Toxic Leadership in Emergency Nurses: Assessing Abusive Supervision and Its Team-Level Impacts on Conflict Management and Organizational Commitment

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Introduction
Emergency departments (EDs) are critical high-stake environments within the healthcare system [1], where the pace is relentless and the margin for error is minimal [2,3].Tese units serve as the central hub for acute treatment, where decisions must be rapid and precise [4][5][6], with the potential to signifcantly alter patient outcomes [3].Te intensity and pressure inherent in emergency departments require a leadership style that not only facilitates rapid decision-making but also nurtures a supportive and cohesive team environment [7,8].However, the prevalence of authoritarian and manipulative leadership styles in such settings often undermines these objectives, introducing a toxic dynamic that can severely afect team functionality, staf well-being, and, ultimately, patient care quality [9][10][11].
Toxic leadership in emergency nursing is characterized by a spectrum of harmful behaviors [12,13], including but not limited to abusive supervision, rigid top-down control [14], exploitation, self-serving actions, and emotional manipulation [15][16][17].Tese behaviors collectively contribute to an environment where nursing staf can experience decreased well-being, reduced morale [18,19], and a general sense of job dissatisfaction [20][21][22][23].Te extreme stress and urgency that defne emergency care exacerbate the negative repercussions of such leadership, amplifying the challenges faced by nursing teams and compromising the quality of care provided to patients [24][25][26].
Te literature extensively documents the adverse efects of toxic leadership in various organizational contexts, highlighting increased workplace stress, burnout, and emotional exhaustion among employees [27][28][29].In the emergency nursing feld, these efects are particularly pronounced due to the specialized nature of the work [30], which demands tight coordination among diferent specialists under intense pressure [31,32].Terefore, the vulnerability of emergency nursing teams to toxic leadership is markedly higher, given the critical reliance on efective communication, collaboration, and team cohesion to ensure optimal patient outcomes [33][34][35].
Despite the well-documented negative impacts of toxic leadership on organizational well-being and performance, there is still a signifcant gap in understanding how such leadership infuences confict confrontation strategies and organizational commitment among emergency nurses [36,37].Tis gap is particularly concerning given the critical importance of efective leadership in fostering team cohesion, maintaining high-performance standards [38][39][40][41], and ensuring the delivery of quality care in high-risk emergency settings [27][28][29][30][31]. Efective communication and the management of interpersonal tensions are crucial for maintaining constructive team dynamics [42,43].Yet, there is a dearth of research focusing on how emergency nurses, who are at the frontline of care delivery and coordination, navigate conficts and maintain commitment in the face of toxic leadership [44][45][46].
Emergency nursing, with its unique challenges related to coordination, decision-making, and high-stakes outcomes, requires a leadership approach that supports rather than undermines team eforts [47,48].Te distinct context of emergency care, where patient lives are frequently in the balance, underscores the nonnegotiable need for leadership that promotes rather than detracts from team cohesion, performance, and care standards [42,49].Terefore, there is a pressing need for research that specifcally examines the repercussions of toxic leadership on emergency nurses [50,51], particularly in terms of their strategies for confronting conficts and their perceptions of organizational commitment [45,[52][53][54][55][56].
Tis study aims to address these critical gaps by providing an in-depth analysis of the impacts of toxic leadership on confict resolution and organizational commitment among emergency nursing staf.By focusing on the unique challenges and dynamics of emergency nursing, the research seeks to uncover the specifc ways in which toxic leadership behaviors manifest in this context and their implications for team dynamics, nurse well-being, and patient care.Te ultimate goal is to inform targeted interventions and reforms that promote constructive communication and ethical leadership practices and support the well-being of nursing staf, thus improving the overall quality of emergency care delivery.
In doing so, this study not only aims to contribute to the existing body of knowledge on leadership in healthcare but also to provide practical insights that can guide the development of policies and practices to mitigate the negative efects of toxic leadership in emergency departments.By elucidating the mechanisms through which toxic leadership impacts emergency nursing teams, this research underscores the urgent need for systemic changes that foster healthier team dynamics, improve nurse welfare, and, most importantly, improve patient outcomes in these high-pressure settings.

Objective
(1) Assess the prevalence of the perceived impact of toxic leadership behaviours experienced by emergency department nurses.(2) Investigate the relationship among the perceived impact of toxic leadership, organizational commitment, and confict management strategies used by emergency department nurses.

