Applied Nursing Research 55 (2020) 151316

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Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

Why nurses stay: Analysis of the registered nurse workforce and the T
relationship to work environments
⁎
Anita C. Reinhardt (PhD, RN)a, , Teresa G. León (PhD, RN)a, Anup Amatya (PhD)b
a
School of Nursing, College of Health and Social Services, New Mexico State University, Las Cruces, NM 88003-8001, United States of America
b
Department of Public Health Services, College of Health and Social Services, New Mexico State University, Las Cruces, NM 88003-8001, United States of America

A R T I C LE I N FO A B S T R A C T

Keywords: Aim: To examine how factors such as a sense of belonging to a nursing work group, work environmental
Nursing characteristics, and workplace violence effects the duration of employment in professional settings in a south-
Work environment west region of the United States.
Belongingness Design: The descriptive correlational survey study conducted in 2014.
Conflict
Methods: A random sample of 700 licensed registered nurses (RN) from a Board of Nursing's list of currently
Magnet® hospitals
Embeddedness
licensed RNs' (approximate n = 2300). Participants completed and returned four survey tools to the principal
Nurse retention investigator. The return rate was 36.8% (258/700).
Results/findings: Analysis indicated that a sense of belonging, as well as supportive workplace characteristics,
played a role in why nurses stay. The three survey tools provided strong correlations in the survey data and
further authenticated the tools' reliability. A healthy work environment supports nurse retention.
Conclusion: The three survey tools used in this study showed substantial and significant correlations. Although
not all sub-scales correlated, those that did had strong Cronbach alpha scores. The weakest correlations were
with the belongingness scale. Rapid turnover rates of nursing staff continue to plague healthcare organizations.
A variety of reasons including difficult practice settings and stressful work environments contribute to the
outflow of nurses.
Impact: Health care administration and management leaders can improve retention via their efforts to continue
to create and sustain healthy work environments that address affiliation, belongingness, and the characteristics
that attract and retain nurses.

1. Introduction 2. Background

Work environments impact job satisfaction, collaborative care, and
patient outcomes (Scruth, Garcia, & Buchner, 2018; Wan, Li, Zhou, &
Shang, 2018; White, 2018). The nursing profession is challenged by the
ever-increasing needs of an aging population, significant shortages of
qualified nurses, and complex health care changes (Wei, Sewell,
Woody, & Rose, 2018). The workplace environment becomes a critical
component to the delivery of health care (Christmas, 2008). The factors
that lead to workplace appeal, employee engagement and retention of
experienced nurses are the focus of this project and understanding why
nurses stay with their healthcare employers in the region (Lewis &
Cunningham, 2016; Manning, 2016; Scrignaro, Marini, Magrin, &
Borreani, 2018; Wan et al., 2018).
There is a lack of research exploring the relationship of professional
affiliation seen in a sense of belonging with the effects of the char-
acteristics in the work environment. This survey study sought to better
understand the aspects of work environments that nurses desire, and to
identify if a sense of belonging made an impact on retention. New re-
search on this topic is essential because dynamic changes have occurred
in employment trends for nurses in the southwestern region of the
United States (Casterle, Willemse, Verschueren, & Milisen, 2008;
Freeman, 2008; Goldsworthy, 2016a; Huston, 2008).
With the looming tsunami of aging and retiring population on the
horizon, the healthcare field needs to retain both new and experienced
nursing personnel. Prior research about the nursing work environments
identified organizational constructs that promote effective and positive
work environments and encourage the retention of nurses (Aiken, 2002;

⁎
Corresponding author.
E-mail addresses: acrein@nmsu.edu (A.C. Reinhardt), tleon@nmsu.edu (T.G. León), uicwebmail@gmail.com (A. Amatya).

