Journal of Nursing Management, 2010, 18, 425–439

The influence of nursing leadership on nurse performance: a

systematic literature review

1 2,3
PAMELA BRADY GERMAIN RN, MN and GRETA G. CUMMINGS PhD, RN
1
Assistant Faculty Lecturer, Faculty of Nursing, University of Alberta, Edmonton, 2Professor, Faculty of Nursing,
University of Alberta, Edmonton and 3CLEAR Outcomes Research Program (Connecting Leadership Education &
Research), University of Alberta, Edmonton, Canada

Correspondence B R A D Y G E R M A I N P . & C U M M I N G S G . G . (2010) Journal of Nursing Management 18, 425–439

Greta G. Cummings The influence of nursing leadership on nurse performance: a systematic literature
Professor review
Faculty of Nursing
3rd Floor Clinical Sciences Building Aim The aim was to explore leadership factors that influence nurse performance
University of Alberta and particularly, the role that nursing leadership behaviors play in nursesÕ percep-
Edmonton tions of performance motivation.
Alberta T6G 2G3 Background Nurse performance is vital to quality patient care outcomes and
Canada nursing leadership behaviors have been linked to nurse performance.
E-mail: gretac@ualberta.ca Evaluations A review of research articles that examined the factors that nurses
perceived as influencing their motivation and performance was conducted. Eight
studies were included in the final analysis.
Key issues NursesÕ perceptions of factors that affect their motivation and ability
to perform were grouped into five categories using content analysis: autonomy,
work relationships, resource accessibility, nurse factors, and leadership practices.
Nursing leadership behaviors were found to influence both nursesÕ motivations
directly and indirectly via other factors.
Conclusion The review suggests that nurse performance may be improved by
addressing nurse autonomy, relationships among nurses, their colleagues and
leaders, and resource accessibility.
Implications for nursing management Nursing managers and leaders may enhance
their nursesÕ performance by understanding and addressing the factors that affect
their ability and motivation to perform.
Keywords: nurse motivation, nurse performance, nursing leadership, systemic review

Accepted for publication: 19 February 2010

nursing work expectations, and advancing technology

Introduction
Nursing performance in todayÕs healthcare system is
centered on quality of care, which is largely measured
by patient outcomes and the achievement of organiza-
tional goals (Morrison et al. 1997). With a severe
nursing shortage, many units are now operating in crisis
mode, which is intensified by increasing patient acuity,
DOI: 10.1111/j.1365-2834.2010.01100.x
ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd
(Acree 2006). In general, job performance relates to an
organizationÕs success, however, it is more than simply
one person doing their job well because they want to.
Performance is an organizational behaviour. In a work
environment strained by financial constraints and
organizational changes, nurse leaders and managers
remain accountable for the success of the organization.
425
P. Brady Germain and G. G. Cummings

Nursing leadership behaviors have been found to defined by the nursesÕ desire and ability to meet their
influence nursesÕ ability to exceed their employerÕs employersÕ goal of providing excellent patient care.
expectation in meeting organizational goals (Chiok • What leadership behaviors positively correlate with
Foong Loke 2001, Cummings 2004). Furthermore, high nurse performance? Leadership behaviors are
leadership styles that support staff needs have also defined as the attributes and tools leaders use to
reduced burnout by influencing nurses to perceive their facilitate their employees to meet organizational
work environment as a challenge as opposed to over- goals.
whelming (Bakker et al. 2000). Nursing performance is
associated with patient outcomes, and nursing leader-
Methods
ship styles have an impact on meeting organizational
goals (Cummings et al. 2010). However, few studies Inclusion criteria
have investigated which leadership factors nurses
Peer reviewed research studies that addressed both
themselves perceive as influencing their motivation to
nursing motivations to perform and nurse assessed
perform well and achieve organizational goals under
leadership practices in healthcare settings were in-
increasing demands. A systematic review was designed
cluded. The third criterion was that the study examined
to collect evidence about the relationship between
a relationship between nurse performance and nursing
leadership and nurse performance from the nursesÕ
leadership behaviors. The fourth criterion was that only
perspective to understand the role of leadership in job
reports of empirical research studies, qualitative or
performance motivation.
quantitative, were included.
Based on the literature reviewed, it is evident that
limited research focuses on what nurses perceive as
motivating them to perform well, including whether or Search strategy and data sources
not nursing leadership style is a factor in individual
Electronic databases searched included CINAHL,
performance. Among various current nursing leadership
Cochrane, EMBASE, HealthSTAR, Medline, and Psy-
theories, in relation to positive employee performance,
chINFO using the following search terms: nurse per-
the emotionally intelligent leadership theory (Cum-
formance; nurse motivation; motivational nursing
mings 2004, Cummings et al. 2005), transformational
leadership behaviors; OR nurse performance. Manual
and transactional leadership theories (Morrison et al.
searches of specific journals such as Journal of Nursing
1997, Strodeur Sabine et al. 2000, Acree 2006), and
Management, Journal of Nursing Administration,
Kouzes and PosnerÕs leadership challenge (Chiok Foong
Canadian Journal of Nursing Leadership, and Leader-
Loke 2001, Kouzes & Posner 2002) have received
ship Quarterly were also completed. Five websites were
considerable attention. However, the majority of nurs-
searched for relevant research reports: Canadian Health
ing leadership research is primarily focused on how the
Services Research Foundation, http://www.chsrf.ca;
behavior of nursing leaders influences nursesÕ job satis-
Canadian Nurses Association, http://www.cna-nurses.-
faction. Nurse leaders must have the ability to influence
ca; Nursing Health Services Research Unit, http://
nursing staff and promote thoughts and actions that
www.nhsru.com; American Organization of Nurse
will lead to the achievement of the organizationÕs goals
Executives, http://www.aone.org/; and National Insti-
such as positive patient outcomes. This paper thus has
tute for Nursing Research, http://ninr.nih.gov. The total
the potential to provide healthcare organizations,
result from the manual and website search was 15 (See
principally nurse managers and nurse leaders, with
Figure 1 for detailed search results).
evidence-based knowledge about what motivates nurses
to meet organizational goals of excellence in patient
care, and furthermore what leadership skills are neces- Screening
sary to facilitate this.
The primary author reviewed titles and abstracts using
The purpose of this study was to describe the findings
the four inclusion criteria and selected abstracts and
of a systematic review of studies that examined factors
titles that included nursesÕ perceptions of nurse perfor-
related to nurse performance, as perceived by nurses,
mance. To establish inter-rater reliability, a second
and to make recommendations for further study. The
reviewer evaluated a sample of abstracts and titles using
following two research questions guided this review.
these criteria and discrepancies between reviewers were
• What factors do RNs perceive as influencing their discussed with agreement using consensus. Eighty-eight
motivation to perform well? Nurse performance is titles and abstracts relevant to nursesÕ perceptions of

