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International Journal of Nursing Studies 51 (2014) 85–92

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International Journal of Nursing Studies


journal homepage: www.elsevier.com/ijns

Review

Nurse retention: A review of strategies to create and enhance


positive practice environments in clinical settings
Di Twigg *, Kylie McCullough
School of Nursing and Midwifery, Edith Cowan University, 270 Joondalup Drive, Joondalup, WA 6027, Australia

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: This paper summarises and critically reviews strategies identified in the
Received 24 June 2012 literature which support retention of nurses by the creation and enhancement of positive
Received in revised form 30 April 2013 practice environments in the clinical setting.
Accepted 31 May 2013 Design: Literature review.
Data sources: A literature search was undertaken in February 2012 of major healthcare-
Keywords: related databases, Cinahlplus, Medline, and Proquest.
Nurse retention Review methods: The keywords ‘‘nurs* AND practice AND environment’’ were used in the
Nursing
first instance. Additional keywords ‘‘retention strategies’’ were also searched. Abstracts
PES-NWI
were reviewed and articles which potentially outlined strategies were identified.
Practice environment
Workforce
Reference lists were scanned for other potential articles. Articles in languages other
than English were excluded. Lake’s Practice Environment Scale of the Nursing Work Index
provided a framework from which to assess the strategies.
Results: Thirty-nine papers reported strategies for creating a positive practice environ-
ment. Only two articles reported on a pre-test post-test evaluation of the proposed
strategy. Strategies included: empowering work environment, shared governance
structure, autonomy, professional development, leadership support, adequate numbers
and skill mix and collegial relationships within the healthcare team.
Conclusions: Creating positive practice environments enhances nurse retention and
facilitates quality patient care. Managers and administrators should assess and manage
their practice environments using a validated tool to guide and evaluate interventions.
ß 2013 Elsevier Ltd. All rights reserved.

What is already known about the topic?  This paper also outlines instruments that may be used to
assess practice environments.
 Positive nursing practice environments improve nurse
retention and quality of care for patients. 1. Introduction
 Organisations with positive practice environments have
lower turnover and higher retention rates of nurses. The global nursing shortage is a challenge for health-
What this paper adds care systems around the world and solutions are critical to
prevent escalating adverse health outcomes (International
 This paper identifies and critically reviews strategies Council of Nurses, 2006). While the exact extent of the
outlined in the literature for enhancing the practice shortage is unknown, several reports provide estimates of
environment of nurses. the size of the problem. The World Health Organisation
(2006) estimated a shortage of almost 4.3 million doctors,
midwives, nurses and support workers globally. Buerhaus
* Corresponding author. Tel.: +61 8 6304 2400; fax: +61 8 6304 2200.
(2008) predicted a deficit in Registered Nurses (RNs) in the
E-mail addresses: d.twigg@ecu.edu.au, d.twigg@pigpond.com
(D. Twigg), k.mccullough@ecu.edu.au (K. McCullough). United States, relative to projected demand, will begin in

0020-7489/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijnurstu.2013.05.015
86 D. Twigg, K. McCullough / International Journal of Nursing Studies 51 (2014) 85–92

