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Research Article
Application of Revised Nursing Work Index to Hospital Nurses of
South Korea
Chul-Woung Kim, PhD, MD,
1
Sang-Yi Lee, PhD, MD,
2
,
*
Jeong-Hee Kang, PhD, RN,
3
Bo-Hyun Park, PhD, RN,
4
Sang-Chul Park, PhD,
5
Hyeung-Keun Park, PhD, MD,
2
Keon-Hyung Lee, PhD,
6
Yun-Jeong Yi, PhD, RN,
7
Baek-Geun Jeong, PhD, MD
8
1
Department of Preventive Medicine, College of Medicine, Research Institute for Medical Sciences, Chungnam National University, Daejeon, South Korea
2
Department of Health Policy and Management, School of Medicine, Jeju National University, Jeju, South Korea
3
Department of Public Health, Chungnam National University, Daejeon, South Korea
4
Department of Nursing, Kimcheon Science College, Gimcheon, South Korea
5
The Department of Future Strategy for Government, The Korea Institute of Public Administration, Seoul, South Korea
6
Askew School of Public Administration and Policy, Florida State University, Tallahassee, USA
7
Department of Nursing Science, College of Nursing, Gachon University, Incheon, South Korea
8
Institute of Health Sciences, Department of Preventive Medicine, College of Medicine, Gyeongsang National University, Jinju, South Korea
article info
Article history:
Received 14 January 2013
Received in revised form
16 April 2013
Accepted 21 June 2013
Keywords:
factor analysis
job satisfaction
professional practice
quality of health care
summary
Purpose: Based on the Revised Nursing Work Index (NWI-R), this research aimed to develop a Korean
Hospital General Inpatient UniteNursing Work Index (KGU-NWI). This study also aimed to compare the
common points and differences between the subfactors of the KGU-NWI and the subfactors from pre-
vious studies.
Methods: Based on opinions from 3,151 nurses in Korean hospital general inpatient unit, this research
used 57 items of NWI-R and the principal axis factor analysis for deriving subfactors. We evaluated the
convergent validity through factor analysis and the content validity of KGU-NWI in terms of the asso-
ciation between nurses’job outcome and the subfactors derived.
Results: Six subfactors and 26 items for KGU-NWI were derived from NWI-R. Among them, ‘physician-
nurse relationship’,‘adequate nurse staffing’and ‘organizational support and management of hospital’
were the same with results from previous studies. In addition, two subfactors, ‘participation of
decision-making processes’and ‘education for improving quality of care’, which were similar with
results from previous Korean studies, were newly added by using Korean hospital cases. In contrast to
previous Korean studies, a unique subfactor this study found was ‘nursing processes’.Thisresearch
confirmed that the six subfactors were highly correlated with job satisfaction, intention to leave, and
quality of health care, which represented a nurse’s job outcome.
Conclusion: KGU-NWI including six subfactors and 26 items is an applicable instrument to investigate
nurse work environment in Korean hospital general inpatient unit.
Copyright Ó2013, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.
Introduction
A common thread for all developed countries is a shortage of
hospital nurses, with clear indicators that the problem will escalate
in the immediate future (Budge, Carryer, & Wood, 2003). Hospitals
in the United States try pulling nurses out of retirement or hire
foreign nurses (Buerhaus, Staiger, & Auerbach, 2003). Although
such efforts are made, a shortage of 400,000 registered nurses is
expected by 2020 in the United States (Shirey, 2006).
However, not all hospitals experienced the shortage. Even if
human resources for nursing were already in the state of national
shortage, the American Nurses Association discovered the charac-
teristics of the hospitals where successfully secured and managed
necessary nurses worked in the 1980s, and named these hospitals
“magnet hospitals”(McClure, Poulin, Sovie, & Wandelt, 1983).
*Correspondence to: Sang-Yi Lee, Department of Health Policy and Management,
School of Medicine, Jeju National University, 690-756, Ara 1-dong, Jeju-si, Jeju-do,
South Korea.
E-mail address: health21@jejunu.ac.kr
Contents lists available at ScienceDirect
Asian Nursing Research
journal homepage: www.asian-nursingresearch.com
1976-1317/$ esee front matter Copyright Ó2013, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.
http://dx.doi.org/10.1016/j.anr.2013.07.003
Asian Nursing Research 7 (2013) 128e135
The developed index that was used to measure nurse work
environment at the magnet hospitals is called the Nursing Work
Index (NWI; Aiken & Patrician, 2000; Kramer & Hafner, 1989). The
index was originally developed by Kramer and Hafner. Aiken and
Patrician modified the NWI in 2000 to produce the Revised Nursing
Work Index (NWI-R) in 57 items.
