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Abstract

Despite efforts to improve management and leadership behaviors among nurse managers, studies have shown the pervasive nature of abusive supervision in nursing practice, with strong evidence linking this type of behavior to reduced work productivity among nurses. This systematic review aimed to appraise and synthesize peer-reviewed studies that examine nurse-related and patient safety outcomes associated with abusive supervision. The review searched nursing literature from five databases (PubMed, CINAHL, Scopus, Web of Science, and PsycINFO) between August and November 2022. A total of 21 relevant studies were identified, with the Abusive Supervision Scale being the most frequently used measurement tool. Through content analysis, the review identified 29 outcomes which were categorized into six groups: (a) affective-based, (b) behavior/performance-based, (c) relationship-based, (d) cognitive-based, (e) health and well-being, and (f) nursing care. In addition, 10 mediators were identified and grouped into three categories: (a) affective-based, (b) motivation-based, and (c) health and well-being. The review findings provide compelling evidence regarding the detrimental effects of abusive supervision in the nursing workforce. Moreover, the review emphasizes the need for further research to explore how such behavior can impact patient safety outcomes. To address abusive supervision, it is crucial to promote positive behaviors among nurse managers through human resource mechanisms, relevant rules and policies, and theory-driven leadership development programs.

Keywords

abusive supervision nursing patient safety organization outcomes nurse manager

The shortage of nurses continues to present challenges to healthcare institutions worldwide, impacting the delivery of healthcare services and jeopardizing patient safety and the quality of nursing care. A global estimate has revealed a deficit of 13 million nurses, and the United States alone will require nearly 1.2 million nurses by 2030 to maintain an effective healthcare delivery system.¹ With the impending retirement of baby boomer nurses within the next 5 years² and the increasing rate of younger nurses leaving the profession,³ the nursing shortage is expected to worsen. Given the detrimental consequences of a persistent nursing staff shortage,⁴ it is not surprising that healthcare organizations have implemented various measures to address this issue, primarily focusing on different elements of the work environment that influence nurses’ decisions to leave.⁵ Evidence has shown that the behaviors of nurse managers play a significant role in sustaining an adequate and committed nursing workforce and improving nursing staff retention.⁶

Effective leadership and management behaviors (e.g. transformational and ethical) among managers and leaders have been consistently cited as strong precursors of employees’ work effectiveness and as strong factors influencing turnover decisions.^6,7 Negative behaviors, including abusive supervision, have often been reported to be associated with a myriad of adverse effects on the labor workforce.^8,9 Tepper¹⁰ conceptualized abusive supervision as a subjective assessment rooted in subordinates’ perceptions of sustained hostile verbal and nonverbal actions by supervisors, excluding physical contact. A leader’s abusive behavior is believed to be affected by an individual’s disposition and the context. A negative workplace culture, the facility size, the span of management, the absence of policies and rules to govern employees’ behaviors in the workplace, and the lack or absence of check and balance systems are some of the contextual elements that may drive a leader to engage in abusive behaviors.^11,12 Abusive behaviors of a leader may be dispositional in nature often as a response when there is a perceived threat to their status or position, when their goals are not met,^10,13 or simply as a way to conceal their incompetence and unproductiveness.¹⁴

In many healthcare settings, nurses are not only supervised by nurse managers but also interact with and receive supervision from their colleagues.¹⁵ This dynamic is particularly evident in team-based healthcare environments where collaboration and interprofessional relationships are essential.¹⁶ The involvement of colleagues in the supervision of nurses can have implications for the occurrence and impact of abusive supervision in nursing practice. Although nurse managers traditionally hold a formal supervisory role and have authority over the nursing staff, abusive behaviors can also be displayed by colleagues within the same hierarchical level or even from subordinate nurses.¹⁷ Abusive supervision from both nurse managers and colleagues can contribute to a toxic work environment, negatively impacting the well-being, job satisfaction, and overall performance of nurses.¹⁸

Although a specific theory explaining the emergence of abusive supervision has not been identified, previous studies have utilized various theoretical frameworks to examine this phenomenon. Some of the theories employed include the Conservation of Resources Theory (COR),¹⁹ the Self-Determination Theory (SDT),²⁰ and the Social Learning Theory (SLT).²¹ Among these theories, the COR has been widely used as a theoretical basis in abusive supervision studies across different disciplines. This theory suggests that individuals experience psychological strain when they perceive their resources to be threatened or lost.^19,22 In response to perceived threats to their resources, individuals may choose to withdraw or disengage to protect their remaining resources and prevent further loss.²³ Applied to the nursing context, a nurse manager or leader who exhibits hostile behaviors or actions may threaten the resources (such as structural resources, work environment, and social support) that nursing staff need to effectively carry out their responsibilities.^24-26 This, in turn, can have a negative impact on the work performance of the nursing staff and potentially affect the quality of care provided to patients.

