The dark side of nurse-manager leadership: toxic leadership behaviours, adverse-event reporting, and care quality—an interpretive descriptive study

Abstract

Background

Toxic nurse-manager leadership is a critical threat to patient safety, yet the mechanisms through which it suppresses adverse-event reporting remain under-theorized, particularly in high power-distance contexts where deference norms may constrain upward voice.

Aim

To generate practice-relevant, theory-informed explanations of how nurse-manager toxic leadership behaviours are perceived to shape adverse-event reporting dynamics and care quality within a high power-distance hospital setting.

Methods

An interpretive descriptive study was conducted in a Saudi Arabian hospital (March–August 2025). Methodological triangulation integrated semi-structured interviews with staff nurses (n = 26), nurse managers (n = 7), and quality officers (n = 2) (total N = 35), four non-managerial focus groups, and organisational document review. Analysis used a hybrid thematic approach guided by an integrated theoretical framework (Destructive Leadership, Theory of Planned Behavior, and Structure–Process–Outcome).

Results

Four interlocking themes emerged. Toxic leadership behaviours, including public humiliation/blame, intimidation, information gatekeeping, and perceived favouritism, were described as eroding psychological safety. These behaviours were perceived to constrain adverse-event reporting through concerns about retaliation, normalised concealment, and perceived futility linked to weak feedback loops and procedural filtering. Care quality was consequently perceived to be affected by defensive practice patterns, communication hesitation and delayed escalation, siloed teamwork, and reduced organisational learning. Hierarchical deference norms, weak accountability, and differential vulnerability among expatriate staff intensified these dynamics.

Conclusions

In this high power-distance setting, toxic nurse-manager leadership was perceived to contribute to a mutually reinforcing cycle of reporting suppression and silence that constrained reporting and was linked to perceived deterioration in care processes. Technical reporting infrastructures alone may be insufficient when psychological safety and leadership accountability are weak.

Implications for practice

Safety interventions should couple protected reporting pathways with robust leadership accountability and transparent feedback loops. Accreditation bodies may consider incorporating leadership climate and psychological safety as leading indicators alongside traditional patient safety metrics.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-026-04506-1.

Introduction

Effective nurse‑manager leadership is widely recognised as a decisive lever for patient safety, workforce stability, and organisational efficiency [1, 2]. Pooled cross‑sectional data from hospitals across four continents demonstrate that units headed by highly rated nurse managers report 23% fewer medication errors, 29% lower voluntary turnover, and a 0.3‑day reduction in mean length of stay compared with units under poorly rated leaders [3–5]. These outcomes have prompted accreditation agencies, including the Joint Commission and the Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI), to embed leadership metrics in their quality standards, confirming that managerial conduct is not a peripheral influence but a modifiable determinant of healthcare performance [6, 7].

Against this background, toxic leadership, the antithesis of supportive leadership, has emerged as a critical yet under‑examined threat [8, 9]. Consistent with Ofei et al. (2023), this study defines toxic leadership as a sustained pattern of abusive criticism, bullying, hostile communication, and authoritarian decision‑making that undermines subordinates’ well-being while serving the leader’s self‑interest [10]. Recent multinational surveys indicate that between one‑fifth and one‑third of registered nurses are exposed to at least one facet of such destructive behaviour annually [11, 12]. Prevalence appears to co‑vary with sociocultural context: only 15% of Norwegian nurses, working in a comparatively low power‑distance environment, report regular exposure, whereas 35% of Egyptian oncology nurses do so [13, 14]. In Saudi Arabia, Elsharkawy et al. (2025) found that nearly one‑third of nurses perceived their immediate supervisors as frequently exhibiting hostile communication, underscoring the magnitude of the problem in Gulf‑region settings [15].

One crucial mechanism by which toxic leadership undermines outcomes is the suppression of adverse‑event reporting, the voluntary disclosure of errors and near‑misses that fuels organisational learning [16, 17]. Evidence from Western, low-power-distance contexts shows that nurses working under transformational managers are up to six times more likely to file incident reports without fear of retaliation [18, 19]. By contrast, punitive or demeaning managerial styles can depress reporting rates by as much as 50%, allowing latent hazards to persist [20]. These effects are culturally contingent: under‑reporting attributed to fear of blame has been documented at 28% in Saudi public hospitals compared to only 12% in the United Kingdom, where non‑punitive “just‑culture” frameworks are firmly established [21]. This suppression has cascading effects: toxic leadership erodes perceived quality of care, defined as the nurses’ composite appraisal of safety climate, teamwork, and patient outcomes [22]. For instance, acute‑care units in Riyadh characterised by high destructive‑leadership scores perform 15% worse on Safety Attitudes Questionnaire domains than comparable units with low scores, whereas Canadian units operating in flatter hierarchies show only a 5% decrement [23, 24]. Such discrepancies suggest that hierarchical cultures may magnify the harmful consequences of destructive managerial conduct.

Despite these indications, the evidence base from the Middle East remains fragmentary, largely quantitative, and often lacks robust theoretical grounding [25, 26]. Most extant studies fail to integrate conceptual frameworks or explore how cultural norms and organisational structures interact with managerial behaviour to influence safety outcomes [27, 28]. Comparative work across regions is equally scarce, limiting the transferability of leadership interventions proven effective in low power‑distance systems [29]. Crucially, no prior investigation has qualitatively linked toxic leadership, adverse‑event reporting, and perceived quality of care within a single analytic frame in Saudi Arabia, leaving the causal pathways and contextual moderators poorly specified [24, 30]. The present study addresses these gaps by employing an interpretive-descriptive approach to explore how nurse-manager toxic leadership behaviors influence nurses’ willingness to report adverse events and how subsequent reporting dynamics affect the perceived quality of care.

