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International Journal of Mental Health Nursing (2015) 24, 262–271
doi: 10.1111/inm.12126
Feature Article
Nursing practice environment: A strategy for mental health nurse retention? Robina Redknap,1,2 Di Twigg,1 Daniel Rock3,4,5 and Amanda Towell1 1
School of Nursing and Midwifery, Edith Cowan University, Joondalup, 2Graylands Hospital, North Metropolitan Health Service, Mental Health, 3North Metropolitan Health Service, Mental Health, 4School of Psychiatry and Clinical Neurosciences, and 5School of Population Health, The University of Western Australia, Perth, Western Australia, Australia
ABSTRACT: Historically, mental health services have faced challenges in their ability to attract and retain a competent nursing workforce in the context of an overall nursing shortage. The current economic downturn has provided some respite; however, this is likely to be a temporary reprieve, with significant nursing shortages predicted for the future. Mental health services need to develop strategies to become more competitive if they are to attract and retain skilled nurses and avoid future shortages. Research demonstrates that creating and maintaining a positive nursing practice environment is one such strategy and an important area to consider when addressing nurse retention. This paper examines the impact the nursing practice environment has on nurse retention within the general and mental health settings. Findings indicate, that while there is a wealth of evidence to support the importance of a positive practice environment on nurse retention in the broader health system, there is little evidence specific to mental health. Further research of the mental health practice environment is required. KEY WORDS: mental health, nurse retention, nursing, nursing shortage, practice environment.
INTRODUCTION Mental health nursing has historically been seen as a less attractive career option for nurses. Major advances occurred during the 1950s–1980s, and can be attributed to the rapid expansion in understanding the important influence that nursing practice had on mental health patient outcomes. This understanding primarily evolved through the influence of nurse theorists, such as Travelbee, Peplau, and Orlando. These theorists emphasized the importance of interpersonal relationships in the Correspondence: Robina Redknap, Graylands Hospital, Brockway Road, Mt Claremont, Western Australia 6010, Australia. Email: [email protected] Robina Redknap, RMHN. Di Twigg, PhD MBA, B Hlth Sc (Nsg) Hons, RN, RM, FACN, FACHSM. Daniel Rock, PhD, MN. Amanda Towell, D Cur, M Cur, B Cur (Ed et Adm), DCH, RCCN, RN. Accepted December 2014.
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development of compassionate and caring therapeutic nurse–patient relationships; integrating nursing theory into practice; and the ability for nurses to use their perception, thoughts, and feelings in the identification of patient needs (McCarthy & Aquino-Russell 2009; Moses 1994; Potter & Tinker 2000). This had a dramatic effect on mental health nursing practice, and resulted in greater recognition for the therapeutic influence that mental health nurses have in ensuring positive patient outcomes and a reduction in the medical dominance and servility of mental health nurses (Hayman-White et al. 2007; Holmes 2002; The Sainsbury Centre for Mental Health 2005). However, the attraction and retention of nurses by mental health services continued to be problematic (Happell 2009). Patients and staff continue to hold different perceptions of the ward environment, with different factors influencing the satisfaction they feel (Friis 1986; Roos 1997; Rossberg & Friis 2004). This has left today’s mental health nurse leaders with significant challenges to
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attract and retain a mental health nursing workforce essential to delivering quality nursing care. This is of significant concern, as nursing workforce shortages are predicted for the future across most developed countries. Global nursing shortages have been acknowledged as a significant issue (Happell 2009), and are not considered a new phenomenon. In the past, international nursing shortages have had a significant impact on the Australian nursing workforce, with demand outstripping supply. The global shortage of nurses in future is once again likely to have a significant impact on Australia, with the population demand for nurses in Australia predicated to outstrip supply by 6.3%, or 20 079 nurses in 2016, increasing to 28% or 109 490 nurses in 2025 (Health Workforce Australia 2012). Mental health has been identified as one of the areas that will be most affected (Health Workforce Australia 2012), thereby leaving mental health nursing particularly vulnerable when competing for the limited available workforce. Added to this, mental health nursing is faced with a double disadvantage. The first disadvantage can be attributed to the secondary stigma associated with working within mental health services, despite the implementation of stigma-reduction strategies (Australian Health Workforce Advisory Committee 2003). Second, the expectation that a large proportion of the workforce is likely to retire within the next 10–15 years, with 61.1% of the mental health nursing workforce over the age of 45 years, and 27.2% over 55 years (Australian Institute of Health and Welfare 2012), exacerbating the already existing shortage of nurses within mental health. As private health providers re-enter the market of mental health-care provision and new contemporary services are established, these issues are likely to compound the difficulties traditional services face, particularly in the public sector, to compete for the smaller pool of nurses who choose mental health as a career. A review of the literature has determined that a major contributing factor to general nursing shortages appears to be related to nurses unwilling to work in certain practice environments, rather than a lack of qualified staff (Buchan 2000; 2006; Buchan & Aiken 2008). It is acknowledged that the practice environment has the ability to influence employee job satisfaction, regardless of the industry in which they work (Samson & Daft 2012). The importance of a positive practice environment is further supported by work undertaken by the American Nurses’ Credentialing Centre (ANCC) during the 1970– 1980 nursing shortages. The ANCC developed a set of criteria known as the Magnet Principles or the Forces of Magnetism (Gaguski 2006). These criteria were considered characteristics of hospitals that were able to attract © 2015 Australian College of Mental Health Nurses Inc.
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and retain nurses, despite shortages. These criteria reflect what researchers consider to be the critical elements of a positive practice environment, including effective leadership, collegial support, and access to professional and career development opportunities (Aiken et al. 2011a; Buchan 2006; Buchan & Aiken 2008; Happell 2009; Norman 2013; Spence Laschinger 2008; Van Bogaert et al. 2010). Within general nursing, there has been a lot of work undertaken that demonstrates that improving the practice environment is an important factor and can have a significant impact on the attraction and retention of staff (Aiken et al. 2008; Hanrahan et al. 2010; Spence Laschinger 2008; Twigg & McCullough 2014). In comparison, a review of the literature has revealed a paucity of studies undertaken in mental health. Researchers have identified that a number of factors, such as stigma, perceived workload, containing clinical risk, and the lack of investment in mental health resources, contributes to the challenges in attracting and retaining a skilled mental health workforce (Brown et al. 2007; Morrissette 2011; O’Connor & Vize 2003). However, further research is needed within mental health on the nursing practice environment, to assess its impact on mental health nurse retention. The aim of this paper was to provide a review of the literature, which has examined the association between the nursing practice environment and retention of nurses, both in general and mental health settings. This will assist in providing mental health nurse leaders a greater understanding of the significance of creating and maintaining positive nursing practice environments as a nurseretention strategy.
