Journal of Psychiatric and Mental Health Nursing, 2013, 20, 679686

Work engagement supports nurse workforce stability

and quality of care: nursing team-level analysis in
psychiatric hospitals
P. V A N B O G A E R T 1 , 3 r n m s p h d , K . W O U T E R S 4 m s p h d , R . W I L L E M S 5 r n m s ,
M . M O N D E L A E R S 2,6 r n m s & S . C L A R K E 7 r n p h d f a a n
1

Professor, 2Lecturer, Division of Nursing and Midwifery Science, Antwerp University, Wilrijk, 3Researcher,
Department of Nursing, Antwerp University Hospital, 4Statistician, Department of Scientific Coordination,
University Hospital Antwerp, Edegem, 5Clinical Nurse Specialist, 6Director of Nursing, Public Psychiatric Hospital
Geel, Geel, Belgium, and 7Professor, Royal Bank of Canada Chair in Cardiovascular Nursing Research, Lawrence
S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada

Keywords: job satisfaction, multilevel

modelling, psychiatric inpatient care,
quality of care, turnover intentions,
work engagement
Correspondence:
P. Van Bogaert
Division of Nursing and Midwifery
Science
Antwerp University
Universiteitsplein 1

Accessible summary

B-2610 Wilrijk
Belgium
E-mail: peter.vanbogaert@ua.ac.be
There is no conflict of interest.
Accepted for publication: 16 August
2012
doi: 10.1111/jpm.12004

2012 John Wiley & Sons Ltd

Burnout and work engagement are two sides of one coin, two opposite poles
related not only to how workers personally experience their jobs but also to how
they experience their jobs within the context of work teams/groups.
Engaged workers have a lot of energy, are very enthusiastic about their jobs and
are absorbed by their work.
Nurses job performance in hospitals, including psychiatric hospitals, is dependent
upon their relationships with physicians and other healthcare workers and their
superiors, how they are involved in the decisions about their work and whether or
not they are provided with the right resources and adequate support.
When nursing teams are able to perform well, nurses tend to be more engaged and
satisfied with their jobs and are more willing to stay in their positions.
Engaged nursing teams report better quality of patient care in psychiatric hospitals.

Abstract
Research in healthcare settings reveals important links between work environment
factors, burnout and organizational outcomes. Recently, research focuses on work
engagement, the opposite (positive) pole from burnout. The current study investigated
the relationship of nurse practice environment aspects and work engagement (vigour,
dedication and absorption) to job outcomes and nurse-reported quality of care
variables within teams using a multilevel design in psychiatric inpatient settings.
Validated survey instruments were used in a cross-sectional design. Team-level analyses were performed with staff members (n = 357) from 32 clinical units in two
psychiatric hospitals in Belgium. Favourable nurse practice environment aspects were
associated with work engagement dimensions, and in turn work engagement was
associated with job satisfaction, intention to stay in the profession and favourable
nurse-reported quality of care variables. The strongest multivariate models suggested
that dedication predicted positive job outcomes whereas nurse management predicted
perceptions of quality of care. In addition, reports of quality of care by the interdisciplinary team were predicted by dedication, absorption, nursephysician relations
and nurse management. The study findings suggest that differences in vigour, dedication and absorption across teams associated with practice environment characteristics
impact nurse job satisfaction, intention to stay and perceptions of quality of care.

