The Dark Side of Nurse-Manager Leadership: Toxic Leadership Behaviours, Adverse-Event Reporting, and Care Quality—An Interpretive Descriptive Study

The Dark Side of Nurse-Manager Leadership: Toxic Leadership Behaviours, Adverse-Event Reporting, and Care Quality—An Interpretive Descriptive Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Dark Side of Nurse-Manager Leadership: Toxic Leadership Behaviours, Adverse-Event Reporting, and Care Quality—An Interpretive Descriptive Study Mohammed Alshmemri This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8549199/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Mar, 2026 Read the published version in BMC Nursing → Version 1 posted 10 You are reading this latest preprint version 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, nurse managers, and quality officers (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 self-reinforcing silence dynamic 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. Toxic leadership patient safety adverse-event reporting nursing management organisational culture interpretive description Figures Figure 1 Figure 2 Figure 3 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 those reporting dynamics subsequently 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 To characterise the specific forms and manifestations of toxic leadership behaviours among nurse managers in the study setting. To identify organisational and cultural conditions (e.g., hierarchy, accountability structures, employment precarity) that facilitate or inhibit adverse-event reporting under toxic leadership. 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 Figure 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]. Integrating these lenses, Figure 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. 2. Materials and Methods 2.1 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. 2.2 Sampling and Setting The study was conducted at Hospital A, a mid-sized (approximately 400-bed) general-care hospital in western Saudi Arabia, operating within a hierarchical organisational context consistent with high power-distance workplace norms and using an electronic incident-reporting platform integrated into 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. We used purposive maximum-variation sampling to capture heterogeneous experiences across clinical areas (intensive care, medical, surgical, and orthopaedic units), professional roles (staff nurses, nurse managers, and quality officers), and participant 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 engaged 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 the study aim, theoretical anchoring, sample specificity, dialogue richness, and analytic strategy rather than a priori numbers [ 36 ]. Recruitment proceeded until sufficiency 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 participated. Data-collection modalities were interview-only (n = 7), focus group-only (n = 0), and both interview and focus group (n = 28). The final dataset comprised 26 staff nurses, 7 nurse managers, and 2 quality officers (Fig. 2 ). 2.3 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): 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) 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 ]. 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 ]. 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 ]. 2.4 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. Phase 2 – Semi-structured interviews were conducted in private rooms by the principal investigator with staff nurses, nurse managers, and quality officers (n = 35; interview only n = 7; interview plus focus group n = 28). Sessions lasted 20–50 minutes (mean ≈ 35 minutes). Participants chose Arabic or English; interpretation support was available as needed. Audio files were encrypted, and recordings were transcribed verbatim. Phase 3 – Focus-group discussions. The principal investigator facilitated four non-managerial focus groups. Each session lasted 40–75 minutes. 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 were reviewed using the predefined extraction framework. Where available, descriptive indicators (e.g., reporting frequencies, classification patterns, and resolution pathways) were abstracted to contextualise qualitative themes and support triangulation during interpretation. 2.5 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 through 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. Reporting indicators were summarised descriptively to compare patterns with qualitative themes and to support triangulation, not causal inference. Unit-level comparisons were interpreted cautiously and only where interview representation was sufficient to support classification. Units were categorised as “toxic” when a majority threshold (≥ 60%) of interviewed staff from that unit reported toxic leadership behaviours. Descriptive comparisons of reporting volumes were used to contextualise the qualitative accounts of reporting culture across these unit categories. 2.6. 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]. 3. 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 (Figure 3). 3.1 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 3.2 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. 1.1 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). 1.2 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. 1.3 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. 1.4 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. 2.1 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. 2.2 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. 2.3 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. 2.4 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. 3.1 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. 3.2 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. 3.3 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. 3.4 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. 4.1 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. 4.2 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. 4.3 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. 4.4 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. 4. 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. 4.1 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]. 4.2 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]. 4.3 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]. 4.4 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 [64, 65]. 