Design.
A cross-sectional design was used that included a survey of emergency nurses in a single dimension and commitment dimensions [57].Te ability to collect substantial descriptive numerical data from a relatively large sample to support quantitative statistical analysis was also an asset for investigating complex phenomena within emergency nursing environments [58].Additionally, crosssectional designs enable accessing samples with diverse perspectives, compared to case studies or longitudinal approaches, which tend to involve fewer subjects.Terefore, the methodology facilitated the evaluation of the impacts of perceived toxic leadership that can be generalizable in fve major emergency departments [59].Overall, the crosssectional approach ofered feasibility and generalizability advantages that aligned well with the study's objectives.Power analysis was performed using RaoSoft software to determine the recommended sample size.Te input included a 95% confdence level, a 5% error margin, an estimated population of nurses of 580 across sites, and a 50% response distribution.Tese parameters detected medium efect sizes between study variables with 80% power.Te minimum adequate sample size calculated was 387 subjects.Tis aligned with the recommendations that nursing research should have sufcient power [60,61].
Te RaoSoft tool was chosen for its user-friendly interface and its ability to provide accurate sample size estimates based on essential criteria such as confdence level, margin of error, and expected distribution of responses [62].Its application in our study was based on a methodological approach that values precision and adherence to the statistical norms recognized by the academic community.Tis approach ensures that our fndings are robust and that the sample size adequately supports the study objectives and anticipated analyses.
A purposive, multistage sampling technique was utilized during recruitment at departmental meetings, through informational fyer distribution, and researcher visits.Of approximately 580 eligible nurses, 580 were invited to participate over a 15-day period [63].Emphasizing voluntary participation and confdentiality during recruitment aimed to minimize sampling bias by encouraging representative enrollment across specialty experience levels.
Purposive sampling was utilized to recruit participants with substantial emergency department experience who could intentionally provide meaningful perspectives on the leadership dynamics central to this research.Although probability methods have advantages with respect to representativeness and generalizability, accessing informed participants was an efcient way to obtain rich insights into this complex phenomenon.During the multistage recruitment process, concerted eforts were made to emphasize voluntary participation and transparency around the purposes of the study to mitigate biases and approximate a representative enrollment of providers.However, the input to assess alternative probability sampling methods is valuable advice should subsequent follow-up studies be conducted to generalize fndings further.
Finally, 387 nurses completed the survey packet, representing a response rate of 67%.Tis purposive approach supported accessing informed perspectives on a complex phenomenon from an adequately powered sample of experienced emergency department nurses.Te sampled nurses refected a diversity of ages, experience levels, genders, and education levels.Limitations include regional specifcity since nurses were recruited from within a single Saudi Arabian province rather than nationally.

Eligibility Criteria (i) Inclusion criteria:
(1) Registered nurses employed full-time in emergency departments.(2) At least one year of experience in emergency care settings.
(3) Currently working in selected public hospitals in the northern province of Saudi Arabia.(4) Provided informed consent to participate in the study.

Data Collection Tools.
Rigorously developed, psychometrically sound instruments were used to ensure a valid and reliable measurement of key variables, including perceived toxic behaviors, confict tendencies, and organizational commitment.Extensive prior research provides confrmation of strong validity and reliability for the selected tools in various settings [64][65][66][67][68]. Reevaluation among the target nursing population during piloting further upholds these measurement properties.Te following descriptions provide an overview of each established data collection tool, including interpretations.
(1) Toxic Leadership Assessment [69]: Tis 30-item scale developed by Schmidt (2008) measures perceived toxicity that spans fve dimensions: abusive supervision, authoritarian leadership, narcissism, self-promotion, and unpredictability.Items use a scale of agreement of 1-6, with higher scores indicating greater perceived destructive behaviors.Previous studies in all felds produced Cronbach's alpha scores of 0.82-0.96[65,70], suggesting excellent internal reliability.Te analysis of confrmation factors during the pilot test supported the multidimensional structure and validity of the construction among the target nurse population.
(2) Rahim Organizational Confict Inventory-II (ROCI-II) [67]: Developed by Rahim in 1983, this validated inventory identifes the tendencies of confict management style on fve subscales: dominating, avoiding, obliging, compromising, and integrating.Te 28 items refect varying concerns for self-versus others when facing conficts using a 5-point Likert scale.Extensive research reports that Cronbach's alpha reliability coefcients exceed 0.70 on subscales, indicating solid internal consistency and the ability to discriminate styles [71].Pilot testing among nurses confrmed the reliability and stability of the factor structure.(3) Organizational commitment scale [72].

