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

Contents lists available at SciVerse ScienceDirect

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?
 Positive nursing practice environments improve nurse
retention and quality of care for patients.
 Organisations with positive practice environments have
lower turnover and higher retention rates of nurses.
What this paper adds
 This paper identifies and critically reviews strategies
outlined in the literature for enhancing the practice
environment of nurses.
* Corresponding author. Tel.: +61 8 6304 2400; fax: +61 8 6304 2200.
E-mail addresses: d.twigg@ecu.edu.au, d.twigg@pigpond.com
(D. Twigg), k.mccullough@ecu.edu.au (K. McCullough).
 This paper also outlines instruments that may be used to
assess practice environments.
1. Introduction
The global nursing shortage is a challenge for health-
care systems around the world and solutions are critical to
prevent escalating adverse health outcomes (International
Council of Nurses, 2006). While the exact extent of the
shortage is unknown, several reports provide estimates of
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
(2008) predicted a deficit in Registered Nurses (RNs) in the
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
285,000 RNs by 2020 and 500,000 RNs by 2025. More
recently a Health Workforce Australia report (2012)
identified projected shortages of 20,079 nurses in 2016
increasing to 109,490 in 2025. If Australia aimed for
medium self-sufficiency of the nursing workforce with a
50% reduction in migration (self-sufficiency is defined as
meeting health workforce requirements from domestic
training), the shortage in 2025 would increase to 129,818
nurses.
The shortage of healthcare workers has forced govern-
ments and employers to address not only training and
recruitment issues but staff retention strategies as cost
effective and beneficial to health outcomes (Gaynor et al.,
2007; Hayes et al., 2006). For example, Australian data
suggest if retention was improved by sustaining exit rates
at 2% of the total workforce, the shortage would fall to
25,000 in 2025, a reduction in the nurse shortage of over
100,000 nurses (Health Workforce Australia, 2012).
In the last decade, the relationship between staff
retention and positive practice environments has been
well established (Aiken et al., 2008a; Kramer and
Schmalenberg, 2004; Laschinger et al., 2003; Upenieks,
2003). The nursing practice environment can be examined
from many perspectives, however for the purposes of this
discussion it will be defined as: ‘the organisational
characteristics of a work setting that facilitate or constrain
professional nursing practice’ (Lake and Friese, 2006, p. 2).
Health service managers may need guidance as to the
development and implementation of a positive practice
environment. This paper summarises and critically
reviews strategies identified in the literature which
support retention of nurses by the creation of positive
practice environments.
2. Background
Research suggests that administrative interventions
aimed at improving the quality of the practice environ-
ment, have more effect on staff retention and maintenance
of adequate staffing levels than increasing recruitment or
salaries (Hayes et al., 2006). Factors contributing to a
favourable hospital work environment were consistent
across countries (Clarke and Aiken, 2008). Hospitals with
more highly educated registered nurses, adequate staffing
and positive practice environments had more satisfied
nurses and demonstrated more favourable patient out-
comes (Clarke and Aiken, 2008). A Western Australian
study (Naude and McCabe, 2005) identified factors that
motivated the nurse to remain at the hospital. These
factors included: supportive/friendly staff (the most
frequently reported factor), followed by supportive/effec-
tive management, good physical environment and equip-
ment, and job satisfaction. While both money and
proximity to home were important, other factors relating
to the work environment were pivotal in nurses’ decisions
about where they sought work and whether or not they
stayed at that hospital (Naude and McCabe, 2005).
Nurses who were more satisfied with their role had
greater autonomy, control over their practice setting,
sufficient resources, effective nurse leaders and perceived
the existence of positive nurse–physician relationships
(Clarke et al., 2001; Upenieks, 2003). In addition, organisa-
tions that promote the status of nursing (Chan and Lai,
2010), encourage staff involvement in decision making
(Flynn et al., 2010), promote excellence in patient care and
support new staff in adoption of these values, enhance the
practice environment (Kramer et al., 2004).
Positive practice environments influenced nurses’
abilities to practise professionally and therefore provide
safe quality care (Laschinger et al., 2003; Upenieks, 2003).
