In the challenging environment of inpatient psychiatric nursing, organizational success requires engaged nurses to prevent turnover and provide high-quality care.1,2 In this article, we share information from a study that investigated engagement levels and the drivers of engagement in a certain population of psychiatric nurses. A second goal was to compare the study results to national benchmarks collected by the survey company.3 We hypothesized that there may be something unique about our nurse population because they're employed at a freestanding psychiatric hospital. A fuller understanding of psychiatric nurse engagement can help psychiatric hospitals set priorities for the use of resources and can lead to improvements in recruitment, retention, and quality of care.
Employee engagement surveys are designed to measure employees' level of engagement (vigor, absorption, and dedication toward their job) and the drivers that positively influence engagement.4,5 Research demonstrates that levels of nurse engagement correlate with more favorable practice environments.6,7 Koppel and colleagues found that “highly engaged nurses feel their organization helps them deal with stress and burnout, which increases their sense of buy-in to organizational priorities and energy to operationalize new strategy.”8 Research also indicates that there's a positive relationship between nurse engagement and both practice environment and nursing participation in the organization.6,7 Additionally, García-Sierra and Fernández-Castro have suggested that the transformational leadership of nurse managers has a double impact on clinical nurses at the unit level: first, increasing empowerment and, second, improving staff engagement.5 It's known that higher levels of nurse engagement are prevalent at Magnet® hospitals, which are associated with positive nurse and patient outcomes.9
Although there's been much investigation into the drivers of nursing engagement in general medical settings, our review of the current literature found few studies that looked at engagement among psychiatric nurses, especially in the US. Based on the lack of research findings, our study asked two questions: 1. What are the levels and statistically significant drivers of engagement? 2. How do the highest scoring drivers of engagement in our sample compare with the national drivers from primarily inpatient medical hospitals?
Methods, sample, and setting
This study had a quantitative descriptive design and was performed from December 31, 2015, to February 28, 2017, using the Employee Engagement Survey (EES)—a propriety tool for measuring nursing engagement. The EES has undergone extensive qualitative and quantitative validation, including meta-analysis of interviews with all levels of nursing, multivariate regression analysis, factor analysis, bivariate correlations between the engagement index and drivers, and reliability testing.10 The Cronbach's alpha score for the EES question set is 0.98, with a 95% confidence interval.11
The EES instrument includes four sets of questions: 6 demographic questions, a 4-question engagement index (see Table 1), and 42 engagement driver questions.11 Nursing engagement levels are determined on the basis of responses to the four engagement index questions and categorized into one of four categories: engaged, content, ambivalent, and disengaged. Each engagement driver question is analyzed and scored as an individual item that reflects factors validated as influencers on nursing engagement. The 42 engagement driver questions are answered on a 6-point Likert scale of 1 = strongly disagree, 2 = disagree, 3 = tend to disagree, 4 = tend to agree, 5 = agree, and 6 = strongly agree, with a maximum score for each item of 6. The engagement driver questions are further categorized into seven categories (communication and input, employee support, feedback and recognition, professional growth, mission and values, teamwork, baseline satisfiers).11
The convenience sample consisted of 85 RNs employed at a nearly 300-bed, freestanding inpatient psychiatric hospital in the Northeast US. The nurses were recruited from several different specialty units; 177 nurses were eligible to participate in the study. When collecting the nurses' demographic information, we were careful not to request certain information that could be perceived as a threat to anonymity. For instance, we didn't ask which specialty unit the nurse worked on because there would often be only two nurses working per shift per specialty unit.
The inclusion criterion was being an RN, regardless of age, race, gender, shift, or clinical unit. Exclusion criteria included per diem and travel nurses and nurses in senior-level management positions (above nurse manager level). Institutional Review Board approval was obtained before study implementation. Study participants were entered in a drawing to win one of four $50 gift cards.
The online survey was administered over a 6-week period: 1 week to communicate the plans to nursing leaders, 1 week to publicize the survey to the nurses, and 4 weeks for data collection and monitoring. The investigators explained the purpose of the study during the monthly leadership meeting, with representatives from all levels of nursing, including nurse managers, directors of nursing, and clinical nurses. An email message was sent to all nursing leaders to inform them about the upcoming survey, and informational and recruitment flyers were posted around the hospital to further boost awareness of the study.
An invitation was emailed to all nurses who met the inclusion criterion with a hyperlink to the EES. A follow-up email was sent to all nurses 14 days before the survey deadline to remind them to complete the survey. Demographic information was retained as aggregated, summarized information.
Data analysis. To investigate research question number one, descriptive and regression analyses were used to characterize the levels and drivers of nursing engagement at the study hospital. In addition, regression analysis was used to identify the drivers associated with engagement at the study hospital.
For research question two, the highest scoring drivers at the study hospital were compared with the national benchmarks for general medical settings. Descriptive statistics were used to describe the percentile ranges of the comparison groups. Additionally, two-sample t-test analyses were used to investigate if there were statistically significant differences between the drivers of engagement from the study hospital sample and the national sample of primarily inpatient medical hospitals.
The response rate was 48% (n = 85). Of the respondents reporting their demographic information, most (70%) were older than age 35, 81% had worked at the hospital for more than 3 years, 65% worked day shift, 69% were White, and 88% were female.
Research question one. The first research question investigated the levels of engagement among psychiatric nurses at the study hospital. Findings indicate that the majority (86.1%) of nurses were either engaged (56.9%) or content (29.2%). (See Figure 1.) Regression analysis suggested that “receiving effective on the job training” was a statistically significant driver of overall engagement. When looking at only engaged nurses, “having the right amount of independence in my work” and “over the past year, I've never been asked to do something that compromises my values” were the major drivers of engagement. The chi-squared test confirmed that there were no statistically significant differences between engaged and nonengaged nurses based on demographic characteristics.
