Factors influencing nurses’ choice to work in mental health services for older people

About the author:

Krizia Ledesma-Libre, RN, PGDipHSc, MN, works as a registered nurse at Puawai, the Midland Regional Forensic Psychiatric Service, Waikato District Health Board, Hamilton, New Zealand.
Her correspondence address is [email protected]

Key words

older people, mental health services, perceptions, motivations, nurses

Aim

The aim of this study was to identify factors influencing nurses’ choice to work in mental health services for older people (MHSOP) and to explore the perspectives of nurses who did not actively choose to work in MHSOP but who have stayed in this service. In MHSOP and dementia services, there are concerns about recruitment and retention of nursing staff, and the need to plan for an ageing workforce. This research explored the factors influencing nurses’ decision to work in this field, including their positive and negative perceptions of MHSOP. It also explored whether they had considered leaving MHSOP and what supported their motivation to work in the specialty. The research question was: “What is the motivation and perception of nurses as to working in, staying, or leaving MHSOP in New Zealand?”

Background

In many countries, the number of people aged 60 years and over is increasing rapidly, compared to other age groups. This increase in the proportion of older people is attributed to a longer lifespan, and decreasing fertility rates (World Health Organization, 2016a). The ageing of the population can be seen as both a positive and a challenge. Worldwide, it is projected that from the years 2015 to 2050, the proportion of the older population will double from 12 percent to 22 percent. It is anticipated that by 2020, there will be more older people than children five years and younger. At 2050, the number of older people aged 60 years and over is estimated to reach 2 billion, from only 900 million in 2015. By 2050, 80 percent of the older population will be living in low and middle-income nations. All nations experience obstacles to providing health and social systems that are equipped to face this demographic shift known as “population ageing” (World Health Organization, 2016b). In New Zealand, the number of older people aged 85 years and over is predicted to increase substantially by 2051; by 2026, nearly 18 percent of the entire population will be aged 65 years and above (Ministry of Health, 2011).

Few researchers see older people nowadays as being healthier in their old age than their parents. The prevalence of severe disability in older people has decreased in higher-income nations in the last 30 years, but there has been no marked improvement in mild to moderate disability over the same period (World Health Organization, 2016b). If older people can live out their longer lifespan in good health, and if they live in a supportive environment, their capacity to perform activities they find meaningful will enable a better quality of life. However, if these latter years involve physical and cognitive decline, the implications for older people and for civilisation are more discouraging (World Health Organization, 2016b).

Methods

The qualitative approach for this research was process-oriented, with a focus on participants’ perceptions and descriptions of their experiences. Data were collected via moderated focus group discussions with 30 mental health nurses, and then treated to thematic analysis. As moderated group discussions, focus groups allow participants to talk, discuss, agree or disagree about views, ideas, attitudes and experiences (Curtis & Redmond, 2007; Kevern & Webb, 2001; Kitzinger, 1995; Parahoo, 2007). Focus groups are an effective way of extracting the viewpoints or attitudes of people on difficult, under-investigated matters (Barbour, 2005). In this study, the focus-group approach was used to enable nurses to freely discuss, agree and disagree with colleagues regarding their motivations and perceptions of working in, staying in or leaving MHSOP.

Setting

The study was carried out in the MHSOP of three New Zealand district health boards (DHBs). These DHBs employ nurses in both inpatient and community settings within the service.

Ethics

The study was given ethical approval by the University of Auckland Human Participants Ethics Committee, ref. 017730, and by the ethics committees of each participating DHB.

Findings

Data analysis revealed three over-arching themes, including:

(1) Mental health nurses vs general nurses: Nurses in MHSOP wanted to be able to use all their skills, in both mental and physical health care.

(2) The work environment: Whether it is a supportive, pleasant place to work; if there is conflict within or between services; the style of management; other challenges encountered in the service.

(3) Characteristics of a MHSOP nurse and what motivates them.

1) Mental health nurses vs general nurses:
Nurses in the focus group felt it was important that they be able to use all their skills to provide the most comforting and therapeutic environment for their patients. Some noted that the role of the MHSOP in two of the DHBs was “delimited”, ie if a patient became physically unwell, they had to be transferred to a general ward. They said DHBs were employing new-graduate nurses who have comprehensive registration, and are therefore able to practice in a broad variety of clinical contexts (NCNZ, 2010), but were missing out on using their skills on complex physical procedures because of the limited nature of the MHSOP. Some participants, however, felt fortunate that they were able to exercise their comprehensive range of nursing skills in the service. In the future, quality nursing practice will need flexible nurses who can provide holistic, patient-centred care (Potgieter, 1999). To provide such service, nurses need to be comprehensive in their approach, and knowledgeable in both mental health and general nursing.

