Buscar en
Enfermería Clínica
Toda la web
Inicio Enfermería Clínica Improving nurses’ performance through remuneration: a literature review
Journal Information
Vol. 28. Issue S1.
1st International Nursing Scholars Congress. Depok (Indonesia), 15-16 November 2016
Pages 130-133 (February - June 2018)
Download PDF
More article options
Vol. 28. Issue S1.
1st International Nursing Scholars Congress. Depok (Indonesia), 15-16 November 2016
Pages 130-133 (February - June 2018)
Full text access
Improving nurses’ performance through remuneration: a literature review
Muthmainnah, Achir Yani Syuhaimie Hamid
Corresponding author

Corresponding author.
, Rr. Tutik Sri Hariyati
Faculty of Nursing, Universitas Indonesia, Depok, Indonesia
Article information
Full Text
Download PDF
Tables (2)
Table 1. Characteristics of literature (n=25).
Table 2. The remuneration system across countries (n=25).
Show moreShow less

A remuneration system greatly influences the quality of nursing care and services.


The goal of this study was to identify the effects of a remuneration system on nurses’ performance.


This research used a literature review design and involved the analysis of 25 articles published in the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, EMBASE, PsycINFO, and Global Health databases. The literature was limited to articles published in English between August 2006 and August 2015.


The results of this study indicate that the improvement of remuneration systems has positive consequences in terms of nurses’ performance and subsequent quality of healthcare services. A well-managed remuneration system has the potential to increase nurses’ motivation, productivity, satisfaction, and even improve retention. In contrast, poorly managed and low remuneration contributes to a shortage of nurses due to high turnover rates.


Adequate remuneration has been shown to improve nurses’ performance and, consequently, improve the quality of healthcare. This literature review provides scientific evidence for decision-makers to consider the implementation of remuneration systems that include credentialing, re-credentialing, and career ladders. Future studies are suggested to investigate the development of well-managed remuneration systems for nurses.

Nurses’ performance
Quality care
Full Text

Hospitals involve a broad range of both healthcare and nonhealthcare professionals. Nurses are an integral part of the healthcare professional team. They are demanded in the healthcare workforce markets1 and play a key role in maintaining the quality of hospital services2. Accordingly, sufficient competencies are pivotal for nurses to provide quality nursing care and services, thereby improving patient satisfaction.

Nurses’ performance in delivering care and services gives rise to the level of patient satisfaction2. A number of studies have indicated that nurses’ performance is considered as one of the essential factors in determining the quality of health service. Exceptional nursing benefits healthcare by contributing to the highest quality of nursing care and improving patient outcomes3.

Within the last few decades, there have been numerous investigations into factors that affect nurses’ performance. A study conducted in Iran indicated that marriage status, age, education levels, work units, working periods, organizational commitment, work satisfaction, nurses’ attitudes in providing nursing care, quality of patient care, and remuneration influence nurses’ performance4.

Additionally, a vast body of research demonstrates a significant relationship between nurses’ performance and the remuneration system. In the studies in question, the amelioration of the remuneration system benefited the healthcare organizations by reducing turnover rates and improving productivity and the quality of care5,6. Also, it improved the nurses’ motivation and satisfaction7. Furthermore, it attracted and retained new employees8.

We performed a literature review of 25 articles, aiming to identify the effects of the remuneration system on nursing performance. Specifically, this review sought to address the following objectives: a) to identify the benefits of adequate remuneration; b) to identify the disadvantages of inadequate remuneration; c) to identify the problems that may occur when remuneration is applied, and d) to examine nurses’ performance in relation to the remuneration system in place.


A series of literature reviews were conducted on 25 articles published in the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, EMBASE, PsycINFO, and Global Health databases. The literature was limited to articles published in English between August 2006 and August 2015.

The search strategy used specific keywords in the databases to screen the words of “nurse remuneration” and “nurses’ performance”. The articles were restricted by study design. In addition, the investigators independently screened the titles, abstracts, and the full texts of the relevant articles. The data collected were relative to factors affecting nurses’ performance, basic salaries, average of nurse's total remuneration, and impacts of the remuneration system.


The findings of this study comprised the characteristics of the literature. These are presented in Table 1.

Table 1.

Characteristics of literature (n=25).

Sample country
United States of America  28 
United Kingdom  16 
Australia  12 
Other European nations 
Other  36 
Study design     
Prospective  18  72 
Retrospective  18 
Data collection method
Original questionnaire/survey  24 
Existing questionnaire/survey  24 
Interview  16 
Literature review  36 
Discussed  20 
Not discussed  20  80 
Publication date
2011-2016  13  52 
2006-2010  12  48 
Sample characteristics

Since the search was limited to articles published in English, it was not surprising that the majority of the sample was drawn from the population in the United States (28%), United Kingdom (16%), and Australia (12%). Also, although our literature search included articles published from August 2006 to August 2015, over half of the articles (52%) had been published since 2011.

Methodological characteristics

Prospective design study accounted for nearly three quarters of the total literature (72%). The literature employed a wide range of data collection approaches, including literature reviews (36%), and previously original surveys and developed surveys (24%). Original and previously developed surveys were undertaken via papers, in-person interviews, or telephone.