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 [66]. 4.5 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 [67]. 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. 4.6 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 [68]. 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 [69]. 4.7 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. 4.8 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 [70]. 5. Conclusion In this high-power-distance hospital context, nurses described toxic nurse-manager leadership behaviours as shaping 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. Abbreviations Abbreviation Definition 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 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. Availability of data and materials: 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. Competing Interests: The author declares that they have no competing interests, financial or non-financial. Funding: Not applicable. 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. Acknowledgments: Not applicable. Clinical trial number: Not applicable. References Alsadaan N, Mohamed O, Ramadan E. Barriers and facilitators in implementing evidence-based practice: a parallel cross-sectional mixed methods study among nursing administrators. 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Supplementary Files SupplementaryFileS1.pdf Cite Share Download PDF Status: Published Journal Publication published 03 Mar, 2026 Read the published version in BMC Nursing → Version 1 posted Editorial decision: Revision requested 17 Feb, 2026 Reviews received at journal 14 Feb, 2026 Reviews received at journal 08 Feb, 2026 Reviewers agreed at journal 07 Feb, 2026 Reviewers agreed at journal 05 Feb, 2026 Reviewers invited by journal 05 Feb, 2026 Editor assigned by journal 03 Feb, 2026 Editor invited by journal 26 Jan, 2026 Submission checks completed at journal 21 Jan, 2026 First submitted to journal 21 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8549199","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":587627253,"identity":"8b8591e2-02d5-499f-b47c-cefa50ec22bf","order_by":0,"name":"Mohammed Alshmemri","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYBACgwMMbGAGG3sDmGZsIKTFEq6F5wCRWuxhWhgkEojUYnb++LNHNyq25fNJvjG8zcNgI7vhAPvDD3i13MgxN845c9uyTTrH2JqHIc14wwEeYwn8WnjYpHPbbhuwSeeYSfMwHE4EamHAq8UA6DDp3H9ALZJnQFr+A7WwP/6BV8uBBDPp3AagFgkekJYDQC0MZvhtuQF0T84xoBaetGLLOQbJxjMP85hZEHRYTs1tA/n2wxtvvKmwk+073v74Bj4tKECCwQBIMhOtHqxlFIyCUTAKRgEWAAAMVEkVMGz4mwAAAABJRU5ErkJggg==","orcid":"","institution":"Umm Al-Qura University","correspondingAuthor":true,"prefix":"","firstName":"Mohammed","middleName":"","lastName":"Alshmemri","suffix":""}],"badges":[],"createdAt":"2026-01-08 08:54:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8549199/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8549199/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12912-026-04506-1","type":"published","date":"2026-03-03T15:59:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":102261374,"identity":"8cfc52c1-c8d5-493f-b0cd-76ac069b8ae7","added_by":"auto","created_at":"2026-02-10 00:39:21","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":128779,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eIntegrated Theoretical Framework: Toxic Leadership, Reporting, and Quality of Care.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8549199/v1/308d52434cfac7397965f125.jpg"},{"id":102261372,"identity":"d05c1bb9-a70f-41b8-863a-1407857b2ca7","added_by":"auto","created_at":"2026-02-10 00:39:19","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":82891,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eParticipant recruitment flow, data collection modalities, and final analytic sample (N = 35).\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8549199/v1/db3deac418e572eba30adbc3.jpg"},{"id":102261403,"identity":"01307f30-18cb-440c-8135-185eb77e623b","added_by":"auto","created_at":"2026-02-10 00:39:26","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":100877,"visible":true,"origin":"","legend":"\u003cp\u003eIntegrated conceptual framework illustrating the perceived influence of toxic nurse-manager leadership.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8549199/v1/81afe7dee4ecd8d535886ea6.jpg"},{"id":104250888,"identity":"b145b6f3-5ddb-403e-ab72-fb4b52ce9c82","added_by":"auto","created_at":"2026-03-09 16:11:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2083278,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8549199/v1/a955f035-84d7-4b32-bde0-edcbe22c17fd.pdf"},{"id":102261338,"identity":"67fa833f-b482-4efb-81f2-dd57a0eab272","added_by":"auto","created_at":"2026-02-10 00:39:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":200233,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFileS1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8549199/v1/dd96a8346f815f8e24fa540b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Dark Side of Nurse-Manager Leadership: Toxic Leadership Behaviours, Adverse-Event Reporting, and Care Quality—An Interpretive Descriptive Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eEffective 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].\u003c/p\u003e\n\u003cp\u003eAgainst 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].\u003c/p\u003e\n\u003cp\u003eOne 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.\u003c/p\u003e\n\u003cp\u003eDespite 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 those reporting dynamics subsequently affect the perceived quality of care.\u003c/p\u003e\u003cul\u003e\n \u003cli\u003eAim\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eTo 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.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eResearch Question\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eHow 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?\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eObjectives\u003c/li\u003e\n \u003cli\u003eTo characterise the specific forms and manifestations of toxic leadership behaviours among nurse managers in the study setting.\u003c/li\u003e\n \u003cli\u003eTo identify organisational and cultural conditions (e.g., hierarchy, accountability structures, employment precarity) that facilitate or inhibit adverse-event reporting under toxic leadership.\u003c/li\u003e\n \u003cli\u003eTo explore how toxic leadership–reporting dynamics are perceived to shape unit-level care processes and overall perceived care quality.