This study aimed to compare nurses' perceptions of career ladder systems, job satisfaction and turnover intention in small- and medium-sized hospitals with and without a career ladder system. A cross-sectional, correlational, descriptive study was conducted. Data were collected using self-report surveys from 130-144 participants in small- and medium-sized hospitals with and without a career ladder system, respectively. The data were collected from July 1, 2019-July 31, 2019. The perception of the career ladder system was positively correlated with job satisfaction in hospitals with and without a career ladder system but negatively correlated with turnover intention in those with a career ladder system only. A positive perception of the system is associated with increased job satisfaction and lowered turnover intention. Hospitals should implement a career ladder system and improve nurses' perception by addressing the specific categories identified in this study.