Existing literature has provided evidence that nurse managers’ abusive supervision can have negative effects on nurses’ work productivity²⁷ and their health and well-being.²⁸ In addition, a limited body of evidence has linked abusive supervision to suboptimal nursing care.²⁹ However, it is important to consider a broader perspective when designing and implementing leadership interventions and formulating measures to enhance work productivity in nurses and maintain an effective nursing workforce. To fill this lacuna, this systematic review was conducted to examine the current state of the science related to abusive leadership in the nursing workforce. Specifically, this review aimed to identify (a) the association between abusive supervision and nurse-related and patient safety outcomes and (b) mediators that serve as pathways between abusive supervision and a broad range of outcomes in nursing.

Methods

Design

This systematic review of literature examined the association between abusive supervision and outcomes in nurses and patients using guidelines from the Center for Reviews and Dissemination.³⁰ The results of the systematic review are presented following the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.³¹ The PRISMA statement provides a structured framework for reporting systematic reviews and meta-analyses, ensuring transparency and consistency in reporting methods, results, and conclusions.

Search Methods

Articles relevant to this review were gathered from five sources, namely, PubMed, CINAHL, Scopus, Web of Science, and PsycINFO. The following Medical Subject Headings (MeSH) and key terms were used individually or in combination, with the utilization of Boolean operators (AND, OR, and NOT): abusive supervision, nursing, nurse manager, nurse leader, nurse administrator, patient safety, care quality, job performance, turnover intention, burnout, job satisfaction, and work engagement. In addition, we manually searched the references of the included articles.

Inclusion and Exclusion Criteria

Inclusion and exclusion criteria were applied to identify relevant articles for this systematic review. The criteria for inclusion were as follows: (a) the study focused on abusive supervision in the nursing context, (b) the study examined outcomes related to abusive supervision (including nurse-related, patient, and organizational outcomes), (c) the study investigated mediators of abusive supervision, and (d) and the articles were peer-reviewed. Owing to the substantial number of abstracts and the sole English language proficiency within our research team, our focus was exclusively on nursing studies that had been published in English. To ensure consistency and comparability among the included studies, qualitative studies, gray literature, and studies where nurses were not the primary population were excluded. No restrictions were set on the publication year to capture all relevant research on abusive supervision in nursing.

Quality Appraisal

The Joanna Briggs Institute (JBI) Critical Appraisal Tool³² was the quality appraisal tool used to evaluate the methodological rigor of the studies reviewed. The JBI checklist evaluates eight elements in a study, including the criteria for selecting samples, research settings and samples, exposure measures, the use of objective and standard criteria for measurement conditions, confounders, management of confounders, measurement, and data analysis.

Data Screening

A total of 375 citations were retrieved and exported to EndNote to facilitate data management and screening. After eliminating duplicate entries, the titles and abstracts of all retrieved documents were reviewed, applying the predefined inclusion/exclusion criteria. For abstracts that remained after this initial screening, full articles were procured and meticulously examined to ascertain their alignment with the inclusion/exclusion criteria. To ensure the rigor of the screening process, two reviewers (LJL/CK) independently evaluated the eligibility of the selected studies, conducting two rounds of assessment. In cases where differences of opinion arose, consensus meetings were convened between the reviewing pair, and any discrepancies were resolved through comprehensive deliberation. Should a unanimous decision prove elusive, a third reviewer was consulted to determine the final inclusion status of the respective article. This systematic and collaborative approach was employed to ensure the thoroughness and reliability of the study selection process.

Data Abstraction and Synthesis

All included articles were assessed by two independent reviewers (LJL and CK), and the following information was extracted and entered into a matrix table: author name, sample size, country, research approach, scales used, and the reliability and validity of the scales (Table 1). Due to the heterogeneity of the study results, statistical pooling was not conducted. Therefore, the mediators and outcomes of abusive supervision were identified through conventional content analysis. Conventional content analysis refers to a process of analyzing and categorizing textual data extracted from included studies in a systematic and structured manner.³³ The two independent reviewers sorted all outcomes and mediators based on their characteristics and commonalities, and clustered them into meaningful categories. Discussion was conducted to reach a consensus and identify the final categories. Tables 2 and 3 present the outcomes and mediators of abusive supervision.

Table 1.

Summary of Articles Reviewed.

