Workplace incivility and bullying across healthcare professionals: patterns and correlates - a cross-sectional study.

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Learn more: PMC Disclaimer | PMC Copyright Notice BMJ Open . 2026 May 28;16(5):e109056. doi: 10.1136/bmjopen-2025-109056 Workplace incivility and bullying across healthcare professionals: patterns and correlates – a cross-sectional study Sina Yousefian 1 , Mehran Shayganfard 2, ✉ , Malihe Safari 3 , Javad Javaheri 4 , Bahman Sadeghi 5 Author information Article notes Copyright and License information 1 Student Research Committee, Arak University of Medical Sciences, Arak, Iran 2 Department of Psychiatry, School of Medicine, Arak University of Medical Sciences, Arak, Iran 3 Department of Biostatistics, School of Medicine, Arak University of Medical Sciences, Arak, Iran 4 Department of Community Medicine, School of Medicine, Arak University of Medical Sciences, Arak, Iran 5 Department of Community and Family Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise. None declared. ✉ Dr Mehran Shayganfard; mshayganfard@yahoo.com Received 2025 Aug 7; Accepted 2026 May 15; Collection date 2026. Copyright © Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: https://creativecommons.org/licenses/by-nc/4.0/ . PMC Copyright notice PMCID: PMC13223654  PMID: 42209011 Abstract Abstract Objectives To estimate the prevalence and frequency of workplace incivility and bullying across multiple healthcare roles; compare experiences among occupational groups; examine associations with psychological symptoms (stress, anxiety and depression); assess interrelations among mistreatment dimensions (experienced workplace incivility (EWI), witnessed workplace incivility (WWI), instigated workplace incivility (IWI and experienced workplace bullying (EWB)); and evaluate associations with demographic and contextual variables. Design Cross-sectional study. Setting Three teaching hospitals in Arak, Iran, between March and December 2023. Participants A stratified random sample of 550 healthcare workers was invited; 392 responded (response rate 71.3%) and 359 with complete data were included, comprising nurses, interns, residents, general practitioners and administrative staff. Outcome measures Workplace incivility (Workplace Incivility Scale), workplace bullying (Negative Acts Questionnaire-Revised) and psychological symptoms (Depression, Anxiety and Stress Scale-21 Items). Results The sample (N=359) was 64% female with a mean age of 32 years. Significant differences were observed across occupational groups for WWI, IWI and EWB (all p<0.001). However, post hoc analyses indicated that most differences involved administrative staff, while clinical roles showed broadly comparable levels of exposure. Interns showed the highest prevalence of both EWI and EWB (38% and 69%, respectively). All mistreatment dimensions were positively correlated with each other (ρ=0.23–0.86) and with stress, anxiety and depression, particularly for EWI and EWB (ρ=0.39–0.62, p<0.03). In adjusted analyses, EWI and EWB remained associated with higher stress, anxiety and depression after adjustment (all p≤0.014), whereas WWI was associated only with stress (p=0.001) and IWI showed no independent associations. Demographic and contextual variables showed weak and inconsistent associations, except smoking, which was associated with higher mistreatment scores across all dimensions (p≤0.001). Conclusions Workplace incivility and bullying are widespread across healthcare roles, with broadly comparable exposure across clinical staff. Direct experiences of mistreatment showed the most consistent associations with psychological distress, and mistreatment dimensions appeared to operate within interconnected patterns. Addressing these issues requires system-level interventions targeting structural and cultural drivers to promote psychologically safe clinical environments. Keywords: Cross-Sectional Studies, Quality in health care, Health Workforce, Occupational Stress, OCCUPATIONAL & INDUSTRIAL MEDICINE, Anxiety disorders STRENGTHS AND LIMITATIONS OF THIS STUDY. Stratified random sampling with proportional allocation ensured representation across key occupational groups within the clinical hierarchy. Use of validated instruments (Workplace Incivility Scale, Negative Acts