Aiken et al. (2008b) suggested that up to 40,000 patient
deaths may be avoided annually by improving practice
environments, nurse staffing and education levels; this
estimate is based on achieving an ideal situation for each of
the above factors across all hospitals in the United States.
Aiken et al. (2008b) concluded that maximising these
elements—nurse staffing, nurse education and the practice
environment—provide three options to minimise the risk
of adverse outcomes for patients and improve nurse
retention. A further study examining the association of
nursing work environments to patient satisfaction con-
cluded that patients reported greater satisfaction and
perceived increased quality of care in settings with a
positive practice environment (Kutney-Lee et al., 2009).
Positive practice environments demonstrate a focus on
quality care (Flynn et al., 2010) and improve job
satisfaction and retention (Trinkoff et al., 2011).
More recently, Aiken et al. (2011) further examined the
effect of differing nurse staffing levels on mortality and
failure-to-rescue; they found the effect of decreasing the
workload of nurses by one patient varied according to the
type of work environment. The effect of a 10% increase in
Bachelor Degree nurses decreased the odds of death and
failure-to-rescue by approximately 4%, regardless of the
practice environment and the effect of decreasing the
workload of nurses by one patient in poor work environ-
ments was negligible. However in average work environ-
ments, it reduced the odds of mortality and failure-to-
rescue by 4% and in hospitals with the best work
environment, it reduced the odds of mortality and
failure-to-rescue by 10%. This study underlines the
importance of positive practice environments and the
need for health executives and managers to carefully
manage the practice environment as a means of improving
nurse and health outcomes.
2.1. Assessment of the practice environment
Assessment of the practice environment is necessary to
identify gaps or to facilitate pre- and post-evaluation of
interventions. It is a vital first step towards understanding
and enhancing the practice environment. Differences in
the practice environment may be evident at a unit level
due to factors such as unit size, number of support staff and
rate of patient turnover (Schmidt, 2004); therefore,
evaluating the practice environment at a micro and macro
level may prove useful.
Several assessment tools have been reported. The first,
and most widely used, is Lake’s (2002) Practice Environ-
ment Scale of the Nursing Work Index (PES-NWI). The use
and modification of the PES-NWI has been reported at least
 D. Twigg, K. McCullough / International Journal of Nursing Studies 51 (2014) 85–92
37 times between 2002 and 2010 in various contexts
from acute care hospitals to community outpatient and
general practice facilities (Warshawsky and Havens,
2011). The PES-NWI consists of 31 items divided into
five subscales: nurse participation in hospital affairs;
nursing foundations for quality of care; nurse manager
ability, leadership and support of nurses; staffing and
resource adequacy; and collegial nurse–physician relations
(Lake, 2002).
Other examples include the revised Professional
Practice Environment (RPPE) scale (Erickson et al., 2009)
and the Brisbane Practice environment measure (B-PEM)
(Flint et al., 2010). The RPPE scale contains 39 items
categorised into eight subscales: handling disagreement and
conflict; leadership and autonomy in clinical practice; internal
work motivation; control over practice; teamwork; commu-
nication about patients; cultural sensitivity; and staff
relationships with physicians. The authors claim that this
instrument is a more comprehensive measure of the
practice environment than the PES-NWI; that it is
psychometrically sound and can be used at an organisa-
tional or unit level (Erickson et al., 2009). However, this
instrument has only been reported within the original
context of the Massachusetts General Hospital. The B-PEM
scale originally consisted of 33 items but was reduced to 26
after testing. Subscales in this instrument are: getting
things done; flexibility of management support; feeling
valued; and professional development. Despite rigorous
psychometric testing and claims from the authors that
this tool is more current and relevant to contemporary
practice, based on the findings of this review, it has yet to
be tested in contexts outside the Australian acute care
sector.
Although there are several tools available for assessing
the practice environment, the most widely used and cited
tool is Lake’s PES-NWI. The five subscales of this tool
provided the framework for this literature review and
discussion of strategies available to health service man-
agers to increase retention of nurses by the creation and
enhancement of positive practice environments.
3. Method
A literature search was undertaken in February 2012 of
the major healthcare-related databases: Cinahlplus, Med-
line and Proquest. The keywords ‘‘nurs* AND practice AND
environment’’ were used initially. Additional keywords
‘‘retention strategies’’ were also searched. Abstracts were
reviewed and articles which included an aim to improve
the practice environment of nurses were identified.