2) The work environment:
Nurses found work environments supportive where there was cohesion and teamwork, and where nurses showed an awareness of and sensitivity to each other. Having autonomy, in terms of being able to pursue their own professional interests in nursing; having access to ongoing education; and participating in a variety of roles were other important aspects of a positive work environment. Having the opportunity to care for and respect patients, and being appreciated by patients, families, and colleagues, added to their job satisfaction. Feedback showing they are appreciated for the job they do and for their accomplishments, effective communication, and being shown respect are some of the key motivators for nurses at work (Global Health Workforce Alliance, 2008). Nurses want to feel independent, proficient and connected (Ryan & Deci, 2000); to achieve self-actualisation and success (Oldham & Hackman, 2010); to do meaningful work; and to experience positive outcomes from their own hard work (Oldham & Hackman, 2010). Supportive, helpful employers, and attention to workplace health and safety, are some of the key motivating circumstances for jobs in hospitals (Global Health Workforce Alliance, 2008).

However, nurses participating in this study also experienced challenges in their jobs. These included: conflict with management; not being listened to; no clear leadership; and lack of communication and inconsistency from the management team. Short staffing, inappropriate staff mix, rapid staff turnover, high-acuity workloads, and dealing with challenging behaviours of mental health patients, were all identified as challenges for nurses working in MHSOP. Retention of nurses in mental health is important for the maintenance of a skilled and knowledgeable workforce. Alexander, Diefenbeck and Brown (2015) concluded that nurses who remain working in mental health do so by overcoming negative attitudes towards their career specialty (often propagated by other nurses or health-care staff) and by fostering pride in their distinctive skills. Given these findings, management could use education, motivation programmes, and mentoring/coaching sessions to promote the self-worth and morale of mental health nurses.

3) Characteristics of a MHSOP nurse and what motivates them:
The third theme identified the characteristics of a MHSOP nurse. According to the focus group nurses, these characteristics include “being real”, not taking things personally, being self-motivated, having a good support system, being internally motivated, having a work-life balance, getting support with training and education, and treating patients as if they were their own parents. Nurses’ job motivation has been recognised as vital to their intentions to remain in the nursing workforce (Brewer, Kovner, Greene, & Cheng, 2009). It gives nurses the bearing and determination to work. However, motivational factors may differ for each individual in different stages of their career. The participants in this study talked about the variety of different motivational factors (both internal and external) they had for working in MHSOP. Alexander et al (2015) pointed out that mental health nurses who stayed in mental health had learned to modify their expectations for clients, and how they perceived achievement; and had faith that they were making a positive difference in the lives of their patients.

Conclusions

This research found that nurses working in MHSOP saw it as both rewarding and challenging. It was found to be a mostly positive experience for nurses who were personally motivated and committed to work with their patients. However, mental health and general nurse specialists and educators need to collaborate to support MHSOP nurses who are interested in improving and developing their physical nursing skills. This might involve MHSOP nurses working one day a week in a general setting to hone their physical nursing skills, and general nurses working in mental health to improve their mental health nursing skills. MHSOP nurses also emphasised their unique qualities: being passionate, flexible, innovative, empathetic and holistic; providing individualised patient care, and being patient-centred and patient advocates. The findings of this research suggest that despite the challenges encountered in the DHB setting, MHSOP nurses are motivated to continue working in this specialty.

References

Alexander, R. K., Diefenbeck, C. A., & Brown, C. G. (2015). Career choice and longevity in US psychiatric-mental health nurses. Issues in Mental Health Nursing, 36(6), 447–454.

Barbour, R. S. (2005). Making sense of focus groups. Medical Education, 39(7), 742–750.

Brewer, C. S., Kovner, C. T., Greene, W., & Cheng, Y. (2009). Predictors of RNs’ intent to work and work decisions 1 year later in a U.S. national sample. International Journal of Nursing Studies, 46(7), 940–956.

Curtis, E., & Redmond, R. (2007). Focus groups in nursing research. Nurse Researcher, 14(2), 25–37.

Global Health Workforce Alliance. (2008). Guidelines: Incentives for health professionals. World Health Organization.

Kevern, J., & Webb, C. (2001). Focus groups as a tool for critical social research in nurse education. Nurse Education Today, 21(4), 323–333.

Kitzinger, J. (1995). Qualitative research: Introducing focus groups. British Medical Journal, 311(7000), 299–302.

Ministry of Health. (2011). Mental Health and Addiction Services for Older People and Dementia Services: Guideline for district health boards on an integrated approach to mental health and addiction services for older people and dementia services for people of any age.

New Zealand Gazette. (2010). Notice of Replacement Scope of Practice and Qualifications Prescribed by the Nursing Council of New Zealand for Registered Nurses, 108, 2916.

Oldham, G. R., & Hackman, J. R. (2010). Not what it was and not what it will be: The future of job design research. Journal of Organizational Behavior, 31(2–3), 463–479.

Parahoo, K. (2007). Focus groups are enjoying increased in popularity as a research method. Nurse Researcher, 14(2), 4–6.

Potgieter, E. (1999). The Whole Brain Creativity Model: Implications for nursing education and practice. Curationis, 22(4), 41–48.

Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55(1), 68-78.

World Health Organization. (2016a). Ageing.

World Health Organization. (2016b). Ageing and health.

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