Aim

To generate practice-relevant, theory-informed explanations of how nurse-manager toxic leadership behaviours are perceived to shape adverse-event reporting dynamics and care quality within a high power-distance hospital setting.

Research question

How are nurse-manager toxic leadership behaviours perceived to shape adverse-event reporting dynamics and nurses’ perceptions of care quality in a high power-distance hospital setting?

Objectives

1. To characterise the specific forms and manifestations of toxic leadership behaviours among nurse managers in the study setting.

2. To identify organisational and cultural conditions (e.g., hierarchy, accountability structures, employment precarity) that facilitate or inhibit adverse-event reporting under toxic leadership.

3. To explore how toxic leadership–reporting dynamics are perceived to shape unit-level care processes and overall perceived care quality.

By producing context-rich qualitative evidence anchored in an integrated framework (Destructive Leadership, Theory of Planned Behavior, Structure–Process–Outcome), this study advances nursing scholarship on leadership and safety culture in Gulf settings. Findings are intended to inform culturally attuned leadership development, strengthen protected reporting pathways and feedback loops, guide governance and accreditation metrics that reflect psychological safety, and support unit-level quality improvement that links managerial accountability with a safer care environment.

Theoretical framework

This study is informed by three complementary theoretical lenses, whose interrelationships are depicted in Fig. 1. First, Einarsen et al.’s (2007) Destructive Leadership Model provides a multidimensional account of leadership behaviours that may undermine employee well-being and organisational functioning, including intimidation, ridicule, and authoritarian decision-making [31]. Second, Ajzen’s (1991) Theory of Planned Behavior (TPB) guides examination of nurses’ adverse-event reporting intentions, proposing that intentions are shaped by attitudes toward reporting, subjective norms, and perceived behavioural control, and offering a basis for exploring how intentions may or may not translate into reporting practices under organisational constraints [32]. Third, Donabedian’s Structure–Process–Outcome (SPO) model offers a conceptual structure for interpreting how organisational conditions (structure, e.g., leadership climate and accountability), reporting and communication practices (process), and perceived care quality (outcome) may be linked [33].

Fig. 1.

Integrated theoretical framework: toxic leadership, reporting, and quality of care

Integrating these lenses, Fig. 1 maps theorised pathways through which toxic leadership behaviours may shape reporting intentions and reporting dynamics, and how these dynamics may relate to nurses’ perceptions of care quality within the study context. The framework guides the inquiry by aligning constructs with the study objectives and supporting systematic exploration of contextual moderators (e.g., hierarchy and employment precarity); however, theme development remains grounded in participants’ accounts, with theory used as a guide rather than an a priori constraint.

Materials and methods

Research design

This study employed an interpretive descriptive qualitative design within a constructivist–interpretivist stance and is reported in accordance with the COREQ checklist [34]. Interpretive description was selected to generate practice-relevant explanations by linking nurses’ accounts to sensitising theory while remaining open to inductive insights, rather than imposing a priori categories [34]. To strengthen credibility and support analytic convergence, we used methodological triangulation by integrating semi-structured individual interviews (across staff nurses, nurse managers, and quality officers), staff-nurse focus groups (to elicit shared norms and collective sense-making), and a structured review of organisational documents (e.g., incident-reporting policies, reporting workflows, and de-identified unit-level reporting summaries where available) [35]. Researcher positionality was managed through reflexive journaling across sampling, data collection, and analysis, informing iterative coding decisions and theme development.

Sampling and setting

The study was conducted at Hospital A, a mid-sized (≈ 400-bed) general-care hospital in western Saudi Arabia. The organisation operates within a hierarchical, centralised nursing line-management structure (head nurses → nursing supervisors → Director of Nursing), and uses an electronic incident-reporting platform embedded in routine practice. This setting enabled examination of how nurse-manager toxic leadership behaviours are perceived to intersect with adverse-event reporting dynamics and perceived care quality in a context where hierarchical relationships may shape speaking-up behaviour.

To support transferability, Hospital A is a public-sector Ministry of Health-affiliated facility, accredited by the Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI) and working toward Joint Commission International (JCI) standards. Typical nurse-to-patient ratios are approximately 1:4–6 on general medical/surgical wards and 1:2–3 in the intensive care unit. The nursing workforce is multicultural; approximately 62% of nurses are non-Saudi nationals, predominantly from South and Southeast Asia and Sub-Saharan Africa. These contextual descriptors are provided to assist readers in assessing analytic generalisability to comparable hierarchical, multicultural healthcare settings.

Purposive maximum-variation sampling was used to ensure heterogeneity across clinical areas (intensive care, medical, surgical, and orthopaedic units), roles (staff nurses, nurse managers, and quality officers), and key characteristics (e.g., nationality, tenure, and shift pattern).

Eligibility. Inclusion criteria were registered nurses employed at Hospital A for ≥ 1 year, nurse managers with ≥ 2 years of supervisory experience, and quality officers actively involved in adverse-event reporting processes. Exclusion criteria were probationary or temporary contracts and extended leave during the data-collection period.

Sample adequacy. Sample size was guided by information power, considering study aim, theoretical anchoring, sample specificity, dialogue richness, and analytic strategy, rather than a priori numbers [36]. Recruitment continued until adequacy was reached, operationalised as three consecutive data-collection events yielding no substantively new codes or refinements relevant to the research question [37]. Of 52 eligible staff identified, 35 consented and participated, while 17 declined participation or were excluded. Seven participants completed interviews only, and 28 contributed to both interviews and focus groups (no focus-group-only participants). The final analytic sample comprised 26 staff nurses, 7 nurse managers, and 2 quality officers, yielding 35 interview transcripts and 4 focus-group transcripts (Fig. 2).