However, the NWI-R with 57 items contained extremely heavy
loads of content describing the nurse work environment. If
“representative category”or “subfactors”could be located or ar-
ranged from the 57 items, the nurse work environment of magnet
hospitals could be expressed more efficiently.
Therefore, many studies have been made to find subfactors from
the 57 items of the NWI-R. Aiken and Patrician (2000) extracted
four subfactors of NWI-R (autonomy of nurses, control over the
nursing activities, relationship between physicians and nurses,
support of organizations) that comprised 15 items. Following their
study, many other studies emerged aimed at developing their own
NWI-R subfactor models (Aiken & Patrician; Choi, Bakken, Larson,
Du, & Stone, 2004; Estabrooks et al., 2002; Lake, 2002; McCusker,
Dendukuri, Cardinal, Laplante, & Bambonye, 2004). Consequently,
the studies introduced models differing in the number of subfactors
and items (Slater & McCormack, 2007).
Among the subfactors that were extracted from the 57 items of
the NWI-R, three subfactors were commonly extracted from the
previous studies (Aiken & Patrician, 2000; Choi et al., 2004;
Estabrooks et al., 2002; Lake, 2002; McCusker et al., 2004).
The first common subfactor was the “physicianenurse rela-
tionship”, composed of three items (No. 2, No. 27, and No. 39) that
were reported by Aiken and Patrician (2000). The second common
subfactor was “adequate nurse staffing and resources”. It corre-
sponds to the “control over nurse action”subfactor that comprises
four of the seven classified items (No. 1, No. 11, No. 12, and No. 16)
developed by Aiken and Patrician. The third common subfactor was
“nurse management”. It corresponds to Aiken and Patrician’s
“nurse autonomy”subfactor and comprises three items (No. 4, No.
13, and No. 35). The fourth subfactor of “organizational support”,as
suggested by Aiken and Patrician, failed to show up in follow-up
studies (Slater & McCormack, 2007).
In South Korea, studies have been made to measure the nurse
work environment by using the NWI-R. These studies have ar-
ranged seven subfactors. Among them, three subfactors were found
to be the same as ones discovered in the previous overseas studies
(Cho, Mark, Yun, & June, 2011). However, the study (Cho, Mark
et al.) was limited to nurses who worked at intensive care units. It
did not use all of the 57 items of the NWI-R.
In South Korea, the turnover rate of nurses has increased
remarkably (Kim, Choi, & Kim, 2009). As such, shortage of nurses in
mid-sizedhospitals located in local regions is becoming more serious.
Not all hospitals in South Korea suffer from shortage of nurses. Some
hospitals may successfully secure and maintain their nurses.
If the characteristics of hospitals that successfully secured and
maintained nurses could be identified through the development of
the Korean edition of revised Nursing Environment Index, it would
be helpful for solving nurse shortage in hospitals. Therefore, the
present study aimed to develop a Korean edition of NWI-R after
measuring the 57 items of NWI-R by studying the nurses who
worked at the general inpatient units of hospitals.
Purpose of the study
The purpose of the study was to evaluate the validity and reli-
ability of the Korean edition of NWI-R by subjecting nurses who
worked at the general inpatient units of hospitals in South Korea.
Also, the study aimed to compare the common points and differ-
ences between the subfactors that were observed from the Korean
edition of NWI-R that was found in the present study and the
subfactors that were observed from other previous studies.
Methods
Study design
By using exploratory factor analysis, subfactors of the Korean
edition of NWI-R were extracted from the 57 items of the NWI-R. Its
validity and reliability were evaluated by analyzing the work
satisfaction level of nurses that could be represented as the nurses’
job outcome, intention to leave, and relationship with quality of
medical services for each subfactor. Also, the extracted subfactors
from the present study were compared with the subfactors that
were extracted from other previous studies.
Setting and samples
The study’s survey population included 11,731 nurses who were
members of the Korea Health and Medical Workers’Union and
participated in its annual workshop. The number was about 52.1%
of the total 22,520 nurse union members. Among the nurses who
participated in the workshop, 5,654 (48.2%) nurses responded to
the survey.
The analysis surveyed 3,151 nurses by collecting at least 10
nurses’responses from each of the general inpatient units of the
following departments: internal medicine, surgery, pediatric, ob-
stetrics, and gynecology. The nurses’responses from special units
(n¼1,666), outpatient units (n¼584), and hospitals which have
fewer than 10 nurses (n¼253) were excluded from the analysis
since the present study aimed to estimate the perceived nurse work
environment by subjecting the nurses who worked in the general
inpatient units of a hospital.