In general, nurses’ performance is annually evaluated using the performance appraisal form published by the Ministry of Health of each country. Approximately one quarter (24%) of the articles reviewed the framework of Maslow's theory of human motivation in relation to subsequent hierarchy of human needs. According to Maslow, there are five main categories of human needs: physiological, safety, love and belonging, esteem, social recognition, and self-actualization needs. Physiological needs are considered to be the most pressing.

The findings of the studies reviewed demonstrated various remuneration systems across the countries. Australia, New Zealand, and the United States, for instance, involve unions and employers in determining their remuneration systems. Meanwhile, the remuneration systems of Czech Republic, Finland, and Japan are mainly regulated by the government. Details of the remuneration system of each country are presented in Table 2.

Table 2.

The remuneration system across countries (n=25).

Country  Current approach to nurses’ pay determination 
Australia  In the public sector, based on state-level bargaining between union and employer representatives 
Czech Republic  National pay determination for government hospital nurses 
Finland  Co-ordinated municipal-level pay determination within a national framework 
New Zealand  Shifted from local/regional to national-level bargaining between unions and employers’ representatives 
Japan  Decentralized system; pay linked to assessment of nursing contribution 
United Kingdom  National level independent pay review body makes recommendations on national pay rates for NHS nurses; takes evidence from national unions, government, and employers; some local flexibility within national framework 
United States  Local (hospital level or equivalent) pay determination; some collective bargaining in hospitals which recognize trade unions (a minority), but mainly employer determined 

This bibliographic review has provided an extensive list of studies that focused on remuneration and nurses’ performance. The studies revealed that, at the beginning, the remuneration system was poorly managed. Furthermore, there were scientific actions undertaken by nurses, including research, to gain better and appropriate remuneration. The remuneration system, accordingly, was in place.

A clear and well-managed remuneration system may substantially improve nurses’ performance, thus improving healthcare quality9. In this review, the remuneration of nurses referred to the average gross annual income, including social security contributions and income taxes payable by the employee. It should normally include all extra formal payments such as bonuses and payments for night shifts and overtime. In most countries, the data related specifically to nurses working in the hospitals5.

Adequate remuneration increases nurses’ motivation10. In various settings, a study showed that the motivation of nurses working in the ICU increased significantly after the improvement of the remuneration system11. Similarly, bonuses within the remuneration system of nurses increased the satisfaction of nurses working in homecare, and even improved staff retention9. Based on this evidence, remuneration is one of the essential contributing factors to the enhancement of nurses’ performance4. In addition, remuneration is a crucial demand with the potential to improve health strategy, with the aim of achieving the MDG's goals12.

Conversely, a decline in remuneration has undesirable consequences. Nurses’ motivation declines, and turnover rate tends to increase13. In Africa, diminished remuneration led nurses to find alternative jobs in the private sectors or to seek work overseas12. Some low and middle income countries with inadequate remuneration experienced emigration of nurses, or “brain drain”, to the United States14. Likewise, low remuneration resulted in brain drain, and subsequent economic crisis, in Greece15.

Nurses’ remuneration varied broadly across countries and regions. It was found to be inadequate in Ontario, Canada16 and the United Kingdom17. In the meantime, remuneration in Germany is determined by city income and homecare rate18.

Problems associated with existing remuneration systems were found in most countries. In the United Kingdom, remuneration is higher among newly recruited nurses than experienced ones19. The discrimination of remuneration is not based on the standardized scoring system of care and performance in the United States20. Moreover, the remuneration is unclearly determined without consideration given to the nurses’ educational background21.

Insufficient remuneration may have unexpected consequences on the nursing workforce. Our studies found that remuneration is low in the United States and the Philippines, and it is lowest in Romania13. This low remuneration, furthermore, has resulted in a serious shortage of nurses in the United States22 and the Philippines14.

Remuneration is an exigent issue in healthcare and greatly influences its quality. Thus, it is important to identify strategies aimed at improving existing remuneration systems. Credentialing and re-credentialing could be the key to addressing problems caused by poorly managed remuneration. Such acts offer constructive and equal remuneration for nurses compared to other health professionals23. Furthermore, a career ladder would be helpful for administrators to discriminate remuneration24 in accordance with nurses’ performance25.

For the purpose of some studies in this literature review, researchers developed their own instruments, while others employed previously validated instruments. Whilst the new instruments allowed researchers to tailor the question to their unique concerns, the validated instruments made ready for the comparison of sample and population with their validated values.

An extensive body of literature on nurses’ remuneration and performance is available. From this body of literature, the authors summarized 25 studies to identify the effects of different remuneration systems on nurses’ performance. Adequate remuneration has been shown to improve nurses’ performance and, consequently, improve the quality of healthcare. This literature review provides scientific evidence for the need for decision-makers to consider the implementation of remuneration systems that include credentialing, re-credentialing, and career ladders. Future studies are suggested to investigate the development of well-managed remuneration systems for nurses.