Author	Sample	Country	Research Design	Instruments	Items	Reliability	Validity
Afsar et al³⁴	359 nurses	Pakistan	Cross-sectional study	Abusive Supervision Scale	15 items, 5-point Likert scale	0.91	PV
				Moral Courage Scale	4 items, 5-point Likert scale	0.85	PV
				Moral Efficacy	9 items, 5-point Likert scale	0.88	PV
				Moral Attentiveness	9 items, 5-point Likert scale	0.92	PV
Badran and Akeel³⁵	171 nurses	Egypt	Cross-sectional study	Abusive Supervision Scale	15 items, 5-point Likert scale	0.88	PV
Badran and Akeel³⁵	171 nurses	Egypt	Cross-sectional study	Counterwork Productive Behavior	33 items, 5-point Likert scale	0.95	CV
Chu³⁶	212 nurses	Taiwan	Cross-sectional study	Abusive Supervision Scale	15 items, 5-point Likert scale	0.90	PV
				Toxic emotions at work scale	15 items, 5-point Likert scale	0.95	PV
				Counterwork Productive Behavior	33 items, 5-point Likert scale	0.87	PV
				Organizational citizenship behavior Scale	20 items, 5-point Likert scale	0.87	PV
Jawad et al²⁵	331 nurses	Pakistan	Cross-sectional study	Abusive Supervision Scale	15 items, 5-point Likert scale	0.981	PV
Jawad et al²⁵	331 nurses	Pakistan	Cross-sectional study	General Health Questionnaire	12 items, 5-point Likert scale	0.984	PV
Lyu et al²⁸	1127 nurses	China	Cross-sectional study	Abusive Supervision Scale	15 items, 5-point Likert scale	0.96	PV
Lyu et al²⁸	1127 nurses	China	Cross-sectional study	Psychological Empowerment at Workplace	22 items, 7-point Likert scale	0.88	PV
Lavoie-Tremblay et al¹³	541 nurses	Canada	Cross-sectional study	Global Transformational Leadership scale	7 items, 5-point Likert scale	0.94	CFA
				Abusive Supervision Scale	15 items, 5-point Likert scale	0.88	CFA
				Quality of Care	4 items, 4-point Likert scale	0.84	CFA
				Intention to Quit	2 items, 5-point Likert scale	NP	PV
Low et al³⁷	337 nurses	Malaysia	Cross-sectional study	Abusive Supervision Scale	15 items, 5-point Likert scale	0.870	PV
				Injustice Scale	20 items, 5-point Likert scale	0.920	PV
				Counterwork Productive Behavior	24 items, 5-point Likert scale	0.810	PV
				Power Distance Orientation	6 items, 5-point Likert scale	0.810	PV
				Work Locus of Control Scale	16 items, 5-point Likert scale	0.850	PV
Osei et al³⁸	343 nurses	Ghana	Cross-sectional study	Abusive Supervision Scale	15 items, 5-point Likert scale	0.90	PV
				Utrecht Work Engagement Scale	17 items, 5-point Likert scale	0.89	PV
				Proactive Personality Scale	1 item, 4-point Likert scale	0.89	PV
Özkan³⁹	230 nurses	Turkey	Cross-sectional study	Abusive Supervision Scale	15 items, 5-point Likert scale	NP	PV
				Workplace Incivility Scale	12 items, 5-point Likert scale	NP	PV
				Workplace Ostracism Scale	10 items, 5-point Likert scale	NP	PV
				Workplace Bullying Scale	12 items, 5-point Likert scale	NP	PV
				Turnover Intention	4 item, 5-point Likert scale	NP	PV
Pyc et al⁴⁰	232 nurses	USA	Cross-sectional study	Abusive Supervision Scale	15 items, 5-point Likert scale	0.95	PV
				Authoritarian leadership style	9 items, 3-point Likert scale	0.86	Face and content
				Anxiety Subscale of Emotional Strain Scale	4 items, 5-point Likert scale	0.69	PV
				Depression Subscale of Emotional Strain Scale	5 items, 5-point Likert scale	0.78	PV
				EE subscale of MBI	5 items, 7-point Likert scale	0.90	PV
				Physical Symptoms Inventory	18 items, 3-point Likert scale	0.88	PV
				Job Satisfaction Scale	3 items, 6-point Likert scale	0.80	PV
				Intention to Quit	1 item, 6-point Likert scale	NP	PV
				Job Performance Scale	5 items, 6-point Likert scale	0.93	PV
Mostaf⁴¹	204 nurses	Egypt	Cross-sectional study	Abusive Supervision Scale	8 items, 5-point Likert scale	0.894	PV
				Moral Courage Scale	4 items, 5-point Likert scale	0.777	PV
				Moral Efficacy Scale	9 items, 5-point Likert scale	0.720	PV
Mullen et al²⁴	177 nurses	Canada	two-wave cross-lagged panel design	Abusive Supervision Scale	15 items, 7-point Likert scale	0.91	PV
				Safety Climate Scale	10 items, 7-point Likert scale	0.73	PV
				Safety Participation Scale	4 items, 7-point Likert scale	0.83	PV
				General Health Questionnaire	12 items, 7-point Likert scale	0.82	PV
Malik et al⁴²	331 nurses	Pakistan	Two-wave cross-lagged panel design	Abusive Supervision Scale	5 items, 5-point Likert scale	0.936/0.929	PV
				EE subscale of MBI	5 items, 5-point Likert scale	0.838/0.838	PV
				Job Neglect Scale	5 items, 5-point Likert scale	0.899/0.908	PV
				Self-compassion Scale	12 items, 5-point Likert scale	0.982/0.983	PV
Ng et al⁴³	219 nurses	Australia	Two-wave cross-lagged panel design	Abusive Supervision Scale	5 items, 5-point Likert scale	0.98	PV
				Shortened Negative Acts Questionnaire	9 items, 5-point Likert scale	0.97	PV
				Job Satisfaction Scale	5 items, 5-point Likert scale	0.73	PV
				Public Service Motivation	5 items, 5-point Likert scale	0.80	PV
Qian et al⁴⁴	227 nurses	China	Cross-sectional study	Abusive Supervision Scale	15 items, 5-point Likert scale	0.93	PV
				Center for Epidemiologic Studies Depression Scale	6 items, 5-point Likert scale	0.88	PV
				Role Ambiguity Scale	5 items, 5-point Likert scale	0.70	PV
				Lack of Reciprocity Scale	3 items, 5-point Likert scale	0.83	PV
Rodwell et al⁴⁵	250 nurses	Australia	Cross-sectional study	Abusive Supervision and the Behaviors Scale	10 items, 6-point Likert scale	0.71	PV
				Satisfaction Scale	5 items, 6-point Likert scale	0.86	PV
				Psychological Strain	1 item, 6-point Likert scale	0.94	PV
				Turnover Intention	3 items, 6-point Likert scale	0.73	PV
Sharif Nia et al²⁹	300 nurses	Iran	Cross-sectional study	Caring Behaviors Inventory	42 items, 5-point Likert scale	0.918	PV
				Job Satisfaction Scale	4 items, 5-point Likert scale	0.857	PV
				Abusive Supervision Scale	15 items, 5-point Likert scale	0.919	PV
				Psychological Ownership Scale	5 items, 5-point Likert scale	0.885	PV
Sun et al⁴⁶	923 nurses	China	Cross-sectional study	Abusive Supervision Scale	15 items, 5-point Likert scale	0.95	PV
				Self-efficacy Scale	17 items, 5-point Likert scale	0.81	PV
				Utrecht Work Engagement Scale	17 items, 5-point Likert scale	0.94	PV
Shih et al²⁶	313 nurses	Taiwan	Cross-sectional study	Abusive Supervision Scale	15 items, 5-point Likert scale	0.862	PV
				Occupational Stress	11 items, 4-point Likert scale	0.894	PV
				Warwick–Edinburgh Mental Well-being Scale	14 items, 4-point Likert scale	0.943	PV
				World Health Organization Quality of Life Scale	7 items, 5-point Likert scale	0.792	PV
				Social Well-being Scale	7 items, 7-point Likert scale	0.792	PV
Whitman et al⁴⁷	460 nurses	USA	Cross-sectional study	Abusive Supervision Scale	11 items, 7-point Likert scale	0.94	PV
				EE of MBI	5 items, 5-point Likert scale	0.90	PV
				Feedback Avoidance	6 items, 7-point Likert scale	0.89	PV
Zhang et al¹¹	1221	China	Cross-sectional study	Workplace Violence	7 items, 6-point Likert scale	0.886	PV
				Anxiety and Depression Scale	14 items, 4-point Likert scale	0.9310	PV
				Abusive Supervision Scale	4 items, 5-point Likert scale	0.928	PV
				Work Ability Item	1 item, 10-point Likert scale	NP	PV