After collecting at least 10 responses from nurses working in general
inpatient units from the departments of internal medicine, surgery,
pediatric, obstetrics, and gynecology, and excluding those responses of
nurses working in special units (n¼1,666), outpatient units (n¼584),
and hospitals with fewer than 10 nurses, the analysis yielded a total
3,151 responses that were pertinent to the KGU-NWI study.
Ethical considerations
For the study, a structured, self-administered questionnaire was
used. The protocol for the study was reviewed and approved by
Institutional Review Boards of the Chungnam National University,
South Korea.
Measurements
The questionnaire comprised the following categories: general
characteristics, job characteristics, 57 items of NWI-R, 6 items
related to job satisfaction, intention to leave, and nurse-assessed
quality of care (at levels of hospitals and units).
The NWI-R developed by Aiken and Patrician (2000) consisted of
57 items. The response of strongly agree wasgradedas4,somewhat
agree as3, somewhatdisagree as 2, and stronglydisagree as 1.The NWI-
R surveys were translated by a professor (from the department of
preventive medicine) from English into Korean before being
reviewed for accuracyat two board meetings. The attendeesincluded
one professor and two specialists from the department of nursing,
and three professors from the department of preventative medicine.
Dependingon the hospital, study meetings(that usually included2 or
3 nurses) were held to further check the survey’s accuracy. Lastly, a
final check for accuracy was conducted by a full-time, Korean-English
bilingual professor from an American university.
C.-W. Kim et al. / Asian Nursing Research 7 (2013) 128e135 12 9
The categories that measured nurses’job outcome were job
satisfaction, intention to leave, and nurse-assessed quality of care
(at level of hospitals and units). The nurses’job satisfaction was
measured in six variables, including the items job itself, rela-
tionship with co-workers, leadership of the nurse manager, salary,
opportunities for advancement, and overall work conditions. Very
dissatisfied was graded as 1, somewhat dissatisfied as 2, fair as 3,
somewhat satisfied as 4, and very satisfied as 5. In this study, the job
satisfaction of nurses only used the “job itself”variable (Robbins,
2009). Regarding “intention to leave”, nurses were asked the
following question: “Are you planning to leave your present job in
the next year?”“Yes ”was graded as 1; “No”was graded as 2
(Stone et al., 2007).Thevariableof“nurse-assessed quality of
care”was measured by using the categories “quality of health care
in hospitals”and “quality of nursing care in units”. The answer
poor was graded as 1, fair as 2, good as 3, and excellent as 4 (Aiken,
Clarke, & Sloane, 2002).
Data collection
For the nurses who participated in the workshop for members of
the Korea Health and Medical Workers’Union in May 2010, the
purpose of the survey was explained and nurses agreed to the data
collection in terms of the survey.
Data analysis
Exploratory factor analysis for measuring convergent validity
Exploratory factor analysis is the method of determining sub-
factors made of 57 NWI-R items when developing a scale. Several
exploratory factor analysis methods are available. Many previous
studies used principal component analysis, but this study used
common factor analysis. Principal axis factor was incorporated
since the 57 NWI-R items did not show normal distributions. The
common factor analysis method was used to recognize the factor
structure commonly present between items. Individual items
that could be categorized as their own factors had more than 10%
overlapping variance. When calculating the repeated distribution
value, only “common variance”was included while “specific
variance”was excluded from the calculation. On the contrary,
principal component analysis included “specific variance”along
with “common variance”when calculating the repeated distribu-
tion value. This would cause a higher estimation of factor loading,
which would consequently, make it difficult for researchers to
estimate a precise factor structure (Chae, 2001; Fabrigar, Wegener,
MacCallum, & Strahan, 1999).
For the number of subfactors, the eigenvalue of 1 was used. The
oblique rotation method of promax was used because the survey
sample size was large, and the correlation between the NWI-R sub-
factors was high. However, the orthogonal varimax rotation
method, used frequently in many previous studies, can be used
when the relationship between factors are considered to be inde-
pendent (Chae, 2001).
When selecting items that are included in a single factor,
factor loading was based on a value of 0.32. This is due to the
fact that repeated distribution between items that could be
included within a single factor may range around 10%, which
was regarded as the minimum factor loading in the criteria. If a
specific item shows the burden of cross loading on two factors,
the items that show a factor loading value of more than 0.50
were removed from the factor (Costello & Osborne, 2005;
Tabachnick & Fidell, 2001). Costello and Osborne defined the
factor structure equipped with both conditions as the “cleanest
factor structure”.