Research question two. Figure 2 shows the comparison of study hospital nurses to the national benchmark of over 1 million inpatient acute care medical nurses in the four engagement categories. In this national comparison, the 56.9% of study hospital nurses who were in the engaged category ranked in the top 99th percentile. Analysis comparing the difference in engagement driver categories with the national benchmark indicated that there was a statistically significant difference in eight driver questions. (See Table 2.) The greatest difference was seen in the engagement driver question “my organization pays me fairly for my job,” with the study hospital averaging a 28.8% higher response when compared with the national benchmark. Three drivers (“my organization supports employee safety,” “I have a manageable workload,” and “my unit/department has enough staff”) had scores that were statistically significantly lower than the national benchmark.
Summary of key findings. The study hospital's psychiatric nurses had a high level of engagement compared with the national benchmark. In addition, the drivers of nursing engagement and their respective categories were different than the national benchmark of inpatient medical nurses. These statistically significant (P = <.05) differences in driver categories between the national benchmark of inpatient medical nurses and the psychiatric nurses at the study hospital were mixed. Although the study hospital nurses indicated that their engagement was driven primarily by pay, benefits, and job security, there were other drivers (employee safety, manageable workload, and staffing) that scored relatively low.
Analysis of the findings. A major goal of this study was to understand the drivers of nursing engagement at an inpatient psychiatric institution to optimize organizational success. The study's research questions overlap to provide insight into psychiatric-specific nursing engagement. Although psychiatric nursing is demanding work, the study hospital nurses still reported being more engaged than the national inpatient medical comparison group.
Furthermore, this benchmark comparison indicated that even when study hospital nurses reported low scores on employee safety, manageable workload, and staffing, they were still very engaged. Logistic regression of only the engaged study hospital nurses indicated that having independence and not having to compromise their ethics were the strongest drivers of commitment to working at the organization. These findings support Herzberg's organizational theory that employees require “motivational factors” in addition to salary and benefits for overall job satisfaction.12 This demonstrates the importance of opportunities for psychological growth and self-actualization as motivational forces.
Strengths and limitations. A major strength of this study is the use of the benchmark comparison group of inpatient medical hospitals, totaling over 1 million responses. Such a large benchmark group provided increased statistical power for comparative analysis. In addition, the difference in practice setting between the study hospital and the benchmark group helps highlight psychiatric-specific nursing engagement characteristics. This study is valuable in terms of its methodology and results, as well as its focus on inpatient psychiatric nurses, for which there's a gap in the literature.
Limitations of this study include the convenience sample. The lack of randomization potentially introduced selection bias into our findings. The response rate was 48%, which is considered very high. The large number of nurses that participated in the survey helped reduce the possibility of bias. Descriptive analysis of survey demographic data indicated that our respondent's characteristics didn't differ significantly from national nursing demographics.13 Replication of this study with other inpatient psychiatric nurse populations would increase generalizability. Finally, additional studies should also consider more objective, non-self-reported measurements of engagement to reduce bias, such as comparisons of the study hospital's nurse turnover rates to the national benchmark.
In demanding healthcare settings such as inpatient psychiatric hospitals, nurse leaders continuously endeavor to understand their nurses and how to maintain and improve engagement. To our knowledge, this is the first study of levels and drivers of engagement among psychiatric nurses working in a freestanding psychiatric hospital in the US. Our findings indicate that there may be psychiatric-specific drivers of engagement, such as “over the past year, I've never been asked to do something that compromises my values” and “my organization pays me fairly for my job,” that should be sustained. It's noteworthy that nurses' concerns about staffing and safety were significant despite their high levels of engagement.
Again, Herzberg's work demonstrates that motivational factors other than salary and benefits are important to employees. When the work itself is rewarding to the worker, other factors that may contribute to engagement matter less. The importance of respect for and recognition of nurses' individual values, psychological growth, and autonomy stands out and aligns well with the goals of psychiatric nursing practice. Psychological growth and increased self-awareness are foundational to effective therapeutic relationships.14-15
It's possible that the unique characteristics of engagement for psychiatric nurses are linked to their deliberate practice of the therapeutic relationship, which requires self-awareness, professional development, and movement toward self-actualization. However, the therapeutic relationship is a core skill and practice for all nurses.16 Also important to all nurses are values, autonomy, and personal and professional growth. Therefore, it wouldn't be surprising to see support for Herzberg's theory in measures of engagement in all specialty areas of nursing, including general practice, not only in psychiatric nursing.
Although the study hospital's nursing engagement was higher than the comparison group, areas for improvement were identified. In the psychiatric setting, staffing and safety are pivotal nursing concerns. However, these challenges can be viewed as an opportunity for individual and organizational growth. Research indicates that organizational improvement is predicated on CNOs shifting their focus to strategic planning.16 Our study results suggest that all nurse leaders may find keys to performance and outcome improvement by implementing measures that support and amplify drivers of engagement. Salary and benefits are clearly important but investigating the potential impact of other drivers is also crucial.
Fanning the flame
Evidence-based strategies that are driven by clinical nurses and associated with engagement should be developed and strengthened over time. The synergistic effect of shared governance and the pursuit of evidence-based practice and nursing research has the potential to further increase nursing engagement. Individual nurses bring their own sparks of intrinsic motivation to their work. When your organization fans those flames, you'll see positive results that count for nurses and patients.
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