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.

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.