Impact of Nurse Leaders Behaviors on Nursing Staff Performance: A Systematic Review of Literature

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Abstract

Nursing leadership is critical in facilitating and improving nurse performance, which is essential for providing quality care and ensuring patient safety. The aim of this study is to explore the relationship between nursing leadership and nurse performance by understanding the leadership behaviors and factors that motivate nurses to perform well. To study the factors that nurses believe motivate them to perform better, a systematic review was undertaken, correlating these factors to leadership behaviors/styles. The PRISMA guidelines were followed to identify relevant articles. After applying the selection criteria, 11 articles were included in the final analysis. Overall, 51 elements that influence nurses’ motivation to perform better were found and categorized into 6 categories, including autonomy, competencies, relatedness, individual nursing characteristics, relationships and support, and leadership styles/practices. It has been discovered that both direct and indirect nursing leadership behaviors affect nurses’ performance. A better understanding of the factors that motivate nurses to perform well and facilitating them in the work environment through leadership behaviors/styles can improve nurses’ performance. There is a need to increase research on nurse leadership and nurses’ performance in the current innovative and technologically integrated work environment to identify new factors of influence.

Effective leadership in nursing can have a positive impact on nurse performance, job satisfaction, and patient outcomes.

It can provide new insights and understanding of how different leadership styles and practices impact nurse performance and patient outcomes

To identify effective leadership practices that promote positive work environments, better nurse performance, and ultimately better patient outcomes, thus leading to improved patient contentment, safety, and care quality.

Introduction

Nurses are essential resources in hospitals as they spend more time with patients than any other healthcare personnel. Therefore, they play a significant role in ensuring quality care and patients’ safety by improving their performance. Despite accounting for 50% of the global healthcare workforce, 1 there is a severe shortage of nursing personnel in almost all countries. Developed countries such as the USA need an additional 275 000 nurses from 2020 to 2030. 2 According to the International Council of Nurses, there is a need for 13 million nurses globally to fill the shortage gap in the future. 3

The shortage of nurses has resulted in an increasing workload for existing nurses, significantly affecting their work life and performance, which can have a direct impact on the quality of care delivered. 4 Nursing performance is influenced by cognitive, physical, and organizational factors. 5 Various factors such as high workloads, lack of technological support, 6 skills and competencies (eg, problem-solving ability, nursing informatics competencies), 7 communication skills and confidence, 8 commitment, 9 quality of work life, 10 job stress, 11 and motivation 12 can significantly influence nursing performance. It is interesting to observe that most of these factors are a part of leadership management, focusing on providing training and support and addressing the issues affecting nurses.

Quality leadership was identified to be one of the major factors for promoting behaviors among the nurses for exhibiting greater responsibility and physical activity. 13 Similarly, workplace incivility from supervisors was identified to be negatively related to nursing performance. 14 Nursing leadership behaviors play a crucial role in shaping nursing performance, thereby achieving the organizational goals of ensuring the delivery of quality care and achieving better patient outcomes. 15 -17 Considering the nursing leadership theories, transformational and transactional leadership styles 18,19 and their impact on nurses’ satisfaction, burnout, and resilience have received lot of attention. 17,18,20 However, most of the studies investigated the leadership styles influence on the factors affecting the nursing performance, but very few studies have focused on the leadership factors influencing the nurses’ motivation to perform well. An attempt in this aspect was made in a study 21 through the systematic review, but it only included studies till 2006. However, major changes have been observed in the factors influencing nursing performance in the past decade. The use of the internet and telecommunication technologies have significantly changed the quality of work of nurses, and led to the new forms of remote practices such as telenursing. 22 Furthermore, advanced innovative technologies such as artificial intelligence, intelligent systems such as IoTs 23,24 have significantly contributed to the nursing practice. 25,26 Additionally, due to the sudden surge of patients caused by the recent Covid-19 pandemic, nurses have experienced heightened levels of burnout, 27 which has significantly affected nurses work-life balance and their performance. 28,29 Furthermore, the COVID-19 pandemic has rendered the nursing shortage a critical issue on a global scale, according to the ICN study report 2023. 30 There are issues including understaffing and low job satisfaction, as well as an aging nursing workforce and a lack of young individuals entering the profession. The report highlighted that nurses’ shortage has grown significantly from 30.6 million in 2019 after the pandemic began. Furthermore, it identified that key research from surveys and reviews in the past 3 years, after the emergence of Covid-19 pandemic, there is a significant increase in nurses burn-out. This has resulted in burn-out nurses either leaving their employment or reducing their work hours, which has led to additional burden of work, increasing levels of stress among the resilient working nurses. 30 Therefore, significant changes in the factors that influence nurses’ motivation to perform well might have occurred. Considering these developments, it is necessary to extend the review conducted in Brady Germain and Cummings, 21 to identify the new developments in the research arena. For that, the purpose of this study is to conduct a systematic review for examining the factors related to nurses’ leadership and nurses’ performance. To achieve this objective, the following research questions are formulated.