679

P. Van Bogaert et al.

Introduction
The impact of nurse burnout on instability of the nurse
workforce such as job dissatisfaction and turnover intentions as well on the quality and safety of patient care has
been studied intensively and thoroughly by researchers
internationally, albeit mainly in acute hospital settings
(Tourangeau et al. 2005, Laschinger & Leiter 2006,
Gunnarsdttir et al. 2007, Aiken et al. 2008, 2011, Friese
et al. 2008, Schubert et al. 2009). Recently, comparable
studies of mental healthcare workers (e.g. nurses, social
workers and clinicians) in community and inpatient facilities have begun to appear (Priebe et al. 2005, Richards et al.
2006, Bowers et al. 2009, 2011, Laslavia et al. 2009, Paris
& Hoge 2010). Another trend in this literature has been to
examine the impact and importance of work engagement
(burnouts positive twin) on nurse workforce and patient
outcomes (Freeney & Tiernan 2009, Laschinger et al. 2009,
Simpson 2009, Abdelhadi & Drach-Zahavy 2011).
However, the body of findings regarding burnout is considerably more developed (Maslach & Leiter 2008). Understandings of work engagement, described as a state in
workers characterized by high levels of energy and enthusiastic involvement in work, are still emerging (Bakker et al.
2011a). In order to provide services that respond to evolving
demands in health care and especially in mental health care,
healthcare organizations must foster a skilled nurse workforce by creating supportive work environments
(Laschinger & Leiter 2006, Laschinger et al. 2009, Van
Bogaert et al. 2009b). Therefore, attention to work environment features that affect to positive job experiences (such as
engagement) as well as negative ones (such as burnout) is
critical for achieving high-quality and safe patient care.
The theoretical basis for and structure of the construct of
work engagement were partially derived from research on
burnout (Maslach 2011, Schaufeli & Salanova 2011). Work
engagement is a combination of the capability to work
(energy, vigour) and the willingness to work (involvement,
dedication). Bakker et al. (2011b) argue that both burnout
and work engagement are important to the definition and
modelling of work-related well-being and that they are two
sides of the same coin. Burnout has been widely measured by
the three-construct Maslach Burnout Inventory (MBI) with
emotional exhaustion, depersonalization and personal
accomplishment. Schaufeli & Bakker (2003) developed
recently the three-construct Utrecht Work Engagement Scale
(UWES) measuring vigour, dedication and absorption. Two
of the three core dimensions in both measurement instruments are direct opposite poles of each other: emotional
exhaustionvigour and depersonalizationdedication.
A study analysing the association between nurses individual characteristics, job features and work engagement
680

(n = 412) found that job satisfaction, quality of working

life, lower social dysfunction and lower stress associated
with patient care predicted vigour and dedication. The
authors suggested that organizational strategies to reduce
stress associated with patient care and to improve social
and communication skills might enhance nurses vigour
and dedication (Jenaro et al. 2011). Another study (n = 508
nurses) showed positive associations between nurses role
stress and feelings of burnout as well as negative associations on work engagement after controlling for personal
resources (optimism, hardy personality and emotional
competence) and social and demographic variables
(Garrosa et al. 2011). Both these studies are consistent with
Bakker et al. (2011b) hypothesis that when employees perceive that their organizations provide a supportive, involving and challenging climate that accommodates their
psychological needs, they are more likely to be engaged.
The authors argue that work environments can facilitate
climates for engagement and in addition can be interpreted
as collective engagement (Schaufeli & Salanova 2011).
Here, collective engagement refers to the combined or
aggregated engagement of the team/group (team vigour,
team dedication and team absorption) as perceived by individual employees. A nested cross-sectional study of 158
nurses working in 40 long-term care wards showed a mediating role of work engagement between work climate and
patient-centred care (Abdelhadi & Drach-Zahavy 2011).
Investigating 136 acute psychiatric wards in 26 National
Health Service Trusts in England, Bowers et al. (2011) concluded that the overall performance of staff teams was
associated with leadership, teamwork, structure, burnout
and attitude to patients at the ward level. A recent multilevel study showed team-level associations between nurse
practice environment and the three-construct burnout
measures of emotional exhaustion, depersonalization and
personal accomplishment with job satisfaction, turnover
intentions and nurse-assessed quality of care variables. The
study design was originally tested in an acute care data set
of 42 nursing teams and 546 participants (Van Bogaert
et al. 2010) and replicated with a psychiatric care sample
of 32 nursing teams and 357 participants (Van Bogaert
et al. 2012a).
The aim of this study was to investigate the impact of
nurse practice environment aspects and work engagement
on job outcome and nurse-assessed quality of care variables
across teams in psychiatric inpatient settings using a multilevel design.

Method
The analyses described here are part of a larger project
investigating the impact of practice environment and work 2012 John Wiley & Sons Ltd

Nurse team-level work engagement

load on job outcomes and quality of care in acute care

hospitals and psychiatric hospitals studying associations
between nurse practice environments, staff well-being, job
outcome and assessed quality of care variables measured
using cross-sectional surveys.

