Ofei et al. BMC Nursing (2023) 22:374 BMC Nursing https://doi.org/10.1186/s12912-023-01539-8 R E S E A R C H Open Access Toxic leadership behaviour of nurse managers and turnover intentions: the mediating role of job satisfaction Adelaide Maria Ansah Ofei1, Collins Atta Poku1,2*, Yennuten Paarima1, Theresa Barnes1 and Atswei Adzo Kwashie1 Abstract Introduction Globally, hospitals are confronted with major challenges of turnover of nurses. Knowledge of the factors that account for the turnover of nurses will aid in creating strategies that will enhance nurse managers’ leadership behaviour and job satisfaction to reduce turnover. The study, therefore, investigated the mediating role of job satisfaction on toxic leadership and turnover intentions of nurses. Methods A multi-centre cross-sectional study was undertaken to assess 943 nurses using the Toxic-leadership Behaviour of Nurse Managers scale, Minnesota Satisfaction Questionnaire and Turnover Intention scale. Descriptive statistics was used to assess the prevalence of toxic leadership, job satisfaction and turnover and Pearson’s correlation examined the relationships between the variables. Hayes’ PROCESS macro approach of mediation was used to determine the effect of toxic leadership behaviour on the turnover intention on the possible influence of job satisfaction. Results The response rate for the study was 76.0%. Mean scores for turnover intentions and toxic leadership behaviour were 3.71 and 2.42 respectively. Nurses who work with toxic managers showed a higher propensity to leave their jobs. Job satisfaction acted as a mediator between the toxic leadership practices of managers and turnover intentions. The total effect of toxic leadership behaviour on turnover intention comprised its direct effect (β = 0.238, SE = 0.017, 95% CI [0.205, 0.271]) and its indirect effect (β = -0.020, SE = 0.017). Conclusions Job satisfaction acted as a mediating factor for toxic leadership behaviour and nurses’ turnover intentions. As part of nurse retention initiatives, avoiding toxic leadership behaviours will be the ultimate agenda. Nurse administrators should recognize the value of excellent leadership and develop a structured training programme through the use of evidence-based professional development plans for nurse managers. Keywords Job satisfaction, Nurse managers, Toxic leadership behaviour, Turnover intentions, Ghana *Correspondence: Collins Atta Poku attapokucollins@yahoo.com; capoku@knust.edu.gh 1School of Nursing and Midwifery, University of Ghana, Legon-Accra, Ghana 2Department of Nursing, Kwame Nkrumah University of Science and Technology, PMB, University Post Office, Kumasi, Ghana © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Ofei et al. BMC Nursing (2023) 22:374 Page 2 of 10 Introduction between the manager and the subordinate is terminated The phenomenon of negative leadership in organiza- or ends, or until the follower modifies their behaviour. tions has been labelled in literature as “toxic leadership,“ Most followers, however, continue to be in toxic relation- “dark side of leadership,“ and “abusive leadership” [1–4]. ships because they depend on abusers [16]. It eventu- The rise in interest in toxic leadership started when early ally creates serious issues at work, leading to a variety of research found that the failure of leadership is brought on behaviours like bullying, violence, hostility, and rudeness, by a variety of causes. Researchers highlighted how the among others, which are linked to detrimental psycho- role of the leader’s problematic dispositions impacted the logical effects like diminished self-efficacy [17, 18]. administrative process [5, 6]. In recent times, nursing professionals are becoming Toxic leadership is a term used to describe leaders who increasingly concerned about the phenomena of abu- exhibit abusive, manipulative, and destructive behaviour sive leadership in healthcare organizations [19–21], as towards their subordinates, which can ultimately harm toxic work culture has become a common issue. In high- their well-being and the organization’s success. These income countries (HICs), nurse managers’ (NMs) toxic leaders often prioritize their interests and goals over the leadership styles have been reported to have a deleteri- needs of their team or organization, and they may use ous impact on the standard of patient care. Working in fear, intimidation, or other forms of coercion to achieve a toxic environment contributed to nurses’ engaging in their objectives. They also display narcissistic tendencies, unproductive work habits, and expressing a greater desire meaning they are excessively self-centred and believe to quit their job [22]. Many research findings have also they are superior to others. They may be insensitive to emphasized the negative effects of working with a toxic the feelings and concerns of their team members and dis- manager on staff and patient well-being, safety, and the miss feedback or criticism from them. They may also cre- overall standard of care [23, 24]. ate a culture of fear, where employees are afraid to speak Toxic leadership compromises organization’s ideals and up or offer suggestions for fear of retribution [7, 8]. legitimate interests; and these diminish staff morale, self- Directing attention to toxic leadership, several esteem, and motivation [25]. The organization’s value sys- researchers have highlighted the role it plays in relation- tem is harmed by the toxic environment, making workers ships between leaders and followers, and organizational less sensitive to others and decreasing employee engage- outcomes. The effects of toxic leadership can be damag- ment, with consequences of lack of commitment, job dis- ing to both individuals and the organization as a whole. satisfaction [26] and turnover intention [27]. While the employees may experience stress, burnout, Job satisfaction is an essential nursing job outcome, and mental health issues due to the negative work envi- which is influenced by the standard of the workplace. ronment created by the toxic leader, there can also be a It is a multifaceted phenomenon that describes a pleas- cascading result in higher turnover rates, lower produc- ant emotional sense resulting from the evaluation of the tivity, and decreased morale [9–11]. The extreme intoxi- work or job experience. Staff feel content if their effort cation of leaders in most work environments has spread a produces significant results, which leads to job satisfac- poison of negativity among individuals in organizations, tion. Additionally, staff who report higher job satisfaction and researchers are concerned about how leaders have feel good about their jobs, tasks, duties, or work Despite lost all sense of purpose