Factors influencing attitudes of nurses in general health care toward patients with comorbid mental illness: an integrative literature review

District Nurses' Experiences of Practice in Caring for People with Mental Ill-Health in Swedish Primary Care

Mental ill-health is one of the greatest public health challenges in Sweden, and it is estimated that every third person seeking primary care in the country suffers from mental ill-health. Without proper treatment at an early stage, mental ill-health may lead to long-term illness and have a significant impact on functional ability. As district nurses are specialists in public health nursing, they have been pointed out as having a key role in the prevention and management of mental ill-health. The aim was to explore district nurses' practice in caring for people with mental ill-health within primary health care. Individual semi-structured interviews were conducted with district nurses (n = 18) and the transcribed text was subjected to qualitative content analysis. The result was formulated as several subthemes, eventually developed into three themes: Practicing within an organisation where traditional attitudes are impediments, Perceiving mental healthcare as not being an obvious part of district nursing, Working as fellow human beings rather than "professionals". The findings indicate that district nurses feel uncertainty in their practice in this area. Working independently with mental ill-health was not always considered socially acceptable among district nurses. Despite these challenges they tried to remain involved without becoming emotionally overwhelmed. They also strived to meet the needs of these patients with 'small things', that could be effective and a part of recovery-oriented practice, even if they might be defined as unprofessional, and their efficacy negated.

Attitudes of polish nurses towards representatives of certain religions

Background

The verification of attitudes of nurses towards people of different religions is essential when it comes to anticipating opportunities for cooperation in the field of provision of healthcare. The purpose of the study was to evaluate the attitudes of Polish nurses, on the example of nurses living in the Lesser Poland region (southern Poland) towards representatives of certain religions.

Methods

The study was cross-sectional and was carried out using both the diagnostic survey and method of estimation. The selection of the study group was purposeful. The research tools used in the study include the Bogardus’ Social Distance Scale adapted by Jasińska-Kania and Staszyńska; Social Dominance Orientation (SDO) by Sidanius and Pratto; Social Approbation Questionnaire by Drwal and Wilczyńska and Author’s questionnaire. A significance level of 0.05 was assumed in the analyzes. The research was carried among 1271 professionally active nurses.

Results

The respondents showed the least significant social distance towards the Orthodox and Protestants and the most significant towards the Muslims. There was a considerable dependence when it comes to the level of the social distance of the respondents shown on sociodemographic variables and frequency of contact with Others, provision of healthcare to people of different religions, and training on transcultural nursing. The relationship between SDO and the modified Bogardus Scale has been shown. All subscales of the Social Dominance Orientation (SDO) correlated significantly and negatively with the Bogardus scale.

Conclusions

The study outcomes show that there is a need to train nurses on transcultural nursing.

Surgical outcomes for people with serious mental illness are poorer than for other patients: a systematic review and meta-analysis

OBJECTIVE

To assess the association between having a serious mental illness and surgical outcomes for adults, including in-hospital and 30-day mortality, post-operative complications, and hospital length of stay.

STUDY DESIGN

Systematic review and meta-analysis of publications in English to 30 July 2018 of studies that examined associations between having a serious mental illness and surgical outcomes for adults who underwent elective surgery. Primary outcomes were in-hospital and 30-day mortality, post-operative complications, and length of hospital stay. Risk of bias was assessed with the Quality in Prognosis Studies (QUIPS) tool. Studies were grouped by serious mental illness diagnosis and outcome measures. Odds ratios (ORs) or mean differences (MDs), with 95% confidence intervals (CIs), were calculated in random effects models to provide pooled effect estimates.

DATA SOURCES

MEDLINE, EMBASE, PsychINFO, and the Cochrane Library.

DATA SYNTHESIS

Of the 3824 publications identified by our search, 26 (including 6 129 806 unique patients) were included in our analysis. The associations between having any serious mental illness diagnosis and having any post-operative complication (ten studies, 125 624 patients; pooled effect: OR, 1.44; 95% CI, 1.15-1.79) and a longer stay in hospital (ten studies, 5 385 970 patients; MD, 2.6 days; 95% CI, 0.8-4.4 days) were statistically significant, but not those for in-hospital mortality (three studies, 42 926 patients; OR, 1.21; 95% CI, 0.69-2.12) or 30-day mortality (six studies, 83 013 patients; OR, 1.85; 95% CI, 0.86-3.99).