The authors wish to thank Allah SWT, my parents, Prof. AchirYani, Dr. Roro and Agustin, M.Sc. for their helpful comments on the manuscript, as well as all of our friends.

S.A. Hassani, M. Abolhallaje, S. Inanlo, H. Hosseini, K. Pourmohammadi, P. Bastani, et al.
Allocation of health resources according to the type and size of Iranian governmental hospitals.
Iran J Public Health., 42 (2013), pp. 166-173
Jan 1
J. Kraja, E. Pjetri, I. Shala, M. Marku.
Evaluation of Nursing Care Performance in the Department of Neurology at the Regional Hospital of Shkodra.
J Int Environmental Application & Science., 10 (2015), pp. 441-444
Dec 1
R.L. Simpson.
Who's minding our profession? Assessing the quality of nursing performance, part 2.
Nurs Manage, 35 (2004), pp. 13-14
Jun 1
H. Al-Ahmadi.
Factors affecting performance of hospital nurses in Riyadh Region.
Saudi Arabia Int J Health Care Qual Assur., 22 (2009), pp. 40-54
Buchan J, Black S. The impact of pay increases on nurses’ labour market: a review of evidence from four OECD countries. OECD Health Working Papers. 2011. Available at: http://dx.doi.org/10.1787/5kg6jwn16tjd-en.
E.T. Kurtzman, D. O’Leary, B.H. Sheingold, K.J. Devers, E.M. Dawson, J.E. Johnson.
Performance-based payment incentives increase burden and blame for hospital nurses.
Health Aff (Millwood)., 30 (2011), pp. 211-218
F. Bogossian, P. Winters-Chang, A. Tuckett.
The pure hard slog that nursing is. a qualitative analysis of nursing work.
J Nurs Scholarsh., 46 (2014), pp. 377-388
George G, Rhodes B. Is there really a pot of gold at the end of the rainbow? Has the Occupational Specific Dispensation, as a mechanism to attract and retain health workers in South Africa, leveled the playing field? BMC Public Health. 2012 Aug 6;12(1):613. Available at: http://www.biomedcentral. com/1471-2458/12/613.
R.M. Werner, R. Tamara Konetzka, K. Liang.
State adoption of nursing home pay-for-performance.
Med Care Res Rev., 67 (2010), pp. 364-377
P. Lambrou, N. Kontodimopoulos, D. Niakas.
Motivation and job satisfaction among medical and nursing staff in a Cyprus public general hospital.
Hum Resour health., 8 (2010), pp. 26
Nov 16
I.H. Osman, L.N. Berbary, Y. Sidani, B. Al-Ayoubi, A. Emrouznejad.
Data envelopment analysis model for the appraisal and relative performance evaluation of nurses at an intensive care unit.
J Med Syst., 35 (2011), pp. 1039-1062
Y. Pillay, P. Mahlati.
Health-worker salaries and incomes in sub-Saharan Africa.
Lancet., 371 (2008), pp. 632-634
Feb 23
O. Duma, T.S. Rosu.
Medical staff remuneration - an ethical perspective.
Rev Rom Bioet., 10 (2012),
Apr 1
B.L. Brush.
Global nurse migration today.
J Nurs Scholarsh., 40 (2008), pp. 20-25
K.L. Phua, J.W. Hue.
The impact of prolonged economic downturns and economic crises on the nursing profession.
Nurs Econ., 33 (2015), pp. 227-232
Jul 1
A. De Guzman, D. Ciliska, A. DiCenso.
Nurse practitioner role implementation in Ontario public health units.
Can J Public Health., 101 (2010), pp. 309-313
S. Attwood.
Rewarding occupational health and safety professionals-part two.
Occupational Health & Wellbeing., 60 (2008), pp. 29
Nov 1
R. Mennicken, B. Augurzky, H. Rothgang, J. Wasem.
Explaining differences in remuneration rates of nursing homes in Germany.
Eur J Health Econ., 15 (2014), pp. 401-410
T. Snow.
Survey reveals vast differences in practice nurse remuneration.
Nurs Stand., 23 (2009), pp. 8
E.M. Sullivan-Marx.
Lessons learned from advanced practice nursing payment.
Policy Polit Nurs Pract., 9 (2008), pp. 121-126
P. Pittman, C.N. Herrera, K. Horton, P.A. Thompson, J.M. Ware, M. Terry.
Healthcare employers’ policies on nurse education.
J Healthc Manag., 58 (2013), pp. 399-410
discussion 410-1, Nov-Dec
J.A. Nelson, N. Folbre.
Why a well-paid nurse is a better nurse.
Nurs Econ., 24 (2006), pp. 127-130
I.L. Bourgeault, P. Khokher.
Making a better living from caregiving: Comparing strategies to improve wages for care providers.
Can Rev Sociol., 43 (2006), pp. 407-425
K. Scott, K. White, J.K. Roydhouse.
Advancing the educational and career pathway for clinical trials nurses.
J Contin Educ Nurs., 44 (2013), pp. 165-170
S.M. Litchfield.
Salary negotiations and occupational health nurses.
Copyright © 2018. Elsevier España, S.L.U.. All rights reserved
Article options
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos