Toxic Leadership in Nursing: A Systematic Review of Its Professional and Organizational Challenges ()
1. Introduction
Toxic Leadership (TL) has been defined as an ineffectual leadership style in which a leader consistently and systematically engages in detrimental behaviors that may potentially harm the organization and its employees [1]. These behaviors often manifest as intemperate actions, narcissism, self-promotion, abusive communication, and a profound lack of empathy, collectively fostering a hostile atmosphere detrimental to team dynamics and emotional well-being [2].
While this review primarily focuses on toxic leadership, it is situated within the broader landscape of detrimental leadership concepts. Toxic leadership encompasses a spectrum of behaviors characterized by self-serving motives and a disregard for subordinates’ well-being. This differentiates it from more specific concepts such as abusive supervision, which involves sustained hostile verbal and nonverbal behaviors, and the more general term destructive leadership, which covers any actions harmful to an organization or its members [3].
TL has far-reaching implications for both individual nurses and healthcare organizations, contributing to decreased job satisfaction, employee silence, and increased turnover intentions [4]. Additionally, these behaviors compromise patient safety (PS) and organizational efficiency, necessitating targeted interventions to foster healthier leadership practices and improve workplace culture [5].
As a foundational profession in healthcare delivery, nursing is particularly vulnerable to TL’s negative effects, including emotional exhaustion, organizational cynicism, and impaired team cohesion [6]. Studies indicate that TL behaviors correlate with higher rates of medication errors and patient complaints, further underscoring the urgent need for intervention strategies [2]. A direct correlation between TL traits and decreased nurse morale, reinforcing the necessity of organizational reforms to combat toxic behaviors has been highlighted [6].
While the detrimental effects of TL are well-documented, some studies suggest that organizational cynicism may act as a buffer, complicating workplace dynamics [2]. This complexity underscores the need for continued research to fully understand TL’s nuances and its impact on both nursing professionals and patient outcomes. Effective mitigation requires early identification, leadership development, and education initiatives that promote respect and accountability [7]. Through structured feedback mechanisms and ongoing monitoring, healthcare institutions can foster environments that support nursing staff and enhance the quality of patient care.
Given TL’s profound effects, this review systematically examines its prevalence, characteristics, and consequences across healthcare contexts. Grounded in empirical evidence, it explores TL’s individual and organizational impact, emphasizing workforce stability, patient safety, and institutional efficiency. This review specifically focuses on empirical studies published between 2020 and 2024. This recent timeframe was chosen to capture the most contemporary research and emerging trends in the field, reflecting recent shifts in healthcare dynamics and leadership challenges, particularly in the post-pandemic era which has brought new scrutiny to workplace conditions and nurse well-being.
2. Methodology
2.1. Review Protocol and Framework
This study adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines [8] to ensure methodological rigor and transparency. The PEO (Population, Exposure, Outcome) framework was utilized to structure the review, validate key issues, and systematically integrate relevant studies. Additionally, fact-finding methods were employed to enhance the robustness of evidence-based outcomes [9].
2.2. Eligibility Criteria
Specific inclusion and exclusion criteria were established to ensure the selection of high-quality empirical studies relevant to TL in nursing management and its organizational impact.
Inclusion Criteria
Design: Peer-reviewed empirical research
Publication Period: January 2020 - December 2024
Population: Nursing professionals in healthcare settings
Focus: TL behaviors in nursing management
Context: Studies from international healthcare contexts
Language: English
Exclusion Criteria
Non-peer-reviewed publications
Studies predating 2020
Non-English language publications
Theoretical or conceptual papers without empirical data
Studies without a nursing-specific focus
Grey literature (e.g., dissertations, conference abstracts)
2.3. Search Strategy and Data Sources
A systematic search was conducted across multiple electronic databases between December 28 and December 30, 2024, ensuring comprehensive coverage of relevant literature. The selected databases include:
To optimize precision and recall, Boolean operators (AND, OR) and Medical Subject Headings (MeSH) were employed. The search strategy aimed to identify studies examining the relationship between TL in nursing management and its impact on organizational outcomes.
