Abstract
Purpose
This study aims to appraise and synthesize evidence examining the effects of toxic leadership on the nursing workforce and patient safety outcomes.
Design/methodology/approach
This is a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. Five electronic databases (SCOPUS, PubMed, Web of Science, CINAHL and Psych INFO) were searched to identify relevant articles. Two independent researchers conducted the data extraction and appraisal. A content analysis was used to identify toxic leadership outcomes.
Findings
The initial literature search identified 376 articles, 16 of which were deemed relevant to the final review. Results of the content analysis identified 31 outcomes, which were clustered into five themes: satisfaction with work; relationship with organization; psychological state and well-being; productivity and performance; and patient safety outcomes. Seven mediators between toxic leadership and five outcomes were identified in the included studies.
Practical implications
Organizational strategies to improve outcomes in the nursing workforce should involve measures to build and develop positive leadership and prevent toxic behaviors among nurse managers through theory-driven strategies, human resource management efforts and relevant policy.
Originality/value
The review findings have provided modest evidence suggesting that working under a leader who exhibits toxic behaviors may have adverse consequences in the nursing workforce; however, more research examining if this leadership style influences patient safety and care outcomes is warranted.
Keywords
Citation
Labrague, L.J. (2024), "Toxic leadership and its relationship with outcomes on the nursing workforce and patient safety: a systematic review", Leadership in Health Services, Vol. 37 No. 2, pp. 192-214. https://doi.org/10.1108/LHS-06-2023-0047
Publisher
:Emerald Publishing Limited
Copyright © 2023, Emerald Publishing Limited
Introduction
Nurses in leadership and management positions are strategically positioned to achieve organizational goals through quality support, resources and information. The ongoing global crisis brought on by the COVID-19 pandemic, along with other constraints, including budget cuts, shortage of qualified nursing staff and the aging population, have further highlighted the importance of having a leader who can effectively lead and navigate the organization (James and Bennett, 2022). Mounting evidence has shown that a leadership style that places a premium on “people” or “relationships,” such as the authentic and transformational leadership styles, is more likely to have positive consequences on nurses, patients and organizations (Al Sabei and Ross, 2023; Cummings et al., 2021). Ineffective leadership styles, such as abusive and destructive leadership styles, have been strongly tied to reduced work effectiveness and poor care quality ratings (Niinihuhta and Häggman‐Laitila, 2022; Shih et al., 2023).
Background
Toxic leadership is defined as a “form of supervision where a leader employs organized, systematic and persistent destructive behaviors that may bring harm to the entire organization” (Webster et al., 2016). While no specific theory explains how toxic leadership emerged, Milosevic et al. (2020) developed the toxic leadership model to illustrate the emergence of toxic leadership, its processes and its intent and outcomes. According to this model, toxic leaders, when compared to other styles of dark leadership (e.g. destructive, abusive, narcissistic), lack a definitive intent to harm others; therefore, the outcomes are less severe. A toxic leader’s intent is often self-directed, primarily to conceal their incompetence and maintain their position, as opposed to destructive and abusive leaders with a high intent to induce harm and pursue destructive goals.
To achieve this intent, toxic leaders, according to Milosevic et al. (2020), engage in downward or upward influence as tactics to create a toxic work environment. An upward influence is used to interfere with a supervisor’s evaluation of a leader’s performance, while downward influence is directed toward interfering with a subordinate’s performance ability (Milosevic et al., 2020). Collectively, these influences may ultimately result in a wide range of adverse individual outcomes (from poor job performance to work dissatisfaction) and organizational outcomes (from reduced organizational effectiveness to decreased productivity). Toxic behaviors in a leader are heightened when surrounded by susceptible followers who submit easily to their leader’s behaviors and in a toxic context where checks and balances are non-existent (Padilla et al., 2007). Behaviors frequently associated with toxic leadership are narcissistic behaviors, abusive supervision, unpredictable mood, self-promoting actions and authoritarianism (Schmidt, 2008).
In the past 30 years, toxic leadership has been extensively researched in other sectors, including education, banking, government, business and the military. Results have consistently linked toxic leadership to a wide range of undesirable work outcomes (e.g. work dissatisfaction, lowered job engagement, reduced job productivity and performance and turnover intention) (Hattab et al., 2022; Klahn Acuña and Male, 2022; Gravili et al., 2022; Rizani et al., 2022) and numerous negative psychological states (e.g. psychological distress, emotional exhaustion and reduced psychological well-being) (Gravili et al., 2022; Hadadian and Sayadpour, 2018; Walton, 2023).
Toxic leadership is a dark side of leadership that has been gaining attention in health care and nursing as an important area of leadership research, with a growing literature seen in the last decade. However, the number of studies is relatively small when compared to studies on positive (e.g. transformational, authentic) (Labrague and Obeidat, 2022; Labrague et al., 2021; Ferreira et al., 2022; Wong et al., 2013) and other ineffective leadership styles (Lavoie‐Tremblay et al., 2016). Behaviors associated with a toxic nurse manager/leader are categorized into the following: “intemperate behavior,” which is attributed to a lack of emotional intelligence (e.g. emotional outbursts, bullying) (Winn and Dykes, 2019); “narcissistic behavior,” which includes behaviors or actions such as excessive selfishness and an increased sense of self-worth, driven primarily by personal ambition (Magwenzi, 2018); “self-promoting behavior,” which includes behaviors or actions to further self-interest, such as taking advantage of the staff and drastic behavior changes when dealing with superiors; and “humiliating behavior,” such as causing embarrassment to staff, lack of concern for staff and the organization and lack of consideration (Labrague et al., 2020a, 2020b). Other studies revealed toxic behaviors such as providing negative feedback, unfair treatment and excessive pressure on nursing staff (Guo et al., 2022; Özer et al., 2017).