METHOD A combined search of the following databases – CINAHL Plus with full text, Medline, PsycARTICLES, PsycBOOKS, PsycINFO, and Embase – was undertaken from February 2013 to June 2014. Google Scholar and Western Australian and Commonwealth Health Department websites were accessed to retrieve health policy documents and reports that had relevance to the study topic. The search was limited to English language articles published from 1990 to 2013. Search terms related to the study topic were used (Fig. 1). The initial search found 17 287 articles. A Boolean and truncated search method was used to further refine the initial search. This search method allows the researcher to search for keywords in both their singular and plural forms. By entering ‘operators’, such as ‘and’ or ‘not’, the researcher is able to narrow
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Search conducted February 2013–June 2014
Database CINHAL, full-text Medline Psychlnfo PsycARTICLES, PsycBOOKS Embase
Initial search terms S1: Mental health nurs* S2: Global nurs* shortage* S3: Nurs* practice environment S4: Nursing leadership S5: Foundation* of nurs* care S6: Standard* of nurs* care
Refined search (boolean and truncated search) S9: S3 and mental health nurs* S10: S3 and patient outcome* S11: S3 and nurs* outcome* S12: S3 and quality care S13: S2 S14: S5
Total retrieved: 17 287 Total retrieved: 284
Abstract review for inclusion criteria English language, peer reviewed, related to the mental health or general health nursing-practice environment and articles, which linked the nursing practice environment and nurse-retention strategies Total retrieved: 47 FIG. 1: Literature search methodology.
a search by retrieving documents that contain the combined specified words. The revised search retrieved 284 articles. The abstract of each article was reviewed to assess relevance to the study. The inclusion criteria for this review was limited to articles that were written in the English language, peer reviewed, related to the mental health or general health nursing practice environment,
and articles that linked the nursing practice environment with nurse-retention strategies. Where required, the full article was reviewed to determine relevance. A total of 49 journal articles were selected for this review. In addition, relevant texts, reports, and Australian state and territories’ and Commonwealth Health Department policy documents and reports identified through the search or from the knowledge of the researcher were also reviewed. © 2015 Australian College of Mental Health Nurses Inc.
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Foundations for quality nursing care Nursing philosophy Role definition Culture of learning
Nursing-practice environment
Collegial physician/nurse relationships Cohesive teamwork Increased confidence Decrease depersonalisation
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Leadership Support and direction Empowerment Innovation
Staffing and resources Adequate staff Appropriate skill mix Adequate support
Participation in hospital affairs Professional autonomy Control over practice Empowerment
FIG. 2: Elements of the nursing practice environment.
NURSING PRACTICE ENVIRONMENT The nursing practice environment is a ‘complex construct to conceptualize and measure’ (Lake 2002), but remains a critical factor in the ability of organizations to attract and retain nursing staff and optimize patient outcomes (Aiken et al. 2011B). The practice environment comprises of factors within an organization, which have a psychological impact on staff and affect the quality and safety of care delivered to patients. These factors include perceived collegial support, leadership, and access to professional and career development opportunities (Norman 2013). The Practice Environment Scale of the Nursing Work Index (PES-NWI) is considered the most useful and reliable instrument to measure the climate of the practice environment (Aiken et al. 2011B; Lake 2007; Twigg & McCullough 2014; Warshawsky & Havens 2011). The PES-NWI was derived by Lake from the original NWI and was constructed from research on hospitals that had successfully attracted and retained nurses during the nursing shortages in the early 1980s (Lake 2002). The PES-NWI has been used in studies at © 2015 Australian College of Mental Health Nurses Inc.
least 37 times between 2002 and 2010, with results published in 23 peer-reviewed international journals (Twigg & McCullough 2014; Warshawsky & Havens 2011). The PES-NWI identifies five key elements as critical areas in the practice environment that link directly to a positive psychological impact on staff: (i) foundations of nursing; (ii) leadership; (iii) staffing and resources; (iv) collegial nurse–physician relationships; and (v) participation in hospital affairs (Aiken et al. 2011b; Buchan 2006; Buchan & Aiken 2008; Happell 2009; Spence Laschinger 2008; Van Bogaert et al. 2010). Aiken et al. (2011b) identified that each of these elements independently contributes to nurse and patient outcomes, supporting that if they are improved collectively, they create the ability for services to achieve high standards of quality patient care, increase staff satisfaction, and reduce intention to leave (Fig. 2). Nursing practice environments that have varying sample size and within considerably differing health-care systems have been extensively studied at an international level. While a number of differing factors have been
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identified as contributing to the climate of the practice environment, many of these studies conclude that the critical elements of the practice environment have distinct similarities worldwide, with a strong link to increased retention rates, decreased burnout in staff, and adverse patient outcomes (Aiken et al. 2011; Hinno et al. 2012; Nantsupawat et al. 2011; Papastavrou et al. 2012; Spence Laschinger 2008; Walker et al. 2010). Studies have found that negative perceptions of the practice environment are predictors of disengagement by nurses with their profession and intent to leave (Unruh & Ning 2013). The majority of these studies have been conducted within general health settings, with Roche and Duffield (2010) identifying that of those that have been undertaken, few have been within mental health-care settings. This has resulted in minimal guidance to mental health nurse leaders to promote positive practice environments within their health services. In Australia, there has been increased focus on promoting mental health nursing as an attractive career option in the hope that workforce shortages could be addressed (Australian Health Workforce Advisory Committee 2003). However, it is becoming increasingly evident that while such strategies might have had some success in attracting nurses, they have had little effect on the long-term retention rates (Hinno et al. 2012), resulting in the need to explore alternative attraction and retention initiatives. With a review of the literature demonstrating that the practice environment is the basis of nurses’ satisfaction and their intention to leave in general settings (Aiken et al. 2008; Choi et al. 2012; Hanrahan et al. 2010; Spence Laschinger 2008), this becomes an important area for mental health nurse leaders to explore. The need for further research to be undertaken to understand the influence and benefits that each of the five elements of a positive practice environment has on retention of mental health nurses has never been more important, particularly as these nurses are reported to evaluate their environments more negatively than nurses in other specialties (Hanrahan & Aiken 2008).
Foundations for quality nursing care The principles of the foundation for quality nursing care form the building blocks of the nursing profession on which nursing standards, ethical practice, and regulatory requirements are based (Middleton et al. 2008). These principles are endorsed by the ANCC, who have determined that they support the foundation for excellence in nursing care (McCrae 2012). Kerr et al. (2011) identified that the ownership by nurses for the quality and standard
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of their own practice is a critical element of creating positive practice environments. Literature demonstrates that there is growing momentum among researchers to stress the importance of a nursing model of care delivery as a major principle, which provides structure and empowerment for nurses to rationalize and own the quality of care they provide to their patients (Lake 2002; Roche & Duffield 2010; Wimpenny 2002). While little research appears to have been conducted within mental health settings (Hanrahan & Aiken 2008), the literature has shown that an absence of a nursing model within general health settings has found to contribute to nurses feeling constrained in their work, inhibiting their inability to practice to their full potential (Carlyle et al. 2012; Kerr et al. 2011; McCrae 2012). With research findings proposing that the presence of nursing models are likely to impact on the standards of nursing care and the intention of nurses to remain within the organization (Aiken et al. 2008; Armstrong et al. 2009; Roche et al. 2011), it is important that mental health services consider further exploration in this area when considering factors that influence the practice environment.