https://doi.org/10.1016/j.apnr.2020.151316
Received 30 January 2020; Received in revised form 21 May 2020; Accepted 3 June 2020
0897-1897/ © 2020 Published by Elsevier Inc.
A.C. Reinhardt, et al.
McClure, 2005; McClure, Poulin, & Sovie, 1983). These constructs in-
clude professional autonomy, control of practice, collegial commu-
nication, organizational support, and moderate/manageable stress le-
vels (Reinhardt, 2010). These constructs of a healthy work environment
are shown to assist in nurse retention, primarily by increasing employee
engagement and connection to the workplace (Bugajski et al., 2017;
Calarco, 2011; Gu & Zhang, 2014; White, 2018).
The aging population is adding to the elder population and bringing
with them an increase in chronic diseases and resource utilization
(Benkert, Tanner, Guthrie, Oakley, & Pohl, 2005; Buerhaus, 2001;
Calarco, 2011; “Older Americans 2010: Key indicators of well-being”,
2010). The nursing workforce itself is also aging, with the average age
of a practicing registered nurse greater than 55 years old (Buerhaus,
Staiger, & Auerbach, 2000; Gabrielle, Jackson, & Mannix, 2008;
Goldsworthy, 2016b; Harmon, Degennaro, Norling, Kennedy, &
Fontaine, 2017; Wargo-Sugleris, Robbins, Lane, & Phillips, 2018). Re-
tention of these experienced nurses and their ability to mentor and
nurture new nurses is very important to the healthcare profession and
the patient population they serve. Unfortunately, new additions to the
nursing workforce have shown rapid turnover rates, which escalate
recruitment/orientation costs and lead to newly educated nurses
leaving the profession (Bryant, 2017; Kenny, Reeve, & Hall, 2016;
Samson, 2013; Silvestre, 2017).
The financial components of recruitment and retention to replace
these nurses have significant impact on health care systems and can
leave staggering costs for what seems like little gains. Lee, Tzeng, Lin,
and Yeh (2009) calculated employee turnover cost at an estimated
$29,541 per person per month (p. 1219) (Lee et al., 2009). Kovner et al.
(2007) maintained 41.5% of nurses would like a new job and up to 13%
of all entry-level nurses have changed occupations or jobs within the
first 12 months of employment (Kovner et al., 2007).
Affiliation to people, places, and profession contribute to individual
decisions to stay or leave a position or profession (Warshawsky,
Wiggins, & Rayens, 2016). Identifying factors that contribute to reten-
tion is vital for the southwestern region to sustain adequate numbers of
professional registered nurses (Bakker et al., 2018; Brady, 2010; Kovner
et al., 2007; Kovner, Brewer, Fatehi, & Jun, 2014; Nelson-Brantley,
2018). Although there are many reasons why nurses change jobs or
leave the profession, it is equally important to know why nurses stay.
The aim of this research project was to identify characteristics and
factors in the work environment that influence nurses' decisions to stay.
2.1. Literature review
2.1.1. Affiliation and a sense of belonging to a nursing work group
New nurses frequently struggle to develop a feeling of affiliation or
belonging as they join a workplace as a new graduate (Banks, 2010;
Beecroft, Dorey, & Wenten, 2008; Burgess & Medina-Smuck, 2018;
Harner, 2014; Rudman, Gustavsson, & Hultell, 2014; Wareing, Taylor,
Wilson, & Sharples, 2017). A weak sense of belonging, in turn, has been
related to marginal performance and job dissatisfaction — factors that
frequently lead to a desire to leave the nursing profession altogether
(Parker & Gadbois, 2000; Winter-Collins & McDaniel, 2000).
A nurse's successful retention in practice not only requires skill
competency and knowledge, but also professional commitment.
Professional commitment refers to the connection one develops with
the profession and the ethical stance a professional in the field takes to
ensure the right action is taken on behalf of the recipient of care
(Beecroft et al., 2008). These concepts are imperative to nursing pro-
fessional connectedness. Winter-Collins and McDaniel (2000) affirmed
that a sense of belonging can have a strong connection to affiliation and
job satisfaction (Winter-Collins & McDaniel, 2000). In addition to
connectedness the research has found a link to leadership and em-
powerment qualities that support work embeddedness and fosters re-
tention of nurses (Manning, 2016; Regan, Laschinger, & Wong, 2016).
Research has suggested that affiliation and a sense of belonging
2
Applied Nursing Research 55 (2020) 151316
contribute to effective nursing practice and retention of nurses in the
profession (Levett-Jones, Lathlean, Higgins, & McMillan, 2009b). Af-
filiation itself refers to the emotional and behavioral interpersonal
bonding necessary for individuals to closely relate and connect with
others (Astra & Singg, 2000; Robinson et al., 2015; Warshawsky et al.,
2016; Zurmehly, Martin, & Fitzpatrick, 2009). A sense of belonging
refers to a component of affiliation that captures the essence of har-
mony by becoming a part of membership or a group through social
connections, attachment, and recognition while comingling with a
sense of identity (Levett-Jones et al., 2009b; Levett-Jones, Lathlean,
Higgins, & McMillan, 2009a). Combined, these factors support nurses
staying in a professional practice position.
Zurmehly et al. (2009) believed that individuals who select a career
in nursing embrace a professional journey grounded in acculturation,
based on the principles of social and professional identity. When ap-
plied, the nurse gains a sense of belonging and affiliation to the nursing
profession, both of which are necessary for successful nursing practice
(Zurmehly et al., 2009). The body of belongingness research along with
Magnet® hospital research also suggest that when a professional nurse
develops a sense of belonging to both the profession and the clinical/
work environment, the nurse is more likely to stay in the setting (Wei
et al., 2018).
2.1.2. Impact of work environmental characteristics
The attraction characteristics of Magnet® hospitals have sustained
their ability to entice and retain nurses through collegiality, control of
practice, autonomy, and organizational support (McClure, 2005;
McClure et al., 1983; Nelson-Brantley, 2018). Schmalenberg and
Kramer (2008), through extensive studies, explored the relationship of
a healthy work environment (HWE) with the standards of the Magnet®
hospital model. Their Essentials of Magnetism (EOM) tool was used to
measure the characteristics of productive and satisfying work in nursing
environments. The tool evolved to the EOM II which provided a more
discriminating evaluation of essentials for positive work environments.
They compared nursing populations in Magnet® hospitals to non-
Magnet hospitals and found significant differences in nurse attitude,
work variables, and characteristics of the work environment. Ad-
ditionally, they found overall job satisfaction and nurse-assessed quality
of patient care to be higher in a Magnet® setting (Schmalenberg &
Kramer, 2008). Nelson-Brantley (2018) studied the transformation of
healthcare from the perspective of critical access hospitals. She found
that the principles of the Magnet® standards, when employed in these
critical access settings, resulted in valuable organizational and patient-
related outcomes similar to Magnet® designated facilities (Nelson-
Brantley, 2018).
Kramer, Maguire, and Brewer (2011) again confirmed that healthy
work environments were found in Magnet hospitals. They evaluated
12,233 nurses in 717 hospitals of which 34 were designated Magnet
hospitals using the EOM 11. The scores from the tool confirmed that the
nurses in the Magnet hospitals were markedly skewed toward ex-
cellence. Interestingly, most of the nurses prepared at the BSN level
worked on the identified healthy work environment units (Blegen,
Spector, Lynn, Barnsteiner, & Ulrich, 2017; Kramer et al., 2011; White,
2018). These characteristics prove their importance in healthcare set-
tings, work environments, and patient outcomes (Choi & Boyle, 2014;