RQ1: What factors do nurses think affect their drive to excel in their work? The ambition and aptitude of the nurses to achieve their companies’ objectives of high-quality care and patient safety serve as the benchmarks for performance in this context.

RQ2: Which leadership traits are associated with strong nurse performance? In this context, behaviors are described as the traits or tactics used by leaders to control nurses’ performance in order to accomplish organizational objectives, such as patient safety and high-quality care.

Materials and Methods

The protocol for this study is registered with PROSPERO (registration number: CRD42023387324), the registration date 15/01/2023.

Design

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines 33 was used for conducting the systematic review of recent literature and reporting the findings relating to nursing leadership attributes and nursing performance.

Search Methods

Various databases, including CINAHL, Cochrane, EMBASE, HealthSTAR, Medline, and PsychINFO, were utilized to search for relevant studies. The search terms “nursing performance,” “nurse motivation,” “nursing leadership,” and “nursing leadership behaviors” were combined using Boolean operators “AND” and “OR.” To improve search sensitivity, keywords from the identified studies were also used in the search process. Only studies published in English were considered. Additionally, studies published within the last 20 years were included to ensure the search was current and covered new literature since the previous study by 23. Therefore, those studies before 2003 are excluded. Inclusion and exclusion criteria, as presented in Table 1 , were applied for selecting studies. Figure 1 provides a detailed overview of the search strategy used to select studies.

Table 1.

Inclusion and Exclusion Criteria.

PRISMA flow diagram.

Quality Appraisal

Two methods were used to rate the methodological quality of the chosen studies. The PRISMA 31 methodological quality criterion, which contains 27 elements, was used to systematic reviews. TREND 32 was used to evaluate quasi-experimental studies. TREND 32 comprises 22 criteria. The last criterion received a “yes,” a “no,” or a “unclear” rating. The “yes” items were added up to create a total score for each study, which ranged from zero to the total number of items that were examined. Studies with low methodological quality were deemed to be omitted from the review if they received a score of less than or equal to 50% on the evaluated items. Studies were deemed to be of medium or high quality and included in the review if they scored more than 50% on the analyzed items.

Data Extraction

Quantitative studies were the source of data, which encompassed details such as the author, publication year, research aim, sample size, methodology employed, independent and dependent variables, measurement criteria, reliability and validity of the measures, analytical techniques, and findings. The number of studies examined and the key conclusions were retrieved for systematic reviews.

Results

Search Outcomes

Initially, 1632 articles were identified from different electronic databases, and 16 articles were identified through manual searching of journals, resulting in a total of 1648 articles. After removing 587 duplicates, 1061 articles were screened for titles and abstracts. Out of these, 984 articles were excluded based on title and abstract assessment, and 77 articles were selected for full-text reviews. After reviewing the full-text articles, 64 articles did not meet the inclusion criteria and were excluded. Finally, 13 articles were deemed eligible for quality assessment. Two articles did not meet quality criteria and were excluded resulting in 11 articles that are included in this review (See Figure 1 ).

Study Characteristics

Table 2 exhibits the attributes of the studies that were incorporated in this review. It can be observed that 6 studies were published recently (1 study in 2020, 3 studies in 2021, and 2 studies in 2022). Majority of the participants in most of the studies were females and were aged above 30 years with high work experience.

Table 2.

Summary of Study Characteristics Included in This Review.

Focusing on the leadership styles, 3 studies considered the effect of different leadership styles on nursing performance, 2 studies exclusively focused on transformational leadership, one each on sustainable leadership, entrepreneurial leadership, and servant leadership. There were 10 studies that have adopted quantitative approach of survey in data collection, and different analysis techniques were utilized in these studies. Only one systematic review was included that focused on the leadership attributes and nursing performance.