2015 and continue to worsen with projected shortages of the existence of positive nurse–physician relationships
285,000 RNs by 2020 and 500,000 RNs by 2025. More (Clarke et al., 2001; Upenieks, 2003). In addition, organisa-
recently a Health Workforce Australia report (2012) tions that promote the status of nursing (Chan and Lai,
identified projected shortages of 20,079 nurses in 2016 2010), encourage staff involvement in decision making
increasing to 109,490 in 2025. If Australia aimed for (Flynn et al., 2010), promote excellence in patient care and
medium self-sufficiency of the nursing workforce with a support new staff in adoption of these values, enhance the
50% reduction in migration (self-sufficiency is defined as practice environment (Kramer et al., 2004).
meeting health workforce requirements from domestic Positive practice environments influenced nurses’
training), the shortage in 2025 would increase to 129,818 abilities to practise professionally and therefore provide
nurses. safe quality care (Laschinger et al., 2003; Upenieks, 2003).
The shortage of healthcare workers has forced govern- Aiken et al. (2008b) suggested that up to 40,000 patient
ments and employers to address not only training and deaths may be avoided annually by improving practice
recruitment issues but staff retention strategies as cost environments, nurse staffing and education levels; this
effective and beneficial to health outcomes (Gaynor et al., estimate is based on achieving an ideal situation for each of
2007; Hayes et al., 2006). For example, Australian data the above factors across all hospitals in the United States.
suggest if retention was improved by sustaining exit rates Aiken et al. (2008b) concluded that maximising these
at 2% of the total workforce, the shortage would fall to elements—nurse staffing, nurse education and the practice
25,000 in 2025, a reduction in the nurse shortage of over environment—provide three options to minimise the risk
100,000 nurses (Health Workforce Australia, 2012). of adverse outcomes for patients and improve nurse
In the last decade, the relationship between staff retention. A further study examining the association of
retention and positive practice environments has been nursing work environments to patient satisfaction con-
well established (Aiken et al., 2008a; Kramer and cluded that patients reported greater satisfaction and
Schmalenberg, 2004; Laschinger et al., 2003; Upenieks, perceived increased quality of care in settings with a
2003). The nursing practice environment can be examined positive practice environment (Kutney-Lee et al., 2009).
from many perspectives, however for the purposes of this Positive practice environments demonstrate a focus on
discussion it will be defined as: ‘the organisational quality care (Flynn et al., 2010) and improve job
characteristics of a work setting that facilitate or constrain satisfaction and retention (Trinkoff et al., 2011).
professional nursing practice’ (Lake and Friese, 2006, p. 2). More recently, Aiken et al. (2011) further examined the
Health service managers may need guidance as to the effect of differing nurse staffing levels on mortality and
development and implementation of a positive practice failure-to-rescue; they found the effect of decreasing the
environment. This paper summarises and critically workload of nurses by one patient varied according to the
reviews strategies identified in the literature which type of work environment. The effect of a 10% increase in
support retention of nurses by the creation of positive Bachelor Degree nurses decreased the odds of death and
practice environments. failure-to-rescue by approximately 4%, regardless of the
practice environment and the effect of decreasing the
2. Background workload of nurses by one patient in poor work environ-
ments was negligible. However in average work environ-
Research suggests that administrative interventions ments, it reduced the odds of mortality and failure-to-
aimed at improving the quality of the practice environ- rescue by 4% and in hospitals with the best work
ment, have more effect on staff retention and maintenance environment, it reduced the odds of mortality and
of adequate staffing levels than increasing recruitment or failure-to-rescue by 10%. This study underlines the
salaries (Hayes et al., 2006). Factors contributing to a importance of positive practice environments and the
favourable hospital work environment were consistent need for health executives and managers to carefully
across countries (Clarke and Aiken, 2008). Hospitals with manage the practice environment as a means of improving
more highly educated registered nurses, adequate staffing nurse and health outcomes.
and positive practice environments had more satisfied
nurses and demonstrated more favourable patient out- 2.1. Assessment of the practice environment
comes (Clarke and Aiken, 2008). A Western Australian
study (Naude and McCabe, 2005) identified factors that Assessment of the practice environment is necessary to
motivated the nurse to remain at the hospital. These identify gaps or to facilitate pre- and post-evaluation of
factors included: supportive/friendly staff (the most interventions. It is a vital first step towards understanding
frequently reported factor), followed by supportive/effec- and enhancing the practice environment. Differences in
tive management, good physical environment and equip- the practice environment may be evident at a unit level
ment, and job satisfaction. While both money and due to factors such as unit size, number of support staff and
proximity to home were important, other factors relating rate of patient turnover (Schmidt, 2004); therefore,
to the work environment were pivotal in nurses’ decisions evaluating the practice environment at a micro and macro
about where they sought work and whether or not they level may prove useful.
stayed at that hospital (Naude and McCabe, 2005). Several assessment tools have been reported. The first,
Nurses who were more satisfied with their role had and most widely used, is Lake’s (2002) Practice Environ-
greater autonomy, control over their practice setting, ment Scale of the Nursing Work Index (PES-NWI). The use
sufficient resources, effective nurse leaders and perceived and modification of the PES-NWI has been reported at least
D. Twigg, K. McCullough / International Journal of Nursing Studies 51 (2014) 85–92 87