Kramer et al., 2011).
Additional work in fostering and creating healthy work environ-
ments founded on Magnet® standards, was seen from the American
Association of Critical Care Nurses (AACN) (National Library of, 2005;
Ulrich et al., 2007). Vollers, Hill, Roberts, Dambaugh, and Brenner
(2009) surveyed critical care nurses across the United States to identify
specifics to the work environment that supported nursing practice and
quality patient outcomes. From this, standards were developed and
published that addressed “quality in patient care, staffing, commu-
nication and collaboration, respect, physical and mental safety, moral
distress, nursing leadership, support for certification and continuing
A.C. Reinhardt, et al.
education, meaningful recognition, job satisfaction, and career plan”
(Vollers et al., 2009, p. 20). A follow-up survey in 2013 validated that
the issues addressed by AACN in work environments affected patient
outcomes, in addition to, job satisfaction and retention. Unfortunately,
the 2013 survey showed a decline in the critical care work environment
but identified areas where attention can be focused. The issues of
practice environments is not corrected and requires continuous colla-
boration and attention (Lorber, 2018; Ulrich, Lavandero, Woods, &
Early, 2014).
The retention of experienced nurses is also affected by the work
environment. The social nature of collaboration and organizational
support create an organizational climate that encourages embedded-
ness and, therefore, connection (Atencio, Cohen, & Gorenberg, 2003;
Cohen, 2006; Cohen, Stuenkel, & Nguyen, 2009). The connection to the
work environment increases peer support which can lead to retention of
“competent colleagues” (Adams, 2016; Hopson, Petri, & Kufera, 2018;
Kramer & Son, 2016; Reitz, Anderson, & Hill, 2010; Stroth, 2010).
2.1.3. Effects of workplace violence effects
Detractors from a healthy work environment are bullying, conflict,
and violence. The influence these factors have on the work environment
is demonstrated in retention, low morale, decreased quality of care, and
overall tension in the workplace (Kang, Lee, & Choi, 2017; McKibben,
2017). As many as 95% of nurses have suffered from at least one in-
cident of verbal abuse during their careers which can lead to both
physical and emotional harm (Keller, Krainovich-Miller, Budin, &
Djukic, 2018). Nurse leaders have also been victims of bullying and
incivility (Tarasenko, 2018). These occurrences have escalated as
workloads and high demands are increased across the work environ-
ment. Fortunately, techniques that support empowerment in healthcare
settings can reduce incivility and support mental health for nurses
(Wing, Regan, & Spence Laschinger, 2015).
2.2. Theoretic framework
A vital part of the work environment in nursing practice is the
ability to advocate for patients and the care they receive. Kanter's
Structural Empowerment Model is a relevant framework to support
health care organizations and nursing practice (Larkin, Cierpial, Stack,
Morrison, & Griffith, 2008). The foundation of the model is based on the
principle that leadership power is enriched, if shared, and increases
organizational performance. Kanter's work in the 1970's (Humphrey,
1992; Mausner, 1979; McEnure, 1984) identifies sources of power as
formal power and informal power. The former is linked to job roles and
high visibility. The latter is deriving from the creation of alliances and
relationships with colleagues and peers. Six conditions are necessary to
allow structural empowerment to develop: 1) opportunity for devel-
opment, 2) access to information, 3) access to support, 4) access to
resources, 5) formal power, and 6) informal power (Laschinger &
Havens, 1996). The development of Magnet® hospital recognition can
be seen when using the components of structural empowerment
(Kramer & Schmalenberg, 1993; Spence Laschinger, Almost, & Tuer-
Hodes, 2003). Through structural empowerment, leaders can influence
work engagement and, therefore, affect work environments (Cziraki &
Laschinger, 2015). Regan et al. (2016) asserted from a study of ex-
perienced nurses that improved work environments, as a result of the
influence of structural empowerment, authentic leadership, and pro-
fessional nursing practice environments, lead to better patient out-
comes (Regan et al., 2016). This study utilized Kanter's framework as a
foundation for analysis of the data from this study because of the ex-
tensive research found from the model and the applicability to the
health care environments.
3
Applied Nursing Research 55 (2020) 151316
3. The study
3.1. Aims
The aims of this study were to assess the relationship between a
sense of belonging (self-esteem, self-efficacy, and connectedness) and
the selected composite score factors in the work environment that en-
courage nurse retention. The comparison factors were professional
autonomy, control of practice, collegial relationships, organizational
support, work environment, workplace conflict, and job satisfaction. An
additional aim was to investigate if there was a relationship between
the demographic variables and the length of employment in a nurse's
first professional position. The above identified variables are all linked
to studies of work environments and reflect the issues of why nurses
stay in a practice setting.
3.2. Design
The study design was a descriptive, correlational survey of currently
licensed registered nurses in a southwest region of the United States.
3.3. Participants
Contact information for registered nurses, actively licensed in the
state was purchased from the State Board of Nursing. Of the 23,000
registered nurses currently licensed, a convenience, random sample was
selected of 700 respondents. This number was determined to achieve
statistical significance based on the number of questions and surveys
included in the study (Lipsey, 1990). A power analysis setting alpha at
0.05, power at 0.80 and estimated a medium effect size (Cohen's
d = 0.3). No exclusion criteria were determined and every 32nd name
was selected from the list to achieve a pool of 700 participants and to
receive the surveys.
3.4. Data collection
The survey instruments used in this study to collect data included
(1) a Demographic Questionnaire, (2) the Belongingness Scale-Clinical
Placement Experience (BS-CPE) (Levett-Jones et al., 2009a), (3) Nurse
Workplace Relational Environment Scale (NWRES) (Duddle and
Boughton, 2009) and (4) the Nurses Work Index – Revised (NWI-R)
(Aiken & Patrician, 2000; Lake, 2002).
• Demographic Questionnaire: This questionnaire was developed by
the principle investigator (P.I.) and contained descriptive informa-
tion about participant education, age, gender, ethnicity, current and
previous employment history, current employment status, and
length of employment.
• Belongingness Scale-Clinical Placement Experience (BS-CPE):
Levett-Jones and Lathlean (2009) developed the 34-question Be-
longingness Scale-Clinical Placement Experience (BS-CPE) tool for
assessing the understanding of belongingness. The 34-question tool
uses a 5-point Likert scale ranging from “always true” to “never
true”. They conducted a pilot study to establish clarity and relia-
bility. The BS-CPE tool has been tested for reliability and validity in
measuring belongingness and has an established Cronbach's alpha of
0.92 (Kim & Jung, 2012; Levett-Jones et al., 2009a; Levett-Jones &
Lathlean, 2009). Scale composite scores and subscales (esteem, ef-
ficacy, and connectedness) were identified in the tool.
• Nurse Workplace Relational Environment Scale (NWRES): Duddle
and Boughton (2009) developed the 22-question Nurse Workplace
Relational Environment Scale (NWRES) tool to assess the under-
standing of nursing workplace environment concepts of sense of
connectedness and belonging, support, collegial relationships,
communication, and unit conflict. The tool uses a 5-point Likert
scale, ranging from “strongly disagree” to “strongly agree”. The
A.C. Reinhardt, et al. Applied Nursing Research 55 (2020) 151316