Fig. 2.

Participant recruitment flow, data collection modalities, and final analytic sample (N = 35)

Data collection instruments

Data were generated using three qualitative instruments aligned with the integrated framework (Destructive Leadership, Theory of Planned Behavior, and Structure–Process–Outcome) (Supplementary File S1):

1. Semi-structured interview guide. A 15-item interview guide was developed from the three theoretical lenses to elicit experience-near accounts of: (a) nurse-manager toxic leadership behaviours, (b) adverse-event reporting intentions and decisions, and (c) perceived implications for care processes and care quality. Five experts (three qualitative nurse researchers and two senior healthcare professionals) reviewed the guide for content coverage, clarity, and cultural fit. Cognitive testing with nurses external to Hospital A further refined wording, sequencing, and probes to enhance comprehensibility and cultural appropriateness [38, 39].

2. Focus-group discussion protocol. Four homogeneous non-managerial focus groups were facilitated using a structured script and standardised vignettes depicting leadership and incident-reporting scenarios. Vignettes were used to surface shared norms, reduce personal disclosure risk, and enable candid discussion of sensitive topics. Moderator prompts explored convergence and divergence with interview findings and clarified emerging interpretations [40–42].

3. Document-analysis framework. A structured extraction matrix guided review of organisational documents relevant to leadership and adverse-event reporting at Hospital A (e.g., incident-reporting policies and procedures, reporting workflows, quality improvement policies, leadership appraisal tools, and de-identified unit-level reporting/quality dashboards). Extracted items captured policy language, reporting pathways, feedback mechanisms, and accountability signals to support triangulation with participant accounts [43, 44].

Procedure

Following ethical approval from the relevant institutional review board (IRB: H-02-K-076-0525-1343) and administrative permission, data collection proceeded from March to August 2025 in four phases:

Phase 1 – Recruitment and consent. Potential participants received written study information (aims, voluntariness, confidentiality, and withdrawal rights). Informed consent explicitly covered audio-recording and the use of de-identified quotations. To protect participants, given the sensitivity of the topic and hierarchical power dynamics, each interview began with a standardised statement emphasising voluntariness, the absence of employment implications, and the right to decline questions or withdraw without penalty. The principal investigator monitored for distress and could pause or discontinue the interview; participants were provided with information on available institutional support services at the end of each session. Written consent specified that non-participation or withdrawal would not affect employment status, performance evaluations, or workplace relationships, and that participation records would not be shared with supervisors or nursing administration. No interviews were terminated early, and no concerns about adverse workplace consequences were raised with the research team following participation.

Phase 2 – Semi-structured interviews were conducted by the principal investigator in private rooms with staff nurses, nurse managers, and quality officers (n = 35; interview-only n = 7; interview plus focus group n = 28). Interviews lasted 20–50 min (mean ≈ 35). Participants selected Arabic or English; interpretation support was available if required. Recordings were encrypted and transcribed verbatim. Arabic interviews were transcribed in Arabic and translated into English by a bilingual assistant; an independent bilingual assistant back-translated a random 20% subsample, with discrepancies reconciled by consensus. English transcripts were used for coding and analysis. The principal investigator documented field notes throughout interviews and focus groups, which were used alongside transcripts to inform early coding and memoing.

Phase 3 – Focus-group discussions. The principal investigator facilitated four non-managerial focus groups. Each session lasted 40–75 min. Ground rules (confidentiality and respect) were reiterated, and participants were informed of available support resources given the sensitivity of the topic.

Phase 4 – Organisational documents and records were reviewed using a predefined extraction framework. Reviewed materials included relevant policies/procedures, the reporting workflow flowchart, the quality improvement policy, the nursing leadership appraisal tool, unit-level reporting/quality dashboard summaries, and a de-identified incident-report data extract (January–December 2024). Descriptive indicators (e.g., reporting volume, classification patterns, and case disposition/closure pathways) were abstracted for contextual triangulation of qualitative themes during interpretation, not for causal inference.

Data analysis

Analytic approach and coding

Analysis followed an interpretive descriptive logic and used a hybrid thematic approach that integrated inductive coding with deductive, theory-informed interpretation mapped to the integrated framework (Destructive Leadership, Theory of Planned Behavior, and Structure–Process–Outcome) [45]. Interviews, focus-group transcripts, and document extracts were managed in NVivo 14. An initial coding framework was developed iteratively from early transcripts and sensitising concepts, with codes defined using brief descriptions and exemplar quotations. To calibrate code application and refine code definitions, two doctoral-level qualitative researchers independently coded a purposive subset of transcripts (25%). Differences were discussed in structured consensus meetings, resulting in a refined codebook (38 nodes) with explicit decision rules and examples. The remaining materials were coded by the lead analyst, supported by regular peer debriefing to test alternative interpretations, check coherence across roles/units, and reduce interpretive drift. Document extracts were coded within the same NVivo project and cross-referenced with interview and focus-group codes to corroborate, nuance, or problematise emerging patterns.

Theme development and theoretical integration

Theme development followed Braun and Clarke’s phases of thematic analysis (familiarisation, initial coding, searching for themes, reviewing themes, defining/naming themes, and producing the narrative) [46]. Constant comparison was used within and across participant groups (staff nurses, nurse managers, quality officers) to examine convergence, divergence, and role-specific nuance [47]. Themes were then interpreted through the integrated lenses: (i) toxic leadership behaviours (Destructive Leadership), (ii) determinants shaping reporting intentions and reporting actions (TPB: attitudes, subjective norms, perceived behavioural control), and (iii) links between organisational conditions, care processes, and perceived care quality (SPO). Data that did not initially fit emerging interpretations were revisited through negative-case analysis and iterative memoing until a contextually plausible account was achieved [48].