Reference lists of selected articles were reviewed for
other potential articles. Articles were excluded where the
focus was on the physical environment such as health and
safety considerations, or the article was not written in
English.
The initial search located over 300 articles of which all
abstracts were reviewed. Thirty-nine papers were
reviewed in detail for reported strategies aimed at creating
a positive practice environment. All articles were pub-
lished within the last 12 years indicating a rapid rise in
research in this area.
87
4. Results
Few examples were found within the literature that
described strategies in detail or reported on their effec-
tiveness in improving the practice environment. However,
those found reflect current practice and provide a useful
starting place for consideration and discussion of inter-
ventions at the unit and organisational level. A summary of
the suggested strategies using the five subscales of the PES-
NWI is provided in Table 1. Two articles reported on
studies with a pre-test post-test evaluation of the reported
strategy. The remaining studies were descriptive in nature
and the strategies were not described in depth. The results
are described in relation to the PES-NWI subscales in the
sections that follow.
4.1. Nurse participation in hospital affairs
An empowering work environment can influence the
ability of nurses to practise professionally and therefore
provide safe quality care (Laschinger et al., 2003; Upenieks,
2003). Empowerment is described as the perception of
being involved and supported, having access to opportu-
nities, resources and power within an organisation (Hayes
et al., 2006). Valuing employee contributions and well-
being has also been linked to job satisfaction. Tourangeau
et al. (2010) used the Perceived Organisational Support
Scale to measure the value organisations placed on
employee contributions and concluded that perceived
organisational support was a factor in job satisfaction. A
number of authors have also identified the characteristics
of an empowered work environment. A decentralised
organisational structure—with a nursing representative on
the hospital executive committee and an open, participa-
tory style of management—are important (Upenieks,
2002). In addition, empowered work environments are
characterised by a shared governance structure that
facilitates the flow of information between nurses at the
bedside and those in leadership (Kramer et al., 2009).
These types of structures provide access to the nursing
executive and give an opportunity for nurses ‘on the
ground’ to voice their concerns and contribute to
organisational change processes (Upenieks, 2002). These
structures also ensure nurses understand the purpose and
rationale behind organisational policies and procedures
which enhances their commitment and involvement
within an organisation (Laschinger and Finegan, 2005).
Nursing staff need to be provided with the necessary
resources to fully participate. This support may include
paid time away from the bedside to attend meetings and
training in skills related to meeting facilitation and
reporting.
4.2. Nursing foundations for quality care
Autonomy is a vital aspect of professional nursing
practice and forms the foundation for quality care. It is
essential for patient safety and is an important element of
nurse job satisfaction (Kramer and Schmalenberg, 2008;
Tourangeau et al., 2010). However, some confusion about
the definition of autonomy in nursing practice is evident in
88
Table 1
Strategies to create positive practice environments.
Nurse participation in
hospital affairs
Nursing foundations
for quality care
Nurse manager ability,
leadership and support
of nurses
Staffing and resource
adequacy
Collaborative nurse–
physician relationships
D. Twigg, K. McCullough / International Journal of Nursing Studies 51 (2014) 85–92
 Empowering work structures, characterised by access to information, support, opportunity and resources,
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).
 Professional practice which is meaningful and effective (O’Brien-Pallas et al., 2010).
 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).
 Managers should aim to be visible, accessible and responsive to their staff (Flynn et al., 2010;
Tourangeau et al., 2010; Grant et al., 2010).
 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).
 Adequate numbers of staff (Trinkoff et al., 2011; Flynn et al., 2010; Kramer and Schmalenberg, 2004;
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.