and have become so drunk on the extensive study on job satisfaction, there are still sub- their power that they are unable to see where this detour stantial levels of nurses’ job dissatisfaction [28, 29]. The is leading organizations [8, 12]. NM frequently has an impact on the support and moti- Toxic leadership, for instance, is centred on leaders’ vation that nurses require to perform their duties. Orga- self-interest rather than the collective gain and well-being nizations need to recognize the signs of toxic leadership of followers. Thus, it jeopardizes the “calling” or prosocial and take steps to address them. This can include pro- essence of the nursing profession. Although inappropri- viding training and support for leaders to develop more ate behaviour by those in leadership or supervisory posi- positive leadership styles, holding toxic leaders account- tions may have significant costs for nurses and patients able for their behaviour, and creating a culture of respect [13, 14], toxic leadership has not been the topic of con- and collaboration within the organization. NMs must siderable research in the nursing field. also establish workplace climates that boost morale and According to Ghislieri and Gatti [15], along with also demonstrate leadership that inspires subordinates. Machiavellianism and psychopathy, the so-called “dark This will eventually increase nurses’ sense of respect, triad” of personality traits also includes narcissism (a trust, and motivation as well as their level of satisfaction component of toxic leadership). Toxic leaders create an to gradually achieve the organization’s ultimate goal [30, organizational environment characterized by abuse of 31]. authority to manipulate subordinates which may be ver- There is a reported association between nurse job sat- bal or non-verbal. It may last until the official association isfaction and work environment; thus job satisfaction Ofei et al. BMC Nursing (2023) 22:374 Page 3 of 10 is influenced by the nature of the workplace; the pace, a Given the shortage of nurses in LMICs, particularly in proportionate workload, relationships with teammates, sub-Saharan Africa, the lack of adequate information on career opportunities, and the capacity to meet patients’ the influence of toxic leadership on nursing job outcomes requirements [32]. To address the significant issues of such as staff turnover is problematic. It is more signifi- standardized care, patient outcomes, and nursing job cant than ever to assess the impact of toxic leadership outcomes in healthcare organizations, job satisfaction is behaviour of NMs on turnover intention in the nursing essential [33, 34]. It is, however, well acknowledged that profession or organization as mediated by job satisfac- effective nursing leadership is the driving force for fos- tion given the rising number of nurses who want to quit tering positive outcomes of job satisfaction and turnover and the high cost of hiring experienced nurses. The out- intention. come of the study may aid in the creation of strategies This concern of turnover is brought up in the context to enhance nurse managers’ leadership behaviour and of the workforce, which occurs when individuals leave job satisfaction, thereby decreasing nurse turnover. The their jobs or professions because they do not enjoy where study, therefore, investigated the mediating role of job they work [35, 36]. Thus, an employee may have a state satisfaction on toxic leadership and turnover intentions of mind known as “turnover intention” if they are deeply of nurses. unhappy at work. The strongest indication for forecast- ing employee turnover behaviour is typically thought to Materials and methods be turnover intention or intentions to quit [37–39]. From Study design and participants an organizational standpoint, turnover intentions result A multi-centre cross-sectional design was used for the in financial loss because it causes increased absenteeism study. The design was chosen because it can offer quick and turnover, and affects employee productivity due to a evidence for relationships between variables and because shift in attitude towards their jobs and their well-being researchers were interested in assessing the perception [40, 41]. of nurses on toxic leadership behaviour among NMs and The identified financial impact of turnover on health- their turnover intention. Ghana is divided into 16 admin- care settings is significant, as most healthcare sectors istrative regions, each with its unique cultural, geograph- have used financial and non-financial incentives to ical, and economic characteristics. These 16 regions are encourage nurses to stay on and also recruit new ones, distributed among the three ecological belts in Ghana, but these initiatives need significant resources and time. including coastal (Greater Accra, Volta, Central, Western Averagely, organizations lose more than US $23  billion and Oti regions), middle (Ashanti, Ahafo, Eastern, Bono, as a result of employees quitting their jobs, consequently Bono East and Western North regions), and northern forcing the closure of facilities; and this is mostly attrib- (Northern, Savannah, North-East, Upper East and Upper uted to the toxic workplace [8, 42]. West regions). The study was undertaken in 12 hospitals The subject of toxic leadership has become more preva- randomly selected from 6 regions in Ghana. The popula- lent and ubiquitous in nursing and healthcare professions tion of the nursing workforce in the selected hospitals is in low-middle-income countries (LMICs). Although estimated to be 1716. All participants who had at least a there is a lot of evidence connecting the toxic environ- year of working experience in public health facilities were ment to poor work outcomes among nurses, the litera- selected as participants. ture has not adequately projected how these behaviours disrupt nursing job processes. The majority of studies, Sampling and sample size thus, focus on the positive side of leadership and patient A sample size of 1240 participants was calculated using and nursing job outcomes [43]. Only a few studies have Cochran’s technique [50]. The participants were cho- examined the impact of toxic leadership behaviours on sen using a multistage sampling technique. A list of all subordinate-leader relationships based on the toxic lead- regions was used as the basis for sampling due to their ership behaviour taxonomy [44, 45]. In these studies, we range of experiences, perspectives, or behaviours to have gained a better understanding of how toxic lead- enhance the external validity or generalizability of your ers’ maladjusted, malcontent, and malevolent behaviour findings. Two regions each were randomly selected from affects personal