scale is divided into three subsections of workplace environment

(fourteen questions), workplace conflict (four questions), and job

Cronbach's
satisfaction (four questions). The NWRES tool was tested for relia-

0.896

0.687

0.674
0.904
0.785
0.850
0.799
0.845
0.848
0.891
0.801
alpha
bility and validity in measuring workplace environments for nurses
and has an established Cronbach's alpha of 0.872 with subscales

11.48
9.39

3.19

2.88

4.67
5.58
4.74
5.71
8.65
3.25
ranging from 0.781–0.972 (Duddle & Boughton, 2009, p. 902). A

4.6
SD
factor analysis indicated a four-factor structure: collegial behaviors,

51.77

13.45

16.05

40.91
40.66
42.39

24.09
39.17
10.67
124.89
relational atmosphere, outcomes of conflict, and job satisfaction

18.5
Mean
(Duddle & Boughton, 2009; Parsons et al., 1997).
• Nurses Work Index – Revised (NWI-R): Aiken and Patrician (2000)
revised the Nurses Work Index based on their study of 40 units in 20

relationship
hospitals to differentiate nurses who worked in a professional

NWI-R:
practice environment from those who did not. They assessed the
tool's ability to explain differences in nurse burnout (Aiken &

1
Patrician, 2000). Cronbach's alpha was 0.96 for the entire NWI-R,

organization
with aggregated subscale alphas of 0.84 to 0.91. The subscales of the
tool were autonomy, control over practice, nurse-physician re-

0.618⁎⁎
NWI-R:
lationships, and organizational support. Validity of the NWI-R was

1
established by the original tool and the revised survey tool illu-
strated its differentiating ability.

0.854⁎⁎
0.362⁎⁎
NWI-R:
control

1
3.5. Protocol

autonomy
In 2014, initial contact with participants was made via a postcard

0.601⁎⁎
0.795⁎⁎
0.352⁎⁎
NWI-R:
informing participants of a survey packet delivered by the postal ser-
vice. One week later, the paper survey packets were mailed via the U.S.

