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

BACKGROUND: Co-created leadership may improve nurses' work environments, but evidence on candidate pathways in hierarchical settings is limited. AIM: To evaluate processes, outcomes and exploratory change pathways associated with a participatory supportive leadership programme in Saudi hospitals. METHODS: 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. RESULTS: 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. CONCLUSIONS: The programme was associated with favourable relational and participatory changes, but the uncontrolled design precludes causal or mediation claims. IMPLICATIONS FOR NURSING MANAGEMENT: 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.