Logistic regression analysis for measuring content validity
To evaluate the correlation between the subfactors extracted
from the NWI-R and the variables of nurses’job outcome (job itself
satisfaction, intention to leave, quality of health care in hospital,
and quality of nursing care in unit), logistic regression analyses
were performed. If a subfactor can be accepted as a meaningful
nursing job environment index, it should have a correlation with
the nursing job outcome, which was considered a resultant variable
of the nursing job environment. In other words, compared to the
low score from the subfactorial logistic regression analysis results, a
higher score indicated higher job satisfaction and lower intention
to leave the job. Therefore, it could be used as an appropriate
nursing job environment index if the quality of nursing care in
hospitals was highly recognized.
The mean score of KGU-NWI subfactors, which was extracted
from the NWI-R, was calculated. Then, the score was transformed
into a binary variable. In other words, if the subfactorial mean score
was distributed within the range of 1e4, the variablewith a score of
more than 2.5 was classified as one that most nurses agreed to be
an appropriate index in evaluating the nursing job environment. If
the score was lower than 2.5, it was classified as one that nurses
disagreed with (Bogaert, Clarke, Vermeyen, Meulemans, & Heying,
2009; Lake, 2002). The outcome variables of job itself satisfaction,
quality of health care in hospitals, and quality of nursing care in
units were also classified in the binary form.
Pearson correlation analysis
To observe the correlation between the subfactors that were
extracted from the 57 NWI-R items, Pearson correlation analysis
was performed.
Reliability
Reliability analysis was performed using the Cronbach’s alpha.
Results
General characteristics of the participants
In the analysis of the general characteristics of nurses, 99.6%
were female. The age group of 25e29 years comprised 41.5% of
the total number of nurses; 30e39 years comprised 30.1%; less
than 25 years comprised 23.6%; over 40 years old comprised only
4.8%. As for their work units in hospitals, 44.3% of the nurses work
in the surgery unit, followed by 43.7% in internal medicine, 7.1% in
pediatrics, and 4.9% in obstetrics and gynecology units. In terms
of clinical experience, 29.6% of the nurses had 3e6 years of
experience, 25.2% had less than 3 years, 23.4% had more than 10
years, and 21.8% had 7e9 years of experience.
In the analysis of the general characteristics of hospitals in
terms of hospital type, 59.5% work at general hospitals, 31.1% at
advanced general hospitals, and 9.4% at other types of hospitals. In
terms of ownership, private and public hospitals comprised 56.8%
and 43.2%, respectively. The nurse-grade indicates the number of
hospital beds per single nurses; 37.8% of the hospitals showed
more than 4.0 hospital beds per nurse, while 28.4% had 3.0e3.4
beds, 17.6% with 3.5e3.9 beds, and 16.2% with less than 3.0 beds
(Table 1).
Exploratory factor analysis results (Principal axis factor analysis):
Subfactorial reliability and correlation analyses
Among the exploratory factor analysis methods, the principal
axis factor analysis method came up with six subfactors of KGU-
NWI comprising 26 of the 57 NWI-R items. The “participation in
decision-making process”factor included seven items, with five
C.-W. Kim et al. / Asian Nursing Research 7 (2013) 128e135130
items in the nursing process, three items in adequate nurse staffing,
four items in education for improving the quality of care, four items
in organizational support and management of the hospital, and
three items in physicianenurse relationship. The factor loading of
the six subfactors of the KGU-NWI resulted in .76e.35 for partici-
pation in the decision-making process, .74e.47 for the nursing
process, .88e.43 for adequate nurse staffing, .85e.33 in education
for improving the quality of care, .76e.33 for organizational support
and management of the hospital, and .64e.61 for the physiciane
nurse relationship. The factor loading for each factor was found to
be more than .32.
Results of analyzing the mean difference of the six subfactors of
KGU-NWI showed the mean value to be 2.16. The mean for
participation in the decision-making process was 1.95; for the
nursing process, 2.68; for adequate nurse staffing, 1.67; in educa-
tion for improving the quality of care, 2.18; for organizational
support and management of the hospital, 2.23; and for the physi-
cianenurse relationship, 2.26. Both factors for participation in
decision-making processes and adequate nurse staffing showed
lower values than the mean value of the six subfactors.
When the reliability is measured using the Cronbach’s alpha
coefficient, Cronbach’s alpha for the 26 items of the six subfactors is
.91. The subfactorial coefficient for Cronbach’s alpha is .83 for the
participation in decision-making process, .75 for the nursing pro-
cess, .77 for adequate nurse staffing, .75 for education for improving
the quality of care, .72 for organizational support and management
of the hospital, and .63 for the physicianenurse relationship. A
relatively higher reliability level was observed.