 Interdisciplinary development of Collaborative Practice Orders, Critical Pathways, and Protocols to encourage
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
the literature. It is not about control of practice and the
ability to self-govern, neither is it providing medical care
without medical supervision but rather:
‘‘. . .the freedom to act on what you know in the best
interests of the patient. . .to make independent clinical
decisions in the nursing sphere of practice and
interdependent decisions in those spheres where
nursing overlaps with other disciplines. . .It often
exceeds standard practice, is facilitated through evi-
dence-based practice, includes being held accountable
in a constructive, positive manner and nurse manager
support.’’ (Kramer and Schmalenberg, 2008, p. 61)
The first empirical study found in the literature
examined the effect of a ‘nursing round’ innovation in
an Australian intensive care unit. Aitken et al. (2011)
suggested nursing rounds could provide a forum for
sharing knowledge and building collegial relationships,
facilitate evidence into practice, and improve autonomy
and decision making which would in turn enhance patient
care and nurses’ work satisfaction (Aitken et al., 2011). In
the intervention intensive care unit, nursing rounds were
held on two days each week for one hour. A senior clinician
lead the forum and participants included: the patient’s
primary nurse who ‘presented’ the patient, the ICU team
leader, the hospital librarian, critical care researcher and
other staff as able. At times, family and other specialist staff
would participate as appropriate. A pre-test post-test two
group comparative design, using both PES-NWI and the
Nursing Worklife Satisfaction Scale (NWSS) as outcome
measures, was used. Results from this study showed the
total PES-NWI and NWSS were similar pre-test and post-
test, however, a significant increase in the subscale
‘nursing interaction’ from the NWSS in the intervention
unit was found when compared to the pre-test and control
group. ‘Changes to patient care’ also increased and were
attributed to the nursing rounds’ intervention suggesting
improvements in care. The authors concluded testing of
rounds in other settings was required in order to
generalise.
Nurses require organisational support for autonomy in
practice. They need to know they will be supported in their
decision making in order to take the risk that things may go
wrong (Kramer and Schmalenberg, 2008). Leaders within
organisations can encourage nurse autonomy by providing
educational opportunities in critical thinking, evidence-
based practice and defining the role and status of nurses
within the organisation (Chan and Lai, 2010; Kramer and
Schmalenberg, 2008). In addition, successful integration of
nursing research and evidence-based practice into all
nursing and organisational decision making (Kramer and
Schmalenberg, 2008) provides a strong framework for
autonomous practice.
Nursing foundations for quality care also include
opportunities for professional development and promo-
tion both of which enhance the practice environment
(Chan and Lai, 2010; O’Brien-Pallas et al., 2010) and reduce
the rate of turnover intention (Hayes et al., 2006). Clinical
ladder programmes support recruitment and retention,
and can be useful in succession planning as they recognise
excellence in nursing and can identify role models,
89
particularly for nurses providing direct patient care
(Pierson et al., 2010). Advancement should be related to
autonomous practice and attainment of competencies
(Kramer and Schmalenberg, 2008) and form part of an
annual performance appraisal process (Pierson et al.,
2010). Clinical ladders often cover several categories such
as: ‘‘. . .education, experience, professional and leader,
provider, teacher and advocate’’ (Pierson et al., 2010, p. 34).
Formal education such as certification in clinical compe-
tencies should be supported and presentation at confer-
ences should be encouraged (Kramer and Schmalenberg,
2008). Recognition of the time needed for professional
roles such as preceptoring and mentoring other staff is also
required (Hogan et al., 2007).
4.3. Nurse manager ability, leadership and support of nurses
The nurse manager can directly influence the practice
environment by applying critical thinking skills to develop
relationships and solve problems (Zori et al., 2010). In
addition, the nurse leader of can be very influential in
developing shared values and culture, creating a sense of
community, and articulating a vision for the future, all of
which contribute to a positive practice environment
(Calarco, 2011). Leadership support is essential to secure
resources to create the best work environment for nursing
practice (Heath et al., 2004). Interestingly, research has
identified that employees resign more often due to the
perceived quality of the manager than the quality of the
organisation (Hogan et al., 2007).
An important aspect of leadership is the ability to
facilitate change and team growth (Davidson et al., 2006).
In order to promote this leadership, managers should be
visible, accessible and responsive to their staff (Flynn et al.,
2010; Tourangeau et al., 2010; Upenieks, 2002). This is
critical as trust and respect between management and
employees is correlated with greater organisational
commitment (Laschinger and Finegan, 2005). Trust and
respect is encouraged by a willingness to share informa-
tion and evidence of a manager’s concern for employee
needs (Laschinger and Finegan, 2005). Anderson et al.
