and educators. Informational posters were also displayed at all five units between September and November 2018. Student nurses were recruited using these posters and through their instructors at the nursing schools.

2.5. Ethics

This study was conducted in accordance with the Declaration of Helsinki and approved by the University of British Columbia Research Ethics Board with operational approval provided by the participating hospitals’ research ethics boards. Participation in the study was voluntary and interested participants were informed that their decision to participate would not impact their work or study status. Complete information on the study was provided to potential participants on an introductory page of the survey. Surveys were anonymous and survey submission indicated provision of informed consent. Participants who chose to provide their contact information in a separate unlinked survey received a $5 gift card and were entered into a draw to win one of four $50 gift cards for each survey (pre and post) to acknowledge their contributions.

2.6. Data collection

All participants completed the online pre-intervention survey prior to attending the Intervention. Pre-surveys began with the creation of a unique participant identifier to allow for anonymous linkage of pre-post test data. A brief demographic questionnaire was included to characterize the study sample. Demographic questions for nurse participants included gender, highest degree completed, professional designation (Registered Nurses [RNs] and Registered Psychiatric Nurses [RPNs]), employment status (full-time/part-time), and work experience. Student nurses were asked about their gender, location of nursing program, non-nursing work experience in a mental health setting, and whether or not they intended to work in mental health.

To assess changes in knowledge about CDs, 11 questions (true/false and multiple choice) were developed by the study team. These questions measured knowledge of intervention content, including questions about substance use and harm reduction. Participant attitudes toward working with patients experiencing CDs were measured using the Comorbidity Problems Perceptions Questionnaire (CMPPQ) (Watson et al., 2003). This self-report questionnaire was developed and validated for content and internal consistency (α = 0.90) for the purpose of measuring health professional attitudes in the context of CD care. The CMPPQ is comprised of six subscales (Role Adequacy, Role Legitimacy, Role Support, Motivation, Self-esteem, and Work Satisfaction) with 33 items rated on 7-point Likert scale ranging from (1) strongly agree to (7) strongly disagree. Lower scores represent more positive attitudes toward patients with CDs.

To augment the CMPPQ, we added nine items focused on emerging best practices in CD care. These items were developed based on the extant literature and included questions measuring attitudes about assessment and symptom management, knowledge and capacity to deliver harm reduction, and empathy toward patients with CDs. These items followed the structure of the CMPPQ, with a 7-point Likert scale ranging from (1) strongly agree to (7) strongly disagree and lower scores indicating more favourable responses. We refer to these items as the Attitudes about Harm Reduction (AHR) questionnaire in the forthcoming analysis. Item validation was conducted through refinements based on input from our point-of-care and nurse leader partners. The Cronbach’s alpha for this new measure was = 0.776 in our sample.

The post-intervention online survey was distributed immediately following intervention delivery and was available up to 2-weeks post-intervention. This survey included the knowledge questions, CMPPQ, and AHR questionnaire.

2.7. Data analysis

Data were analysed using SPSS version 26. Descriptive statistics were performed for demographic variables and a paired t-test was utilized to compare mean differences in pre- and post-intervention scores on the knowledge and attitude scales. Additionally, a t-test for two independent samples was used to compare scores between nurse and student nurse participants and Cohen’s d was used to estimate the effect size of change scores. Three two-way ANOVAs were performed for both the nurse and student groups to examine relationships between demographics and change scores. The dependent variable for each analysis was 1) change in knowledge score; 2) change in Total CMPPQ score; and 3) change in AHR score. Change scores in the nurse group were compared between type of original nursing degree (RN or RPN) and years of nursing experience. In the student nurse group, change scores were examined between plans to work in mental health and previous experience in mental health nursing. Differences in amount of change for students were also examined relative to professional designation being sought (RN or RPN).

3. RESULTS

3.1. Sample demographics

In total, 213 participants completed the pre-intervention survey and 164 participants completed the post-intervention survey. Of these, 76 completed both surveys and provided a unique identifier that could be linked. The demographic details of these 76 participants who comprise our study sample are presented in Table 1. For all analyses, the full sample was used (n = 76) except for the AHR where one student and one nurse skipped questions.

