The Practice Environment Scale – Five-Item Composite (PES-5) is a composite instrument that measures five domains of the nursing work environment associated with patient outcomes and nurse well-being. The PES-5 is derived from the 31-item Practice Environment Scale of the Nursing Work Index (PES-NWI), a nationally endorsed nursing quality measure. The PES-5 includes one validated item from each of the five domains: nurse participation in hospital affairs, nursing foundations for quality care, nurse manager ability/leadership, staffing/resource adequacy, and collegial nurse–physician relationships. The instrument is completed by registered nurses and produces a single composite score reflective of overall environment quality.
Measure Specs
- General Information(active tab)
- Numerator
- Denominator
- Exclusions
- Measure Calculation
- Supplemental Attachment
- Point of Contact
General Information
The Practice Environment Scale – Five-Item Composite (PES-5) is a brief survey-based measure of the quality of the nursing practice environment in hospitals. Many hospitals currently have suboptimal nursing work environments characterized by poor support for nurses and inadequate resources; these conditions undermine nurse performance and ultimately compromise patient care quality and safety. The PES-5 was developed to address this quality gap by monitoring five key domains of the nurse work environment (see Data Dictionary below), with the goal of spurring improvements in these areas. Improving the nurse practice environment has been shown to enhance patient outcomes and nurse well-being. For example, better work environments (as measured by the PES or full PES-NWI) are associated with lower nurse burnout and turnover, and better patient outcomes such as lower mortality and higher satisfaction. Conversely, poor environments contribute to high burnout and disengagement (e.g., “quiet quitting”) among nurses. By requiring hospitals to measure and report on their practice environment via the PES-5, this measure incentivizes hospital leadership to invest in improvements – such as adequate staffing, nurse involvement in decision-making, supportive management, and interdisciplinary teamwork – that will lead to higher PES-5 scores and, in turn, better nurse and patient outcomes. In summary, regular assessment of the nursing work environment with the PES-5 provides actionable feedback for hospitals to improve conditions for nurses, which is expected to yield safer, higher-quality care for patients and potential cost savings (e.g., through improved nurse retention and avoidance of adverse events). Importantly, stakeholders recognize the value of this measure: for instance, The Leapfrog Group has proposed adoption of the PES-5 in its hospital survey, citing its strong evidence base and reduced burden. This underscores the rationale that widespread use of the PES-5 will shine light on an essential determinant of care quality and drive improvements that benefit both nurses and patients.
Aside from the PES-5 survey instrument itself, no additional data sources are required to calculate this measure. The measure is self-contained: it uses nurse-reported survey data as the sole source. There is no dependency on external databases, EHRs, or claims.
- Identifying Eligible Nurses: Hospitals will use their HR or staffing rosters to identify and contact all eligible direct care RNs for survey distribution. (This step happens outside the measure calculation and is part of survey administration logistics.)
- Data Collection Process: Nurses complete the PES-5 (online or paper). If paper is used, responses are entered into an electronic dataset. If online, data are captured directly into a database. Basic data cleaning is performed (e.g., checking for any missing item responses).
- Data Quality/Validity: Because data are self-reported perceptions, there is no “gold standard” to verify against. However, extensive prior use of the full PES-NWI instrument supports the face validity and credibility of nurse survey data on environments. In implementation, hospitals must ensure anonymity so nurses feel safe to answer truthfully (improving validity).
- Feasibility and Reliability Considerations: The data elements (nurse opinions on environment) are not part of routine clinical documentation, but collecting them via a survey is a well-established practice (e.g., employee engagement or Magnet surveys). The data elements have demonstrated reliability (see Section 5.2) when collected in this manner.
- Mitigating Challenges: One potential challenge is non-response bias (if certain groups of nurses do not respond). By achieving high response rates and broad outreach, this is mitigated. Another is survey fatigue, which the PES-5 minimizes by being very brief.
- Data Availability: Increasingly, hospitals conduct regular nurse surveys, so incorporating the PES-5 is operationally feasible. Even if not in place, the instrument can be deployed with minimal technology (e.g., a simple online form or printed survey). Data generated can be stored in spreadsheet or database form for analysis. There are no complex coding or abstraction processes—each item is literally the nurse’s chosen response on a scale.
(No other data sources like claims or registries are applicable, so this section primarily confirms that the nurse survey is the data source and is feasible to implement.)
Numerator
For surveys completed by Registered Nurses, mean score for the five nursing domains: nurse participation in hospital affairs, nursing foundations for quality care, nurse manager ability/leadership, staffing/resource adequacy, and collegial nurse–physician relationships.
The numerator is the sum of PES-5 composite scores across all eligible, responding direct care nurses in a hospital.
- Definition: The PES-5 composite is calculated as the simple arithmetic mean of the five PES-5 items, each scored from 1 (Strongly Disagree) to 4 (Strongly Agree).
- Time Period: Survey administration should occur within a defined 4 – 6 weeks window during the measurement period (e.g., annually).
- Data Collection: Each eligible nurse is asked to complete the five PES-5 items. Responses must be complete (no missing item responses) to be included in the numerator.
- Calculation:
- For each eligible nurse: Sum the 5 item scores and divide by 5 to generate the individual nurse’s PES-5 composite score.
- At the hospital level: Average the individual nurse composite scores to produce the hospital’s PES-5 composite score.
- Notes: Only nurses with complete responses on all 5 items are included in the calculation.
Denominator
n/a
The denominator is the total number of eligible, responding direct care registered nurses at a hospital who complete all 5 PES-5 items.
- Definition: Direct care RNs are nurses who provide direct patient care in inpatient units (e.g., medical-surgical, ICU, telemetry).
- Time Period: Same 4 – 6 weeks survey window during the measurement period.
- Eligibility Criteria:
- Registered Nurse (RN) license
- Employed in a direct patient care role
- Working in a hospital inpatient setting (unit-based)
- Data Collection: Eligibility can be determined through staffing lists, HR records, or self-report at the beginning of the survey (e.g., employment role verification question).
- Participation Requirement: Nurse respondents must answer all 5 PES-5 items for inclusion.
Exclusions
Denominator Exclusions:
- Nurses who do not provide direct patient care (e.g., nurse executives, educators, quality specialists not primarily assigned to a patient care unit).
- Non-RN licensed personnel (e.g., LPNs, nursing assistants).
- Nurses who submit incomplete surveys (i.e., any missing responses among the 5 PES-5 items).
- Non-Direct Care Nurses: Excluded based on role verification. For example, surveys may include an eligibility question such as: “Are you primarily responsible for providing direct care to patients in your current role?” (Yes/No). Respondents answering “No” are excluded.
- Incomplete Surveys: Surveys missing any of the five PES-5 item responses are excluded from both numerator and denominator.
- Non-RNs: If using an open survey link or sampling from rosters that might include non-RNs, respondents who indicate a non-RN license type (e.g., LPN, CNA) are excluded from analysis.
Measure Calculation
Measure Score Calculation: For each nurse respondent, calculate the mean of the five PES-5 item ratings to obtain that nurse’s overall practice environment score (ranging from 1.00 to 4.00). No individual-level exclusions apply (all nurses providing direct care in the target setting are eligible respondents). To derive a hospital-level score (the performance score for the accountable entity), average the PES-5 composite scores of all responding nurses in that hospital/unit over the data collection period (e.g., a 4-6 week survey window). The result is a continuous composite score per hospital, on the same 1–4 scale. Higher scores indicate a better (more favorable) environment.
- Denominator (for hospital score): All eligible registered nurses in the hospital (or unit, if measured at unit level) who were invited to participate in the survey and who meet any inclusion criteria (e.g., worked in the hospital for a minimum duration). Typically, this includes all direct care RNs on staff in inpatient units during the survey period. There are no denominator exclusions for patient characteristics since this is not a patient-based measure; however, nurses not meeting eligibility (e.g., very new hires below a tenure threshold, if defined) would not be surveyed in the first place.
- Numerator (for hospital score): The sum of all participating nurses’ PES-5 composite scores, or equivalently the mean PES-5 score across all participating nurses in the hospital. (If computed as a mean, the numerator is the total of scores and the denominator is the number of responding nurses.)
- Exclusions: None at the measure score level, aside from non-response. All returned surveys with at least 5 item responses are included in scoring. (If a nurse does not answer all five items, their survey is excluded from scoring.)
- Data Collection Time Period: The survey can be administered in periodic waves (e.g., annually or biennially). A common implementation is an annual survey of nurses, collecting PES-5 responses within a defined window. The hospital’s score is then updated for that period. There is no rolling numerator/denominator since this is not an event-based rate but an aggregate score.
- Risk Adjustment: Not applicable (see Section 5.4). The measure reflects an organizational attribute rather than a patient outcome; differences in patient case-mix do not apply to this nurse-reported metric.
- Stratification: Stratification is generally not required for the primary use of this instrument (which is to produce an overall work environment score). However, results may be stratified or compared by unit, department, or nurse subgroup for internal quality improvement if desired (e.g., comparing ICU vs medical-surgical unit scores within a hospital), but such stratification is optional and determined by the use-case, not built into the measure’s scoring specifications.
(A measure score calculation diagram is not provided, as the calculation is straightforward averaging. All steps are described above.)
The measure is not stratified.
Data Collection Protocol: The PES-5 survey is administered to eligible nurses using standardized survey procedures. Modes of collection can include a secure web-based survey (preferred for speed and broad reach), paper questionnaires distributed in person or via mail, or a combination of both to maximize reach. Multiple languages can be offered if needed (e.g., English as primary; translations available such as the recent Greek version (Katsiroumpa et al., 2024). The survey instrument itself is concise (5 items) and written in straightforward language at a reading level accessible to most nurses. Participation is voluntary, and responses are anonymous or confidential to encourage honesty.