Search Terms and Filters
Key search terms were systematically categorized as follows:
Population terms: “nurse” OR “nursing staff” OR “clinical nurse”
Exposure terms: “toxic leader*” OR “abusive supervision” OR “destructive leadership” OR “nurse manager”
Outcome terms: “job satisfaction” OR “turnover” OR “burnout” OR “workplace deviance”
Additionally, forward and backward citation tracking of key papers was conducted to ensure comprehensive coverage of relevant studies, minimizing the risk of omitting critical research contributions. In all stages of the review process, including screening, eligibility assessment, and data extraction, two independent reviewers were involved, with any discrepancies resolved through discussion and consensus, consulting a third senior researcher when necessary.
2.4. Quality Appraisal
The methodological quality and risk of bias of the included studies were independently assessed by the reviewers using the Joanna Briggs Institute (JBI) Critical Appraisal Checklists [10]. Specific checklists were applied based on the study design of each article (e.g., JBI Critical Appraisal Checklist for Qualitative Studies, JBI Critical Appraisal Checklist for Cohort Studies, etc.). Any discrepancies in the appraisal were resolved through discussion and consensus between the two reviewers; a third senior researcher was consulted for arbitration if consensus could not be reached. The findings from the quality appraisal were used to inform the interpretation of the synthesized evidence and to highlight potential limitations, rather than for the exclusion of studies based on quality scores alone. Overall, the quality appraisal helped in understanding the robustness of the evidence and guided the interpretation of the synthesized findings.
2.5. PEO Framework and Justification
This review applies the PEO framework to systematically examine TL behaviors in nursing and their impact on individual and organizational outcomes [11]. PEO ensures a structured and rigorous analysis by clearly defining the relationships between Population (nurses), Exposure (TL behaviors), and Outcome (individual and organizational effects).
PEO is widely used in healthcare research, particularly in leadership studies, since it facilitates the examination of both individual nurse experiences and organizational consequences. By categorizing findings within the PEO framework, this approach supports cross-study comparisons while integrating diverse research methodologies. Given that TL behaviors contribute to workplace distress, EE, turnover intention, and compromised PS, PEO provides a logical framework for evaluating these effects. Table 1 presents the psychological and professional consequences of TL behaviors on nurses, structured using the PEO framework.
Table 1. Impact of TL behaviors on nurses.
Category |
Elements |
Population |
Nurses |
Exposure |
1. Intemperate behavior 2. Narcissistic behavior 3. Self-promoting behavior 4. Humiliating behavior |
Outcomes |
1. Cynicism & interpersonal deviance 2. Psychological distress & emotional exhaustion 3. Reduced employee engagement 4. Negative silence and confusion 5. Negative mindsets on relationships 6. Communication disorders 7. Excessive flattery and ingratiation 8. Emotional exhaustion 9. Decreased motivation and action 10. Negative impact on employees’ personal lives 11. Psychological distress 12. Increased conflicts 13. Harmful impacts on job satisfaction 14. Personal attack 15. Absenteeism 16. Psychological behavior issues 17. Neglect of needs 18. Slackness at work 19. Reduced personal safety and security 20. Entitlement abuse and irregular behavior 21. Leaving the profession altogether 22. Ethical issues |
Table 2. Effects of TL on healthcare organizations.
Category |
Elements |
Population |
Organizations |
Exposure |
1. Intemperate behavior 2. Narcissistic behavior 3. Self-promoting behavior 4. Humiliating behavior |
Outcomes |
1. Declining healthcare system quality 2. Increased risk to patient safety standards 3. Deterioration of workplace climate and culture 4. Negative effect on overall organizational success 5. Barriers to organizational efficiency and productivity 6. Lack of organizational transparency 7. Communication breakdowns in the workplace 8. Organizational and interpersonal deviance (cynicism) 9. Impact on internal assignments and patient care 10. Impact on employees & organizational growth and health 11. Supervision gaps 12. Higher employee turnover intent 13. Inefficient management causing organizational decline 14. Lack of nursing staff |
Table 2 highlights the organizational challenges that arise from TL behaviors, demonstrating their broader impact on workplace culture, efficiency, and healthcare system quality.
2.6. Key Characteristics and Effects of TL in Nursing
TL in nursing is characterized by a range of detrimental behaviors that significantly impact the work environment, staff morale, and ultimately patient care. These behaviors can create a hostile atmosphere, leading to increased emotional exhaustion, organizational cynicism, and workplace deviance among nursing staff [12].