CONCLUSIONS

Having a serious mental illness is associated with higher rates of post-operative complications and longer stays in hospital, but not with higher in-hospital or 30-day mortality. Targeted pre-operative interventions may improve surgical outcomes for these vulnerable patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42018080114 (prospective).

Nurses' and Mental Health Technicians' Attitudes and Social Acceptance of People with Mental Illness

Over 43 million Americans are diagnosed with a mental illness. Various factors, including health professionals' attitudes, prevent patients from seeking care. Previous evidence fails to identify nursing staff attitudes toward patients with mental illness. This cross-sectional study investigated attitudes toward mental illness of 146 registered nurses and mental health technicians in a psychiatric hospital. The study was guided by the Modified Labeling Theory. Respondents expressed stereotyping beliefs that people with mental illness would be devaluated and discriminated, and endorsed stigmatizing attitudes expressing stronger desire for social distance from a person with schizophrenia than depression or diabetes. Implications for future research, nursing education and practice are discussed.

How Stigma and Discrimination Influences Nursing Care of Persons Diagnosed with Mental Illness: A Systematic Review

One in four people in the world will be affected by mental illness in their lifetime, placing mental disorders as the leading cause of disability worldwide. This qualitative systematic review was to explore perceived stigma and discrimination experienced by individuals seeking care for physical or mental health concerns. Specifically, it sought to uncover the level of perceived stigma and discrimination experienced by mentally ill patients seeking care for physical or mental health concerns. Seven databases were searched between January 1, 2007 to November 1, 2018. Selected studies met the following inclusion criteria: 1) English language and published within North America, Australia, or United Kingdom; 2) studies and articles that consider individuals with mental illness seeking help for either mental or physical conditions in the hospital setting except for within mental health wards; and 3) research in which the phenomenon of interest examined how stigma and discrimination influences the perception of nursing care received by the mentally ill patient and the perception of nurses who provide care to the mentally ill patient. Eight studies met the inclusion criteria. Studies reported that both patients and nurses perceive similar barriers to person-centered care resulting from stigma toward mental illness. This significantly compromised quality person-centered care, and negatively affected the nurse-client relationship. Results indicate the need for further research to determine how health care and educational institutions play a role in perpetuating stigma against mental illness through the prioritization of physical illness over mental illness.

Korean Nursing Students' First Experiences of Clinical Practice in Psychiatric Nursing: A Phenomenological Study

Nursing students have a more negative attitude toward psychiatric practice than other practices. In particular, Korean nursing students experience increased pressure during clinical practice in psychiatric nursing due to sociocultural and institutional influences, such as prejudices, fear, and anxiety towards mental illnesses. This study aimed to conduct an investigation on students’ first experiences of clinical practice in psychiatric nursing. Participants were 12 fourth year nursing students in South Korea. The data were collected through semi-structured interviews, and data analysis was done using Colaizzi’s phenomenological method. The students’ experiences of clinical practice in psychiatric nursing could be categorized into emotional fluctuation, burnout, transformation, and growth. The results of this study show that nursing students experienced emotional fluctuation and burnout at the beginning of their clinical practice in psychiatric nursing. At the end of the clinical practice, they experienced transformation and growth. The study suggests that nursing instructors and on-site staff need to interact with nursing students to understand the nature of these first experiences and support them through teaching and field guidance.

Burnout and Mental Health Stigma Among Juvenile Probation Officers: The Moderating Effect of Participatory Atmosphere

Despite high rates of mental health problems among juvenile justice-involved youth, mental health stigma among juvenile probation officers (JPOs) is under-studied. This cross-sectional study examined effects of job burnout and workplace participatory atmosphere on mental health stigma among JPOs across Indiana (n = 226). Participatory atmosphere moderated the relationship between JPO burnout-related cynicism and mental health stigma (interaction β = - 0.14, p = .04); burnout was related to greater mental health stigma at low levels of participatory atmosphere. Findings suggest participatory atmosphere mitigates effects of burnout on mental health stigma among JPOs. Organizational-level interventions might help to reduce mental health stigma and combat negative effects from burnout among JPOs.

Knowledge and attitude towards mental illness among primary healthcare nurses in Brunei: A cross-sectional study

BACKGROUND

Mental Health problems are one of the leading disabilities worldwide. Individuals seeking help for their mental illness expect nurses to be cognisant of their needs without prejudice and discrimination. Existing evidences suggest a growing number of patient referral from primary healthcare to psychiatric consultations. This study aimed to explore primary healthcare nurses' knowledge and attitude towards mental illness and people with mentally illness.

