The current competitive nature of the healthcare industry requires that people are attracted and motivated to participate in leadership roles to meet consumer needs and expectations. In nursing, effective leadership is at the core of management roles, and ample evidence has shown that effective leadership achieves good results among nurses, patients and their families, and organizations (Andrews et al., 2012; Fontes et al., 2019).

To date, most substantial surveys have mainly focused on the positive and effective aspects of leadership, whereas the evaluation of ineffective and negative leadership has mostly been ignored (Rosenstein, 2011). Many leaders in many institutions exhibit toxic leadership behaviors and intentionally or unintentionally harm employees and the organizations they work for Roter (2017). Toxic leadership behaviors, defined as a form of supervision where leaders engage in organized, systematic, and sustained destructive behavior that may cause harm to the entire organization (Webster et al., 2016), Behaviors that indicate negative leadership styles include bullying, jealousy, micromanagement, unfair treatment, narcissism, unethical behavior, authoritarian behavior, distrust of others, aggression, intimidation, manipulation of others, and incompetence (Green, 2014; Bakkal et al., 2019; Milosevic et al., 2020).

In recent years, toxic leadership has become increasingly prominent and widespread in the nursing and other healthcare fields. Existing evidence suggests that continuous exposure to toxic nurse managers or leaders may weaken nurses’ motivation and efforts, possibly leading to adverse work consequences such as job dissatisfaction, job disengagement, poor job performance, job burnout, and frequent absenteeism (Rodwell et al., 2014; Erkutlu and Chafra, 2017; Mullen et al., 2018; Örgev and Demir, 2019). In addition, nurses who work under toxic nurse managers or leaders have reported their inclination to leave their organization and the nursing industry (Lavoie-Tremblay et al., 2016). Employee turnover has significant financial implications for healthcare institutions, as training new nurses is more time and capital intensive (Roche et al., 2015). Therefore, urgent development of a nurse retention strategy, which is currently a top priority, is needed. Furthermore, recognizing the level of toxic behavior among nursing managers and identifying influencing factors are necessary in the development of prevention strategies.

Labrague et al. developed the Toxic Leadership Behaviors of Nurse Managers (ToxBH-NM) scale, which specifically measures toxic leadership behaviors among nurse managers (Labrague et al., 2020). This scale is divided into four behavioral dimensions: intemperate, narcissistic, self-promoting, and humiliating. At the same time, it also reflects the four aspects of toxic leadership, which are supported by a large amount of literature (Green, 2014; Bakkal et al., 2019; Milosevic et al., 2020). The items included in “extremist behavior” are related to the aggressive behavior of nursing managers, reflecting a lack of emotional control. The items included in “narcissistic behavior” are related to behaviors or behaviors exhibited by nursing managers for their own interests or personal agendas. The self-promoting behavior refers to the behavior or actions exhibited by nursing managers to promote personal or professional growth and progress while ignoring the welfare of employees or organizations. Finally, the humiliating behavior reflects the behavior that nursing managers may bring embarrassment and shame to employees (Labrague et al., 2020). This scale has been widely adapted and used in various languages and cultures (Labrague et al., 2020, 2021; Ofei et al., 2022; Farghaly Abdelaliem and Abou Zeid, 2023), but its reliability and validity have only been tested among nurses in Türkiye. Its EFA results show that the scale has four dimensions (Celebi Cakiroglu and Tuncer, 2024), the same as the four dimensions of the original scale (Labrague et al., 2020)^. However, the ToxBH-NM scale is rarely used in Chinese settings because it has not yet been translated into Chinese. In China, studies that have evaluated^, toxic leadership behaviors among nurse managers have used scales such as the “Abusive Supervision Item” and “Destructive Leadership Scale,” (DLS) which have been validated in China (Tepper, 2000; Zhong, 2013). However, the items in these scales may not accurately reflect the complex nature of the nursing profession.

This study aimed to translate the ToxBH-NM scale from English into Chinese and test its psychometric properties among Chinese nurses. The results of this study can possibly enhance the cross-cultural validation of the scale. In addition, the Chinese version of the ToxBH-NM (C-ToxBH-NM) scale can provide an innovative, a multidimensional, and an effective research tool for related research.

