CLR

Nurses are exiting the workforce for other professions, taking the skills, knowledge, and education with them resulting in a loss not only to the organisation, but also to the nursing workforce. Turnover and low morale in nursing has the capacity to cause numerous undesirable affects, involving increased workload, a rise in medication errors, adverse outcomes, and excessive costs to managers and employers when attempting to replace personnel (Madathil, Heck, & Schuldberg, 2014). Employees are the most valuable asset in any organisation, who clearly affect the operational success of the organisation for which they work. The economic cost to an organisation in failing to adequately support employees in the delivery of satisfactory patient care and sound clinical practice is significant (O'Donnell, Livingston, & Bartram, 2012).

Australian and global research summarises an account of causes and effects of poor workplace culture on nursing personnel. It is clear that the results of poor workplace culture not only add great expense to organisations, but also have detrimental influences on the care patients receive, even though there is an absence of agreement regarding the determinants of workplace culture (Day et al. 2006). Nurses' abilities to meet organisational goals and research on what leadership factors nurses perceive as influential on their staff morale has not been explored (Germain & Cummings, 2010). Previous research has implied that the retention of staff is prompted by 'on-the-job' aspects which further influence low morale and dissatisfaction, fueling a 'wish' to exit the organisation, and causes staff to leave when they sense comparative effortlessness in exiting the organisation. Therefore, inciting inner enthusiasm in employees will produce a deeper lasting feeling of fulfilment, contentment, increased morale, and related efficiency at work Stapleton et al., 2007).

Nurse manager behaviours that influence nurses' morale are most commonly described only theoretically, and chiefly from the perspective of the nurse managers. Limited research articles have investigated the personal anecdotal experiences of the nursing workforce concerning the connection linking their levels of morale and career fulfilment and the leadership practices of their executives (Feather, 2015). While styles of leadership have been extensively examined, they continue to be weakly grasped. For instance, a key awareness into the association concerning the morale of nurses and the behaviour of nurse managers could support nursing directors and managers to embrace strategic directives (Feather, 2015).

Nurse managers are in a position to influence the morale of their staff, thus affecting patient outcomes, career fulfilment and retain nursing staff due to their leadership practices (Bormann & Abrahamson, 2014). Organisational achievements and staff member's capability to succeed are prompted by a leader's proficiency to provoke exceptional performance within the individual. When a leader generates a meaningful work atmosphere or a sense of optimism, this can facilitate the best in employees, consequently generating inherent morale, ongoing learning, and motivation (Stapleton et al., 2007). Low morale and motivation, increased turnover, and employee dissatisfaction should be primary concerns in any workplace setting.

The structured question formulated for this critical review is 'What factors of leadership do nurses perceive as influential on staff morale?' The aim of this critical literature review is to address the identified research gap and provide insight and value into identifying and exploring the factors of leadership that influence the morale of nurses.

Method:

The most appropriate systematic review typology for this topic of research is an experiential (qualitative) review, with the emphasis on evaluating nurses' perceptions of leadership traits that influence staff morale. Munn, Stern, Aromataris, Lockwood, & Jordan (2018) convey that the question format guides its development, therefore influencing the type of review required. As the research question is specifically examining the subjective experience of nurses' perceptions, a non-positivist approach is best suited (Munn et al., 2018).

The PICo format, in this instance, is employed to drive the formation of the question and examine the population’s subjective perception of the phenomenon of significance within an environment (Munn et al., 2018). The population is staff nurses; the Phenomenon of Interest is factors of leadership; and the Context is the influence on staff morale.

In guaranteeing that primarily an appropriate question was solicited, and that it is associated with the issue, this stipulates the foundation for retrieving the material from diverse areas, (Munn et al, 2018). Submitting the formulated question using the PICo technique, is a methodical formula which identifies the problem statement and makes sure all sections of the question will augment evidence-based searching of the research (Milner & Cosme, 2017). Munn et al (2018) highlights the magnitude of generating a well-structured and precise question to advance with collecting applicable documentation on a subject for additional study or employing a practice modification or guideline. The question criteria, population, phenomenon of interest, and context guarantee that the search of the primary literature is thorough, and recognises bias while developing the systematic review, (Pollock & Berge, 2018).