Abbreviations: CV, content validity; NP, not provided; PV, previously validated.

Table 2.

Summary of Outcomes of Abusive Supervision.

Outcomes (Direct effects)	Reference	Outcome
Affective based outcomes
1. Turnover intention	Rodwell et al⁴⁵	Significantly increased
	Lavoie-Tremblay et al¹³	Significantly increased
	Pyc et al⁴⁰	Significantly increased
	Lyu et al²⁸	Significantly increased
	Özkan³⁹	Significantly increased
2. Job satisfaction	Ng et al⁴³	Significantly decreased
	Pyc et al⁴⁰	Significantly decreased
	Rodwell et al⁴⁵	Significantly decreased
	Sharif Nia et al²⁹	Significantly decreased
3. Work engagement	Sun et al⁴⁶	Significantly decreased
3. Work engagement	Osei et al³⁸	Significantly decreased
4. Public service motivation	Ng et al⁴³	No change
Behavior or performance–based outcomes
5. Counterwork productive behavior	Low et al³⁷	Significantly increased
	Chu³⁶	Significantly increased
	Badran and Akeel³⁵	Significantly increased
6. Organizational citizenship behavior	Chu³⁶	Significantly decreased
7. Work performance	Pyc et al⁴⁰	Significantly decreased
8. Job neglect	Malik et al⁴²	Significantly increased
Relational-based outcomes
9. Workplace violence	Zhang et al¹¹	Significantly increased
9. Workplace violence	Özkan³⁹	Significantly increased
10. Workplace injustice	Low et al³⁷	Significantly increased
11. Safety climate	Mullen et al²⁴	Significantly decreased
12. Workplace bullying	Ng et al⁴³	Significantly increased
13. Workplace incivility	Özkan³⁹	Significantly increased
14. Workplace ostracism	Özkan³⁹	Significantly increased
15. Lack of reciprocity	Qian et al⁴⁴	No change
Cognitive-based outcomes
16. Moral courage	Afsar et al³⁴	Significantly decreased
16. Moral courage	Mostaf⁴¹	Significantly decreased
17. Role ambiguity	Qian et al⁴⁴	No change
18. Self-efficacy	Sun et al⁴⁶	Significantly decreased
19. Moral efficacy	Mostaf⁴¹	Significantly decreased
Health and well-being
20. Psychological well-being/health	Shih et al²⁶	Significantly decreased
	Jawad et al²⁵	Significantly decreased
	Mullen et al²⁴	Significantly decreased
21. Psychological strain	Shih et al²⁶	Significantly increased
21. Psychological strain	Rodwell et al⁴⁵	Significantly increased
22. Burnout	Pyc et al⁴⁰	Significantly increased
22. Burnout	Malik et al⁴²	Significantly increased
23. Anxiety	Pyc et al⁴⁰	Significantly increased
24. Depression	Pyc et al⁴⁰	Significantly increased
25. Mental health risk	Qian et al⁴⁴	Significantly increased
26. Physical symptoms	Pyc et al⁴⁰	Significantly increased
27. Physical well-being	Shih et al²⁶	Significantly decreased
28. Social well-being	Shih et al²⁶	Significantly decreased
Nursing care outcomes
29. Quality of care	Lavoie-Tremblay et al¹³	Significantly decreased
29. Quality of care	Sharif Nia et al²⁹	Significantly decreased

