The Levels, Prevalence, and Related Factors of Toxic Leadership Among Nurses Outside the United States: A Systematic Review and Meta-Analysis

OBJECTIVE: To systematically estimate the levels, prevalence, and related factors of toxic leadership among nurses outside the United States. BACKGROUND: Toxic leadership contributes to nurse burnout, turnover, and reduced care quality, yet its extent and determinants remain unclear. METHODS: Following PRISMA 2020 guidelines, 10 databases were searched from inception to February 2025. Eligible quantitative studies were synthesized using meta-analyses to pool mean scores, SDs, and prevalence rates. RESULTS: Twenty-eight studies comprising 13,010 nurses in practice settings outside the United States were included. The pooled mean toxic leadership score was 2.36 (95% CI: 1.89-2.83), and the pooled prevalence of high toxic leadership was 29% (95% CI: 10%-48%). CONCLUSIONS: Nurses outside the United States experience moderate toxic leadership levels, with nearly 1/3 exposed to high levels. Both individual and organizational factors contribute to these perceptions, underscoring the need for leadership training and system-level interventions to improve nurse well-being and care quality.