Participants
Staff surveys were conducted in two public psychiatric
hospitals with approximately 400 beds in different areas of
Flanders, the Dutch-speaking region of Belgium. During a
5-month period between December 2010 and April 2011,
members of 34 nursing teams including acute care, chronic
care, geriatric care and child and adolescent care units
were invited voluntarily to complete the questionnaire. A
response rate of more than 70% was reached for both
hospitals (n = 163 and 194 respondents) for a study sample
of 357 registered nurses (57.5%), licensed practical nurses
(20.6%) and non-registered caregivers (10.6%). A substantial proportion of non-registered caregivers [described by
Sorgaard et al. (2010) as care personnel who are not psychiatrists, psychologists, social workers, or nurses and who
hold a credential lower than a masters degree] assigned to
clinical teams and delivering high proportion of direct
contact with patients were also invited to participate.
Responses from two nursing teams with particularly low
response rates (17% and 22%) were dropped from the
analysis (Van Bogaert et al. 2010). The response rate of the
included teams ranged from 37% to 100% (mean 68%).
The ethics review committees of the two hospitals
approved this study.

Measures
Demographic characteristics of the respondents including
age, gender, years in nursing and present unit, qualification
and work schedule were collected and analysed at team/
unit level. Unit-level means are shown in Table 1.
The questionnaire was composed of previously validated measures of nurse practice environment, workload,
work engagement, job outcomes and nurse-assessed quality
of care (Van Bogaert et al. 2009a,b, 2010). All measures
have been thoroughly examined in the current study
sample with exploratory and confirmatory factor analyses
as well as assessment of subscale internal consistency
(Van Bogaert et al. 2012b,c).
Nurse practice environment features were measured
with a translated and validated version of the Revised
Nursing Work Index (NWI-R-vl) that includes three dimensions: nursephysician relations (three items), unit-level
nurse management (13 items) and hospital management
organizational support (15 items) (Van Bogaert et al.
2012 John Wiley & Sons Ltd

Table 1
Characteristics of the nursing units (n = 32)
Mean
Nursephysician relations (mean)
Nurse management at the unit
level (mean)
Hospital management &
organizational support (mean)
Nurse-perceived workload (mean)
Vigour (mean)
Dedication (mean)
Absorption (mean)
Job satisfaction (%)
Intention to stay nursing (%)
Quality of care at the unit
(goodexcellent) (%)
Quality of care at the last shift
(goodexcellent) (%)
Quality of care of the
interdisciplinary team
(goodexcellent) (%)

SD

p25

p75

2.74
2.88

0.30
0.20

2.56
2.77

2.91
3.02

2.51

0.15

2.41

2.61

2.32
4.67
5.01
4.41
88.9
92.3
82.8

0.34
0.38
0.37
0.41
9.3
8.7
17.2

2.04
4.51
4.81
4.01
84.6
86.2
67.3

2.59
4.94
5.28
4.71
94.3
100.0
100.0

90.8

10.4

82.2

100.0

69.0

24.3

45.8

90.6

2009a). Respondents are asked to indicate their agreement

that various positive work environment features exist in
their current positions on a 4-point Likert-type scale from
strongly disagree to strongly agree. Extensive work with
the tool originally described (Aiken & Patrician 2000, Lake
2002) in international studies has identified a variety of
subscales (Estabrooks et al. 2002, Choi et al. 2004,
Gunnarsdttir et al. 2007, Li et al. 2007, Schubert et al.
2007) with similar thematic content to those originally
described and confirmed by a number of North American
authors (Tourangeau et al. 2005, Laschinger & Leiter
2006, Aiken et al. 2008, Friese et al. 2008). Nurse practice
environment dimensions measured using the NWI show
consistent associations with various nurse and patient outcomes such as job satisfaction, turnover intentions and
quality and safety of care variables in studies principally
involving registered nurses in acute care settings.
Workload was measured with an intensity of labour
(Richter et al. 2000) questionnaire consisting of six statements rated using 4-point Likert-type scales (from strongly
disagree to strongly agree). Several studies showed the
impact of high workload on feelings of emotional exhaustion (Maslach & Leiter 2009, Kowalski et al. 2010).
Work engagement was measured with a shortened nineitem version of the UWES (Schaufeli et al. 2006). The
UWES measures work engagement as a unitary construct
as well as three different yet closely related subconstructs:
vigour (e.g. At my work, I feel bursting with energy; When
I get up in the morning, I feel like going to work), dedication (e.g. I am enthusiastic about my job; I am proud of the
work that I do) and absorption (e.g. I feel happy when I am
working intensely; I get carried away when Im working).
681