METHODS

A cross-sectional study using the Mental Health Problem Perception and the Community Attitudes to Mental Illness questionnaires. Descriptive and multivariate regression using maximum likelihood procedures were applied.

RESULTS

Regression analysis showed significantly high correlation between knowledge and authotarianism (β = 0.775, p = 0.007) and moderate inverse correlation with social restrictiveness (β = -0.517, p < 0.001). However, no significant correlation with benevolence (β = -0.057, p = 0.181) was detected. Nurses with higher educational level were significantly associated with authotarianism attitude.

CONCLUSIONS

This is the first study examining knowledge and attitude of primary healthcare nurses in Brunei. The relationship between the study variables as well as demographic factors, in comparison to other countries, were discussed. Overall, negative attitude among nurses is still a challenging issue; therefore, developing re-education initiatives and increase contact time, especially for healthcare front liners with negative attitudes regardless of education level, to favour change of attitude, is important to foster holistic care to people with mental illness and promote mental health in the population.

Primary health care nurses attitude towards people with severe mental disorders in Addis Ababa, Ethiopia: a cross sectional study

BACKGROUND

Negative attitude and discriminatory behavior of health professionals constitute a major obstacle in psychiatric care and have been pointed out as a key issue in working with mental illness. Understanding about the attitude of nurses is crucial for quality and holistic care of psychiatric services and essential for the successful integration of mental health into primary health care. However, there is a paucity of study to examine the attitude of primary health care nurses towards severe mental disorder in Ethiopia. Therefore, this study aimed to assess the attitude of primary health care nurses and its associated factors towards people with severe mental illness in Addis Ababa.

METHODS

Institutional based cross-sectional study was conducted among nurses working at primary health care in Addis Ababa from May to June, 2018. Multistage sampling technique was used to select 634 participants. A structured self-administered questionnaire was used. Data were coded and entered into EPIDATA 3.1 and exported to SPSS version 20 for analysis. Bivariate and multivariate binary logistic regression analysis was used to identify factors associated with attitudes of nurses in primary health care. The level of significance was declared at P-value < 0.05 with 95% confidence interval.

RESULTS

A total of 610 respondents were included in the study with a response rate of 96.2%. The mean age of participants was 28.6 ± 5.9 (SD) years and the prevalence of negative attitude was 48.2%. Multiple logistic regression models revealed that respondents who have diploma [AOR = 3.09, CI (1.20-7.95)], work experience of < 5 years [AOR = 4.49, CI (2.37-8.49)], respondents who didn't took mh-Gap training [AOR = 4.92, CI (3.05-7.95)] and poor knowledge about mental illness [AOR = 2.84, CI (1.82-4.44) were associated with negative attitude towards people with severe mental illness.

CONCLUSION

Nearly half of the participants have negative attitude towards people with severe mental disorders. Therefore, evidence based and contextualized models are warranted to mitigate negative attitudes of primary health care nurses.

Investigation of attitudes toward mental illness among nursing students in Indonesia

Objective

People with mental illness (PMI) are often stigmatized or experience negative attitudes from society. In particular, nursing students’ attitudes toward PMI will influence the quality of care these patients receive. Some factors influencing attitudes toward PMI among nursing students have been identified. The present study aimed to examine factors influencing attitudes toward mental illness among nursing students in Indonesia.

Methods

Nursing students (n = 317) were assessed for attitudes toward mental illness using the Community Attitude toward the Mentally Ill questionnaire. Details regarding sociodemographic variables (age, gender, ethnicity, year of study, monthly family income, personal experience with mental illness, family history of mental illness, and knowing or having direct contact with PMI) and knowledge about mental illness by using Mental Health Knowledge Schedule questionnaire were also obtained.

Results

The mean Community Attitude toward the Mentally Ill questionnaire score was 103.75 ± 9.15, with the highest mean of the four subscales being that of authoritarianism 27.97 ± 2.87 followed by social restrictiveness, community mental health ideology, and benevolence 27.52 ± 3.68, 24.38 ± 3.80, and 23.89 ± 3.27, respectively. The factors significantly associated with nursing students’ attitudes toward mental illness were age (r = −0.18, P = 0.001), year of study (H = 16.65, P < 0.001), knowing or having direct contact with PMI (Z = −2.35, P = 0.019), and knowledge of mental illness (r = −0.22, P < 0.001).

Conclusions

Several demographic variables, direct contact with PMI, and level of knowledge about mental illness can contribute to variations in attitudes toward PMI among nursing students in Indonesia. Education and direct contact with PMI serve as intervention strategies to reduce negative attitudes and stigma associated with mental illness among nursing students.

Health Care Professionals Attitudes Towards Mental Illness: Observational Study Performed at a Public Health Facility in Northern Italy

The United Nations Convention on the Rights of Persons with Disabilities Defines stigma as the process of social oppression barring persons with mental illness from enjoying social interaction through discrimination, exclusion and denial of human and social rights. Modern stereotypes still portray the mentally ill as guilty, unpredictable and violent. Observational studies report how healthcare professionals, including nurses, are often part of the stigma. Such phenomenon belittles the needs of people seeking mental care. The aim of this study is to describe attitudes held by psychiatric nurses and mental care professionals from different care settings of an Italian Healthcare Facility, towards the mentally ill and to identify any associated factors. Mental health care professionals were recruited for this observational study from 10 Italian different psychiatric care units. The Italian version of the Community Attitudes Mentally Ill inventory (CAMI-I) was validated and used for this study. 120 completed questionnaires were deemed valid. Optimal internal consistency (α=0.856) was measured by calculating Cronbach's Alpha for the CAMI-I. Demographic variables were correlated to items grouped into three factors of the CAMI-I (authoritarian attitudes, benevolence, social restrictiveness). Parametric test (ANOVA) highlight significant differences between CAMI-I results for different demographic variables. Significant data were obtained by comparing responses for each factor of the CAMI-i per professional profile. All healthcare professionals studied show sensitivity and positive attitude towards mental illness. Positive approaches to mental illness contribute towards easing therapeutic care and recovery in patient-centred care. CAMI-I will be a useful tool to identifying discriminatory approaches and sensitize health professionals in Italy.

Determining the effectiveness of a video-based contact intervention in improving attitudes of Penang primary care nurses towards people with mental illness

BACKGROUND

Mental illness-related stigma is common, and is associated with poorer outcomes in people with mental illness. This study evaluated the attitudes of primary care nurses towards people with mental illness and its associated factors; and the effectiveness of a short video-based contact intervention (VBCI) in improving these attitudes using a Malay version of the 15-item Opening Minds Stigma Scale for Healthcare Providers (OMS-HC-15-M).

METHODS

A 5-minute VBCI was developed comprising elements of psychoeducation and interviews of people with mental illness and the people they interact with, relating to experience of mental illness and recovery. A pre-post cross-sectional study was conducted on 206 randomly selected primary care nurses in Penang, Malaysia. The OMS-HC-15-M questionnaire was administered before and immediately after participants viewed the VBCI. The difference in mean pre-post VBCI scores using paired t-tests, effect size and standardised response mean (SRM) were obtained. Factors correlating to attitudes were obtained using univariate and multivariate regression analyses.

RESULTS

Differences in pre-post VBCI score were statistically significant (p<0.001) with a 14% score reduction, a moderate effect size and SRM at 0.97 (0.85-0.11) and 1.1 (0.97-1.2) respectively. By factoring in the Minimal Detectable Change statistic of 7.76, the VBCI produced a significant improvement of attitudes in 30% of the participants. Factors associated with less stigmatising attitudes at baseline were previous psychiatry-related training, desiring psychiatric training, and positive contact with people with mental illness.

CONCLUSIONS

This is the first study in Malaysia to show that a brief VBCI is effective in improving attitudes of primary care nurses towards people with mental illness in the immediate term. Further studies are needed to determine if these results can be sustained in the longer term and generalizable to other health care professionals. Qualitative studies are warranted to provide insight to the factors correlating to these attitudes. (300 words).

Acknowledging Rural Disadvantage in Mental Health: Views of Peer Workers

PURPOSE

The aim of this article was to present views and opinions of people employed to work from their personal experience of significant mental health challenges (peer workers). The specific focus was on their capacity to contribute meaningfully to mental health service provision and in rural areas and associated barriers.

DESIGN AND METHODS

Grounded Theory was the methodology utilized. In-depth interviews were conducted with peer workers throughout Australia.

FINDINGS

Participants described significant barriers to the provision of quality mental health services in rural and regional locations. The two main areas identified were the following: transport and distance, and lack of mental health staff and services.

CONCLUSIONS

The identified barriers place limitations on the capacity of peer workers to maximize effectiveness in rural settings. Peer workers could potentially play an important role in overcoming shortages of staff and services and improving mental health service delivery.

Do Physiotherapists Have the Skill to Engage in the "Psychological" in the Bio-Psychosocial Approach?

Purpose: To describe a cross-sectional exploration of attitudes of physiotherapists in general practice in Western Australia toward psychiatry and mental illness, how often they treat people with mental illness, their perceptions of how well their undergraduate education prepared them to work with these people, and their opinions about what further education would enable them to provide best-practice care. Methods: A questionnaire that included questions about participants' demographic information, personal experiences with mental illness, the Attitudes to Psychiatry (ATP-30), and open-ended questions about participants' preparedness to work with people with mental illness was distributed through 110 email contacts to physiotherapy departments in Western Australia. Results: A total of 75 completed questionnaires contributed to the findings; 11 returned questionnaires were incomplete and were not included in the data analysis. ATP-30 scores indicated moderately positive attitudes toward psychiatry and mental illness. Women indicated significantly more positive attitudes than men. Of the full sample, 41% (n=31) reported treating someone with a comorbid mental health problem every day and 76% (n=57) reported treating someone every week. Conclusion: Physiotherapists in general practice in Western Australia have generally positive perceptions of psychiatry. The majority of clinicians reported treating patients with mental illness at least once a week. Participants indicated feeling underprepared to work with this patient group, a need for the undergraduate curriculum to be revised, and an overwhelming need for postgraduate training in psychiatry and mental health.

Physiotherapy Students' Attitudes toward Psychiatry and Mental Health: A Cross-Sectional Study

Purpose: A cross-sectional exploration of Notre Dame Australia physiotherapy students' attitudes toward psychiatry and mental illness, students' perceptions regarding preparation in this area for general clinical practice, and a cross-sectional investigation of current mental health-and psychiatry-related content in physiotherapy curricula across Australia and New Zealand. Methods: A questionnaire including demographic details, level of exposure to mental illness, and the Attitudes Toward Psychiatry-30 items (ATP-30) was completed by pre-clinical and clinically experienced physiotherapy students from the University of Notre Dame Australia. Students with clinical experience were asked additional questions about preparedness for practice. Staff of 10 of 17 physiotherapy programmes across Australia and New Zealand responded to an online questionnaire investigating relevant content and quantity of learning experiences in mental health. Results: Student response rate was 89%. Students generally had a positive attitude about psychiatry and mental health. Women were significantly more positive than men, and students who had completed clinical experience had a significantly more positive attitude. Physiotherapy program responses (response rate=59%) highlighted disparate approaches to psychiatry and mental health learning opportunities in terms of quantity and content. Conclusion: Entry-level physiotherapy students who have clinical experience generally have a more positive attitude toward psychiatry and people with mental illness. Given the prevalence of mental health problems and the increase in physical and mental health comorbidities, it is imperative that future clinicians have positive educational experiences in psychiatry. A coherent, integrated approach to mental illness and psychiatry is suggested for entry-level physiotherapy programmes in Australia and New Zealand.

Medical-Surgical Nurses' Perceptions of Psychiatric Patients: A Review of the Literature With Clinical and Practice Applications

The literature consistently shows that medical-surgical nurses frequently lack the knowledge, skills, and attitudes necessary to render holistic nursing care to patients with severe mental illness (SMI). The negative perceptions often portrayed by medical-surgical nurses towards SMI patients with comorbid medical-surgical disorders must be addressed in order to ameliorate treatment gaps. Current concepts, issues, and challenges associated with the perceptions of nurses who care for patients with (SMI) in medical-surgical settings can prove overwhelming to both nurses and patients, and can result in concerning practice gaps. In accordance with a contemporary model of patient-centered care, it is imperative that medical-surgical nurses acquire the knowledge, skills, and attitudes necessary to work with this high-risk population. Cultivating an environment that promotes apposite attitudes along with effective training programs for medical-surgical nurses, may shift negative perceptions and ultimately meet best practice standards and improve outcomes for patients with SMI.

Implementing a major stream in mental health nursing: barriers to effectiveness

Changes to the educational preparation of the nursing workforce in mental health continue to have profound effects on the availability of sufficient numbers of skilled graduates willing to work in this field. The longevity of the problem has focused attention on possible solutions. Introducing a major stream in mental health nursing in undergraduate Bachelor of Nursing programmes was proposed and supported as a potentially beneficial strategy, adopted by some Australian universities. Despite the promise invested in this strategy, systematic evaluations to determine the effectiveness or otherwise of this approach were not initiated. A qualitative exploratory study was undertaken with Australian universities, which had implemented the major stream, regarding their experiences and observed outcomes. In-depth interviews were conducted with a mental health nurse academic from each university. The barriers to the effectiveness of the major in mental health nursing are the specific focus of this paper. Thematic data analysis revealed three main barriers: clinical placements, lack of support from other academics, and integrated curricula. These barriers substantially limited the effectiveness of this strategy - in some instances, leading to the programme's termination - and must be assertively addressed to maximize the potential of the major in mental health nursing.

Mental health nursing staff's attitudes towards mental illness: an analysis of related factors

Employer/workplaces have an impact on mental health nursing staff's general attitudes towards persons with mental illness. Staff have more positive attitudes if their knowledge about mental illness is less stigmatized and currently have or have once had a close friend with mental problem. More favourable attitudes among staff towards persons with mental illness could be developed and transmitted in the subculture at work places. There is growing awareness that mental illness is surrounded by negative attitudes and stigmas. The aim of the present study was to investigate factors associated with mental health nursing staff's attitudes towards persons with mental illness. Data were collected from 256 mental health nursing staff employed by one county council and 10 municipalities. The findings show that staff have more positive attitudes towards persons with mental illness if their knowledge about mental illness is less stigmatized, their work places are in the county council, and they currently have or have once had a close friend with mental health problems. The multiple regression model explained 16% of the variance; stigma-related knowledge and employer had significant Beta-coefficients. To account for unknown correlations in data, a linear generalized estimating equation was performed. In this model, stigma-related knowledge and employer remained significant, but a new significant factor also emerged: personal contact, i.e. currently having or having once had a close friend with mental health problems. This indicates correlations at unit level in the county council and in the municipalities. The conclusion is that more favourable attitudes among staff towards persons with mental illness could be developed and transmitted in the subculture at work places.

Keeping the flame alight: understanding and enhancing interest in mental health nursing as a career

Mental health nursing is not regarded favourably by most Bachelor of Nursing (BN) students as a desirable career option. However, little is known about what attracts those students who do become interested. The primary aim of the current study was to explore BN students' reasons for choosing to undertake the major in mental health nursing and the degree to which completing the subject: "Recovery for mental health nursing practice", confirmed that interest or otherwise. A secondary aim was to examine their perceptions about the attitudes of others to their expressed interest in mental health nursing. A qualitative exploratory study was undertaken with undergraduate nursing students (BN) (n = 12) enrolled in a major stream in mental health nursing. In-depth individual interviews were conducted primarily by telephone. Data were analysed using Colaizzi's steps to explicate the main themes. Two main themes emerged: Swimming against the tide - that's not real nursing, captures participants' experience of the negative attitudes of others to their interest in mental health nursing; and, creating and confirming an interest in mental health nursing, where participants discuss how their interest emerged and how it had been enhanced after completing the subject: Recovery for Mental Health Nursing Practice. Mental health nursing continues to be a stigmatised and undervalued profession both within nursing and the general public. Despite this, participants of this research were attracted to the specialty, and their interest was generally strengthened after completing the Recovery subject. Further research is required to examine the impact of being taught by an academic with lived experience on interest in mental health nursing as a career.

Attitude disentangled: a cross-sectional study into the factors underlying attitudes of nurses in Dutch rehabilitation centers toward patients with comorbid mental illness

In rehabilitation centers, many patients suffer a comorbid mental illness. Nurses have different attitudes toward these patients. A cross-sectional, questionnaire-based study among nurses in Dutch rehabilitation centers was undertaken to clarify the factors that underlie attitudes toward patients with comorbid mental illness. The main factors associated with attitudes were feelings of competence and experiences with dealing with patients with mental illness. Other associations were perceived support; frequency of caring for patients with comorbid mental illness; work experience in mental health care; additional psychiatric training; and the personality traits "extraversion," "emotional stability," and "openness to experience." Perceived support had the strongest association with feelings of competence.