Leadership Leadership has been recognized as having a direct influence on the resolution of conflict and staff engagement, behaviour, and performance within any organization (Handy 1999; Samson & Daft 2012). Effective leadership is widely recognized as the facilitator of innovation, and is seen as pivotal to successfully achieving the vision and goals at both individual and organizational level (Stanley 2011). Research conducted in health-care settings consistently support its importance, identifying that effective leadership ‘has a substantial indirect effect on all other elements of the nursing practice environment’, and is seen as the starting point from which to influence others (Leiter & Spence Laschinger 2006; Pretorius & Klopper 2012; Spence Laschinger 2008). Duffield et al. (2009) supports this by suggesting that ‘the effectiveness of strong nursing leadership at ward level to job satisfaction, satisfaction with nursing and intent to leave, cannot be overstated’ (p. 11). A review of the literature further determines that nursing practice environments, which support their staff through visible and accessible leadership and open communication, are instrumental in the perception of empowerment, clarity of roles, and a sense of value by nursing staff (Hansen et al. 2007; Laschinger et al. 2009; Ng 2011; Roche et al. 2011; Van Bogaert et al. 2010). Leadership is seen as a significant predictor for the standard of care delivered by nurses and the level of © 2015 Australian College of Mental Health Nurses Inc.
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commitment they have to the organization (Spence Laschinger 2008). As such, leadership needs to be recognized as an important consideration in the nursing practice environment and a critical factor in planning to address future nursing shortages. Despite this, it is noteworthy that investment in leadership development has not always been considered a priority within the health-care industry, notwithstanding the recognition by leading international corporations that heavy investment in this area is critical to innovation and success (Samson & Daft 2012). Although leadership development has been gaining momentum within the Australian health system, it is evident that the nursing profession will need to channel its efforts into investing in current and future nurse leaders if it is to effectively attract and retain skilled nursing staff. What cannot be argued is that effective leadership is a key driver to the relationship and interaction between the other four elements of the nursing practice environment (Spence Laschinger 2008). By providing clarity of roles and direction for nursing practice, it is considered to be the central factor to the satisfaction nurses feel in their profession (Hansen et al. 2007; Roche et al. 2011), and ultimately their intention to stay.
Staffing and resources The current global economic crisis has placed increased political scrutiny on the use of resources internal and external to the health industry. This has intensified the challenges nurse leaders face in determining and ensuring appropriate numbers and skill mix of nurses to provide safe, quality care at an efficient cost. Policy makers need to be mindful that increased workloads and dissatisfaction of nurses have, in the past, shown to exacerbate nursing shortages at times of growing health costs and reduction in nursing resources (Stone & Tourangeau 2003). To date, studies that have examined the relationship between nurse staffing resources, and nurse and patient outcomes, have predominantly focused on the general health setting, with a paucity of research evident within mental health. It is acknowledged that the roles and responsibilities of a nurse working in a mental health setting differ to that of a general nurse by the very nature of the patients they care for. However, the principles behind the relationship between staffing resources and patient outcomes appear to be inherently similar within both health-care settings, supporting its importance in mental health (Roche & Duffield 2010). When examining the relationship of staffing and resources on the practice environment, it is important to consider the findings by Lake and Friese (2006), which indicate that staffing ratios, levels of nurses’ professional © 2015 Australian College of Mental Health Nurses Inc.
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education, and other elements of the practice environment are intimately entwined. Extensive studies, in both mental health and general health settings, have evidenced that better staffing levels in hospitals, more highlyeducated nurses, and improved practice environments are associated with lower mortality rates, resulting from a more rapid response to the deteriorating patient and decreased failure to rescue (Aiken et al. 2011a; Cheung et al. 2008; Choi et al. 2012; Hanrahan & Aiken 2008; Hinno et al. 2012; Shuldham et al. 2009; Twigg et al. 2011). Studies conducted in the USA by Aiken et al. (2008) clearly identified that these factors have the potential to reduce patient mortality rates by approximately 40 000 deaths per year, reduce staff burnout and stress, and are a significant precursor of intention to leave (Aiken et al. 2008; 2011; Spence Laschinger 2008). More recent studies continue to support the findings that lower nurseto-patient ratios negatively impact on patient mortality, with an increased risk of inpatient deaths, while an increase in nurses with a bachelor degree has been associated with a decrease risk of adverse outcomes (Aiken et al. 2014; Twigg & McCullough 2014). With this in mind, it is essential that nurse leaders employ strategies to provide adequate staffing and skill mix in their nursing workforce to ensure positive patient outcomes and to optimize the retention of staff.
Collegial physician–nurse relationships Magnet Principles support the importance of collegial relationships between physician and nurse, and have recognized it as one of the fundamental criteria for excellence in nursing care and nurses’ satisfaction in their work (Aiken et al. 2011; Buchan 2006; Buchan & Aiken 2008; Happell 2009; Spence Laschinger 2008; Van Bogaert et al. 2010). The importance of collegial physician–nurse relationships is twofold: (i) to promote the confidence of nurses to freely and effectively communicate with physicians in relation to patient care; and (ii) to promote a feeling of value and satisfaction in the care they provide (Van Bogaert et al. 2010). Studies undertaken by Van Bogaert et al. (2010) found that supportive and collegial physician–nurse relationships decreased the depersonalization of nursing staff and promoted a cohesive and constructive team approach to the care of the patient. These supportive relationships are extensively recognized as a key factor affecting the degree of stress and burnout experienced by nurses and their intent to stay (Aiken et al. 2008; 2011b; Van Bogaert et al. 2010). The ability of mental health medical and nursing staff to develop strong working relationships is likely to be of significant importance in Australia, where models of care
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have a strong multidisciplinary approach to care delivery. Roche and Duffield (2010) report that mental health nurses consider that collaborative and collegial relationships and support of their colleagues have a significant influence on their sense of value and job satisfaction (Roche & Duffield 2010). Research also supports a direct link between the effectiveness of the mental health physician–nurse relationship and patient outcomes, particularly in the incidence of threats of violence and seclusion and restraint (Duffield et al. 2009; Roche & Duffield 2010). A review of the literature indicates that over 75% of nurses working in mental health inpatient settings are reported to have experienced violence and aggression from patients, with it being cited as the leading cause of staff-related stress and physical injury (Patient Safety Surveillance Unit 2013; Ward 2013). With clear evidence that the support of nurses by physicians contributes to the empowerment of nursing teams, the creation of a greater capacity for nurses to cope with complex and challenging patient care, and ultimately, the impact on their intent to remain in nursing (Lake & Friese 2006; Manojlovich 2005; Papastavrou et al. 2012; Van Bogaert et al. 2010), the relationship between nurses and physicians is an essential element of the mental health nursing practice environment for nurse leaders to consider.