Journal of Nursing Management
Tis instrument, conceptualized by Meyer and Allen (1991), assesses employee attachment across three commitment dimensions: afective, normative, and continuance.Using a 7-point Likert agreement format, higher scores refect stronger feelings of emotional connection, perceived obligation, and necessity-driven commitment, respectively [72,73].Confrmatory research supports predictive validity regarding outcomes like turnover and performance [73].Reliability analysis during piloting maintains internal consistency with an alpha of 0.88.

Ethical Approval.
Ethical approval for this study was obtained from the Research Ethics Committee for Health Afairs in the Hail region, KSA (IRB: KACS, KSA: H-08-L-074).Permission to access the study sites and participants was granted by the nursing directors of the fve participating emergency departments.Participants were provided with information sheets detailing the purpose of the study, voluntary participation, potential risks/benefts, and confdentiality measures.Written informed consent was obtained from each participant before the distribution of the surveys, and they had the option to withdraw at any time.Te study followed ethical guidelines for nursing research according to the Declaration of Helsinki and the Code of Ethics of the International Council of Nurses, and the Ethics Committee reviewed all procedures and protocols to protect the rights and welfare of participants.

Procedure.
A systematic procedure was developed, validated, and implemented to obtain quantitative measurements that aligned with the study objectives on perceived toxic leadership and the consequent outcomes among emergency nurses.
Following approval from the institutional ethics review board, the data collection process began across the 5 major hospital sites based on a multistage cluster sampling technique detailed in the dedicated Sample and Sampling section.Te directors of the nursing department also provided site access approvals prior to recruitment.
Te initial participation of the participants involved raising awareness through announcements at staf meetings and informational fyers on the importance of leadership dynamics research to evoke interest among emergency nurses.For nurses expressing interest and meeting the experience inclusion criteria, the principal investigator obtained written informed consent to participate after discussing: (i) Te purpose is to investigate perceived leadership behaviors and impacts.(ii) Survey response process and types of deidentifed data collected (iii) Minimal risk and direct benefts associated with voluntary participation (iv) Right to withdraw participation anytime despite initial agreement (v) Storage of completed surveys in an access-restricted locked cabinet Consenting participants received numbered survey packets, including validated Likert-type scale instruments on perceived leadership toxicity (30 items), confict confrontation tendencies (28 items), and organizational commitment (24 items), along with a basic demographic questionnaire.Te packets had an estimated completion time of 15-20 minutes during work hours without disrupting the operation of the emergency department.
Te sealed envelope collection boxes were placed in accessible common staf areas within each unit for returned packets over 2 consecutive weeks.Daily secured recovery, storage protocols, and tracking of response rates enabled midpoint reminders to optimize participation and motivational prompts during meetings to underscore the importance and encourage collaboration.
At the conclusion of the study, a participation rate of 67% was achieved, providing 387 fully completed nurse surveys for sufcient statistical power in the planned quantitative analyses.Encrypted data sets excluded any identifying details to uphold respondent rights and confdentiality standards governing ethical research.Restricted access and data aggregation protected anonymity prior to controlled analyses.Tis rigorous procedure allowed signifcant quantitative measurements aligned directly with the specifc research questions on perceived toxic leadership outcomes.
2.9.Statistical Analysis.All data were analyzed using SPSS version 22.0 (IBM Corp, Armonk, NY).Descriptive statistics, such as means and standard deviations, summarized sample demographics and scale measurement scores.Pearson's correlation analysis quantifed the bivariate relationships among perceived toxicity, confict management styles, and organizational commitment types.Multiple linear regression examined predictors of afective commitment.Te mediation analysis evaluated whether confict management tendencies mediated the efect of destructive leadership on reduced commitment.For all tests, a p value <0.05 was considered statistically signifcant.Reliability analysis confrmed the internal consistency of measurement instruments.Te assumptions of parametric testing were checked, including normality and homoscedasticity evaluation to meet the application criteria.Te efect sizes were calculated to quantify the strengths of the observed relationship.