Despite the growing literature that examines this type of leadership in relation to nursing workforce outcomes, evidence synthesizing this literature is not located. This information is vital, as it could guide hospital and nursing administrators when developing strategies to prevent toxic behaviors and build positive leadership skills. Therefore, this review was carried out to appraise and synthesize literature examining the mediators and the impact of toxic leadership on the nursing workforce and patient safety outcomes.
Methods
This is a systematic review appraised and synthesized evidence examining the effects of toxic leadership on the nursing workforce and patient safety outcomes. The results of the systematic review were presented following the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Page et al., 2021). The PRISMA statement provides a structured framework for reporting systematic reviews and meta-analyses, ensuring transparency and consistency in reporting methods, results and conclusions.
Search methods
An electronic search of articles published from 2010 onwards using five databases (SCOPUS, PsychINFO, PubMed, Web of Science and CINAHL) was conducted from September 2022 to December 2022 using the following key and search terms: nursing, toxic leader, toxic manager, toxic leader, toxic administrator, toxic supervisor, staff outcome, job satisfaction, performance, turnover intention, burnout, stress, productivity, patient outcome, patient safety, care quality, patient satisfaction and adverse events. A thorough search of the cited literature was conducted to check for potentially relevant studies (Table 1).
Articles included met the following inclusion criteria: peer-reviewed article; published in the English language; and primary studies that assessed the impact of toxic leadership on the nursing workforce and patient safety outcomes. This review was limited to quantitative studies for homogeneity purposes. Grey literature and dissertations were excluded from this review.
Search outcomes
An initial search of the literature identified a total of 376 articles. After the removal of duplicates, 189 articles were retained, which were further reviewed for their relevance to the review. Based on the inclusion and exclusion criteria, the titles and abstracts were evaluated and screened, resulting in the exclusion of 99 articles and the inclusion of 90 articles. The remaining articles were subjected to full readings, and 74 were excluded. A total of 16 articles were included in the final review (Figure 2).
Quality appraisal
The quality scores of the included studies were assessed using the quality rating tool by Cummings et al. (2021). The tool, composed of 13 criteria, was designed to measure the research approach, sampling technique, measurement and data analysis. Twelve items were rated as 0 (not met) to 1 (met), and one item was rated as 0 (not met), 1 (self-report) and 2 (objective observation). A quality rating from 0 to 4 indicates a low rating, 5 to 9 a moderate rating and 10 to 14 a high-quality rating. Articles were not excluded based on quality scores due to the scarcity of high-quality research on this topic.
Data screening
A comprehensive search yielded a total of 376 citations, which were organized and managed using EndNote for efficient data handling and screening. After eliminating duplicate entries, the titles and abstracts of all retrieved documents underwent a meticulous review, guided by predefined inclusion and exclusion criteria. Among the remaining abstracts, full articles were obtained and subjected to a rigorous examination to verify their alignment with the stipulated criteria for inclusion. To ensure the robustness of the screening process, two independent reviewers performed dual rounds of assessment to determine the eligibility of the selected studies. In instances where disparities in judgment arose, consensus meetings were convened between the reviewing pair, with any differences being resolved through comprehensive discussions. Should unanimity prove challenging, a third reviewer was consulted to make the final determination regarding the inclusion status of the concerned article. Using this systematic and collaborative approach upheld the integrity and dependability of the study selection process.
Data extraction, data synthesis and model development
Two independent researchers conducted the data extraction and appraisal. Relevant data, including the author(s), samples, country of origin, research design, instruments, items, reliability, validity, outcome measures and quality rating were extracted and presented in Table 2. Statistical pooling was not possible due to the heterogeneity of the articles included. Hence, a narrative synthesis was used to present the findings. A content analysis was used to identify toxic leadership outcomes. Next, the identified outcomes were sorted based on their commonalities and characteristics. Conventional content analysis refers to a process of analyzing and categorizing textual data extracted from included studies in a systematic and structured manner (Hsieh and Shannon, 2005). This approach involved categorizing and organizing information to discern patterns and relationships between various factors. Through this analysis, the mediators that link toxic leadership with its outcomes were identified. These mediators acted as bridges, elucidating the ways in which toxic leadership behaviors translate into adverse nurse and patient safety outcomes. The synthesized information from the content analysis was then used to formulate the toxic leadership model in nursing (Figure 1), which visually represented the interconnectedness of toxic leadership, its mediators and the broader array of consequences. This model stands as a valuable tool for nursing administrators, guiding the design and implementation of interventions to foster positive leadership traits and prevent the emergence of detrimental leadership practices in the nursing and health-care domain.
Results
Study characteristics
A total of 16 articles were found suitable for this review. Most of the studies were cross-sectional and were conducted in Egypt (n = 6) and Turkey (n = 6), while the remaining studies were from the Philippines (n = 2), Ghana (n = 1) and the USA (n = 1). Cronbach’s alphas of the scale ranged from 0.76 to 0.95. The reviewed studies’ sample sizes ranged from 250 to 1053.