P. Van Bogaert et al.

Respondents rated statements on a 7-point frequency scale

ranging from never to always. The three-construct structure of UWES seems to be consistent across nations, occupational groups as well as over time (Schaufeli & Bakker
2010). Its factor structure was confirmed in the current
study population (Van Bogaert et al. 2012c).
Two single-item job outcome variables were measured:
satisfaction with the current job (very dissatisfied, dissatisfied, satisfied, very satisfied) and intention to stay the profession over the next year (yes, no). Three single-item
nurse-reported quality of care variables were included:
quality of care on the unit, during the last shift and by the
interdisciplinary team (poor, fair, good, excellent). Both
sets of variables were used in previous studies examining
associations between work environment and burnout (Van
Bogaert et al. 2009a,b, 2010). Higher scores on all measures indicate stronger agreement or more favourable
ratings except for the intensity of labour scale, where
higher scores represent more unfavourable ratings.

Data analysis
Descriptive analyses were initially conducted. Unit mean
value of vigour, dedication and absorption was compared
with mean values of a study sample of various occupational
groups (n = 9679) used for validation of the measurement
instrument (Schaufeli & Bakker 2003). To examine the
unit-level effect of nurse practice environment, work
engagement on job outcome and nurse-reported quality of
care variables multilevel modelling was used. Consistent
with theoretical work and prior empirical findings, nurse
practice environment dimensions were treated as independent variables, and work engagement dimensions and nurseperceived workload were treated as potentially dependent
on practice environment dimensions and also potentially
predictive of study outcome variables (Maslach et al. 1996,
Schaufeli & Bakker 2004, Laschinger & Leiter 2006,
Maslach & Leiter 2009, Van Bogaert et al. 2010). Conventional regression analyses ignore the correlated structure of
the observations on clustered data because they underestimate standard errors and increase the likelihood of type I
error, while a two-level model incorporating a nested structure of staff members with nursing units corrects for the
dependency of observations. Therefore, the effects of independent variables on dependent variables were tested with
two-level linear mixed-effects models with a random intercept: level 1 involved variables related to the staff members
on a given nursing unit and level 2 involved variables
related to the nursing unit (Fitzmaurice et al. 2004, Park &
Lake 2006, Van Bogaert et al. 2010). For continuous and
discrete dependent variables, linear mixed-effects models
and generalized linear mixed-effects models were fitted,
682

respectively. To determine the best predictive models, the

final models were assessed with backward procedures
dropping variables that did not improve goodness of fit.
Coefficients for all the independent measures were estimated in both unadjusted models as well as models
adjusted for several nurse characteristics: age, years in
nursing and the present unit, gender, education and work
schedule to rule out major potential confounding effects.
The Statistical Package for the Social Sciences (spss) version
18.0 software was used for descriptive and correlational
analyses and analyses of variance, and PROC MIXED
and PROC NLMIXED under sas 9.2 were used to fit the
multilevel models.

Results
Table 1 summarizes the main study variables in terms of
mean unit values and unit values at the 25th and 75th
percentiles. Nurses rating of the practice environment
dimensions nursephysician relations and nurse management at the unit level were predominantly favourable (mean
unit values of above 2.5 suggesting agreement with the
statements), while hospital managementorganizational
support was rated neither favourably nor unfavourably
(2.51). In addition, mean unit perceived workload values
were favourable (<2.5). Quality of care at the unit and the
latest shift were rated as good or excellent with mean unit
values of more than 80% and 90% respectively. However,
quality of care by the interdisciplinary team was rated less
favourably with mean unit value of 69%. The mean proportion of staff on units reporting job dissatisfaction was
10.1% and average rate of staff reporting intentions to
leave the nursing profession was 7.7%. Work engagement
mean unit values ranged from 4.62 to 4.81 and proportions
of staff reporting high or very high score of vigour, dedication and absorption according to the cut-off values of
Schaufeli & Bakker (2003) of 58.3%, 70.3% and 64.0%,
respectively.
Table 2 shows significant associations between all three
nurse practice environment dimensions and all three work
engagement dimensions. Moreover, all three work engagement dimensions were significantly associated with job
outcome and quality of care variables (Table 3). Testing the
best predictive models (Table 4), team dedication predicted
job satisfaction and intention to the stay in the profession.
Nurse management at the unit level predicted quality of
care at the unit and the latest shift. Quality of care by the
interdisciplinary team was predicted by several variables:
dedication, absorption, nursephysician relations and
nurse management at the unit level. All unadjusted results
were confirmed after adjustments for potential confounding variables.
2012 John Wiley & Sons Ltd