426 ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 425–439
 Nursing leadership and nurse performance

Database articles
screened for
inclusion/exclusion
6289

Manual and websites Abstracts included nurse

search perception of motivation
15 abstracts retained 73

88
Papers screened for 77
inclusion/exclusion Papers screened
criteria and excluded

11 2 Quantitative papers removed

Papers screened after quality assessment, as they
for inclusion did not actually meet inclusion
criteria.
1 Qualitative paper removed
following quality assessment
for low quality.

8
Papers reviewed for
data extraction

8
Studies retained

Figure 1
Search and retrieval process.

nurse performance were selected, and full study
manuscripts were retrieved for screening. The primary
author excluded studies using the inclusion criteria,
leaving 11 studies for quality assessment and data
extraction.
Quality review
Each published article was reviewed for methodolog-
ical quality using a quality-rating tool. Quantitative
papers were reviewed using Cummings and Esta-
brooks (2003) Quality Assessment and Validation
Tool for Correlational Studies (Figure 2), adapted
from Estabrooks et al. (2001), as well as the Effective
Public Health Practice Quality Assessment Tool
(McMaster University School of Nursing 2003). The
two qualitative studies were reviewed using the
Critical Appraisal Skills Programme Tool (National
CASP Collaborations for Qualitative Methodologies
2002). Cummings and EstabrooksÕ tool assesses four
areas of each study: research design, sampling, mea-
surement and statistical analysis, and has been used in
several other studies (Wong & Cummings 2007,
Cummings et al. 2008, Lee & Cummings 2008).
Thirteen items comprise the tool and a total of 14
possible points can be assigned for the 13 criteria.
Twelve items were scored as 0 (= not met) or one (=
met) and the items related to outcome measurement
were scored out of two. Based on points assessed,
each study was placed in one of three possible
categories: strong (10–14), moderate (5–9) and
weak (0–4). The Effective Public Health Practice
Project Quality Assessment Tool is used to assess in
eight areas of a study: selection bias, allocation bias,

ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 425–439 427
P. Brady Germain and G. G. Cummings

The influence of nursing leadership on nurse performance

A systematic review (2008)
Quality Assessment and Validity Tool for Correlational studies

Study:________________________________________
First Author: _______________________

Publication Information: Date: ____________________

Journal: ___________________________

Design: NO YES
1. Was the study prospective?…………………………… 8 0
2. Was probability sampling used?……………………… 5 3

Sample:
1. Was sample size justified? ………………………………… 4 4
2. Was sample drawn from more than one 5 3
site?…………………
6 2
3. Was anonymity protected?………………………… 4 4
4. Response rate more than 60%……………………

Measurement:
Independent variable
1. Is the independent variable measured reliably?……………… 7 1
2. Was independent variable measured using a valid
4 4
instrument?……
Factors affecting nurse’s perceptions of nurse workplace
performance (DV)
1. Are effects observed rather than self-reported? (2 points) 8 0
2. If scale was used for measuring effects, is internal
consistency > .70? 7 1
3. Was a theoretical model/framework used for guidance?

Statistical Analysis:
1. If multiple effects studied, are correlations analyzed? 8 0
2. Are outliers managed? 0 8

Overall Study Validity Rating (circle TOTAL: _____

one)…………………………. LO MED HI
(key: 0–4 = LO; 5–9 = MED; 10–14 = HI)

Figure 2
Quality assessment and validity tool for correlational studies [adapted from Cummings and Estabrooks (2003)].