Theoretical Framework

Theories in research provides a rationale for developing hypothesis and testing the relationship between the variables, 44 and therefore it is important that the research studies should be guided by theoretical framework or a model that either confirmation of existing theory or generating new theories. Ten out of the 11 studies in this review were guided by a theoretical framework or a model. Six studies 33 -37,45 in this review adopted leadership theories or developed a model for testing the leadership attributes on nursing performance. Social exchange theory and self-determination theories were used in Kül and Sönmez, 38 supporting the role of servant leadership in developing the innovative behavior of nurses (guided by social exchange) and motivating them in improving their performance by developing autonomy, competence and relatedness (self-determination theory: extrinsic motivation from leaders leading to intrinsic motivation among nurses). 39 Another study conducted by Salanova et al 40 emphasized the significance of social interactions in the work environment in improving self-efficacy by adopting social cognitive theory, where self-efficacy is considered as the primary personal resource, and transformational leadership as contextual resource for motivating nurses. In extending the leadership theories, another study 41 linked it with Innovative work behavior theory.

This theory contends that while functional competences give entrepreneurial nursing leaders the ability to inspire nurses to take innovative action while providing care, personal competencies enable them to establish an innovative vision. This builds confidence and commitment to adopting new ideas. 42,43 Wang et al 37 argued that leadership is a position that can be achieved by gaining skills, which contradicts leadership theories that suggest some people are born leaders. This also contradicts psychological theory that women have low aggressiveness and avoid leadership positions 46,47 However, recent studies focus on theories relevant to changes in the nursing industry, including the introduction of innovative technologies and new business models such as gig economy and eHealth. Many frameworks continue to focus on leadership styles such as transformational and transactional styles and relevant attributes that have been extensively researched over the past few decades. 21 However, new leadership attributes such as nursing informatics leadership, in light of growing influence of technology and industry policies in the quality care sector, have been neglected.

Measures of Nurse Performance

Twenty-two distinct measurement instruments were employed to evaluate the various factors that influence nursing performance in relationship with nursing leadership attributes. Five studies used questionnaires developed by authors for measuring nurses’ performance in relation to different aspects such as motivation, engagement, self-efficacy, performance, problem solving skills, and job satisfaction. Multifactor leadership questionnaires or its components were used in 3 studies focusing on different leadership styles and their impact on nursing performance as a part of the study model designed by respective authors. 34,35,40 Other major instruments used for measuring nurses’ performance related attributes include Caring Efficacy Scale, nurses’ activity scale, 45 Nurses performance evaluation checklist, 34,38 Innovative work behavior scale, 38 generic job satisfaction scale, 35 and innovative work behavior questionnaire. 41

Factors Influencing Nurses’ Performances

A total of 51 different factors that affected the nurses’ performance were identified from the studies included in the review ( Table 3 ). These factors were grouped into 6 categories including autonomy, competencies, relatedness, individual nurse characteristics, relationships and support, and leadership practices.

Table 3.

Factors Affecting Nurses’ Performance.

Autonomy

Three studies 33,38,45 examined the influence of autonomy related factors on nurses’ performance. Manojlovich 45 identified that strong nursing leadership behavior can contribute to the empowerment and self-efficacy on practice behaviors of the nurses, indicating that nursing leaders should provide more access to structural empowerment factors for nurses and exhibit unit-level nursing leadership. Kim and Sim 33 suggest that utilizing action-oriented and self-reward strategies, along with constructive thinking, can improve self-efficacy and empower individuals, leading to a significant improvement in their performance.

However, it is also observed that nursing performance can be affected by their communication abilities, indicating that in developing autonomy, communication skills play a significant role. Kül and Sönmez 38 identified that servant leadership attributes, such as being humanistic, empathetic, mutually beneficial, and service-oriented, can empower nurses to develop innovative behavior, which can improve their job performance. Innovative behaviors reflect an autonomy in nurses’ attitudes, where they autonomously take decisions in developing new ideas and new ways of delivering care, thereby improving the performance.

Competencies

Four studies 37,36,41,48 examined the influence of competencies related factors on the nurses’ performance. Few of these studies reflected new approaches in leadership and their impact on new areas of performance. For instance, Bagheri and Akbari 41 found that entrepreneurial leadership has positively influenced nurses’ innovation work behavior such as ideas exploration, generation, implementation, and championing, which can improve the overall performances and can support the achievement of organizational goals such as sustainability. Similarly, by creating a positive work environment and effectively managing resources and transformational leadership practices, nurse managers can significantly improve sustainability of nursing leadership. Moreover, Fing et al 36 found that competencies such as treating employees like family members, guiding them, and letting them make independent decisions have led to improvements in several areas that can impact nurses’ performance. These improvements include decision-making, the ability to accept criticism and suggestions. 36 Wang et al 48 found that leaders’ skills, such as idealized influence and intellectual stimulation, have a significant positive impact on nurses’ self-efficacy and work engagement.