Measures of toxic leadership
The Toxic Leadership Scale (Schmidt, 2008) was the most common tool used to assess nurse managers’ toxic leadership behaviors. This scale was used in 9 out of 16 studies reviewed. This scale consists of 30 items clustered into five dimensions: “abusive supervision,” “authoritarian leadership,” “narcissism,” “self-promotion,” and “unpredictability.” Three studies used the Turkish version of the Toxic Leadership Scale (Schmidt, 2008), which was tested by Çelebi et al. (2015). The modified version consists of 30 items classified into four subscales: “inappreciativeness,” “self-interest,” “selfishness,” and “negative spiritual state.” In the remaining four studies, the Toxic Leadership Behaviors of Nurse Managers Scale (ToxBH-NM) (Labrague et al., 2020a, 2020b) was used. This scale was primarily designed and developed to examine nurse managers’ toxic behaviors. The scale contains 30 items categorized into four dimensions: “intemperate,” “narcissistic,” “self-promoting,” and “humiliating” behaviors.
Summary of quality review
The results of the quality review are presented in Table 2. Three studies were rated low quality, ten studies with moderate quality and three with strong quality. With regard to the sample, all studies used the non-probability sampling method, only two studies justified the sample size (Labrague et al., 2020a, 2020b; Labrague, 2021a, 2021b), and less than five reported the response rates. All studies used valid and reliable toxic leadership scales; however, all outcomes of toxic leadership were self-reported and not observed. With regard to statistical analysis, higher statistics such as correlations, regression and structural modeling were used; however, none of the reviewed studies reported how outliers were managed. Due to the absence of quality papers, no studies were excluded based on the quality rating.
Major findings
Toxic leadership outcomes
A total of 31 outcomes of toxic leadership were identified and sorted into five themes as shown in Table 3: satisfaction with work; relationship with organization; psychological state and well-being; productivity and performance; and patient safety outcomes.
Satisfaction with work.
Satisfaction with work pertains to the effects of toxic leadership on various constructs related to employees’ contentment and fulfillment in their work environment. This theme encompasses factors such as job satisfaction, turnover intention and absenteeism. In the context of toxic leadership, this theme focuses on how toxic leadership behaviors can impact employees’ overall job satisfaction, their likelihood to consider leaving their job and the frequency of their unplanned absences. In this review, eight studies reported three outcomes related to satisfaction with work. Work satisfaction was the most frequently assessed leadership outcome, followed by turnover intention and absenteeism. In five studies, toxic leadership had a significant negative direct effect on nurses’ job satisfaction (Atalla and Hassan Mostafa, 2023; Bakkal et al., 2019; Budak and Erdal, 2022; Erdal and Budak, 2021; Labrague et al., 2021). Three studies examined turnover intention as an outcome of toxic leadership (Labrague et al., 2021; Bakkal et al., 2019; Reyhanoglu and Akin, 2022). Results in two studies showed that working under toxic leadership may result in higher turnover intention in nurses (Labrague et al., 2021; Reyhanoglu and Akin, 2022); however, in one study, toxic leadership did not influence nurses’ decisions to leave their jobs (Bakkal et al., 2019). Toxic leadership had a significant positive direct effect on nurses’ absenteeism, with increased absenteeism in nurses who had experience working with a toxic leader (Khaled Abd El-Aziz Zaki and Samir Abd El-Aziz Elsaiad, 2021).
Relationship with organization.
Relationship with organization centers on the effects of toxic leadership on relational and psychological dynamics within the workplace. This theme encompasses variables such as organizational trust, organizational commitment and organizational justice. In this review, five studies reported six outcomes related to relationships with work. Outcomes frequently assessed were organizational trust, followed by organizational commitment and organizational justice. In two studies, toxic leadership correlated negatively and significantly with organizational commitment. In the study by Atalla and Hassan Mostafa (2023), nurses exposed to a toxic leader reported an overall reduction in the composite organizational commitment scores. In two separate studies, toxic leadership was associated with a significant reduction in affective (Abou Ramadan and Eid, 2020), normative (Abou Ramadan and Eid, 2020) and continuance commitment (Honer and Burchell, 2022). Organizational justice and organizational trust were outcomes tested in three studies. Toxic leadership had a negative and significant correlations with nurses’ perceptions of organizational justice, suggesting that when exposed to a toxic leader, nurses may perceive a lower level of organizational justice (Reyhanoglu and Akin, 2022). Meanwhile, a significant reduction in trust in their organization was seen in nurses who rated their nurse managers as toxic (Atalla and Hassan Mostafa, 2023; Erdal and Budak, 2021).
Personal and psychological state and well-being.
This theme delves into the impact of toxic leadership on the emotional and psychological well-being of individuals within the nursing workforce. It encompasses a range of variables that reflect how toxic leadership can affect employees’ mental and emotional state, as well as their interactions with others and the organization. In this review, eight outcomes related to personal and psychological state and well-being were reported in six studies, including emotional intelligence, conflict management style, silence behavior, deviant workplace behavior, vengeful behavior, psychological distress and job burnout. In two separate studies, increased stress (Labrague et al., 2021) and burnout levels (Budal and Erdal, 2022) were found in nurses who worked with toxic leaders. Other studies found a significant and positive association between toxic leadership, vengeful behavior and deviant behavior. These studies suggest that working under a toxic leader may result in an increase in vengeful (Koç et al., 2022) and deviant behavior in nurses (Khaled Abd El-Aziz Zaki and Samir Abd El-Aziz Elsaiad, 2021). Two studies reported a significant increase in silence behavior in nurses who perceived their nurse managers as toxic (Abdelaliem and Abou Zeid, 2023; Reyhanoglu and Akin, 2022). Other studies associated toxic leadership by nurse managers with reduced emotional intelligence (Abdallah and Mostafa, 2021) and increased use of conflict management styles such as avoiding, accommodating, competing and collaborating (Abou Ramadan and Eid, 2020). Toxic leadership had no significant effects on nurses’ professional values, as reported in one study (Özkan et al., 2022).