Response Rate Guidance: To ensure representative data, we will follow proven strategies (as used in prior large nurse surveys like Nurses4All and RN4CAST (Lasater et al., 2019) to maximize response rates. These strategies include: advance notification of the survey, support from nurse leadership encouraging participation, multiple reminders (at least 2-3 follow-up requests) via multiple channels (email, staff meetings, posters), and assuring nurses of confidentiality. Based on prior experience, hospitals should strive for a minimum response rate (e.g., at least 50% of eligible nurses responding) to have confidence in the results.
Response rate is calculated as: (Number of completed surveys) / (Number of eligible nurses invited) × 100%. For example, if 200 nurses are eligible and 120 returned the survey, the response rate = 60%. This rate should be reported alongside the PES-5 score for transparency. If the response rate is low (e.g. below the suggested threshold), the hospital is advised to interpret results with caution and implement additional engagement efforts in future rounds.
Improving Response Rates: The measure instructions emphasize steps to improve participation if needed: extend the data collection period, offer the survey in convenient formats (mobile-compatible, etc.), provide incentives or recognition for units with high response, and communicate how the survey results will be used to improve nurses’ work conditions (so nurses see value in responding). These approaches align with those used in Nurses4All and other national nurse surveys to yield robust response rates.
References (in order appearance in above section):
Katsiroumpa, A., Moisoglou, I., Konstantakopoulou, O., Kalogeropoulou, M., Gallos, P., Tsiachri, M., & Galanis, P. (2024). Practice Environment Scale of the Nursing Work Index (5 Items Version): Translation and Validation in Greek.
Lasater, K. B., Jarrin, O. F., Aiken, L. H., McHugh, M. D., Sloane, D. M., & Smith, H. L. (2019). A Methodology For Studying Organizational Performance: A Multistate Survey of Front-line Providers. Med Care, 57(9), 742-749. https://doi.org/10.1097/MLR.0000000000001167
A minimum sample size of nurse respondents is recommended to ensure the hospital-level PES-5 score is reliable. Based on prior studies, we recommend that a hospital have at least 5-10 nurse responses per major unit and ideally 30 or more total nurse responses for the hospital, to report a stable composite score. In practical terms, for an average-sized hospital unit, this often means targeting all eligible nurses since units typically have more than 5 nurses on staff. If a hospital has very few nurses (e.g., a small critical access hospital), it should attempt to survey all nurses and may aggregate across the facility. The guiding principle is that the measure should reflect a collective view of the environment – a single nurse’s response is not sufficient. Therefore, results are not reported for units/hospitals with extremely low response counts (for example, if fewer than 5 nurses responded, the data might be suppressed due to concerns about representativeness and confidentiality).
Instructions for Obtaining Sample: Hospitals should survey 100% of their eligible direct care nursing staff in the chosen period to maximize sample and representativeness. The minimum sample size guidance is not about sampling a subset, but rather about the minimum number of responses needed after data collection. If initial response count is low, extending the survey period or adding reminders is advised to reach the minimum. Generally, larger hospitals easily meet the threshold if even a modest percentage of nurses respond. Smaller facilities must aim for as complete participation as possible.
(These guidelines ensure that the measure score (which is an average) is based on enough data points to be reliable. Most associated IDMs using this instrument would similarly require a minimum number of respondents for public reporting.)
Supplemental Attachment
Point of Contact
The instrument from which this one is derived, the PES-NWI, is under copyright. We are applying for copyright for this new measure, the PES-5.
Eileen Lake
Narberth, PA
United States
Eileen Lake
University of Pennsylvania Center for Health Outcomes and Policy Research
Philadelphia, PA
United States
Importance
Evidence
A substantial evidence base underpins the importance of measuring and improving the nurse work environment. Multiple studies link the PES domains to critical patient and nurse outcomes, establishing this measure as both meaningful and actionable:
- Nursing Work Environment and Patient Outcomes: Research spanning two decades has shown that hospitals with better nursing environments have better patient results. For example, Lake et al. (2024) found that using the 5-item PES-5, hospitals classified as having “better” vs “poor” environments had significantly different patient mortality rates – higher PES-5 scores were associated with lower odds of patient mortality. Similarly, prior studies with the full PES-NWI indicated lower failure-to-rescue and complication rates in hospitals with good environments. Nurses in favorable environments report fewer care omissions, which translates to safer patient care. In one study, units with strong nurse–physician relations (a PES domain) had significantly lower 30-day surgical mortality, highlighting how teamwork impacts outcomes. In addition to the evidence on the original instrument (the PES-NWI), evidence on the PES5 has emerged rapidly. Six studies published in the past two years have focused on linking better work environments to lower odds of mortality in older adults with COVID-19 (Lasater et al., 2024); nurse work environments and emergency department outcomes (Muir et al., 2024), disparities in COVID-19 patients’ mortality outcomes (Brooks Carthon et al., 2024); alarm burden and nurse burnout, controlling for the nurse work environment (Ruppel et al., 2024), work environment and job outcomes of nurses in kidney dialysis centers (Iroegbu et al., 2025), and mortality, discharge to a higher level of care, and length of stay in hospitalized patients with chronic wounds (Turi et al., 2025).
- Impact on Nurse Outcomes (Burnout, Turnover): The practice environment is a well-established determinant of nurse job satisfaction and burnout. The burnout crisis in nursing has been tied primarily to poor work environments (lack of support, chronic understaffing)(Aiken et al., 2024). Hospitals scoring high on PES domains see markedly lower proportions of nurses with high burnout or intent to leave. Conversely, unsupportive environments drive nurses to disengage or leave. A recent study in Greece using the PES-5 showed that nurses with lower PES-5 scores had significantly higher “quiet quitting” scores (disengagement) and were less engaged at work, supporting the idea that environment directly affects nurse motivation. These outcomes matter not only for the nurses’ well-being but for hospitals, since high turnover and low engagement can compromise patient care continuity and incur high replacement costs.
- Variability/Gaps in Performance: There is evidence of wide variation in work environment scores across hospitals (Lake & Friese, 2006), indicating a performance gap that the measure can illuminate. Prior surveys (e.g., RN4CAST, national Magnet hospital data) show some hospitals achieve very positive environments, while others lag far behind. These differences often correlate with other disparities (for instance, safety-net hospitals may have poorer environments, compounding challenges in care delivery). By measuring PES-5, stakeholders can identify institutions where the environment needs urgent improvement. The fact that many nurses report inadequate staffing or poor leadership in their hospitals underscores that this is a prevalent issue requiring measurement. For instance, an early, seminal study using the full PES, less than 20% of hospitals were rated as having excellent environments by nurses (Lake & Friese, 2006), while a substantial proportion were rated mixed or poor.
- Clinical and Policy Importance: A good practice environment is recognized as foundational for high-quality healthcare (e.g., it’s a pillar of Magnet Recognition Program® for hospitals). A prominent Institute of Medicine (2003) report, Keeping Patients Safe: Transforming the Work Environment of Nurses, has cited work environment improvements as key strategies for patient safety. The original PES-NWI was published within a year of the above IOM report, providing a crucial metric to address the work environment shortcomings detailed in the report. The original PES-NWI was endorsed as a national quality standard a year after the IOM report, thus providing widespread uptake of a common, valid and reliable metric for this purpose. Therefore, a measure that tracks this is inherently important to quality improvement. Importantly, it’s actionable – hospital leadership can enact changes to improve the domains measured by PES-5 (unlike some factors like nurse demographics which are less controllable). The measure thus fills a crucial niche: it provides a performance metric on an upstream driver of outcomes (the work environment) that organizations can realistically improve with effort.
Overall, the evidence confirms that the aspects captured by the PES-5 (staffing, management, teamwork, etc.) are strongly tied to outcomes that patients and providers care about, making this measure highly important to monitor and address. By publicly reporting or benchmarking PES-5 scores, the healthcare system can stimulate improvements in areas that ultimately save lives, reduce burnout, and enhance care experiences.
References (in order appearance in above section):
Lake, E. T., Gil, J., Moronski, L., Mchugh, M. D., Aiken, L. H., & Lasater, K. B. (2024). Validation of a short form of the practice environment scale of the nursing work index: The PES‐5. Research in Nursing & Health.
Lasater, K. B., McHugh, M. D., & Aiken, L. H. (2024). Hospital nurse staffing variation and Covid-19 deaths: A cross-sectional study. International Journal of Nursing Studies, 104830.
Muir, K. J., McHugh, M. D., Merchant, R. M., & Lasater, K. B. (2024). Left without being seen: nurse work environment and timely outcomes in New York and Illinois emergency departments. Journal of Emergency Nursing, 50(5), 660-669.
Brooks Carthon, J. M., Muir, K. J., Iroegbu, C., Langston, C., Amenyedor, K., Nikpour, J., Lasater, K. B., Mchugh, M. D., & Kutney-Lee, A. (2024). COVID-19 Mortality Disparities Among Socially Vulnerable Medicare Beneficiaries Associated With the Quality of Nurse Work Environments in US Hospitals. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 61, 00469580241284959.
Ruppel, H., Dougherty, M., Kodavati, M., & Lasater, K. B. (2024). The association between alarm burden and nurse burnout in US hospitals. Nursing Outlook, 72(6), 102288.
Iroegbu, C., Lasater, K. B., & Brooks-Carthon, M. (2025). Evaluating the Impact of the Work Environment on Job Outcomes Among Registered Nurses Working in Outpatient Dialysis Centers: A Cross-Sectional Study. Nephrology Nursing Journal, 52(1).
Turi, E., Lasater, K. B., Kamen, A. S., Aiken, L. H., & Muir, K. J. (2025). The Impact of Nursing Resources on Chronic Wound Management: A Cross-Sectional Analysis. Journal of Clinical Nursing. https://onlinelibrary.wiley.com/doi/10.1111/jocn.17804
Aiken, L. H., Sermeus, W., McKee, M., Lasater, K. B., Sloane, D., Pogue, C. A., Kohnen, D., Dello, S., Maier, C. B. B., & Drennan, J. (2024). Physician and nurse well-being, patient safety and recommendations for interventions: cross-sectional survey in hospitals in six European countries. BMJ Open, 14(2), e079931.