Questionnaire-Revised, and Depression, Anxiety and Stress Scale-21 Items) enabled standardised measurement of workplace mistreatment and psychological symptoms. Item-level frequency thresholds were used to define prevalence based on repeated exposure criteria. Multivariable regression analysis was used to assess associations after adjustment for key covariates. The cross-sectional design precludes causal inference and temporal ordering. Introduction Workplace incivility and bullying are significant challenges in healthcare, shaped by structural pressures that affect team functioning and patient care. The emotional demands of clinical work, complex interprofessional coordination and performance pressures make healthcare particularly vulnerable to hostile work environments. 1 Workplace mistreatment can take multiple forms, including direct experience (experienced workplace incivility (EWI) and experienced workplace bullying (EWB)), witnessing others being mistreated (witnessed workplace incivility (WWI)), and engaging in uncivil behaviour oneself (instigated workplace incivility (IWI)). 2 Incivility refers to low-intensity, norm-violating behaviours (eg, rudeness) that are often ambiguous in intent 3 and perceived as irritating rather than threatening. 4 Bullying, by contrast, involves more severe repeated acts (eg, harassment) characterised by power imbalance and clearer intent to harm. 5 6 Both are defined by repetition and persistence, distinguishing them from isolated incidents. Prevalence estimates for incivility and bullying in healthcare vary widely—from 3.9% to 86.5% depending on occupational role and context—yet both are consistently associated with anxiety, depression, emotional exhaustion and cognitive impairment. 7 8 Organisationally, mistreatment erodes morale, teamwork and communication. 2 7 In healthcare, these effects may lead to treatment delays, medical errors, reduced quality of care and adverse patient outcomes. 19 , 11 Evidence from Iran indicates that workplace incivility and bullying are also significant concerns in local healthcare settings. Iranian studies report substantial exposure to workplace mistreatment, with regular exposure among 29% to over 50% of nurses and a similarly high burden among medical residents. 12 , 14 Hierarchical training structures, high workload, and limited institutional support have been identified as contributing factors. 15 16 Despite growing evidence, workplace incivility and bullying remain underexplored across the full professional spectrum of healthcare. Most studies have focused on nurses and direct victims, neglecting other occupational groups and perspectives, including witnesses and instigators. Given the hierarchical and interdependent nature of healthcare systems, shaped by authority gradients and interprofessional interactions, understanding mistreatment requires a multidimensional, system-level approach that captures multiple roles and perspectives simultaneously. Teaching hospitals, where diverse professional groups interact within shared clinical environments, provide an appropriate setting for such analyses. Study contribution and objectives This study aims to (1) estimate the frequency and prevalence of workplace incivility and bullying across roles; (2) compare experiences among occupational groups; (3) examine associations with psychological symptoms (stress, anxiety and depression); (4) assess interrelations among mistreatment dimensions (EWI, WWI, IWI and EWB) and (5) evaluate associations with demographic and contextual variables (age, gender, work experience, marital status, parental status and smoking). Materials and methods Study design and setting This cross-sectional study was conducted from March to December 2023 across three teaching hospitals affiliated with Arak University of Medical Sciences in Arak, Markazi Province, Iran (Amiralmomenin, Valiasr and Amirkabir hospitals). Arak is an industrial city with a mixed urban population and serves as a major healthcare hub for the surrounding region. The participating hospitals are public tertiary care teaching centres providing multispecialty services and serving as training sites for medical students and residents. Amiralmomenin and Valiasr hospitals provide general adult multispecialty services, including internal medicine, surgery, obstetrics and