and organisational development. Health each belt (6 regions in all). Two hospitals each were workers in Ghana, for instance, have complained about selected from six [6] regions (12 hospitals) to represent poor working conditions and leadership [46], as more the population. Regional hospitals in each of the six than 20% of all nurses have reported the presence of toxic regions were purposely selected while a district hospi- leadership in healthcare facilities [47, 48]. Toxic leader- tal was randomly selected from the 6 regions. The ran- ship behaviour of nurse managers has been cited as a domization was done using random number generators. contributing factor to nurses’ increased absenteeism and In the 12 selected hospitals, a proportionate stratified turnover or otherwise [49]. sample based on the nursing workforce enrolment was Ofei et al. BMC Nursing (2023) 22:374 Page 4 of 10 assigned to each hospital. The participants were conve- points) were the interpretations of the ToxBH-NM com- niently selected from the hospitals from each shift within posite score. When the sub-scale composite mean is the units. Table  1 presents the population and sample higher, it signifies that toxic leadership behaviour is more size for each site used for the study. prevalent. The Cronbach alpha for the ToxBH-NM scale as reported was 0.88. In previous studies, the scale also Method of data collection indicated a satisfactory reliability coefficient score of at Formal and ethical approvals were sought from the vari- least 0.70 [2, 52, 53]. ous hospitals’ management and the review board respec- tively. Communication with participants was established Job satisfaction of nurses and data collection was initiated with the assistance Nurses’ job satisfaction was assessed using the Minne- of the NMs and the ward in-charge from September to sota Satisfaction Questionnaire (MSQ-short version) December 2021. The questionnaire was in English lan- [54]. The scale had 20 items and a Likert-type scale with guage and the researchers administered it themselves. a range of 1 to 5 (very dissatisfied-1 and very satisfied-5). The study’s participants voluntarily joined the study, and The composite score of all items is divided into 1.0–3.0 they were made aware of their right to withdraw from the (low satisfaction), 3.1-4.0 (moderate satisfaction, and study. The study’s potential benefits and risks were also 4.1-5.0 (high satisfaction). Satisfactory reliability coeffi- discussed before participants signed an informed written cients range from 0.85 to 0.91 in previous research that consent form. The researchers collected the completed employed this scale [55–58]. questionnaires from the participants. Turnover intentions Measures Nurses’ intention to quit their current job and/or pro- The Turnover Intention (TIS-6), Minnesota Satisfaction fession was assessed using a 6-item TIS [59]. The scale Scale (MSQ) and the Toxic Leadership Behaviours of is measured with a Likert scale between 1 = Never to Nurse Managers’ Scale (ToxBH-NM) were the three self- 7 = Most of the time. A composite mean score of ≥ 3.5 report scales used. indicated a higher turnover intention of the nurse. The Reliability Coefficient of the scale was 0.80 [60]. Toxic leadership behaviour of nurse managers The ToxBH-NM scale with a 30-item was used [51]. Data analysis The scale has four sub-dimensions of toxic leadership - Using SPSS software version 26, descriptive and infer- humiliating behaviour (3 items), intemperate behaviour ential statistics were used to analyze the data. While (15 items), narcissistic behaviour (9 items), and self-pro- means, percentages, and standard deviations were used moting behaviour (3 items) was used to measure nurses’ to describe the data, Pearson Moment Correlation was perceptions of the toxic leadership behaviours of NMs. A used to assess the relationship between the variables. Likert scale with five possible ratings was used (1 - not at Mediation analysis was also undertaken using Hayes’ all and 5 - All the time). Non-toxic (1.0–2.2 points), mod- PROCESS macro (Model 4, version 4.2) to examine the erately toxic (2.3–3.6 points), and highly toxic (3.7–5.0 impact of toxic leadership behaviour and job satisfaction on turnover intentions. Hayes’s mediation approach is a powerful analytical method that has been recommended Table 1 Number of Participants by Hospitals (n = 1240) for nursing research [61, 62]. It is a percentile bootstrap- Hospitals Popula- Calculated Response % of the total ping process whereby the sample distribution is resam- tion of (expected) rate (% of population in nurses sample size sample size) the study pled 5000 times to calculate mediation effects at a 95% Site 1 238 172 138 (80.2%) 14.6 Confidence Interval (CI). Statistically significant variables Site 2 194 140 92 (65.7%) 9.8 in univariate analysis were included as covariates (age, Site 3 181 131 95 (72.5%) 10.1 highest qualification and duration at the facility): Toxic Site 4 125 90 71 (78.9%) 7.5 leadership behaviour as an independent variable (X); Site 5 146 106 83 (78.3%) 8.7 job satisfaction as a mediator variable (M); and turnover Site 6 115 83 64 (77.1%) 6.8 intention as a dependent variable (Y). The macro allows Site 7 152 110 75 (68.2%) 8.0 calculating and testing the direct effect, the total effect, Site 8 104 75 61 (81.3%) 6.5 and the indirect effect. The indirect effect is consid- Site 9 162 117 98 (83.8%) 10.4 ered statistically significant if zero is not included in the Site 10 107 77 62 (80.5%) 6.6 reported CI. All study variables were tested for multicol- Site 11 91 66 48 (72.7%) 5.1 linearity and a p-value < 0.05 was considered statistically Site 12 101 73 56 (76.7%) 5.9 significant. Total 1716 1240 943 (76.0%) 100 Ofei et al. BMC Nursing (2023) 22:374 Page 5 of 10 Table 2 Socio-demographic characteristics of the participants participants; confidentiality and anonymity were also Socio-demographic data N=943 % Mean SD ensured. Participants were made aware of their right to Age 30 4.43 withdraw in the course of the study when the need be. Gender Male 265 28.1 Results Female 678 71.9 Demographic data and nurses’ job characteristics Marital status With a sample size of 1240, a total of 943 fully answered Married 398 42.2 questionnaires were recovered from participants (76.0% Unmarried 545 57.8 response rate). The mean age of the participants was Highest qualification 30 (SD:4.43) years. Moreover, half of the participants Certificate 263 27.9 (n = 267, 57.8%) were single and women made up more Diploma 487 51.7 than two-thirds of the participant population (n = 678, Degree 172 18.2 71.9%). Close to a third of the participants (n = 286, or Masters 21 2.2 30.3%) constituted staff nurses, and nearly half (n = 