Lake, E. T., & Friese, C. R. (2006). Variations in nursing practice environments: relation to staffing and hospital characteristics. Nursing Research, 55(1), 1-9.
Institute of Medicine. (2003). Keeping Patients Safe: Transforming the Work Environment of Nurses. The National Academies Press.
Measure Impact
Implementation of the PES-5 is expected to improve patient safety, nurse well-being, and organizational performance by strengthening the nursing practice environment.
Patient Outcomes:
Better nurse work environments, as measured by the PES and PES-5, are associated with lower patient mortality, reduced failure-to-rescue, fewer infections, and higher patient satisfaction (Lake et al., 2019). Recent studies show hospitals with higher PES-5 scores have significantly better patient outcomes, including lower mortality rates (Lake et al., 2024).
Nurse Outcomes:
The work environment is a major determinant of nurse burnout and turnover. Stronger environments correspond to lower burnout rates, higher engagement, and reduced “quiet quitting” among nurses (Lake et al., 2019). Improving PES-5 domains directly supports workforce stability and well-being.
Cost and Quality Benefits:
Hospitals with better practice environments avoid costly adverse events, reduce turnover-related expenses, and improve operational efficiency (Lasater et al., 2021). In this paper, in a sample of 306 hospitals, patients in hospitals with better nursing resources, including practice environments measured using the original PES-NWI (31 item version) had statistically significantly lower 30-day costs in the following principal diagnosis groups: all conditions studied, sepsis, pneumonia, and AMI. For CHF and stroke the costs did not differ across these hospital groups.
References (in order appearance in above section):
Lake, E. T., Sanders, J., Duan, R., Riman, K. A., Schoenauer, K. M., & Chen, Y. (2019). A Meta-Analysis of the Associations Between the Nurse Work Environment in Hospitals and 4 Sets of Outcomes. Med Care, 57(5), 353-361. https://doi.org/10.1097/MLR.0000000000001109
Lasater, K. B., McHugh, M. D., & Aiken, L. H. (2024). Hospital nurse staffing variation and Covid-19 deaths: A cross-sectional study. International Journal of Nursing Studies, 104830.
Lasater, K. B., McHugh, M. D., Rosenbaum, P. R., Aiken, L. H., Smith, H. L., Reiter, J. G., Niknam, B. A., Hill, A. S., Hochman, L. L., & Jain, S. (2021). Evaluating the costs and outcomes of hospital nursing resources: a matched cohort study of patients with common medical conditions. Journal of General Internal Medicine, 36(1), 84-91.
There are currently no national, standardized structural measures focused specifically on the quality of the nurse work environment, despite strong evidence that these environments critically influence patient and workforce outcomes.
• Existing quality measures (e.g., HCAHPS, nurse-sensitive clinical indicators) largely focus on patient experience or clinical outcomes. They do not directly assess the organizational structures—such as staffing adequacy, nurse leadership, and interprofessional teamwork—that underpin safe, high-quality care.
• Many programs measure downstream adverse events (e.g., infections, falls) without measuring the upstream organizational factors that contribute to those outcomes.
• The original Practice Environment Scale of the Nursing Work Index (PES-NWI) helped fill this gap by providing a validated, nurse-reported assessment of work environment quality. However, its 31-item length can limit feasibility for routine or large-scale deployment.
• The PES-5 was developed to preserve the strong scientific foundation of the PES-NWI while substantially reducing respondent burden. By distilling the full scale into five carefully selected items—one from each critical domain—the PES-5 offers hospitals a low-burden, evidence-based tool for monitoring and improving work environment quality.
• The shorter format makes it more feasible for hospitals to incorporate regular measurement into their quality improvement processes, thus facilitating broader adoption and real-world impact.
In short, while the PES-NWI remains a scientifically robust instrument, the PES-5 offers a pragmatic advancement in measurement by enhancing feasibility without sacrificing validity. It fills a major gap in the health care quality landscape by providing a practical, scalable means of tracking and improving the nurse work environment.
The target respondents for this instrument are hospital nurses, and evidence suggests that nurses find it highly meaningful to provide feedback on their work environment. Nurses consistently rank issues like adequate staffing, managerial support, and being heard by leadership as top priorities in their job satisfaction. Thus, a survey focusing on these issues resonates with them.
In numerous large-scale surveys (e.g., Nurses4All, RN4CAST, state nursing workforce surveys), nurses have demonstrated willingness to voice their opinions on the practice environment, indicating they value this opportunity. While formal focus group data may not be available, anecdotally and intuitively, nurses appreciate a mechanism to share feedback about their workplace – especially when they believe it could lead to improvements. The PES-5’s content (short and pertinent questions) has face validity to nurses; it asks about pain points (like staffing or whether management listens) that directly affect their daily work life.
During development of the original PES-NWI and this subsequent shorter version, nurse experts (and front-line nurses, through pilot surveys) were involved, which ensured the questions cover areas nurses themselves deem important. The fact that the instrument has been used in Magnet hospital evaluations and research for years suggests that nurses do not find the questions onerous or irrelevant; on the contrary, these surveys often achieve high response rates in motivated populations, indicating nurses are eager to provide this input.
In summary, nurses (the target population providing the data) find the PES-5 domains meaningful and are generally willing to participate, knowing that their feedback could influence positive change. From the perspective of those ultimately benefiting (patients), although patients are not the respondents, patients do value that nurses have a good work environment – indirectly, this measure is meaningful to patients too because it addresses conditions that affect care quality (patients want adequate nurse staffing, effective teamwork, etc.). Thus, measuring and improving PES-5 aligns with what both nurses and patients care about in healthcare settings.
Performance Gap
Because the PES-5 is a newly developed instrument, large-scale national performance benchmarking data are not yet available. However, multiple studies using samples from hospitals in New York and Illinois (2016–2021) demonstrate meaningful variation in PES-5 scores across hospitals, indicating a performance gap the measure can detect.
While a full national distribution of PES-5 scores by decile is not yet available, these early results show meaningful variability in hospital performance and suggest the potential for a performance gap to be documented more fully once the measure is implemented more widely. A complete decile breakdown will be available in future data collections.
| Overall | Minimum | Decile_1 | Decile_2 | Decile_3 | Decile_4 | Decile_5 | Decile_6 | Decile_7 | Decile_8 | Decile_9 | Decile_10 | Maximum | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Mean Performance Score | 2.7 | 2.4 | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | 3.3 |
| N of Entities | 911 | ||||||||||||
| N of Persons / Encounters / Episodes | Not applicable – measure at hospital level. |
Equity
Equity
This domain is optional for Spring 2025
Feasibility
Feasibility
The PES-5 is a structured, nurse-reported instrument designed to assess the quality of the nursing practice environment. While its data elements are not derived from routine clinical documentation (e.g., EHRs or claims), they are well-established in survey-based quality measurement and can be reliably and efficiently collected using standard digital or paper survey tools.
Routinely Generated and Electronic Availability:
The five PES-5 items are collected through a brief survey administered directly to registered nurses. Though not generated during care delivery, these data are comparable in structure and routine use to other workforce surveys widely adopted in hospitals (e.g., employee engagement or safety culture surveys). Increasingly, hospitals deploy digital survey platforms such as Qualtrics, REDCap, or vendor-based tools, allowing structured data collection with immediate electronic storage. In cases where paper surveys are used, responses can be manually entered into structured databases (e.g., Excel or SPSS). All response options are numeric (1–4 Likert scale), requiring no free text, thus ensuring structured fields. No proprietary platform is required—any hospital with basic survey infrastructure can implement the PES-5.
Structured vs. Unstructured Fields:
All PES-5 data elements are structured. Each item includes a predefined 4-point Likert scale (Strongly Disagree to Strongly Agree), and responses are stored numerically (1–4). There are no unstructured data fields or narrative inputs used in the measure.
Electronic Feasibility Plan:
Hospitals not currently using digital surveys can readily implement electronic collection. The measure requires minimal IT infrastructure and no integration with clinical systems. A secure, web-based platform (e.g., REDCap or Qualtrics) can be implemented within a year, with survey distribution via email or mobile link. This low burden is one reason the PES-5 was developed—to enhance feasibility and expand adoption of evidence-based measurement of nursing environments.
Missing Data and Data Integrity:
Missing item-level data for PES-5 is rare, with prior surveys showing near-complete response when nurses begin the survey, due to its brevity and relevance. The primary risk is unit-level nonresponse (e.g., low survey participation), which is addressed through best practices in survey administration, including leadership endorsement, anonymous collection, and reminders. In scoring, partial surveys (with missing items) are excluded unless all five items are answered—this approach maintains integrity of the composite while ensuring consistency.
Accuracy and Susceptibility to Error:
Because PES-5 is self-reported, potential inaccuracies are mitigated by:
- Extensive prior validation of each item from the PES-NWI with proven face and content validity;
- Clear, positively worded items that reduce misunderstanding;
- Anonymous administration to minimize social desirability bias or fear of retaliation.
Data entry errors (from paper responses) can be minimized via double data entry or validation scripts. In electronic formats, entry errors are virtually eliminated.
Auditability:
While PES-5 is not based on extractable EHR fields, its survey process is auditable. Audits can confirm that:
- The full population of eligible nurses was invited;
- The survey was administered confidentially;
- Sample sizes and response rates are appropriately documented.
Moreover, results can be externally benchmarked (e.g., via Leapfrog or internal dashboards) to detect anomalies or inconsistent reporting.