Table 1.

Socio-demographic description of nurse and nursing student respondents.

	Nurses Frequency (%) (N = 35)	Nursing Students Frequency (%) (N = 41)
Gender
Woman	28 (80.0)	29 70.7)
Man	7 (20.0)	10 (24.4)
Other		2 (4.9)
Nurses’ Highest Degree (n = 34)
Registered Nurse (Diploma)	5 (14.2)
Registered Psychiatric Nurse (Diploma)	10 (28.5)
Bachelor of Science in Nursing	8 (22.8)
Bachelor of Science in Psychiatric Nursing	11 (31.4)
Master of Science in Nursing	1 (2.8)
Nurses’ years of Experience (years)
<5	15 (42.9)
5–10	6 (17.1)
11–15	3 (8.6)
16–20	5 (14.3)
21–25	3 (8.6)
>25	3 (8.6)
Nurses’ years of Experience in Mental Health (years)
<5	18 (51.4)
5–10	9 (25.7)
11–15	2 (5.7)
16–20	3 (8.6)
21–25	3 (8.6)
Nurses’ Work Status
Full-time	21 (60.0)
Part-time	8 (22.9)
Casual	6 (17.1)
Nurses’ Role
Direct Care	24 (68.6)
Nurse Educator	1 (2.9)
Other (Nurse Educator, Administrator)	10 (28.6)
Students’ Nursing Program
Registered Nurse		36 (87.8)
Registered Psychiatric Nurse		5 (12.1)
Students’ (non-nursing) Experience in Mental Health Setting
Yes		10 (24.3)
No		31 (75.6)

Note: numbers do not always add to total due to some demographic data missing.

3.2. Change in concurrent disorder knowledge and attitudes

A one-group comparison of the difference between pre- and post-test scores for the knowledge items, all six CMPPQ subscales, and the AHR questionnaire, showed statistically significant improvement at the post-intervention time point (Table 2). Cohen’s d indicated a medium effect on knowledge items (d = 0.47, p < .001), small-to-medium effect on the CMPPQ sub-scales for Role Legitimacy, Role Support, Role Motivation, Self-efficacy, Work Situation (d = 0.38–0.65, p < .001), and a large effect size for the sub-scale measuring Role Adequacy (d = 1.10, and p < .001) and the AHR items (d = 0.93, p < .001).

Table 2.

Before and after knowledge and attitudes about concurrent disorder care among nurse and nursing student participants (n = 74).

Variables	Pre- intervention Mean (SD)	Post-intervention Mean (SD)	Mean Difference Mean (SD) (95 % CI)	Cohen’s d	p-value
Knowledge about CD	6.64 (1.521)	7.43 (1.268)	0.789 (1.644) (0.414,1.165)	0.47	<0.001
Attitudes (CMPPQ questionnaire)
Role Adequacy	38.68 (12.328)	26.84 (7.098)	−11.842 (10.67) (−14.2,−9.40)	1.10	<0.001
Role Legitimacy	10.64 (3.265)	8.53 (2.447)	−2.118 (3.327) (−1.35,−5.55)	0.63	<0.001
Role Support	9.01 (3.671)	7.45 (3.202)	−1.566 (3.594) (−2.38,−0.745)	0.43	<0.001
Role Motivation	13.47 (4.174)	11.96 (3.627)	−1.513(3.914) (−2.40,−0.619)	0.38	<0.001
Self-Esteem	17.38 (5.904)	15.00 (5.065)	−2.382(4.382) (−3.38,−1.38)	0.54	<0.001
Work Satisfaction	14.59(4.324)	12.28 (3.870)	-2.316 (3.526) (−3.12,−1.51)	0.65	<0.001
Total CMPPQ (6 sub-dimensions)	103.79(25.405)	82.05(17.931)	−21.737 (18.75) (−26.02,−17.45)	1.15	<0.001
Harm Reduction (Attitudes about Harm Reduction questionnaire)	28.52 (6.860)	22.41(6.260)	−6.107 (6.534) (−7.61,−4.60)	0.93	<0.001

