A Systematic Literature Review on the Impact of Leader-Member Exchange (LMX) and Nurse Morality in the Healthcare Sector

This systematic literature review examines the impact of Leader-Member Exchange (LMX) on nurse morality within healthcare settings. LMX theory, which emphasizes the quality of leader-member relationships, significantly influences nurses’ ethical decision-making, moral distress, and job performance. Given the ethical complexities of healthcare, understanding how leadership dynamics shape nurses’ moral behaviour is crucial for improving patient care and organizational effectiveness. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework, this review systematically analysed 40 peer-reviewed studies published between 2020 and 2024, sourced from Scopus and Web of Science. The findings indicate that high-quality LMX relationships foster trust, enhance moral sensitivity, and mitigate moral distress, leading to improved ethical decision-making among nurses. On the other hand, low-quality LMX relationships correlate with increased moral distress, ethical disengagement, and reduced job satisfaction, negatively affecting patient care outcomes. Transformational leadership was identified as a key enabler in strengthening LMX relationships, while transactional leadership contributed to ethical erosion and nurse disengagement. The review also highlights structural barriers such as heavy workloads, leadership training deficiencies, and organizational constraints that hinder the development of strong LMX relationships. To address these challenges, healthcare organizations must invest in leadership development programs, ethical training, and supportive workplace cultures that prioritize open communication and trust. Future research should explore the moderating effects of institutional policies, cultural factors, and longitudinal LMX dynamics on nurse morality. Strengthening LMX relationships can significantly enhance ethical nursing practices, ultimately benefiting patient care and healthcare system sustainability.