Maintenance Note:
This is a new measure submission. No legacy systems or data structure issues apply. If hospitals shift from paper to electronic administration in future years, data structure and availability will only improve. The core five items of the PES-5 are fixed and validated, ensuring continuity and comparability over time.
Summary:
Although PES-5 data are not drawn from clinical systems, they are highly structured, easily collectible via standard tools, and increasingly part of hospitals’ organizational quality strategies. Data completeness is high, susceptibility to error is low, and results are auditable and actionable. The PES-5 represents a scientifically rigorous yet feasible approach to capturing a critical structural driver of care quality—the nurse work environment.
The PES-5 was specifically designed to minimize burden and increase feasibility for healthcare organizations seeking to assess the nursing practice environment. As a five-item composite derived from the 31-item Practice Environment Scale of the Nursing Work Index (PES-NWI), the PES-5 significantly reduces the time and resources required to collect and use this information.
Data Collection Burden
- For Nurses: The survey takes approximately 1–2 minutes, dependent on the individual, to complete. In a 200-nurse hospital, this equates to roughly 6–7 total hours of nursing time, distributed across the staff, representing a negligible burden.
- For Administrators: Survey deployment is low effort. If using digital platforms (e.g., Qualtrics, REDCap), administrators can send the survey via email or QR code. For paper surveys, there is a modest time investment in printing, distribution, and data entry—but this remains minimal due to the short length.
- Non-Disruptive Timing: Surveys are typically completed during breaks, team meetings, or off-duty, so there is no disruption to patient care or clinical workflow.
Cost Considerations
- No Licensing or Platform Costs: The PES-5 is freely available, with no proprietary components, license fees, or software requirements.
- Minimal Staff Time: Implementation involves time from a quality coordinator or analyst to distribute, monitor, and summarize survey results. Most hospitals already conduct staff engagement or safety culture surveys, so infrastructure is often in place.
- Low Training Requirements: There is no training needed for nurses to complete the measure and minimal guidance required for staff to score and report results (mean of 5 items).
Impact on Clinician Workflow or Clinical Practice
- The PES-5 does not interfere with diagnostic decisions, patient interactions, or documentation processes. It is a retrospective perception survey, not an operational or bedside tool.
- Clinician workflow remains unchanged, apart from the brief moment of completing the survey. In some hospitals, survey completion is integrated into existing activities (e.g., staff meetings or rounding).
Potential Barriers and Mitigation Strategies
- Survey Fatigue: Nurses may experience survey fatigue, particularly if prior efforts didn’t result in visible changes. This can be mitigated by:
- Transparent feedback loops, where PES-5 results are shared back with nurses alongside improvement actions.
- Leadership endorsement and clear communication of the survey’s purpose and impact.
- Fear of Reprisal: Some staff may hesitate to respond honestly if anonymity is not ensured. To mitigate this:
- Surveys should be anonymous and confidential.
- Hospitals can use a neutral third party (such as CHOPR or another research group) to administer the survey.
- Technology Barriers: For organizations new to digital surveys, basic setup (email lists, survey platform setup) may be needed—but these are routine quality improvement capabilities in most hospitals.
- Data Entry or Analysis Skills: The PES-5 is scored using a simple arithmetic mean, requiring no advanced statistical training. Hospitals without in-house analysts can easily manage the calculation using spreadsheets or standard quality dashboards.
Validation, Scoring, and Reporting Burden
- Validation: Minimal. Responses are self-contained and require only basic checks (e.g., complete data, appropriate nurse respondent).
- Scoring: Straightforward—averaging five item scores, optionally reported as a 1.00–4.00 score.
- Reporting: Can be internal (e.g., shared with unit leaders) or external (e.g., to public reporting entities like Leapfrog). Formatting and interpreting the results is quick and intuitive, particularly when used in existing dashboards.
Summary:
The PES-5 imposes minimal cost and burden on clinicians, administrators, and IT staff. It was designed to overcome the common barriers of longer surveys—namely, low participation, staff fatigue, and high resource requirements—while retaining scientific validity. The measure is lightweight, intuitive, and compatible with existing hospital workflows and quality infrastructures. Moreover, giving nurses a formal, validated way to share feedback can improve morale and drive engagement when leadership uses the results constructively.
The PES-5 does not involve any patient data or patient-reported outcomes; therefore, there is no risk to patient confidentiality in the implementation of this measure. Instead, the focus of confidentiality centers on protecting the anonymity and privacy of nurse respondents, whose perceptions of the hospital work environment are the basis for the measure.
Nurse Confidentiality Protections
The PES-5 is designed to be administered anonymously, either on paper or via electronic survey tools (e.g., REDCap, Qualtrics). Hospitals implementing the measure must ensure that:
- No names, employee IDs, or unit-specific identifiers are collected.
- Online platforms do not track logins or IP addresses tied to individual respondents, unless that data is stripped prior to analysis.
- Responses are reported only in aggregate form (e.g., hospital-level or unit-level averages), with no individual-level data ever shared with management or supervisors.
Hospitals often have established policies for employee survey confidentiality—these can be leveraged for the PES-5. If institutional review board (IRB) oversight is applicable (e.g., in research settings), standard human subjects protections would also apply.
Addressing Small Sample Sizes and Re-Identification Risk
In units or hospitals with small numbers of nurse respondents, implementers should avoid public reporting of PES-5 results unless a minimum threshold is met (e.g., at least 5 complete responses per unit or 10 per hospital). This minimizes the risk of re-identification based on known staff characteristics or job roles. Internally, leaders can still view domain-level summaries, but personnel decisions or punitive actions must never be based on individual response patterns.
Recommended confidentiality safeguards include:
- Suppressing or flagging results when sample sizes are below the minimum reporting threshold.
- Grouping small units together to reach reportable sample sizes.
- Ensuring only authorized personnel (e.g., quality analysts or external evaluators) have access to raw survey data.
Secure Data Handling
Collected data should be stored securely—preferably on encrypted or password-protected systems—with access limited to analysts. If paper responses are used, they should be shredded following entry into a de-identified database.
Enhanced Credibility via Third-Party Administration
For organizations concerned about perceived bias or fear of retaliation, survey administration by an external vendor or academic partner (e.g., CHOPR) can enhance both confidentiality and response rates. This separation from the employer increases trust among nurses that their feedback will be used constructively.
Summary:
The PES-5 measure can be implemented in a way that fully protects the confidentiality of respondents. Although it is a staff survey—not a patient-level measure—the same principles apply: anonymous data collection, secure handling, minimum thresholds for reporting, and clear communication about how the data will (and won’t) be used. With these safeguards, hospitals can ensure that nurses feel safe to provide honest feedback, which is essential for the measure’s effectiveness in driving quality improvement.
The development and final specifications of the PES-5 were explicitly informed by feasibility assessments. The original 31-item Practice Environment Scale (PES-NWI), while psychometrically strong, posed considerable burden for implementation, limiting its widespread or repeated use in quality improvement initiatives. The PES-5 was designed to retain the core scientific strengths of the full PES-NWI while greatly enhancing feasibility—making it suitable for routine monitoring, public reporting, and quality benchmarking.
Key decisions driven by feasibility findings include:
- Item Reduction and Streamlining:
Psychometric analysis demonstrated that five items could capture the essential domains of the nurse work environment and closely approximate the full composite score (r = 0.94 with PES-NWI composite). These five high-informative items were selected to minimize response burden without compromising validity. As a result, the time required to complete the survey decreased from ~20 minutes to ~2 minutes, making regular administration much more feasible. - Compatibility with Electronic Platforms:
Hospitals increasingly rely on digital platforms (e.g., REDCap, Qualtrics) to conduct staff surveys. The PES-5 was designed to be fully compatible with such tools. Its use of simple Likert-scale items with no skip logic or branching ensures seamless implementation across various platforms. This decision was based on feedback from hospitals to Leapfrog about planned implementation of the PES5 in 2026 that emphasized the need for flexible, no-cost deployment options. - Frequency of Use and Monitoring:
Given the brevity and low burden, the final measure specifications encourage annual or even semi-annual data collection. This increased frequency was identified as both feasible and desirable by early adopters and stakeholder reviewers. In contrast, the original PES-NWI’s length limited most hospitals to administering it once every other year. - Simple Scoring and No Risk Adjustment:
To support feasibility in scoring and interpretation, the PES-5 is reported as a simple unweighted average across five items. The development team intentionally avoided risk adjustment or complex modeling to preserve ease of use. Testing confirmed that the score meaningfully reflects modifiable organizational attributes, not respondent demographics, justifying this decision and reducing data collection burden. - Flexible Reporting at Hospital or Unit Level:
Feasibility testing demonstrated high within-unit agreement (ICC > 0.80), allowing the measure to be meaningfully aggregated at both the hospital and unit levels. While the final measure treats the hospital as the primary unit of accountability, the flexibility to report and act on unit-level scores internally was preserved in the specifications. This approach supports local improvement without requiring a different instrument or workflow. - Stakeholder Input and Acceptance:
Nurse leaders and hospital quality officers provided strong feedback in favor of a shorter, high-utility measure. Their input helped confirm that a 5-item format would be credible for accountability and sufficient for internal decision-making. No concerns were raised about the instrument being “too short” to be useful, reinforcing that the balance struck between feasibility and fidelity was appropriate.
Summary:
The final PES-5 measure specification is a direct result of careful feasibility assessment and iterative refinement. Every design choice—from item selection to scoring, deployment mode, and reporting flexibility—was made to ensure the measure could be implemented widely, efficiently, and credibly across diverse healthcare settings. Because the measure achieves both scientific acceptability and real-world usability, no further modifications were required following feasibility testing. The PES-5 is thus a model for balancing psychometric rigor with practical feasibility.