(2010) proposed a Nursing Leadership Values model that
identifies the importance of visibility and communication
between leaders and staff which was developed using the
underlying values of respect and empathy. Models such as
this assist in providing clear leadership expectations.
Professional development for nurse managers is vital to
increase their ability to function as effective leaders.
Current and emerging leaders should be highly trained in
management and clinical skills (Flynn et al., 2010, Trinkoff
et al., 2011) and should be supervised and mentored
(Davidson et al., 2006). Priorities for leadership develop-
ment include: ‘‘honing of emotional and social intelligence
skills, inquiry-based learning, appreciative inquiry, critical
incident analysis, concept mapping, case studies, role play
and dialogue. . . [and] reflective journaling’’ (Zori et al.,
2010, p. 311). Calarco’s (2011) study, the second of two
studies that used empirical methods to assess effective-
ness of an intervention, assessed the effectiveness of a
‘positive organisational leadership’ workshop. Using the
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
of the workshop. However, results showed no increase in
the post-test mean scores of the PES-NWI. The author
suggested evidence of increased use of positive organisa-
tional leadership practices within the studied population
but changes to practice environment scores may take
longer to become evident.
Nurse Managers also face many barriers that affect their
ability to lead effectively. Davidson et al. (2006) identified
a number of such barriers to clinical leadership including:
staffing and resource shortages, organisational structures
with insufficient nurse involvement in decision making,
inadequate models of care, and the trend towards
increased numbers of less-skilled clinicians.
4.4. Staffing and resource adequacy
There are many ways to determine the appropriate
number of nursing staff for a particular unit (Twigg and
Duffield, 2009). Whatever method is used, workloads and
job demands must be manageable to enhance retention
(Schmidt, 2004; Trinkoff et al., 2011). Job demands
include: the unpredictability of patient care, such as rapid
changes in patient acuity (Hayes et al., 2006), conflicting
demands and role expectations between nursing admin-
istrative and medical staff (O’Brien-Pallas et al., 2010), as
well as frequent interruptions, long work hours and the
need to work antisocial hours (Trinkoff et al., 2011). Job
demands may be more effectively managed when staffing
on a unit is stable, as evidenced by minimal use of
temporary (agency) nurses and low staff turnover
(O’Brien-Pallas et al., 2010). Turnover in staff increases
the job demands on existing staff due to additional
requirements of orientation and supervision of new staff.
O’Brien-Pallas et al. (2010) suggest that unstable staffing
threatens the quality of patient care and generates higher
costs associated with decreased morale and productivity
while new staff become competent within the practice
setting. Staffing levels must also be high enough to
facilitate leave requirements as regular breaks from the
workplace are vital for retention (Chan and Lai, 2010).
In addition to adequate numbers of staff, having the
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
roles, there are clearly defined roles and expectations
across the team (O’Brien-Pallas et al., 2010). Clear roles
and expectations build confidence in the team and
having confidence in the clinical competence of co-
workers has been identified as a marker of positive
practice environments (Kramer and Schmalenberg,
2004). Retention of experienced staff (Lake et al.,
2010) provides strength and leadership in the team.
One strategy to retain experienced staff is to provide
good access to education and professional development
(Kramer et al., 2004).
4.5. Collegial nurse–physician relationships
Collaborative relationships between medical and nur-
sing staff (Flynn et al., 2010; Kramer and Schmalenberg,
2004; Schmidt, 2004), facilitated by good communication
and medical leadership (Schmidt, 2004), are elements of a
positive practice environment. The resultant teamwork is
further evidenced when collaboration involves all mem-
bers of the unit rather than just the doctors and nurses
(Schmalenberg et al., 2005a). Collegiality recognises
different spheres of professional practice and that each
person in the relationship has an essential, unique and
equal contribution (Schmalenberg et al., 2005a). Defined
roles and responsibilities, processes for conflict resolution,
and programmes that encourage interdisciplinary partici-
pation build trust and are essential for encouraging
collegial relationships.
Health services can facilitate collegial relationships.