Productivity and performance.
This theme explores the effects of toxic leadership on various aspects of individual and team performance within the nursing workforce. It highlights how toxic leadership can influence work dynamics and the overall functioning of the organization. Five outcomes related to productivity and performance were reported in five studies. Outcomes measures were work productivity, group cohesion, organizational citizenship, followers’ effectiveness and organizational performance. Two studies examined work productivity as an outcome of toxic leadership, with both studies showing a negative but significant correlation between toxic leadership and nurses’ assessment of their work productivity (Atalla and Hassan Mostafa, 2023; Ofei et al., 2022). In Egypt, the toxic behavior of nurse managers was linked to significantly decreased followers’ effectiveness (Abd El Fatah Shipl et al., 2022) and reduced organizational citizenship behavior (Abdallah and Mostafa, 2021). Interestingly, in two cross-sectional studies, toxic leadership had significant but positive effects on nurses’ perceptions of organizational performance (Abdelaliem and Abou Zeid, 2023) and workgroup cohesion (Atalla and Hassan Mostafa, 2023). These studies suggest that when surrounded by a toxic leader, employees tend to be more cohesive, and organizational performance is enhanced.
Patient safety outcomes.
This theme centers on the implications of toxic leadership for patient safety and the quality of care provided. It examines how toxic leadership can indirectly impact patient outcomes through its effects on the nursing workforce. One study reported two outcomes of toxic leadership related to adverse patient events and care quality. The adverse events included falls, drug errors, complaints from patients and families, abuse from patients and nosocomial infections. Increased toxic behavior in nurse managers was associated with more complaints and verbal abuse from patients and families, increased incidence of falls, higher health-care-associated infections and increased drug errors (Labrague, 2021a, 2021b). Further, an increased toxic leadership was attributed to reduced nursing care quality ratings (Labrague, 2021a, 2021b).
Mediators of toxic leadership
This review identified seven mediators between toxic leadership and five outcomes. Silence behavior was tested as a mediator in two studies linking toxic leadership with turnover intention and organizational performance (Abdelaliem and Abou Zeid, 2023; Reyhanoglu and Akin, 2022). Increased scores on the toxic leadership scale were associated with increased silence behavior and, in effect, increased turnover intention (Reyhanoglu and Akin, 2022) and reduced organizational performance (Abdelaliem and Abou Zeid, 2023). Mediators relating to the nurses’ relationship to work, including organizational trust and organizational justice, were tested in relation to toxic leadership. A significant and indirect influence of toxic leadership on nurses’ turnover intention via the intermediary effect of organizational justice was found, suggesting that working with a leader who exhibits toxic behaviors results in decreased perceptions of organizational justice and an increased desire to leave work (Reyhanoglu and Akin, 2022). In one study, organizational trust partially mediated the toxic leadership–job satisfaction relationship. The result suggests that working with a toxic leader may decrease nurses’ trust in the organization and, in effect, reduce their job satisfaction (Erdal and Budak, 2021).
Mediators relating to nurses’ psychological states, including job burnout and psychological well-being, were examined in relation to toxic leadership. Job burnout had a partial indirect effect on the relationship between toxic leadership and job satisfaction (Budal and Erdal, 2022); however, psychological well-being did not influence the toxic leadership-vengeful behavior relationship (Koç et al., 2022). In other words, working with a toxic leader may increase job burnout, leading to job dissatisfaction (Budal and Erdal, 2022). In one study, job satisfaction was tested as a mediator in the relationship between toxic leadership and nurses’ intent to leave their job. In the Bakkal et al. (2019) study, an increased rating on the toxic leadership scale was associated with work dissatisfaction and an increased desire to leave the organization.
Discussion
Review findings
This review was the first to synthesize the literature on the dark side of leadership and, in particular, toxic leadership in health care and nursing, hence providing new knowledge that could guide hospital and nursing administrators when designing and implementing leadership programs and initiatives. Notably, review findings have identified a significant increase in toxic leadership studies in health care in the last 10 years, suggesting an increasing recognition and presence of this leadership style in the profession. Results of the systematic review suggest that working under toxic leadership may have a wide range of adverse consequences for the nursing workforce and the organization. This result yielded support for research in non-nursing sectors linking toxic leadership to increased counterproductive behaviors (Hattab et al., 2022), work disengagement (Klahn Acuña and Male, 2022), work discontentment (Gravili et al., 2022), poor organizational performance (Rizani et al., 2022), increased attrition rates (Hattab et al., 2022; Gravili et al., 2022), heightened emotional exhaustion (Gravili et al., 2022), stress (Hadadian and Sayadpour, 2018) and reduced affective (Hadadian and Sayadpour, 2018) and psychological well-being (Walton, 2023).
