Favorable nurse work environments in hospitals have been associated with positive nurse, patient, and organizational outcomes.1-7 The Magnet® hospital model is known for excellent nurse work environments, which incorporates standards that work together to create and maintain exceptional work settings for nurses. Initially, Magnet hospitals were those that attracted and retained nurses during a nursing labor shortage.8 Over time, the American Nurses Credentialing Center developed the Magnet Recognition Program® to designate hospitals that have invested in nursing and have highly favorable nurse work environments.9 This certification process is rigorous, demanding, and typically involves widespread organizational culture change, which could account for the small number (8.9%) of all US hospitals that have achieved this designation.9
Since the earliest Magnet hospitals were certified, various research studies have evaluated differences in the nurse work environments among Magnet and non-Magnet hospitals. One systematic review of 10 low to medium quality studies found no differences in patient or nurse outcomes in Magnet hospitals compared with non-Magnet hospitals.10 However, a more recent systematic review of 21 published articles found that 86% of these studies reported better outcomes in Magnet hospitals.11
Although Magnet hospitals are known for their superior patient, nurse, and organizational outcomes,11,12 the Magnet model is not the only hospital model associated with highly favorable nurse work environments. Recent work has shown that hospitals in the Kaiser Permanente system have nurse work environments and outcomes comparable with Magnet hospitals, yet none of the reported system hospitals were Magnet certified.13 McHugh and colleagues13 attributed Kaiser Permanente's success to investments in professional nursing and recognition of nursing as the “glue that holds hospitals together.” Other researchers have found that US Veterans Health Administration (VA) hospitals have positive work environment characteristics similar to Magnet hospitals.14
For more than 2 decades, this research team had used the Practice Environment Scale of the Nursing Work Index (PES-NWI) to measure and evaluate the nurse work environment in military hospitals.15 We noted overall favorable scores in US military (largely Army) hospitals. The US government-funded Military Health System cares for military service members, retirees, and their families worldwide. It is the 2nd largest healthcare system in the United States,16 with the VA being the largest.17 Features within the military hospital nurse work environments are similar to those in Magnet hospitals. This study, for the 1st time, directly compared PES-NWI scores between Army and multiservice military hospitals with those from civilian hospitals participating in the National Database for Nursing Quality Indicators (NDNQI). Specifically, the goal of this article is to report a comparison of the nurse work environments, job satisfaction, and intent to leave (ITL) among military, Magnet, Magnet-aspiring (ie, those in the process of applying for Magnet status), and non-Magnet civilian hospitals.
Adequate staffing, managerial support for nurses, a culture that emphasizes quality nursing care, and good nurse-physician relationships are characteristics of hospitals' excellent nurse work environments. A favorable nurse work environment is an important organizational characteristic associated with positive nurse and patient outcomes. Favorable professional nurse work environments have been associated with lower nurse burnout1,2 and lower occupational injuries,3,4 in addition to higher job satisfaction5,6 and lower intent to leave the job.5,6 Exceptional nurse work environments are associated with higher nurse-rated quality of care2 and lower rates of adverse events1,5 and patient mortality.5-7 Consequently, nurse work environments are crucial for safe, high-quality patient care and should be a key concern for all nurse leaders, regardless of hospital type or Magnet accreditation status.
Thus, our research team was motivated to determine if military hospitals could be yet another type of organization to have nurse work environments similar to those in Kaiser and Magnet hospitals. A 2104 external review of the Military Health System further inspired this research. Reviewers recommended broad use of nursing-sensitive quality and safety indicators in the military's comprehensive measurement system.18 The purpose of this article is to explore the nurse work environment, job satisfaction, and intent to leave in military hospitals compared with Magnet, Magnet-aspiring, and non-Magnet civilian hospitals.
Sample, Setting, and Data Source
This was a descriptive, correlational analysis using secondary data from the Impact of Nursing on Readmissions, Failure to Rescue, and Mortality in Department of Defense Hospitals (TriService Nursing Research Program grant number N16-PO8) study. We analyzed data from 2014 that were obtained from a routine survey of nursing staff within 22 military hospitals. Civilian hospital staff nurse data were obtained from the NDNQI for the same year (N = 71 Magnet, 55 Magnet-aspiring, and 164 non-Magnet hospitals). The NDNQI is a voluntary nursing quality registry owned by Press Ganey Associates. The parent study aimed to compare outcomes based on the Centers for Medicare and Medicaid Hospital Compare data; therefore, these NDNQI hospitals were selected on the basis of whether they contributed to the 2014 Hospital Compare dataset.