Participation in hospital affairs The need for individuals to feel secure, needed, and appreciated was identified in 1954 through Maslow’s empirical work, and conceptualized by what is commonly known as Maslow’s Hierarchy of Needs (Benson & Dundis 2003). Through the fulfilment of these needs comes a sense of empowerment and the ability to achieve one’s full potential, or self-actualization. A critical element to attain self-actualization requires the belief by the individual that they have the opportunity to contribute to their environment and that their opinions are seen as important and valuable. It is hardly surprising, therefore, that the ability of nurses to influence decisionmaking in their workplace is seen as an important element of this process and critical to the creation of positive practice environments. The ability for nurses to participate in hospital affairs encompasses a number of components, each seen as an important element of the practice environment (Aiken et al. 2011a; Armstrong et al. 2009; Lake 2002; 2007; Leiter & Spence Laschinger 2006; Roche & Duffield 2010; Roche et al. 2011; Spence Laschinger et al. 2010). These components are considered to promote and foster empowerment in the nursing workforce, and include an
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inclusive commitment to staff participation, prompt responsiveness to concerns, and the opportunity for nurses to have their voices heard (Armstrong et al. 2009; Spence Laschinger 2008; Spence Laschinger et al. 2010). This empowerment is recognized as generating confidence in nurses, enabling them to influence their practice environment, increase their sense of autonomy and perception of control over their practice, and generate an increased sense of accomplishment in their work and commitment to the organization (Middleton et al. 2008; Roche et al. 2011). While seen as critical, there are risks that need to be managed when promoting professional autonomy. Roles and responsibilities must remain within the nurses’ clearly-defined scope of practice, and meet standards of care that will ensure patient safety and positive health outcomes (Hansen et al. 2007; Huntington et al. 2011). Roche and Duffield (2010) support the autonomy of nurses, suggesting that increased participation in hospital decision-making and policy development will strengthen role competency and confidence in the nursing workforce. A feeling of lack of control and autonomy, and the inability to participate in practice and hospital decisionmaking, contribute to decreased nurse satisfaction and retention in general health settings (Leiter & Spence Laschinger 2006; Papastavrou et al. 2012). Studies examining this concept in the mental health setting are minimal (Roche & Duffield 2010). With the consistent argument from researchers that the empowerment, acknowledgement, and value of nurses is intricately linked to the ability to participate in hospital decisionmaking, this is a significant gap for mental health services, which will compromise their competitiveness to attract and retain staff in times of nursing shortages. Further research to understand and enhance nurses’ ability to contribute to the internal governance of mental health services is required.
SUMMARY Mental health nursing is considered to be particularly vulnerable to future nursing shortages, with supply unlikely to meet workforce demand (Health Workforce Australia 2012). Mental health nurse leaders urgently need to identify strategies to improve mental health nurse retention in preparation for future shortages. Failure to do so has the potential to significantly impact on the quality of care delivered to patients and the satisfaction nurses feel in their work. © 2015 Australian College of Mental Health Nurses Inc.
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International research undertaken in general health settings has clearly established the link that strategies, which successfully promote supportive nursing practice environments, have a direct association to lower levels of stress, greater job satisfaction, higher attraction and retention rates, and ultimately, better patient outcomes (Aiken et al. 2008; Choi et al. 2012; Hanrahan et al. 2010; Spence Laschinger 2008). However, a review of the literature has evidenced that, to date, minimal research has been undertaken to determine the effects of these strategies on the mental health practice environment. With future nursing shortages expected to significantly impact on mental health services, and mental health nursing seen as a less attractive career option, further research to bridge this gap needs to occur, and nurse leaders need to urgently explore strategies to create positive mental health practice environments if they are to become the employers of choice in the future. Researchers must also partner with nurse leaders to undertake rigorous review and evaluation of strategies as they evolve.
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R. REDKNAP ET AL. and recommendations. Journal of Psychiatric and Mental Health Nursing, 18 (7), 595–601. Moses, M. M. (1994). Caring incidents: A gift to the present. Journal of Holistic Nursing, 12 (2), 193–203. Nantsupawat, A., Srisuphan, W., Kunaviktikul, W., Wichaikhum, O., Aungsuroch, Y. & Aiken, L. (2011). Impact of nurse work environment and staffing on hospital nurse and quality of care in Thailand. Journal of Nursing Scholarship, 43 (4), 426–432. Ng, L. (2011). Best management practices. Journal of Management Development, 30 (1), 93–105. Norman, I. (2013). The nursing practice environment. International Journal of Nursing Studies, 50, 1577–1579. O’Connor, S. & Vize, C. (2003). The ‘catch-22’ of recruitment and retention in psychiatry. Psychiatric Bulletin, 27 (12), 443–445. Papastavrou, E., Efstathiou, G., Acaroglu, R. et al. (2012). A seven country comparison of nurses’ perceptions of their professional practice environment. Journal of Nursing Management, 20 (2), 236–248. Patient Safety Surveillance Unit (2013). Your Safety in Our Hands in Hospital. An Integrated Approach to Patient Safety Surveillance in WA Hospitals, Health Services and the Community: 2013. Delivering Safer Care Series Report Number 2. Perth: Health Department of Western Australia. Potter, M. & Tinker, S. (2000). Put power in nurses’ hands. Nursing Management, 31 (7), 40–41. Pretorius, R. & Klopper, H. C. (2012). Positive practice environments in critical care units in South Africa. International Nursing Review, 59 (1), 66–72. Roche, M. & Duffield, C. (2010). A comparison of the nursing practice environment in mental health and medical–surgical settings. Journal of Nursing Scholarship, 42 (2), 195–206. Roche, M., Duffield, C. & White, E. (2011). Factors in the practice environment of nurses working in inpatient mental health: A partial least squares path modeling approach. International Journal of Nursing Studies, 48 (12), 1475–1486. Roos, R. H. (1997). Evaluating Treatment Environments: A Social Ecological Approach. New York: Wiley. Rossberg, J. I. & Friis, S. (2004). Patient’s and staff’s perception of the psychiatric ward environment. Psychiatric Services, 55 (7), 798–803. Samson, D. & Daft, R. (2012). Management, 4th edn. Orlando, FL: Dryden Press. Shuldham, C., Parkin, C., Firouzi, A., Roughton, M. & Lau-Walker, M. (2009). The relationship between nurse staffing and patient outcomes: A case study. International Journal of Nursing Studies, 46 (7), 986–992. Spence Laschinger, H. (2008). Effects of empowerment on professional practice environments, work satisfaction, and patient care quality: Further testing the nursing worklife model. Journal of Nursing Care Quality, 23 (4), 322–330. Spence Laschinger, H., Gilbert, S., Smith, L. & Leslie, K. (2010). Towards a comprehensive theory of nurse/patient © 2015 Australian College of Mental Health Nurses Inc.