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eBy 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.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eTheoretical Framework:\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThis study is informed by three complementary theoretical lenses, whose interrelationships are depicted in Figure 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].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIntegrating these lenses, Figure 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.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Research Design\u003c/h2\u003e \u003cp\u003eThis study employed an interpretive descriptive qualitative design within a constructivist\u0026ndash;interpretivist stance and is reported in accordance with the COREQ checklist [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Interpretive description was selected to generate practice-relevant explanations by linking nurses\u0026rsquo; accounts to sensitising theory while remaining open to inductive insights, rather than imposing a priori categories [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. 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) [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Researcher positionality was managed through reflexive journaling across sampling, data collection, and analysis, informing iterative coding decisions and theme development.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Sampling and Setting\u003c/h2\u003e \u003cp\u003eThe study was conducted at Hospital A, a mid-sized (approximately 400-bed) general-care hospital in western Saudi Arabia, operating within a hierarchical organisational context consistent with high power-distance workplace norms and using an electronic incident-reporting platform integrated into 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.\u003c/p\u003e \u003cp\u003e We used purposive maximum-variation sampling to capture heterogeneous experiences across clinical areas (intensive care, medical, surgical, and orthopaedic units), professional roles (staff nurses, nurse managers, and quality officers), and participant characteristics (e.g., nationality, tenure, and shift pattern).\u003c/p\u003e \u003cp\u003e\u003cb\u003eEligibility.\u003c/b\u003e Inclusion criteria were registered nurses employed at Hospital A for \u0026ge;\u0026thinsp;1 year, nurse managers with \u0026ge;\u0026thinsp;2 years of supervisory experience, and quality officers actively engaged in adverse-event reporting processes. Exclusion criteria were probationary or temporary contracts and extended leave during the data-collection period.\u003c/p\u003e \u003cp\u003eSample adequacy. Sample size was guided by information power, considering the study aim, theoretical anchoring, sample specificity, dialogue richness, and analytic strategy rather than a priori numbers [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Recruitment proceeded until sufficiency was reached, operationalised as three consecutive data-collection events yielding no substantively new codes or refinements relevant to the research question [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Of 52 eligible staff identified, 35 participated. Data-collection modalities were interview-only (n\u0026thinsp;=\u0026thinsp;7), focus group-only (n\u0026thinsp;=\u0026thinsp;0), and both interview and focus group (n\u0026thinsp;=\u0026thinsp;28). The final dataset comprised 26 staff nurses, 7 nurse managers, and 2 quality officers (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data Collection Instruments:\u003c/h2\u003e \u003cp\u003eData were generated using three qualitative instruments aligned with the integrated framework (Destructive Leadership, Theory of Planned Behavior, and Structure\u0026ndash;Process\u0026ndash;Outcome) (Supplementary File S1):\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eSemi-structured interview guide.\u003c/b\u003e 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) 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 [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eFocus-group discussion protocol.\u003c/b\u003e 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 [\u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eDocument-analysis framework.\u003c/b\u003e 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 [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Procedure\u003c/h2\u003e \u003cp\u003eFollowing 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:\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase 1\u003c/b\u003e \u0026ndash; 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.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase 2\u003c/b\u003e \u0026ndash; Semi-structured interviews were conducted in private rooms by the principal investigator with staff nurses, nurse managers, and quality officers (n\u0026thinsp;=\u0026thinsp;35; interview only n\u0026thinsp;=\u0026thinsp;7; interview plus focus group n\u0026thinsp;=\u0026thinsp;28). Sessions lasted 20\u0026ndash;50 minutes (mean\u0026thinsp;\u0026asymp;\u0026thinsp;35 minutes). Participants chose Arabic or English; interpretation support was available as needed. Audio files were encrypted, and recordings were transcribed verbatim.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase 3\u003c/b\u003e \u0026ndash; Focus-group discussions. The principal investigator facilitated four non-managerial focus groups. Each session lasted 40\u0026ndash;75 minutes. Ground rules (confidentiality and respect) were reiterated, and participants were informed of available support resources given the sensitivity of the topic.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase 4\u003c/b\u003e \u0026ndash; Organisational documents were reviewed using the predefined extraction framework. Where available, descriptive indicators (e.g., reporting frequencies, classification patterns, and resolution pathways) were abstracted to contextualise qualitative themes and support triangulation during interpretation.\u003c/p\u003e \u003cp\u003e \u003cb\u003e2.5 Data Analysis\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eAnalytic approach and coding.\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAnalysis 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\u0026ndash;Process\u0026ndash;Outcome) [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. 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.