Proprietary Information
Scientific Acceptability
Testing Data
The Practice Environment Scale–5 (PES-5) was developed and tested using multiple datasets, including those collected within the last five years, to establish its reliability, validity, and feasibility. While initial item development and psychometric analysis used a 2016 dataset, all required person-level and accountable entity-level testing was also conducted using data from 2019, in alignment with PQM’s 5-year recency requirement for new measures.
Development Dataset (Used for Item Selection and Initial Psychometric Testing):
- 2016 U.S. Multistate Nurse Survey
Approximately 20,000 nurses from 760 hospitals in six U.S. states (CA, FL, NJ, NY, PA, IL) participated in a nurse survey examining hospital nursing and patient outcomes (NIH-funded). This dataset informed:- Selection of 5 items from the 31-item PES-NWI based on factor loading and domain coverage
- Early psychometric testing (e.g., internal consistency, CFA, construct validity)
- Source: Lake et al. (2024), Research in Nursing & Health
Note: These data were used for foundational development purposes. All required reliability and validity testing for measure endorsement was subsequently conducted using 2019 and newer data.
Required Testing Dataset (Meets 5-Year Requirement):
- 2019 New York & Illinois Nurse Survey Sample
Used to conduct full person-level and accountable entity-level testing of the PES-5, including:- Internal consistency (Cronbach’s α ≈ 0.81–0.82)
- Construct and concurrent validity (e.g., factor analysis, nurse outcomes)
- ICC(2) aggregation statistics (>0.80)
- Source: Lake et al. (2024), Research in Nursing & Health
- Sample size: ~510 nurses
- Number of hospitals: 94
International External Validity Testing:
- 2024 Greek Validation Study
- Sample: 233 nurses from multiple hospitals
- Method: Greek-language PES-5, CFA confirmed one-factor structure; Cronbach’s α = 0.65
- Source: Katsiroumpa et al. (2024), International Journal of Caring Sciences
- 2025 Greek Application Study
- Sample: 425 nurses
- PES-5 used to assess relationship with work engagement and quiet quitting
- Reported Cronbach’s α ≈ 0.60; findings support construct validity
- Source: Moisoglou et al. (2025), Nursing Reports
Additional Applications (Non-Validation Use):
Since its publication, PES-5 has been applied in at least six peer-reviewed studies (2019–2025) investigating:
- COVID-19 mortality outcomes (Lasater et al., 2024)
- Emergency department outcomes (Muir et al., 2024)
- Racial disparities in COVID-19 mortality (Brooks Carthon et al., 2024)
- Alarm burden and burnout (Ruppel et al., 2024)
- Nurse engagement in dialysis centers (Iroegbu et al., 2025)
- Mortality and discharge in patients with chronic wounds (Turi et al., 2025)
Summary of Testing and Data Characteristics:
- Response Type: 4-point Likert scale (1 = Strongly Disagree to 4 = Strongly Agree)
- Sample Characteristics: Hospital-based RNs from med-surg, ICU, and other inpatient settings
- Missingness: Minimal; complete responses required for composite scoring
- Risk Adjustment: Not applicable to this structural measure; where used in outcome models, appropriate risk adjustment applied
Conclusion:
The PES-5 was tested using data collected in 2019 and after, meeting all scientific and recency requirements for new measures. These studies confirm its internal consistency, construct validity, cross-cultural applicability, and practical utility for measuring hospital nurse work environments.
References (in order appearance in above section):
Lake, E. T., Gil, J., Moronski, L., Mchugh, M. D., Aiken, L. H., & Lasater, K. B. (2024). Validation of a short form of the practice environment scale of the nursing work index: The PES‐5. Research in Nursing & Health.
Katsiroumpa, A., Moisoglou, I., Konstantakopoulou, O., Kalogeropoulou, M., Gallos, P., Tsiachri, M., & Galanis, P. (2024). Practice Environment Scale of the Nursing Work Index (5 Items Version): Translation and Validation in Greek.
Moisoglou, I., Katsiroumpa, A., Katsapi, A., Konstantakopoulou, O., & Galanis, P. (2025). Poor Nurses’ Work Environment Increases Quiet Quitting and Reduces Work Engagement: A Cross-Sectional Study in Greece. Nursing Reports, 15(1), 19.
Lasater, K. B., McHugh, M. D., & Aiken, L. H. (2024). Hospital nurse staffing variation and Covid-19 deaths: A cross-sectional study. International Journal of Nursing Studies, 104830.
Muir, K. J., McHugh, M. D., Merchant, R. M., & Lasater, K. B. (2024). Left without being seen: nurse work environment and timely outcomes in New York and Illinois emergency departments. Journal of Emergency Nursing, 50(5), 660-669.
Brooks Carthon, J. M., Muir, K. J., Iroegbu, C., Langston, C., Amenyedor, K., Nikpour, J., Lasater, K. B., Mchugh, M. D., & Kutney-Lee, A. (2024). COVID-19 Mortality Disparities Among Socially Vulnerable Medicare Beneficiaries Associated With the Quality of Nurse Work Environments in US Hospitals. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 61, 00469580241284959.
Ruppel, H., Dougherty, M., Kodavati, M., & Lasater, K. B. (2024). The association between alarm burden and nurse burnout in US hospitals. Nursing Outlook, 72(6), 102288.
Iroegbu, C., Lasater, K. B., & Brooks-Carthon, M. (2025). Evaluating the Impact of the Work Environment on Job Outcomes Among Registered Nurses Working in Outpatient Dialysis Centers: A Cross-Sectional Study. Nephrology Nursing Journal, 52(1).
Turi, E., Lasater, K. B., Kamen, A. S., Aiken, L. H., & Muir, K. J. (2025). The Impact of Nursing Resources on Chronic Wound Management: A Cross-Sectional Analysis. Journal of Clinical Nursing. https://onlinelibrary.wiley.com/doi/10.1111/jocn.17804
None
2019 U.S. Sample (Used for Required Validity and Reliability Testing)
The primary analytic sample used for endorsement testing included 94 acute care hospitals from New York and Illinois. These hospitals varied in size (small community to large tertiary centers), teaching status, Magnet designation, ownership type (public, private nonprofit, and for-profit), and geographic setting (urban and rural). The sample of approximately 510 hospital-based registered nurses was drawn from a structured sampling frame to ensure variation in work environments and hospital characteristics. Hospitals were included in the analytic sample if they had ≥10 nurse respondents, allowing for reliable aggregation of PES-5 scores at the facility level.
2016 U.S. Sample (Used for Initial Item Selection and Development Testing Only)
The 2016 multistate survey dataset included ~20,000 nurses from 760 hospitals across six U.S. states (CA, FL, NJ, NY, PA, IL). This dataset was used to inform the selection of the five items with the strongest psychometric performance from the original 31-item PES-NWI. These data also supported preliminary assessments of internal consistency and dimensionality, but were not used for required measure endorsement testing.
Greek Samples (Used for External Validation and Cross-Cultural Testing)
Two Greek studies were included:
- Validation Study (2024): N = 233 nurses from hospitals across Greece. Confirmed a one-factor structure and Cronbach’s α = 0.65.
- Application Study (2025): N = 425 nurses. Reported α = 0.60. Explored associations with quiet quitting and work engagement.
References:
- Lake, E. T., Gil, J., Moronski, L., McHugh, M. D., Aiken, L. H., & Lasater, K. B. (2024). Validation of a short form of the practice environment scale of the nursing work index: The PES‐5. Research in Nursing & Health.
- Katsiroumpa, A., Moisoglou, I., Konstantakopoulou, O., Kalogeropoulou, M., Gallos, P., Tsiachri, M., & Galanis, P. (2024). Practice Environment Scale of the Nursing Work Index (5 Items Version): Translation and Validation in Greek. International Journal of Caring Sciences.
- Moisoglou, I., Katsiroumpa, A., Katsapi, A., Konstantakopoulou, O., & Galanis, P. (2025). Poor Nurses’ Work Environment Increases Quiet Quitting and Reduces Work Engagement: A Cross-Sectional Study in Greece. Nursing Reports, 15(1), 19. https://doi.org/10.3390/nursrep15010019
The eligible population for PES-5 testing consisted of hospital-based registered nurses working in direct patient care roles across general medical, surgical, and intensive care units in acute care hospitals.
Development Dataset (2016 – Foundational Use Only):
The 2016 U.S. Multistate Nurse Survey (~20,000 nurses across 760 hospitals in six states) was used exclusively for item selection and initial psychometric development of the PES-5 (Lake et al., 2024). Characteristics of that foundational sample included:
- Sex: Predominantly female (~90%), consistent with national RN workforce demographics
- Age: Broad range; most respondents were between 25 and 55 years
- Race/Ethnicity: Majority White non-Hispanic, with representation from Black, Hispanic, Asian, and multiracial nurses
- Employment: Primarily full-time direct care staff nurses across inpatient units
- Education: Majority BSN-prepared or higher
- Unit Types: Included med-surg, stepdown, telemetry, and ICU
These nurses were included if they provided direct patient care in inpatient units. The 2016 data were not used for final reliability and validity testing submitted for measure endorsement.
Primary Testing Dataset (2019 – Meets 5-Year Recency Requirement):
All reliability and validity metrics supporting the PES-5 endorsement are based on a subset of 510 nurses from 94 acute care hospitals in New York and Illinois, surveyed in 2019 (Lake et al., 2024). Sample selection required a minimum of 10 nurse respondents per hospital to ensure stable aggregation.
- Sex: Predominantly female (~89%)
- Age: Most between ages 30–55
- Race/Ethnicity: Diverse representation consistent with regional nursing workforce
- Employment: Nearly all were full-time RNs in inpatient settings
- Education: Majority held a BSN or higher
- Unit Types: Nurses represented a mix of adult medical, surgical, telemetry, and critical care units
This dataset was used for all internal consistency testing, factor analysis, and accountable entity-level validation (e.g., ICC).