Table 3.

Summary of Mediators of Abusive Supervision.

Mediators (Indirect effects)	Source	Effect
Affective-based mediators
Abusive supervision → job satisfaction
→ Turnover intention	Rodwell et al⁴⁵	Partial mediating effect
→ Turnover intention	Lyu et al²⁸	Partial mediating effect
→ Quality of care	Sharif Nia et al²⁹	Partial mediating effect
→ Public service motivation	Ng et al⁴³	Partial mediating effect
Motivation-based mediators
Abusive supervision → workplace injustice → counterproductive work behavior	Low et al³⁷	Partial mediating effect
Abusive supervision → workplace ostracism → turnover intention	Özkan³⁹	Partial mediating effect
Abusive supervision → workplace incivility → turnover intention	Özkan³⁹	Partial mediating effect
Abusive supervision → workplace bullying → turnover intention	Özkan³⁹	Partial mediating effect
Abusive supervision → silence behavior → work engagement	Osei et al³⁸	No mediating effect
Health and well-being mediators
Abusive supervision → anxiety
→Job satisfaction	Pyc et al⁴⁰	Partial mediating effect
→Job performance	Pyc et al⁴⁰	Partial mediating effect
→Workplace ability	Zhang et al¹¹	Partial mediating effect
→Job burnout	Pyc et al⁴⁰	Partial mediating effect
→Physical symptoms	Pyc et al⁴⁰	Partial mediating effect
→Turnover intention	Pyc et al⁴⁰	Partial mediating effect
Abusive supervision → psychological distress
→Psychological well-being	Shih et al²⁶	Partial mediating effect
→Physical well-being	Shih et al²⁶	Partial mediating effect
→Social well-being	Shih et al²⁶	Partial mediating effect
→Turnover intention	Rodwell et al⁴⁵	Partial mediating effect
Abusive supervision → emotional exhaustion
→Avoidance feedback	Whitman et al⁴⁷	Partial mediating effect
→Job neglect	Malik et al⁴²	Partial mediating effect

Results

Search Outcomes

During the initial search, a total of 375 articles were identified. After removing duplicates, 213 articles remained for further screening. Based on the screening of titles and abstracts, 167 articles were excluded, leaving 46 articles for full-text screening. After assessing the full-text articles, an additional 25 articles were excluded, resulting in a final selection of 21 articles for inclusion in the systematic review. The search and selection processes are visually presented in Figure 1, illustrating the flow of articles throughout the review.

Figure 1.

Diagram of the process used to identify references for the review.

Study Characteristics

The systematic review included a total of 21 studies, with varying geographic distribution. Four studies were conducted in China, while three studies each were conducted in Pakistan, Egypt, the United States, Australia, Taiwan, and Canada. In addition, one study each was conducted in Malaysia, Ghana, Turkey, and Iran. Eighteen studies employed a cross-sectional research design, providing a snapshot of the relationship between abusive supervision and its outcomes. In three studies, a two-wave cross-lagged panel design was utilized, allowing for the examination of causal relationships over time. The sample sizes across the studies ranged from 171 to 1221 nurses, representing a diverse range of participants. In terms of measurement, all studies utilized the Abusive Supervision Scale, originally developed by Tepper,¹⁰ to assess nonphysical abusive behaviors exhibited by managers. Among the studies, 18 used the original 15-item scale, while two studies used a five-item version and one study used an eight-item version of the scale.

Quality Rating

Quality appraisal identified 13 studies with moderate quality scores, and eight with high quality scores. Quality appraisal was conducted by the two researchers independently; however, when disagreement arose, both researchers discussed the evaluation. Quality ratings were not used as a basis to exclude articles from the review. The focus was to capture as much relevant information and evidence as possible, given the existing literature landscape on the topic (Supplementary File 1).