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eTheme development and theoretical integration.\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eTheme development followed Braun and Clarke\u0026rsquo;s phases of thematic analysis (familiarisation, initial coding, searching for themes, reviewing themes, defining/naming themes, and producing the narrative) [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Constant comparison was used within and across participant groups (staff nurses, nurse managers, quality officers) to examine convergence, divergence, and role-specific nuance [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eRigour and trustworthiness.\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eRigour was addressed using Lincoln and Guba\u0026rsquo;s criteria [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. 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 through 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.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eData sufficiency.\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eData 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.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eDocumentary triangulation using incident-report extracts.\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eTo contextualise qualitative interpretations, we extracted de-identified incident-report data from the hospital\u0026rsquo;s electronic reporting system for 1 January\u0026ndash;31 December 2024. The extract included event date, clinical unit code, reporter role, and case disposition. Reporting indicators were summarised descriptively to compare patterns with qualitative themes and to support triangulation, not causal inference. Unit-level comparisons were interpreted cautiously and only where interview representation was sufficient to support classification. Units were categorised as \u0026ldquo;toxic\u0026rdquo; when a majority threshold (\u0026ge;\u0026thinsp;60%) of interviewed staff from that unit reported toxic leadership behaviours. Descriptive comparisons of reporting volumes were used to contextualise the qualitative accounts of reporting culture across these unit categories.\u003c/p\u003e \u003c/div\u003e\u003cp\u003e\u003cstrong\u003e2.6. Ethical approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 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\u0026rsquo;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].\u003c/p\u003e"},{"header":"3.\tResults","content":"\u003cp\u003eThis 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\u0026rsquo; perceptions of care quality (Figure 3).\u003c/p\u003e\n\u003ch2\u003e3.1 Participant Characteristics\u003c/h2\u003e\n\u003cp\u003eParticipants represented surgical, medical, intensive care, orthopaedic, and other units and had 2\u0026ndash;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.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Demographic and Professional Characteristics of Participants (N=35)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"630\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStaff Nurses (n=26)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNurse Managers (n=7)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuality Officers (n=2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e32.7 (5.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e41.3 (6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e39.5 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e25\u0026ndash;48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e35\u0026ndash;53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e36\u0026ndash;43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e23 (88.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e5 (71.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e1 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e3 (11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e2 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e1 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNationality, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003eSaudi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e10 (38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e3 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e1 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003eFilipino\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e8 (30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e2 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003eEgyptian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e3 (11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e2 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e1 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e5 (19.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperience (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e8.3 (4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e16.2 (5.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e12.5 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e2\u0026ndash;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e10\u0026ndash;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e10\u0026ndash;15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDepartment, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003eSurgical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e9 (34.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e2 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003eMedical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e6 (23.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e2 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003eIntensive Care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e5 (19.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e1 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003eOrthopaedic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e4 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e1 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e2 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e1 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIncident reports submitted in the past year (staff nurses only), n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e10 (38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003e1\u0026ndash;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e12 (46.