1
Postal Service. Each packet contained an information letter that ex-
plained the purpose of the study, four surveys explained above, and a connectedness
$5.00 gift card to Walmart as a “thank you” for participation. A

−0.192⁎⁎
−0.114
−0.051
−0.101
BS-CPE:

postage-paid envelope was provided for convenience in returning the

1
surveys to the researcher. As an alternative, the study respondents were
given an Internet link that allowed the respondent to complete the
surveys online using Qualtrics (www.chssnmsu.qualtrics.com). Each

0.833⁎⁎

−0.217⁎⁎
−0.091
−0.109
−0.108
BS-CPE:
efficacy

participant had a unique code to access the Qualtrics website to ensure

1
no duplicate entries were submitted. Another postcard was sent to the
participants two weeks after the survey packet mailer, reminding them
and thanking them for their participation. A cross-reference of those
0.757⁎⁎
0.693⁎⁎
−0.112
−0.041
−0.036
−0.117
BS-CPE:
esteem

completing the written surveys vs. the online surveys was conducted
1

using a confidential numbering system to ensure anonymity. All survey

responses were initially entered into the Qualtrics data file for con-
sistency.
composite

0.857⁎⁎
0.914⁎⁎
0.886⁎⁎
−0.160⁎

−0.180⁎
−0.111
−0.131
BS-CPE:

3.6. Ethical considerations

NWRES: job

The University's Institutional Review Board (IRB) approved this

satisfaction

0.417⁎⁎
0.362⁎⁎
0.405⁎⁎
0.292⁎⁎
−0.204⁎⁎

−0.218⁎⁎
−0.149⁎

study. Information was sent to each participant to explain the study and
−0.048

their participation implied consent (IRB # (10609-) Why Nurses Stay).

1

3.7. Data analysis

workplace

−0.232⁎⁎
−0.214⁎⁎
−0.224⁎⁎
−0.227⁎⁎

Statistically significant * = p < .05; **p < .01.

−0.171⁎

0.149⁎
NWRES:

0.082
0.021
0.031
conflict

Scores on sub-scales from the BS-CPE, NWRES, and NWI-R were

1

summarized in terms of means and standard deviations. Persons pro-

duct-moment correlation coefficients of the sub-scales from the BS-CPE,
NWRES, and NWI-R were calculated to see the relationships between
NWRES: work
environment

these tools (Table 1). Statistical significance of the pairwise relation-

−0.369⁎⁎

0.399⁎⁎
0.527⁎⁎
0.451⁎⁎
0.502⁎⁎
0.400⁎⁎

−0.209⁎⁎
−0.166⁎
−0.131
−0.130

ships was assessed using the Fisher's z-transformation. Cronbach's alpha

1

was used to measure internal consistency of the items and scale relia-
Survey tools correlations.

bility. Categorical demographic variables were summarized in terms of

NWRES: job satisfaction

BS-CPE: connectedness

the number of participants and percentages and the mean sub-scales

NWI-R: organization

*Indicates statistical
NWI-R: relationship
NWRES: workplace

BS-CPE: composite

scores were reported for each category of these variables. The Kaplan-
NWI-R: autonomy
environment

BS-CPE: efficacy

significance
BS-CPE: esteem

NWI-R: control

Meier method for censored data was used to analyze length of stay in
NWRES: work

conflict

the first professional position related to the nurse's demographic data.

The overall difference in the distribution of length of stay for selected
Table 1

demographic factors was assessed using log-rank tests. Length of stay by

gender is summarized in terms of means and standard deviations.

4
 Table 2
Demographic data compared to survey sub-scores.
N % Mean 1st. job length
of stay in
A.C. Reinhardt, et al.

NWRES: work NWRES: NWRES: job BS-CPE: BS-CPE: BS-CPE: BS-CPE: NWI-R: NWI-R: NWI-R: NWI-R; months
environment workplace satisfaction composite esteem efficacy connectedness autonomy control organization relationship
conflict

Range of scores 13–70 4–20 4–20 34–170 11–55 11–55 12–60 5–20 7–28 10–50 3–12
Race ethnicity
White 188 75.5 51.5 13.7 16.0 124.6 40.6 40.6 42.5 18.4 24.25 39.1176 10.7219 56.3
Hispanic 40 16.1 53.7 12.3 16.1 127.4 42.3 41.6 42.9 19.6 23.9063 40.5938 10.4857 67.4
Black 5 2 46.0 13.8 16.0 121.3 39.0 40.0 40.3 16.5 26.25 41.5 12.5 68.0
Native American 8 3.2 47.5 13.6 16.1 119.1 40.7 38.1 39.1 17.9 22.25 35.75 9.25 100.5
Asian 5 2 55.2 16.2 16.8 128.0 43.8 42.6 43.5 20.0 22.2 38.5 11.6 42.0
Pacific Islander 1 0.4 62.0 7.0 19.0 45.0 15.0 21 36 14 24.0
Other 2 0.8 57.5 10.0 14.5 125.0 38.5 41.5 45.5 9.0 23 26 5 48.0
Highest degree
Diploma 12 4.8 48.9 13.7 16.0 130.3 42.6 43.1 45.4 18.2 24.7 40.9 11.1 37.1
ADN 79 31.7 51.4 13.6 16.1 125.6 40.9 40.7 42.2 18.4 24.4 39.3 10.8 70.9
BSN 93 37.3 52.1 13.3 16.0 124.5 40.8 40.8 42.5 18.9 24.1 39.6 10.9 58.6
MSN 55 22.1 52.5 13.1 16.3 123.6 41.1 40.2 42.2 18.1 23.7 37.7 10.0 55.6
Professional 5 2 46.0 15.2 15.2 124.0 36.2 38.2 38.0 18.3 24.3 40.3 10.2 30.4
Doctorate 5 2 53.6 16.0 15.4 126.2 42.4 41.6 43.0 18.2 21.0 39.0 11.4 15.6
NP specialty
Acute care 4 16.7 59.5 12.5 16.5 125.3 42.3 41.0 41.3 16.5 20.8 31.3 6.8 116.3
Adult 2 8.3 55.0 11.0 17.0 115.5 35.5 38.0 38.0 21.0 27.0 42.0 11.0 21.0
Adult Gero 2 8.3 55.0 19.0 16.0 126.0 44.0 40.0 43.0 9.0 16.0 31.0 13.0 6.5