gynaecology and their subspecialties, along with emergency medicine, neurology, orthopaedics and infectious diseases. Amirkabir Hospital provides paediatric, psychiatric, cardiology and emergency services. The Iranian healthcare system integrates medical education with service delivery within hierarchical training structures, where interns and residents work under supervision in high-demand clinical environments, within a sociocultural context characterised by hierarchical professional relationships. Interns were defined as medical students in the final 2 years of a 7-year undergraduate programme undergoing clinical rotations. Participants included nurses, interns, residents (across internal medicine, surgery, paediatrics, psychiatry and obstetrics/gynaecology), general practitioners (GPs) and administrative staff. Occupational groups were selected a priori to represent key roles within the clinical hierarchy and workplace interaction network. Interns and residents represented trainee roles exposed to supervision and authority gradients; nurses represented the frontline workforce with sustained patient-facing and interprofessional interaction; GPs represented physicians working across teams; and administrative staff provided a non-clinical comparison group. A stratified random sampling approach was used, with proportional allocation based on the size of each occupational group ( online supplemental table 1 ). The total number of eligible individuals in each group was obtained from institutional staff rosters and training programme records. Sample sizes were allocated proportionally to group size, and participants were selected within each stratum using random selection procedures applied to staff rosters and duty schedules. Eligibility required at least 6 months of experience in the current role to ensure sufficient workplace exposure. Sample size was calculated using Teo et al ’s method, 17 based on Fisher’s Z-transformation for correlation coefficients. Assuming a moderate correlation (r=0.3), a two-sided alpha of 0.05 and 80% power, the minimum required sample was 357 participants. Because the primary analytic objective was to examine associations between mistreatment dimensions and psychological symptoms, the study was powered for correlational analyses rather than for pairwise subgroup comparisons. To accommodate non-response, 550 questionnaires were distributed; 392 were returned (response rate: 71.3%) and 359 valid responses remained after excluding questionnaires with missing data on key variables. Complete case analysis was used, and no imputation was performed because the proportion of missing data was low. Instruments All instruments were administered in their validated Persian versions. Participants provided self-reported data on age, gender, job title, work experience, marital status, parental status, smoking status, weight and height. Depression, Anxiety and Stress Scale-21 Item The Depression, Anxiety and Stress Scale-21 Item (DASS-21) includes three 7-item subscales (depression, anxiety and stress), scored from 0 to 3, with subscale totals doubled to match the DASS-42 metric. Both the original (α=0.87–0.94) 18 and Persian version (α=0.79–0.93) 19 demonstrate good reliability. Raw subscale scores were used as continuous variables in analyses. Workplace Incivility Scale The 21-item WIS assesses EWI, WWI and IWI over the past 6 months using a 5-point scale. Developed by Cortina et al 20 and revised by Blau and Andersson, 21 it shows strong reliability in the original and Persian versions (α=0.83–0.96 and 0.85–0.89, respectively). 22 23 Subscale scores for EWI, WWI and IWI were analysed as continuous variables. Negative Acts Questionnaire-Revised The 22-item Negative Acts Questionnaire-Revised (NAQ-R) assesses exposure to workplace bullying using a 5-point scale. Developed by Einarsen et al , 24 it demonstrates high internal consistency in the original and Persian versions (α=0.86–0.93 and 0.94, respectively). 