37 times between 2002 and 2010 in various contexts 4. Results


from acute care hospitals to community outpatient and
general practice facilities (Warshawsky and Havens, Few examples were found within the literature that
2011). The PES-NWI consists of 31 items divided into described strategies in detail or reported on their effec-
five subscales: nurse participation in hospital affairs; tiveness in improving the practice environment. However,
nursing foundations for quality of care; nurse manager those found reflect current practice and provide a useful
ability, leadership and support of nurses; staffing and starting place for consideration and discussion of inter-
resource adequacy; and collegial nurse–physician relations ventions at the unit and organisational level. A summary of
(Lake, 2002). the suggested strategies using the five subscales of the PES-
Other examples include the revised Professional NWI is provided in Table 1. Two articles reported on
Practice Environment (RPPE) scale (Erickson et al., 2009) studies with a pre-test post-test evaluation of the reported
and the Brisbane Practice environment measure (B-PEM) strategy. The remaining studies were descriptive in nature
(Flint et al., 2010). The RPPE scale contains 39 items and the strategies were not described in depth. The results
categorised into eight subscales: handling disagreement and are described in relation to the PES-NWI subscales in the
conflict; leadership and autonomy in clinical practice; internal sections that follow.
work motivation; control over practice; teamwork; commu-
nication about patients; cultural sensitivity; and staff 4.1. Nurse participation in hospital affairs
relationships with physicians. The authors claim that this
instrument is a more comprehensive measure of the An empowering work environment can influence the
practice environment than the PES-NWI; that it is ability of nurses to practise professionally and therefore
psychometrically sound and can be used at an organisa- provide safe quality care (Laschinger et al., 2003; Upenieks,
tional or unit level (Erickson et al., 2009). However, this 2003). Empowerment is described as the perception of
instrument has only been reported within the original being involved and supported, having access to opportu-
context of the Massachusetts General Hospital. The B-PEM nities, resources and power within an organisation (Hayes
scale originally consisted of 33 items but was reduced to 26 et al., 2006). Valuing employee contributions and well-
after testing. Subscales in this instrument are: getting being has also been linked to job satisfaction. Tourangeau
things done; flexibility of management support; feeling et al. (2010) used the Perceived Organisational Support
valued; and professional development. Despite rigorous Scale to measure the value organisations placed on
psychometric testing and claims from the authors that employee contributions and concluded that perceived
this tool is more current and relevant to contemporary organisational support was a factor in job satisfaction. A
practice, based on the findings of this review, it has yet to number of authors have also identified the characteristics
be tested in contexts outside the Australian acute care of an empowered work environment. A decentralised
sector. organisational structure—with a nursing representative on
Although there are several tools available for assessing the hospital executive committee and an open, participa-
the practice environment, the most widely used and cited tory style of management—are important (Upenieks,
tool is Lake’s PES-NWI. The five subscales of this tool 2002). In addition, empowered work environments are
provided the framework for this literature review and characterised by a shared governance structure that
discussion of strategies available to health service man- facilitates the flow of information between nurses at the
agers to increase retention of nurses by the creation and bedside and those in leadership (Kramer et al., 2009).
enhancement of positive practice environments. These types of structures provide access to the nursing
executive and give an opportunity for nurses ‘on the
3. Method ground’ to voice their concerns and contribute to
organisational change processes (Upenieks, 2002). These
A literature search was undertaken in February 2012 of structures also ensure nurses understand the purpose and
the major healthcare-related databases: Cinahlplus, Med- rationale behind organisational policies and procedures
line and Proquest. The keywords ‘‘nurs* AND practice AND which enhances their commitment and involvement
environment’’ were used initially. Additional keywords within an organisation (Laschinger and Finegan, 2005).
‘‘retention strategies’’ were also searched. Abstracts were Nursing staff need to be provided with the necessary
reviewed and articles which included an aim to improve resources to fully participate. This support may include
the practice environment of nurses were identified. paid time away from the bedside to attend meetings and
Reference lists of selected articles were reviewed for training in skills related to meeting facilitation and
other potential articles. Articles were excluded where the reporting.
focus was on the physical environment such as health and
safety considerations, or the article was not written in 4.2. Nursing foundations for quality care
English.
The initial search located over 300 articles of which all Autonomy is a vital aspect of professional nursing
abstracts were reviewed. Thirty-nine papers were practice and forms the foundation for quality care. It is
reviewed in detail for reported strategies aimed at creating essential for patient safety and is an important element of
a positive practice environment. All articles were pub- nurse job satisfaction (Kramer and Schmalenberg, 2008;
lished within the last 12 years indicating a rapid rise in Tourangeau et al., 2010). However, some confusion about
research in this area. the definition of autonomy in nursing practice is evident in
88 D. Twigg, K. McCullough / International Journal of Nursing Studies 51 (2014) 85–92