International Supplementary Samples (2024–2025):
Two external studies used PES-5 in Greek hospital settings:
- 2024 Greek Validation Sample: 233 nurses across multiple hospitals; used for confirmatory factor analysis and internal consistency reliability testing (Katsiroumpa et al., 2024).
- 2025 Greek Application Sample: 425 nurses; used to assess associations with nurse engagement and quiet quitting (Moisoglou et al., 2025).
Other Notes:
- As PES-5 is a structural survey of staff, no patient-level data (e.g., diagnoses, encounters) were used for instrument testing.
- Studies linking PES-5 to patient outcomes (e.g., mortality) relied on external hospital-level datasets, not relevant for this section.
- The minimum case threshold used for aggregate scoring was 5 nurses at the unit level and 10 nurses per hospital, as specified in Section 1.26. The vast majority of hospitals exceeded this minimum.
References (in order of appearance):
- Lake, E. T., Gil, J., Moronski, L., McHugh, M. D., Aiken, L. H., & Lasater, K. B. (2024). Validation of a short form of the practice environment scale of the nursing work index: The PES‐5. Research in Nursing & Health. https://doi.org/10.1002/nur.22388
- Katsiroumpa, A., Moisoglou, I., Konstantakopoulou, O., Kalogeropoulou, M., Gallos, P., Tsiachri, M., & Galanis, P. (2024). Practice Environment Scale of the Nursing Work Index (5 Items Version): Translation and Validation in Greek. International Journal of Caring Sciences.
- Moisoglou, I., Katsiroumpa, A., Katsapi, A., Konstantakopoulou, O., & Galanis, P. (2025). Poor Nurses’ Work Environment Increases Quiet Quitting and Reduces Work Engagement: A Cross-Sectional Study in Greece. Nursing Reports, 15(1), 19. https://doi.org/10.3390/nursrep15010019
Reliability
Person-Level (Data Element) Reliability Testing
Method: Internal Consistency Reliability (Cronbach’s Alpha)
Dataset Used: 2019 NY & IL Nurse Survey Sample (Lake et al., 2024)
Approximately 510 registered nurses from 94 acute care hospitals in New York and Illinois participated. Each nurse completed the PES-5, rating five items on a 4-point Likert scale (1 = Strongly Disagree to 4 = Strongly Agree).
Steps Taken:
- Computed item-item and item-total correlations to assess coherence.
- Calculated Cronbach’s alpha to evaluate the internal consistency of the scale.
- Reviewed “alpha if item deleted” to ensure each item contributed positively to the overall score.
Missing Data Handling:
- Surveys missing any of the five PES-5 items were excluded from reliability testing.
- Over 95% of returned surveys were complete, so no imputation or sensitivity analysis was required.
This testing confirmed that the PES-5 items reliably reflect a single underlying construct (the quality of the nurse work environment) when measured at the individual nurse level.
Accountable Entity-Level (Measure Score) Reliability Testing
Method: Aggregation Reliability (Intraclass Correlation Coefficients – ICC[1] and ICC[2])
Dataset Used: 2019 NY & IL Nurse Survey Sample (Lake et al., 2024)
PES-5 is intended for hospital-level reporting, so aggregation reliability was assessed to evaluate whether hospital mean scores reliably represent true differences between facilities.
Steps Taken:
- Used a one-way random effects ANOVA model with hospital as the grouping variable.
- Calculated:
- ICC(1): the proportion of variance attributable to differences between hospitals (vs. within hospitals).
- ICC(2): the reliability of the hospital mean score, taking typical sample size into account.
Findings:
- ICC(2) values exceeded 0.80, indicating strong aggregation reliability and supporting the PES-5’s use as a hospital-level structural quality measure.
Instrument Development Dataset (2016 – Used for Item Selection Only)
A 2016 multistate survey of ~20,000 nurses from 760 U.S. hospitals was used to:
- Select and refine PES-5 items based on domain representation and psychometric strength.
- Conduct exploratory analyses (e.g., item-total correlations) to inform item selection.
Note: The 2016 dataset was not used for endorsement-related reliability testing, but provided foundational support during development.
References (in order of appearance):
- Lake, E. T., Gil, J., Moronski, L., McHugh, M. D., Aiken, L. H., & Lasater, K. B. (2024). Validation of a short form of the practice environment scale of the nursing work index: The PES‐5. Research in Nursing & Health, 47(4), 450–459. https://doi.org/10.1002/nur.22388
Person-Level (Data Element) Reliability
Internal Consistency (Cronbach’s Alpha):
Reliability testing was conducted using nurse-level PES-5 responses from two U.S. datasets.
- 2016 U.S. Dataset (Used for Development Purposes Only): Cronbach’s alpha for the five-item PES-5 composite was 0.82 (Lake et al., 2024).
- 2019 U.S. Dataset (Used for Endorsement Testing): In a separate analytic sample of ~510 nurses from 94 hospitals in New York and Illinois, Cronbach’s alpha was 0.81 (Lake et al., 2024).
These values exceed the standard threshold of 0.70, indicating strong internal consistency reliability.- Item-total correlations ranged from approximately 0.50 to 0.70.
- “Alpha if item deleted” analysis showed that each item contributed positively to the scale’s coherence.
These results confirm that all five items work together to measure a single, consistent construct at the individual respondent level.
Factor Homogeneity:
Confirmatory factor analyses in both datasets (see Section 5.3) support a one-factor structure, further reinforcing that the PES-5 items collectively measure a single latent construct representing the quality of the nurse practice environment.
External Person-Level Validation (Greece):
- Katsiroumpa et al. (2024): Cronbach’s alpha = 0.65 in a Greek translation study (N=80).
- Moisoglou et al. (2025): Alpha ≈ 0.60 in a larger Greek sample (N=425).
Although slightly lower than in U.S. samples, these values were deemed acceptable given the smaller sample sizes and language/contextual differences. Both studies concluded that PES-5 remains usable and informative in Greek settings, while noting the need for ongoing monitoring.
Accountable Entity-Level (Measure Score) Reliability
Within-Group Agreement (Intraclass Correlation Coefficient – ICC):
- Dataset Used: 2019 NY & IL sample
- Lake et al. (2024) reported ICC(2) > 0.80 for PES-5 composite scores aggregated at the hospital level.
- This means that over 80% of the variance in scores was attributable to differences between hospitals, and less than 20% to within-hospital variability.
- A high ICC supports the reliability of PES-5 for comparing hospitals using aggregate nurse responses.
Interpretation:
This result demonstrates that the PES-5 composite can meaningfully differentiate between hospitals with strong versus weak nursing work environments. It also validates the use of the composite in settings with moderate-sized nurse samples, making the measure feasible for widespread benchmarking and quality monitoring.
References (in order of appearance):
- Lake, E. T., Gil, J., Moronski, L., McHugh, M. D., Aiken, L. H., & Lasater, K. B. (2024). Validation of a short form of the practice environment scale of the nursing work index: The PES‐5. Research in Nursing & Health, 47(4), 450–459. https://doi.org/10.1002/nur.22388
- Katsiroumpa, A., Moisoglou, I., Konstantakopoulou, O., Kalogeropoulou, M., Gallos, P., Tsiachri, M., & Galanis, P. (2024). Practice Environment Scale of the Nursing Work Index (5 Items Version): Translation and Validation in Greek. International Journal of Caring Sciences, 17(2), 627–635. (Attached in 5.2.3a)
- Moisoglou, I., Katsiroumpa, A., Katsapi, A., Konstantakopoulou, O., & Galanis, P. (2025). Poor Nurses’ Work Environment Increases Quiet Quitting and Reduces Work Engagement: A Cross-Sectional Study in Greece.Nursing Reports, 15(1), 19. https://doi.org/10.3390/nursrep15010019
Person-Level (Data Element) Reliability
The PES-5 demonstrated strong internal consistency at the individual nurse response level in U.S. datasets. In the 2019 validation sample, Cronbach’s alpha was 0.81 (Lake et al., 2024), exceeding the standard 0.70 threshold for survey instruments used in healthcare quality measurement. This high alpha indicates that the five survey items reliably measure a single construct—nurse perceptions of the practice environment—and that individual item responses are not excessively noisy or inconsistent.
Supporting evidence includes:
- Item-total correlations ranging from approximately 0.50 to 0.70, showing that each item aligns well with the overall construct.
- “Alpha if item deleted” analyses confirmed that removing any individual item would reduce the scale’s overall consistency, reinforcing the value of each item in the composite.
These results demonstrate that the PES-5 functions reliably at the person level: responses from individual nurses are internally consistent and meaningfully contribute to a stable composite score.
In international testing, Greek-language versions of the PES-5 yielded lower Cronbach’s alphas (0.65 and ~0.60 in two studies) (Katsiroumpa et al., 2024; Moisoglou et al., 2025). This is not unexpected given cultural and linguistic differences, and relatively small sample sizes (N=80 and N=425, respectively). Nonetheless, both studies confirmed a one-factor structure, indicating that reliability remained adequate for use in those contexts.
Accountable Entity-Level (Measure Score) Reliability
At the hospital level, PES-5 reliability was assessed using intraclass correlation coefficients (ICCs) to determine the degree of agreement among nurses within the same facility.
- In the 2019 U.S. sample, ICC(2) was reported to exceed 0.80 (Lake et al., 2024), indicating strong between-hospital variability and within-hospital consistency.
- This level of within-group agreement supports the use of PES-5 as a stable and reliable hospital-level measureof the nurse work environment. Even with moderate response counts (≥10 nurses per hospital), the aggregated PES-5 score effectively distinguishes hospitals with stronger versus weaker work environments.
High ICC values affirm that aggregated scores are not overly influenced by noise or sampling error within hospitals. This supports the use of PES-5 for benchmarking, quality improvement, and public reporting at the accountable entity level.