This study translated and validated the ToxBH-NM scale in the Chinese context, providing empirical evidence for the psychometric properties of a leadership scale among Chinese nursing managers.

The results of this study show that the content validity of the C-ToxBH-NM scale is good, indicating that ToxBH-NM is scientific and reasonable. In addition, after expert consultation and pilot testing, the scale was found to be clear and suitable for evaluating the leadership behavior of nursing managers. Furthermore, items on the C-ToxBH-NM scale were homogenous, relevant, functional, and not redundant as reflected by the inter-item/inter-total correlations, with inter-item correlations of 0.587 to 0.774 and item-total correlations of 0.762 and 0.922, showing a significant positive correlation (r > 0.4). This finding indicates that each item of the C-ToxBH-NM scale can effectively reflect the overall toxic leadership level of nursing managers.

CFA is used to determine the validity of measurement tools developed based on other samples and cultures (Murat, 2017). In this study, the EFA and CFA demonstrated that the construct validity of the scale was good. EFA proved that the scale has only two dimensions, which is different from the four dimensions of the original scale (Labrague et al., 2020). This difference may be related to the race of the research participants. On the one hand, Chinese work culture emphasizes the harmony of collective relationships. Managers need to be impartial and caring for their subordinates. On the other hand, it requires managers to strictly reward and punish and target orientation. There is a significant power distance and clear organizational hierarchy in Chinese work (Sun et al., 2020; Yin et al., 2021). Due to the influence of traditional Chinese culture on the leadership behavior of Chinese managers (Ma and Tsui, 2015), compared to foreign countries, when nursing managers do not like or blame employees, they rarely show obvious suprasocial “hostility” and prefer to use covert and disguised ways to express these thoughts and feelings implicitly (Guo et al., 2022). Therefore, toxic leadership in the context of Chinese culture may differ from other countries. The CFA results indicated that all the fitting data of the C-ToxBH-NM scale are within an acceptable range. Additionally, significant associations between the C-ToxBH-NM scale and C-DLS were observed. These results support the assumption that the C-ToxBH-NM scale has satisfactory criteria-related reliability among Chinese nurse.

The internal consistency of the C-ToxBH-NM scale was acceptable, with a Cronbach’s alpha coefficient of 0.989, which was higher than the generally accepted guideline coefficient of 0.80 (Lance et al., 2006). Compared with the original scale, the Cronbach’s alpha coefficient of the Chinese version is higher than that of the English version.

Finally, the test–retest reliability coefficient of the C-ToxBH-NM was 0.978, indicating that the scale has good reliability over a period. This result provides evidence for the effectiveness of intervention measures aimed at reducing the level of toxic leadership among nursing managers.

In recent years, the leadership of nursing managers has become a hot topic with increasing attention both domestically and internationally, but negative leadership is often overlooked, and no specific measurement tools are available. This study strictly followed the principles of translation, back translation, and cultural adjustment based on Brislin’s translation method to translate the ToxBH-NM questionnaire into Chinese. The C-ToxBH-NM scale included two dimensions and a total of 30 items. The scale has a short title, is easy to understand, has moderate items, and requires a filling duration of 5.47 min, indicating strong feasibility. The research results show that the scale has good reliability and validity and can be used to evaluate the severity of toxic leadership behavior among nursing managers. The total score of this scale can be divided into three levels (mild, moderate, and severe) to provide targeted intervention measures. Moreover, this scale can be used to dynamically evaluate the effectiveness of interventions in real time, indicating its good practical value.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

The studies involving humans were approved by the Ethics Committee of Xiangyang No.1 People’s Hospital, Hubei University of Medicine. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

YZ: Data curation, Investigation, Project administration, Writing – original draft, Writing – review & editing. JL: Data curation, Writing – original draft, Writing – review & editing. XL: Data curation, Writing – original draft. SG: Data curation, Writing – review & editing. FY: Data curation, Writing – review & editing. HX: Conceptualization, Data curation, Methodology, Supervision, Writing – original draft.