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\n \u003cp\u003e\u0026gt;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e4 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003e3.2 Key Themes and Subthemes\u003c/h2\u003e\n\u003cp\u003eFour 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Prevalence of Themes and Sub‑themes Across Participant Groups (N=35)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme \u0026rarr; Sub-theme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStaff Nurses n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNurse Managers n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuality Officers n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1. Manifestations of toxic leadership\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.1 Public humiliation and blame attribution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18 (69.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.2 Intimidation and threat deployment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17 (65.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.3 Information withholding and gatekeeping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16 (61.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (71.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.4 Cultural bias and favoritism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15 (57.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2. Barriers to adverse-event reporting under toxic leadership\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.1 Fear of retaliation and scapegoating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19 (73.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.2 Normalised concealment and informal workaround\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18 (69.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.3 Lack of actionable feedback and perceived futility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17 (65.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (71.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.4 Bureaucratic hurdles and managerial filtering\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15 (57.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3. Perceived impacts on care quality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.1 Defensive practice patterns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20 (77.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.2 Communication breakdowns and delayed escalation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18 (69.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.3 Teamwork erosion and siloed care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17 (65.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.4 Organisational learning failure and recurrence of incidents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16 (61.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e4. Contextual conditions shaping these dynamics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.1 Hierarchical power structures and norms of deference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19 (73.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (71.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.2 Weak leadership accountability mechanisms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17 (65.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.3 Employment precarity and differential vulnerability among expatriate staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16 (61.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.4 Competing institutional priorities and performative compliance pressures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15 (57.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003eDetailed Thematic Analysis\u003c/h2\u003e\n\u003ch2\u003e- Theme 1: Manifestations of Toxic Leadership\u003c/h2\u003e\n\u003cp\u003eAcross roles, toxic leadership was described as a patterned leadership style that reduced psychological safety and shaped what nurses felt was \u0026ldquo;safe\u0026rdquo; 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.1 Public humiliation and blame attribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStaff 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:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDuring the doctor\u0026apos;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\u0026apos;t constructive; it was humiliating. (Nurse 8)\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWhen something goes wrong, there\u0026apos;s no private conversation. It becomes a public spectacle. This fosters a culture of fear rather than learning (Nurse 3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants 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).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2 Intimidation and threat deployment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThreats 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.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSome managers threaten contract termination, while others threaten disciplinary action, which instils fear and silences nurses. (Nursing Manager1)\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePerformance evaluations are weaponized. If you\u0026apos;re labeled difficult, which usually means you speak up about problems, your evaluation will reflect it, regardless of your clinical competence. (Nurse 7).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese accounts portray intimidation as both a relational tactic and a structural mechanism, in which evaluation systems became linked to the willingness to speak up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.3 Information withholding and gatekeeping\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants 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:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThere\u0026apos;s an inner circle that receives updates and training opportunities first. If you\u0026apos;re not part of it, you learn about changes after you\u0026apos;ve already made errors. (Nurse 22)\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe often find no response to our complaints\u0026hellip; and sometimes critical updates only after errors occur.\u0026nbsp;(Nurse Manager 3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNurses framed information withholding as particularly unsafe because it simultaneously increased the probability of error and the likelihood of blame when errors occurred.