Intemperate Behavior
Intemperate leaders often exhibit behaviors such as anger, impatience, and unpredictability. These types of behavior foster stress and anxiety among team members, creating an unsettling work environment that can hinder effective collaboration and communication [2] [7].
Narcissism
Narcissistic leaders prioritize their personal needs over the collective welfare of their team. This self-centered approach undermines trust and collaboration, as these leaders may disregard the contributions of others, leading to a culture of resentment and diminished team morale [6].
Self-Promoting Behavior
Toxic leaders often engage in self-promotion, highlighting their own achievements at the expense of recognizing the efforts of their subordinates. This behavior not only reduces team cohesion but can also discourage staff from striving for excellence, as their contributions go unacknowledged [7].
Abusive Communication
Abusive communication is a hallmark of TL. This may include belittling remarks, public criticism, or derogatory comments directed at staff. Such behaviors damage self-esteem and foster a toxic work culture, ultimately leading to higher turnover rates and decreased job satisfaction among nurses [6].
Lack of Empathy
Toxic leaders frequently exhibit a lack of empathy towards their staff, ignoring their emotional and psychological needs. This insensitivity can exacerbate feelings of isolation and stress among nurses, further contributing to a negative work environment [7].
Impact on Nursing Workforce and Patient Care
The effects of TL extend beyond individual staff members, negatively influencing PS and care standards. Research has shown a direct correlation between TL behaviors and adverse outcomes such as increased rates of medication errors, patient complaints, and overall decline in care quality [6]. In nursing settings, the prevalence of TL is linked to high levels of absenteeism and turnover intentions, as nurses seek healthier work environments away from abusive leadership styles [6].
Toxic leaders often shift blame onto staff for failures or setbacks, rather than assuming responsibility for their decisions and management styles. This behavior fosters an atmosphere of fear and discouragement, particularly when discharge times or patient outcomes are at stake [4]. Toxic leaders may also engage in exclusionary practices, such as sharing information selectively with a chosen “inner circle” while neglecting to inform the wider team, leading to feelings of mistrust and disenfranchisement among staff [13].
Mitigating Factors
The presence of organizational cynicism can sometimes act as a buffer against the adverse effects of TL. While TL can foster a negative atmosphere, high levels of organizational cynicism among staff may lead to reduced instances of workplace deviance in some contexts. This counterintuitive relationship underscores the complexity of how these dynamics operate within healthcare environments [2] [14].
3. Results
Figure 1. Summary of Included and Excluded Records in Systematic Review.
In accordance with PRISMA 2020 guidelines, initially, 63 records were identified through systematic searches across different databases. After removing 3 duplicates, 60 records remained. During the screening phase, titles and abstracts were reviewed, resulting in the exclusion of 13 records, leaving 47 remaining. In the eligibility phase, the full texts of these 47 records were assessed, resulting in the exclusion of 32 due to reasons such as lack of relevance, methodological limitations, or insufficient data. In the final inclusion phase, 15 articles were incorporated into the qualitative synthesis, with no additional records identified through supplementary searches. Thus, the total number of records included in the qualitative synthesis remained at 15, all sourced from the systematic search process (Figure 1).
Relevant data, including the author(s), samples, countries of origin, research designs, instruments, items, reliability, validity, outcome measures, and quality ratings were extracted and presented in Table 3.
Table 3. Key details of research studies in the qualitative synthesis.