428 ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 425–439

confounders, blinding, data collection methods,
withdrawals and dropouts, analysis, and intervention
integrity. Each area is assessed as strong, moderate, or
weak. The Critical Appraisal Skills Programme Tool
uses 10 questions to assess qualitative research. The
10 questions are grouped into screening questions,
research design, sampling, data collection, reflexivity,
ethical issues, data analysis, findings, and value of the
research.
Data extraction
The following data was extracted from the quantitative
studies: author, year, journal, research purpose, sample,
independent variable, dependent variable, measures,
reliability of measures, validity of measures, analysis,
and results.
Results
Six thousand two hundred and eighty-nine titles and
abstracts were reviewed (Figure 1). English abstracts of
non-English papers were also reviewed but none
met our inclusion criteria. Eighty-eight articles were
screened for inclusion criteria and 76 articles were
excluded. Quality assessments were completed on 11
papers. Following the quality assessment, two more
quantitative papers were excluded, as their focus did
not specifically pertain to this reviewÕs objective. One
qualitative paper was excluded for low quality. Eight
studies comprised the final group of included studies
(Figure 1).
Summary of quality review
In this review, all eight quantitative studies were rated
moderate or higher (scores > 5). The strengths in these
studies included: (1) all but one utilized a theoretical or
conceptual framework to ground their work and (2) five
studies were judged to have acceptable sample sizes
collected from more than one site resulting in greater
heterogeneity in the resulting samples. Sample size was
justified based on appropriate power calculations
(power = 0.8), or other rules of thumb, such as sample
size of at least 10 per independent variable studied.
Instrument reliability was reported in seven studies and
validity in three. Acceptable levels of reliability for
factors associated with nursesÕ performance (alpha
coefficients > 70) were achieved in seven of the eight
studies (Figure 2).
The most common weaknesses in the eight quantita-
tive studies related to sampling and design. All studies
ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 425–439
Nursing leadership and nurse performance
utilized non-experimental, cross-sectional or descriptive
designs that limit inferences of causality. All studies
were prospective in design as data requirements were
developed in advance and collected prospectively. A
low response rate (<60%) was evident in four of the
studies. One study did not include nurse demographics.
Failure to address the management of outliers was ob-
served in all studies.
Characteristics of studies included
The final set of included studies and their characteristics
are presented in Table 1.
Of the eight studies, published between 1995 and
2007, one was conducted in Singapore, three in the
United States of America, and four in Canada. The
studies reflected nursesÕ perception of performance and
the factors associated with it in acute care inpatient
units of hospitals. Demographics of nurses were
reported in seven of the eight studies. The majority of
respondents were baccalaureate prepared full-time
working females averaging 40 years of age with
15 years nursing experience.
Theoretical framework
Seven of the eight studies were guided by either a the-
oretical framework or model. This is important because
theory provides a rationale to develop hypotheses and
empirically test relationships between ideas and vari-
ables (LoBiondo-Wood & Haber 1998). Two of the
studies used Rosabeth KanterÕs structural theory of
organizational behavior (Spence Laschinger et al. 1999,
Greco et al. 2006). Kanter argues that work attitudes
and behaviors are in response to situations that arise
and an individualÕs position in an organization (Spence
Laschinger & Havens Sullivan 1996). Another study
used an integration of KanterÕs theory and Conger and
KunongoÕs model of the leader empowerment process
(Spence Laschinger et al. 1999). Conger and Kunungo
argue that managers create empowering work envi-
ronments through motivating staff to accomplish tasks
and by eliminating situations that encourage power-
lessness (Spence Laschinger et al. 1999). Kramer et al.
(2007) used DonabedianÕs structure-process-outcome
paradigm. Structures are what leaders and others use to
create functional processes that lead to outcomes.
Therefore, structures, processes, and outcomes are
causally related. EdgarÕs (1999) study used the Job
Characteristics Model of Work Motivation framework,
which proposes that motivation to work arises from the
characteristics of jobs. Another framework adapted by
429
 Table 1

430
Characteristics of included studies

Measure of Measures Quality

Author(s)/year/ Study Participants/ leadership or of nurse assessment
Journal purpose sample work factors performance Measures Reliability Validity Analysis score

Edgar (1999). To use the A random The characteristics The relationship The job diagnostic Reported as Not reported Bonferroni 11/14
Canadian characteristics of sample of 159 of nursing care between nurse survey – 19 items satisfactory correlated
Journal of the nursing care Registered delivery systems motivation and Framework Not reported Assessed in a correlations
Nursing delivery system Nurses (RN) including; job satisfaction questionnaire to pre-test with 23
Leadership to describe the who work in autonomy, analyze components nurses. Test–
relationship medical/ communication, of nursing practice retest = 95%
among nurse surgical units at division of tasks models
P. Brady Germain and G. G. Cummings

motivation and four teaching and the patient

job satisfaction hospitals environment
Greco et al. To use KanterÕs A random Nurse leaders RN perception of Leader empowering a = 0.71–0.97 Not reported Correlational 11/14
(2006). Nursing Theory of sample of 322 empowerment nurse behavior scale – 27 and
Leadership Structural Power full/part-time behaviors, and empowerment items regression
in Organizations working RNs areas of work life Conditions of work a = 0.67–0.95 analysis
to examine the and work effectiveness
relationship engagement questionnaire-II – 18
between items
perceptions of Areas of worklife scale a = 0.62–0.88
nurse – 29 items
empowerment Emotional exhaustion a = 0.93
and nurse subscale of the
leaders Maslach burnout
empowerment inventory-general
behaviors scale – seven point
Likert scale
Kramer et al. To discover A random Supportive nurse Staff nursesÕ Modified essentials of a = 0.90 Content validity Post hoc 11/14
(2007). Nursing supportive nurse sample of 2382 manager role perception of magnetism tool – 30 multiple
Administration manager role staff nurses behaviors supportive items comparison
Quarterly behaviors as working on 199 nurse manager analysis
identified by staff clinical units in behaviors
nurses eight Magnet
hospitals
Chiok Foong To determine the A convenience Leadership Productivity, job LPI (self/observer) – 30 a = 0.81–0.91 Not reported Analysis of 9/14
Loke (2001). effect of sample of 20 behaviors satisfaction, items variance
Journal of leadership managers and and Job-in-General Scale – a = 0.91–.095 Convergent PearsonÕs
Nursing behavior on 100 Registered organizational 18 items validity correlations
Management employee Nurses commitment (r = 0.066–
outcomes 0.88)
Productivity scale – 15 a = 0.90–0.93 Not reported Regression
items analysis
Organizational a = 0.82–0.92 Predictive
commitment scale – validity
15 items (r = )0.22)

ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 425–439
 Table 1
(Continued)

Measure of Measures Quality

Author(s)/year/ Study Participants/ leadership or of nurse assessment
Journal purpose sample work factors performance Measures Reliability Validity Analysis score

McLennan NursesÕ views on A random Work enabling NurseÕs Enabling work index – a = 0.89 Not reported Multiple 7/14
(2005). Journal work enabling sample of 60 factors, priority perception of 13 items regression
of Nursing factors, priority RNs working in issues for work enabling Stress/satisfaction Not reported Not reported analysis
Administration issues for a Canadian improvements, factors offset score
improvement, hospital and stress and Data containing Not reported Not reported
and stress and satisfaction levels personal
satisfaction characteristics – six
levels were items
examined Two open-ended
questions
Spence To test a model A random Leader empowering Staff nurseÕs The conditions of work a = 0.92 Construct Structural 13/14
Laschinger linking staff sample of 537 behaviors perception of effectiveness validity equation
et al. (1999). nurse RNs employed work questionnaire – 37 established by modeling
Journal of perceptions of at two sites of a effectiveness items factor analysis and inter-
Nursing workplace merged The job activities scale a = 0.69 Not reported correla-
Administration empowerment hospital – 12 items. tional
and specific The organizational a = 0.88 Not reported analysis
leader- relationship scale – 20
empowering items.
behaviors The leader empowering a = 0.96 Not reported
behavior scale – 27
items.
Lyons job tension index a = 0.81 Not reported
– nine point Likert
scale
Salyer (1995). To examine the 97 randomly Hardiness, Staff nurseÕs Six dimension scale of a = 0.84 Not reported Path analysis 10/14
Journal of effect of selected staff ambiguity perception of nursing performance –
Nursing environmental RNs tolerance, and performance six subscales
Administration turbulence on quality of technical during The hardiness scale – a = 0.70 Not reported
nursesÕ job support services environmental 36 items

ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 425–439
performance turbulence Tolerance-intolerance a = 0.72 Not reported
of ambiguity scale –
16 items, seven point
Likert scale
Technical support a = 0. 84 Not reported
services questionnaire
Investigator developed a = 0.79 Not reported
perceived
environmental
uncertainty scale – 11
items

431
Nursing leadership and nurse performance
P. Brady Germain and G. G. Cummings

Salyer (1995) was the Eliot and Eisdorfer model, which

assessment
Quality

score
summarizes research on human health and stress.

11/14
Finally, Chiok Foong LokeÕs (2001) study was based on
Kouzes and PosnerÕs model of leadership behaviors,
which reports five leadership practices; encouraging the
Analysis

Regression
heart, inspiring a shared vision, enabling others to act,

analysis
challenging the process, and modeling the way. Kouzes
and Posner show that these practices affect employeesÕ
and thus organizational performance. It is promising to
the development of meaningful in nursing leadership
Validity

Not reported

Not reported
Not reported

Not reported

Not reported
that most of the research questions were guided by
conceptual frameworks. However, none of the frame-
works incorporated nurse perception as a mediating
variable between their work motivation and their per-
a = 0.76–0.95

a = 0.76–0.95
a = 0.76–0.95

a = 0.76–0.95

a = 0.76–0.95
formance. Further testing of models should incorporate
Reliability

nursesÕ perceptions and how theoretical approaches of

nurse performance affect healthcare organizations and
patient care.
The conditions of work

Gerbers control over

relationships scale

Measures of nurse performance

Job activities scale
questionnaire – 4

BassÕs multifactor
Measures

nursing practice
questionnaire

questionnaire
effectiveness

Organizational

Twenty-three different instruments were used to mea-

leadership
subscales

sure factors affecting nurse performance in the eight

quantitative studies. Five studies each used a different
instrument. These included the job diagnostic survey
(Edgar 1999), the modified essentials of magnetism
empowerment
performance

perception of

tool (Kramer et al. 2007), the hardiness scale, toler-

Measures
of nurse

Staff nurseÕs

workplace

ance-intolerance of ambiguity scale, technical support

services questionnaire, perceived environmental uncer-
tainty scale, the six dimension scale of nursing perfor-
mance (Salyer 1995), the enabling work index and
nursing practice,

stress/satisfaction offset score (McLennan 2005), and

leadership or
work factors

empowerment,
Measure of

the LPI self/observer scale, jobs-in-general scale, pro-

control over

satisfaction

ductivity scale and organizational commitment scale

and job

(Chiok Foong Loke 2001). The remaining three studies

Work

used the conditions of work effectiveness questionnaire

(Spence Laschinger & Havens Sullivan 1996, Spence
of Organizational from two urban
Participants/

Laschinger and Structural Theory selected RNs

Laschinger et al. 1999, Greco et al. 2006) job activities

127 randomly
sample

American

scale (Spence Laschinger & Havens Sullivan 1996,

hospitals

Spence Laschinger et al. 1999) leader empowering

behavior scale (Spence Laschinger et al. 1999, Greco
et al. 2006) and the organizational relationships scale
and staff nursesÕ
perceived work