Both data sets measured the nurse work environment using the PES-NWI.19,20 The subscales for the PES-NWI are nurse participation in hospital affairs (NPHA) (9 items); nursing foundations for quality care (10 items); nurse manager ability, leadership, and support of nurses (5 items); staffing and resource adequacy (SRA) (4 items); and collegial nurse-physician relationships (NPR) (3 items). We compared the composite and subscale scores among the military and civilian hospitals in this study.
Job satisfaction and intent to leave the organization are nurse outcomes frequently examined in relation to the nurse work environment. Job satisfaction was assessed with a single-item measure that asked, “Overall, how satisfied are you with your current job?” We used a 4-point Likert-type scale from 1 = very dissatisfied to 4 = very satisfied to force a negative or positive response. The scale was dichotomized for the analysis (very dissatisfied and dissatisfied vs satisfied and very satisfied). The most similar item on the NDNQI survey was, “As RNs, we are fairly well satisfied with our jobs on our unit” using a 6-point Likert-type scale that we dichotomized. The intent to leave was evaluated on the military survey with the question, “If you could leave your job (ie, you or your spouse had no military or other obligations), would you? The responses were categorical, with no or yes, within 3 months, 6 months, or 12 months. This measure was collapsed into no and yes for the analysis. The NDNQI survey from the civilian hospitals included an intent to leave item, “What are your job plans for the next year?” Nurses were considered as intending to leave their job (ie, yes) if they selected any choice except “stay in my current position” (ie, no). We aggregated individual nurse responses to the hospital level. For this study, we did not report survey demographics because no identifying information was collected for military surveys because of concerns for confidentiality. This study was determined to be Not Human Subjects Research by the institutional review board of the University of Alabama at Birmingham, with concurrence by the Uniformed Services University.
Descriptive statistics were calculated for all study variables. Because of the nonnormal distribution of the residuals of the variables in the military dataset, the Kruskal-Wallis test was used to compare median ranks of PES-NWI composite and subscales, job satisfaction, and intent to leave scores between military, civilian Magnet, civilian Magnet-aspiring, and civilian non-Magnet hospitals.
For work environment, Magnet hospitals scored better than non-Magnet and Magnet-aspiring hospitals in all PES-NWI subscale and composite scores; however, the differences were only significant between Magnet and non-Magnet civilian hospitals. Mean military and Magnet hospitals' PES-NWI composite scores were identical (M = 2.97). Military hospitals scored higher than Magnet hospitals on the SRA subscale (M = 2.88, SD = 0.30 vs M = 2.64, SD = 0.25; P = .005). Magnet hospitals scored higher than military hospitals on all other subscales; however, the only statistically significant difference was on the NPHA subscale (M = 2.92, SD = 0.20 vs M = 2.76, SD = 0.26; P = .03). Military hospitals outperformed non-Magnet and Magnet-aspiring hospitals on the SRA subscale (M = 2.88, SD = 0.30 vs M = 2.57, SD = 0.28; P = .002 and M = 2.61, SD = 0.22; P = .001, respectively) and outperformed non-Magnet hospitals on the NPR subscale (M = 3.18, SD = 0.23 vs M = 3.01, SD = 0.19, P = .006). Job satisfaction scores were higher in military hospitals than in the other 3 civilian hospital categories, but these differences were not statistically significant. Intent to leave scores were much higher and statistically significant in military hospitals compared with the other 3 types of hospitals (Tables 1 and 2).