Author |
Sample |
Country |
Design |
Instruments |
Items |
Reliability |
Validity |
Ahmed et al. (2024) |
243 |
Egypt |
Multicenter cross-sectional |
ToxBH-NM |
30 items 4 dimension 5-point Likert Scale |
0.88 |
PV |
Emotional Exhaustion Scale |
9 items 5-point Likert scale |
0.76 |
Workplace Deviance Scale |
5 items 5-point Likert Scale |
0.82 |
Alsadaan & Alqahtani (2024) |
387 |
Saudi Arabia |
Cross-sectional |
TL Assessment |
30 items 5 dimensions 6-point Likert Scale |
0.82 - 0.96 |
PV |
ROCIII |
28 items 5-point Likert Scale |
0.70 |
Organizational Commitment Scale |
3 dimensions 7-point Likert Scale |
0.88 |
Celebi Cakiroglu & Tuncer Unver (2024) |
559 |
Turkey |
Cross-sectional |
ToxBH-NM |
30 items 4 dimensions 5-point Likert Scale |
0.98 |
PV |
Warwick–Edinburgh Mental Well-Being
Scale |
14 items 5-point Likert Scale |
0.92 |
UWES |
17 items 3 dimensions 6-point Likert Scale |
0.89 |
Farghaly Abdelaliem & Abou Zeid (2023) |
750 |
Egypt |
Cross-sectional |
TL scale |
30 items 5 dimensions 6-point Likert Scale |
0.97 |
PV |
Organizational Performance Questionnaire |
11 items 5-point Likert Scale |
0.95 |
Nurses Silence Scale |
12 items 7-point Likert Scale |
0.89 |
Guo et al. (2022) |
12 |
China |
Phenomenology |
Semi-structured interviews |
|
PV |
Guo et al. (2023) |
455 |
China |
Cross-sectional |
Negative Behavior Scale |
36 items 6 dimensions 5-point Likert Scale |
0.92 |
PV |
Hossny et al. (2023) |
250 |
Egypt & Saudi Arabia |
Descriptive Comparative |
Organizational Climate Questionnaire |
42 items 5-point Likert scale |
0.82 |
PV |
TL scale |
30 items 5 dimensions 6-point Likert Scale |
0.88 - 0.97 |
Intent to Stay Scale (Chinese Version) |
0.79 |
Labrague (2021) |
1,053 |
Philippines |
Multicentre cross-sectional study |
ToxBH-NM |
30 items 4 dimensions 5-point Likert Scale |
0.96 |
PV |
APES |
5 items 7-point Likert Scale |
0.93 |
|
Single-item Quality-of-care |
1 item 4-point Likert Scale |
0.89 |
|
Author |
Sample |
Country |
Design |
Instruments |
Items |
Reliability |
Validity |
Labrague et al. (2020) |
770 |
Philippines |
Cross-sectional |
ToxBH-NM |
30 items 4 dimensions 5-point Likert Scale |
0.98 |
PV |
GTL Scale |
7 items 5-point Likert Scale |
0.91 |
Job Satisfaction Index |
6 items 5-point Likert Scale |
0.81 |
Labrague et al. (2024a) |
285 |
Philippines |
Cross sectional |
ToxBH-NM |
30 items 4 dimensions 5-point Likert Scale |
0.98 |
PV |
Job Stress Scale |
13 items 5-point Likert Scale |
0.80 |
Job Satisfacton Index |
5 items 5-point Likert scale |
0.83 |
Nonehkaran, et al. (2023) |
551 |
Iran |
Multicenter cross-sectional |
ToxBH-NM |
30 items 4 dimension 5-point Likert Scale |
0.98 |
PV |
Turnover Intention Questionnaire |
15 items 5-point Likert Scale |
0.89 |
Ofei et al. (2022) |
1240 |
Ghana |
Multi-centre cross-sectional |
ToxBH-NM |
30 items 4 dimensions 5-point Likert Scale |
0.85 |
PV |
Perceived Productivity of Nurses |
9 items 3-point Likert Scale |
0.85 |
MSQ |
20 items 5-point Likert Scale |
0.86 |
Ofei et al. (2023) |
943 |
Ghana |
Multi-centre cross-sectional |
ToxBH-NM |
30 items 4 dimension 5-point Likert scale |
0.88 |
PV |
MSQ |
20 items 5-point Likert Scale |
0.85 - 0.91 |
TIS |
3 items 7-point Likert Scale |
0.80 |
Özkan et al. (2022) |
244 |
Turkey |
Cross-sectional |
NPVS-R |
26 items 1 dimension 5-point Likert Scale |
0.91 |
PV |
ToxBH-NM |
30 items 4 dimensions 5-point Likert Scale |
0.92 |
Türkmen Keskin & Özduyan Kiliç (2024) |
168 |
Turkish |
Cross-sectional |
TL Scale |
30-item 5 dimensions 6-point Likert Scale |
0.98 |
PV |
TIS |
5-point Likert Scale |
0.90 |
Note. APES: Adverse Patient Events Scale; GTL: Global Transformational Leadership; MSQ: Minnesota Satisfaction Questionnaire; NPVS-R: Nursing Professional Values Scale-Revised; PV: Predictive Validity; ROCIII: Rahim Organizational Con3ict Inventory-II; TIS: Turnover Intention scale; ToxBH-NM Scale: Toxic Leadership Behaviors of Nurse Managers Scale; UWES: Utrecht Work Engagement Scale.