A comparison of mean differences between the nurse and student nurse paired data showed improved mean scores in both groups across a variety of domains (Table 3). Students showed a statistically significant improvement for all measures, while nurses showed a statistically significant improvement across all measures, except for the CMPPQ sub-scales for Role Support, Role Motivation and Self-Esteem. The largest change observed for both groups was on the CMPPQ sub-scale measuring Role Adequacy. Specifically, nurses improved by 7.6 points and students improved by 14.5 points. The difference in change for the Role Adequacy sub-scale between nurses and students was also statistically significant (mean difference = 6.94, SE = 2.234, p = .003), indicating that students improved more than nurses in this domain. Indeed, students’ degree of change was larger than for nurses on all measures, with statistically significant differences between the groups for the total CMPPQ scores, the sub-scale for Self-esteem, and the AHR questionnaire items. Cohen’s d showed medium-to-large effect sizes for statistically significant items and small-to-medium effect sizes for non-significant measures.

Table 3.

Differences between knowledge and attitudes about concurrent disorder care among nurse and nursing student participants (n = 74).

Variables	Nurses			Students
	Baseline Mean (SD)	Post-intervention Mean (SD)	Mean Difference (SD)	Baseline Mean (SD)	Post-intervention Mean (SD)	Mean Difference	Difference of differences (SE difference) (95 % C.I.)	Cohen’s d	p-value
Knowledge about CD	7.00 (1.723)	7.68 (1.273)	0.676* (1.701)	6.35 (1.272)	7.28 (1.261)	0.925* (1.575)	−0.249 (0.381). (−1.008, 0.511)	0.152	0.516
Attitudes (CMPPQ questionnaire)
Role Adequacy	32.29 (9.615)	24.74 (6.653)	−7.559** (7.593)	43.53 (11.469)	29.03 (6.758)	−14.500** (10 .983)	6.94 (2.234) (2.487, 11.395)	0.735	0.003*
Role Legitimacy	9.29 (2.949)	7.71 (2.342)	−1.588* (2.787)	11.80 (3.090)	9.28 (2.353)	−2.525** (3.602)	−0.937 (0.759) (−2.450, 0.576)	0.291	0.221
Role Support	8.56 (3.359)	7.35 (3.634)	−1.206 (3.756)	9.50 (3.909)	7.60 (2.818)	−1.900* (3.558)	−0.694 (0.851) (−2.391, 1.003)	0.190	0.418
Role Motivation	12.32 (4.248)	11.68 (3.914)	−0.647 (4.256)	14.50 (3.616)	12.13 (3.252)	−2.375** (3.491)	−1.728 (0.901) (−3.523, 0.067)	0.444	0.059
Self-Esteem	15.29 (5.167)	14.18 (5.447)	−1.118 (3.599)	19.15 (5.637)	15.80 (4.724)	−3.350** (4.527)	−2.232 (0.963) (−4.152, −0.313)	0.546	0.023*
Work Satisfaction	13.62 (3.893)	11.94 (3.789)	−1.676* (2.931)	15.45 (4.500)	12.78 (3.893)	−2.675** (3.872)	−0.999 (0.810) (−2.613, 0.616)	0.291	0.222
Total CMPPQ (6 sub-dimensions)	91.38 (22.694)	77.59 (17.882)	−13.794** (14.352)	113.93 (21.821)	86.60 (17.034)	−27.325** (18.544)	−13.531 (3.908) (−21.321, −5.741)	0.816	0.001*
Harm Reduction (Attitudes about Harm Reduction questionnaire)	24.47 (5.023)	20.68 (5.398)	−3.794** (5.080)	31.58 (6.160)	24.03 (6.608)	−7.550** (6.417)	−3.756 (1.363) (−6.473, −1.039)	0.649	0.007*

Note: Except for knowledge scores, lower score indicates more competent and reduction in score indicates improvement; t-test performed on the differences between the amount of change for each group from pre to post.

^*p < .05.

^**p < .001.