487, Rank or 51.7%), and 50.5% (n = 469) had worked at their cur- Enrolled Nurse (Snr/Prin. EN) 269 28.5 Staff Nurse/Snr Staff Nurse 486 51.6 rent facility for at least five years. Participants’ sociode- Nursing Officer 121 21.8 mographic and job characteristics details are shown in Senior Nursing Officer 67 7.1 Table 2. Duration at facility Less than 2 years 108 11.4 Toxic leadership behaviour, job satisfaction and turnover 2–4 years 359 38.1 intentions 4 years and more 469 50.5 The results of the perception of toxic leadership behav- iours among NMs, job satisfaction, and nurses’ turnover Table 3 Toxic Leadership Behaviour, Job Satisfaction and intention are shown in Table 3. The mean score for toxic Turnover Intention of Nurses leadership behaviour of NMs was 2.42 (SD: 1.39); the Scale/Subscales Com- SD subscale measuring narcissistic behaviour had a compos- posite ite mean score of 2.53 (SD: 1.36) followed by humiliating Mean behaviour (M: 2.49, SD: 1.45), Intemperate behaviour (M: Toxic Leadership behaviour 2.42 1.39 2.40, SD: 1.36), and self-promoting behaviour (M: 2.27, Intemperate behaviour 2.40 1.35 SD: 1.38). The composite mean score of nurses’ job satis- Narcissistic behaviour 2.53 1.36 faction and turnover intentions were 2.75 (SD = 0.99) and Self-promoting 2.27 1.38 4.71 (SD = 1.56) respectively. behaviour Job Satisfaction Humiliating behaviour 2.49 1.45 Relationship between job satisfaction, turnover intentions Turnover Intention 2.75 0.99 4.71 1.56 and perception of toxic leadership behaviour of NMs Using Pearson’s moment product correlation, the asso- ciation between the toxic leadership behaviour of NMs, Ethical considerations turnover intentions, and job satisfaction were measured According to the Helsinki Declaration, ethics was as presented in Table  4. A significant positive relation- sought from the Noguchi Memorial Institute of Medi- ship was established between the turnover intention cal Research of the University of Ghana (NMIMR-IRB of nurses and scores on the various dimensions of toxic CPN 010/21–22). Before administering the question- leadership behaviour; narcissistic behaviour (r = .383, naire, written informed consent was requested from all p < .01), self-promoting behaviour (r = .483, p < .01), Table 4 Correlation between Toxic Leadership Behaviour, Turnover Intentions, and Job Satisfaction Correlations 1 2 3 4 5 6 7 1. Turnover Intentions 1 2. Job Satisfaction − .146* 1 3. Narcissistic Behaviour .383* − .490* 1 4. Self-Promoting Behaviour .483* − .139* .594* 1 5. Humiliating Behaviour .336* − .481* .879* .575* 1 6. Intemperate behaviour .368* − .551* .936* .515* .863* 1 7. Toxic Leadership Behaviour .406* − .517* .977* .634* .911* .980* 1 *p < .01 Ofei et al. BMC Nursing (2023) 22:374 Page 6 of 10 Table 5 Results of Mediation analysis Paths Estimate SE t p-value 95% CI R2 TLB→JS − 0.2494 0.0138 -18.0637 0.0000 (-0.2766, -0.2223) 0.5267 JS→TIs 0.0805 0.0403 1.9967 0.0462 (0.0014, 0.1595) 0.4455 TL→TIs 0.2379 0.0170 14.0348 0.0000 (0.2046, 0.2712) 0.4416 Indirect effect Effect Boot SE Boot LLCI Boot ULCI TLB→JS→Tis − 0.0201 0.0114 − 0.0436 − 0.0019 Toxic Leadership Behaviour; TLB, Turnover Intentions; TIs, Job Satisfaction; JS, bootstrap standard error; Boot SE, variance accounted for; R2, lower limit confidence interval; LLCI, standard error; SE, upper limit confidence interval; ULCI by job satisfaction (estimate for b = 0.2379, SE = 0.0170, 95% CI [0.2046 to 0.2712]). Discussion This study augments the corpus of data on NMs’ toxic leadership and nurses’ turnover intention in Ghana. This study assesses the role of toxic leadership on turnover intention among staff nurses as mediated by job satisfac- tion. Nurses’ job satisfaction declines as toxic leadership behaviour occurs more frequently. The turnover inten- tion (to leave the profession or organization) follows a decline in job satisfaction. It has also been empirically Fig. 1 The impact of toxic leadership behaviour on turnover intentions: the mediating role of job satisfaction proven that this link exists [63–65]. Meanwhile, the study Mediation model explaining the relationship between Toxic Leadership reported a higher turnover intention among nurses; and Behaviour (TLB) and Turnover Intentions (TIs) among nurses through Job is consistent with a study among nurses in China [63], the Satisfaction (JS) (in Table 5). N = 943; controlled for age, highest qualifica- US [66, 67], Saudi Arabia [68] and the Philippines [69]. A tion and duration at the facility; a = direct effect of TLB on JS; b = direct possible explanation for this phenomenon is the rise in effect of JS on TIs; c = total effect of TLB on TIs; c1 = direct effect of TLB on TIs. *p < .05, **p < .001 social demand for nurses. Nurses require greater atten- tion if they are to have lesser intentions of leaving their humiliating behaviour (r = .336, p < .01), intemperate jobs. behaviour (r = .368, p < .01), and toxic leadership behav- This study finding is consistent with what was reported iour (r = .406, p < .01). A negative significant correlation in Egypt with nurses perceiving their managers as mod- was noted between job satisfaction and turnover inten- erately toxic [70], though low to no toxic leadership tions (r = − .146, p < .01) and toxic leadership behaviour behaviour has been reported in parts of the world [52, (r = − .517, p < .01). 71]. These findings on the specific predictors of turnover intentions should provide helpful information for hospi- Impact of toxic leadership behaviour and job satisfaction tal and nursing leaders when implementing interventions on turnover intention to improve job satisfaction and retain nurses. This is a The mediation role of toxic leadership behaviour and job disappointing conclusion given the relative role of lead- satisfaction on turnover intention is detailed in Table 5. ership in creating and promoting nursing work environ- Toxic leadership behaviour had a significantly negative ments that empower nurses and advance nursing job and association with job satisfaction (estimate for a = -0.2494, patient outcomes [52, 72, 73]. SE = 0.0138, 95% CI [-0.2799 to -0.2223]). Also, job sat- Additionally, nurses have a moderately negative per- isfaction had a positive association with turnover inten- ception of the toxic leadership behaviours of NMs, sug- tion (estimate for c = 0.0805, SE = 0.0403, 95% CI [0.0014 gesting that nurse managers are likely to engage in such to 0.1595]). The total indirect effect of toxic leadership behaviours. Conspicuously, the mean score of all sub- behaviour on turnover intentions was statistically signifi- scales falls into the moderate category. The results are cant (b= -0.0201, SE = 0.0114, 95% CI [-0.0436 to -0.0019]. consistent with other