Table 1 -
Summary Statistics of Variables by Hospital Type
||Military, Mean ± SD (Median)
||Magnet, Mean ± SD (Median)
||Aspiring, Mean ± SD (Median)
||Non-Magnet, Mean ± SD (Median)
||N = 22
||N = 71
||N = 55
||N = 164
||Effect Size, η2
|Nurse participation in hospital affairs
||2.76 ± 0.26 (2.78)
||2.92 ± 0.20 (2.91)
||2.90 ± 0.22 (2.92)
||2.81 ± 0.22 (2.80)
|Nurse foundations for quality care
||3.10 ± 0.18 (3.08)
||3.16 ± 0.14 (3.16)
||3.13 ± 0.14 (3.14)
||3.07 ± 0.16 (3.05)
|Nurse manager ability, leadership, and support
||2.93 ± 0.35 (2.97)
||3.05 ± 0.20 (3.08)
||3.02 ± 0.19 (3.03)
||2.97 ± 0.22 (2.96)
|Staff and resource adequacy
||2.88 ± 0.30 (2.89)
||2.64 ± 0.25 (2.67)
||2.61 ± 0.22 (2.64)
||2.57 ± 0.28 (2.56)
|Collegial nurse-physician relations
||3.18 ± 0.23 (3.19)
||3.10 ± 0.15 (3.08)
||3.06 ± 0.17 (3.06)
||3.01 ± 0.19 (3.02)
||2.97 ± 0.22 (3.02)
||2.97 ± 0.16 (2.96)
||2.95 ± 0.16 (2.97)
||2.88 ± 0.19 (2.88)
||73.19 ± 10.06 (74.00)
||67.68 ± 14.88 (68.24)
||65.92 ± 16.38 (67.10)
||64.55 ± 16.85 (65.00)
|Intent to leave
||46.10 ± 8.23 (47.00)
||15.29 ± 6.28 (15.62)
||16.54 ± 6.75 (16.28)
||17.71 ± 8.30 (16.59)
Table 2 -
Pairwise Post Hoc Comparison, P
Values Are Reported
||Hospital Type Comparisons
||Military vs Magnet
||Military vs Aspiring
||Military vs Non-Magnet
||Magnet vs Aspiring
||Magnet vs Non-Magnet
||Aspiring vs Non-Magnet
|Nurse participation in hospital affairs
|Nurse foundations for quality care
|Nurse manager ability, leadership, and support
|Staff and resource adequacy
|Collegial nurse-physician relationships
|Intent to leave
This was the 1st study to directly compare military and civilian nurse work environments. We found that military hospitals' scores were identical to those of civilian Magnet hospitals on the composite score of the PES-NWI. This indicates that military hospitals may be another model for excellence in nurse work environments. However, when viewing the subscale components of the PES-NWI, there were notable differences.
An average of the subscales determines the composite score of the PES-NWI. It is clear from our analysis that the staffing and resource adequacy and the collegial nurse-physician relations subscales, which were rated much higher by nurses in military hospitals, contributed to the high PES-NWI composite score in military hospitals. Military hospitals seem to be better resourced than civilian hospitals in personnel and material resources. This could be related to the military's mission, which is to always be ready to deploy whenever and wherever needed; thus, having adequate resources to support this mission is essential. In addition, military hospitals scored high on the PSE-NWI nurse-physician relations subscale. Because of the equalizing military rank structure, staff nurses routinely outrank physicians, altering the perceived hierarchy observed in civilian hospitals.21
Military hospitals scored lower than Magnet and other civilian hospitals in other aspects of the nurse work environment, particularly the nurses' participation in hospital affairs. This may be a function of military culture and governance, in that more senior leaders assume the responsibility for decision-making. The military hospitals also scored lower than all types of civilian hospitals on the nurse manager ability, leadership and support of nurses subscale. Military nurses are provided with leadership opportunities, such as serving as a nurse manager, within 3 to 5 years after their bachelor of science in nursing graduation. Unlike most civilian hospitals' nurse managers, they also rotate to new geographic assignments every 2 to 3 years; thus, the nurse managers in military hospitals change frequently. As a result, many military nurse managers are relatively inexperienced. As nurse managers are known to influence nurse and patient outcomes,22 this experience and turnover tradition should be further explored.
Although not statistically significant, job satisfaction scores were higher in military hospitals than in the other 3 civilian hospital categories. However, intent to leave was significantly higher in military hospitals compared with the other 3 types of hospitals. In a previous article, we addressed the need to explore the reasons why nurses intend to leave their jobs and coined the term “potentially preventable losses.”23 In that article, evidence was provided that although intent to leave is high, the preventable reasons for leaving, or those that management has control over, are low. Further research is needed to compare reasons for intent to leave between military and civilian hospitals to determine if there are differences in potentially preventable loss. Because of the nature of military work assignments, it could be that although intent to leave is higher than in civilian hospitals, potentially preventable reasons, such as conflict with team members or dissatisfaction with schedule, are lower.
The PES-NWI has become a gold standard in measuring the work environment in hospitals and units.24 Using this particular instrument allows comparisons across various forms of hospital nursing organization. This research and that of others demonstrate that certain types of hospitals have inherently created good work environments for nurses.13 Other than Magnet, there are likely other hospital or even unit-specific models that have excellent work environments for nurses. On the basis of 2 decades of research findings, these excellent environments in which nurses work lead to better patient, nurse, and organizational outcomes. Future research should explore and distill the “secret sauce” that leads to the development and sustainment of excellent work environments for nurses.
The limitations of this study were the cross-sectional nature of our secondary data, which deters us from reporting any causation. In addition, because we wanted to compare the work environment directly, we did not include any control variables in our analyses. Furthermore, the civilian hospital sample may not be representative of civilian hospitals in the United States because the NDNQI is a voluntary and proprietary registry. Finally, intent to leave and job satisfaction were assessed using items that were similar, but not exactly the same, between the military and NDNQI surveys.