The Academic Search Planner, CINAHL, MedLine, ProQuest, and Scopus electronic data bases accessible via University Library were used to conduct systematic searches for literature. These databases were chosen as they are appropriate to nursing and allied health and are readily accessible and simple to navigate. The following key search terms were selected and combined with Boolean operators: (leadership and management styles in nursing) AND (staff perceptions or attitudes or opinion or experience or view or reflection or beliefs). Academic Search Planner, CINAHL and MedLine all had the same key search strategies. ProQuest and Scopus required extensive delimiters and different key search strings due to their different operational structure. Secondary and grey sources of literature were excluded from this review.

The search strategy, including the databases, key search terms and the number of articles found using this method, is shown in Table 1. The search was undertaken during March 2019; it was limited to articles published between 2006-2019 to capture research that was current, accurate, and evidence-based. The following inclusion criteria were applied during article selection:

- Population was over the age of 20 and had to be either an enrolled or registered nurse in a healthcare setting

- Published between 2006-2019

- Discussion of Leadership and Management perceptions and/or expectations of staff nurses

- Scholarly (peer reviewed) journals

- Studies that addressed nurse assessed leadership practices/factors

- Language - English

These criteria were employed to ensure that the research question is answered appropriately without returning too many articles and duplications.

Table 1. Databases and search terms used to identify literature for review

Figure 1 demonstrates how the articles were screened and selected. This literature search method yielded 56 articles. Once the duplicate (n=1 article) was removed, the abstract of 55 articles were screened for inclusion in this review. Most of the rejected articles (n=40) were either focused on the nursing manager's perceptions or conflict-resolution based, not based on the inclusion criteria, or literature reviews. Elements of these articles were also, not current and were not concentrated on nursing. These articles were excluded. The remaining 15 full-text articles were screened for inclusion in this review. A further two articles were excluded for the following reasons:

- The work environment/resources, quality of care and job satisfaction were addressed, but no leadership factors were discussed. (Chevalier, Lejeune, Fouquereau, Coillot, Gillet, Gandemer, Michon,. & Colombat, 2017)

- Johansen and Cadmus (2016) discussed conflict management as opposed to factors of leadership.

- Both Chevalier et al. (2017) and Johansen and Cadmus (2016) targeted very specific specialties, emergency and paediatric oncology, within nursing, which could potentially influence the research outcomes, as different specialties usually have quite specific requirements.

- Chevalier et al. (2017) discussed the mediation role between managerial and nursing organisational resources, therefore demonstrating that the study lacked relevance to the research topic.

The remaining articles (n=13) were both Australian and international studies. These studies often overlapped and used differing study designs and data collection methods for the different sections within their research. The studies included 2 phenomenological-hermeneutic approaches; 2 mixed method designs; 4 cross-sectional designs; 2 quasi-experimental, pre-post-test designs; 2 explorative descriptive designs; 1 descriptive correlational; 1 descriptive phenomenological; and 1 longitudinal design.

Potentially relevant articles identified through database searching (n = 56)

Articles excluded after evaluation of titles/abstract (n=40)

· Nursing manager focused

· Conflict-Resolution based

· Literature reviews

Articles after duplicates removed

(n = 55)

Full-text articles assessed for eligibility (n = 15)

Articles excluded with reasons, after full-text assessment (n= 2)

· Incorrect aim

· Incorrect setting

· Conflict Management

Additional studies identified through reference list search (n=0)

Total articles included in review (n =13, based on multiple study designs)

Articles included in review {(13 articles based on multiple study designs, that often overlapped: mixed-method (2), cross sectional (4), explorative (4), phenomenological-hermeneutic (2), longitudinal (1), and quasi-experimental pre and post (2)}.

Figure 1. Modified PRISMA flow Diagram of article screening and selection

Results:

The final set of included studies and their characteristics are presented in Table 2. Of the thirteen studies, published between 2006-2019, three were conducted in Australia, one in Italy, one in Iceland, one in Saudi Arabia, one in Ghana, West Africa, one in the United Kingdom (UK), one in Canada, two in Sweden, and two in the United States of America (USA). The studies reflected nurses’ perceptions of leadership factors, how staff morale was influenced, and the subsequent impact/s. Demographics of nurses were reported in ten out of the thirteen studies. The majority of respondents were female registered nurses, working in a healthcare facility, averaging 40 years of age, with an approximate mean of at least nine years nursing experience. The female predominance is reflective of the current global nursing workforce demographic, as ninety percent of the nursing population is female (Fischer, 2017). However, one study, that still had a predominantly female sampling population claimed in its limitations section that the male population was over represented (Mannix, Wilkes, & Daly, 2015). Two of the sample populations were selected randomly, four purposively, and seven via the convenience method. The sample populations ranged in size from 14 (O’Donnell et al., 2012) to 1249 (Lornudd, Tafvelin & von Thiele Schwarz, 2015).