Two-way ANOVAs exploring the relationships between select demographics (professional designation, years of experience) and change scores showed no difference on any of the measures (i.e., Knowledge, CMPPQ, or AHR) among nurses (see Table 4). For students (Table 5), there were no differences in change scores for Knowledge or AHR items based on previous non-nursing work experience in mental health contexts and plans to work in mental health settings. However, there was a statistically significant difference in CMPPQ scores with a larger difference seen in students who had no previous non-nursing experience working in mental health and no plans to work in mental health settings. There was no difference in amount of change for students based on professional designation being sought (RN or RPN).

Table 4.

Change in knowledge and attitude scores based on professional designation and years of experience among nurse participants (n = 74).

Years’ Experience	Change in Knowledge Mean (SD)	Change in CMPPQ Mean (SD)	Change in AHR Mean (SD)
Registered Nurse
<5	1.5 (1.91)	20 (19.3)	6.75 (4.03)
5 to 10	0(0)	−3(7.07)	0.5(0.71)
11 to 15	0(0)	9(0)	1(0)
16 to 20	2(1.63)	21.25(16.15)	5.5(2.08)
21 to 25	3(0)	−3(0)	1(0)
>25	−1(1.41)	15(5.66)	1(0)
Registered Psychiatric Nurse
<5	0.36(1.96)	14.27(14.99)	3(7.79)
5 to 10	0.25(0.96)	16(10.03)	3.75(5.32)
11 to 15	1(2.83)	18(18.38)	7.5(2.12)
16 to 20	2(0)	16(0)	6(0)
21 to 25	0.5(0.71)	14(2.83)	4.5(0.71)
>25	0(0)	−11(0)	0(0)
	F (11,35) = 0.78, p = .66	F (11,35) = 0.83, p = .62	F (11,34) = 0.44, p = .92

Table 5.

Change in knowledge and attitude scores based on previous experience and plans to work in mental health among nursing student participants (n = 74).

	Change in Knowledge Mean (SD)	Change in CMPPQ Mean (SD)	Change in AHR Mean (SD)
No, Student experience (non-nursing) in MH setting
Plans to work in MH	1.39 (1.59)	36.17 (16.31)	7.91 (6.17)
No plans to work in MH	0.25 (1.04)	22.25 (19.45)	9.5 (4.96)
Yes, Student experience (non-nursing) in MH setting
Plans to work in MH	0.5 (1.73)	16.5 (27.67)	8.25 (10.01)
No plans to work in MH	−0.17 (1.83)	15.17 (16.89)	3.17 (6.05)
	F (3,37) = 2.27, p = .097	F (3,37) = 3.34, p = .03*	F (3,36) = 1.24, p = .31

^*p < 0.05.

4. DISCUSSION

Within the healthcare system – and inpatient mental health settings in particular – patients with CDs are known to experience inequities in treatment and care, including instances of stigma and discrimination (Pinderup, 2018a, Pinderup, 2018b; Rani and Byrne, 2012). These experiences are partially attributable to gaps in training among health care professionals, including nurses, around substance use and its intersection with mental health (Balhara et al., 2016). Using a quasi-experimental pre-post test design, this study examined the impacts of the ‘Enhancing Concurrent Disorder Care Intervention’ on nurses’ and student nurses’ capacity for providing care to patients with CDs in inpatient mental health settings. In doing so, we identified significant post-intervention improvements in participants’ knowledge and attitudes about their role in enhancing care and outcomes for patients with CDs, as well as in their understanding of and intention to incorporate harm reduction principles and practices. These findings suggest an overall positive change in CD care-related knowledge and attitudes among both practicing and student nurses following this 1-day educational intervention.