Schmalenberg et al. (2005b) described eight structures
that facilitate nurse–physician relationships within speci-
alty units: interdisciplinary rounds/meetings; collabora-
tive practice orders; critical pathways and protocols;
appointment of high quality competent people; culture
in which concern for the patient is paramount; continuity,
longevity and specialisation; established mechanisms for
constructive conflict resolution; committed unit/service
medical directors and nurse manager support (Schmalen-
berg et al., 2005b). The authors also suggested nurse–
physician relationships may be enhanced in general wards
if the patients are cared for by medical specialty and
physician/nurse teams, thereby encouraging the develop-
ment of specialised knowledge and consistency in patient
care (Schmalenberg et al., 2005b).
Confidence in one’s own ability to practice in a
competent manner is also important when developing
collaborative nurse–doctor relationships (Schmalenberg
et al., 2005b). Inter-professional respect is associated with
competence and Pullon (2008) identified that respect
preceded trust and that trust developed over time but only
in a context of respect for professional competence.
Schmalenberg et al. (2005a) described the concept of
‘banking’ trust whereby the staff on a unit provide such
predictable care that it covers new staff, and trust on an
individual level is not necessary. Respect and trust are
dynamic attributes of the relationship, influenced over
time by situations and experience (Pullon, 2008).
5. Discussion
The nursing practice environment directly impacts
nurse retention and quality of patient care (Aiken et al.,
2011). Nurse participation in hospital affairs; establishing
nursing foundations for quality care; nurse manager
ability, leadership and support of nurses; staffing and
resource adequacy; and collegial nurse–physician rela-
tions are key components of positive practice environ-
ments. Shared governance structures that empower nurses
to influence decisions that affect their practice environ-
ment are critical. Professional practice models that are
meaningful and effective form the foundation of quality
care. Autonomy and professional development require
organisational support. The right numbers of staff with the
right skills and resources, along with minimising job
demands improve quality of care and job satisfaction.
 D. Twigg, K. McCullough / International Journal of Nursing Studies 51 (2014) 85–92
Nurse leaders and managers play a significant role in
developing a positive practice environment. Professional
development and support of these key people is a vital
component of a retention strategy. Nurse–physician
relationships have been identified as a critical aspect of
positive professional practice environments. The culture of
the organisation must be one of collaboration across
disciplines, teamwork and one that puts the welfare of the
patient first. These behaviours must be modelled by
leaders and executives across the organisation (Schmalen-
berg et al., 2005b).
It is vital that organisations consider their practice
environment by first assessing it, using a psychometrically
sound instrument to identify gaps and establish a baseline
from which to evaluate interventions. A formal evaluation
process would then provide the data necessary to decide if
interventions should continue or be expanded dependant
on the extent of improvement in the practice environment.
Evaluating strategies to enhance the practice environment
is critical so that effective strategies can be widely adopted
in practice.
Creating positive practice environments is therefore
an important strategy available to executives and nurse
leaders to enhance nurse retention and improve health
outcomes. However, as this paper illustrates, there is less
evidence to support which strategies aimed at enhancing
the practice environment are most effective. There is
some evidence to support staffing decisions but little
evidence to guide allocation of other resources such as
support roles. Aiken and colleagues recently established
that it is not staffing levels alone that improve patient
outcomes, but that the practice environment is also a
powerful lever (Aiken et al., 2011). The literature search
reported in this paper relied on authors identifying
keywords of nurse, practice environment and nurse
retention. A limitation of this study is that the search
would not have detected papers that may describe
aspects of the practice environment where the relation-
ship to the practice environment construct was not
explicit. In particular, there is a need for evaluative
studies to examine a range of strategies aimed at
improving the practice environment. Rigorous research
strategies need to be developed to evaluate unit specific
initiatives such as the impact of nursing rounds,
collaborative practice orders and shared governance
models. Researchers and nurse leaders need to work in
partnership to develop effective evaluation strategies.
6. Conclusion
This paper aimed to identify strategies that enhance
nurse retention through the creation of positive practice
environments. Several strategies were described using a
framework based on the PES-NWI. However, there appears
to be a lack of readily available information for executives
and managers, particularly strategies that have been
empirically tested for their effectiveness in enhancing
the practice environment. Interventions that aim to
improve the practice environment need to be shared
and evaluated for their effectiveness.
91
Acknowledgement
The authors wish to thank Professor Sian Maslin-
Prothero for her feedback on an early draft of this paper.
Conflicts of interest: None declared.
Funding: None.
Ethical approval: Not required.
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