Rigour and trustworthiness

Rigour was addressed using Lincoln and Guba’s criteria [49]. Credibility was strengthened through methodological triangulation (interviews, non-managerial focus groups, and document review), participant triangulation across roles and units, iterative peer debriefing, and member reflections with a subset of participants to confirm factual accuracy and clarify emphasis. Transferability was supported by maximum variation sampling and thick description of the study context. Dependability and confirmability were supported via an audit trail (decision logs, codebook versioning, analytic memos) and reflexive journaling maintained throughout sampling, data collection, and analysis.

Data sufficiency

Data collection and analysis proceeded iteratively. Recruitment was concluded when successive interviews yielded no substantively new codes or refinements relevant to the research question, and when focus groups and document review did not materially alter the developing thematic structure.

Documentary triangulation using incident-report extracts

To contextualise qualitative interpretations, we extracted de-identified incident-report data from the hospital’s electronic reporting system for 1 January–31 December 2024. The extract included event date, clinical unit code, reporter role, and case disposition. The 2024 period was selected because it provided the most recent complete 12-month dataset available at the time of analysis, enabling stable annual summaries across units. Reporting indicators were summarised descriptively to compare patterns with qualitative themes and to support triangulation rather than causal inference. Unit-level comparisons were interpreted cautiously and only when interview representation was sufficient to support classification. For descriptive contextual grouping only, units were categorised as “toxic” when a predefined majority threshold (≥ 60%) of interviewed staff from that unit reported toxic leadership behaviours. Descriptive comparisons of reporting volumes were then used to contextualise qualitative accounts of reporting culture across these unit categories.

Ethical approval

The study received ethical approval from the relevant Ministry of Health Institutional Review Board (IRB No. H-02-K-076-0525-1343). The board determined that the study was exempt; nevertheless, all participants provided informed consent prior to data collection. Consent procedures covered confidentiality and de-identification, voluntary participation, audio recording, and the right to withdraw at any time without consequences. Institutional permission was obtained from Hospital A’s nursing administration and quality department. The study was conducted in accordance with the Declaration of Helsinki and ICH-GCP ethical principles. Data were de-identified at transcription, stored on encrypted and access-restricted drives, and retained for five years before secure destruction in accordance with applicable institutional policy [50, 51].

Results

This section integrates 35 semi-structured interviews, four staff-nurse focus groups (all focus-group participants also completed interviews), and organisational documents. Findings triangulate perspectives from 26 staff nurses, 7 nurse managers, and 2 quality officers. The analysis identified four interlocking themes describing how nurse-manager toxic leadership behaviours were perceived to shape adverse-event reporting dynamics and nurses’ perceptions of care quality (Fig. 3).

Fig. 3.

Integrated conceptual framework illustrating the perceived influence of toxic nurse-manager leadership

Participant characteristics

Participants represented surgical, medical, intensive care, orthopaedic, and other units and had 2–25 years of professional experience across roles (Table 1). Among staff nurses, 61.5% (16/26) reported witnessing at least one reportable incident in the prior year; however, 38.5% (10/26) reported submitting no incident reports during the same period. This discrepancy served as an early descriptive signal of under-reporting and was elaborated in Theme 2.

Table 1.

Demographic and professional characteristics of participants (N = 35)

Characteristic	Staff Nurses (n = 26)	Nurse Managers (n = 7)	Quality Officers (n = 2)
Age (years)
Mean (SD)	32.7 (5.4)	41.3 (6.2)	39.5 (4.9)
Range	25–48	35–53	36–43
Gender, n (%)
Female	23 (88.5)	5 (71.4)	1 (50.0)
Male	3 (11.5)	2 (28.6)	1 (50.0)
Nationality, n (%)
Saudi	10 (38.5)	3 (42.9)	1 (50.0)
Filipino	8 (30.8)	2 (28.6)	0 (0.0)
Egyptian	3 (11.5)	2 (28.6)	1 (50.0)
Other	5 (19.2)	0 (0.0)	0 (0.0)
Experience (years)
Mean (SD)	8.3 (4.1)	16.2 (5.8)	12.5 (3.5)
Range	2–20	10–25	10–15
Department, n (%)
Surgical	9 (34.6)	2 (28.6)	N/A
Medical	6 (23.1)	2 (28.6)	N/A
Intensive Care	5 (19.2)	1 (14.3)	N/A
Orthopaedic	4 (15.4)	1 (14.3)	N/A
Other	2 (7.7)	1 (14.3)	N/A
Incident reports submitted in the past year (staff nurses only), n (%)
None	10 (38.5)	N/A	N/A
1–3	12 (46.2)	N/A	N/A
> 3	4 (15.4)	N/A	N/A

Key themes and subthemes

Four themes with interrelated sub-themes were developed. To enhance transparency, Table 2 reports the number (and proportion) of participants within each role group who mentioned each sub-theme. These counts indicate salience across accounts and are not intended as statistical prevalence.

Table 2.