Numerous reviews and individual studies have strongly linked positive leadership styles (e.g. transformational, authentic) to improved care quality and fewer adverse events (Labrague and Obeidat, 2022; Labrague et al., 2021; Ferreira et al., 2022; Wong et al., 2013); however, only one study attempted to link negative leadership style (abusive leadership) (Lavoie‐Tremblay et al., 2016) to these outcomes. This, together with the results of this review, underscores the need for more research examining how this leadership style influences patient safety and care outcomes.
Implications for leadership theory
Despite the prominence of toxic leadership research in the literature over the last 30 years, a comprehensive search of the literature revealed the absence of a specific theory that could explain the toxic leadership process; that is, until 2020 when Milosevic et al. (2020) developed a model of toxic leadership that illustrates the processes underlying this style of leadership, the intent and its outcomes. Therefore, it is not surprising that all reviewed studies did not report any theoretical framework, except for the work of Labrague et al. (2020a, 2020b), whereby the leader–member exchange theory (Dansereau et al., 1975) was used to guide their research. A sound theoretical underpinning is vital in any research undertaking, as it serves as a foundation and guides researchers when making sense of the data and interpreting results (Kivunja, 2018).
The findings of this review provide validity to the toxic leadership model by Milosevic et al. (2020), which demonstrated the ill effects of the downward influence tactic of a toxic leader, resulting in varying negative consequences to the nursing workforce (e.g. work dissatisfaction, poor work performance) and the organization (e.g. organizational ineffectiveness, decreased productivity). This review extends this model by providing modest evidence of the different factors that explain how toxic leaders affect nurse outcomes. Based on the findings of this review, a model was created to illustrate the outcomes of toxic leadership, which could be applied to nursing and health care (Figure 2). The model shows the interaction between toxic leadership, its mediators and the broad list of nurse and patient safety outcomes. This model could be useful to nursing administrators when designing and implementing interventions to build positive leadership skills and prevent dark forms of leadership.
Implications for leadership research
This review offers several implications for future leadership research. First, given that all included studies used the cross-sectional approach to data collection, future studies should consider a more rigorous research design, such as a longitudinal research design, to examine the interaction between toxic leadership and its outcomes. About 75% of studies (n = 12) used Schmidt’s (2008) Toxic leadership scale, originally designed to capture toxic leadership in military sectors. While such a tool was found reliable and valid, items on the scale may not precisely capture the dynamic and complex nature of the profession. The use of a psychometrically sound data collection tool such as the ToxBH-NM by Labrague et al. (2020a, 2020b) may yield a more meaningful result that reflects the nature of the profession.
More than 80% of the reviewed articles (n = 13) used non-probability sampling; hence, to improve the validity and generalizability of the results, future studies should consider probability sampling, a more rigorous sampling design. In this review, outcomes of leadership were all self-reported by nurses rather than observed, which could potentially contribute to response bias. A more rigorous method of data collection (e.g. chart review or actual observation) may be beneficial, particularly when assessing care quality and adverse patient events.
Due to the limited number of toxic leadership studies in nursing, other outcomes were not tested. Milosevic et al. (2020), the proponent of the toxic leadership model, theoretically assumes that the upward and downward influence tactics of a toxic leader may ultimately lead to a higher level of frustration and powerlessness among employees. No studies in this review tested these areas. The fact that only one study (Labrague, 2021a, 2021b) assessed the influence of toxic leadership on patient outcomes underscores the need for more research in this vital area.
Previous reviews of leadership studies concluded that working with effective leaders may effectively reduce the incidence of adverse events and missed care while improving patient and family satisfaction (Al Sabei and Ross, 2023; Lee et al., 2023; Wong et al., 2013). Therefore, toxic leadership could also negatively influence patient safety outcomes. Evidently, studies that examine mechanisms by which toxic leaders influence outcomes in the nursing workforce remained under research, with only six studies found (Abdelaliem and Abou Zeid, 2023; Bakkal et al., 2019; Budal and Erdal, 2022; Erdal and Budak, 2021; Koç et al., 2022; Reyhanoglu and Akin, 2022). Finally, as the samples from all but three studies (Labrague, 2021a, 2021b; Labrague et al., 2020a, 2020b; Ofei et al., 2022) were derived from a single site, future studies should consider multi-site data collection to further increase the reliability and validity of the results.
Implications for practice and policy
Behaviors indicative of a toxic leader (e.g. lack of emotional intelligence) may be identified during the hiring process or the promotion of staff to leadership positions using valid leadership scales. Consistent monitoring and evaluation of nurse manager/leader competencies may provide a clearer picture of the leadership areas that need to be strengthened or addressed. A 360-degree feedback mechanism whereby a nurse manager is evaluated by their superior and other team members who interact with them will provide multiple perspectives of the leadership behaviors of nurse managers (Kanaslan and Iyem, 2016). Human resource policies should incorporate strategies to identify, address and prevent toxic leadership. Clear guidelines on reporting and addressing negative leadership behaviors should be in place, along with mechanisms to ensure confidentiality and protection for whistleblowers (Magwenzi, 2018). Policies should be put in place to identify and address toxic behaviors among nurse managers promptly. This may involve regular assessments of leadership styles and behaviors, with appropriate measures for intervention and correction when necessary (Labrague, 2021a, 2021b).