25 26 Total scores were used as a continuous indicator of EWB. Procedure Questionnaires were distributed during working hours and completed privately. Participants received standardised instructions and returned completed forms in sealed envelopes. Anonymity was assured, and no identifying information was collected. Occupational roles were recorded for stratification purposes, and data were deidentified and analysed in aggregate. Statistical analysis Analyses were conducted using SPSS V.24, with significance set at p<0.05. Continuous variables included NAQ-R scores, DASS-21 and WIS subscale scores, age, work experience and body mass index (BMI) (kg/m²). Categorical variables included gender, marital status, parental status, smoking status and occupational group. Prevalence analysis Prevalence and frequency were determined using item-level analysis, based on responses to individual items rather than average scale scores—consistent with standard definitions that emphasise the repetitive nature of workplace incivility and bullying. 6 EWI frequency was defined as the highest frequency reported across items in the EWI subscale of WIS. For EWB, frequency required at least two distinct bullying behaviours (from the NAQ-R) reported at the same frequency. For both EWI and EWB, prevalence was defined as the proportion of individuals reporting weekly or daily exposure, consistent with Mikkelsen and Einarsen’s threshold. 27 Comparative analyses Due to non-normal distributions of outcome variables (Shapiro-Wilk tests) and unequal group sizes, non-parametric tests were employed for most comparisons. Psychological and workplace variables were compared across the five occupational groups using Kruskal-Wallis tests, followed by post hoc Mann-Whitney U tests. Two-group comparisons (eg, gender and smoking) were analysed using Mann-Whitney U tests. For subgroup analyses among residents: EWB scores met the assumption of normality and were analysed using one-way analysis of variance (ANOVA) with Tukey HSD post hoc tests. EWI scores did not meet normality assumptions and were analysed using Kruskal-Wallis with Mann-Whitney U post hoc tests. To control for Type I error inflation, the Bonferroni correction was applied where appropriate. For Mann-Whitney U tests, effect size (r) was calculated as r = |Z|/√N and interpreted using Cohen’s guidelines as small (≈0.10), moderate (≈0.30) and large (≈0.50). For Kruskal-Wallis analyses, ε² was computed as (H−k+1)/(n−k) and interpreted as small (≈0.01), moderate (≈0.06) and large (≈0.14). 28 Associational analyses Spearman’s rank-order correlations examined associations among workplace incivility and bullying, psychological symptoms and continuous demographic variables. Multivariable regression analysis Multiple linear regression analyses were performed to examine associations between workplace mistreatment and psychological outcomes after adjustment for covariates, with stress, anxiety and depression scores as dependent variables. The main predictors were EWI, WWI, IWI and EWB. Age, gender, smoking status and occupational group were entered as covariates, with occupational group modelled using dummy variables. Covariates were selected a priori based on theoretical relevance and potential confounding effects. All models were constructed using the enter method. Standardised beta coefficients (β), p values and model fit indices (R² and adjusted R²) were reported. Model assumptions were assessed prior to interpretation. Normality, linearity and homoscedasticity of residuals were evaluated using standardised residual plots. Multicollinearity was assessed using tolerance and variance inflation factor (VIF), with VIF values <5 considered acceptable. Influential observations were identified using standardised residuals, leverage values and Cook’s distance. Cases with standardised residuals exceeding ±3 were excluded. One case was excluded from the stress model and four cases from the anxiety model, while no cases were excluded from the depression model. Final regression models were estimated on these datasets after exclusion of influential observations. Sensitivity analyses using the full dataset confirmed consistent results. Patient and public involvement Patients or the public were not involved in the design, conduct, reporting or dissemination of this research. Results Participant demographics Demographic characteristics are presented in table 1 . The sample (N=359) was 64% female, with a mean age of 32 years. Nurses and obstetrics/gynaecology residents were predominantly female, whereas general surgery and psychiatry residents were predominantly male. Administrative staff were the oldest group and interns the