Findings from this study add to the growing evidence on the effectiveness of brief educational interventions for enhancing clinician capacity to care for patients with CDs (Danda, 2012; Graham et al., 2006; Pinderup, 2018a; Schulte et al., 2010). Indeed, our data indicate that the intervention resulted in significant improvements in knowledge and attitudes among both practicing and student nurses, with larger changes observed for students. These between-group differences are presumably due to the degree of prior experience with and exposure to working with patients experiencing CDs. As nurses’ baseline CD knowledge is likely higher than students’, the degree of change resulting from the intervention is smaller. This is further supported by our data showing that among students, previous non-nursing work experience in mental health settings was associated with smaller intervention effects. Interestingly, years of experience among practicing nurses in this study did not influence intervention effects, potentially suggesting that this educational intervention ceases to provide differential benefit once a baseline level of practice knowledge is achieved. The intervention benefits were also the same across professional designations, demonstrating that the intervention is effective at improving knowledge and attitudes for all nurses practicing in mental health settings, regardless of their program of preparation. Together, these findings are promising but nonetheless must be considered with care, particularly since knowledge is only one factor influencing practice. Indeed, multi-level approaches addressing intersecting factors (e.g., training, policies, staffing, power dynamics) are needed to meaningfully address systemic barriers to improving CD care (Mental Health Commission of Canada, 2012; National Institute for Health and Care Excellence, 2016; Pinderup, 2018a, Pinderup, 2018b).

The current study has similarities to existing research into educational interventions in CD care (Danda, 2012; Graham et al., 2006; Pinderup, 2018a; Schulte et al., 2010), but is also unique in its use of participatory approaches, grounding the educational intervention in patient and nursing knowledge. Indeed, one of the key elements of the current study’s intervention was the integration of patients’ and other stakeholders’ lived experiences and expertise. This is significant because collaborative approaches to research and intervention are known to facilitate the generation of relevant, effective, and sustainable health care solutions (Case et al., 2014; Wallerstein et al., 2018). This consideration is particularly salient in the educational intervention context, where changes in knowledge may not always lead to changes in clinical practice (Pinderup, 2018a). Nonetheless, evidence does suggest that incorporating patient perspectives is fundamental to improving health professional’s attitudes toward CDs, contributing to better insights into care requirements and helping to overcome barriers to quality care (Borge et al., 2013; Edward and Robins, 2012). Based on our data demonstrating improvements in attitudes, including enhanced empathy, as well as participants’ open-ended feedback responses (to be reported in a forthcoming paper), the inclusion of lived experience perspectives was a powerful component of this intervention that facilitated a better understanding of CD patients’ perspectives and potential care needs.

This study and the related intervention have many strengths, though there are also limitations that warrant discussion. First, the quasi-experimental design and lack of control group limit the ability to make causal inferences. Future research should incorporate a more rigorous experimental design to enhance confidence in the findings. Further, the use of a convenience sample holds the potential to introduce selection bias. However, in the present study, selection bias would likely result in a more conservative estimate of effect size as participants were likely more engaged in the topic, with less room to demonstrate improvement in CD-related knowledge and attitudes. Another limitation is the challenges that we experienced in linking participants’ pre-post test data, which diminished our sample size. Although participants were prompted to create unique identifiers to facilitate this process, the identifiers entered were inconsistent across time points for many of the participants, ultimately diminishing study power. Despite these limitations, the results indicate that the intervention was effective in providing a low-barrier and accessible educational intervention to improve nursing capacity to care for this priority patient population. Future research should include a focus on patient-reported outcomes in relation to sustained changes in care among nurses completing this or other CD training. Additionally, examinations of the intervention in other clinical contexts, including community mental health settings and other acute care contexts with high prevalence of patients with CDs (e.g., emergency departments) are needed to draw further conclusions about the external validity of the results.

5. CONCLUSIONS

Nurses have a key role to play in enhancing care and outcomes for patients experiencing CDs. Brief educational interventions, including the ‘Enhancing Concurrent Disorder Care Intervention’, can provide an effective means for addressing knowledge gaps and associated structural forces (e.g., stigma) that are currently serving as barriers to safe and effective care for patients with CDs. Equipped with the necessary foundational knowledge, nurses will be better positioned to lead improvements in care and outcomes for patients with co-occurring mental health and substance use disorders, a key priority globally.

Highlights.

• Patients commonly experience concurrent mental health and substance use disorders.

• Gaps in health professions training impact the quality of concurrent disorder care.

• This study reports on a nursing education intervention about concurrent disorders.

• The intervention improved knowledge and attitudes among nurses and student nurses.

• Brief educational interventions with nurses can enhance concurrent disorder care.