5
primary
Adult psych 1 4.2
Family 12 50 52.6 14.2 17.0 127.3 40.8 41.3 41.6 17.5 22.7 35.8 9.3 46.1
Gero 2 8.3 30.0 16.0 13.0 114.0 39.5 38.5 40.5 13.0 19.0 31.0 9.0 9.5
Pediatric 1 4.2 59.0 12.0 20.0 146.0 46.0 48.0 52.0 25.0 48.0 5.0 24.0
APRN degree
NMSU 4 11.1 56.3 13.3 16.0 127.0 41.7 40.7 44.3 23.3 27.7 43.7 11.0 30.3
UNM 14 38.9 55.0 12.6 18.3 123.8 40.7 40.8 41.9 17.2 21.6 33.7 9.1 67.5
Other 18 50 52.8 14.7 15.8 126.7 41.1 40.3 42.1 17.6 22.1 36.1 9.0 31.4
CNS specialty
Adult 5 41.7 60.2 14.2 17.6 131.0 42.4 43.8 47.5 15.2 22.2 33.8 9.0 46.0
Adult psych 1 8.3 57.0 11.0 19.0 41.0 43.0 48.0 26.0 36.0 53.0 10.0 36.0
Home health 2 16.7 62.0 11.5 17.0 133.5 42.0 45.5 47.0 23.0 25.0 40.5 7.5 49.0
Pediatric 2 16.7 58.0 10.0 17.0 117.5 39.0 40.0 40.0 16.0 20.0 33.0 8.0 176.5
Community 1 8.3 64.0 4.0 20.0 148.0 49.0 46.0 54.0 9.0 17.0 27.0 9.0 12.0
Public/ 1 8.3 63.0 14.0 17.0 151.0 51.0 49.0 54.0 9.0 13.0 24.0 9.0 72.0
community
Credential
NP 22 43.1 54.2 13.9 16.9 126.6 41.1 41.1 41.8 18.1 22.8 36.6 9.0 50.8
CNS 9 17.6 58.6 11.2 18.0 132.1 43.4 44.0 46.8 15.3 22.1 34.7 8.6 38.0
CRNA 2 3.9 33.0 17.0 11.0 102.0 33.5 34.0 34.0 17.0 26.0 39.0 12.0 24.0
CMW 4 7.8 55.5 15.5 17.0 128.3 43.0 41.0 43.8 20.0 21.3 38.5 9.5 66.0
CNE 5 9.8 51.4 14.4 16.6 125.0 42.6 41.6 42.4 16.8 24.0 35.4 10.2 10.6
CN admin 1 2 54.0 12.0 17.0 122.0 39.0 39.0 42.0 19.0 25.0 37.0 12.0 7.0
CCRN 7 13.7 54.2 14.0 14.1 129.7 41.7 42.3 44.4 16.4 21.7 38.8 12.0 45.4
CNRN 1 2 53.0 14.0 125.0 41.0 42.0 42.0 13.0 14.0 28.0 9.0 12.0

Statistically significant * = p < .05; **p < .01.