Leadership styles significantly influence nurses’ workplace experiences, affecting both conflict management approaches and organizational commitment. [15] examined five major Saudi hospitals and found that TL behaviors in emergency departments correlated with adverse conflict management styles and decreased organizational commitment among nurses. Their findings highlighted that conflict management partially mediates this relationship, emphasizing the need for leadership interventions to improve workplace dynamics. [16] also investigated factors influencing nurses’ perception of TL behaviors. Their study, conducted among 455 nurses in China, revealed that nurses generally perceived TL behaviors at a moderate level, with “improper supervision” being the most frequently observed dimension. Key factors significantly shaping these perceptions and explaining 43.1% of the total variance included gender, educational level, department type, night shift frequency, and employment nature. Specifically, female nurses, those with lower education levels, nurses in high-stress departments like pediatrics and intensive care medicine, those with unstable employment modes, and those with frequent night shifts reported higher exposure to TL behaviors.
[17] conducted a phenomenological study with 12 Chinese nurses in a Wuhan tertiary hospital, revealing four key themes concerning toxic leadership (TL) among nurse managers. The study found that nurses generally perceive TL as “hard to avoid” but desire attention to its negative aspects. Specific toxic behaviors identified included negative feedback, ignoring, unfair treatment, self-centeredness, excessive pressure, and work inaction from nurse managers. These behaviors were attributed to underlying reasons such as heavy workload, personality traits of both nurses and managers, and in some cases, nurses’ job performance. Nurses responded to TL in various ways, including confusion and silence, seeking department or industry change, self-reflection and communication, or resorting to flattery and ingratiation.
TL behaviors have been repeatedly linked to job dissatisfaction and high turnover rates among nurses. [18] studied 244 nurses in a Turkish university hospital and found that TL behaviors did not significantly correlate with professional values; however, nurses who deliberately chose their profession and had higher education levels demonstrated greater resilience against TL. Similarly, [19] conducted a cross-sectional study of 770 nurses across 15 Philippine hospitals, demonstrating that while transformational leadership improved job satisfaction and lowered turnover intention, TL behaviors resulted in reduced job satisfaction, psychological distress, absenteeism, and an increased desire to leave the profession. This aligns with findings by [20], who examined nursing leadership in Ghana and reported that narcissistic TL behaviors significantly predicted nurses’ productivity and turnover intentions, with job satisfaction acting as a mediating factor in this relationship.
The effects of TL behaviors extend beyond job dissatisfaction to negatively shape organizational climate and nurses’ psychological well-being. [21] investigated 1,053 nurses across 20 hospitals in the Philippines, revealing that TL behaviors significantly correlated with increased adverse events such as patient falls, infections, and medication errors, ultimately reducing care quality. However, nurses still rated their units’ overall care quality as good to excellent.
Further studies have reinforced the psychological burden associated with TL. [22] found that TL levels were low (25.6%) among nurses in two Egyptian hospitals, and that the organizational climate was predominantly negative (13.6%). They identified authoritarian leadership behaviors as a key factor influencing nurses’ intention to stay in their roles. Similarly, [23] highlighted how TL behaviors among emergency nurse managers negatively impacted job satisfaction and mental health, identifying work-family conflict as a mediating factor. [2] also demonstrated a strong connection between TL and workplace deviance (B = 16.132), with emotional exhaustion acting as a mediator and organizational cynicism functioning as a moderator, though its presence unexpectedly mitigated deviant workplace behaviors (B = −3.012).
