Diagnosing the Nursing Practice Environment: An Importance‐Performance Analysis of Job Satisfaction Across Clinical Ladder Levels

This study aimed to diagnose priority areas within the nursing practice environment by applying importance-performance analysis to examine job satisfaction across clinical ladder levels. Using a cross-sectional secondary data analysis, 8009 valid survey responses from registered nurses at a tertiary medical center in Taiwan were analyzed across nine survey waves collected between 2020 and 2025. Sequential regression revealed that personal and job-related characteristics accounted for only 3.2% of the variance in job satisfaction. Satisfaction demonstrated a U-shaped distribution across career stages, with the lowest levels observed among competent (N2) nurses. Importance-performance analysis identified professional autonomy as the sole dimension located in the "concentrate here" quadrant, signifying a high-importance but low-performance area and highlighting a marked structural autonomy gap. In contrast, nursing workload, although rated lowest in performance, was not located in the immediate intervention quadrant because of its comparatively lower association with overall job satisfaction. Findings suggest that nurse retention challenges are primarily associated with structural conditions, particularly for intermediate-level nurses who face increasing clinical responsibility without commensurate decision-making authority. Healthcare organizations should shift retention strategies from individual-level selection toward environment-focused diagnosis, prioritizing structural empowerment initiatives that enhance professional autonomy and participation in decision-making.