(Spence Laschinger & Havens Sullivan 1996, Spence

To use KanterÕs

perceptions of

empowerment
effectiveness
purpose

relationships
Study

Sullivan (1996). Behavior to

Laschinger et al. 1999). These studies also used the

between
examine

following additional measuring tools; areas of worklife

work

scale, emotional exhaustion subscale of the Maslach

burnout inventory, enabling work index, LyonsÕ job
tension index scale, GerberÕs control over nursing
Administration
Author(s)/year/

practice questionnaire, and BassÕs multifactor leader-

(Continued)

Journal of

ship questionnaire. The qualitative portions of the

Nursing
Havens
Table 1

Spence
Journal

mixed method study used interviews to collect infor-

mation on nursesÕ views of supportive nurse manager

432 ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 425–439
 Nursing leadership and nurse performance

Table 2
Factors affecting nurse performance

Leadership factors Findings Work factors Findings Source

Autonomy
Leader empowering behaviors (e.g.: + Work empowerment + Spence Laschinger et al. (1999)
fostering autonomy, confidence in + Structural empowerment + Greco et al. (2006)
employees) Empowerment + Spence Laschinger and Havens
Sullivan (1996)
Using knowledge and skills * McLennan (2005)
Autonomy NS Edgar (1999)
Working relationships
Career development (e.g.: stimulate, * Kramer et al. (2007)
guide and encourage staff) Communication NS Edgar (1999)
Informal and formal power + Spence Laschinger and Havens
Sullivan (1996)
Clearly defined nursing roles and * McLennan (2005)
responsibilities
Trust and respect * McLennan (2005)
Fair and respectful practices * McLennan (2005)
Raise workload concerns * McLennan (2005)
Access to resources
Managing the unit (e.g.: patient flow, * Kramer et al. (2007)
direct care)
Management resources * Kramer et al. (2007)
Resources to do job * McLennan (2005)
Ongoing training * McLennan (2005)
Being able to provide quality care * McLennan (2005)
Resources (e.g.: information, opportunity, + Spence Laschinger and Havens
support) Sullivan (1996)
Perceived environmental turbulence + Salyer (1995)
Number of admissions/discharges in a + Salyer (1995)
24 hour period
Individual nurse characteristics
Ambiguity tolerance + Salyer (1995)
Hardiness + (indirect) Salyer (1995)
Leadership practices
Enabling the heart NS Chiok Foong Loke (2001)
Modeling the way NS Chiok Foong Loke (2001)
Challenging the process NS Chiok Foong Loke (2001)
Encouraging the heart NS Chiok Foong Loke (2001)
Inspiring a shared vision NS Chiok Foong Loke (2001)
Leadership: building, coaching, and * Kramer et al. (2007)
mentoring

NS, Not significant.

+ = Significant positive relationship between factor and nurse perceived performance.
*Nurse reported this an important relation.

behaviors. This study used content analysis to generate

findings on nurse manager support behaviors.
Factors that nursesÕ reported influence their
performance
In total, nurses reported 25 different factors that
affected their motivation or their performance in the
final included group of studies (Table 2). Using simple
content analysis, we grouped the factors into five
categories labeled as: autonomy, relationship building,
access to resources, individual nurse characteristics,
and leadership practices (Table 2).
Autonomy
Five studies examined the influence of autonomy on
nurse performance (Spence Laschinger & Havens Sul-
livan 1996, Edgar 1999, Spence Laschinger et al. 1999,
McLennan 2005, Greco et al. 2006). These studies
suggest that when nurse leaders express confidence in
their subordinateÕs ability to perform at a high level,
nurses feel empowered to perform. Nurses are
empowered to perform because they feel important in
the organization through having the freedom to make
decisions and propose and engage in activities without
needing to seek approval (Spence Laschinger et al.

ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 425–439 433
P. Brady Germain and G. G. Cummings
1999). Furthermore, nurses felt that their work life was
enhanced through leaders that displayed confidence in
employees (Greco et al. 2006). Accordingly, promoting
autonomy not only benefits nurses, but also the orga-
nization in which they are employed. Nurses with a
positive work life are in turn able to reward their
organization through increased retention and the ability
to provide better quality care (Greco et al. 2006).
The ability to deliver high quality care through nurses
using their skills and abilities was examined as a factor
of autonomy in one study and found to be significantly
related to nursesÕ perception of their ability to perform
well (Spence Laschinger & Havens Sullivan 1996).
EdgarÕs (1999) study indicates that support for auton-
omy might be related to work performance through
increased self-esteem. In Spence Laschinger and Havens
SullivanÕs (1996) study, control over nursing practice
was significantly related to nursesÕ perceived work
effectiveness. Perhaps effective nursing outcomes and
the associated positive patient outcomes are related to
nursesÕ abilities to make autonomous decisions using
their clinical skills and critical thinking abilities. In
McLennanÕs (2005) study, nurses perceived the highest
work-enabling factor as the ability to use their skills and
knowledge. Nurses felt they were better able to provide
quality care when their skills and knowledge were
trusted and respected. This suggests that nurses who can
practice autonomously feel they are a valued member of
the healthcare team and therefore feel empowered to
perform in their organization.
Working relationships
In order for nurses to gain the confidence of not only
their nurse leader, but also their colleagues to practice
autonomously, trusting and supportive relationships
should exist. Four studies examined the influences of
working relationships on nursesÕ perceived work per-
formance (Spence Laschinger & Havens Sullivan 1996,
Edgar 1999, McLennan 2005, Kramer et al. 2007).
The importance of effective communication was
examined as factor of relationships in EdgarÕs (1999)
study. Strong communication among nurses and their
leaders is helpful in building trusting relationships.
SalyerÕs (1995) study suggests that interpersonal rela-
tionships developed through good communication skills
are related to effective nurse performance. This is
important because patient care is optimized through
cooperation and collaboration of colleagues. Open
communication lines also welcome participation in
decision-making processes between nurse leaders and
their subordinates. Spence Laschinger et al.Õs (1999)
434 ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 425–439
findings suggest that when nurses perceive themselves as
empowered team members, they are motivated to per-
form because there is additional purpose and meaning
to their work. Chiok Foong Loke (2001) further sup-
ports the idea that relationship orientated organizations
is valued by nurses. This is also supported by a study
that suggests that nurses prefer leaders who are
employee-orientated through respecting subordinates
as individuals as well as valuing their contributions
(Sellgreen et al. 2006). A positive working relationship
is the framework for nurses and managers to gain
respect for one another. Edgar (1999) also suggests
that communication is significantly related to task
identity.
McLennanÕs (2005) examined clearly defined nursing
roles and responsibilities as a factor in building rela-
tionships and the ability to provide high quality care.
Nurses who felt that expectations were known and
clear felt increased ability and confidence to perform
their job well (Kramer et al. 2007). McLennanÕs (2005)
findings also indicate that nursesÕ perceptions of being
able to provide quality nursing care were linked to
clearly defined nursing roles. Based on these findings it
is reasonable to suggest that the foundation of a good
working relationship opens up communication channels
between nurses and both their colleagues and leaders.
Leadership behaviors were found to be influential to
building relationships (Kramer et al. 2007). Spence
Laschinger and Havens Sullivan (1996) study suggests
that nurse leaders who are visible in the clinical setting
demonstrate their support for clinical nurses. Nurses are
provided with the opportunity to ask questions and
leaders with the opportunity to listen to nursesÕ per-
spectives of the work setting. This is the building block
to forming relationships among leaders and subordi-
nates. It is interesting to note that in McLennanÕs (2005)
study, manager-staff relationships scored the lowest of
all factors in affecting nursesÕ abilities to provide high
quality care. Furthermore, improving management was
suggested as a priority for change. However, the same
study identifies working relationships with colleagues as
a strong indicator of nursesÕ views on work enabling
factors. Thereby, nurses view positive working rela-
tionships as an indicator of their ability to provide high
quality care. Despite McLennanÕs findings on leaders
and subordinates, Spence Laschinger et al.Õs (1999)
findings discovered leaders can provide purpose and
meaning to nursesÕ work through relationship building.
Kramer et al. (2007) suggests that leadership behaviors
of building, coaching, and mentoring are perceived to
be supportive nurse manager behaviors that enhance
nursesÕ abilities to perform.