Results and Discussion
3.1.Results.Te results of this cross-sectional study provide important insights into the complex relationships between perceived toxic leadership, confict management approaches, and organizational commitment among emergency department nurses.Key fndings demonstrate the high prevalence of destructive leadership behaviours reported by participants, with authoritarian, narcissistic, and unpredictable actions notably prevalent.Signifcant correlations emerged between perceived toxicity and confict management styles, with passive and aggressive approaches positively associated but constructive strategies negatively related.Toxic leadership also related to lower afective/ normative commitment but higher continuance commitment.Furthermore, confict tendencies were found to partially mediate the link between destructive leadership and reduced commitment.Finally, higher nurse experience and education predicted higher perceived toxicity.Te following sections delve deeper into these results, underscoring the need for supportive leadership and confict training tailored to the intense emergency context.Elucidating these dynamics is the frst step toward fostering healthy environments where nurses can thrive and provide optimal patient care even in high-stake situations.
Table 1 presents key demographic characteristics of the 387 emergency care nurses sampled in this study.Te table shows a relatively young sample, with 83% under 40 years of age.Most were women (58%), typical for the nursing feld.A range of education levels were represented, from diplomas to master's degrees, with most holding a bachelor's degree (65%).In terms of experience, most nurses had 1-10 years of tenure (72%), while few were new nurses or very experienced.
Table 2 efectively highlights the prevalence and characteristics of perceived toxic leadership behaviours among emergency nurse leaders.Inclusion of both the percentage of respondents reporting each behaviour and the mean score with standard deviations ofers a nuanced understanding of the problem.Te table shows that authoritarian leadership and narcissism are the most commonly perceived toxic behaviours, with 77% and 75% of nurses reporting these experiences, respectively, and correspondingly high mean scores (4.0 and 3.9).Tis suggests a signifcant impact of these behaviours on the workplace.In contrast, abusive supervision, although serious, is reported less frequently (43%), with a lower mean score of 2.3.Te range of standard deviations (0.3 to 0.7) indicates the variability in how these behaviours are experienced among the respondents.Te high prevalence rates, combined with notable mean scores, underscore the critical nature of addressing toxic leadership in emergency nursing settings to improve workplace dynamics and overall quality of care.
Table 3 of the study presents insightful fndings on the relationship between various toxic leadership behaviours and organizational commitment, mediated by confict management styles.Te table reveals a negative correlation between all forms of toxic leadership and organizational commitment, indicating that higher levels of toxic behaviour's correspond to lower levels of commitment among emergency care nurses.In particular, authoritarian leadership shows the strongest negative correlation (−0.45), suggesting that it has the most detrimental impact on organizational commitment.Te sizes of the mediation efect, ranging from 0.15 for self-promotion to 0.22 for authoritarian leadership, indicate that confict management styles play a signifcant role in mediating these relationships.Te statistical signifcance of these relationships is further underscored by the p values, with most falling below 0.001.Tese data imply that the way nurses manage confict can signifcantly bufer or amplify the negative efects of toxic leadership on their commitment to the organization.Table 4 presents the results of a mediation analysis that examined whether the confict management style of nurses mediated the relationship between perceived toxic leadership and organizational commitment.Te signifcant indirect efect (B � −0.33) suggests that confict management partially mediates the association between perceived toxic leadership and commitment.Tis lends preliminary support to the hypothesis that leadership toxicity may infuence nurses' confict approaches, which in turn impacts their organizational commitment.However, the cross-sectional design prevents determining directionality or causality.Te results should also be interpreted with caution given the reliance on subjective assessments of leadership toxicity.However, the table succinctly conveys that confict management appears to play a mediating role in the link between perceived toxic leadership and organizational commitment among these emergency care nurses.Te results provide initial evidence that the modifcation of confict approaches could potentially counteract some negative impacts of toxic leadership on nurses' commitment.Table 5 presents the results of a multiple linear regression model that predicts the afective organizational commitment of nurses to perceive toxic leadership, avoidant confict style, integration of confict style, age, and education level.Te model was signifcant, which explained 28% of the variance in afective commitment.Higher perceived toxicity and avoidant confict are independently related to lower afective commitment, while integrating style and age are associated with higher commitment.Te large sample size lends confdence in the fndings.However, limitations include the cross-sectional design and the reliance on subjective assessments.Te variation of the common method can also infate the relationships between the measured variables.However, the table succinctly summarizes key predictors of nurses' afective commitment, highlighting the negative impacts of destructive leadership and confict avoidance, as well as the positive efects of collaborative confict management.
Table 6 shows the results of a hierarchical linear regression mediation analysis.Te signifcant indirect efect indicates that confict management partially mediated the relationship between perceived toxic leadership and organizational commitment.Approximately 29% of the total efect of leadership on commitment operated indirectly through confict management styles.Tis supports the hypothesis that toxic leadership may infuence nurses' confict approaches, which then afects their commitment.However, the cross-sectional design prevents determining causation or directionality.Te subjective nature of leadership and confict measures should also be considered.However, the table succinctly summarizes evidence that confict management plays a mediating role in the association between perceived toxic leadership and commitment among these nurses.It points to the confict style as a potential mechanism through which destructive leadership relates to reduced organizational commitment.Table 7 presents the results of a logistic regression model that predicts the likelihood that nurses will perceive high levels of toxic leadership based on their demographics.Nurses with higher education levels and more years of experience showed signifcantly greater odds of reporting high toxicity.Te model provides initial evidence that personal factors can afect perceptions and experiences of destructive leadership behaviours.However, the crosssectional design prevents determining causality.Response biases are also a concern with self-reported leadership ratings.However, the table succinctly summarizes the exploratory fndings suggesting that nurse education and tenure may predict perceived leadership toxicity, warranting further investigation.Although preliminary, the results point to potential vulnerabilities based on nursing background that could inform prevention eforts.