The correlation coefficients between the six subfactors of the
KGU-NWI is .50e.57 for participation in decision-making process,
.22e.46 for the nursing process, .42e.50 for adequate nurse staff-
ing, .43e.57 in education for improving the quality of care, .31e.57
Table 2 Exploratory Factor Analysis of Korean General Unit-Nursing Work Index (N ¼3,151)
Loading MSD Cronbach’s alpha (r
a
)
Composite measure as mean of 6 subfactors 2.16 0.52
Participation in decision-making process (7 items) 1.95 0.51 .83 (.50e.57)
44. Nurse managers consult with staff on daily problems & procedures .76 1.97 0.71
38. Staff nurses are involved in the internal governance of the hospital (e.g., practice & policy committees) .75 1.74 0.71
42. Staff nurses have the opportunity to serve on hospital & nursing committees .73 2.07 0.78
43. The contributions that nurses make to patient care are publicly acknowledged .67 2.12 0.71
34. The nursing staff participates in selecting new equipment .46 1.94 0.79
36. Administration that listens & responds to employee concerns .45 2.01 0.68
46. Opportunity to work on a highly specialized patient care unit .35 1.80 0.67
Nursing process (5 items) 2.68 0.49 .75 (.22e.46)
52. Use of nursing diagnoses .74 2.84 0.73
51. Standardized policies, procedures & ways of doing things .68 2.72 0.66
54. Each nursing unit determines its own policies & procedures .61 2.59 0.65
55. Use of problem-oriented medical record .57 2.39 0.75
56. Working with experienced nurses who “know”the hospital .47 2.85 0.65
Adequate nurse staffing (3 items) 1.67 0.53 .77 (.42e.50)
16. Enough staff to get the work done .88 1.64 0.64
12. Enough registered nurses on staff to provide quality patient care .83 1.55 0.63
1. Adequate support services allow nurses to spend time with patients .43 1.83 0.66
Education for improving quality of care (4 items) 2.18 0.52 .75 (.43e.57)
7. Active inservice/continuing education programs for nurses .85 2.09 0.67
8. Career development/clinical ladder opportunity .81 1.96 0.66
3. A good orientation program for newly employed nurses .41 2.49 0.71
10. Support for new and innovative ideas about patient care .33 2.18 0.70
Organizational support and management of hospital (4 items) 2.23 0.58 .72 (.31e.57)
13. A nurse manager who is a good manager and leader .76 2.49 0.79
35. A nurse manager backs up the nursing staff in decision-making, even if the conflict is with a physician .63 2.47 0.84
14. A chief nursing officer who is highly visible and accessible to staff .49 2.00 0.77
15. Flexible or modified work schedules are available .33 1.96 0.75
Physicianenurse relationship (3 items) 2.26 0.50 .63 (.33e.50)
2. Physicians and nurses have good working relationships .64 2.47 0.65
28. Physicians give high quality medical care .61 2.17 0.64
27. Much team work between nurses and physicians .61 2.15 0.68
a
Correlation among subscales.
Table 1 General Characteristics (N ¼3,151)
Variables n (%)
Nurse-level
Gender Male 14 (0.4)
Female 3,137 (99.6)
Age(yr) <25 733 (23.6)
25-29 1,287 (41.5)
30-39 934 (30.1)
40 149 (4.8)
Education College 1,765 (56.7)
University 1,209 (38.8)
Graduate school 141 (4.5)
Position Staff nurse 2,926 (92.9)
Charge nurse 225 (7.1)
Work unit Internal medicine 1,378 (43.7)
Pediatric 222 (7.1)
Surgery 1,397 (44.3)
Obstetrics and gynecology 154 (4.9)
Clinical experience(yr) <3 714 (25.2)
3e6 840 (29.6)
7e9 617 (21.8)
10 664 (23.4)
Total 3,151 (100.0)
Hospital-level
Type of hospital Hospital 7 (9.4)
General hospital 44 (59.5)
Advanced general hospital 23 (31.1)
Ownership Private 42 (56.8)
Public 32 (43.2)
Bed to nurse ratio
(beds per nurse)
<3.0 12 (16.2)
3.0e3.4 21 (28.4)
3.5e3.9 13 (17.6)
4.0 28 (37.8)
Total 74 (100.0)
Note. Variables of age, education and clinical experience had 48, 36, and 316 missing
cases respectively.
C.-W. Kim et al. / Asian Nursing Research 7 (2013) 128e135 131
for organizational support and management of the hospital, and
.33e.50 for the physicianenurse relationship. The correlation be-
tween the subfactors is considered to be low, since the correlation
coefficient is lower than .60 (Table 2).
Logistic regression analysis on correlation between job outcome and
six subfactors of the KGU-NWI
To investigate the correlation between the nurse’sjob
outcome and the six subfactors of the KGU-NWI, logistic
regression analyses were performed. The job itself satisfaction of
the nurses showed a statistically significant correlation with
all six subfactors of the KGU-NWI. The four subfactors that
showed a correlation with intention to leave were the following:
participation in the decision-making process, nursing process,
organizational support and management of hospital, and physi-
cianenurse relationship. In addition, the four subfactors that
showed a correlation with the quality of health care in hospital
and quality of nursing care in unit were the following: the
nursing process, education for improving the quality of care,
organizational support and management of hospital, and physi-
cianenurse relationship.