Access to resources
Four studies examined accessibility of resources as a
factor associated with nursesÕ abilities to perform
through providing high quality care (Spence Laschinger
& Havens Sullivan 1996, Spence Laschinger et al.
1999, McLennan 2005, Kramer et al. 2007). Resource
accessibility was identified as nursesÕ accessibility to
reasonable resources to perform expected job role and
the quality of technical support services. Kramer et al.
(2007) findings suggest that nurse leaders who appro-
priately manage workplace resources foster a more
productive workforce with positive outcomes. Both
Spence Laschinger and Havens Sullivan (1996) and
Spence Laschinger et al.Õs (1999) studies suggest that
nurses who had increased access to information and
resources had increased perceived work effectiveness.
These authors suggest that leaders are responsible for
their nursesÕ work effectiveness through creating envi-
ronments where nurses have the resources to manage
their workload. This includes managing resources
through hiring competent staff and staffing units
appropriately (Kramer et al. 2007). McLennanÕs (2005)
findings suggest that nursesÕ perceptions of providing
high-quality care are linked to nurses using their skills
and knowledge with reasonable resources. Salyer
(1995) reported that quality of technical support ser-
vices enhance nurse performance. It is indicated that
when nurses have access to appropriate resources,
such as necessary equipment, the availability of
support services frees the nurse to plan, implement and
evaluate care. Individual nurse characteristics were also
identified as influencing nursesÕ abilities to provide
quality care.
Individual nurse characteristics
Salyer (1995) found a significant relationship between
nursesÕ tolerance of ambiguity and hardiness on their
performance in chaotic work situations. Hardiness is
defined by personality traits of commitment to work
and self, welcoming new challenges, and an internal
locus of control whereas ambiguity tolerance includes
being comfortable with new situations and complex
issues (Salyer 1995). These findings indicate nurses can
effectively deal with turbulent work environments be-
cause they perceive the uncertainty in their environment
as not threatening but challenging. Nurses who have
both hardiness and ambiguity tolerance personality
characteristics view their work environment as a posi-
tive force (Salyer 1995). Thus they have both the
motivation and ability to provide quality care.
ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 425–439
Nursing leadership and nurse performance
Leadership practices
Chiok Foong Loke (2001) examined the effect of
Kouzes and PosnerÕs leadership practices on nursesÕ
productivity. Kouzes and Posner (2002) suggest that
staff members are influenced by their leadersÕ practices,
and therefore behaviors utilized by leaders can make a
difference in employee outcomes. For leaders to effec-
tively model the way, they must have clear guiding
principles. Modeling the way is about earning the re-
spect and right to lead through direct involvement and
action (Kouzes & Posner 2002). Nurse leaders model by
doing and therefore earn employee respect through
setting clear goals and providing the example (McNe-
ese-Smith 1993). Leaders inspire a shared vision
through inspiring commitment (Kouzes & Posner
2002). In inspiring a shared vision, nurse leaders gather
support and have personal knowledge of staffÕs visions,
values, and hopes (McNeese-Smith 1997). Challenging
the process involves leaders venturing out and searching
for opportunities to create, develop, and improve pro-
cesses (Chiok Foong Loke 2001). They proceed in the
face of adversity and take risks in order to find better
ways of doing things (McNeese-Smith 1997). Enabling
others to act involves assisting constituents to feel
competent and dedicated (McNeese-Smith 1997). This
is considered important because if employees feel
empowered they will commit to exceeding employers
and possibly even exceed their own expectations
(Kouzes & Posner 2002). Encouraging the heart con-
sists of leaders providing encouragement and celebrat-
ing accomplishments. The value of nursesÕ work is
recognized through leaders noting contributions, having
high but reasonable expectations and through reward-
ing solid performance (McNeese-Smith 1997). In Chiok
Foong LokeÕs (2001) study, this theory was tested in
relation to nurse perceived productivity and all five
leadership practices were all found to be non-signifi-
cant. It is reasonable to suggest that more research on
these leadership practices must be conducted in relation
to nurse performance. However, Kramer et al.Õs (2007)
found that building, coaching, and mentoring leader-
ship behaviors were perceived as important in nursesÕ
abilities and motivation to perform. Nurses felt that
these supportive nurse manager behaviors resulted in a
healthy productive work environment that enabled
them to perform better (Kramer et al. 2007).
Discussion
This study focused on a review of research examining
the relationship between factors that nurses perceive as
435
P. Brady Germain and G. G. Cummings
affecting their motivation or ability to perform, partic-
ularly whether nurses perceived leadership behaviors as
a factor. While many studies have focused on nursing
leadership and nurse performance, less research has
investigated nursesÕ perception of factors that influence
their motivation to perform. A total of eight methodo-
logically sound studies (seven quantitative and one
mixed method) reflect the small group of studies that
advance our understanding of factors nurses perceive to
affect their ability to perform well through providing
quality patient care. Given that many factors, such as
organizational culture, workload, intrinsic motivation,
work values, and productivity could affect nurse per-
formance, our findings only represent a small number of
factors that influence perceived nurse performance and
indicate that this topic needs further research. An
interesting finding of this review is that nurses did not
directly perceive nurse leaders as influencing their
motivation to perform. However, nursing leadership
has a direct influence on autonomy, relationship
building, resource accessibility, and nursing leadership
practices, four of the factors that nurses perceived as
influencing their motivation to perform. Therefore, it is
reasonable to suggest that nursing leadership has an
indirect influence on nursesÕ perceptions of factors
influencing their motivation to perform. The important
connection may be that effective nursing leadership is
essential to the creation of practice environments that
support nursesÕ ability to perform. In general, these
findings suggest an important relationship between
nursing leadership and nurse performance. Nurse
leaders play a key role in fostering autonomy, building
relationships, and managing resources, the very factors
that nurses state they require to effectively perform.
(1)
(2)
Leadership
Behaviours
& Practices
(3)
Figure 3
Leadership behaviors related to nurse reported factors of motivation to perform. (1) Spence Laschinger et al. (1999), Greco et al. (2006); (2)
Kramer et al. (2007); (3) Kramer et al. (2007); (4) Spence Laschinger and Havens Sullivan (1996), Spence Laschinger et al. (1999), McLennan
(2005), Greco et al. (2006); (5) Spence Laschinger and Havens Sullivan (1996), McLennan (2005), Kramer et al. (2007); (6) Salyer (1995),
Spence Laschinger and Havens Sullivan (1996), McLennan (2005), Kramer et al. (2007); (7) Salyer (1995); (8) Kramer et al. (2007).
436 ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 425–439
Furthermore, nurse leaders can also influence nurse
factors through their leadership practices of guiding,
mentoring, and coaching, ultimately affecting nursesÕ
ability to perform. The findings of this review suggest a
beginning theoretical model on motivators of nurse
performance, which should be expanded on and tested
in future research (Figure 3).
Implications for nurse performance
Nurses are expected to perform their roles and
responsibilities as designated by their professional reg-
ulatory body and healthcare organization. Furthermore,
healthcare organizations are responsible to provide the
necessary means for nurses to fulfill their professional
responsibilities. However, nurses should also take
responsibility for their own behaviors and actions
within organizations. Nurses participate in creating
their own workplace cultures through engaging in
activities that enhance both their and their colleagues
work life and experiences. Nurses who feel like valued
team members experience a positive work life. Nurses
can prove themselves as valuable team members
through demonstrating their skills and abilities. Fur-
thermore, nurses view autonomy as affecting both their
motivation and ability to perform. Nurses who have
patience in gaining the trust and respect of their col-
leagues and nurse leaders may have the opportunity to
experience more autonomous practice within their
scope. Nurses also consider working relationships as a
factor affecting their performance. It is important that
nurse leaders build relationships between themselves
and nurse colleagues. Yet, nurses must also desire po-
sitive working relationships through valuing and
Autonomy
Working (4)
Relationships
(5)
(8)
Performance
Motivation
(6)
Resources
(7)
Individual
Nurse Char.