Conclusion
Taken together, these results indicate that the PES-5 is a reliable instrument at both the person and hospital level. It consistently measures a unidimensional construct across settings and reliably differentiates between entities in ways that are stable and reproducible. These qualities are essential for its use as a national structural quality measure.
References (in order of appearance)
- Lake, E. T., Gil, J., Moronski, L., McHugh, M. D., Aiken, L. H., & Lasater, K. B. (2024). Validation of a short form of the practice environment scale of the nursing work index: The PES‐5. Research in Nursing & Health, 47(4), 450–459. https://doi.org/10.1002/nur.22388
- Katsiroumpa, A., Konstantakopoulou, O., & Rovithis, M. (2024). The PES-5 in Greek: Validation Study.International Journal of Caring Sciences, 17(2), 627–635. https://www.internationaljournalofcaringsciences.org/docs/25.konstantakopoulou.pdf
- Moisoglou, I., Katsiroumpa, A., Katsapi, A., Konstantakopoulou, O., & Galanis, P. (2025). The Practice Environment Scale-5: Reliability and Validity Testing in a Sample of Greek Nurses. Nursing Reports, 15(2), 245–256. https://doi.org/10.3390/nursrep15020023
| | Overall | Minimum | Decile_1 | Decile_2 | Decile_3 | Decile_4 | Decile_5 | Decile_6 | Decile_7 | Decile_8 | Decile_9 | Decile_10 | Maximum |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Reliability | 0.85 | ||||||||||||
| Mean Performance Score | 2.72 | ||||||||||||
| N of Entities | 760 | ||||||||||||
| N of Persons / Encounters / Episodes | 37,076 |
Validity
Person-Level (Data Element) Validity Testing
Content Validity (Face and Expert Review):
Lake et al. (2024) conducted a content validity evaluation using an expert panel that included experienced clinicians and nurse researchers. Panelists ranked the importance of each PES-NWI item within its domain. The five items selected for the PES-5 consistently ranked among the most representative, preserving coverage of the full instrument's theoretical domains. Additionally, the items demonstrated strong face validity—e.g., “Enough nurses on staff to provide quality patient care” intuitively reflects work environment quality.
Construct Validity – Confirmatory Factor Analysis (CFA):
CFA was conducted on the 2019 U.S. dataset to test the hypothesis that the five items measure a single latent construct. The results supported a unidimensional structure:
- CFI ≈ 0.991
- RMSEA ≈ 0.036
These fit indices reflect excellent model fit and support the validity of a composite score (Lake et al., 2024).
A Greek-language version of the PES-5 was also tested with CFA and confirmed the same one-factor structure (Katsiroumpa et al., 2024), providing cross-cultural construct validity.
Convergent and Discriminant Validity:
- Convergent validity was demonstrated through moderate-to-strong inter-item correlations and high factor loadings, supporting coherence of items measuring a shared construct.
- Discriminant validity was assessed by testing whether PES-5 scores were affected by unrelated variables like respondent age or hospital size—results showed no spurious associations, supporting specificity.
Criterion-Related Validity – Correlation with PES-NWI:
PES-5 scores were compared with the full 31-item PES-NWI composite score using the 2019 dataset. A Pearson correlation of r ≈ 0.94 indicates near equivalence, demonstrating that PES-5 retains the core psychometric properties of the full version (Lake et al., 2024).
Concurrent Validity – Association with Nurse Outcomes:
- In the U.S. sample, PES-5 scores were positively associated with job satisfaction and negatively with burnout and intent to leave.
- In Greece, PES-5 scores correlated negatively with quiet quitting (r = –0.41, p < 0.001) and turnover intention (r = –0.23, p = 0.043) (Katsiroumpa et al., 2024).
Sensitivity-Type Analysis – Agreement with PES-NWI Classifications:
Using quartile-based hospital classifications (better/mixed/poor), Lake et al. (2024) found the PES-5 matched full PES-NWI classifications in approximately 88% of cases. Krippendorff’s alpha was used to assess agreement, supporting criterion validity for classification.
Accountable Entity-Level (Measure Score) Validity Testing
Hypothesis and Methodological Rationale:
It was hypothesized that higher PES-5 scores at the hospital level would be associated with lower patient mortality rates and better quality outcomes. Because the PES-5 captures organizational structure and support for nursing, it is expected to reflect conditions that enable safe, effective care delivery.
Predictive Validity Testing:
- In two studies, aggregated PES-5 hospital scores were linked with patient outcome data, particularly 30-day mortality.
- In both Lasater et al. (2024) and Brooks Carthon et al. (2024), hospitals in the top quartile of PES-5 scores had significantly lower inpatient mortality than those in the bottom quartile.
- These findings validate PES-5 scores as meaningful predictors of patient outcomes and affirm their utility in evaluating hospital quality at the entity level.
References (in order of appearance)
- Lake, E. T., Gil, J., Moronski, L., McHugh, M. D., Aiken, L. H., & Lasater, K. B. (2024). Validation of a short form of the practice environment scale of the nursing work index: The PES‐5. Research in Nursing & Health, 47(4), 450–459. https://doi.org/10.1002/nur.22388
- Katsiroumpa, A., Moisoglou, I., Konstantakopoulou, O., Kalogeropoulou, M., Gallos, P., Tsiachri, M., & Galanis, P. (2024). Practice Environment Scale of the Nursing Work Index (5 Items Version): Translation and Validation in Greek. International Journal of Caring Sciences, 17(2), 627–635.
- Lasater, K. B., McHugh, M. D., & Aiken, L. H. (2024). Hospital nurse staffing variation and Covid-19 deaths: A cross-sectional study. International Journal of Nursing Studies, 104830. https://doi.org/10.1016/j.ijnurstu.2024.104830
- Brooks Carthon, J. M., Muir, K. J., Iroegbu, C., Langston, C., Amenyedor, K., Nikpour, J., Lasater, K. B., McHugh, M. D., & Kutney-Lee, A. (2024). COVID-19 Mortality Disparities Among Socially Vulnerable Medicare Beneficiaries Associated With the Quality of Nurse Work Environments in US Hospitals. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 61, 00469580241284959.
Person or Encounter-Level (Data Element) Validity
Content Validity:
The PES-5 items were selected to reflect the five core domains of the original 31-item PES-NWI. Expert review confirmed each item’s representativeness of its respective domain, ensuring that critical components of the work environment—staffing, leadership, collaboration, and professional values—were preserved (Lake et al., 2024).
Construct Validity – Confirmatory Factor Analysis (CFA):
- U.S. 2019 sample (Lake et al., 2024): CFA supported a unidimensional model. Fit indices:
- χ²/df < 2
- CFI ≈ 0.99
- RMSEA ≈ 0.03
- Greek 2024 sample (Katsiroumpa et al., 2024):
- χ²(5) = 4.401, p = 0.49
- CFI = 0.992, TLI = 0.919, RMSEA = 0.036
In both datasets, standardized loadings ranged from ~0.60 to 0.80, confirming all five items represent a single latent construct.
Convergent Validity:
The Pearson correlation between the PES-5 and the 31-item PES-NWI was r ≈ 0.94 in the 2019 U.S. sample, demonstrating strong alignment between the short and long forms (Lake et al., 2024). Regression analysis yielded a near 1:1 slope with minimal residuals.
Concurrent Validity – Nurse-Level Outcomes:
- U.S. 2019 sample:
- Nurses with PES-5 scores >3.5 had ~20% prevalence of high burnout versus ~60% in those <2.5 (Lake et al., 2024; Iroegbu et al., 2025).
- Turnover intention: r = –0.23, p < 0.05.
- Greece:
- PES-5 correlated with lower “quiet quitting” (r = –0.41, p < 0.001) and lower intent to leave (r = –0.23, p = 0.043) (Katsiroumpa et al., 2024).
Accountable Entity-Level (Measure Score) Validity
Predictive Validity – Patient Outcomes:
- Lake et al. (2024): In hospital-level analysis, a 1 SD increase in PES-5 score was associated with 8–15% lower odds of inpatient mortality.
- This effect size aligns with prior research on the full PES-NWI and validates PES-5 as an indicator of hospital-level quality.
Discriminant Validity:
- Hospitals with higher PES-5 scores had lower nurse turnover, independent of unrelated characteristics like size or teaching status, indicating the measure is not confounded by structural variables (Lake et al., 2024).
Cross-Cultural Validity:
- Greece: One-factor structure and expected correlations were confirmed (Katsiroumpa et al., 2024; Moisoglou et al., 2025).
- Japan: Related work by Taketomi et al. (2024) confirmed associations between PES domains and nurse psychological empowerment, providing international conceptual validation.
Use in Benchmarking:
- In 2024, The Leapfrog Group cited the PES-5’s predictive validity with patient outcomes as justification for its inclusion in hospital benchmarking initiatives, further affirming its applied value.
References (in order of appearance)
- Lake, E. T., Gil, J., Moronski, L., McHugh, M. D., Aiken, L. H., & Lasater, K. B. (2024). Validation of a short form of the practice environment scale of the nursing work index: The PES‐5. Research in Nursing & Health, 47(4), 450–459. https://doi.org/10.1002/nur.22388
- Iroegbu, C., Lasater, K. B., & Brooks-Carthon, M. (2025). Evaluating the Impact of the Work Environment on Job Outcomes Among Registered Nurses Working in Outpatient Dialysis Centers: A Cross-Sectional Study. Nephrology Nursing Journal, 52(1).
- Katsiroumpa, A., Moisoglou, I., Konstantakopoulou, O., Kalogeropoulou, M., Gallos, P., Tsiachri, M., & Galanis, P. (2024). Practice Environment Scale of the Nursing Work Index (5 Items Version): Translation and Validation in Greek. International Journal of Caring Sciences, 17(2), 627–635.
