Psychiatric nurses’ preferences for job: a discrete choice experiment

Mental disorders are increasingly acknowledged as a significant contributor to the global disease burden, and more than one billion people worldwide suffer from mental disorders [1], resulting in 418 million disability-adjusted life years [2]. People with mental disorders face an elevated risk of chronic illness and suicide, coupled with a shortened life expectancy [3‐6]. By 2030, mental disorders will be number one in the global burden of disease, with economic costs rising to $6 trillion [2, 6]. The burden of mental illness has become an urgent global public health issue, and the Lancet Global Commission on Sustainable Development of Mental Health emphasizes that mental health care is a fundamental human right, and should be integrated into the global response to other health priorities [7].

However, the severe shortage of psychiatric workforce [8, 9] makes it unfeasible to provide mental health care to meet the growing mental/mental health needs of patients [10, 11]. This issue is particularly pressing in middle- and low-income countries, where the mental healthcare workforce continues to be largely overlooked [12], and the shortage of psychiatric labor is even pronounced, thereby hindering numerous patients’ access to psychiatric services [8, 9, 13, 14]. Nurses, constituting the largest healthcare professional group, can play a huge role in mental health care [8, 9]. Nonetheless, a critical shortage of psychiatric nurses currently persists [11]. In developing countries, exemplified by China, the number of nurses employed in psychiatric hospitals stands at approximately 96,000¹⁰, which is substantially lower than the number of psychiatric nurses in most countries in the world. Factors such as workplace violence (WPV), job dissatisfaction, and burnout exacerbate the turnover rates among these nurses [15], thereby intensifying the shortage of psychiatric nurses and further restricting the accessibility of mental and psychological healthcare services.

Developing effective strategies to attract and retain psychiatric nurses to provide mental health services for patients with mental disorders remains a persistent challenge, which is further complicated by the lack of publicly available data on psychiatric nurses’ job preferences. The existing literature has identified job characteristics that are important to nurses, such as income [16, 17], but has not adequately demonstrated how psychiatric nurses can make trade-offs between desirable and undesirable job characteristics to determine the best possible choice.

Discrete Choice Experiment (DCE) is based on the theory of random utility and can investigate individual preferences and quantify the relative importance of factors that influence decision making [18, 19]. Random utility theory is a decision theory that holds that the utility obtained by a decision-maker for a certain decision is a random variable rather than a definite value. Numerous studies have used discrete choice experiments to understand the determinants of nurses’ job preferences, including financial and non-financial factors that influence job, workplace, or specialization choices [17, 20]. However, these studies did not explore the determinants of psychiatric nurses’ job choices. Given the unique characteristics and nature of hospitalized psychiatric patients, psychiatric nurses will more factors affect the choice of psychiatric nurses [21, 22]. Consequently, the findings from prior studies provide only limited reference for the development of effective strategies to attract and retain psychiatric nurses. We applied a DCE to understand which factors might most support the recruitment and retention of psychiatric nurses.

Although this is an important management decision in healthcare human resources, little is known about the preferences of psychiatric nurses in terms of economic and other non-economic attributes when developing strategies to attract or retain them. For policy makers or decision makers, our study provides compelling evidence regarding the relative importance of factors that may influence career-related decisions for psychiatric nurses, identifies highly valued job characteristics that can be modified at the hospital or health system level, and complements the international literature.

Financial incentive, particularly income enhancement, is an important driving force for psychiatric nurses to choose jobs, and many previous studies have confirmed our findings [17, 29, 30]. Nonetheless, other non-economic attributes seem more important. Attribute level ‘Violent coping strategies-Impeccable’ emerged as the foremost among psychiatric nurses’ preferences for job, and psychiatric nurses had the highest willingness to pay for it. This finding is not consistent with the results of previous studies [17, 31], in which nurses most preferred cohesive team with frequent interaction. The reasons for this difference may be multifactorial. Firstly, our study specifically targeted psychiatric nurses, whereas the aforementioned studies did not exclusively focus on this subgroup. Secondly, they were conducted in the United States, a developed country, while our study was conducted in China, a developing country, where economic development levels and cultural contexts differ significantly. A study conducted in China that confirmed registered nurses’ preferences for safety and security in ‘Internet plus’ nursing services through a discrete choice experiment [32], which is consistent with our research results. Our findings reflect the emphasis psychiatric nurses place on safety, which is in line with global trends. Psychiatric nurses frequently encounter unstable patients with mental or affective disorder [33‐35], so the situations they face in clinical practice are more complex and unpredictable [36]. There is research confirming that the incidence of workplace violence against psychiatric nurses is relatively high [35, 37], with 84.2% experiencing verbal and/or physical workplace violence within a year [33]. Consistent with this, 83.88% of the psychiatric nurses in our study had experienced workplace violence. The complexity of the work environment and the experience of workplace violence have heightened their emphasis on safety. Therefore, they prefer impeccable-violent coping strategies and demonstrate a heightened willingness to pay to obtain this attribute level.