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.4 Cultural bias and favoritism\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePreferential 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:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFavoritism is obvious; some nationalities receive protection, while others are constantly criticized. (Nurse 17)\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLanguage becomes a weapon. If your Arabic or English isn\u0026apos;t perfect, managers will deliberately speak quickly during important announcements, then blame you for misunderstanding. (Nurse 16)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants characterised these dynamics as shaping perceived vulnerability, which later intersected with fear of retaliation and employment precarity (Theme 4).\u003c/p\u003e\n\u003ch3\u003eTheme 2: Barriers to adverse-event reporting under toxic leadership\u003c/h3\u003e\n\u003cp\u003eParticipants 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1 Fear of retaliation and scapegoating\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFear 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:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMost staff are afraid of filing a complaint against my boss because of the potential consequences for my future at work, so we won\u0026apos;t file the complaint. (Nurse 6)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThose who report often fear negative consequences and changes in their work. (Quality Officer 2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis fear functioned as a behavioural constraint: reporting was perceived to trigger personal risk without assurance of organisational protection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Normalised concealment and informal workaround\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants described informal \u0026ldquo;fix and move on\u0026rdquo; practices, especially for near misses or incidents without visible harm, framed as safer than formal reporting in a punitive environment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe have an unofficial system: if the patient wasn\u0026apos;t harmed, we fix the problem quietly and move on. It\u0026apos;s safer for everyone. (Nurse 21)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInformal practices of hiding incidents became standard to avoid trouble. (Nurse 19)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese workarounds were described as protective for staff, but also as diverting learning away from formal systems designed to identify recurrent hazards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Lack of actionable feedback and perceived futility\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants across roles described limited feedback after reporting and little visibility of change. In this context, reporting was experienced as effortful, risky, and often unrewarded.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI have filed complaints about the administrative issue. \u0026hellip;.. later, nothing had changed\u0026hellip; What\u0026apos;s the point of the reporting system?\u0026nbsp;\u003c/em\u003e\u003cem\u003e(Nurse 3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThere\u0026apos;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)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4 Bureaucratic hurdles and managerial filtering\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants described procedural obstacles in reporting workflows and expressed concern that reports implicating leadership or systemic issues could be delayed, altered, or effectively suppressed.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSometimes reports disappear from the system or no response, especially if they implicate certain individuals or highlight systemic problems. (Nurse 19)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSometimes, the manager reviews the reports before they\u0026apos;re submitted to quality. Reports that might reflect poorly on leadership are \u0026lsquo;revised\u0026rsquo; or delayed until they\u0026apos;re no longer relevant. (Quality Officer 1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOrganisational 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.\u003c/p\u003e\n\u003ch3\u003eTheme 3: Perceived impacts on care quality\u003c/h3\u003e\n\u003cp\u003eParticipants 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.1 Defensive practice patterns\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStaff 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.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI\u0026apos;ve stopped suggesting alternative approaches that might benefit patients because of toxic leaders\u0026hellip; and of course, it could affect the quality of care\u0026hellip;. \u0026nbsp;(Nurse 17)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe document everything to protect ourselves. I spend time writing notes that don\u0026apos;t improve patient care but might shield me from blame later. (Nurse 15)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDefensive practice was thus described as a trade-off: reduced exposure to criticism at the cost of diminished flexibility and responsiveness in care delivery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Communication breakdowns and delayed escalation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants described fear of criticism as inhibiting escalation and contributing to incomplete or delayed communication, with perceived implications for timely intervention.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI\u0026apos;ve witnessed nurses hesitate to inform about changes in patient condition because our manager previously criticized them for \u0026lsquo;unnecessary escalation.\u0026rsquo; These delays directly impact patient outcomes. (Nurse 21)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eVital patient care details\u0026hellip; aren\u0026apos;t shared in a timely manner due to heavy workload. (Quality Officer 1).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese accounts describe a climate in which communication was filtered through anticipated managerial response, not solely by clinical need.