In response to the growing concerns about TL behaviors in nursing, researchers have explored tools and strategies to mitigate their negative effects. [24] investigated a sample of 559 Turkish nurses and revealed that mental well-being partially mediates the relationship between TL and work engagement. In a similar study, [25] demonstrated through structural equation modeling that TL predicted 65% of nurses’ silence and 87% of organizational performance variance, with silence mediating 73% of the relationship between TL and performance outcomes. Similarly, [26] examined 168 nurses in Turkish hospitals and found that TL negatively affected organizational trust (R2 = 0.691) and increased turnover intention (R2 = 0.267), with nearly half (46.4%) of nurses reporting exposure to negative managerial behaviors within the past year. [27] further highlighted the predictors of turnover intention, conducting a multicenter study among 551 Iranian nurses. Their findings revealed a significant correlation (r = 0.475) between TL behaviors and turnover, with regression analysis identifying specific toxic behaviors—such as intemperate, narcissistic, self-promoting, and humiliating tendencies—as the most influential predictors, alongside demographic factors.
4. Discussion
The review of TL in nursing reveals a complex and multifaceted phenomenon that extends far beyond simple interpersonal dynamics, representing a critical challenge in contemporary healthcare environments. Across the 15 studies analyzed, a compelling narrative emerges that highlights the profound impact of destructive leadership behaviors on nursing professionals, organizational effectiveness, efficiency, and productivity, and ultimately, patient care quality. The prevalence of TL behaviors demonstrates significant variability across different healthcare settings, ranging from 25.6% to 87% of nursing environments. Our review highlights emergency departments as the most vulnerable environments, likely due to high-stress conditions, complex hierarchical structures, and intense emotional labor inherent in these clinical settings.
Narcissistic leadership behaviors represent a particularly concerning manifestation of TL in nursing, characterized by self-promotion, disregard for team contributions, and persistent prioritization of personal achievements. These behaviors systematically undermine team cohesion and professional collaboration. The studies reviewed reveal a direct correlation between narcissistic leadership traits and decreased organizational commitment, highlighting the profound psychological impacts on nursing professionals [28].
Communication patterns emerge as a critical dimension of TL, with abusive and manipulative communication strategies significantly eroding workplace trust and professional efficacy. Public criticism, selective information sharing, and deliberate exclusionary practices were also identified as primary mechanisms through which toxic leaders maintain control and diminish team morale. These communication dynamics create an environment of psychological distress, reducing nurses’ ability to provide optimal patient care, and maintain professional satisfaction [29].
Besides, the emotional intelligence deficits of toxic leaders represent a fundamental challenge in nursing leadership. Limited empathy, inability to manage team emotions, and heightened reactivity consistently appear as key characteristics that compromise workplace effectiveness. These emotional intelligence gaps not only impact immediate team dynamics but also contribute to long-term organizational challenges, including increased turnover intentions and reduced professional commitment [30].
Organizational implications of TL extend beyond individual psychological experiences, demonstrating systemic consequences that fundamentally challenge healthcare delivery models. The research consistently shows significant correlations between TL and increased workplace deviance, decreased organizational commitment, and compromised PS metrics. These findings underscore the critical need for comprehensive leadership development interventions that address both individual behavioral patterns and broader institutional cultures [31].
TL was further shown to directly contribute to financial losses through increased absenteeism, higher turnover rates, and decreased productivity among nurses. Decreased motivation, job satisfaction, and overall performance directly impact efficiency and therefore increase operational costs related to recruitment and training. A toxic environment fosters a culture of fear and mistrust, hindering the collaboration necessary for continuous improvement in care delivery. TL severely damages the organizational climate by creating an environment characterized by negativity, hostility, and dysfunction. This leads to reduced job satisfaction, elevated turnover intentions, and increased instances of workplace deviance. Such leadership behaviors foster an unfair culture, lack of psychological safety, and a quiet climate where nurses tolerate TL behaviors and are reluctant to voice concerns [32].
Furthermore, the review demonstrates nuanced mediating factors that complicate our understanding of TL. Emotional exhaustion emerges as a significant mediator, suggesting that the psychological toll of TL creates a cyclical pattern of workplace dysfunction. Moreover, according to [33], organizational cynicism demonstrates unexpected moderating effects, indicating that workplace cultures develop complex adaptive mechanisms in response to destructive leadership behaviors.
Besides, the international comparative analysis reveals both universal and contextually specific manifestations of TL. While core characteristics remain consistent across diverse healthcare environments, subtle variations in cultural, institutional, and professional contexts demonstrate the importance of localized understanding and intervention strategies. This complexity, as argued by [34], challenges simplistic, one-size-fits-all approaches to addressing TL in nursing.