studies that noted NM’s toxic lead- The bootstrapped CI for the indirect effect was below ership behaviour to be poor [74, 75]. This outcome is sig- zero, suggesting a statistically significant mediation nificant in light of the negative effects that having NMs effect. The model (Fig.  1) demonstrated that the nega- who practice toxic leadership can have on the organiza- tive relationship between toxic leadership behaviour and tion and its staff. turnover intention was statistically significantly mediated The significant consequence of toxic leadership of NMs on nursing job outcomes, particularly, turnover Ofei et al. BMC Nursing (2023) 22:374 Page 7 of 10 intentions was perhaps the most important finding of satisfaction can mediate the relationship between toxic this study. Nurses who work with NMs who exhibited leadership behaviour and turnover intentions. When toxic leadership behaviours expressed a greater desire nurses are satisfied with their jobs, they may be less likely to quit their jobs and or even their profession. A similar to leave their jobs, even in the face of toxic leadership position was reported in Canada by Lavoie-Tremblay et behaviour. Conversely, when nurses are dissatisfied with al. [22] who reported that nurses indicated a higher turn- their jobs, they may be more likely to leave, even in the over intention when they observed more toxic leadership absence of toxic leadership behaviour. The mediation of practices. By establishing a connection between toxic job satisfaction on the relationship between toxic lead- leadership behaviours and nurses’ intentions to leave the ership behaviour of managers and turnover intentions profession through the lens of job satisfaction, this study of nurses, therefore, highlights the importance of creat- adds new knowledge to the field of nursing, principally in ing a positive work environment that supports nurses’ the areas of nursing management. job satisfaction and retention. Organizations can do this The negative impacts of toxic leadership behaviours by promoting positive leadership behaviours, providing by NMs on nurses’ work attitudes were more or less opportunities for professional development and growth, anticipated and consistent with the literature. Intem- and fostering a culture of respect, trust, and collabora- perate, humiliating, narcissistic, and self-promotion tion [34, 85, 86]. behaviour are frequently used by toxic leaders, which results in job dissatisfaction, productivity as well as a Implications lack of motivation for their jobs [34], frequent absentee- The finding of the study is an indication that organi- ism [76], and increased turnover intentions [77]. This zational measures to overcome nurse turnover should finding supported earlier research showing that a toxic include tackling toxic leadership practices. To reduce or leader’s actions and behaviours, which were primarily avoid toxic behaviours among NMs, some of the most motivated by personal interests to advance their growth important interventions are education, training, and pro- and advancement, had a significant negative impact on fessional development. The structured leadership devel- nurses’ level of job satisfaction, which ultimately led to opment training modules should be a priority of every turnover [78–80]. healthcare organization. The training will help nurse Accordingly, there was a positive correlation between managers to acquire the skills and knowledge needed to toxic leadership behaviours and intentions to leave the lead effectively. This may include training in communica- organization. As a way to reduce turnover, a potential tion, conflict resolution, emotional intelligence, and other institutional measure in the form of a development plan key leadership competencies. for effective leadership practices among NMs through Again, organizations should foster a positive organiza- training, and policy formulation should be instituted to tional culture by promoting values such as respect, trust, lessen the incidence of toxic leadership behaviours. and transparency. When these values are ingrained in A considerable amount of research has been done on the culture of an organization, it is less likely that toxic the level of job satisfaction among nurses in several coun- leadership behaviour will be tolerated or encouraged. tries, although further studies are needed in West Africa Nurse leaders can effectively build a positive workplace and Ghana. According to our study, nurse job satisfaction culture by staying up to date on the most recent research is low in Ghana. We found that our results were almost on effective leadership practices. Moreover, healthcare similar to what we found among nurses in Ethiopia [81], managers must encourage open communication by cre- Kenya [82] and Ghana [83]. In Ghana, however, job sat- ating channels for employees to provide feedback and isfaction among nurses has been studied extensively, but express their concerns. When employees feel that their not concerning toxic leadership behaviour. voices are being heard and their opinions are valued, they Job satisfaction acts as a buffer against the negative are more likely to report toxic behaviour and seek help effects of toxic leadership on nurses’ turnover inten- when needed. Every organization should make it stan- tions. Several studies have shown that toxic leadership dard practice to have a zero-tolerance policy intended to behaviour can have a significant impact on nurses’ job reduce toxic behaviours at work and a clear policy that satisfaction and turnover intentions. Toxic leaders can sets behaviour expectations for all staff. Therefore, a create a negative work environment that causes stress, leadership assessment tool may be used by recruitment burnout, and low morale among nurses, and in turn, can teams tasked with finding competent NM candidates to lead to reduced job satisfaction and increased turnover screen and identify leaders who can help the organiza- intentions [27, 52, 84]. When nurses are satisfied with tion accomplish its goals. By gathering feedback from their jobs, they are more likely to be committed to their the members of the health team, a leader evaluation uti- organizations, have higher levels of productivity, and lizing a suitable method may help understand the lead- experience less stress and burnout. Consequently, job er’s performance and leadership needs. Programs such Ofei et al. BMC Nursing (2023) 22:374 Page 8 of 10 as mentoring and coaching for new NMs may also be ensure nurse retention and improve the overall quality of beneficial. patient care, healthcare institutions must cultivate a posi- Additionally, the improvement of NMs’ leadership tive and supportive leadership culture that promotes