A STRATEGY FOR MENTAL HEALTH NURSE RETENTION? empowerment: Applying Kanter’s empowerment theory to patient care. Journal of Nursing Management, 18 (1), 4–13. Stanley, D. (2011). Clinical Leadership, Innovation into Action. Melbourne: Palgrave MacMillan. Stone, P. & Tourangeau, A. (2003). Measuring nursing services in patient safety research. Applied Nursing Research, 16 (2), 131–132. The Sainsbury Centre for Mental Health (2005). Acute Care 2004: A national survey of adult psychiatric wards in England. London. Twigg, D. & McCullough, K. (2014). Nurse retention: A review of strategies to create and enhance positive practice environments in clinical settings. International Journal of Nursing Studies, 51 (1), 85–92. Twigg, D., Duffield, C., Bremner, A., Rapley, P. & Finn, J. (2011). The impact of the nursing hours per patient day (NHPPD) staffing method on patient outcomes: A retrospective analysis of patient and staffing data. International Journal of Nursing Studies, 48 (5), 540–548. Unruh, L. & Ning, J. (2013). The role of work environment in keeping newly licensed RNs in nursing: A questionnaire
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survey. International Journal of Nursing Studies, 50 (12), 1678–1688. Van Bogaert, P., Clarke, S., Roelant, E. & Meulemans, H. (2010). Impacts of unit-level nurse practice environment and burnout on nurse-reported outcomes: A multilevel modelling approach. Journal of Clinical Nursing, 19 (11–12), 1664– 1674. Walker, K., Middleton, S., Rolley, J. & Duff, J. (2010). Nurses report a healthy culture: Results of the Practice Environment Scale (Australia) in an Australian hospital seeking Magnet recognition. International Journal of Nursing Practice, 16 (6), 616–623. Ward, L. (2013). Ready, aim, fire! Mental health nurses under siege in acute inpatient facilities. Issues in Mental Health Nursing, 34, 281–287. Warshawsky, N. E. & Havens, D. S. (2011). Global use of the practice environment scale of the nursing work index. Nursing Research, 60 (1), 17–31. Wimpenny, P. (2002). The meaning of models of nursing to practising nurses. Journal of Advanced Nursing, 40 (3), 346– 354.
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doi: 10.1111/inm.12126
Feature Article
Nursing practice environment: A strategy for mental health nurse retention? Robina Redknap,1,2 Di Twigg,1 Daniel Rock3,4,5 and Amanda Towell1 1
School of Nursing and Midwifery, Edith Cowan University, Joondalup, 2Graylands Hospital, North Metropolitan Health Service, Mental Health, 3North Metropolitan Health Service, Mental Health, 4School of Psychiatry and Clinical Neurosciences, and 5School of Population Health, The University of Western Australia, Perth, Western Australia, Australia
ABSTRACT: Historically, mental health services have faced challenges in their ability to attract and retain a competent nursing workforce in the context of an overall nursing shortage. The current economic downturn has provided some respite; however, this is likely to be a temporary reprieve, with significant nursing shortages predicted for the future. Mental health services need to develop strategies to become more competitive if they are to attract and retain skilled nurses and avoid future shortages. Research demonstrates that creating and maintaining a positive nursing practice environment is one such strategy and an important area to consider when addressing nurse retention. This paper examines the impact the nursing practice environment has on nurse retention within the general and mental health settings. Findings indicate, that while there is a wealth of evidence to support the importance of a positive practice environment on nurse retention in the broader health system, there is little evidence specific to mental health. Further research of the mental health practice environment is required. KEY WORDS: mental health, nurse retention, nursing, nursing shortage, practice environment.
INTRODUCTION Mental health nursing has historically been seen as a less attractive career option for nurses. Major advances occurred during the 1950s–1980s, and can be attributed to the rapid expansion in understanding the important influence that nursing practice had on mental health patient outcomes. This understanding primarily evolved through the influence of nurse theorists, such as Travelbee, Peplau, and Orlando. These theorists emphasized the importance of interpersonal relationships in the Correspondence: Robina Redknap, Graylands Hospital, Brockway Road, Mt Claremont, Western Australia 6010, Australia. Email: [email protected] Robina Redknap, RMHN. Di Twigg, PhD MBA, B Hlth Sc (Nsg) Hons, RN, RM, FACN, FACHSM. Daniel Rock, PhD, MN. Amanda Towell, D Cur, M Cur, B Cur (Ed et Adm), DCH, RCCN, RN. Accepted December 2014.
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development of compassionate and caring therapeutic nurse–patient relationships; integrating nursing theory into practice; and the ability for nurses to use their perception, thoughts, and feelings in the identification of patient needs (McCarthy & Aquino-Russell 2009; Moses 1994; Potter & Tinker 2000). This had a dramatic effect on mental health nursing practice, and resulted in greater recognition for the therapeutic influence that mental health nurses have in ensuring positive patient outcomes and a reduction in the medical dominance and servility of mental health nurses (Hayman-White et al. 2007; Holmes 2002; The Sainsbury Centre for Mental Health 2005). However, the attraction and retention of nurses by mental health services continued to be problematic (Happell 2009). Patients and staff continue to hold different perceptions of the ward environment, with different factors influencing the satisfaction they feel (Friis 1986; Roos 1997; Rossberg & Friis 2004). This has left today’s mental health nurse leaders with significant challenges to
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attract and retain a mental health nursing workforce essential to delivering quality nursing care. This is of significant concern, as nursing workforce shortages are predicted for the future across most developed countries. Global nursing shortages have been acknowledged as a significant issue (Happell 2009), and are not considered a new phenomenon. In the past, international nursing shortages have had a significant impact on the Australian nursing workforce, with demand outstripping supply. The global shortage of nurses in future is once again likely to have a significant impact on Australia, with the population demand for nurses in Australia predicated to outstrip supply by 6.3%, or 20 079 nurses in 2016, increasing to 28% or 109 490 nurses in 2025 (Health Workforce Australia 2012). Mental health has been identified as one of the areas that will be most affected (Health Workforce Australia 2012), thereby leaving mental health nursing particularly vulnerable when competing for the limited available workforce. Added to this, mental health nursing is faced with a double disadvantage. The first disadvantage can be attributed to the secondary stigma associated with working within mental health services, despite the implementation of stigma-reduction strategies (Australian Health Workforce Advisory Committee 2003). Second, the expectation that a large proportion of the workforce is likely to retire within the next 10–15 years, with 61.1% of the mental health nursing workforce over the age of 45 years, and 27.2% over 55 years (Australian Institute of Health and Welfare 2012), exacerbating the already existing shortage of nurses within mental health. As private health providers re-enter the market of mental health-care provision and new contemporary services are established, these issues are likely to compound the difficulties traditional services face, particularly in the public sector, to compete for the smaller pool of nurses who choose mental health as a career. A review of the literature has determined that a major contributing factor to general nursing shortages appears to be related to nurses unwilling to work in certain practice environments, rather than a lack of qualified staff (Buchan 2000; 2006; Buchan & Aiken 2008). It is acknowledged that the practice environment has the ability to influence employee job satisfaction, regardless of the industry in which they work (Samson & Daft 2012). The importance of a positive practice environment is further supported by work undertaken by the American Nurses’ Credentialing Centre (ANCC) during the 1970– 1980 nursing shortages. The ANCC developed a set of criteria known as the Magnet Principles or the Forces of Magnetism (Gaguski 2006). These criteria were considered characteristics of hospitals that were able to attract © 2015 Australian College of Mental Health Nurses Inc.
