The relationship between the work environment and therapeutic commitment of nurses working in mental health

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The therapeutic relationship is the central focus of nursing work in mental health (Peplau, 1992, 1997). However, there is currently little research that has examined influences on the nurses’ capacity to effectively engage in this relationship. This study investigated the impact of nurse, patient and work environment factors on the willingness and ability of nurses to engage in therapeutic relationships. This attribute of the nurse, identified as therapeutic commitment, is essential for an effective therapeutic relationship (Lauder, et al., 2000; Rogers, 1957), which has been identified by users of mental health services as the foundation of their care (Forchuk & Reynolds, 2001). The therapeutic relationship is central to nursing in mental health and has been linked to improved patient outcomes (Horvath, 2005). Environmental factors hypothesised to impact the nurse’s therapeutic commitment included leadership, collegial nurse-doctor relationships, participation in hospital affairs, the foundations of quality nursing, clinical supervision, staffing, skill mix and patient turnover (Aiken, et al., 2008; Duffield, et al., 2009a; Estabrooks, et al., 2002; Kramer & Schmalenberg, 2004; Lake & Friese, 2006; McGillis-Hall & Doran, 2004; Needleman, et al., 2002; Proctor, 1986). These factors, together with measures of the nurse’s qualifications and experience, were assembled into an hypothesised model, based on an earlier framework that included the nurse’s perception of support, adequacy and legitimacy in their role along with their therapeutic commitment (Lauder, et al., 2000; Shaw, et al., 1978). Data were collected from 76 nurses across six mental health wards in general acute hospitals in New South Wales. A nurse survey collected the identified factors using the Practice Environment Scale of the Nursing Work Index (Lake, 2002), the Mental Health Problems Perception Questionnaire (Lauder, et al., 2000), and other questions. A ward profile was used to collect staffing, skill mix and patient movement data. Partial least squares path modelling was applied to the model in order to identify the most influential relationships. The most significant factors in the model were the foundations for quality care, nurse experience, participation in hospital affairs and clinical supervision. Services should enhance the support provided to clinical nurses in mental health through improved access to preceptorship, continued education and clinical supervision. In addition, the therapeutic commitment of nurses in mental health can be increased through improved continuity of care, access to career development opportunities such as the involvement of mental health nurses in the governance of the hospital, and improved responsiveness of administration to the needs of nurses in mental health. Engagement in these supportive activities should be enacted through structured mechanisms that both facilitate involvement and encourage evaluation. This study provides a basis on which to modify the operation of mental health services in general hospitals in order to improve the nursing work environment.
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