When reviewing the major subfactorial relationship, the nurses
who agreed upon the appropriateness of nurse staffing under the
current nurse work environment showed a 1.63 times higher pos-
sibility of satisfaction of the job itself (p¼.017). If the nurses agreed
upon the appropriateness of the physicianenurse relationship, they
showed 1.95 times higher satisfaction with their current work
(p<.001), the possibility of showing no intention to leave was 1.34
times as high (p¼.007), and the possibility of favorably assessing
the quality of health care in the hospital and the quality of nursing
care in unit reached 2.59 and 1.91 times as high, respectively
(p<.001). For those nurses who agreed upon the appropriateness
of the organizational support and management of hospital, their
possibility of satisfaction at the job itself was 1.82 times as high
(p<.001) and the possibility of showing no intention to leave was
1.82 times as high, while the possibility of favorably assessing the
quality of health care in hospital and the quality of nursing care in
unit was found to be 1.43 (p¼.001) and 1.35 (p¼.002) times as
high, respectively.
In general, compared to the subfactors showing lower scores,
subfactors with higher scores showed higher job satisfaction of the
nurses, lower intention to leave, and more highly recognized
quality of hospital care services. Therefore, the six subfactors of the
KGU-NWI could be considered as appropriate indexes to evaluate
the outcomes of nurses who worked at general inpatient units
(Table 3).
Discussion
Reliability and validity of the KGU-NWI at the general inpatient
units of hospitals in South Korea
The six subfactors of the KGU-NWI showed a high correlation
with the nurses’job outcome. Thus, the study results revealed
the KGU-NWI to be an index with high content validity that
measures nurses’work environment at the general inpatients
units in South Korean hospitals. When evaluating the content
validity of the NWI-R, the method of confirming its relationship
with nurses’job outcome has been used in previous studies
(Aiken & Patrician, 2000). Also, the KGU-NWI was divided into
six subfactors and 26 items through the main frame analysis.
Since each factor loading was found to show more than the
minimum factor loading limit by recording 0.32, its convergent
validity is considered appropriate (Costello & Osborne, 2005). In
addition, the six subfactors of the KGU-NWI generally showed a
high reliability.
The common KGU-NWI subfactors that have effects on the
nurse’s job outcome at the general inpatient units of hospitals in
South Korea include “nursing process”,“organizational support and
management of hospital”, and “physicianenurse relationship”.
Although all of the subfactors of NWI-R did not show statistically
significant correlation with nurses’job outcome in the previous
studies, they seemed to show an agreement with the results of the
present study (Aiken, Clarke, & Sloane, 2002; Bogaert et al., 2009;
Choi et al., 2004).
Comparison to previous nursing work environment research
findings
This study suggests six subfactors of the KGU-NWI composed of
26 of the 57 items of NWI-R (developed by Aiken & Patrician, 2000)
using the principal axis factor analysis method. Among the six
subfactors, “adequate nurse staffing”,“physicianenurse relation-
ship”, and “organizational support and management of hospital”
are consistent with the previous study results reported interna-
tionally (Aiken & Patrician, 2000;Cho, Choi, Kim, Yoo, & Lee, 2011;
Cho, Mark et al., 2011; Choi et al., 2004; Estabrooks et al., 2002;
Lake, 2002; McCusker et al., 2004).
When reviewing the results, the three items included in the
physicianenurse relationship factor are consistent with that of the
Table 3 Logistic Regression Analysis of Korean General Unit-Nursing Work Index
a
(N ¼3,151)
BpOR 95% CI
Job itself satisfaction
b
Participation in decision-making process .41 .006 1.51 1.12e2.03
Nursing process .81 <.001 2.25 1.77e2.86
Adequate nurse staffing .49 .017 1.63 1.09e2.44
Education for improving quality of care .27 .013 1.31 1.06e1.62
Organizational support & management of
hospital
.60 <.001 1.82 1.48e2.24
Physician-nurse relationship .67 <.001 1.95 1.59e2.41
Intention to leave
c
Participation in decision-making process .44 .008 1.56 1.12e2.16
Nursing process .27 .010 1.31 1.07e1.60
Adequate nurse staffing e.18 .425 0.84 0.55e1.29
Education for improving quality of care .05 .638 1.05 0.85e1.31
Organizational support & management
of hospital
.60 <.001 1.82 1.49e2.24
Physician-nurse relationship .30 .007 1.34 1.08e1.66
Nurse-assessed quality of health care
d
ehospital
Participation in decision-making process .13 .389 1.14 0.85e1.55
Nursing process .85 <.001 2.33 1.79e3.02
Adequate nurse staffing .09 .663 0.92 0.61e1.37
Education for improving quality of care .60 <.001 1.82 1.47e2.26
Organizational support & management
of hospital
.36 .001 1.43 1.15e1.77
Physician-nurse relationship .95 <.001 2.59 2.10e3.21
Nurse-assessed quality of health care
d
eunit
Participation in decision-making process .11 .467 1.12 0.83e1.49
Nursing process .91 <.001 2.48 2.01e3.06
Adequate nurse staffing .10 .617 0.91 0.61e1.34
Education for improving quality of care .53 <.001 1.69 1.39e2.06
Organizational support & management
of hospital
.30 .002 1.35 1.11e1.64
Physicianenurse relationship .65 <.001 1.91 1.57e2.33
Note.OR¼odds ratio; CI ¼confidence interval.