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and retain nurses, despite shortages. These criteria reflect what researchers consider to be the critical elements of a positive practice environment, including effective leadership, collegial support, and access to professional and career development opportunities (Aiken et al. 2011a; Buchan 2006; Buchan & Aiken 2008; Happell 2009; Norman 2013; Spence Laschinger 2008; Van Bogaert et al. 2010). Within general nursing, there has been a lot of work undertaken that demonstrates that improving the practice environment is an important factor and can have a significant impact on the attraction and retention of staff (Aiken et al. 2008; Hanrahan et al. 2010; Spence Laschinger 2008; Twigg & McCullough 2014). In comparison, a review of the literature has revealed a paucity of studies undertaken in mental health. Researchers have identified that a number of factors, such as stigma, perceived workload, containing clinical risk, and the lack of investment in mental health resources, contributes to the challenges in attracting and retaining a skilled mental health workforce (Brown et al. 2007; Morrissette 2011; O’Connor & Vize 2003). However, further research is needed within mental health on the nursing practice environment, to assess its impact on mental health nurse retention. The aim of this paper was to provide a review of the literature, which has examined the association between the nursing practice environment and retention of nurses, both in general and mental health settings. This will assist in providing mental health nurse leaders a greater understanding of the significance of creating and maintaining positive nursing practice environments as a nurseretention strategy.
METHOD A combined search of the following databases – CINAHL Plus with full text, Medline, PsycARTICLES, PsycBOOKS, PsycINFO, and Embase – was undertaken from February 2013 to June 2014. Google Scholar and Western Australian and Commonwealth Health Department websites were accessed to retrieve health policy documents and reports that had relevance to the study topic. The search was limited to English language articles published from 1990 to 2013. Search terms related to the study topic were used (Fig. 1). The initial search found 17 287 articles. A Boolean and truncated search method was used to further refine the initial search. This search method allows the researcher to search for keywords in both their singular and plural forms. By entering ‘operators’, such as ‘and’ or ‘not’, the researcher is able to narrow
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Search conducted February 2013–June 2014
Database CINHAL, full-text Medline Psychlnfo PsycARTICLES, PsycBOOKS Embase
Initial search terms S1: Mental health nurs* S2: Global nurs* shortage* S3: Nurs* practice environment S4: Nursing leadership S5: Foundation* of nurs* care S6: Standard* of nurs* care
Refined search (boolean and truncated search) S9: S3 and mental health nurs* S10: S3 and patient outcome* S11: S3 and nurs* outcome* S12: S3 and quality care S13: S2 S14: S5
Total retrieved: 17 287 Total retrieved: 284
Abstract review for inclusion criteria English language, peer reviewed, related to the mental health or general health nursing-practice environment and articles, which linked the nursing practice environment and nurse-retention strategies Total retrieved: 47 FIG. 1: Literature search methodology.
a search by retrieving documents that contain the combined specified words. The revised search retrieved 284 articles. The abstract of each article was reviewed to assess relevance to the study. The inclusion criteria for this review was limited to articles that were written in the English language, peer reviewed, related to the mental health or general health nursing practice environment,
and articles that linked the nursing practice environment with nurse-retention strategies. Where required, the full article was reviewed to determine relevance. A total of 49 journal articles were selected for this review. In addition, relevant texts, reports, and Australian state and territories’ and Commonwealth Health Department policy documents and reports identified through the search or from the knowledge of the researcher were also reviewed. © 2015 Australian College of Mental Health Nurses Inc.
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Foundations for quality nursing care Nursing philosophy Role definition Culture of learning
Nursing-practice environment
Collegial physician/nurse relationships Cohesive teamwork Increased confidence Decrease depersonalisation
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Leadership Support and direction Empowerment Innovation
Staffing and resources Adequate staff Appropriate skill mix Adequate support
Participation in hospital affairs Professional autonomy Control over practice Empowerment
FIG. 2: Elements of the nursing practice environment.
NURSING PRACTICE ENVIRONMENT The nursing practice environment is a ‘complex construct to conceptualize and measure’ (Lake 2002), but remains a critical factor in the ability of organizations to attract and retain nursing staff and optimize patient outcomes (Aiken et al. 2011B). The practice environment comprises of factors within an organization, which have a psychological impact on staff and affect the quality and safety of care delivered to patients. These factors include perceived collegial support, leadership, and access to professional and career development opportunities (Norman 2013). The Practice Environment Scale of the Nursing Work Index (PES-NWI) is considered the most useful and reliable instrument to measure the climate of the practice environment (Aiken et al. 2011B; Lake 2007; Twigg & McCullough 2014; Warshawsky & Havens 2011). The PES-NWI was derived by Lake from the original NWI and was constructed from research on hospitals that had successfully attracted and retained nurses during the nursing shortages in the early 1980s (Lake 2002). The PES-NWI has been used in studies at © 2015 Australian College of Mental Health Nurses Inc.