Table 1
Strategies to create positive practice environments.
Nurse participation in  Empowering work structures, characterised by access to information, support, opportunity and resources,
hospital affairs enhanced meaning in work (Tourangeau et al., 2010; Hayes et al., 2006; Laschinger and Finegan, 2005).
 Increase employees understanding of the rationale behind decision making (Laschinger and Finegan, 2005).
Nurse advocates on major committees (Vollers et al., 2009). Shared governance structure with time
to participate (Kramer et al., 2009). ‘Why can’t we?’ form submitted to committee representative
with mandatory reply (Kramer et al., 2009).
 Nursing grand rounds (Vollers et al., 2009) Stickers to promote attendance (Vollers et al., 2009).
 Magnet champions (Grant et al., 2010).
 Publications and other achievements acknowledged at multi-disciplinary functions (Vollers et al., 2009).
 Flat, flexible and decentralised organisational structure (Grant et al., 2010). Access to hospital executive
(Upeneiks, 2002).

Nursing foundations  Professional practice which is meaningful and effective (O’Brien-Pallas et al., 2010).
for quality care  Nurses given flexibility to make decisions in an environment of trust and respect
(Laschinger and Finegan, 2005; Schmidt, 2004).
 Encourage nurse autonomy by supporting staff presentation at conferences, workshops on clinical
autonomy, interdisciplinary evidence-based practice teams, critical thinking courses. Discuss
meaning of autonomous practice at a unit level (Kramer and Schmalenberg, 2008).
 Promoting the status of nursing as independent practitioners by clearly defining the role and
improving salaries (Chan and Lai, 2010). Outlining expected behaviours in common clinical
situations e.g. use of non-prescription medicines, verbal orders (Weston, 2010).
 Nurses included in decision-making about patient care (Weston, 2010). Nursing grand rounds,
case study presentations (Weston, 2010). Nursing rounds (Aitken et al., 2011).
 Support to attend meetings and develop skills related to meeting facilitation (Weston, 2010).
 Clinical career ladder programmes (Kramer and Schmalenberg, 2008; Kramer et al., 2009). Promotion
by portfolio of evidence including exemplars of practice (Pierson et al., 2010)
or assessment by an independent board with self and peer review processes (Chan and Lai, 2010).
 Support specialty certification including salary increase (Schmalenberg et al., 2005b). Encourage
education (Kramer and Schmalenberg, 2004).
 Nursing research and evidence-based practice imbedded in nursing practice and organisational
decision-making (Turkel et al., 2005; Weston, 2010). Establishment of nursing research committee
(Turkel et al., 2005). Time and resources to establish
and maintain scholarly nursing practice (Beal et al., 2008).
 Support for professional roles such as preceptoring students or mentoring staff (Hogan et al., 2007).

Nurse manager ability,  Managers should aim to be visible, accessible and responsive to their staff (Flynn et al., 2010;
leadership and support Tourangeau et al., 2010; Grant et al., 2010).
of nurses  Key attributes of a clinical leader: ‘‘. . .expert clinical skills, patient-focus, vision, stamina,
innovation, dynamism, confidence, selflessness, assertiveness and collaboration with other
health professionals’’ (Davidson et al., 2006, p. 182). Visibility and
communication, and the values of respect and empathy (Anderson et al., 2010).
 Stability in leadership positions (Tourangeau et al., 2010).
 Encourage collaborative relationships (Schmalenberg et al., 2005b; Pearson et al., 2006).
 Leadership support for staff (Kramer et al., 2004; Trinkoff et al., 2011), particularly for professional
development (Hogan et al., 2007; Pearson et al., 2006). Managers should be highly trained in
management (Flynn et al., 2010; Trinkoff et al., 2011; Pearson et al., 2006) and highly knowledgeable
in the clinical setting (Tourangeau et al., 2010). Leadership education workshops for managers
who then deliver a workshop to their staff (Calarco, 2011). Positive organisational scholarship focus
on empowerment, communication and leadership skills.
 Professional development of current and emerging nurse leaders (Davidson et al., 2006;
Pearson et al., 2006). Includes a career pathway that develops specific skills including:
negotiation, conflict resolution (Davidson et al., 2006), emotional intelligence
(Pearson et al., 2006) and critical thinking strategies (Zori et al., 2010). Mentorship, supervision
programmes and involvement in professional societies (Davidson et al., 2006).