Discussion
. Tis cross-sectional study aimed to address gaps regarding perceived toxic leadership impacts on confict and commitment specifcally in emergency nursing.Te objectives were to assess the prevalence of the perceived impact of toxic leadership behaviors experienced by emergency department nurses and investigate the relationship between the perceived impact of toxic leadership, organizational commitment, and confict management strategies used by emergency department nurses.By elucidating these complex dynamics, the intent was to inform interventions tailored to intense emergency contexts where leadership failures could profoundly impact nurse and patient outcomes.Te following discussion interprets results regarding the stated objectives of delineating relationships among perceived toxic leadership, confict management, and commitment in this understudied yet high-stake specialty setting.
Leadership behaviors have far-reaching impacts in healthcare settings, yet toxic leadership remains an understudied phenomenon among nurses [23,74].Tis concern is  [75].
Emergency departments represent a high-stake context where leadership failures could have dire consequences [76].
However, little research has examined toxic leadership among emergency nurses specifcally [23,39,77,78].Tis study helps address this gap by elucidating the impacts of perceived toxicity on the management of nurses' conficts and organizational commitment.Te fndings promise to inform interventions to foster healthy leadership and optimal team functioning in this fast-paced environment where lives are on the line.Our sample of 387 nurses from fve emergency departments in Saudi Arabia reported high perceived toxicity, especially authoritarian, narcissistic, and unpredictable behaviours.Leadership toxicity was positively correlated with passive and aggressive confict styles but negatively associated with constructive confict approaches.Additionally, the increased perceived toxicity is related to a lower afective/ normative commitment but a greater commitment to continued commitment.A salient fnding was the mediating efect of confict management, which explained nearly a third of the relationship between leadership and commitment.Finally, nurses with more experience and education showed a greater likelihood of perceiving toxic leadership.

Prevalence of Toxic Leadership Behaviours.
Te high prevalence of perceived authoritarian (77%), narcissistic (75%), and unpredictable (63%) leadership behaviours confrm toxic leadership as an issue in emergency care settings.Tese rates exceed estimates from a recent metaanalysis that aggregates toxicity prevalence between industries (10-15%) [23].Te extreme stress and urgency of emergency departments can partially explain this elevated toxicity [7,41].However, the authors in [79] found lower perceived toxicity among Indian emergency nurses (14-23% for diferent behaviours).Tis discrepancy highlights the need for comparative data from multiple sites, as the organizational and cultural context can infuence the prevalence.Furthermore, the reliance of this study on selfreports could bias the results, as nurses' attitudes, expectations, and attributions shape their perceptions of leaders [80,81].Integrating peer, supervisor, and patient assessments would provide a more balanced perspective.