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 Teamwork erosion and siloed care\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants 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.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDepartments operate in silos. No one wants to help each other because if something goes wrong, no one wants to be involved. (Nurse 1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCross-departmental collaboration has virtually disappeared\u0026hellip; \u0026lsquo;That\u0026apos;s your problem, not ours.\u0026rsquo; Patients suffer from this fragmentation. (Nurse 9)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTeamwork was described as replaced by risk-avoidant boundary-setting, which was experienced as particularly harmful for complex patients requiring coordinated care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4 Organisational learning failure and recurrence of incidents\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants 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.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRepeated incidents occur because we never address the underlying causes. (Nurse 22)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEach case was treated as an isolated incident, with individual nurses blamed. The possibility of a systemic issue was never investigated. (Nurse 17)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDocument review was used to triangulate on whether the reporting pathways, feedback mechanisms, and accountability signals described in the policy were reflected in participants\u0026rsquo; lived experience.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eTheme 4: Contextual conditions shaping these dynamics\u003c/h3\u003e\n\u003cp\u003eParticipants 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.1 Hierarchical power structures and norms of deference\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHierarchy was described as shaping the perceived social acceptability of questioning decisions or escalating concerns upward.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQuestioning authority is culturally unacceptable here, amplifying toxic behaviour\u0026hellip;\u0026nbsp;\u003c/em\u003e\u003cem\u003e(Nurse 18)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHierarchy dictates silence; expressing concerns upwards is seen as disrespectful. (Nurse 14)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants framed hierarchy as both organisational structure and social norm, constraining speaking up even when clinical risk was perceived.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.2 Weak leadership accountability mechanisms\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants described limited safe pathways to report manager misconduct and few visible consequences for harmful leadership behaviours.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLeadership evaluations overlook staff wellbeing entirely, and managers face no consequences. (Quality Officer 1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThere\u0026apos;s no safe way to report manager misconduct; accountability is nonexistent. (Nurse 6)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis governance gap was perceived as normalising toxic conduct and weakening trust in reporting and complaint mechanisms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.3 Employment precarity and differential vulnerability among expatriate staff\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants described expatriate vulnerability as shaping reporting calculations, particularly when employment or residency was perceived as contingent.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eExpat nurses fear that reporting incidents is simply too risky. (Nurse 3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI\u0026apos;ve seen foreign nurses deported, raising serious concerns\u0026hellip; the message to the rest of us was unmistakable. (Nurse 10).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEmployment precarity amplified the perceived personal cost of reporting and reinforced norms against reporting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.4 Competing institutional priorities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants described perceived tensions between quality/metrics and deeper safety culture work, interpreting these priorities as shaping what was visibly rewarded and what remained unaddressed.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOur hospital is enhancing quality\u0026hellip;. That\u0026apos;s why we need to follow the protocol and policy to maintain staff stability and quality of care. (Nurse 19)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe organization allocated some programs to visible problems that might affect the quality of care, not to the underlying cultural issues\u0026hellip;. (Nurse 14)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese accounts positioned organisational priorities as indirectly shaping the reporting climate by signalling which issues were \u0026ldquo;safe\u0026rdquo; to surface.\u003c/p\u003e\n\u003ch2\u003eIntegrated Conceptual Framework\u003c/h2\u003e\n\u003cp\u003eSynthesising 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.\u003c/p\u003e\n\u003cp\u003eThis 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.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.1 Toxic leadership manifestations in a high power-distance context\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants 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].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.2 Adverse-event reporting under toxic leadership\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdverse-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 \u0026ldquo;filters\u0026rdquo; (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].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.3 Perceived implications for care quality\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants 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., \u0026nbsp;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\u0026ndash;Process\u0026ndash;Outcome lens, through which leadership climate may propagate into everyday care processes and influence nurses\u0026rsquo; global appraisals of care quality [63].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.4 Contextual conditions shaping these dynamics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFour 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 [64, 65]. 