Because toxic leaders assert upward influence tactics to conceal their incompetence (Milosevic et al., 2020), leadership development interventions to enrich their leadership competence can be seen as a potential strategy for handling toxic behavior in the workplace. In two separate systematic reviews (Chen et al., 2022; Cummings et al., 2021), interventions for leadership development, while seen to improve leadership behavior and practices in nurse managers, could also potentially reduce toxic and other undesirable behavior in nurse managers. Other leadership strategies may include leadership mentoring and coaching (Kanninen et al., 2021), leadership simulation (Labrague, 2021a, 2021b), leadership fellowship (MacPhee et al., 2012) and leadership certifications (Foster et al., 2018). An organizational policy that does not tolerate displays of toxic practices could potentially curve the survival of this type of leadership behavior.
The identification of mediators between toxic leadership and various nursing workforce outcomes has profound implications for nursing practice, highlighting areas that require focused attention and intervention. Recognizing the role of silence behavior as a mediator between toxic leadership and turnover intention underscores the importance of fostering an environment where nurses feel empowered to voice their concerns and provide constructive feedback without fear of retribution. The mediating effects of organizational justice and trust emphasize the need for transparent and fair leadership practices. Nurse managers should prioritize equitable treatment, clear communication of decisions and procedural fairness to enhance nurses’ perceptions of justice and trust within the organization (Reyhanoglu and Akin, 2022). The link between toxic leadership, job burnout and subsequent job dissatisfaction accentuates the significance of preventing burnout through supportive measures. Nursing leaders should implement strategies such as workload management, emotional support and wellness programs to mitigate the impact of toxic leadership on nurses’ well-being (Budal and Erdal, 2022). The mediating role of job satisfaction between toxic leadership and nurses’ intent to leave reinforces the necessity of fostering job satisfaction as a protective factor against turnover. Nurse leaders should prioritize creating a positive work environment, recognizing accomplishments and providing opportunities for professional growth. Improved job satisfaction diminishes the desire to leave and bolsters nurse retention (Bakkal et al., 2019).
Conclusion
The findings of this systematic review have provided modest evidence suggesting that working under a leader exhibiting toxic leadership may have adverse consequences in the nursing workforce; however, further research is warranted to confirm if this type of leadership also affects patient safety and care outcomes. The recent growth in toxic leadership studies in nursing over the last 10 years confirms the persistence of this style of leadership and underscores the need to review existing leadership efforts in many health-care organizations to ensure they are led and managed by leaders who can bring positive outcomes to nurses, patients and the organization. Finally, the findings of this review may guide prospective leaders and managers about the importance of building positive leadership and how to identify signs of toxic leadership. Nursing faculty can assist in building positive leadership competencies in nursing students by highlighting the value of effective leadership in achieving organizational goals and the different strategies to further enhance these competencies.
Figures
Literature search strategy
| Search and MeSH terms | Databases | |||||
|---|---|---|---|---|---|---|
| PubMed | Scopus | CINAHL | PsycINFO | Web of Science | Manual search | |
| “Nurs”* OR “nurse” [MeSH] OR “registered nurse” | 7,324,654 | 8,542,022 | 11,324,987 | 10,124,243 | 16,789,24 | – |
| “toxic leadership” OR “toxic manager” OR “toxic leader” OR “toxic supervisor” | 512 | 9,654 | 62 | 298 | 546 | – |
| “staff outcome” OR “job satisfaction” OR “performance” OR “turnover intention” OR “work productivity” OR “burnout” OR “stress” OR “patient outcome” OR “patient safety” OR “care quality” OR “patient satisfaction” OR “adverse events” | 25,323,133 | 26,256,987 | 23,325,866 | 19,245,322 | 29,445,346 | -- |
| Combined search | 68 | 87 | 68 | 80 | 73 | – |
| Final selection | 4 | 3 | 4 | 1 | 4 | – |
| Articles included in the review | 16 | |||||
Source: Author’s own work
Summary of articles reviewed
| Author | Sample | Country | Research design | Instruments | Items | Reliability | Validity | Quality rating |
|---|---|---|---|---|---|---|---|---|
| Abd El Fatah Shipl et al. (2022) | 343 nurses | Egypt | Cross-sectional study | Toxic Leadership Scale (Schmidt, 2008) | 15 items, five-point Likert scale | 0.89 | PV | Low |