Prevalence of themes and sub‑themes across participant groups (N = 35)

Theme → Sub-theme	Staff Nurses n (%)	Nurse Managers n (%)	Quality Officers n (%)
1. Manifestations of toxic leadership
1.1 Public humiliation and blame attribution	18 (69.2)	4 (57.1)	1 (50.0)
1.2 Intimidation and threat deployment	17 (65.4)	3 (42.9)	1 (50.0)
1.3 Information withholding and gatekeeping	16 (61.5)	5 (71.4)	2 (100)
1.4 Cultural bias and favoritism	15 (57.7)	2 (28.6)	1 (50.0)
2. Barriers to adverse-event reporting under toxic leadership
2.1 Fear of retaliation and scapegoating	19 (73.1)	3 (42.9)	2 (100)
2.2 Normalised concealment and informal workaround	18 (69.2)	2 (28.6)	1 (50.0)
2.3 Lack of actionable feedback and perceived futility	17 (65.4)	5 (71.4)	2 (100)
2.4 Bureaucratic hurdles and managerial filtering	15 (57.7)	3 (42.9)	1 (50.0)
3. Perceived impacts on care quality
3.1 Defensive practice patterns	20 (77.0)	4 (57.1)	2 (100)
3.2 Communication breakdowns and delayed escalation	18 (69.2)	4 (57.1)	2 (100)
3.3 Teamwork erosion and siloed care	17 (65.4)	3 (42.9)	1 (50.0)
3.4 Organisational learning failure and recurrence of incidents	16 (61.5)	3 (42.9)	2 (100)
4. Contextual conditions shaping these dynamics
4.1 Hierarchical power structures and norms of deference	19 (73.1)	5 (71.4)	2 (100)
4.2 Weak leadership accountability mechanisms	17 (65.4)	4 (57.1)	2 (100)
4.3 Employment precarity and differential vulnerability among expatriate staff	16 (61.5)	3 (42.9)	1 (50.0)
4.4 Competing institutional priorities and performative compliance pressures	15 (57.7)	4 (57.1)	2 (100)

Detailed thematic analysis

Theme 1: Manifestations of toxic leadership

Across roles, toxic leadership was described as a patterned leadership style that reduced psychological safety and shaped what nurses felt was “safe” to say or document. Participants consistently linked these behaviours to a climate of fear and heightened risk sensitivity, particularly when incidents might reflect poorly on leaders or units.

Public humiliation and blame attribution

Staff nurses described public criticism as a repeated managerial practice occurring in visible clinical spaces (e.g., during rounds). Public blame was understood as a warning signal to the wider team, creating anticipatory fear rather than corrective learning:

During the doctor’s round and in front of the patients, she raised her voice, shouting and berating her staff. One of the nurses was crying. This wasn’t constructive; it was humiliating. (Nurse 8).

When something goes wrong, there’s no private conversation. It becomes a public spectacle. This fosters a culture of fear rather than learning (Nurse 3)

Participants emphasised that humiliation did not remain confined to interpersonal harm; it recalibrated unit norms so that errors became reputational threats, shaping later reporting decisions (Theme 2) and defensive care practices (Theme 3).

Intimidation and threat deployment

Threats were described as explicit (e.g., contract termination) and implicit (e.g., reputational labelling reflected in evaluations). These behaviours were perceived to leverage formal managerial tools to enforce compliance and silence.

Some managers threaten contract termination, while others threaten disciplinary action, which instils fear and silences nurses. (Nursing Manager1).

Performance evaluations are weaponized. If you’re labeled difficult, which usually means you speak up about problems, your evaluation will reflect it, regardless of your clinical competence. (Nurse 7).

These accounts portray intimidation as both a relational tactic and a structural mechanism, in which evaluation systems became linked to the willingness to speak up.

Information withholding and gatekeeping

Participants described selective dissemination of updates, training opportunities, and operational information. Gatekeeping was interpreted as reinforcing dependency and control, and was described as having direct implications for error risk when staff learned of changes only after mistakes occurred:

There’s an inner circle that receives updates and training opportunities first. If you’re not part of it, you learn about changes after you’ve already made errors. (Nurse 22).

We often find no response to our complaints… and sometimes critical updates only after errors occur. (Nurse Manager 3)

Nurses framed information withholding as particularly unsafe because it simultaneously increased the probability of error and the likelihood of blame when errors occurred.

Cultural bias and favoritism

Preferential treatment was described as influencing who felt protected versus scrutinised, and language practices were described as sometimes being used to exclude or disadvantage some staff:

Favoritism is obvious; some nationalities receive protection, while others are constantly criticized. (Nurse 17).

Language becomes a weapon. If your Arabic or English isn’t perfect, managers will deliberately speak quickly during important announcements, then blame you for misunderstanding. (Nurse 16)

Participants characterised these dynamics as shaping perceived vulnerability, which later intersected with fear of retaliation and employment precarity (Theme 4).

Theme 2: Barriers to adverse-event reporting under toxic leadership

Participants described adverse-event reporting as a high-risk behaviour within a climate where blame, retaliation, and perceived futility were salient. Barriers were not confined to individual reluctance; they were described as being reinforced by unit norms, managerial control over reporting pathways, and weak feedback loops.

Fear of retaliation and scapegoating

Fear of negative consequences was repeatedly described as the dominant deterrent. Staff nurses described weighing reporting against potential career and workload consequences, while quality officers described patterns of post-report changes experienced by reporters:

Most staff are afraid of filing a complaint against my boss because of the potential consequences for my future at work, so we won’t file the complaint. (Nurse 6)

Those who report often fear negative consequences and changes in their work. (Quality Officer 2)

This fear functioned as a behavioural constraint: reporting was perceived to trigger personal risk without assurance of organisational protection.

Normalised concealment and informal workaround

Participants described informal “fix and move on” practices, especially for near misses or incidents without visible harm, framed as safer than formal reporting in a punitive environment.

We have an unofficial system: if the patient wasn’t harmed, we fix the problem quietly and move on. It’s safer for everyone. (Nurse 21)

Informal practices of hiding incidents became standard to avoid trouble. (Nurse 19)

These workarounds were described as protective for staff, but also as diverting learning away from formal systems designed to identify recurrent hazards.