a
Adjusted variables: sex, age, position, education, work unit, clinical experience,
type of hospital (no. of beds), ownership, nurse-grade; six subfactors of Korean
General Unit-Nursing Work Index, above 2.5 (1), below 2.5 (0);
b
job itself satisfaction: very/rarely satisfied (1), fair/rarely/very dissatisfied (0);
c
intention to leave: yes (0), no (1);
d
quality of care (hospital, unit): good/excellent (1), fair/poor (0).
C.-W. Kim et al. / Asian Nursing Research 7 (2013) 128e135132
previous studies (Slater & McCormack, 2007; Cho, Choi et al., 2011;
Cho, Mark et al., 2011): One item “enough time and opportunities to
discuss patient management with other nurses”was included with
the adequate nurse staffing factor, while the other item “supervi-
sory staff is supportive of nurses”included with the organizational
support and management of hospital factor was excluded from this
study. However, in the organizational support and management of
hospital factor, the two items “staff nurses can easily contact top-
level hospital executives”and “flexible and adjustable nurse work
schedules are available”were new additions (Table 4).
Of the 10 items that were included within the three sub-
factors, as suggested in previous studies, 8 items were found to
be in line with the results (Slater & McCormack, 2007) while 2
items were transformed into other items. Meanwhile, the inter-
pretation for the three subfactors was not changed. Among the
six KGU-NWI subfactors, three subfactors are the most repre-
sentative in measuring the nurse work environment. As such,
those three remained the most essential. In addition, the five
subfactors of this study are consistent with results from the
previous study (Cho, Mark et al., 2011) that examined nurses in
hospitals in South Korea. Three of five subfactors are consistent
with the aforementioned three factorsd“participation in the
decision-making process”and “education for improving
the quality of care”. When reviewing the results, six items under
the “participation in the decision-making process”factor and two
items under the “education for improving the quality of care”
Table 4 Comparison of Previous Findings from Nurse Work Environment Study
Factor Items NWI-R
a
PES-NWI NWI-R KGU-NWI
Slater & McCormack
(2007)
Cho, Choi et al.
(2011)
Cho, Mark et al.
(2011)
Result of this study
Adequate nurse
staffing
1. Adequate support services allow nurses
to spend time with patients
nnnn
11. Enough time and opportunity to discuss
patient care problems with other nurses
nnnN/A
12. Enough registered nurses on staff to
provide quality patient care
nnnn
16. Enough staff to get the work done nnnn
Physicianenurse
relationship
2. Physicians & nurses have good working
relationships
nnnn
27. Much team work between nurses
& physicians
nnnn
39. Collaboration (joint practice) between
nurses & physicians
nnnn
Organizational support
& management
of hospital
4. A supervisory staff that is supportive
of nurses
nnnN/A
13. A nurse manager who is a good manager
& leader
nnnn
35. A nurse manager backs up the nursing
staff in decision-making,
even if the conflict is with a physician
nnnn
Participation in
decision-making
process
44. Nurse managers consult with staff on
daily problems & procedures
N/A nN/A n
38. Staff nurses are involved in the internal
governance of the hospital
(e.g., practice and policy committees)
N/A nn n
42. Staff nurses have the opportunity to
serve on hospital and nursing committees
N/A nn n
43. The contributions that nurses make to
patient care are publicly acknowledged
N/A N/A nn
34. The nursing staff participates in selecting
new equipment
N/A N/A nn
36. Administration that listens & responds
to employee concerns
N/A nn n
46. Opportunity to work on a highly
specialized patient care unit
N/A N/A nn
Nursing process 51. Standardized policies, procedures &
ways of doing things
N/A N/A N/A n
52. Use of nursing diagnoses N/A N/A N/A n
54. Each nursing unit determines its own
policies & procedures
N/A N/A N/A n
55. Use of problem-oriented medical record N/A N/A N/A n
56. Working with experienced nurses who
“know”the hospital
N/A N/A N/A n
Education for
improving
quality of care
3. A good orientation program for newly
employed nurses
N/A N/A nn
7. Active inservice/continuing education
programs for nurses
N/A N/A nn
8. Career development/clinical ladder
opportunity
N/A nN/A n
10. Support for new and innovative ideas
about patient care
N/A N/A N/A n
Note. N/A ¼not applicable. v ¼Item within the factor structure after factor analysis.