| Followership Styles Questionnaire (Kelley, 1992) | 20 items, four-point Likert scale | 0.71 | PV | |||||
| Abdelaliem and Abou Zeid (2023) | 750 nurses | Egypt | Cross-sectional study | Toxic Leadership Behaviors of Nurse Managers Scale (Labrague et al., 2020a, 2020b) | 30 items, five-point Likert scale | 0.975 | PV | High |
| Organizational Performance Questionnaire (Top, 2013) | 11 items, five-point Likert scale | 0.956 | PV | |||||
| Nurses Silence Scale (Knoll and Dick, 2013) | 12 items, seven-point Likert scale | 0.892 | PV | |||||
| Khaled Abd El-Aziz Zaki and Samir Abd El-Aziz Elsaiad (2021) | 250 nurses | Egypt | Cross-sectional study | Toxic Leadership Scale (Schmidt, 2008) | 15 items, five-point Likert scale | 0.79 to 0.85 | PV | Low |
| Researcher-designed Nurses’ Absenteeism Questionnaire | 60 items, five-point Likert scale | 0.92 | Content validity | |||||
| Deviant Workplace Behaviors (Bennett and Robinson, 2000) | 19 items, five-point Likert scale | 0.81 to 0.87 | PV | |||||
| Abdallah and Mostafa (2021) | 486 nurses | Egypt | Cross-sectional study | Toxic Leadership Questionnaire (Çelebi et al., 2015) | 30 items, five-point Likert scale | 0.783 | PV | Moderate |
| Emotional Intelligence Questionnaire (Ugoani, 2015) | 50 items, five-point Likert scale | 0.801 | PV | |||||
| Organizational Citizenship Behavior Questionnaire (Kumar and Shah, 2015) | 45 items, five-point Likert scale | 0.775 | PV | |||||
| Abou Ramadan and Eid (2020) | 544 nurses | Egypt | Cross-sectional study | Toxic Leadership Assessment Scale (Çelebi et al., 2015) | 30 items, five-point Likert scale | 0.85 | PV | Moderate |
| Conflict Management Assessment Scale (Rahim 1983) | 20 items, five-point Likert scale | 0.91 | PV | |||||
| Organizational Commitment Assessment Scale (Tett and Meyer, 1993) | 18 items, five-point Likert scale | 0.90 | PV | |||||
| Atalla and Hassan Mostafa (2023) | 475 nurses | Egypt | Cross-sectional study | The Toxic Leadership Scale (Schmidt, 2008) | 15 items, five-point Likert scale | 0.9 | PV | Low |
| Researcher-designed Work Outcomes Scale | 21 items, five-point Likert scale | 0.86 | Face and content validity | |||||
| Bakkal et al. (2019) | 664 nurses | Turkey | Cross-sectional study | Toxic Leadership Scale developed by Schmidt (2008) | 30 items, five-point Likert scale | 0.971 | PV | Moderate |
| Minnesota Job Satisfaction Scale (Weiss et al., 1967) | 20 items, five-point Likert scale | 0.969 | PV | |||||
| Turnover Intention Scale (Rosin and Korabik, 1995) | x items, five-point Likert scale | 0.753 | PV | |||||
| Budak and Erdal (2022) | 412 nurses | Turkey | Cross-sectional study | Toxic Leadership Assessment Scale (Çelebi et al., 2015) | 30 items, five-point Likert scale | 0.908 to 0.963 | PV | Moderate |
| Maslach Burnout Inventory (Maslack and Jackson, 1981) | 22 items, seven-point Likert scale | 0.721 to 0.850 | PV | |||||
| Job Satisfaction Scale (Schwepker, 2001) | 20 items, five-point Likert scale | 0.625 to 0.925 | PV | |||||
| Erdal and Budak (2021) | 470 nurses | Turkey | Cross-sectional study | Toxic Leadership Assessment Scale (Özer et al., 2017) | 30 items, five-point Likert scale | 0.996 | PV | Moderate |
| Organizational Trust Scale (Nyhan and Marlowe, 1997) | 12 items, five-point Likert scale | 0.984 | PV | |||||
| Job Satisfaction Scale (Schwepter, (2001) | 20 items, five-point Likert scale | 0.937 | PV | |||||
| Honer and Burchell, 2022 | 30 nurses | USA | Cross-sectional study | Toxic Leadership Scale developed by Schmidt (2008) | 30 items, five-point Likert scale | 0.99 | PV | Moderate |
| Organizational Commitment Questionnaire (Allen and Meyer, 1991) | 23 items, five-point Likert scale | 0.80 | PV | |||||
| Koç et al. (2022) | 311 nurses | Turkey | Cross-sectional study | Toxic Leadership Scale developed by Schmidt (2008) | 30 items, five-point Likert scale | 0.964 | PV | Moderate |
| Vengeful Behavior Scale (Coelho et al., 2018) | Ten items, five-point Likert scale | 0.94 | PV | |||||
| Psychological Well-Being Scale (Diener et al., 2009) | Eight items, five-point Likert scale | 0.929 | PV | |||||
| Labrague (2021a, 2021b) | 1053 nurses | Philippines | Cross-sectional study | Toxic Leadership Behaviors of Nurse Managers Scale, (Labrague et al., 2020) | 30 items, five-point Likert scale | 0.967 | PV | High |
| Adverse Patient Events Scale (Laschinger and Leiter, 2006) | Six items, seven-point Likert scale | 0.93 | PV | |||||
| Single-item quality-of-care-measure (Aiken et al., 2017) | One item, four-point Likert scale | 0.89 | PV | |||||
| Labrague et al. (2021) | 770 nurses | Philippines | Cross-sectional study | Toxic Leadership Behaviors of Nurse Managers Scale, (Labrague et al., 2020a, 2020b) | 30 items, five-point Likert scale | 0.98 | PV | High |