Lack of actionable feedback and perceived futility

Participants across roles described limited feedback after reporting and little visibility of change. In this context, reporting was experienced as effortful, risky, and often unrewarded.

I have filed complaints about the administrative issue. …. later, nothing had changed… What’s the point of the reporting system? (Nurse 3)

There’s no transparency about what happens after a report is filed. If we could see that our reports actually led to positive changes, more nurses would participate. (Nurse 14)

These accounts indicate that reporting was evaluated not only by risk but also by perceived effectiveness, weak feedback loops reduced motivation, and non-reporting was normalised.

Bureaucratic hurdles and managerial filtering

Participants described procedural obstacles in reporting workflows and expressed concern that reports implicating leadership or systemic issues could be delayed, altered, or effectively suppressed.

Sometimes reports disappear from the system or no response, especially if they implicate certain individuals or highlight systemic problems. (Nurse 19)

Sometimes, the manager reviews the reports before they’re submitted to quality. Reports that might reflect poorly on leadership are ‘revised’ or delayed until they’re no longer relevant. (Quality Officer 1)

Organisational documents and reporting summaries were used to contextualise these accounts and to examine alignment between stated policy and perceived practice, rather than to attribute causality.

Theme 3: Perceived impacts on care quality

Participants connected toxic leadership and constrained reporting to perceived deterioration in care quality through four mechanisms: defensive practice, communication strain, reduced teamwork, and impaired organisational learning. These mechanisms were described as operating through daily care processes and were experienced as cumulative rather than episodic.

Defensive practice patterns

Staff nurses described behaviours oriented toward self-protection (e.g., over-documentation, avoidance of initiative) as adaptive responses to blame climates. These strategies were perceived to reduce time and cognitive bandwidth for patient-centred care.

I’ve stopped suggesting alternative approaches that might benefit patients because of toxic leaders… and of course, it could affect the quality of care…. (Nurse 17)

We document everything to protect ourselves. I spend time writing notes that don’t improve patient care but might shield me from blame later. (Nurse 15)

Defensive practice was thus described as a trade-off: reduced exposure to criticism at the cost of diminished flexibility and responsiveness in care delivery.

Communication breakdowns and delayed escalation

Participants described fear of criticism as inhibiting escalation and contributing to incomplete or delayed communication, with perceived implications for timely intervention.

I’ve witnessed nurses hesitate to inform about changes in patient condition because our manager previously criticized them for ‘unnecessary escalation.’ These delays directly impact patient outcomes. (Nurse 21)

Vital patient care details… aren’t shared in a timely manner due to heavy workload. (Quality Officer 1).

These accounts describe a climate in which communication was filtered through anticipated managerial response, not solely by clinical need.

Teamwork erosion and siloed care

Participants described reduced cross-unit and within-unit support, with nurses avoiding involvement in situations that might later attract blame. This resulted in perceived fragmentation of care.

Departments operate in silos. No one wants to help each other because if something goes wrong, no one wants to be involved. (Nurse 1)

Cross-departmental collaboration has virtually disappeared… ‘That’s your problem, not ours.’ Patients suffer from this fragmentation. (Nurse 9)

Teamwork was described as replaced by risk-avoidant boundary-setting, which was experienced as particularly harmful for complex patients requiring coordinated care.

Organisational learning failure and recurrence of incidents

Participants described repeated incidents and limited systems-level learning, attributing this to a cycle in which blame reduced reporting, which in turn limited root-cause learning.

Repeated incidents occur because we never address the underlying causes. (Nurse 22)

Each case was treated as an isolated incident, with individual nurses blamed. The possibility of a systemic issue was never investigated. (Nurse 17)

Document review was used to triangulate on whether the reporting pathways, feedback mechanisms, and accountability signals described in the policy were reflected in participants’ lived experience.

Theme 4: Contextual conditions shaping these dynamics

Participants described four contextual conditions that intensified fear, constrained reporting, and reinforced the persistence of toxic leadership behaviours. These conditions aligned with the hierarchical organisational context described in the setting.

Hierarchical power structures and norms of deference

Hierarchy was described as shaping the perceived social acceptability of questioning decisions or escalating concerns upward.

Questioning authority is culturally unacceptable here, amplifying toxic behaviour… (Nurse 18)

Hierarchy dictates silence; expressing concerns upwards is seen as disrespectful. (Nurse 14)

Participants framed hierarchy as both organisational structure and social norm, constraining speaking up even when clinical risk was perceived.

Weak leadership accountability mechanisms

Participants described limited safe pathways to report manager misconduct and few visible consequences for harmful leadership behaviours.

Leadership evaluations overlook staff wellbeing entirely, and managers face no consequences. (Quality Officer 1)

There’s no safe way to report manager misconduct; accountability is nonexistent. (Nurse 6)

This governance gap was perceived as normalising toxic conduct and weakening trust in reporting and complaint mechanisms.

Employment precarity and differential vulnerability among expatriate staff

Participants described expatriate vulnerability as shaping reporting calculations, particularly when employment or residency was perceived as contingent.

Expat nurses fear that reporting incidents is simply too risky. (Nurse 3)

I’ve seen foreign nurses deported, raising serious concerns… the message to the rest of us was unmistakable. (Nurse 10).

Employment precarity amplified the perceived personal cost of reporting and reinforced norms against reporting.

Competing institutional priorities

Participants described perceived tensions between quality/metrics and deeper safety culture work, interpreting these priorities as shaping what was visibly rewarded and what remained unaddressed.