Staffing and resource  Adequate numbers of staff (Trinkoff et al., 2011; Flynn et al., 2010; Kramer and Schmalenberg, 2004;
adequacy Lake et al., 2010; Twigg et al., 2011), and appropriate skill mix (Lake et al., 2010; Twigg et al., 2012).
 Retention of experienced staff (Lake et al., 2010).
 Decrease job demands (Trinkoff et al., 2011) by minimising: interruptions (Trinkoff et al., 2011) and
unpredictability (Hayes et al., 2006), conflicting demands (O’Brien-Pallas et al., 2010), adverse work
schedules and extended work hours.

Collaborative nurse–  Interdisciplinary development of Collaborative Practice Orders, Critical Pathways, and Protocols to encourage
physician relationships autonomous practice and inter-professional collaboration (Schmalenberg et al., 2005b; Vollers et al., 2009).
 Doctors and Nurses participating in on-going education together (Pullon, 2008). Rotating or co-leadership
of interdisciplinary rounds or meetings (Schmalenberg et al., 2005a).
 Programmes that encourage team members to get to know each other as a person and not an
occupation (Schmalenberg et al., 2005a).
 Interdisciplinary respect and competence builds trust (Pullon, 2008).
 Process for conflict resolution (O’Brien-Pallas et al., 2010; Schmidt, 2004).
 Defined roles and responsibilities (O’Brien-Pallas et al., 2010). Periodically renegotiate the scope of
practice, dictated by best-practice, new technology or research and facilitated by inter and intra
professional dialogue (Kramer and Schmalenberg, 2008).
D. Twigg, K. McCullough / International Journal of Nursing Studies 51 (2014) 85–92 89