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 \u0026ldquo;safe\u0026rdquo; to raise and which were likely to be minimised [66].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.5 Theoretical contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 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\u0026ndash;behaviour gap), particularly when perceived behavioural control is constrained by retaliation risk and reporting pathway filters [67]. 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.6 Practical implications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 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 [68]. 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 [69].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.7 Strengths and limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKey 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.8 Future research\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFuture 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 [70].\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eIn this high-power-distance hospital context, nurses described toxic nurse-manager leadership behaviours as shaping 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.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDefinition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCBAHI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSaudi Central Board for Accreditation of Healthcare Institutions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCOREQ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConsolidated Criteria for Reporting Qualitative Research\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eICH-GCP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInternational Council for Harmonisation \u0026ndash; Good Clinical Practice\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIRB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInstitutional Review Board\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStandard Deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSPO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStructure\u0026ndash;Process\u0026ndash;Outcome\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTPB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTheory of Planned Behavior\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThe 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.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e 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.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCompeting Interests:\u0026nbsp;\u003c/strong\u003eThe author declares that they have no competing interests, financial or non-financial.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e Not applicable.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e Mohammed Alshmemri conceptualized the study, designed the methodology, collected the data, conducted the analysis, interpreted the findings, and drafted and revised the manuscript.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e Not applicable.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAlsadaan N, Mohamed O, Ramadan E. 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Aust N Z J Public Health. 2023;47:100074. https://doi.org/10.1016/J.ANZJPH.2023.100074.\u003c/li\u003e\n\u003cli\u003eAguilera R V., De Massis A, Fini R, Vismara S. Organizational Goals, Outcomes, and the Assessment of Performance: Reconceptualizing Success in Management Studies. Journal of Management Studies. 2024;61:1\u0026ndash;36. https://doi.org/10.1111/JOMS.12994.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Toxic leadership, patient safety, adverse-event reporting, nursing management, organisational culture, interpretive description","lastPublishedDoi":"10.21203/rs.3.rs-8549199/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8549199/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eToxic 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn interpretive descriptive study was conducted in a Saudi Arabian hospital (March–August 2025). Methodological triangulation integrated semi-structured interviews with staff nurses, nurse managers, and quality officers (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).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFour 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this high power-distance setting, toxic nurse-manager leadership was perceived to contribute to a self-reinforcing silence dynamic 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSafety 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.\u003c/p\u003e","manuscriptTitle":"The Dark Side of Nurse-Manager Leadership: Toxic Leadership Behaviours, Adverse-Event Reporting, and Care Quality—An Interpretive Descriptive Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-10 00:38:53","doi":"10.21203/rs.3.rs-8549199/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-17T08:30:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-14T12:35:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-08T06:20:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"80356380676735536237396348307961751431","date":"2026-02-07T12:46:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"219354261558952140685337367410738521433","date":"2026-02-05T19:33:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-05T07:19:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-04T04:33:21+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-27T04:25:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-21T07:52:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2026-01-21T06:48:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"38a051e6-16af-4f5d-90b1-22677d55e19e","owner":[],"postedDate":"February 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T16:06:34+00:00","versionOfRecord":{"articleIdentity":"rs-8549199","link":"https://doi.org/10.1186/s12912-026-04506-1","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2026-03-03 15:59:08","publishedOnDateReadable":"March 3rd, 2026"},"versionCreatedAt":"2026-02-10 00:38:53","video":"","vorDoi":"10.1186/s12912-026-04506-1","vorDoiUrl":"https://doi.org/10.1186/s12912-026-04506-1","workflowStages":[]},"version":"v1","identity":"rs-8549199","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8549199","identity":"rs-8549199","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}