youngest. Parental status was highest among administrative staff and lowest among GPs. Hospital-specific demographics are provided in online supplemental table 2 . Table 1. Demographic characteristics of study participants by occupational group. Group (N) Male n (%) Female n (%) Mean age (SD) Single n (%) Married n (%) Parent n (%) Non-parent n (%) Nurses (110) 24 (22) 86 (78) 30.54 (5.91) 56 (51) 54 (49) 30 (27) 80 (73) Interns (71) 34 (48) 37 (52) 25.49 (0.96) 64 (90) 7 (10) 1 (1.4) 70 (98.6) Residents (69) 30 (43) 39 (57) 33.6 (7.57) 27 (39) 42 (61) 15 (22) 54 (78) GPs (30) 12 (40) 18 (60) 26.73 (1.36) 27 (90) 3 (10) 0 (0) 30 (100) Administrative staff (79) 29 (37) 50 (63) 40.56 (6.48) 18 (23) 61 (77) 51 (65) 28 (35) Open in a new tab Demographic characteristics of the participants across five healthcare occupational groups, including gender, mean age, marital status and parental status. GP, general practitioner. Patterns of incivility and bullying across occupational groups Descriptive statistics for workplace mistreatment dimensions are presented in table 2 . Interns showed the highest mean scores for WWI and IWI, while nurses had the highest mean scores for EWB and EWI. Residents also showed relatively elevated scores across most dimensions, while administrative staff consistently reported the lowest levels across all scales. Table 2. Descriptive statistics for workplace incivility and bullying dimensions by occupational group. Occupational group EWI (mean±SD) Median (IQR) WWI (mean±SD) Median (IQR) IWI (mean±SD) Median (IQR) EWB (mean±SD) Median (IQR) Nurses 15.35±7.12 12.5 (10.0) 18.07±8.87 16 (13.25) 10.05±3.34 9.5 (4.0) 52.02±21.80 46 (34.5) Administrative staff 13.63±6.52 12 (8.0) 14.58±7.67 12 (8.0) 9.48±3.28 9 (3.0) 36.61±15.05 32 (20.0) Interns 14.46±5.34 13 (9.0) 19.48±7.40 18 (11.0) 12.90±6.31 11 (8.0) 50.10±17.72 45 (29.0) GPs 14.13±5.20 13 (9.25) 17.03±7.18 18 (10.25) 9.77±3.13 9 (4.25) 42.37±14.44 43.5 (24.0) Residents 15.19±6.93 13 (7.0) 18.17±7.14 17 (11.0) 11.17±4.76 10 (4.0) 46.93±17.54 45 (23.5) Open in a new tab Distribution of workplace incivility (EWI, WWI, IWI) and bullying (EWB) scores across occupational groups. Values are presented as mean±SD and median (IQR) to reflect non-normal distributions. EWB, experienced workplace bullying; EWI, experienced workplace incivility; GP, general practitioner; IWI, instigated workplace incivility; WWI, witnessed workplace incivility. Kruskal-Wallis tests showed significant occupational group differences for WWI, IWI and EWB (all p<0.001), but not for EWI (p=0.279) ( table 3 ). The largest effect was observed for EWB (ε²=0.096), indicating a moderate-to-large effect, followed by IWI and WWI (ε²=0.050 and 0.048), both indicating small-to-moderate effects. Table 3. Kruskal-Wallis comparisons of workplace incivility and bullying dimensions across occupational groups. Variable H (df=4) ε² P value EWI 5.08 0.003 0.279 WWI 21.11 0.048 <0.001 IWI 21.74 0.050 <0.001 EWB 39.09 0.096 <0.001 Open in a new tab Kruskal-Wallis tests comparing workplace mistreatment dimensions across occupational groups. ε² represents effect size. EWB, experienced workplace bullying; EWI, experienced workplace incivility; IWI, instigated workplace incivility; WWI, witnessed workplace incivility. Post hoc Mann-Whitney U tests with Bonferroni correction (adjusted α=0.005) were conducted for variables with significant group differences ( online supplemental table 3 ). After correction, most significant pairwise differences involved administrative staff, who reported lower WWI than interns (r=0.376) and residents (r=0.29), lower IWI than interns (r=0.33), and lower EWB than nurses (r=0.399), interns (r=0.43), and residents (r=0.32) (all p≤0.001). Interns also reported higher IWI than nurses (r=0.24, p=0.001). Pairwise effects were generally small-to-moderate. Variation in mistreatment by residency specialty EWI and EWB were compared across four residency specialties (internal medicine, general surgery, psychiatry and obstetrics/gynaecology) ( online supplemental tables 4 and 5 ). Paediatric residents were excluded from specialty comparisons because of the small subgroup size (n=6). For EWI, the Kruskal-Wallis test indicated no significant overall differences among specialties (p=0.094), although the effect size suggested small-to-moderate