job behaviour and the advancement of their professional satisfaction. It is important that toxic leadership behav- growth may be possible through the pursuit of higher iours are addressed and that a nurturing work environ- education and the acquisition of essential training. ment is promoted as part of healthcare management and Training courses for learning healthy ways to man- leadership strategies. This can be achieved through train- age emotions should be encouraged to effectively avoid ing on professional development and implementation exhibiting toxic behaviours. The construction and devel- of leadership reform strategies to derail toxic leadership opment of strong leadership styles in the future nursing behaviours among NMs. workforce depend on nurse education at the graduate level, which emphasizes the need for successful leader- List of abbreviationsHICs H igh-income countries ship as well as techniques to improve leadership compe- JS J ob Satisfaction tencies. Not only does toxic leadership behaviour impact LMICs Low-middle-income countries on turnover of nurses, but it also has negative effects on MSQ Minnesota Satisfaction QuestionnaireNMs Nurse Managers the quality of care and patient safety [23, 32, 87]. TIS Turnover Intention Scale ToxBH NM-Toxic Leadership Behaviour of Nurse Managers Limitations Acknowledgements The methodology utilized in this study makes it difficult The authors sincerely thank all nurses who participated in the study. to establish causality. By examining nurses’ perceptions of their leaders, we evaluated the toxic leadership prac- Authors’ contributionsA.M.A.O., C.A.P., T.B., and Y.P. conceptualized and designed the study method. tices of NMs. Based on the type of relationship between A.M.A.O., C.A.P., A.A.K., Y.P. and T.B. collected, analysed and interpreted the data. the NMs and their subordinates, this strategy may pres- A.M.A.O. and C.A.P. drafted the original manuscript. All authors read, revised, ent a socially desired response. However, the likelihood and approved the final manuscript for submission. of obtaining skewed responses was decreased by using Funding a multi-stage sampling technique and a sizable sample No funding was received for this study. (n = 943). Although nurses’ views about the toxic lead- Data Availability ership behaviour of NMs may significantly influence All data generated or analyzed during this study are included in this published turnover intentions, other factors such as the workplace article. environment, the presence of collegiate nurse-physicians relation, the adequacy of resources, and nurses’ participa- Declarations tion in decision-making may also be possible mediators; Ethics approval and consent to participate future studies should therefore focus on employing other According to the Helsinki Declaration, ethics was sought from the Noguchi designs such as mixed-method or observational designs Memorial Institute of Medical Research of the University of Ghana (NMIMR-IRB to comprehensively analyse the leadership behaviour CPN 010/21–22). Before administering the questionnaire, written informed consent was requested from all participants; confidentiality and anonymity of NMs and other associated characteristics that affect were also ensured. Participants were made aware of their freedom to the nursing workforce. Once the baseline data from this withdraw in the course of the study when the need be. study has been used to suggest future directions, investi- Consent for publication gating other detrimental contributions of toxic leadership Not applicable. by NMs, such as absenteeism, workplace violence, inci- vility, and adverse patient outcomes should be studied. Competing interestsThe authors declare no competing interests. Conclusion Received: 27 November 2022 / Accepted: 26 September 2023 The study has produced new insight into nursing lead- ership and administration. In terms of their leadership styles, nurses often evaluated their NMs as being mod- erately toxic. This position supports earlier studies that found a link between the toxic leadership behaviour of References NMs and poor nursing job outcomes, especially, the 1. Liu D, Liao H, Loi R. The dark side of leadership: a three-level investigation of the cascading effect of abusive supervision on employee creativity. Acad turnover intention of leaving the profession or post. Manage J. 2012;55(5):1187–212. Nurse managers’ toxic leadership behaviour harms 2. Matos K, O’Neill O, Lei X. Toxic leadership and the masculinity contest nurse turnover intentions, mediated by job satisfaction, culture: how win or die cultures breed abusive leadership. J Soc Issues. 2018;74(3):500–28. underscoring the critical importance of addressing lead- 3. Whicker ML. Toxic leaders: when good organizations go bad. New York: ership dynamics within healthcare organizations. To Greenwood; 1996. Ofei et al. BMC Nursing (2023) 22:374 Page 9 of 10 4. Winkler I. Contemporary leadership theories: enhancing the understanding 29. Wang KY, Chou CC, Lai JCY. A structural model of total quality management, of the complexity, subjectivity and dynamic of leadership. Springer Science & work values, job satisfaction and patient-safety-culture attitude among Business Media; 2010. nurses. J Nurs Manag. 2019;27(2):225–32. 5. Son SY, Pak J. Enough is enough! The impact of core self-evaluation on the 30. Adams AMN, Chamberlain D, Giles TM. Understanding how nurse managers relationship between despotic leadership and individual outcomes. Rev see their role in supporting ICU nurse well-being—A case study. J Nurs Manag Sci. 2023;1–22. Manag. 2019;27(7):1512–21. 6. Spagnoli P, Manuti A, Buono C, Ghislieri C. The good, the bad and the blend: 31. McCauley L, Kirwan M, Riklikiene O, Hinno S. A scoping review: the role of the the strategic role of the middle leadership in work-family/life dynamics dur- nurse manager as represented in the missed care literature. J Nurs Manag. ing remote working. Behav Sci. 2021;11(8):112. 2020;28(8):1770–82. 7. Milosevic I, Maric S, Lončar D. Defeating the toxic boss: the nature 32. Boamah SA, Laschinger HKS, Wong C, Clarke S. Effect of transformational of toxic leadership and the role of followers. J Leadersh Organ Stud. leadership on job satisfaction and patient safety outcomes. Nurs Outlook. 2020;27(2):117–37. 2018;66(2):180–9. 8. Kılıç M, Günsel A. The dark side of the leadership: the effects of toxic leaders 33. Falatah R, Conway E. Linking relational coordination to nurses’ job satisfaction, on employees. Eur J Soc Sci. 2019;2(2):51–6. affective commitment and turnover intention in Saudi Arabia. J Nurs Manag. 