Nurse team-level work engagement

Table 2
Linear mixed-effects model multilevel model with random
intercept: work engagement dimensions (dependent variables with
continuous distributions) and nurse practice environment
dimensions (independent variables)

n = 32
Vigour2
Nursephysician relations
Nurse management at the unit
level
Hospital management &
organizational support
Dedication2
Nursephysician relations
Nurse management at the unit
level
Hospital management &
organizational support
Absorption2
Nursephysician relations
Nurse management at the unit
level
Hospital management &
organizational support

Unadjusted

Adjusted1

Slope

Slope

SE

n = 32
SE

2.31***
3.24***

0.37
0.56

2.20***
3.10***

0.38
0.57

3.29***

0.54

3.28***

0.58

2.37***
4.05***

0.35
0.52

2.29***
3.96***

0.36
0.53

3.17***

0.52

3.17***

0.55

2.38***
3.64***

0.39
0.59

2.36***
3.39***

0.40
0.59

3.55***

0.57

3.36***

0.60

1
Adjusted for years in nursing years on present unit gender
bachelor of nursing science and work schedules.
2
Mean value.
Slope, slope of fixed effects; SE, standard error.
***P < 0.001; **P < 0.01; *P < 0.05.

Discussion
Unit mean values for the work engagement scale were
higher than those seen in the sample of workers from
multiple occupational groups (n = 9679) in which it was
validated (Schaufeli & Bakker 2003). Favourable teamlevel experiences of nurse practice environment were associated with team work engagement measured with three
constructs (vigour, dedication and absorption) and all work
engagement dimensions were associated with job satisfaction, intention to stay in nursing work and favourable
ratings of quality of care on the unit, during the last shift
and by the interdisciplinary team. In the best predictive
models, team-level dedication predicted all job outcomes.
Favourable team ratings of nurse management at the unit
level predicted quality of care at the unit and on the last
shift. Only quality of care by the interdisciplinary team was
predicted by engagement factors of dedication and absorption alongside nursephysician relations and nurse management at the unit level. There were no associations
between nurse perceived workload and the work engagement variables.
Comparing the current study results with those from a
previously reported multilevel study analysing the same
study data set using burnout instead of work engagement
dimensions as predictors (Van Bogaert et al. 2012a), low
2012 John Wiley & Sons Ltd

Table 3
Generalized linear mixed-effects model multilevel model with
random intercept: job outcome and nurse-assessed quality of care
(dependent variables) and work engagement dimensions
(independent variables)
Unadjusted OR

Satisfaction with the current job2

Vigour3
1.17* [1.07; 1.28]
Dedication3
1.20** [1.10; 1.31]
Absorption3
1.15* [1.06; 1.26]
Intention to stay nursing4
Vigour3
1.16* [1.04; 1.29]
Dedication3
1.20** [1.09; 1.33]
Absorption3
1.13* [1.01; 1.26]
The quality of care at the unit5
Vigour3
1.12* [1.03; 1.22]
Dedication3
1.18** [1.08; 1.29]
Absorption3
1.10* [1.01; 1.19]
The quality of care at the last shift5
Vigour3
1.16* [1.06; 1.29]
Dedication3
1.22** [1.10; 1.35]
Absorption3
1.15* [1.04; 1.27]
The quality of the interdisciplinary team5
Vigour3
1.19** [1.10; 1.29]
Dedication3
1.27*** [1.16; 1.39]
Absorption3
1.14* [1.06; 1.22]

Adjusted1 OR

1.19** [1.08; 1.30]

1.23** [1.11; 1.36]
1.16* [1.03; 1.30]
1.18* [1.05; 1.33]
1.21* [1.09; 1.36]
1.14* [1.01; 1.28]
1.15* [1.05; 1.25]
1.22** [1.11; 1.34]
1.12* [1.02; 1.22]
1.19* [1.07; 1.32]
1.26** [1.13; 1.41]
1.19* [1.06; 1.32]
1.22** [1.12; 1.32]
1.32*** [1.19; 1.46]
1.15** [1.06; 1.24]