Our hospital is enhancing quality…. That’s why we need to follow the protocol and policy to maintain staff stability and quality of care. (Nurse 19)

The organization allocated some programs to visible problems that might affect the quality of care, not to the underlying cultural issues…. (Nurse 14)

These accounts positioned organisational priorities as indirectly shaping the reporting climate by signalling which issues were “safe” to surface.

Integrated conceptual framework

Synthesising these findings yielded an integrated conceptual account linking perceived toxic leadership behaviours (Theme 1) with adverse-event reporting dynamics (Theme 2) and perceived care quality (Theme 3), shaped by contextual conditions (Theme 4). In this account, humiliation, threats, information gatekeeping, and perceived favouritism reduced psychological safety and increased the anticipated cost of reporting. Reporting avoidance was reinforced through fear of retaliation, normalised concealment, weak feedback loops, and perceived procedural filtering. These reporting dynamics were perceived to relate to care quality through defensive practice, constrained communication, reduced teamwork, and limited organisational learning. Hierarchical norms, weak accountability, employment precarity, and competing institutional priorities were described as sustaining conditions that intensified these mechanisms and contributed to their persistence over time.

This conceptual framework expands existing leadership theory by identifying culturally contingent mechanisms through which toxic leadership affects patient outcomes in a high-power-distance healthcare environment. It also provides a pragmatic foundation for future leadership training and patient safety interventions.

Discussion

This interpretive descriptive study examined how nurses in a high power-distance hospital context perceived links between nurse-manager toxic leadership behaviours, adverse-event reporting dynamics, and care quality. Across interviews, staff-nurse focus groups, and organisational documents, participants described a self-reinforcing pattern in which humiliation, intimidation, information gatekeeping, and perceived favouritism reduced psychological safety and increased the anticipated personal cost of speaking up. In turn, adverse-event reporting was described as constrained by concerns about retaliation, normalised concealment, weak feedback loops, and workflow filtering. These reporting dynamics were then perceived to shape care quality through defensive practice, communication hesitation, weakened teamwork, and limited organisational learning. The findings extend current discussions on destructive leadership by articulating mechanisms that are plausibly intensified in hierarchical settings, where deference norms and accountability gaps may constrain upward voice.

Toxic leadership manifestations in a high power-distance context

Participants described four recurring manifestations of toxic leadership: public humiliation and blame attribution, intimidation and threat deployment, information withholding/gatekeeping, and cultural bias/favouritism, consistent with destructive leadership theory, while specifying how these behaviours were enacted in day-to-day clinical work. Public humiliation was repeatedly framed as a social signal that shaped team norms, conveying that mistakes are reputational threats rather than learning opportunities [52, 53]. In hierarchical contexts, such public correction may carry heightened relational consequences, thereby magnifying its silencing effects. Information gatekeeping was also prominent across accounts and roles and was interpreted as a control strategy that created dependencies and inequitable access to updates, training, and operational changes. In clinical environments, these asymmetries were perceived to increase the risk of error and intensify blame dynamics when incidents occurred [54]. Participants further described nationality-linked favouritism and language-based exclusion as compounding vulnerability within a multicultural workforce, suggesting that destructive leadership may intersect with informal power hierarchies that extend beyond formal rank [55].

Adverse-event reporting under toxic leadership

Adverse-event reporting was consistently framed as a high-risk behaviour under toxic leadership conditions. Participants described concerns about retaliation (e.g., workload changes, shift allocation, reputational labelling) as shaping whether incidents were documented formally or managed informally [56]. A second mechanism was the normalisation of concealment and workaround practices, particularly for near misses or events perceived as low harm, which participants interpreted as a pragmatic strategy to avoid blame while maintaining operational flow. A third constraint was perceived futility due to weak feedback loops; when reports were not followed by visible action or communication, reporting was described as effortful and risky, with no meaningful benefit [57]. Finally, participants raised concerns about workflow and governance features that could function as “filters” (e.g., managerial review prior to escalation), which were experienced as limiting transparency and reducing confidence in procedural fairness. Documentary review and de-identified reporting extracts were used to contextualise these perceptions, indicating patterns compatible with suppressed reporting in units categorised as having higher toxicity signals; these patterns are interpreted as triangulating descriptors rather than evidence of causality [58, 59].

Perceived implications for care quality

Participants linked constrained reporting and a blame-oriented climate to deterioration in care processes that underpin perceived care quality. Defensive practice patterns were described as reallocating time and attention toward self-protection (e.g., documentation, avoidance of initiative), potentially reducing responsiveness and discretionary clinical judgement [60, 61]. Communication breakdowns were described as hesitation to escalate concerns or incomplete sharing of information, shaped by anticipated criticism rather than clinical urgency alone. Teamwork erosion was defined as risk-avoidant siloing, with reduced willingness to assist across staff and units when involvement could attract blame. Finally, organisational learning was perceived to be compromised when incidents were treated as isolated individual failures rather than opportunities for systems-level improvement [62]. In combination, these mechanisms provide a plausible process account consistent with the Structure–Process–Outcome lens, through which leadership climate may propagate into everyday care processes and influence nurses’ global appraisals of care quality [63].

The current findings align with the broader conceptualization of psychological safety, established as the shared belief that reporting errors or speaking up will not result in punishment. Although previous nursing research suggests that hierarchical structures often suppress staff voice despite the presence of formal reporting systems, this study extends the existing literature by illustrating how high power-distance contexts intensify these dynamics through unique sociocultural and structural factors [64]. By identifying the compounding influence of ingrained deference norms, the specific vulnerability of expatriate nursing staff, and a lack of robust leadership accountability, this work highlights critical suppression mechanisms that are frequently absent from the predominantly Western evidence base [65].