Theoretical/Conceptual Framework

Of the 21 articles reviewed, only five used a theoretical basis to guide the research, while the remaining studies used varied conceptual frameworks to illustrate the interaction between the key study variables. Three studies utilized the conservation of resources (COR) theory as the theoretical underpinning,^25,26,47 one study used the SDT,⁴³ and one study used the SLT.³⁹

Abusive Supervision Outcomes

Content analysis revealed 29 outcomes, which were categorized into six clusters: (a) affective-based, (b) behavior/performance-based, (c) relationship-based, (d) cognitive-based, (e) health and well-being, and (d) nursing care.

Affective-based outcomes

Affective-based outcomes of abusive leadership refer to the emotional or affective responses experienced by individuals who are subjected to abusive supervision. In this review, 11 studies reported four affective-based outcomes, including turnover intention, job satisfaction, work engagement, and public service motivation. Turnover intention was the most frequently tested outcome and was reported in five studies.^{13,28,39,40,45} In these studies, abusive supervision was associated with a higher turnover intention among nurses. Four studies attributed increased job dissatisfaction to a higher perception of abusive supervision.^29,40,43,45 Other studies associated abusive supervision with decreased work engagement,^38,46 but not with public service motivation.⁴³

Behavior/performance-based outcomes

Performance-based outcomes of abusive leadership refer to the effects of abusive supervision on employees’ job performance and work-related behaviors. In this review, five studies reported four behavior/performance-based outcomes of abusive supervision. In three studies,^35-37 abusive supervision was significantly but positively associated with counterproductive work behavior in nurses. In addition, abusive supervision was attributed to increased job neglect,⁴² poor work performance,⁴⁰ and decreased organizational citizenship behavior.³⁶

Relationship-based outcomes

Relationship-based outcomes of abusive leadership refer to the effects and consequences of abusive supervision on the relationships between leaders and their subordinates. Across six studies, four relationship-based outcomes of abusive supervision were identified. Workplace violence was highlighted as a significant outcome in two studies.^11,39 The findings of a Turkish study indicated that abusive behaviors exhibited by nurse managers were associated with increased workplace incivility and ostracism.³⁹ Moreover, abusive supervision was linked to workplace injustice,³⁷ workplace bullying,⁴³ and an unsafe work climate.²⁴

Cognitive-based outcomes

Cognitive-based outcomes of abusive leadership pertain to the effects of abusive supervision on the cognitive processes, perceptions, and beliefs of individuals within a work environment. Four studies identified four cognitive-based outcomes of abusive supervision. Among them, two studies reported a significant decrease in moral courage among nurses who worked with abusive nurse managers.^34,41 Sun et al⁴⁶ demonstrated a significant negative influence of abusive supervision on nurses’ self-efficacy, while Mostaf⁴¹ reported a negative effect of abusive supervision on nurses’ moral efficacy. However, one study found no effect of abusive supervision on role ambiguity.⁴⁴

Health and well-being outcomes

Health and well-being outcomes of abusive leadership refer to the effects that abusive supervision has on the physical, psychological, and social well-being of employees, specifically in the context of their health-related outcomes. Seven studies examined the outcomes of abusive supervision related to health and well-being, identifying nine key outcomes. Specifically, three studies highlighted the significant impact of abusive supervision on the psychological health and well-being of nurses.^24-26 Two studies each reported a correlation between abusive behaviors of nurse managers and increased emotional exhaustion^42,45 as well as psychological strain.^26,45 In addition, several studies found associations between abusive supervision and increased anxiety,⁴⁰ depression,⁴⁰ and mental health risks.⁴⁴ Poorer physical well-being^26,40 and social well-being²⁶ were also identified as significant outcomes of abusive supervision.

Nursing care outcomes

The outcomes of abusive supervision related to patient care were reported in two studies. Lavoie-Tremblay et al¹³ and Sharif Nia et al²⁹ found a significant and negative association between abusive supervision and nurse-assessed quality of nursing care. These findings suggest that exposure to an abusive nurse manager may have an impact on the delivery of quality, safe, and effective nursing care to patients.

Abusive supervision mediators

Ten mediators were identified in this review, which were categorized into three clusters: (a) affective-based, (b) motivation-based, and (c) health and well-being.

Affective-based mediators

Job satisfaction was the most frequently tested affective-based mediator between abusive supervision and the four nurse-related outcomes. Job satisfaction had a partial mediating influence on the association between abusive supervision and turnover intention⁴⁵ and public service motivation.⁴³ In other words, nurses who experienced abusive supervision were more likely to have lower job satisfaction, which, in turn, increased their intention to leave their job and negatively affected their motivation to serve the public. However, job satisfaction did not mediate the relationship between abusive supervision and work engagement, as indicated by Osei et al.³⁸ Although abusive supervision may negatively impact work engagement among nurses, job satisfaction may not be the mechanism through which this relationship operates. Sharif Nia et al²⁹ found that job satisfaction acted as a pathway between abusive supervision and nursing care quality, suggesting that nurses who experienced abusive supervision may have lower job satisfaction, which subsequently affected the quality of care they provided.