the literature. It is not about control of practice and the particularly for nurses providing direct patient care
ability to self-govern, neither is it providing medical care (Pierson et al., 2010). Advancement should be related to
without medical supervision but rather: autonomous practice and attainment of competencies
‘‘. . .the freedom to act on what you know in the best (Kramer and Schmalenberg, 2008) and form part of an
interests of the patient. . .to make independent clinical annual performance appraisal process (Pierson et al.,
decisions in the nursing sphere of practice and 2010). Clinical ladders often cover several categories such
interdependent decisions in those spheres where as: ‘‘. . .education, experience, professional and leader,
nursing overlaps with other disciplines. . .It often provider, teacher and advocate’’ (Pierson et al., 2010, p. 34).
exceeds standard practice, is facilitated through evi- Formal education such as certification in clinical compe-
dence-based practice, includes being held accountable tencies should be supported and presentation at confer-
in a constructive, positive manner and nurse manager ences should be encouraged (Kramer and Schmalenberg,
support.’’ (Kramer and Schmalenberg, 2008, p. 61) 2008). Recognition of the time needed for professional
roles such as preceptoring and mentoring other staff is also
The first empirical study found in the literature required (Hogan et al., 2007).
examined the effect of a ‘nursing round’ innovation in
an Australian intensive care unit. Aitken et al. (2011) 4.3. Nurse manager ability, leadership and support of nurses
suggested nursing rounds could provide a forum for
sharing knowledge and building collegial relationships, The nurse manager can directly influence the practice
facilitate evidence into practice, and improve autonomy environment by applying critical thinking skills to develop
and decision making which would in turn enhance patient relationships and solve problems (Zori et al., 2010). In
care and nurses’ work satisfaction (Aitken et al., 2011). In addition, the nurse leader of can be very influential in
the intervention intensive care unit, nursing rounds were developing shared values and culture, creating a sense of
held on two days each week for one hour. A senior clinician community, and articulating a vision for the future, all of
lead the forum and participants included: the patient’s which contribute to a positive practice environment
primary nurse who ‘presented’ the patient, the ICU team (Calarco, 2011). Leadership support is essential to secure
leader, the hospital librarian, critical care researcher and resources to create the best work environment for nursing
other staff as able. At times, family and other specialist staff practice (Heath et al., 2004). Interestingly, research has
would participate as appropriate. A pre-test post-test two identified that employees resign more often due to the
group comparative design, using both PES-NWI and the perceived quality of the manager than the quality of the
Nursing Worklife Satisfaction Scale (NWSS) as outcome organisation (Hogan et al., 2007).
measures, was used. Results from this study showed the An important aspect of leadership is the ability to
total PES-NWI and NWSS were similar pre-test and post- facilitate change and team growth (Davidson et al., 2006).
test, however, a significant increase in the subscale In order to promote this leadership, managers should be
‘nursing interaction’ from the NWSS in the intervention visible, accessible and responsive to their staff (Flynn et al.,
unit was found when compared to the pre-test and control 2010; Tourangeau et al., 2010; Upenieks, 2002). This is
group. ‘Changes to patient care’ also increased and were critical as trust and respect between management and
attributed to the nursing rounds’ intervention suggesting employees is correlated with greater organisational
improvements in care. The authors concluded testing of commitment (Laschinger and Finegan, 2005). Trust and
rounds in other settings was required in order to respect is encouraged by a willingness to share informa-
generalise. tion and evidence of a manager’s concern for employee
Nurses require organisational support for autonomy in needs (Laschinger and Finegan, 2005). Anderson et al.
practice. They need to know they will be supported in their (2010) proposed a Nursing Leadership Values model that
decision making in order to take the risk that things may go identifies the importance of visibility and communication
wrong (Kramer and Schmalenberg, 2008). Leaders within between leaders and staff which was developed using the
organisations can encourage nurse autonomy by providing underlying values of respect and empathy. Models such as
educational opportunities in critical thinking, evidence- this assist in providing clear leadership expectations.
based practice and defining the role and status of nurses Professional development for nurse managers is vital to
within the organisation (Chan and Lai, 2010; Kramer and increase their ability to function as effective leaders.
Schmalenberg, 2008). In addition, successful integration of Current and emerging leaders should be highly trained in
nursing research and evidence-based practice into all management and clinical skills (Flynn et al., 2010, Trinkoff
nursing and organisational decision making (Kramer and et al., 2011) and should be supervised and mentored
Schmalenberg, 2008) provides a strong framework for (Davidson et al., 2006). Priorities for leadership develop-
autonomous practice. ment include: ‘‘honing of emotional and social intelligence
Nursing foundations for quality care also include skills, inquiry-based learning, appreciative inquiry, critical
opportunities for professional development and promo- incident analysis, concept mapping, case studies, role play
tion both of which enhance the practice environment and dialogue. . . [and] reflective journaling’’ (Zori et al.,
(Chan and Lai, 2010; O’Brien-Pallas et al., 2010) and reduce 2010, p. 311). Calarco’s (2011) study, the second of two
the rate of turnover intention (Hayes et al., 2006). Clinical studies that used empirical methods to assess effective-
ladder programmes support recruitment and retention, ness of an intervention, assessed the effectiveness of a
and can be useful in succession planning as they recognise ‘positive organisational leadership’ workshop. Using the
excellence in nursing and can identify role models, PES-NWI as an outcome measure, Calarco hypothesised an
90 D. Twigg, K. McCullough / International Journal of Nursing Studies 51 (2014) 85–92