Applied Nursing Research 55 (2020) 151316
A.C. Reinhardt, et al.
Fig. 1. Kaplan-Meier Survival curves of race and length of stay in first profes-
sional position.
4. Results
A total of 258/700 surveys were returned for a 36.8% return rate.
The average age of survey participants was 29.68 (SD 9.16) years. Most
participants were White (75%) while other participants identified as
Hispanic (16%), Native American (3.2%), Black (2%), Asian (2%) and
Pacific Islander (0.4%). A final group of participants marked “Other”
(0.8%). Most nurses reported their highest nursing degree as a BSN
(37.3%), followed by ADN [Associate Degree in Nursing] (31.7%), MSN
(22.1%), Diploma (4.8%) and doctorate (2%). Those participants who
identified their highest degree as “professional” did not specify an
academic distinction (2%) (Table 2).
A large percentage of Nurse Practitioners (NP) responding to the
survey had specialization in family practice (50%). The remaining
specializations were in Acute Care (16.7%), Adult (8.3%), Adult Gero
(8.3%), Gero (8.3%), Adult Psych (4.2%) and Pediatrics (4.2%).
Another group of advanced practice nurses self-identified as Clinical
Nurse Specialists (CNS). The majority were Adult CNS (41.7%), fol-
lowed by Home Health CNS (16.7%), and Pediatric CNS (16.7%). The
remaining CNS specialties were Adult Psych CNS, Community CNS, and
Public Health Community CNS representing 8.3% each (Table 2).
To further describe the participants with advanced credentialing,
most self-identified as Nurse Practitioner (43.1%). Clinical Nurse
Specialist (17.6%), Critical Care Registered Nurse (13.7%), Certified
Nurse Educator (9.8%), Certified Midwife (7.8%), Certified Registered
Nurse Anesthetist (3.9%), Certified Nurse Administrator (2%), and
Certified Neurological Registered Nurse (2%) made up the remainder of
credentials identified. Advanced Practice degrees for these participants
were awarded from institutions outside the state of New Mexico (50%),
University of New Mexico (38.9%), and New Mexico State University
(11.1%) (Table 2).
4.1. Correlations of BS-CPE, NWRES, and NWI-R
Belongingness Scale-Clinical Placement Experience (BS-CPE) sub-
scales were (composite, esteem, efficacy, and connectedness), in gen-
eral, negatively correlated with all NWI-R subscales and NWRES
workplace conflict but are positively correlated with work environment
and job satisfaction subscales of NWRES. NWRES subscales and NWI-R
sub–scales were negatively correlated except for workplace conflict.
Strong statistically significant negative correlation was seen between
NWI-R autonomy and collegial relationships and NWRES job satisfac-
tion. Another strong statistical correlation was seen between NWRES
6
Applied Nursing Research 55 (2020) 151316
work environment and NWI-R collegial relationships. BS-CPE compo-
site scores were all highly correlated positively to NWRES work en-
vironment and job satisfaction but negatively to conflict. The Cronbach
alpha values of internal reliability for sub-domains of BSE-CPE and
NWI-R were close to or higher than 0.8. The Cronbach alpha values for
the NWRES were 0.9 for work environment, 0.68 for work conflict, and
0.67 for job satisfaction. (Table 1.)
4.2. Demographic table compared to survey tools (Table 2)
The score range for work environment in the NWRES tool was
13–70 points. The higher scores reflected a positive work environment.
The scores for Black and Pacific Islander nurses was 46 and 62 re-
spectively but only represented six participants. Average work en-
vironment score was highest for nurses with doctoral degrees (53.6)
and lowest for nurses with “professional” degrees (46.0). Average work
environment score was 58.6 for nurses with the Clinical Nurse
Specialist certification and was the highest among all other advanced
practice nurses.
Workplace conflict score was highest for nurses with Asian ethnicity
(16.2 points, n = 5) and lowest for Hispanic or “other” ethnic groups
races (10–12 points, n = 42). Workplace conflict score was higher for
nurses with doctorate or professional degree than those with other
degrees, and highest for nurses with CRNA credentials. Job satisfaction
score did not vary substantially across race/ethnicity or highest degree
attained. Job satisfaction score varied between 17 and 20 points across
CNS specialty, and 14 to 18 points across credentials. BS-CPE scores
were higher among Asian nurses and lowest among native American
nurses. BS-CPE was highest for nurses with Diploma and lowest among
MSN. BS-CPE was highest for CNS and lowest for CRNA credentials.
Length of stay in the first professional position was longest for na-
tive American nurses and shortest for Asian nurses. Length of stay in the
first job was longest for nurses with ADN and shortest for nurses with
doctoral degrees. Length of stay in the first job was longest for NPs in
the specialty of acute care and shortest for NPs with geriatric specialty.
The result of Kaplan-Meier analysis indicates that there is significant
difference between white and other races based on the likelihood of
staying in the first professional position (Fig. 1). The other races are
more likely to stay in the first professional position longer than white
(Table 3). Correlation between age and length of stay in the first pro-
fessional position was 0.166 and statistically non-significant (age: Mean
29.68) (sd 9.16). Other demographic variables such as gender were also
not significantly associated with length of stay.
Written comments from participant nurses who stayed in practice
for more than two years indicated they stayed because of pay/benefits
(26.9%), comfort with the job (23.1%), and satisfaction with the em-
ployer (22.4%). These nurses reported they felt they were supported by
nursing colleagues and indicated the quality of workplace relationships
affected their job satisfaction. The linear regression analysis between
the BS-CPE and NWRES indicated there was a relationship between a
sense of belonging and a connection with the workplace environment.
Table 3
Length of stay in first professional position related to race.
Overall comparisons Chi-square df Sig.
Log rank (Mantel-Cox) 8.727 1 0.003⁎⁎
Breslow (Generalized Wilcoxon) 9.396 1 0.002⁎⁎
Tarone-Ware 9.745 1 0.002⁎⁎
Test of equality of survival distributions for the different levels of race recode.
Statistically significant * = p < .05; **p < .01.
The result in this analysis indicates that there is significant difference between
white and other races is the likelihood of staying in the first job. The other races
are more likely to stay in the first job than White.
A.C. Reinhardt, et al.
5. Discussion
In this study the reasons for leaving a position varied vastly.
Obviously, many reasons may have been beyond the nurse's profes-
sional practice and related to personal/family considerations, such as
family required relocation or a desire to return for further education in
another region. However, of the nurses surveyed, the Kaplan-Meier
Survival curve indicated that the majority of the ethnic groups re-