Motivation-based mediators

Three studies in this review reported motivation-based mediators that linked abusive supervision to three outcomes: turnover intention, work engagement, and counterproductive work behavior. Low et al³⁷ found that workplace injustice partially mediated the association between abusive supervision and counterproductive work behavior. This implied that nurses who experienced abusive supervision were more likely to perceive workplace injustice, which, in turn, increased their engagement in counterproductive work behaviors. Similarly, Özkan³⁹ found that workplace incivility, ostracism, and bullying acted as mediators between abusive leadership and turnover intention. Nurses who experienced abusive leadership may also have encountered workplace mistreatment, such as incivility, ostracism, and bullying, which then contributed to their intention to leave the organization. However, Osei et al³⁸ found that silence behavior did not mediate the relationship between abusive supervision and work engagement. Although nurses may have chosen to remain silent in response to abusive supervision, it may not have directly affected their level of work engagement.

Health and well-being mediators

Six studies in this review reported mediators related to health and well-being, including anxiety, psychological distress, and emotional exhaustion. Anxiety was found to be a mediator between abusive supervision and job satisfaction,⁴⁵ work performance,⁴⁵ and workplace ability.¹¹ Nurses who experienced abusive supervision were more likely to experience higher levels of anxiety, which in turn negatively impacted their job satisfaction, work performance, and overall ability to function effectively in the workplace. Pyc et al⁴⁰ also found that anxiety partially mediated the relationship between abusive supervision and emotional exhaustion, physical symptoms, and turnover intention. This indicates that abusive supervision may contribute to increased anxiety levels, which then lead to higher levels of emotional exhaustion, physical symptoms, and a greater likelihood of considering leaving the organization. In other studies, occupational stress was identified as a mediator between abusive supervision and physical, social, and psychological well-being²⁶ and turnover intention.⁴⁵ Nurses who experienced abusive supervision may also experience higher levels of occupational stress, which can negatively impact their overall well-being and increase their intention to leave the organization. Emotional exhaustion was found to mediate the association between abusive supervision and feedback avoidance⁴⁷ and job neglect.⁴² Nurses who experienced abusive supervision were more likely to experience emotional exhaustion, which then led to avoidance of feedback and neglect of job responsibilities.

Discussion

Numerous reviews in nursing have been conducted to illustrate the association between effective leadership (e.g. ethical, authentic, and transformational) and nurse-related and patient safety outcomes.^6,7 However, to the best of our knowledge this systematic review represents the first comprehensive synthesis of literature on abusive supervision specifically in the nursing field. The findings of this review offer valuable insights that can greatly assist hospital and nursing administrators in formulating effective strategies aimed at enhancing the leadership competence of nurse managers. Furthermore, these findings can inform the development of targeted programs aimed at improving work productivity, enhancing the health and well-being of nursing staff, and promoting higher levels of staff retention. In general, the findings of this review suggest that abusive supervision could result in multiple dysfunctional consequences for nurses. These findings provide additional support to research conducted in nursing^28,39 and nonnursing sectors,^9,48 showing that a leader’s abusive behavior may have motivational, relational, cognitive/social-cognitive, and affective impacts on subordinates.

The concept of supervision in leadership involves the behaviors exhibited by leaders, which have an impact on outcomes that are not directly connected to those behaviors. Instead, these outcomes are influenced by intermediate variables known as mediators. In other words, the actions and behaviors of leaders have an indirect effect on distal outcomes through the involvement of proximate variables or mediators.¹¹ Prior studies in other disciplines have identified a myriad of mediators (e.g. affective, motivational, and behavioral) that could explain how a leader’s abusive behavior leads to dysfunctional outcomes in workers.⁴⁸ This review found that the most frequently assessed mediators were affective (e.g. job satisfaction), motivational (e.g. workplace incivility), and health-related (e.g. psychological strain) in nature, consistent with earlier reports.^49,50 Based on our findings, we developed a model (Figure 2) illustrating the interaction between the mediators and outcomes of abusive supervision, which could be applied in nursing and healthcare.

Figure 2.

Synthesis of the review findings.