The nursing work environment is intimately tied to patient, nurse, and organizational outcomes. We found that Magnet hospitals and military hospitals have identical composite scores on the PES-NWI. However, the subscale scores must be further explored to determine areas for improvement. This work is a step toward better understanding the composition and dynamics of the nurse work environment. Our research suggests that there are other aspects beyond Magnet recognition to achieve optimal outcomes in hospital settings.
1. Montgomery AP, Azuero A, Baernholdt M, et al. Nurse burnout predicts self-reported medication administration errors in acute care hospitals. J Healthc Qual
2. Montgomery AP, Patrician PA, Azuero A. Nurse burnout syndrome and work environment impact patient safety grade. J Nurs Care Qual
3. Clarke SP. Hospital work environments, nurse characteristics, and sharps injuries. Am J Infect Control
4. Wu Y, Zheng J, Liu K, et al. The associations of occupational hazards and injuries with work environments and overtime for nurses in China. Res Nurs Health
5. Aiken LH, Sloane DM, Clarke S, et al. Importance of work environments on hospital outcomes in nine countries. International J Qual Health Care
6. Lake ET, Sanders J, Duan R, Riman KA, Schoenauer KM, Chen Y. A meta-analysis of the associations between the nurse work environment in hospitals and 4 sets of outcomes. Med Care
7. Olds DM, Aiken LH, Cimiotti JP, Lake ET. Association of nurse work environment and safety climate on patient mortality: a cross-sectional study. Int J Nurs Stud
8. McClure ML, Poulin MA, Sovie MD, Wandelt MA. Magnet Hospitals: Attraction and Retention of Professional Nurses. American Academy of Nursing. Task Force on Nursing Practice in Hospitals. Kansas City, MO: American Nurses Association; 1983.
9. American Nurse Credentialing Center. About Magnet: new 2020 Magnet mission and vision statement [Internet]. American Nurse Credentialing Center. https://wwwnursingworldorg/organizational-programs/magnet/about-magnet
. Accessed August 2, 2021.
10. Petit Dit Dariel O, Regnaux JP. Do Magnet®-accredited hospitals show improvements in nurse and patient outcomes compared to non-Magnet hospitals: a systematic review. JBI Database System Rev Implement Rep
11. Rodríguez-García MC, Márquez-Hernández VV, Belmonte-García T, Gutiérrez-Puertas L, Granados-Gámez G. Original research: how Magnet hospital status affects nurses, patients, and organizations: a systematic review. Am J Nurs
12. Salmond SW, Begley R, Brennan J, Saimbert MK. A comprehensive systematic review of evidence on determining the impact of Magnet designation on nursing and patient outcomes: is the investment worth it?JBI Libr Syst Rev
13. McHugh MD, Aiken LH, Eckenhoff ME, Burns LR. Achieving Kaiser Permanente quality. Health Care Manage Rev
14. Sales AE, Sharp ND, Li YF, et al. Nurse staffing and patient outcomes in Veterans Affairs hospitals. J Nurs Adm
15. Patrician PA, Loan LA, McCarthy MS, et al. Twenty years of staffing, practice environment, and outcomes research in military nursing. Nurs Outlook
16. Military Health System. About the military health system [Internet]. Health.mil
. Accessed August 21, 2021.
17. US Department of Veterans Affairs. Veterans Health Administration [Internet]. US Department of Veterans Affairs. https://www.va.gov/health/
. 2021. Accessed August 2, 2021.
18. Department of Defense. Final Report to the Secretary of Defense: Military Health System Review
. Washington, DC: Department of Defense; 2014.
19. Lake ET. Development of the practice environment scale of the Nursing Work Index. Res Nurs Health
20. Swiger PA, Loan LA, Raju D, Breckenridge-Sproat ST, Miltner RS, Patrician PA. Relationships between Army nursing practice environments and patient outcomes. Res Nurs Health
21. Patrician PA, Shang J, Lake ET. Organizational determinants of work outcomes and quality care ratings among Army Medical Department registered nurses. Res Nurs Health
22. Wong CA, Giallonardo LM. Authentic leadership and nurse-assessed adverse patient outcomes. J Nurs Manag
23. Breckenridge-Sproat ST, Swiger PA, Belew DL, Raju D, Patrician PA, Loan LA. A program evaluation of the Patient CaringTouch System: a pre- and postimplementation assessment. Nurs Outlook
24. Swiger PA, Patrician PA, Miltner RSS, Raju D, Breckenridge-Sproat S, Loan LA. The Practice Environment Scale of the Nursing Work Index: an updated review and recommendations for use. Int J Nurs Stud