Relatedness

Relatedness reflects how the nurse managers relate them to nurses and vice versa, which is reflected in their behavior toward each other. The study conducted by El-Azim et al 34 was the only study that did not find a significant statistical relationship between nursing leadership styles and nurses’ performance.

Individual Nurse Characteristics

Two studies have identified individual nursing characteristics related to nurses’ performance. The interest of nurses’ in taking up extra roles in addition to the existing roles supported by the nurse managers supported by transformational leadership practices through increased work engagement. 40 The findings of this study indicated that through supportive leadership practices, extra-role performance can be enhanced which in turn increases hospital efficacy. Wang et al 48 identified that psychological safety (a belief that nurses won’t be punished or humiliated for sharing ideas, concerns, and issues) could effectively improve nurses’ performance.

Relationships and Support

Wang et al 37 assessed the impact of nursing performance on nursing leadership along with other variables. They found that a caring and supportive work environment can positively affect nurses’ behavior and performance, and in turn, nursing leadership. This emphasizes the need for support from nursing leaders. 37

Leadership Styes/Practices

Although leadership practices were considered in most of the studies, significant approaches can be analyzed from 3 studies. Firstly, as discussed in the autonomy section, servant leadership approaches, such as humanistic, empathic, mutual benefit, and service-oriented approaches, can improve nurses’ competencies and skills, especially their ability to express themselves, communicate, and apply innovative ideas. Secondly, both transformational and transactional approaches, such as motivation, support, contingent rewards, and intellectual stimulation, can improve nurses’ satisfaction levels and job performance. 35 Thirdly, paternalistic leadership practices, such as treating nurses as family members, and laissez-faire practices, such as enabling nurses to make independent decisions, were identified as improving nurses’ performance. However, paternalistic approaches were found to be more influential than laissez-faire approaches. Fourthly, entrepreneurial leadership practices, such as driving innovation, risk-taking, and passion for work, were identified as promoting innovative behavior among nurses, which can improve their performance.

Discussion

This study mainly focused on examining the link between nursing leadership and nurses’ performance by assessing the factors that nurses believed had an impact on their motivation to perform well; and the leadership behaviors that correlate with nurses’ performance. There has been a significant rise in the identification of number of factors that nurses perceive to be influencing their performance in the recent literature. This study has identified 51 such factors from research studies published since 2005, compared to a study conducted by Ronquillo et al 23 which included studies from 1995 to 2006, identifying 25 factors. This development indicates that significant progress can be observed in the research related to nurses’ leadership and nurses’ performance. One of the interesting findings in the review is that most of the studies (10 out of 11) were quantitative and adopted survey strategy for data collection; and only one study adopted systematic review approach, indicating the gaps in adoption of different methodological approaches in the research, which can contribute to diverse findings.

Most of the previous studies adopted social theories and the self-determination theory in assessing the relationship between nursing leadership and nurses’ performance. As a result, few studies mainly focused on the nurses’ approaches in providing quality care through social interaction, rather than on their personal attributes such as satisfaction, quality of life, and motivation. However, some studies attempted to develop theoretical models, 34,35,40 indicating the emergence of various constructs and relations between nursing leadership and nurses’ performance. One of the effective qualities of leaders is promoting autonomy among the team and making them self-reliant by developing skills and competencies to improve overall processes. Accordingly, from the findings ( Table 3 ), it was observed that the majority of the factors identified were in relation to leadership practices that focused on promoting autonomy and competencies among nurses

In the past few years, significant developments can be observed in the adoption of Industry technologies such as the Internet of Things, Artificial Intelligence, Cloud computing, block chain technology etc., 49 -52 giving rise to new form of leadership such as nursing informatics leadership. 53,54 These developments can influence various factors within hospital settings, including organizational culture, workload, motivation, values in hospital settings that can directly or indirectly influence nursing performance. However, no studies were identified in this review which considered these developments in identifying the factors that influence nurses’ performance. Studies reviewed indicated that nursing leadership can influence autonomy, 33,38,45 relatedness, 34 competencies, 36,37,41,48 individual characteristics, 40,48 and relationships and support, 37 as perceived by nurses influencing their motivation to perform well. In addition, leadership practices were identified to be nurses’ abilities to perform well. Furthermore, leadership behaviors that support autonomy, inclusivity, transformation (improving skills, innovation abilities, and competencies), and staff prioritization (caring, paternalistic behavior, empathy) can result in high nursing performance. 33,38,45 It is important that nurse leaders share organizational goals to encourage staff, offer suggestions, and receive feedback on innovative practices for achieving goals in a cooperative and supportive work culture. The studies reviewed suggest leadership plays a crucial role in influencing nurses’ performance in various areas, such as innovation, decision-making, and work engagement. 36,37,41,48 Furthermore, new approaches to leadership, such as entrepreneurial leadership and transformational leadership practices, can positively impact nurses’ performance and support the achievement of organizational goals such as sustainability. 41 Therefore, it is important for nurse managers to continuously develop their leadership skills and create a positive work environment that supports nurses’ ability to perform well. 36 By doing so, nurse managers can help to create practice environments that promote nurses’ ability to perform their roles effectively, thus enhancing overall nursing performance.