Seven out of 13 studies were guided by either a theory, framework or model; some incorporated more than one theory in each research article. This is significant as theories, frameworks and models offer a justification for development of hypotheses and pragmatically examine associations regarding variables and concepts (LoBiondo-Wood & Haber, 1998). Five out of 13 studies used the Transformational Leadership (TL) Theory. TL ‘is defined as a leadership style in which the leader encourages his or her subordinates to achieve higher levels of performance through training programs, mentoring, and skill development programs; they are type of leader that make an impact on organisational growth’ (Akrajindanon, 2018). Sellgren, Ekvall & Tomson, (2006) and Lornudd et al. (2015), both used the change, production, employee (CPE) model to evaluate ‘desired’ leadership behaviours. Sellgren et al. (2006) and Lornudd et al. (2015) both used this model to develop the questionnaires presented to their sample populations. Although the CPE model has predominantly been assessed for use in the private industrial sector, relevance of the model in the healthcare setting is supported (Lornudd et al., 2014). Sellgren et al. (2006), Bormann & Abrahamson (2014) and Morsiani, Bagnasco, & Sasso (2016), all employed the Multifactor Leadership Questionnaire (MLQ) which is based on the ‘Full Range Leadership Development Theory’ by Bass and Avolio (1995) which explores nine leadership styles and is associated with measuring effectiveness, extra effort and outcomes of satisfaction (Bass & Avolio, 1995). Saleh, O’Connor, Al-Subhi,Alkattan, Al-Harbi and Patton (2018) employed the Ricoeur philosophy, which uses a hermeneutic phenomenological approach for describing and interpreting the data that was collected through out their study. Hermeneutic phenomenology is not just a method of research, nonetheless, more accurately, it is both a conjectural perspective and an approach. Ricoeur’s philosophy warrants being deliberated over by the human science researchers who pursue a rigorous basis for their studies (Tan, Wilson, & Olver, 2009). Brunetto, Farr-Wharton and Shacklock (2011) utilised the Leader-member exchange (LMX) theory which maintains that in perfect environments valauble collegial associations – particularly the employer-employee relationship steers towards advantages for the staff member and the workplace. This theory claims that supervisors govern staff contrarily and subsequently, some staff have good work experiences and outcomes and others don’t, but in empowering employees, best management practices are employed (Brunetto et al., 2011). In using the LMX theoretical framework, staff should sense an increase in autonomy when the messages coming from their supervisors are clear and succinct, and subsequently would distinctly comprehend their allocated work duties and understand who to approach for assistance required to address the needs of their patients (Brunetto et al., 2011). Dahinten, MacPhee, Hejazi, Laschinger, Kazanjian, McCutcheon, Skelton-Green, & O’Brien-Pallas (2014) used a theoretical workplace empowerment framework which is centred on executive and organisational theories and social-psychological theories and a conceptual model of programme effects (Dahinten et al., 2014). This framework emphasises the significance of developing high-quality leader-staff connections that empower the nursing workforce.

Four methods of data collection were identified. Some studies used more than one method for data collection. Two studies conducted interviews (Saleh et al., 2018; Azaare & Gross, 2011). Morsiani et al. (2017) and O’Donnell et al. (2014) utilised focus groups. Mannix et al. (2015), Borman and Abrahamson (2014), Madathil et al. (2014), and Brunetto et al. (2011) all used surveys and eight studies used questionnaires. Twenty-five different instruments were used to measure factors of leadership that nurses perceive as influential on staff morale. Seven out of 13 studies used the Likert Scale. Likert scales are used to investigate how participants rate their response to a question or account by having them select a numbered category or statement. Likert scales are useful for gathering participants’ opinions, feelings, or attitudes on the topic in question. The responses are given a score by the researchers and the variables are subsequently measured (Norman, 2010). Three out of 13 used the MLQ. The MLQ distinguishes the main common leadership styles and practices. It ensures firm validity and reliability as a measurement of leadership (Bormann & Abrahamson, 2014). Two out of 13 used the CPE tool. The CPE tool measures leadership from three fundamental dimensions, change/development, employee/relations and production/task/structure, which can be combined into leadership profiles (Sellgren et al., 2006). Many of the included studies used multiple measurement instruments, indexes, tools, and scales throughout different sections of their analyses.