least 37 times between 2002 and 2010, with results published in 23 peer-reviewed international journals (Twigg & McCullough 2014; Warshawsky & Havens 2011). The PES-NWI identifies five key elements as critical areas in the practice environment that link directly to a positive psychological impact on staff: (i) foundations of nursing; (ii) leadership; (iii) staffing and resources; (iv) collegial nurse–physician relationships; and (v) participation in hospital affairs (Aiken et al. 2011b; Buchan 2006; Buchan & Aiken 2008; Happell 2009; Spence Laschinger 2008; Van Bogaert et al. 2010). Aiken et al. (2011b) identified that each of these elements independently contributes to nurse and patient outcomes, supporting that if they are improved collectively, they create the ability for services to achieve high standards of quality patient care, increase staff satisfaction, and reduce intention to leave (Fig. 2). Nursing practice environments that have varying sample size and within considerably differing health-care systems have been extensively studied at an international level. While a number of differing factors have been
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identified as contributing to the climate of the practice environment, many of these studies conclude that the critical elements of the practice environment have distinct similarities worldwide, with a strong link to increased retention rates, decreased burnout in staff, and adverse patient outcomes (Aiken et al. 2011; Hinno et al. 2012; Nantsupawat et al. 2011; Papastavrou et al. 2012; Spence Laschinger 2008; Walker et al. 2010). Studies have found that negative perceptions of the practice environment are predictors of disengagement by nurses with their profession and intent to leave (Unruh & Ning 2013). The majority of these studies have been conducted within general health settings, with Roche and Duffield (2010) identifying that of those that have been undertaken, few have been within mental health-care settings. This has resulted in minimal guidance to mental health nurse leaders to promote positive practice environments within their health services. In Australia, there has been increased focus on promoting mental health nursing as an attractive career option in the hope that workforce shortages could be addressed (Australian Health Workforce Advisory Committee 2003). However, it is becoming increasingly evident that while such strategies might have had some success in attracting nurses, they have had little effect on the long-term retention rates (Hinno et al. 2012), resulting in the need to explore alternative attraction and retention initiatives. With a review of the literature demonstrating that the practice environment is the basis of nurses’ satisfaction and their intention to leave in general settings (Aiken et al. 2008; Choi et al. 2012; Hanrahan et al. 2010; Spence Laschinger 2008), this becomes an important area for mental health nurse leaders to explore. The need for further research to be undertaken to understand the influence and benefits that each of the five elements of a positive practice environment has on retention of mental health nurses has never been more important, particularly as these nurses are reported to evaluate their environments more negatively than nurses in other specialties (Hanrahan & Aiken 2008).
Foundations for quality nursing care The principles of the foundation for quality nursing care form the building blocks of the nursing profession on which nursing standards, ethical practice, and regulatory requirements are based (Middleton et al. 2008). These principles are endorsed by the ANCC, who have determined that they support the foundation for excellence in nursing care (McCrae 2012). Kerr et al. (2011) identified that the ownership by nurses for the quality and standard
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of their own practice is a critical element of creating positive practice environments. Literature demonstrates that there is growing momentum among researchers to stress the importance of a nursing model of care delivery as a major principle, which provides structure and empowerment for nurses to rationalize and own the quality of care they provide to their patients (Lake 2002; Roche & Duffield 2010; Wimpenny 2002). While little research appears to have been conducted within mental health settings (Hanrahan & Aiken 2008), the literature has shown that an absence of a nursing model within general health settings has found to contribute to nurses feeling constrained in their work, inhibiting their inability to practice to their full potential (Carlyle et al. 2012; Kerr et al. 2011; McCrae 2012). With research findings proposing that the presence of nursing models are likely to impact on the standards of nursing care and the intention of nurses to remain within the organization (Aiken et al. 2008; Armstrong et al. 2009; Roche et al. 2011), it is important that mental health services consider further exploration in this area when considering factors that influence the practice environment.
Leadership Leadership has been recognized as having a direct influence on the resolution of conflict and staff engagement, behaviour, and performance within any organization (Handy 1999; Samson & Daft 2012). Effective leadership is widely recognized as the facilitator of innovation, and is seen as pivotal to successfully achieving the vision and goals at both individual and organizational level (Stanley 2011). Research conducted in health-care settings consistently support its importance, identifying that effective leadership ‘has a substantial indirect effect on all other elements of the nursing practice environment’, and is seen as the starting point from which to influence others (Leiter & Spence Laschinger 2006; Pretorius & Klopper 2012; Spence Laschinger 2008). Duffield et al. (2009) supports this by suggesting that ‘the effectiveness of strong nursing leadership at ward level to job satisfaction, satisfaction with nursing and intent to leave, cannot be overstated’ (p. 11). A review of the literature further determines that nursing practice environments, which support their staff through visible and accessible leadership and open communication, are instrumental in the perception of empowerment, clarity of roles, and a sense of value by nursing staff (Hansen et al. 2007; Laschinger et al. 2009; Ng 2011; Roche et al. 2011; Van Bogaert et al. 2010). Leadership is seen as a significant predictor for the standard of care delivered by nurses and the level of © 2015 Australian College of Mental Health Nurses Inc.
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commitment they have to the organization (Spence Laschinger 2008). As such, leadership needs to be recognized as an important consideration in the nursing practice environment and a critical factor in planning to address future nursing shortages. Despite this, it is noteworthy that investment in leadership development has not always been considered a priority within the health-care industry, notwithstanding the recognition by leading international corporations that heavy investment in this area is critical to innovation and success (Samson & Daft 2012). Although leadership development has been gaining momentum within the Australian health system, it is evident that the nursing profession will need to channel its efforts into investing in current and future nurse leaders if it is to effectively attract and retain skilled nursing staff. What cannot be argued is that effective leadership is a key driver to the relationship and interaction between the other four elements of the nursing practice environment (Spence Laschinger 2008). By providing clarity of roles and direction for nursing practice, it is considered to be the central factor to the satisfaction nurses feel in their profession (Hansen et al. 2007; Roche et al. 2011), and ultimately their intention to stay.
Staffing and resources The current global economic crisis has placed increased political scrutiny on the use of resources internal and external to the health industry. This has intensified the challenges nurse leaders face in determining and ensuring appropriate numbers and skill mix of nurses to provide safe, quality care at an efficient cost. Policy makers need to be mindful that increased workloads and dissatisfaction of nurses have, in the past, shown to exacerbate nursing shortages at times of growing health costs and reduction in nursing resources (Stone & Tourangeau 2003). To date, studies that have examined the relationship between nurse staffing resources, and nurse and patient outcomes, have predominantly focused on the general health setting, with a paucity of research evident within mental health. It is acknowledged that the roles and responsibilities of a nurse working in a mental health setting differ to that of a general nurse by the very nature of the patients they care for. However, the principles behind the relationship between staffing resources and patient outcomes appear to be inherently similar within both health-care settings, supporting its importance in mental health (Roche & Duffield 2010). When examining the relationship of staffing and resources on the practice environment, it is important to consider the findings by Lake and Friese (2006), which indicate that staffing ratios, levels of nurses’ professional © 2015 Australian College of Mental Health Nurses Inc.