9. Huang C, Du PL, Wu LF, Achyldurdyyeva J, Wu LC. Lin CSLeader–member 2019;27(4):715–21. exchange, employee turnover intention and presenteeism: the mediating 34. Specchia ML, Cozzolino MR, Carini E, Di Pilla A, Galletti C, Ricciardi W, et al. role of perceived organizational support. Leadersh Organ Dev J. 2021. Leadership styles and nurses’ job satisfaction. Results of a systematic review. 10. Naeem F, Khurram S. Influence of toxic leadership on turnover intention: Int J Environ Res Public Health. 2021;18(4):1552. the mediating role of psychological wellbeing and employee engagement. 35. Duffield CM, Roche MA, Homer C, Buchan J, Dimitrelis S. A comparative Naeem F Khurram S2020 Influ toxic leadersh turnover intent Mediat Role Psy- review of nurse turnover rates and costs across countries. J Adv Nurs. chol Wellbeing Empl Engagem pak. J Commer Soc Sci. 2020;14(3):682–713. 2014;70(12):2703–12. 11. Walker S, Watkins D. Shadows of leadership: the lived experiences of 36. Falatah R, Salem OA. Nurse turnover in the Kingdom of Saudi Arabia: an oppressed followers of toxic leaders. J Leadersh Account Ethics. 2020;17(2). integrative review. J Nurs Manag. 2018;26(6):630–8. 12. Coldwell DA. Negative influences of the 4th industrial revolution on the 37. Park J, Min HK. Turnover intention in the hospitality industry: a meta-analysis. workplace: towards a theoretical model of entropic citizen behaviour in toxic Int J Hosp Manag. 2020;90:102599. organizations. Int J Environ Res Public Health. 2019;16(15):2670. 38. Van der Heijden BI, Peeters MC, Le Blanc PM, Van Breukelen JWM. Job char- 13. Hofmeyer A, Taylor R. Strategies and resources for nurse leaders to use to acteristics and experience as predictors of occupational turnover intention lead with empathy and prudence so they understand and address sources and occupational turnover in the european nursing sector. J Vocat Behav. of anxiety among nurses practising in the era of COVID-19. J Clin Nurs. 2018;108:108–20. 2021;30(1–2):298–305. 39. Zhang H, Sun L, Zhang Q. How Workplace Social Capital affects turnover 14. Wang YX, Yang YJ, Wang Y, Su D, Li SW, Zhang T, et al. The mediating role of intention: the mediating role of job satisfaction and burnout. Int J Environ inclusive leadership: work engagement and innovative behaviour among Res Public Health. 2022;19(15):9587. Chinese head nurses. J Nurs Manag. 2019;27(4):688–96. 40. Labrague LJ. Organisational and professional turnover intention among 15. Ghislieri C, Gatti P. Generativity and balance in leadership. Leadership. nurse managers: a cross-sectional study. J Nurs Manag. 2020;28(6):1275–85. 2012;8(3):257–75. 41. Lee YH, Lee J, Lee SK. The mediating effect of workplace incivility on organiza- 16. Tiwari M, Jha R. Narcissism, toxic work culture and abusive supervision: a tion culture in South Korea: a descriptive correlational analysis of the turnover double-edged sword escalating organizational deviance. Int J Organ Anal. intention of nurses. J Nurs Scholarsh. 2022;54(3):367–75. 2021. 42. Holloway EL, Kusy ME. Disruptive and toxic behaviors in healthcare: zero 17. Abalkhail JM. Dysfunctional leadership: investigating employee experiences tolerance, the bottom line, and what to do about it. J Med Pr Manage. with dysfunctional leaders. Career Dev Int. 2022;(ahead-of-print). 2010;25(6):335–40. 18. Chaudhary A, Islam T. Unravelling the mechanism between despotic leader- 43. Dartey-Baah K, Quartey SH, Asante KG. Examining toxic leadership, pay sat- ship and psychological distress: the roles of bullying behaviour and hostile isfaction and LMX among nurses: evidence from Ghana. Ind Commer Train. attribution bias. Kybernetes. 2022;(ahead-of-print). 2023;55(3):388–401. 19. Crawford CL, Chu F, Judson LH, Cuenca E, Jadalla AA, Tze-Polo L, et al. An inte- 44. Agarwal UA. Examining links between abusive supervision, PsyCap, LMX and grative review of nurse-to-nurse incivility, hostility, and workplace violence: a outcomes. Manag Decis. 2018;57(5):1304–34. GPS for nurse leaders. Nurs Adm Q. 2019;43(2):138–56. 45. Ofei AMA, Paarima Y, Barnes T, Poku CA. Toxic leadership behaviour of nurse 20. Hartin P, Birks M, Lindsay D. Bullying and the nursing profession in Australia: managers on perceived job satisfaction and productivity of the nursing an integrative review of the literature. Collegian. 2018;25(6):613–9. workforce in sub-saharan Ghana: a multi-centre cross-sectional study. J Nurs 21. Labrague LJ, Lorica J, Nwafor CE, Cummings GG. Predictors of toxic leadership Manag. 2022;30(7):2733–42. behaviour among nurse managers: a cross-sectional study. J Nurs Manag. 46. Abuosi AA, Abor PA. Migration Intentions of nursing students in Ghana: 2021;29(2):165–76. implications for human Resource Development in the Health Sector. J Int 22. Lavoie-Tremblay M, Fernet C, Lavigne GL, Austin S. Transformational and Migr Integr. 2015;16(3):593–606. abusive leadership practices: impacts on novice nurses, quality of care and 47. Hassan Mekawy S, Ali Mohamed Ismail S. Effects of the toxic leadership intention to leave. J Adv Nurs. 2016;72(3):582–92. style of nurse managers on counterproductive work behaviors and inten- 23. Labrague LJ. Influence of nurse managers’ toxic leadership behaviours tion to quit among staff nurses: a comparative study. Egypt J Health Care. on nurse-reported adverse events and quality of care. J Nurs Manag. 2022;13(3):1466–81. 2021;29(4):855–63. 48. Hossny EK, Alotaibi HS, Mahmoud AM, Elcokany NM, Seweid MM, Aldhafeeri 24. Majeed M, Fatima T. Impact of exploitative leadership on psychological NA, et al. Influence of nurses’ perception of organizational climate and toxic distress: a study of nurses. J Nurs Manag. 2020;28(7):1713–24. leadership behaviors on intent to stay: a descriptive comparative study. Int J 25. Laguda E. Toxic leadership: managing its poisonous effects on employees Nurs Stud Adv. 2023;5:100147. and organizational outcomes. Palgrave Handb Workplace Well-Being. 49. Ofei AMA, Paarima Y. Nurse managers leadership styles and intention 2020;1–31. to stay among nurses at the unit in Ghana. Int J Health Plann Manage. 26. Rasool SF, Wang M, Tang M, Saeed A, Iqbal J. How toxic workplace environ- 2022;37(3):1663–79. ment effects the employee engagement: the mediating role of organiza- 50. Cochran WG. Sampling techniques. John Wiley & Sons; 1977. tional support and employee wellbeing. Int J Environ Res Public Health. 51. Labrague LJ, Lorica J, Nwafor CE, van Bogaert P, Cummings GG. Development 2021;18(5):2294. and psychometric testing of the toxic leadership behaviors of nurse manag- 27. Bakkal E, Serener B, Myrvang NA. Toxic leadership and turnover intention: ers (ToxBH-NM) scale. J Nurs Manag. 2020;28(4):840–50. mediating role of job satisfaction. Rev Cercet Si Interv Sociala. 2019;66:88. 