Adjusted for years in nursing years on present unit gender

bachelor of nursing science and work schedules.
2
Strongly satisfied or satisfied (1) versus dissatisfied or strongly
dissatisfied (0).
3
Mean value.
4
Yes (1) versus no (0).
5
Good or excellent (1) versus fair or poor (0).
OR, odds ratio; 95% CI [lower and upper bound].
***P < 0.0001; **P < 0.001; *P < 0.05.

team-level depersonalization and its opposite pole, high

dedication, predicted intentions to stay in the profession
and better ratings of quality of care by the interdisciplinary
team. However, low team-level emotional exhaustion
rather than depersonalization and dedication predicted job
satisfaction. These results showed differences in team-level
impact of burnout as contrasted with engagement dimensions on job satisfaction. These findings support measuring
burnout and work engagement with different instruments
in research and management practice and not relying solely
on the MBI (Schaufeli & Salanova 2011). Another difference from the previous multilevel study was the failure of
any of the work engagement dimensions to predict quality
of care on the unit or during the latest shift in multivariate
models. In contrast, together with nurse management at the
unit level, emotional exhaustion and depersonalization
predicted quality of care on the unit and the latest shift,
respectively. Feelings of burnout at the team level appear to
have a stronger impact on perceptions of quality of care
than work engagement. Results of both studies suggest
impacts of the variable pair depersonalizationdedication
and absorption together with nursephysician relations
683

P. Van Bogaert et al.

Table 4
Final generalized linear mixed-effects model multilevel model
with random intercept: job outcome and nurse-assessed quality of
care (dependent variables) and nurse work environment and work
engagement dimensions (independent variables)
n = 32
Satisfaction with the current job2
Dedication3
Intention to stay nursing4
Dedication3
The quality of care at the unit5
Nurse management at the unit
level3
The quality of care at the last shift5
Nurse management at the unit
level3
The quality of the interdisciplinary
team5
Dedication3
Absorption3
Nursephysician relations3
Nurse management at the unit
level3

Unadjusted OR

Adjusted1 OR

1.20**
[1.10; 1.31]

1.23**
[1.11; 1.36]

1.20**
[1.09; 1.33]

1.21*
[1.09; 1.36]

20.91***
[6.28; 69.65]

28.92***
[7.90; 105.88]

20.81**
[5.57; 77.77]

32.62***
[7.33; 145.15]

1.29*
[1.09; 1.52]
0.86*
[0.74; 0.99]
4.14*
[1.77; 9.67]
40.71***
[8.76; 189.16]

1.36*
[1.14; 1.64]
0.83*
[0.71; 0.97]
5.12*
[1.98; 13.19]
48.86***
[9.43; 253.14]

1
Adjusted for years in nursing years on present unit gender
bachelor of nursing science and work schedules.
2
Strongly satisfied or satisfied (1) versus dissatisfied or strongly
dissatisfied (0).
3
Mean value.
4
Yes (1) versus no (0).
5
Good or excellent (1) versus fair or poor (0).
OR, odds ratio; 95% CI [lower and upper bound].
***P < 0.0001; **P < 0.001; *P < 0.05.

and nurse management at the unit on ratings of quality

of care by the interdisciplinary team. Despite awareness
of the importance of collaborative team-based practice
and interdisciplinary care to address complex client
needs, implementation methodologies and outcomes
related to collaborative and interdisciplinary care are quite
challenging in the current rapidly changing healthcare
environment (Ward & Cowman 2007, Jansen 2008).
To attract and retain nurses sustaining a stable and
skilled nurse workforce in psychiatric hospitals the level of

References
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dedication not only as a personal experience but also as a

team (shared) experience would appear to have a potentially important role. Dedication as a work engagement
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Interdisciplinary care models, a common feature of mental
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the results will be necessary with additional facilities and
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nurse-assessed survey items. Carefully selected independently measured patient outcomes will offer more insights
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with patient outcome variables, is recommended as the
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Conclusion
Study results suggest that nurse practice environments
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physicians, nurse management and leaders in fostering
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