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education, and other elements of the practice environment are intimately entwined. Extensive studies, in both mental health and general health settings, have evidenced that better staffing levels in hospitals, more highlyeducated nurses, and improved practice environments are associated with lower mortality rates, resulting from a more rapid response to the deteriorating patient and decreased failure to rescue (Aiken et al. 2011a; Cheung et al. 2008; Choi et al. 2012; Hanrahan & Aiken 2008; Hinno et al. 2012; Shuldham et al. 2009; Twigg et al. 2011). Studies conducted in the USA by Aiken et al. (2008) clearly identified that these factors have the potential to reduce patient mortality rates by approximately 40 000 deaths per year, reduce staff burnout and stress, and are a significant precursor of intention to leave (Aiken et al. 2008; 2011; Spence Laschinger 2008). More recent studies continue to support the findings that lower nurseto-patient ratios negatively impact on patient mortality, with an increased risk of inpatient deaths, while an increase in nurses with a bachelor degree has been associated with a decrease risk of adverse outcomes (Aiken et al. 2014; Twigg & McCullough 2014). With this in mind, it is essential that nurse leaders employ strategies to provide adequate staffing and skill mix in their nursing workforce to ensure positive patient outcomes and to optimize the retention of staff.
Collegial physician–nurse relationships Magnet Principles support the importance of collegial relationships between physician and nurse, and have recognized it as one of the fundamental criteria for excellence in nursing care and nurses’ satisfaction in their work (Aiken et al. 2011; Buchan 2006; Buchan & Aiken 2008; Happell 2009; Spence Laschinger 2008; Van Bogaert et al. 2010). The importance of collegial physician–nurse relationships is twofold: (i) to promote the confidence of nurses to freely and effectively communicate with physicians in relation to patient care; and (ii) to promote a feeling of value and satisfaction in the care they provide (Van Bogaert et al. 2010). Studies undertaken by Van Bogaert et al. (2010) found that supportive and collegial physician–nurse relationships decreased the depersonalization of nursing staff and promoted a cohesive and constructive team approach to the care of the patient. These supportive relationships are extensively recognized as a key factor affecting the degree of stress and burnout experienced by nurses and their intent to stay (Aiken et al. 2008; 2011b; Van Bogaert et al. 2010). The ability of mental health medical and nursing staff to develop strong working relationships is likely to be of significant importance in Australia, where models of care
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have a strong multidisciplinary approach to care delivery. Roche and Duffield (2010) report that mental health nurses consider that collaborative and collegial relationships and support of their colleagues have a significant influence on their sense of value and job satisfaction (Roche & Duffield 2010). Research also supports a direct link between the effectiveness of the mental health physician–nurse relationship and patient outcomes, particularly in the incidence of threats of violence and seclusion and restraint (Duffield et al. 2009; Roche & Duffield 2010). A review of the literature indicates that over 75% of nurses working in mental health inpatient settings are reported to have experienced violence and aggression from patients, with it being cited as the leading cause of staff-related stress and physical injury (Patient Safety Surveillance Unit 2013; Ward 2013). With clear evidence that the support of nurses by physicians contributes to the empowerment of nursing teams, the creation of a greater capacity for nurses to cope with complex and challenging patient care, and ultimately, the impact on their intent to remain in nursing (Lake & Friese 2006; Manojlovich 2005; Papastavrou et al. 2012; Van Bogaert et al. 2010), the relationship between nurses and physicians is an essential element of the mental health nursing practice environment for nurse leaders to consider.
Participation in hospital affairs The need for individuals to feel secure, needed, and appreciated was identified in 1954 through Maslow’s empirical work, and conceptualized by what is commonly known as Maslow’s Hierarchy of Needs (Benson & Dundis 2003). Through the fulfilment of these needs comes a sense of empowerment and the ability to achieve one’s full potential, or self-actualization. A critical element to attain self-actualization requires the belief by the individual that they have the opportunity to contribute to their environment and that their opinions are seen as important and valuable. It is hardly surprising, therefore, that the ability of nurses to influence decisionmaking in their workplace is seen as an important element of this process and critical to the creation of positive practice environments. The ability for nurses to participate in hospital affairs encompasses a number of components, each seen as an important element of the practice environment (Aiken et al. 2011a; Armstrong et al. 2009; Lake 2002; 2007; Leiter & Spence Laschinger 2006; Roche & Duffield 2010; Roche et al. 2011; Spence Laschinger et al. 2010). These components are considered to promote and foster empowerment in the nursing workforce, and include an
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inclusive commitment to staff participation, prompt responsiveness to concerns, and the opportunity for nurses to have their voices heard (Armstrong et al. 2009; Spence Laschinger 2008; Spence Laschinger et al. 2010). This empowerment is recognized as generating confidence in nurses, enabling them to influence their practice environment, increase their sense of autonomy and perception of control over their practice, and generate an increased sense of accomplishment in their work and commitment to the organization (Middleton et al. 2008; Roche et al. 2011). While seen as critical, there are risks that need to be managed when promoting professional autonomy. Roles and responsibilities must remain within the nurses’ clearly-defined scope of practice, and meet standards of care that will ensure patient safety and positive health outcomes (Hansen et al. 2007; Huntington et al. 2011). Roche and Duffield (2010) support the autonomy of nurses, suggesting that increased participation in hospital decision-making and policy development will strengthen role competency and confidence in the nursing workforce. A feeling of lack of control and autonomy, and the inability to participate in practice and hospital decisionmaking, contribute to decreased nurse satisfaction and retention in general health settings (Leiter & Spence Laschinger 2006; Papastavrou et al. 2012). Studies examining this concept in the mental health setting are minimal (Roche & Duffield 2010). With the consistent argument from researchers that the empowerment, acknowledgement, and value of nurses is intricately linked to the ability to participate in hospital decisionmaking, this is a significant gap for mental health services, which will compromise their competitiveness to attract and retain staff in times of nursing shortages. Further research to understand and enhance nurses’ ability to contribute to the internal governance of mental health services is required.
SUMMARY Mental health nursing is considered to be particularly vulnerable to future nursing shortages, with supply unlikely to meet workforce demand (Health Workforce Australia 2012). Mental health nurse leaders urgently need to identify strategies to improve mental health nurse retention in preparation for future shortages. Failure to do so has the potential to significantly impact on the quality of care delivered to patients and the satisfaction nurses feel in their work. © 2015 Australian College of Mental Health Nurses Inc.
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International research undertaken in general health settings has clearly established the link that strategies, which successfully promote supportive nursing practice environments, have a direct association to lower levels of stress, greater job satisfaction, higher attraction and retention rates, and ultimately, better patient outcomes (Aiken et al. 2008; Choi et al. 2012; Hanrahan et al. 2010; Spence Laschinger 2008). However, a review of the literature has evidenced that, to date, minimal research has been undertaken to determine the effects of these strategies on the mental health practice environment. With future nursing shortages expected to significantly impact on mental health services, and mental health nursing seen as a less attractive career option, further research to bridge this gap needs to occur, and nurse leaders need to urgently explore strategies to create positive mental health practice environments if they are to become the employers of choice in the future. Researchers must also partner with nurse leaders to undertake rigorous review and evaluation of strategies as they evolve.
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