52. Labrague LJ, Nwafor CE, Tsaras K. Influence of toxic and transformational 28. O’Hara MA, Burke D, Ditomassi M, Lopez RP. Assessment of millennial nurses’ leadership practices on nurses’ job satisfaction, job stress, absenteeism and job satisfaction and professional practice environment. JONA J Nurs Adm. turnover intention: a cross-sectional study. J Nurs Manag. 2020;28(5):1104–13. 2019;49(9):411–7. 53. Örgev C, Demir H. Toxic leadership in a public university hospital. J Int Health Sci Manag. 2019;5(8):48–63. Ofei et al. BMC Nursing (2023) 22:374 Page 10 of 10 54. Weiss DJ, Dawis RV, England GW. Manual for the Minnesota satisfaction 73. Wei H, Sewell KA, Woody G, Rose MA. The state of the science of nurse questionnaire. Minn Stud Vocat Rehabil. 1967. work environments in the United States: a systematic review. Int J Nurs Sci. 55. Abugre JB. Job satisfaction of public sector employees in sub-saharan Africa: 2018;5(3):287–300. testing the Minnesota satisfaction questionnaire in Ghana. Int J Public Adm. 74. Estes BC. Abusive supervision and nursing performance. Nursing forum. Wiley 2014;37(10):655–65. Online Library; 2013. 3–16. 56. Gulsen M, Ozmen D. The relationship between emotional labour and job 75. Low YM, Sambasivan M, Ho JA. Impact of abusive supervision on counterpro- satisfaction in nursing. Int Nurs Rev. 2020;67(1):145–54. ductive work behaviors of nurses. Asia Pac J Hum Resour. 2021;59(2):250–78. 57. Lakatamitou I, Lambrinou E, Kyriakou M, Paikousis L, Middleton N. The 76. Jin Y, Bi Q, Song G, Wu J, Ding H. Psychological coherence, inclusive leader- greek versions of the TeamSTEPPS teamwork perceptions questionnaire ship and implicit absenteeism in obstetrics and gynecology nurses: a multi- and Minnesota satisfaction questionnaire short form. BMC Health Serv Res. site survey. BMC Psychiatry. 2022;22(1):1–10. 2020;20(1):1–10. 77. Hadadian Z, Sayadpour Z. Relationship between toxic leadership and job 58. Olatunde BE, Odusanya O. Job satisfaction and psychological wellbeing related affective well-being: the mediating role of job stress. Eur Online J Nat among mental health nurses. Int J Nurs Didact. 2015;5(8):12–8. Soc Sci Proc. 2018;7(1 s):pp–137. 59. Roodt G. The turnover intention scale. Unpubl Doc Johannesbg Univ Johan- 78. Kim MH, Yi YJ. Impact of leader-member-exchange and team-member- nesbg. 2004. exchange on nurses’ job satisfaction and turnover intention. Int Nurs Rev. 60. Bothma CF, Roodt G. The validation of the turnover intention scale. SA J Hum 2019;66(2):242–9. Resour Manag. 2013;11(1):1–12. 79. Perry SJ, Richter JP, Beauvais B. The effects of nursing satisfaction and turn- 61. Hayes AF. Mediation, moderation, and conditional process analysis. Introd over cognitions on patient attitudes and outcomes: a three-level multisource Mediat Moderat Cond Process Anal Regres-Based Approach. 2013;1:20. study. Health Serv Res. 2018;53(6):4943–69. 62. Igartua JJ, Hayes AF. Mediation, moderation, and conditional process analysis: 80. Quek SJ, Thomson L, Houghton R, Bramley L, Davis S, Cooper J. Distributed concepts, computations, and some common confusions. Span J Psychol. leadership as a predictor of employee engagement, job satisfaction and turn- 2021;24:e49. over intention in UK nursing staff. J Nurs Manag. 2021;29(6):1544–53. 63. Liu W, Zhao S, Shi L, Zhang Z, Liu X, Li LI, et al. Workplace violence, job satis- 81. Gebregziabher D, Berhanie E, Berihu H, Belstie A, Teklay G. The relation- faction, burnout, perceived organisational support and their effects on turn- ship between job satisfaction and turnover intention among nurses in over intention among Chinese nurses in tertiary hospitals: a cross-sectional Axum comprehensive and specialized hospital Tigray, Ethiopia. BMC Nurs. study. BMJ Open. 2018;8(6):e019525. 2020;19(1):79. 64. Lo WY, Chien LY, Hwang FM, Huang N, Chiou ST. From job stress to intention 82. Tengah SA. Factors Influencing Job Satisfaction among Nurses in Public to leave among hospital nurses: a structural equation modelling approach. J Health Facilities in Mombasa, Kwale and Kilifi Counties, Kenya. Adv Soc Sci Adv Nurs. 2018;74(3):677–88. Res J [Internet]. 2019 May 31 [cited 2023 Sep 18];6(5). Available from: https:// 65. Senek M, Robertson S, Ryan T, King R, Wood E, Taylor B, et al. Determinants of journals.scholarpublishing.org/index.php/ASSRJ/article/view/6389 nurse job dissatisfaction-findings from a cross-sectional survey analysis in the 83. Afulani PA, Nutor JJ, Agbadi P, Gyamerah AO, Musana J, Aborigo RA, et al. UK. BMC Nurs. 2020;19(1):1–10. Job satisfaction among healthcare workers in Ghana and Kenya during the 66. Gandhi A, Yu H, Grabowski DC. High nursing staff turnover in nursing Homes COVID-19 pandemic: role of perceived preparedness, stress, and burnout. offers important quality information: study examines high turnover of nurs- PLOS Glob Public Health. 2021;1(10):e0000022. ing staff at US nursing homes. Health Aff (Millwood). 2021;40(3):384–91. 84. Brouwers M, Paltu A. Toxic leadership: Effects on job satisfaction, commit- 67. Kelly LA, Gee PM, Butler RJ. Impact of nurse burnout on organizational and ment, turnover intention and organisational culture within the south african position turnover. Nurs Outlook. 2021;69(1):96–102. manufacturing industry. SA J Hum Resour Manag. 2020;18(1):1–11. 68. Kaddourah B, Abu-Shaheen AK, Al-Tannir M. Quality of nursing work life and 85. Wong C, Walsh EJ, Basacco KN, Mendes Domingues MC, Pye DR. Authentic turnover intention among nurses of tertiary care hospitals in Riyadh: a cross- leadership and job satisfaction among long-term care nurses. Leadersh sectional survey. BMC Nurs. 2018;17(1):1–7. Health Serv. 2020;33(3):247–63. 69. Labrague LJ, De Los Santos JAA, Falguera CC, Nwafor CE, Galabay JR, Rosales 86. Kaffashpoor A, Sadeghian S. The effect of ethical leadership on subjective RA, et al. Predictors of nurses’ turnover intention at one and five years’ time. wellbeing, given the moderator job satisfaction (a case study of private Int Nurs Rev. 2020;67(2):191–8. hospitals in Mashhad). BMC Nurs. 2020;19(1):1–8. 70. Abou Ramadan A, Eid W. Toxic Leadership: conflict management style and 87. Al Omar M, Salam M, Al-Surimi K. Workplace bullying and its impact on the organizational commitment among intensive care nursing staff. Evid-Based quality of healthcare and patient safety. Hum Resour Health. 2019;17(1):1–8. Nurs Res. 2020;2(4):46–59. 71. Al-Yami M, Galdas P, Watson R. Leadership style and organisational commit- ment among nursing staff in Saudi Arabia. J Nurs Manag. 2018;26(5):531–9. Publisher’s Note 72. Boamah SA. Emergence of informal clinical leadership as a catalyst Springer Nature remains neutral with regard to jurisdictional claims in for improving patient care quality and job satisfaction. J Adv Nurs. published maps and institutional affiliations. 2019;75(5):1000–9.