a
Construct arrangement in studies relating to the 15 items of the NWI-R (Slater & McCormack, 2007). PES-NWI was developed by Lake (2002), and Cho, Choi et al. (2011)
applied it to Korean nurse by confirmation factor analysis.
C.-W. Kim et al. / Asian Nursing Research 7 (2013) 128e135 13 3
factor are consistent with the results from Cho, Mark et al. (2011).
When compared with the results of Cho, Choi et al. (2011),the
study shared three items in common under the “participation in
the decision-making process”factor and one item under the
“education for improving the quality of care”factor. Unlike re-
sults from previous national studies (Cho, Choi et al.; Cho,
Mark et al.), however, this study newly suggested the “nursing
process”subfactor.
There could be several reasons why this study resulted in
rather different subfactors and items compared to the results of
the previous studies conducted domestically and internationally.
Most of all, it might be attributable to a difference in particular
items in the nurse work environment index and the different
hospital units surveyed. As a result, the subfactor extraction
method was different. For example, Cho and Mark et al. (2011)
conducted their study on nurses who worked in intensive care
units, whereas this study was performed on nurses who worked in
general inpatient units. Cho and Mark et al. used 50 of the 57
items of the NWI-R developed by Aiken and Patrician (2000). The
reason they excluded five items in their study was because of
inappropriateness of those items in the hospitals in South Korea
environment. Therefore, the five items under the newly extracted
subfactor “nursing process”were already excluded. For the factor
extraction method, Cho and Mark et al. used the principal
component analysis method and varimax rotation method, with
the factor loading based on 0.40. In contrast, this study used the
principal axis factor analysis method and used the promax rota-
tion method, with the factor loading based on 0.32. Due to the
differences of the analysis methods, the subfactors and the items
were categorized differently.
Another study by Cho, Choi et al. (2011) surveyed nurses at
hospitals in South Korea. It measured the nurse work environment
of the nurses who worked in general units and special units of
hospitals, using the 29 items of the PES-NWI developed by Lake
(2002) and the confirmative factor analysis method to examine
the representativeness of the sample population. Due to the
difference of nursing work environment tool such as PES-NWI and
the analysis method, the results were different from this study
(Table 4).
The causes for differently extracted subfactors compared to
previous studies are attributed to the use of different survey tools,
survey population, and analysis methods in the studies. In future
studies, it may be necessary to conduct common factor analysis or
principal component analysis according to the survey’s purpose.
When extracting subfactors using the common factor analysis, it
may be necessary to apply one factor extracting process, rotation
method, and factor loading that fits the distribution characteristics
of the analysis tool. In addition, if the factor analysis results can be
described by showing the differences between the previous factor
analysis results, it might be helpful for developing an appropriate
tool that fits with the nurse work environment of hospitals in South
Korea.
As a tool for measuring nurse work environment, KGU-NWI has
the advantage of having its results being compared with those of
domestic and international research using NWI-R. Using KGU-NWI,
nurse work environment factors related to increasing job satisfac-
tion and reducing turnover could be explored, so that KGU-NWI
may contribute to providing information that would improve the
quality of hospital care services.
If the KGU-NWI can be included within the evaluation of the
Korean Institute for Healthcare Accreditation, it may play a role in
identifying problems and solution, so that quality of healthcare can
be improved within the nurse work environment. This could
possibly lead to improvement in medical quality for hospital
managers and determine changes in policy.
Conclusion
The six subfactors and 26 items of KGU-NWI that were extracted
from the NWI-R, developed by Aiken and Patrician (2000), included
subfactors that could be observed in previous studies. The six
subfactors tend to show high correlation with nurses’job satisfac-
tion, intention to leave, quality of health care in hospitals, and with
the quality of nursing care in units. The study results strongly
suggest that the KGU-NWI is an appropriate tool for measuring the
nurse work environment at the general inpatient units of hospitals
in South Korea.
Conflict of Interest
The authors declare no conflict of interest.
Acknowledgments
This study was financially supported by the research fund of
Chungnam National University in 2011.
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