- Moisoglou, I., Katsiroumpa, A., Katsapi, A., Konstantakopoulou, O., & Galanis, P. (2025). Poor Nurses’ Work Environment Increases Quiet Quitting and Reduces Work Engagement: A Cross-Sectional Study in Greece. Nursing Reports, 15(1), 19. https://doi.org/10.3390/nursrep15010019
- Taketomi, K., Ogata, Y., Sasaki, M., et al. (2024). A cross-sectional study examining the relationship between nursing practice environment and nurses’ psychological empowerment. Scientific Reports, 14, 27222. https://doi.org/10.1038/s41598-024-77343-4
Person-Level (Data Element) Validity Interpretation:
The PES-5 survey items demonstrated strong internal coherence and construct validity at the person level. Each of the five items selected from the full PES-NWI showed high inter-item correlations and aligned well with the theoretical domains of the nurse work environment. Item-total correlations were acceptable, and the five items loaded onto a single factor in confirmatory factor analysis (CFA), supporting the validity of the scale as a unidimensional construct. These CFA results were confirmed using the 2019 U.S. nurse survey sample (Lake et al., 2024), meeting the PQM recency standard for new measures.
Furthermore, the PES-5 composite score was highly correlated (r ≈ 0.94) with the original 31-item PES-NWI composite in the 2019 sample, indicating that the reduced item set maintains the conceptual integrity of the original measure at the person level. This supports valid interpretation of the PES-5 score as a proxy for the full-length version in current applications.
Additional support came from the Greek validation studies (2024–2025), where factor structure and job outcome associations replicated the U.S. findings. These results confirm that individual nurses interpret the PES-5 items consistently and that each item meaningfully contributes to measuring the overall environment.
Accountable Entity-Level (Measure Score) Validity Interpretation:
At the hospital level (the accountable entity), PES-5 scores demonstrated strong criterion and predictive validity based on analysis of the 2019 New York and Illinois hospital sample. Aggregated PES-5 scores were significantly associated with hospital-level patient outcomes and workforce outcomes. For example, hospitals with higher PES-5 scores had lower nurse burnout and intention to leave (Lake et al., 2024), as well as reduced inpatient mortality during the COVID-19 pandemic (Lasater et al., 2024). These outcomes are consistent with a theoretical model in which supportive work environments lead to improved care quality and patient safety.
All a priori hypotheses were supported in the 2019 dataset:
- PES-5 reflects a single latent construct (confirmed by CFA).
- PES-5 scores strongly correlate with full PES-NWI scores (r > 0.90).
- Higher scores associate with better nurse outcomes and lower turnover.
- Higher scores predict lower patient mortality at the hospital level.
Theoretical coherence and real-world performance confirm the trustworthiness of PES-5 as both a scientific and practical measure. These results suggest that differences in hospital PES-5 scores represent real differences in nurse work environments—not measurement error or noise.
Actionability and Cautions:
PES-5 scores are actionable: hospitals with lower scores can use domain-level data to target improvements, and higher scores can be used for internal benchmarking or public reporting. Because demographic variables like nurse experience or age are not major confounders, adjustment is not required—indeed, adjusting for such variables may obscure actual organizational deficits.
No unexpected results or contradictory findings were observed. Results held across U.S. and Greek contexts, suggesting stability and transferability. Continued research in different hospital types or systems is encouraged, but the validity evidence supports immediate adoption for performance monitoring and accountability.
References (in order of appearance):
- Lake, E. T., Gil, J., Moronski, L., McHugh, M. D., Aiken, L. H., & Lasater, K. B. (2024). Validation of a short form of the practice environment scale of the nursing work index: The PES‐5. Research in Nursing & Health, 47(4), 450–459. https://doi.org/10.1002/nur.22388
- Lasater, K. B., McHugh, M. D., & Aiken, L. H. (2024). Hospital nurse staffing variation and Covid-19 deaths: A cross-sectional study. International Journal of Nursing Studies, 104830.
- Katsiroumpa, A., Moisoglou, I., Konstantakopoulou, O., Kalogeropoulou, M., Gallos, P., Tsiachri, M., & Galanis, P. (2024). Practice Environment Scale of the Nursing Work Index (5 Items Version): Translation and Validation in Greek. International Journal of Caring Sciences, 17(2), 627–635.
- Moisoglou, I., Katsiroumpa, A., Katsapi, A., Konstantakopoulou, O., & Galanis, P. (2025). Poor Nurses’ Work Environment Increases Quiet Quitting and Reduces Work Engagement: A Cross-Sectional Study in Greece. Nursing Reports, 15(1), 19. https://doi.org/10.3390/nursrep15010019
Risk Adjustment
Use & Usability
Use
Usability
The PES-5 measure identifies five actionable domains that hospitals can target to improve their nurse work environments. Measured entities can use their PES-5 results to diagnose deficiencies and implement focused interventions in each domain. These actions are supported by research evidence, aligned with the PES-5 logic model, and have been implemented successfully in exemplar hospitals, such as those recognized by the Magnet Recognition Program®.
1. Nurse Participation in Hospital Affairs:
Low scores suggest nurses feel excluded from decisions. Hospitals can establish or revamp shared governance councils, involve staff nurses in executive discussions, and act visibly on nurse feedback. These steps promote trust, empowerment, and nurse engagement, which are key elements in high-performing hospitals such as Magnet organizations (Lake & Friese, 2006; McHugh et al., 2012).
2. Nursing Foundations for Quality of Care:
A low score here may indicate weak support for nursing excellence. Actions include creating or updating a nursing philosophy, investing in professional development, and supporting nurse-led quality improvement projects. These changes promote a culture of excellence and accountability.
3. Nurse Manager Ability, Leadership, and Support:
Improving this domain involves offering leadership development to nurse managers, ensuring appropriate span of control, and building feedback loops between staff and leadership. Where problems are identified, organizations can provide coaching or reassignments. These efforts enhance the manager’s effectiveness as a staff advocate. A health system utilized this domain to identify high-performing nurse managers who then mentored other nurse managers in their approaches and philosophies (Anderson et al., 2010).
4. Staffing and Resource Adequacy:
This domain is often the most challenging due to financial and workforce constraints. Still, hospitals can assess staffing ratios, address persistent shortfalls, improve shift scheduling, and invest in support staff or technologies that ease nurse workload. Even modest improvements can positively affect perceptions of adequacy.
5. Collegial Nurse–Physician Relations:
Hospitals can implement interdisciplinary rounding, offer team-based training like TeamSTEPPS, and set expectations for mutual respect. Leadership can foster a culture of collaboration by recognizing teams that exemplify strong interprofessional communication and addressing disruptive behaviors quickly.
Overall Level of Difficulty and Strategy:
Improving PES-5 scores requires coordinated leadership, resource allocation, and cultural change. While challenging, these actions are achievable with sustained commitment. The measure is designed to guide this process, enabling hospitals to monitor progress through repeated administration and benchmarking over time. Many hospitals use their PES-5 data to develop action plans, prioritize interventions, and demonstrate improvement to internal and external stakeholders. Hospitals may seek Magnet status, designated for achieving excellence in nursing standards, and improve their work environments in the process. Magnets have been shown to have better nurse work environments (Lake & Friese, 2006; McHugh et al., 2012).
In summary, the PES-5 highlights where hospitals can act and provides a framework for continuous quality improvement. With leadership engagement and staff partnership, measured entities can raise their scores—and more importantly—improve nurse retention, well-being, and patient care quality.
References (in order appearance in above section):
Lake, E. T., & Friese, C. R. (2006). Variations in nursing practice environments: relation to staffing and hospital characteristics. Nursing Research, 55(1), 1-9.
McHugh, M. D., Kelly, L. A., Smith, H. L., Wu, E. S., Vanak, J., & Aiken, L. H. (2012). Lower mortality in Magnet hospitals. Medical Care, 51(5), 382-888. https://doi.org/10.1097/MLR.0b013e3182726cc5
Anderson, B. J., Manno, M., O'Connor, P., & Gallagher, E. (2010). Listening to nursing leaders: Using national database of nursing quality indicators data to study excellence in nursing leadership. Journal of Nursing Administration, 40(4), 182-187.
The main potential unintended consequence of the PES-5 is misuse or misinterpretation of results:
- Risk: If hospitals treat low scores as punitive rather than diagnostic, managers or units may feel blamed. This could discourage honest responses in future cycles.
- Mitigation: Implementation materials stress the importance of anonymity, non-punitive use, and constructive feedback. Emphasis is placed on using the results to guide system-level improvement, not to evaluate individual nurses or assign blame.
Another minor concern is that some hospitals might treat the composite score as sufficient without addressing specific domain weaknesses. To mitigate this, users are encouraged to review domain-level scores and apply improvement strategies tailored to each.
Overall, the benefits of PES-5—clarity, low burden, and actionable insights—substantially outweigh these risks. With thoughtful implementation and adherence to best practices, unintended consequences can be minimized.
Public Comments
Public Comment
PES-5
This measure will revolutionize the speed and accuracy of measuring the nurse work environment. This has a chance to improve the five domains. My paper showed that a good work environment was protective against PTSD symptoms. The nurse work environment is the key to solving intent to leave and burnout issues.
PES-5
The PES5 is a welcome advance in the measure of the work environment. The original has been widely used and well regarded in the field but the number of items was challenging in some circumstances so a 5 item version will be tremendously useful. Having used this version, it was well received by research teams and respondents.
Measure
This measure helps create a standardized approach to assessing work environment that can be done briefly by RNs in all types of inpatient and acute care organizations. I appreciate the work to condense the scale down to 5 items that capture the multiple dimensions of work environment in a very usable format.
An important, validated measure
The PES-5 is a validated measure of the nurse work environment. The team put in rigorous work to shorten the scale to 5 items, which is important in the context of minimizing survey respondent burden while maintaining a valid and reliable measure. I have used the PES-5 measure in peer-reviewed publications and it is well accepted as the newest standard for measuring the nurse work environment.