| Job Satisfaction Index (Schriesheim and Tsui, 1980) | Six items, five-point Likert scale | 0.81 | PV | |||||
| Perceived Stress Scale (Cohen et al., 1994) | Four items, five-point Likert scale | 0.89 | PV | |||||
| Two single-item turnover intention measure (O’Driscoll and Beehr, 1994) | Two items, five-point Likert scale | 0.91 | PV | |||||
| A single-item measure to capture absenteeism | One item, five-point Likert scale | 0.89 | PV | |||||
| Ofei et al. (2022) | 943 nurses | Ghana | Cross-sectional study | Toxic Leadership Behaviors of Nurse Managers Scale, (Labrague et al., 2020a, 2020b) | 30 items, five-point Likert scale | 0.851 | PV | High |
| Researcher-designed nurse productivity scale | Nine items, three-point Likert scale | 0.85 | Face and content | |||||
| Minnesota Satisfaction Questionnaire (MSQ-short version) | 20 items, five-point Likert scale | 0.86 | PV | |||||
| Özkan et al. (2022) | 244 nurses | Turkey | Cross-sectional study | Toxic Leadership Scale (Schmidt, 2008) | 30 items, five-point Likert scale | 0.92 | PV | Moderate |
| Nurses Professional Values Scale (Weis and Schank, 2009) | 26 items, five-point Likert scale | 0.91 | PV | |||||
| Reyhanoglu and Akin (2022) | 347 nurses | Turkey | Cross-sectional study | Toxic Leadership Scale (Schmidt, 2008) | 30 items, five-point Likert scale | 0.88 | PV | Moderate |
| Organizational Justice Scale (Moorman, 1991) | 20 items, five-point Likert scale | 0.93 | PV | |||||
| Organizational Silence Scale (Dyne et al., 2003) | 15 items, five-point Likert scale | 0.86 | PV | |||||
| Intention to Leave measure (Ramesh, 2007) | Four items, five-point Likert scale | 0.91 | PV |
PV = previously validated
Source: Author’s own work
Summary of outcomes and mediators of toxic leadership
| Outcomes (direct effects) | Source | Direction | Significance |
|---|---|---|---|
| Satisfaction with work | |||
|
Atalla and Hassan Mostafa (2023) Bakkal et al. (2019) Budak and Erdal (2022) Erdal and Budak (2021) Labrague et al. (2021) |
↓ ↓ ↓ ↓ ↓ |
S S S S S |
|
Khaled Abd El-Aziz Zaki and Samir Abd El-Aziz Elsaiad (2021) | ↑ | S |
|
Labrague et al. (2021) Reyhanoglu and Akin (2022) Bakkal et al. (2019) |
↑ ↑ = |
S S NS |
| Relationship with organization | |||
|
Atalla and Hassan Mostafa (2023) | ↓ | S |
|
Abou Ramadan and Eid (2020) | ↓ | S |
|
Abou Ramadan and Eid (2020) | ↓ | S |
|
Honer and Burchell, 2022 | ↓ | S |
|
Reyhanoglu and Akin (2022) | ↓ | S |
|
Atalla and Hassan Mostafa (2023) Erdal and Budak (2021) |
↓ ↓ |
S S |
| Productivity and effectiveness | |||
|
Abdallah and Mostafa (2021) | ↓ | S |
|
Abd El Fatah Shipl et al. (2022) | ↓ | S |
|
Abdelaliem and Abou Zeid (2023) | ↑ | S |
|
Ofei et al. (2022) Atalla and Hassan Mostafa (2023) |
↓ ↓ |
S S |
|
Atalla and Hassan Mostafa (2023) | ↑ | S |
| Personal psychological state and well-being | |||
|
Abdallah and Mostafa (2021) | ↓ | S |
|
Abou Ramadan and Eid (2020) | ↑ | S |
|
Abou Ramadan and Eid (2020) | ↑ | S |
|
Abou Ramadan and Eid (2020) | ↑ | S |
|
Abou Ramadan and Eid (2020) | ↑ | S |
|
Abdelaliem and Abou Zeid (2023) Reyhanoglu and Akin (2022) |
↑ ↑ |
S S |
|
Khaled Abd El-Aziz Zaki and Samir Abd El-Aziz Elsaiad (2021) | ↑ | S |
|
Özkan et al. (2022) | = | NS |
|
Koç et al. (2022) | ↑ | S |
|
Labrague et al. (2021) | ↑ | S |
|
Budak and Erdal (2022) | ↑ | S |
| Patient safety outcomes | |||
|
Labrague (2021a, 2021b) | ↓ | S |
|
Labrague (2021a, 2021b) | ↑ | S |
|
Labrague (2021a, 2021b) | ↑ | S |
|
Labrague (2021a, 2021b) | ↑ | S |
|
Labrague (2021a, 2021b) | ↑ | S |
|
Labrague (2021a, 2021b) | ↑ | S |
| Mediators (indirect effects) | Source | Direction | Significance |
|
Reyhanoglu and Akin (2022) | ↓ ↑ | S |
|
Reyhanoglu and Akin (2022) | ↑ ↑ | S |
|
Koç et al. (2022) | ↓ ↑ | NS |
|
Abdelaliem and Abou Zeid (2023) | ↑ ↓ | S |
|
Bakkal et al. (2019) | ↓ ↑ | S |
|
Erdal and Budak (2021) | ↓ ↓ | S |
|
Budak and Erdal (2022) | ↑ ↓ | S |
NS = not significant; S = significant; ↑ = increased; ↓ = decreased
Source: Author’s own work
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Further reading
Gaffney, T. (2022), “Retaining nurses to mitigate shortages”, American Nurse Journal, Vol. 17 No. 1, pp. 14-17.
Örgev, C. and Demir, H. (2019), “Toxic leadership in a public university hospital”, Journal of International Health Sciences and Management, Vol. 5 No. 8, pp. 48-63.
Acknowledgements
The expertise of Dr. Anthony Monnae is acknowledged.
Research fund: This study is non-funded.
Conflict of interest: The author declares no conflict of interest.
Availability of data: Available upon request.
Ethical clearance: This review study does not require ethical approval since human samples were included.
Corresponding author
About the author
Leodoro J. Labrague, RN, DM, PhD, CNE, is a Clinical Assistant Professor at Marcella Niehoff School of Nursing, Loyola University Chicago, USA.