mained in the area, but those indicating “White” as their ethnic group
spent less time in their first professional position. Use of censored data
accounts for the number of nurses who are still in their first professional
position, as well as the number of nurses who are not.
The use of the three surveys allowed the researchers to investigate
several different approaches to retention. It is interesting that the NWI-
R, which assesses the Magnet® concepts showed little correlation to the
concepts of the Belongingness Scale. However, strong relationships to
the Work Environment and Job Satisfaction sub-scales in the NWRES
survey tool supported the Belongingness concepts. The outcomes could
have been influenced by the way the questions were asked.
The NWRES concept of conflict showed a negative correlation to the
belongingness concepts and to concepts in the NWI-R survey tool. This
recognizes that conflict can poison a work setting and create an orga-
nizational culture and climate that dismays employees and diminishes
retention.
Although the overall sample of advanced practice nurses in the
study was small, the information gained about their work environment
perceptions and overall belongingness scores was informative. The CNS
role had an overall positive perception of the work. This may be due to
the close connection that the role has to patient populations and their
health care settings. Many in the CNS role have a closer connection to
ongoing care of a patient population (Scruth et al., 2018).
The healthy work environment remains essential for health care
facilities to retain nurses (Huddleston & Gray, 2016). Belongingness
and Magnet® factors identify workplace characteristics that foster re-
tention of nursing staff, but these factors can be thwarted by incivility
and conflict. Others issues such as compassion satisfaction and com-
passion fatigue can influence the healthy work environment (Al-Majid,
Carlson, Kiyohara, Faith, & Rakovski, 2018). The Kanter Structural
Empowerment Model recognizes these factors as vital to a healthy
workplace.
5.1. Limitations
There were a few of limitations in the study. The first limitation was
that only registered nurses licensed in the state were surveyed. It would
be costly to survey nurses from other states, but the results would be
strengthened if more nurses from additional southwestern states were
surveyed. Secondly, there was a participant return rate of 36.8%. While
36.8% is consistent with an average response rate of 32.52% (Hamilton
& Wilkie, 2001), the overall study would have benefitted from a higher
return rate. Thirdly, the study grouped both pay and benefits together
and did not inquire specifically regarding the amount of pay or specific
benefits participants enjoyed. It is difficult to discern whether the pay
or the benefits were related to job satisfaction or if each, individually,
had some impact on retention. Further research is necessary to under-
stand which factors the greatest determinants in job satisfaction are.
6. Conclusion
The aim of this research project was to examine characteristics and
factors in the work environment that encourage nurses to stay. The top
reason nurses indicated they stayed in their first professional position
was for pay/benefits. The top reason they left their first place of em-
ployment was because they moved to another location. The results in-
dicated nurses are influenced by intrinsic and extrinsic factors. Many
stayed in their positions because they were connected to the community
7
Applied Nursing Research 55 (2020) 151316
and embedded in their work setting. Others identified that they left the
organization due to conflict, lack of supportive leadership, and peer
incivility, which all characterize unhealthy workplaces. Of interest, the
statistical findings indicate nurses can be very mobile today and can opt
for several work settings as they progress in their careers. The tool
assessing job satisfaction suggests there is no statistically significant
difference in job satisfaction related to duration on the job. There was,
however, a relationship to work stress and management's lack of sup-
port.
Although affiliation and a sense of belonging to a nursing work
group was important in the conceptual understanding of work en-
vironment effects on practice settings, this study found significant re-
lationships to fundamental work environmental issues of positive nurse
assessments of the work environment and negative effect related to
workplace conflict. The impact of work environmental characteristics
as seen in the Magnet® concepts correlated to other work environment
measures but didn't reflect measures related to belongingness. This
finding was interesting, but belongingness did reflect the measures in
the general work environment scale. It was not a surprise in the study
that the effects of workplace violence were negatively correlated to
nurse retention. Lessons learned from this study can empower nursing
leaders to continue their efforts to support nursing workers through
creating and maintaining a healthy work environment. For a healthy
work environment, Magnet® themes (autonomy, control of practice,
organizational support, and collegial interaction), affiliation, conflict
management, and belongingness are still important today.
CRediT authorship contribution statement
Anita C. Reinhardt:Conceptualization, Methodology, Funding
acquisition, Supervision, Data curation, Formal analysis,
Investigation, Writing - original draft.Teresa G. León:Writing - ori-
ginal draft.Anup Amatya:Formal analysis, Writing - original draft.
Declaration of competing interest
No conflict of interest has been declared by the author(s).
Acknowledgement
The authors with to acknowledge and thank the School of Nursing,
College of Health and Social Services, New Mexico State University for
the support for this project. In addition, we thank Pamela Schultz, PhD,
RN for her persistent dedication to our research. We also thank the
nurses in New Mexico for their dedication to practice for the citizens in
the southwestern United States.
Funding
This research was funded by an internal faculty development grant
from the College of Heal and Social Services, New Mexico State
University, Las Cruces, NM, 88003-8001 USA in 2014.
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Anita C Reinhardt is Associate Professor within the School of Nursing in the College of
Health and Social Services at New Mexico State University. She joined the faculty in
March 2008. Dr. Reinhardt has an extensive background in nursing clinical practice,
administration, and nursing education and has worked in various locations throughout
the U.S. and Saudi Arabia.
Teresa G. León is a College Associate Professor and Associate Director of the
Undergraduate Nursing Programs in the School of Nursing. Her expertise is pedagogy in
nursing curriculum.
Anup Amatya is an Associate Professor in the Department of Public Health Services in the
College of Health and Social Services. As an expert in statistical analysis, he is a vital
resource for the college and the School of Nursing.