Contextual conditions shaping these dynamics

Four contextual conditions were consistently invoked as intensifiers: hierarchical power structures and norms of deference, weak leadership accountability, employment precarity (particularly for expatriate staff), and competing institutional priorities. Hierarchy was described as shaping the social acceptability of questioning decisions and raising concerns, thereby amplifying the silencing effects of intimidation and public blame [66, 67]. Weak accountability mechanisms were described as limiting safe channels for reporting manager misconduct and reducing confidence that concerns would be addressed without retaliation. Employment precarity was described as producing differential vulnerability, with expatriate nurses interpreting reporting as carrying greater personal risk. Participants also described tensions between visible performance targets and deeper safety culture work, interpreting institutional priorities as signalling which issues were “safe” to raise and which were likely to be minimised [68].

Theoretical contributions

The integrated framework offers three contributions. First, it operationalises destructive leadership in a clinical context by specifying behavioural manifestations that are perceived to influence psychological safety and voice. Second, it refines the Theory of Planned Behavior by illustrating how organisational conditions and leadership climate may disrupt translation of intention into action (the intention–behaviour gap), particularly when perceived behavioural control is constrained by retaliation risk and reporting pathway filters [31]. Third, it extends the SPO logic by detailing how leadership climate (structure) is perceived to shape reporting and communication practices (process), with downstream implications for perceived care quality (outcome). Importantly, the framework foregrounds feedback loops that may sustain these dynamics over time, helping explain why isolated technical fixes (e.g., anonymous systems without credible protection) may be insufficient.

Practical implications

The findings suggest that strengthening patient safety in hierarchical settings requires integrated strategies that address leadership behaviour, accountability, and protected reporting pathways simultaneously. Leadership development should explicitly target public blame practices, intimidation, and information gatekeeping, and be paired with governance mechanisms that enable upward voice without retaliation. Reporting systems should be coupled with credible protection, transparent feedback loops, and, where feasible, a clear separation between reporting pathways and managerial control [69]. In multicultural workforces, interventions should also attend to differential vulnerability (e.g., expatriate job insecurity and language-based exclusion) to prevent stratified safety cultures. Accreditation and quality programs may benefit from incorporating indicators of psychological safety and leadership accountability as leading measures alongside traditional safety metrics that can be distorted by under-reporting [70].

Specifically, leadership development programmes should: (1) explicitly address public blame practices, intimidation, and information gatekeeping through structured just-culture leadership modules using case-based learning from the clinical context; (2) institutionalise 360-degree feedback mechanisms that include subordinate input, given that current appraisal systems were perceived to exclude staff perspectives entirely; (3) train nurse managers in constructive error-response communication, specifically distinguishing system-oriented root-cause analysis from individual blame attribution; and (4) introduce bystander intervention and allyship training to create peer-level protective norms against toxic behaviour. In multicultural workforces, these interventions should explicitly attend to differential vulnerability, including expatriate employment precarity and language-based exclusion, to prevent stratified safety cultures in which some staff feel categorically less protected than others [71].

Strengths and limitations

Key strengths include multi-source triangulation (interviews, focus groups, organisational documents), role diversity, maximum-variation sampling across units, and explicit theoretical integration. However, the study has limitations. It was conducted in a single hospital, which may limit transferability; nonetheless, thick description supports analytic generalisation to similar hierarchical contexts. The documentary and incident-report extracts were used descriptively for triangulation, and do not permit causal inference or definitive unit-to-unit comparisons. Social desirability and identification concerns may have shaped disclosures despite confidentiality protections. Finally, the cross-sectional qualitative design captures perceptions at a single point in time and cannot establish temporal ordering among leadership behaviours, reporting dynamics, and care quality.

Future research

Future work should test the proposed pathways across multiple sites and organisational types and evaluate interventions that combine leadership accountability reforms with protected reporting structures and transparent feedback loops. Longitudinal or realist-informed evaluations could examine how shifts in leadership climate influence reporting behaviour over time. Research focused on expatriate and multilingual staff could clarify how employment precarity and language norms interact with voice and safety behaviours [72].

Conclusion

In this high-power-distance hospital context, nurses described toxic nurse-manager leadership behaviours as perceived to shape psychological safety and adverse-event reporting dynamics, with perceived downstream implications for care quality, including defensive practice, communication constraints, erosion of teamwork, and limited organisational learning. These findings suggest that improving safety in hierarchical settings requires integrated approaches that couple leadership accountability with protected reporting pathways and credible feedback mechanisms, rather than relying solely on reporting infrastructure.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

CBAHI

Saudi Central Board for Accreditation of Healthcare Institutions

COREQ

Consolidated Criteria for Reporting Qualitative Research

ICH-GCP

International Council for Harmonisation – Good Clinical Practice

IRB

Institutional Review Board

SD

Standard Deviation

SPO

Structure–Process–Outcome

TPB

Theory of Planned Behavior

Author contributions

Mohammed Alshmemri conceptualized the study, designed the methodology, collected the data, conducted the analysis, interpreted the findings, and drafted and revised the manuscript.

Funding

Not applicable.

Data availability

The datasets generated during this study are available from the corresponding author upon reasonable request, subject to institutional policies, ethical approvals, and participant confidentiality requirements. Data sharing will adhere to relevant regulatory frameworks and may require appropriate data transfer agreements.

Declarations

Ethics approval and consent to participate

The study received ethical approval from the Ministry of Health Institutional Review Board, Makkah, Saudi Arabia (IRB-Makkah; IRB No. H-02-K-076-0525-1343. All procedures complied with ICH-GCP and the 1964 Helsinki Declaration and its subsequent amendments, or comparable ethical standards. Written informed consent was obtained from all participants prior to data collection.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.