Toxic leadership behaviors among nurse managers: a cross-sectional study in academic hospitals using the ToxBH-NM scale

Abstract Background Effective leadership is crucial for healthcare, human resource management and quality of care. Conversely, toxic leadership behaviors in nursing management can severely impair the work environment. This study aimed to evaluate nurses’ perceptions of toxic leadership behaviors exhibited by nurse managers and to identify the associated factors in academic referral hospitals. Methods This cross-sectional, analytical study was conducted among 275 registered nurses employed in academic medical centers in Rasht, Iran. Proportional stratified sampling was utilized. Data was collected using a demographic checklist and the Toxic Leadership Behaviors of Nurse Managers (ToxBH-NM) scale (score range:30–150). Data were analyzed using descriptive statistics, Mann–Whitney U, Kruskal–Wallis H tests, and multiple linear regression. Results The mean ToxBH-NM score was 61.8 ± 29.14, reflecting a moderate level of perceived toxic leadership. Nurses in high-intensity clinical units reported significantly higher scores ( p < 0.05). In the multivariable model (R² = 0.517, p < 0.001), The hospital of employment and the nurse manager’s marital status emerged as the only independent predictors. Compared with the reference hospital (S), nurses in R Hospital reported significantly higher toxic leadership scores, whereas those in H Hospital reported lower scores. Additionally, supervision by widowed or divorced nurse managers was associated with higher perceived toxic leadership. No other demographic or occupational variables remained significant in the adjusted model. Conclusion Although the overall perception of toxic leadership is moderate, its high concentration in specific clinical units warrants immediate managerial interventions. Implementing targeted positive leadership training and screening protocols using the ToxBH-NM scale are recommended to mitigate toxicity and improve nurse retention.