If nursing managers and leaders are conscious of their own leadership profile, the healthcare organisation in which they are employed, the expectations of their role, in combination with being able to enhance the performance of their staff by addressing the aforementioned factors and affects, they can positively influence the morale and motivation of staff to perform; and subsequently have the greatest potential for success in empowering and retaining their staff.

Table 2. Results Table

Discussion:

This critical literature review focused on an appraisal of research examining the factors of leadership that nurses perceive as influential on staff morale. Even though numerous research articles have concentrated on nursing leadership and nurse performance, fewer studies have explored nurses’ perceptions of these leadership factors.

A total of 13 methodologically sound studies reflect the small group of studies that advance our understanding of factors that nurses perceive to affect their morale and capability to function satisfactorily by delivering solid care to their patients. The revolution of staff morale embarks on a transformation of organisational culture that empowers nurse leaders and employs mutual decision making to establish environments where the autonomy and satisfaction of nurses can prosper (Bormann & Abrahamson, 2014).

The strengths in the included studies were the verification of existing knowledge, the contribution of new knowledge, advocation of the significance of leaders to assume the transformational leadership style, the research has linked poor morale and dissatisfaction to lower standards of patient care and negative outcomes for patients (O’Donnell et al., 2012). Bormann and Abrahamson’s (2014) findings correlate with previous research results in substantiating that the transformational leadership style has a certain affect in the nursing workplace. The questionnaire used by Sellgren et al. (2006) was advantageous as both construct and predictive validity were demonstrated and important connections between staff who rated the same manager (Sellgren et al., 2006). Dahinten et al. (2014) showed remarkable results given the amount of time to complete the follow-up. The large number of respondents, in the quantitative survey that was completed in the research undertaken by Mannix et al. (2015), who reported anecdotal information, enhanced the study (Mannix et al, 2015). Reliability levels for influences associated with factors of leadership were acceptable.

The most common weaknesses in the studies related to low response rates, sampling sizes, dropout rates, and study design. Data could have been more rigorous if sample sizes were larger, however, small sample sizes are not uncommon in nursing populations. Only three studies collected data across more than one site, the remaining ten were collected from a single site, resulting in lower heterogeneity in the resulting samples. Three studies did not include complete sets of demographics. Method bias is obvious in four out of the 13 studies, as self-rating is not objective (Lornudd et al., 2015). There is also a female predominance which is reflective of the current global nursing workforce demographic, as ninety percent of the nursing population is female (Fischer, 2017).

Conclusion:

The aim of this critical literature review was to identify and explore the factors of leadership that influence the morale of nurses. The factors identified were autonomy, professional development, empowering staff, communication and transformational leadership. In applying these factors to daily practice, nurse leaders and managers can successively increase morale, job satisfaction, organisational commitment, motivation and retention. Furthermore, through practicing of all these components, patient care and outcomes are improved, and organisational performance improves. The literature has highlighted that the extrinsic factors, leadership traits and management styles, fears about job security, and excessive workload, are what reduce staff morale, whereas the intrinsic factors, feeling valued and respected, having good relationships with colleagues, and giving good patient care, appear to enhance staff morale.

It is recommended that additional study on leadership practices that influence nurses’ proficiencies to accomplish organisational goals should be investigated. Given that the current healthcare system is constantly excessively burdened, and staff and managers are obliged to respond to the stresses of their organisation, studies that investigate and connect the factors include nursing leadership, nurse performance, and organisational goals must likewise be ongoing. Non-positivist studies would provide improved transparency and vigour to the current research available and supplement quantitative measurements of morale. Additional thought-provoking and beneficial studies might comprise of research that addresses what nurses interpret as their responsibility in performance versus what nursing managers expect of them. These proposed further studies may enhance strategic development criteria at the organisational, profession and government stages and planning for personnel, and by understanding the key variables that impact nursing morale, managers will be able to develop appropriate workplace strategies.

Maintaining leadership modifications to affect levels of morale in a work environment is superior to an employee’s fundamental fulfilment with and efficiency in their role. Given the ongoing and cumulative expectations being placed on the nursing workforce, and the essential functions that they perform in the delivery of superior standards of care, it is imperative that the issue of staff morale should be acknowledged as a strategic directive by nursing managers and hospital directors, and continued efforts are made to decrease turnover and increase morale and job satisfaction within the nursing population so that the vocation can keep hold of an elevated standard of nurses into the future.

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