This review has identified several limitations that could have implications for future research on abusive supervision. First, a limited number of studies have provided well-grounded theoretical frameworks to help explain the association between abusive supervision and a broad range of nurse-related outcomes and mediators. Interestingly, only four studies^25,26,39,47 provided a theoretical basis, which is partly attributed to the lack of a specific theory explaining how abusive supervision occurs. Having a well-grounded theoretical basis is useful as it can guide researchers in interpreting and analyzing results effectively. Meanwhile, given the dynamic nature of abusive leadership and its associated constructs, using a more rigorous research design, such as a longitudinal design, could provide clearer and more meaningful results. Most of the studies reviewed used nonprobability sampling, and future studies should employ probability sampling methods, which could yield more valid and generalizable findings. Although Tepper’s¹⁰ scale has been widely tested across professions and found to be highly valid and reliable in assessing abusive supervision, developing a scale specific to nursing may generate results that best reflect the unique nature and behaviors of nurse managers/leaders. Finally, it is worth noting that the majority of studies included in this review originated from non-Western countries. This is significant because cultural and contextual factors can influence the expectations and perceptions of nursing practice and what constitutes an abusive work setting. Different countries may have distinct cultural norms, power dynamics, and organizational structures that shape their understanding of workplace abuse. Therefore, the concept of abusive supervision may be interpreted differently in non-Western contexts, reflecting the unique cultural and societal values prevalent in those countries. This highlights the importance of considering cultural variations when studying and addressing abusive supervision in nursing practice, as interventions and strategies may need to be tailored to specific cultural contexts to effectively mitigate its negative impacts.

Limitations of the Review

The interpretation of this review’s findings should take into account several potential limitations. The exclusive reliance on studies published in English could introduce publication bias, possibly excluding pertinent research in other languages and thereby affecting the overall comprehensiveness of the synthesized literature. While the deliberate focus on abusive supervision in the nursing field serves a clear purpose, it could inadvertently limit the examination of abusive leadership dynamics within broader healthcare contexts, potentially constraining the generalizability of the findings. In addition, the limited number of studies investigating the correlation between abusive supervision and patient safety outcomes might curtail a comprehensive understanding of the potential ramifications of abusive leadership on patient care. Notably, the absence of longitudinal studies in the review might impede the establishment of causal relationships between abusive supervision and outcomes pertinent to nurses. The existence of variations in how workplace abuse is defined across diverse cultural contexts could potentially restrict the applicability of the findings on a universal scale. Although the review hints at possible implications for strategies aimed at mitigating the adverse effects of abusive supervision, it lacks specific insights into the formulation of such strategies. Finally, the review’s emphasis on affective, motivational, and health-related mediators could inadvertently overshadow other potential mediators, emphasizing the necessity for a more comprehensive exploration of this aspect.

Relevance to Nursing Practice

The overall findings of this systematic review suggest that promoting positive leadership and behaviors among nurse managers can be an effective strategy for enhancing nurses’ work satisfaction, productivity, and retention, ultimately leading to improved nursing care quality. Addressing abusive supervision in the workplace requires a multifaceted approach that can be categorized into three levels of prevention.⁸ At the first level of prevention, it is important to implement rigorous screening processes for potential abusive behaviors in nurse or nurse manager candidates, conduct thorough background checks to identify any history of hostile behaviors, and regularly assess the leadership and behaviors of nurse managers. In addition, establishing clear organizational policies that outline expected behaviors of nursing staff is crucial.⁵¹ The second level of prevention involves providing relevant training programs to enhance the behaviors of nurse managers, including anger management, sensitivity training, and emotional intelligence programs. It is also important to offer counseling sessions, stress management programs, and strategies for coping and building resilience for nurses who have been exposed to abusive behaviors.^13,29 The third level of prevention focuses on changing the behaviors of nurse managers and providing leadership competency training programs based on theoretical frameworks. Extensive research has highlighted the significance of leadership and management development programs in promoting positive leadership and behaviors among nurse managers, as well as their potential in reducing abusive behaviors or management styles.^7,52 Other strategies that have shown significant improvements in leader behaviors and management styles include simulation-based activities for management and leadership, leadership mentoring, and leadership certifications.^12,53,54

Conclusions

With the current shortage of qualified nurses and the challenges in retaining skilled and experienced nursing staff, the promotion of positive leadership and behaviors among nurse managers has become increasingly crucial in organizations. The results of this systematic review provided compelling evidence of the detrimental consequences associated with abusive supervision in the nursing workforce. Furthermore, the review highlighted the pathways through which abusive supervision impacts various nurse-related and patient safety outcomes. The findings emphasized the significance of developing a cohort of nurse leaders and managers who possess the skills to effectively lead and manage a nursing workforce dedicated to delivering safe and high-quality nursing care. However, despite the growing body of evidence linking abusive behaviors of nurse managers to a wide range of outcomes in nurses, there remains a scarcity of studies examining how such behaviors may affect patient safety outcomes. To address this research gap, future studies should focus on exploring the impact of abusive supervision on patient safety outcomes.

Supplemental Material

sj-docx-1-wjn-10.1177_01939459231212402 – Supplemental material for Abusive Supervision and Its Relationship With Nursing Workforce and Patient Safety Outcomes: A Systematic Review

Supplemental material, sj-docx-1-wjn-10.1177_01939459231212402 for Abusive Supervision and Its Relationship With Nursing Workforce and Patient Safety Outcomes: A Systematic Review by Leodoro J. Labrague in Western Journal of Nursing Research

Footnotes

Acknowledgements

The expertise of Dr. Claire Kirmas is acknowledged.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Clearance

This review study does not require ethical approval since human samples were included.

ORCID iD

Leodoro J. Labrague

Supplemental Material

Supplemental material for this article is available online.

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