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Toxic leadership and its relationship with outcomes on the nursing workforce and patient safety: a systematic review

Leodoro J. Labrague (Marcella Niehoff School of Nursing, Loyola University Chicago, Chicago, Illinois, USA)

Leadership in Health Services

ISSN: 1751-1879

Article publication date: 9 October 2023

Issue publication date: 18 March 2024




This study aims to appraise and synthesize evidence examining the effects of toxic leadership on the nursing workforce and patient safety outcomes.


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.


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.


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.



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.


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.



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