Co-Creating Supportive Leadership and Nurse Work Environments: A Mixed-Methods Participatory Action Research Study in...

Co-created leadership may improve nurses' work environments, but evidence on candidate pathways in hierarchical settings is limited.

To evaluate processes, outcomes and exploratory change pathways associated with a participatory supportive leadership programme in Saudi hospitals.

We conducted a five-hospital participatory action research evaluation with an uncontrolled three-wave cohort (N = 200), mixed-effects outcome models, exploratory bootstrap product-of-coefficients analyses, nine interaction tests with Benjamini-Hochberg false-discovery-rate control and longitudinal qualitative data.

Retention was 86.0%. Practice Environment Scale of the Nursing Work Index scores improved (d = 0.36), while personal and work-related burnout and turnover intention decreased and job satisfaction increased; client-related burnout did not change significantly. Thirteen of 20 unadjusted change-pathway intervals excluded zero. Four interactions were nominally significant, but none survived false-discovery-rate correction. Complete-case analyses preserved the significance classification for 10 of 11 outcomes; staffing/resource adequacy attenuated (p = 0.038 to 0.054). Qualitative themes contextualised, but did not confirm, quantitative patterns.

The programme was associated with favourable relational and participatory changes, but the uncontrolled design precludes causal or mediation claims.

Managers can use structured co-creation to support nurse voice and psychological safety while pairing local leadership action with staffing policy and readiness-sensitive implementation.