Characteristics of the Nursing Practice Environment Related to Creating Healthy Work Environments for Nurses

Saturday, 18 March 2017: 11:15 AM

Yasuko Ogata, PhD, MM
Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo,113-8519, Japan
Kimiko Katsuyama, PhD
School of Medicine Nursing Course, Graduate School of Medicine Department of Nursing Management, Yokohama City University, Yokohama-city, 236-0004,, Japan
Sachiko Tanaka, PhD
School of Nursing, The Jikei University, Tokyo, 182-8570, Japan
Midori Nagano, MSN
School of Nursing, The Jikei University, Tokyo 182-8570, Japan
Yoshie Yumoto, MSN
Department of Gerontological Nursing and Care System Development, Tokyo Medical and Dental University, Tokyo 113-8519, Japan
Masaomi Ikeda, PhD, BSc
Oral Prosthetic Engineering, Graduate School, Tokyo Medical and Dental University, Tokyo, 113-8549, Japan


An advanced aging population demands increasing nursing services for the elderly. Therefore, identifying organizational factors that affect the job retention of nurses is urgently needed. There is a positive relationship between a healthy work environment (HWE) and the retention of nurses in a hospital setting (Ritter, 2011). Furthermore, a healthy work environment and Magnet status have a strong connection (Ritter, 2011). The Practice Environment Scale of the Nursing Work Index (PES-NWI) is one of the measurements that were developed based on the characteristics of magnet hospitals in the 1980s (Lake, 2002). Previous studies of the PES-NWI demonstrated that its scores were significantly related to nurse outcomes, patient outcomes, and organizational variables such as nurse turnover (Warshawsky & Sullivan Havens, 2011; Ogata et al., 2011). The PES-NWI (Lake, 2002) includes as one of its five subscales “Nurse Manager Ability, Leadership, and Support of Nurses,” which is similar to the key standards of HWE by the American Association of Critical-Care Nurses (AACN), which are “Skilled Communication,” “True Collaboration,” “Effective Decision Making,” “Appropriate Staffing,” “Meaningful Recognition,” and “Authentic Leadership.”

The purpose of this study is to explore how the nursing practice environment, including nurse managers’ leadership, is related to staff nurses’ self-rating of their health condition and their tendency to remain working in their hospitals.


In this study, two types of mail surveys were done by anonymous self-report questionnaire. The first mail survey was carried out for 7,434 staff nurses working at 22 hospitals in Japanese cities such as Tokyo, Yokohama and Osaka. For that survey, nursing directors from the 647 hospitals that had more than 200 beds and were located in cities with population higher than 200,000 were invited to join the study. From that number, 22 hospitals joined the survey in September and October 2014. University hospitals were excluded, because of the differences in the type of care offered; the main functions of university hospitals differ from those of non-university hospitals. In the questionnaire, nurses were asked questions of the PES-NWI, their self-rated health condition, items of the Kessler Psychological Distress Scale (K6), whether they would work at the same hospital next year or not, and their characteristics as nurses.

In the second mail survey, in order to identify whether nurse participants had left their hospitals or not, Directors of Nursing of the 22 hospitals were asked the ID numbers of nurses who had resigned from the hospital at the end of the fiscal year, namely the end of March 2015. The ID numbers had been originally decided by the nursing department of each participating hospital, without disclosing the names associated with the numbers.

Logistic regression analyses were done, with nurses’ self-rated health condition (healthy = 1, unhealthy = 0), K6 (5 or more = 1, 4 or less = 0)*, “intention to retain or leave the hospital next year (remain = 1, leave = 0),” whether or not they had resigned from the hospital (remain = 1, resign = 0), and the five sub-scales and composite of the PES-NWI (range: 1.0 to 4.0, the neutral midpoint: 2.5), as independent variables. In all models of the logistic regression analysis, categories of nurse age were used as control variables. Before the first survey, ethics committee approval was obtained in June 2014 from the Tokyo Medical and Dental University (Ethics Approval no.1674), where the first author serves on the faculty.

* For Japanese populations, a K6 score of 5 or greater indicates the high possibility of a diagnosis of depression.


Among the 3,066 participants (response rate: 41.2%), the 2,206 full-time nurses’ answers that had no missing values for the PES-NWI items and the ID numbers were analyzed (ratio of valid responses: 80.0%). The average age of the nurse respondents was 33.3 years old; 93.6% of them were female; 68.8% of them rated “healthy” for their health condition; 41.7% rated higher than 5 for K6 (range: 0-24), which is a screening measure of depressive tendency; 79.4% of them intended to remain at the hospitals in the next year; and 7.1% of them had actually resigned. Cronbach’s alpha coefficients of the sub-scales of the PES-NWI were from 0.79 to 0.88.

Two sub-scales (OR: 1.61 and 1.74) out of five, including “Nurse Manager Ability, Leadership, and Support of Nurses (nurse managers’ leadership),” and the composite (OR: 3.48) of the PES-NWI were significantly associated with the nurses’ self-rated health condition (healthy = 1, unhealthy = 0) (p<0.001). Three sub-scales (OR: 0.66-0.74) out of five, including nurse managers’ leadership, and the composite (OR: 0.39) of the PES-NWI were significantly associated with the nurses’ K6 scores (more than 5 = 1, 4 or less = 0) (p<0.05). Similarly, three sub-scales (OR: 1.36-1.92) out of five, including nurse managers’ leadership, and the composite (OR: 3.42) of the PES-NWI were significantly associated with the nurses’ intention to remain (remain = 1, leave = 0) (p<0.05). Regarding nurses’ resignation behavior (remain = 1, resign = 0), although the subscales of the PES-NWI were not related, the composite (OR: 1.59) was significantly related (p<0.05).


“Nurse Manager Ability, Leadership, and Support of Nurses” is an important part of the nursing practice environment; managers’ behaviors significantly affect staff nurses’ physical and mental health and their intention to remain in or leave their job. To create a healthy work environment for nurses, authentic leadership by managers that is respected by the staff nurses is vital. The relationship between the nursing practice environment and whether they actually resigned showed that creating an attractive nursing practice environment was an important factor for retaining nurses in their hospitals. In order to assess whether there is a causal relationship among nursing practice environment and nurses’ retention over a longer period, more long-term longitudinal research is needed.