Confict Management as a Mechanism.
A signifcant fnding was the mediating efect of confict management, which explained almost a third of the total leadershipcommitment relationship.Tis proposes confict tendencies as a key mechanism that converts toxic leadership into attitudinal outcomes.Longitudinal and experimental studies could further validate this mediation model and directionality [82][83][84].However, the results suggest that strengthening nurses' confict management skills could potentially neutralize some detrimental impacts of poor leadership.

Individual Susceptibility Factors.
Finally, higher education and experience predicted greater perceived toxicity compared to some research in which novice nurses reported worse leadership [85].It implies that standards for acceptable leader conduct increase with experience.Alternatively, toxic leaders can target underconfdent junior nurses.In either case, the results underscore the need to cultivate leadership skills at all levels and protect those most vulnerable.

Relationships among Toxic Leadership, Confict
Management, and Commitment.Signifcant positive correlations emerged between perceived toxic leadership and dominating/avoiding confict styles, while negative associations with integrating and compromising approaches were observed.Tis is consistent with meta-analytic fndings linking abusive supervision to more passive and aggressive confict tendencies [86,87].However, contrasting reports show toxic leadership that specifcally relates to avoiding rather than dominating confict [23,88].Tis discrepancy could refect situational factors, as the emergency context may require more dominant behaviors to match the urgency.Additionally, higher perceived leadership toxicity is related to lower afective/normative commitment but higher continuance commitment.Tese results support conclusions from a nursing review that identifed leadership as an important determinant of organizational commitment [32,89,90].However, the authors in [91] found no

Conclusions
Tis cross-sectional study provides valuable insights into the concerning prevalence of perceived toxic leadership behaviors among emergency department nurse leaders and the implications for nurses' confict management approaches and organizational commitment.Key fndings demonstrate high rates of authoritarian, narcissistic, and unpredictable leadership, which are positively associated with destructive confict tendencies like domination and avoidance.In turn, these connect to lower afective/normative commitment.A salient fnding is that confict management explains almost a third of the total efect of toxic leadership on reduced commitment.Te signifcant correlations found among toxic leader behaviours, adverse confict strategies, and diminished commitment highlight the vital need to cultivate supportive leadership that fosters constructive communication and healthy team dynamics in intense, high-stake emergency departments.Doing so promises to improve nurses' well-being, performance, and patient care quality.Te mediating efect of confict management also suggests that this could be leveraged to mitigate detrimental leadership impacts.However, there are limitations given the single-source design and reliance on subjective measurement.Te cross-sectional methodology also prevents determining causality.Follow-up longitudinal and experimental studies validating the directionality and causal pathways are warranted.Additionally, the sample is regionally limited so that generalizability may be restricted.Nonetheless, by elucidating the prevalence and outcomes associated with destructive leadership in understudied emergency care contexts, this study meaningfully informs policies, training programs, and interventions to counteract toxicity.

Table 2 :
Prevalence of perceived toxic leadership behaviours among emergency nurse leaders.

Table 3 :
Relationship between toxic leadership and organizational commitment mediated by confict management.

Table 4 :
Mediation analysis of the confict management style on the relationship between toxic leadership and organizational commitment.

Table 5 :
Multiple linear regression analysis that predicts afective organizational commitment.

Table 6 :
Mediation analysis using hierarchical linear regression.

Table 7 :
[92]stic regression predicts the likelihood of high toxic leadership based on nurse demographics.thetotalefect.Tis suggests that leadership behaviors can alter nurses' confict approaches in a way that reduces commitment.Although scarce research has directly tested this mechanism, the authors in[92]similarly implicated confict management as a mediator in the leadership-engagement relationship.However, the cross-sectional design prevents causal inferences.Longitudinal designs could help establish directionality.3.2.6.Practical Implications and Future Directions.Te fndings of this study underscore the critical need for the development of confict management training programs specifcally tailored for emergency department nursing staf.Such initiatives could potentially serve as a bufer against the detrimental efects of toxic leadership, potentially improving organizational commitment and workplace morale.Future research should extend these fndings through longitudinal studies to determine the long-term impact of confict management training, examine individual nurse characteristics that afect perceptions of leadership, and assess implications for patient care outcomes.Expanding the scope of research to include diverse cultural and organizational settings would enrich the understanding of toxic leadership dynamics in the emergency care environment.