High level of respect was the second most important attribute for psychiatric nurses. The public image of nursing is the subject of longstanding challenges [38, 39]. Although in the past few decades, the strong educational foundation of the global nursing profession has enabled nursing to make significant progress towards professionalization based on scientific theory [40]. However, discrimination and injustice persist between nursing and medical professions [41], and nurses are still seen as dependent on doctors [42, 43]. This outdated public stereotype contributes to the low social recognition for nurses. Furthermore, the professional identity of Chinese psychiatric nurses is relatively low [44]. Chinese managers often adopt a restrictive approach to the prioritization of psychiatric care [45], which may limit the voice of psychiatric nurses in clinical practice. All of this elucidate why psychiatric nurses value high levels of respect. Media portrayal is a major source of public understanding of the role of nurses and has a significant impact on public perceptions of nursing [46, 47]. Therefore, enhancing the media portrayal of nurses’ images to foster a correct understanding of their roles among the public and elevate the professional identity of psychiatric nurses may be a way to improve the respect of nurses, and then attract and retain psychiatric nurses with potential.

The job characteristics that were important to psychiatric nurses in our study reflected the expectations psychiatric nurses had for organizational culture. Some of our attributes are similar to previous discrete choice experiments involving nurse job choices, such as income [17, 29], but our study also introduced novel and timely attributes. For instance, the violence coping strategy reflects the desire for safety of psychiatric nurses under the high incidence of workplace violence. Similarly, the interactive and cohesive work atmosphere echoes the increasing emphasis on teamwork and collaborative care as drivers of patient care [48]. As young nurses join the workforce, the setting of attribute ‘study assistance for children’ responds to the changing expectations of staff regarding work-life balance [49].

We found that psychiatric nurses living in cities preferred higher levels of respect, whereas those living in towns prioritize thorough study assistance for their children. We speculate that this disparity stems from variations in economic development. In China, there is a large gap between city and town in terms both governmental financial income and residents’ income [50], and lower financial income makes less investment in education, so the accessibility of quality educational resources in towns or rural areas is not as good as that in urban areas [51]. Therefore, psychiatric nurses living in towns value the thorough study assistance for children most. Higher income makes psychiatric nurses living cities have higher esteem needs, which is in line with Maslow’s hierarchy of needs. Meanwhile, there are differences in job preferences among nurses with different years of work seniority. Job choice is a complex issue, and in addition to job characteristics, personal, family, social, economic, and other related variables are also significant influencing factors that cannot be ignored [52]. Therefore, the regional and seniority differences of nurses should be fully considered when formulating talent attraction and retention strategies.

The simulation results showed that changes in single job characteristics and/or combinations of multiple job characteristics affected psychiatric nurses’ job choice to different degrees. Although the optimal job characteristics have the greatest impact on the job choices of psychiatric nurses, it is crucial to acknowledge that China, as a developing nation, may face practical constraints in promptly and comprehensively enhancing all job attributes. Fortunately, establishing impeccable violence response strategies and increasing monthly income by 3000 yuan can significantly increase the probability of psychiatric nurses choosing to work. Therefore, regions with high economic development can attract and retain psychiatric nurses by increasing monthly income and improving violence response strategies. For regions with lower levels of economic development, establishing and improving violence response strategies may be a more cost-effective approach.

Some limitations in our study should be recognized. Firstly, in our study, most of the participants had suffered from workplace violence, which to some extent led to the bias of the results. It is worth noting that the proportion of nurses who had suffered from workplace violence in our study was similar to that in a previous study [33]. Secondly, the unlabeled design used in this study may have introduced bias, and it should be acknowledged that the unlabeled approach helped to identify the work preferences of psychiatric nurses more accurately. Finally, although subgroup analysis showed that participants with different demographic characteristics had different preferences, the overall preferences of participants were universal. One important reason may be that our scenario only considers a limited number of attributes, which to some extent limits our discussion of the results. Further studies that include more diverse psychiatric nurses from different regions with more attribute exploration may be an important direction for future research.

Psychiatric nurses would prefer jobs with higher income, more respect, better coping strategies with violence, better opportunities for promotion, and a good working atmosphere. Psychiatric nurses with different seniority and residence had different preferences. Policy makers should consider these preference differences when developing policies/strategies to attract and retain psychiatric nurses.