working with nurse leaders and colleagues as team
members. Finally, nurses perceive resource accessibility
as affecting their motivation and ability to perform.
Nurse leaders can recognize the importance and time-
savings in a nurseÕs workday through having access to
appropriate resources. Yet, nurses are responsible
to communicate professionally with their nurse
leader about what they need to complete their
tasks efficiently and expertly. While all the studies
discussed what nurses perceive as motivation to
perform, none of the addressed what nurses view as
their responsibility in performance. This is an area for
future research.
Implications for nurse leaders
Leadership skills that encourage employee motivation
can be taught, with the potential to influence organi-
zational practices and promote organizational success
(Kouzes & Posner 2002).
The reality of the nurse leaderÕs role creates barriers
to their ability to influence nurses to perform. Lee and
Cummings (2008) suggest that the workload and span
of control of nurse leaders is too large and thus their
work effectiveness is affected. Therefore, nurse leadersÕ
workloads must be addressed in order to optimize their
functionality because nurse leaders both indirectly and
directly influence their subordinatesÕ performance and
thereby the goals of the healthcare organization they
represent.
It is evident that nurse leaders who prioritize their
staff above all in their role are rewarded with strong
nurse performance, and as a result, positive patient
outcomes. Nurse leaders who engage staff through
using an inclusive leadership style motivate nurses to
feel empowered to perform through participative deci-
sion-making and autonomy (Greco et al. 2006).
Therefore, it would be helpful for nurse leaders to share
the organizations goals and to encourage staff to offer
suggestions on how those goals must be met. Nurse
leaders must share their power by establishing working
relationships where nurses feel their thoughts and ideas
are important (Spence Laschinger et al. 1999). Nurses
may then reward their nurse leader through being
engaged in their work. Furthermore, nurse leaders who
use open informal and formal feedback channels foster
work goals that assist in developing autonomy and
building relationships. Nurse leaders who commit to a
leadership style of informing, encouraging and sup-
porting staff will reap the associated outcomes of a
positive workplace culture and solid patient care. Fur-
thermore, it is the responsibility of healthcare organi-
ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 425–439
Nursing leadership and nurse performance
zations to screen leadership applicants for skills that
will ensure quality patient outcomes through strong
staff performance.
Implications for nurse researchers
To date published literature suggests that leadership
practices that recognize and value nurse contributions
are effective. Despite considerable research on leader-
ship practices and employee outcomes, many unan-
swered questions remain. It is important for healthcare
organizations to have successful patient outcomes. It is
also important for nurses to work in healthy environ-
ments. Therefore, further research on what factors
nurses perceive as influences on their motivation to
meet their organizationÕs goals must be completed.
Furthermore, leadership characteristics that affect nur-
sesÕ abilities to meet those organizational goals could be
examined. The healthcare system is consistently over-
loaded and nurses and nurse leaders have to respond to
the demands of their working environment. Research
that examines and links the determinants among nurse
performance, nursing leadership, and organizational
goals should continue. Furthermore, additional quali-
tative study could add greater clarity and depth to the
current quantitative research available on nurse per-
formance. Further helpful and interesting research
could include studies that address what nurses view as
their responsibility in performance.
Study limitations
This review has potential limitations. One limitation in
this field of research is that there have not been studies
published in non-English speaking countries. A report-
ing bias may also exist as published studies tend to over
report positive findings. The variability in conceptuali-
zation and measurement of factors of nurse perfor-
mance may also limit the validity and generalizability of
findings as no specific tool was utilized to assess nurse
performance. Furthermore, individual nurse character-
istics were found only as a determinant in one study.
Therefore, this factor has limited evidence-based liter-
ature supporting it as a measurement of nurse perfor-
mance. All of the studies reviewed were cross sectional,
correlational studies and have possible disadvantages.
Cross sectional, correlational studyÕs weaknesses
include; limited ability to estimate causation, prone to
bias, and decreased generalizability (LoBiondo-Wood
& Haber 1998). However, the purpose of this review
was to determine whether there was a relationship
between leadership behaviors and nurse performance
437
P. Brady Germain and G. G. Cummings
and cross-sectional, correlational studies are helpful in
examining a relationship between variables (LoBiondo-
Wood & Haber 1998).
Conclusion
Ultimately, a goal of any healthcare organization should
be to influence the quality of patient care. Nursing
leadership plays a key role in encouraging staff to gain a
better understanding of patientÕs needs and values.
Empowered nurses are eager to implement evidence-
based practices to ensure quality of care. Research
shows that nursing leadership style has an impact on
nurse performance. From this review, the factors that
nurses perceive as motivating them to perform well
include autonomous practice, working relationships,
resource accessibility, individual nurse characteristics,
and leadership practices. Understanding these factors
and how nurse leaders can influence them is a necessary
step in promoting quality nursing care and the associ-
ated positive patient and organizational outcomes.
Therefore, healthcare organizations and effective nurse
leaders must understand what factors nursesÕ perceive
as influencing their motivation to perform well. It is the
responsibility of nurse scholars and healthcare organi-
zations to continue to explore whether nurses view
leadership style as a factor influencing their motivation
to perform well. Healthcare organizations that invest in
exploring employee motivation will be rewarded with
high performing and committed staff.
Acknowledgements
Supported by a New Investigator award, Canadian Institutes
of Health Research (CIHR), and a Population Health Inves-
tigator award, Alberta Heritage Foundation for Medical
Research (AHFMR) to Dr Greta Cummings.
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