It is also observed that professional experience and educational background significantly influence the perceptions and experiences of TL. Nurses with advanced education and longer professional tenures demonstrate greater resilience and more sophisticated strategies for navigating challenging leadership environments. As claimed by [35], this finding highlights the potential of targeted professional development and leadership training as critical intervention mechanisms.
These consequences compromise the broader healthcare ecosystem’s ability to provide high-quality and compassionate patient care [36]. As maintained by [37], TL behavior has profound negative consequences. When leaders exhibit manipulative, controlling, or abusive behavior, employees tend to feel undervalued, overworked, and emotionally drained, and this often leads to high turnover, decreased productivity, and long-term damage to organizational culture.
From a theoretical perspective, TL in nursing transcends individual behavioral patterns, representing a complex systemic phenomenon deeply embedded in organizational power dynamics, professional socialization processes, and the unique emotional labor characteristics of nursing. This comprehensive understanding demands multifaceted intervention strategies that address individual, interpersonal, and institutional levels of workplace dynamics [38].
Interventions should focus on cultivating a positive organizational culture that prioritizes fairness, employee well-being, and trust in leadership to reduce the breeding ground for toxic behavior [39]. Creating explicit policies and procedures, such as zero-tolerance guidelines and reporting systems, is one way to implement effective interventions [40]. Enhancing resilience offers a crucial avenue for supporting nurses in high-pressure environments, enabling nurses to recover from difficult professional situations and maintain their energy levels under pressure. Strategies to foster professional resilience include promoting self-leadership, encouraging self-care, building strong social support networks, and developing problem-solving skills. Moreover, organizations should strive for antifragility – the capacity not just to withstand shocks and recover, but to actually improve and grow stronger as a result of stressors, volatility, and disorder. This involves actively embracing challenges as opportunities for learning and adaptation, moving beyond simply bouncing back to instead bouncing forward.
Transformational and Entrepreneurial leadership models are highly effective in fostering resilience and antifragility as crucial interventions against the challenges posed by toxic leadership. Implementing and fostering these positive leadership styles can serve as powerful interventions against TL [41]. This includes developing and implementing training programs and workshops for all levels of nursing management. Such programs should emphasize empathetic communication, conflict resolution, ethical decision-making, visionary thinking, and calculated risk-taking. Actively cultivating an antifragile organizational culture that values transparency, accountability, open communication, and respect, with clear policies against toxic behaviors and robust reporting mechanisms, is essential.
There is also a clear and urgent need for targeted training programs for nurses. As stated by [39], such training must empower nurses with the knowledge and skills to identify TL behaviors, understand their implications, and develop effective coping mechanisms, thereby enhancing their resilience and antifragility. These programs should equip nurses with strategies for asserting professional boundaries, advocating for a healthy work environment, and leveraging organizational resources to address and report toxic behaviors. Proactive training fosters an aware and empowered nursing workforce, capable of navigating challenging leadership dynamics and contributing to a safer, more supportive, and ultimately more resilient healthcare system.
5. Conclusion
The phenomenon of TL within nursing is not merely a managerial concern but a systemic challenge with profound implications for individual professionals, organizational effectiveness, and the quality of patient care, both directly and indirectly. This literature review has provided compelling evidence of the adverse effects that TL behaviors have on psychological well-being, job satisfaction, and organizational dynamics. TL behaviors can also contribute to workforce instability, compelling nursing professionals to seek employment elsewhere in healthier work environments, and this can lead to significant staff shortages, creating a cascade of challenges for healthcare systems, with fewer nurses available to manage workloads effectively.
Building on these critical insights, it is evident that addressing TL requires a comprehensive multi-level approach that integrates individual, organizational, and systemic interventions. At the individual level, fostering professional resilience and offering advanced education can empower nurses to navigate and mitigate the impacts of toxic behaviors. Organizational strategies, such as the development of clear feedback mechanisms, leadership training, and the cultivation of supportive workplace cultures, are essential to dismantle the systemic roots of TL. Moreover, healthcare systems must prioritize policy reforms that enforce accountability and promote ethical leadership standards. As claimed by [42], addressing TL requires awareness, accountability, and a commitment to building a healthier, more inclusive work environment. Future research is crucial to deepen our understanding of TL and to implement proper strategies to mitigate its impact on health care system safety and quality, as well as workforce sustainability.