While one study included in the review did not find any significant statistical association between nursing leadership styles and nurses’ performance, it suggested that further research is needed to better analyze the relationship between nursing leadership and nurses’ performance by adopting relatedness factors in the areas of advanced leadership approaches and providing performance appraisal. 34 This highlights the importance of considering relatedness factors in nursing leadership to support nurses’ performance and promote positive relationships between nurse managers and nurses.

The results of Salanova et al 40 study highlight the significance of nurse managers adopting transformational leadership practices to increase nurses’ interest in taking up extra roles, which can lead to improved hospital efficacy. Additionally, promoting psychological safety in the workplace can create a supportive work environment that encourages open communication and enhances nurses’ performance. 48 This indicates the nurses should have enough freedom with nurse managers for sharing their opinions without any hesitation or fear, which may benefit both of them.

Therefore, nursing leadership has a significant impact on nurses’ perceptions of the factors that influence their motivation to perform. This impact can be both direct and indirect. Therefore, it is essential to have competent nursing leaders to create practice settings that can foster nurses’ capacity to succeed. In other words, the link between nursing leadership and nurses’ success is critical, and it is necessary to prioritize leadership development in the nursing profession to achieve optimal patient outcomes.

As observed from the recent report by ICN, 30 the lack of strategic and systematic approach by the employers and policymakers is one of the key challenges associated with rising nursing problems. In this context, it may be implied that effective leadership approaches coupled with systematic management of nursing resources could be one of the effective ways to improve nursing performance, retention, and reduced burn-out rates. Accordingly, apart from the patient-related aspects, personal, co-worker, organizational, and societal related factors were identified to be the significantly contributing factors of nurses’ burn-out during the pandemic, 55 highlighting the issues with nurses’ leadership and organizational/employer approaches. In this context, a systematic review on interventions to reduce occupational stress and burn-out, 56 observed that the interventions were effective when they focus at individual level and organization directed, implying the strategic and systematic approach adopted by the employers and led by nursing leaders, with an individualized focus, signifying the relevance of transformational, motivational, and supportive leadership styles. For instance, spiritual intelligence among nursing leaders was identified to be influencing nursing managers’ competencies in managing stress and burn-out, 57 and similar strategies could be directed by employers to effectively manage nursing resources. Such streamlined approaches may be effective in not only improving nurses’ performance, but also in addressing the challenges such as nurses’ burn-out, retention, and increasing stress in the post-pandemic era.

Implications for Nurse Researchers

The findings from this review supports a theoretical model ( Figure 2 ) on factors that influences nurses’ motivation to perform well, which may be tested and evaluated in future research. Analyzing published research till date in this review has suggested that leadership practices that support autonomy, competencies, and relatedness through inclusive approaches reflect that nurses’ contributions are valued and this process resulted in increased motivation of nurses to perform well. In addition, leadership practices that support innovation (entrepreneurial), and cooperative culture (transformational) were identified to be more influencing in improving nurses’ motivation to perform better. Although, different leadership practices and their relationship with nurses’ performance were investigated, significant changes have been observed in the nursing work environment in the past few years. The introduction of innovative technologies and business models, such as the gig economy and online health services, is among the many changes. These changes can lead to new leadership practices and new factors that influences nurses’ performance, such as informatics competencies and skills, remote work culture. These are some areas that future researchers can investigate to identify new leadership practices and the factors that influence nurses’ performance. Furthermore, sustainability has become a core component of all organizations, including healthcare. Therefore, it is important to examine leadership behaviors that can have an impact on nurses’ abilities to help achieve sustainable organizational goals. Furthermore, unexpected disasters such as the recent Covid-19 pandemic has significantly increased the burden on nursing care. Leadership practices in such a highly demanding workload environment and their impact on nurses’ abilities to provide quality care and achieve better patient outcomes could be examined. Finally, it is evident from the review that most of the studies have adopted quantitative methods. Diverse methodological framework adoption can contribute to the quality of research. Therefore, future researchers should focus on adopting other frameworks such as qualitative, and mixed methods in conducting the research.