increase in PES-NWI scores following the implementation 2004; Schmidt, 2004), facilitated by good communication
of the workshop. However, results showed no increase in and medical leadership (Schmidt, 2004), are elements of a
the post-test mean scores of the PES-NWI. The author positive practice environment. The resultant teamwork is
suggested evidence of increased use of positive organisa- further evidenced when collaboration involves all mem-
tional leadership practices within the studied population bers of the unit rather than just the doctors and nurses
but changes to practice environment scores may take (Schmalenberg et al., 2005a). Collegiality recognises
longer to become evident. different spheres of professional practice and that each
Nurse Managers also face many barriers that affect their person in the relationship has an essential, unique and
ability to lead effectively. Davidson et al. (2006) identified equal contribution (Schmalenberg et al., 2005a). Defined
a number of such barriers to clinical leadership including: roles and responsibilities, processes for conflict resolution,
staffing and resource shortages, organisational structures and programmes that encourage interdisciplinary partici-
with insufficient nurse involvement in decision making, pation build trust and are essential for encouraging
inadequate models of care, and the trend towards collegial relationships.
increased numbers of less-skilled clinicians. Health services can facilitate collegial relationships.
Schmalenberg et al. (2005b) described eight structures
4.4. Staffing and resource adequacy that facilitate nurse–physician relationships within speci-
alty units: interdisciplinary rounds/meetings; collabora-
There are many ways to determine the appropriate tive practice orders; critical pathways and protocols;
number of nursing staff for a particular unit (Twigg and appointment of high quality competent people; culture
Duffield, 2009). Whatever method is used, workloads and in which concern for the patient is paramount; continuity,
job demands must be manageable to enhance retention longevity and specialisation; established mechanisms for
(Schmidt, 2004; Trinkoff et al., 2011). Job demands constructive conflict resolution; committed unit/service
include: the unpredictability of patient care, such as rapid medical directors and nurse manager support (Schmalen-
changes in patient acuity (Hayes et al., 2006), conflicting berg et al., 2005b). The authors also suggested nurse–
demands and role expectations between nursing admin- physician relationships may be enhanced in general wards
istrative and medical staff (O’Brien-Pallas et al., 2010), as if the patients are cared for by medical specialty and
well as frequent interruptions, long work hours and the physician/nurse teams, thereby encouraging the develop-
need to work antisocial hours (Trinkoff et al., 2011). Job ment of specialised knowledge and consistency in patient
demands may be more effectively managed when staffing care (Schmalenberg et al., 2005b).
on a unit is stable, as evidenced by minimal use of Confidence in one’s own ability to practice in a
temporary (agency) nurses and low staff turnover competent manner is also important when developing
(O’Brien-Pallas et al., 2010). Turnover in staff increases collaborative nurse–doctor relationships (Schmalenberg
the job demands on existing staff due to additional et al., 2005b). Inter-professional respect is associated with
requirements of orientation and supervision of new staff. competence and Pullon (2008) identified that respect
O’Brien-Pallas et al. (2010) suggest that unstable staffing preceded trust and that trust developed over time but only
threatens the quality of patient care and generates higher in a context of respect for professional competence.
costs associated with decreased morale and productivity Schmalenberg et al. (2005a) described the concept of
while new staff become competent within the practice ‘banking’ trust whereby the staff on a unit provide such
setting. Staffing levels must also be high enough to predictable care that it covers new staff, and trust on an
facilitate leave requirements as regular breaks from the individual level is not necessary. Respect and trust are
workplace are vital for retention (Chan and Lai, 2010). dynamic attributes of the relationship, influenced over
In addition to adequate numbers of staff, having the time by situations and experience (Pullon, 2008).
right skill mix is essential (Duffield et al., 2011; Rafferty
et al., 2007; Twigg et al., 2012). It is important that
where there are different levels of nurses and assistant 5. Discussion
roles, there are clearly defined roles and expectations
across the team (O’Brien-Pallas et al., 2010). Clear roles The nursing practice environment directly impacts
and expectations build confidence in the team and nurse retention and quality of patient care (Aiken et al.,
having confidence in the clinical competence of co- 2011). Nurse participation in hospital affairs; establishing
workers has been identified as a marker of positive nursing foundations for quality care; nurse manager
practice environments (Kramer and Schmalenberg, ability, leadership and support of nurses; staffing and
2004). Retention of experienced staff (Lake et al., resource adequacy; and collegial nurse–physician rela-
2010) provides strength and leadership in the team. tions are key components of positive practice environ-
One strategy to retain experienced staff is to provide ments. Shared governance structures that empower nurses
good access to education and professional development to influence decisions that affect their practice environ-
(Kramer et al., 2004). ment are critical. Professional practice models that are
meaningful and effective form the foundation of quality
4.5. Collegial nurse–physician relationships care. Autonomy and professional development require
organisational support. The right numbers of staff with the
Collaborative relationships between medical and nur- right skills and resources, along with minimising job
sing staff (Flynn et al., 2010; Kramer and Schmalenberg, demands improve quality of care and job satisfaction.
D. Twigg, K. McCullough / International Journal of Nursing Studies 51 (2014) 85–92 91

Nurse leaders and managers play a significant role in Acknowledgement


developing a positive practice environment. Professional
development and support of these key people is a vital The authors wish to thank Professor Sian Maslin-
component of a retention strategy. Nurse–physician Prothero for her feedback on an early draft of this paper.
relationships have been identified as a critical aspect of
positive professional practice environments. The culture of Conflicts of interest: None declared.
the organisation must be one of collaboration across
disciplines, teamwork and one that puts the welfare of the Funding: None.
patient first. These behaviours must be modelled by
leaders and executives across the organisation (Schmalen- Ethical approval: Not required.
berg et al., 2005b).
It is vital that organisations consider their practice References
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