variation (ε² = 0.057). Pairwise Mann-Whitney U comparisons were not significant after Bonferroni correction. However, general surgery residents reported higher EWI scores than other specialties, and the comparison with internal medicine showed a moderate-to-large effect size (U=52.00, p=0.022, r=0.426). Other pairwise comparisons demonstrated small-to-moderate effect sizes (r=0.09–0.33). For EWB, one-way ANOVA showed no statistically significant differences among specialties (p=0.217), although the effect size was small-to-moderate (η² = 0.072). General surgery residents had the highest mean EWB scores. Frequency and prevalence of mistreatment Item-level analysis revealed patterns in frequency and prevalence of EWI and EWB across occupational groups ( table 4 ). Interns and nurses showed the highest levels, with 51% of interns reporting daily experiences of bullying. The lowest prevalence of EWI and EWB was reported by residents and administrative staff, respectively. Around 20% of administrative staff reported no exposure to either incivility or bullying, compared with much lower non-exposure rates (0%–5%) among clinical staff. Table 4. Frequency and prevalence of experienced workplace incivility and bullying by occupational group. Group Domain Daily Weekly Monthly Occasionally Never Prevalence Nurses Incivility 17% 18% 20% 43% 1% 35% Bullying 46% 14% 13% 25% 2% 60% Administrative staff Incivility 11% 21% 10% 38% 20% 32% Bullying 15% 7% 11% 46% 21% 22% Interns Incivility 13% 25% 33% 24% 5% 38% Bullying 51% 18% 13% 18% 0% 69% GPs Incivility 9% 17% 30% 30% 13% 26% Bullying 22% 17% 13% 30% 17% 39% Residents Incivility 9% 13% 27% 43% 9% 22% Bullying 26% 15% 17% 32% 11% 41% Open in a new tab Frequency categories are based on item-level analysis of EWI and EWB. Prevalence was defined as weekly or daily exposure. EWB, experienced workplace bullying; EWI, experienced workplace incivility; GP, general practitioner. Differences in stress, anxiety and depression across occupational groups Kruskal-Wallis tests showed significant group differences for stress (p=0.007, ε²=0.028), anxiety (p=0.005, ε²=0.031) and depression (p=0.011, ε²=0.026). Despite statistical significance, effect sizes were small across all outcomes. Nurses had the highest mean ranks for all three measures; interns ranked next highest for stress and depression, whereas administrative staff ranked next highest for anxiety ( table 5 ). Table 5. Stress, anxiety and depression scores by occupational group. Stress Anxiety Depression Mean Mean rank Mean Mean rank Mean Mean rank Nurses 19.09 202.76 11.99 202.10 14.76 206.77 Interns 17.23 193.70 9.41 172.02 12.01 181.77 Residents 13.25 150.26 10.49 181.61 11.39 169.43 GPs 15.13 168.77 5.67 121.75 10.00 149.07 Administrative staff 15.28 166.23 11.44 177.12 11.24 162.12 P value 0.007 0.005 0.011 H (df=4) 13.987 15.052 13.142 ε² 0.028 0.031 0.026 Open in a new tab Mean scores, mean ranks and Kruskal-Wallis test results for stress, anxiety and depression across occupational groups. ε² was calculated as (H−k+1)/(n−k), where k=5 and n=359. GP, general practitioner. Associations between workplace mistreatment and psychological symptoms Spearman’s correlation analyses showed generally positive associations between workplace mistreatment dimensions (EWI, WWI, IWI and EWB) and psychological symptoms (stress, anxiety and depression) across occupational groups ( table 6 ). EWI and EWB demonstrated the most consistent patterns, with statistically significant moderate-to-strong correlations across all symptoms and groups (ρ=0.39–0.62, all p≤0.030). Table 6. Spearman’s correlations between workplace incivility and bullying dimensions and psychological symptoms by occupational group. Stress Anxiety Depression Spearman’s ρ P value Spearman’s ρ P value Spearman’s ρ P value EWI Nurses 0.48 <0.001 0.42 <0.001 0.40 <0.001 Interns 0.48 <0.001 0.39 <0.001 0.41 <0.001 Residents 0.40 0.001 0.39 0.001 0.41 0.001 GPs 0.48 0.007 0.48 0.007 0.42 0.020 Administrative staff 0.59 <0.001 0.59 <0.001 0.62 <0.001 Stress Anxiety Depression Spearman’s ρ P value Spearman’s ρ P value Spearman’s ρ P value WWI Nurses 0.37 <0.001 0.28 <0.001 0.21 0.030 Interns 0.29 0.014 0.12 0.329 0.12 0.307 Residents 0.35 0.003 0.27 0.023 0.34 0.004 GPs 0.42 0.022 0.44 0.014 0.48 0.007 Administrative staff 0.50 <0.001 0.57 <0.001 0.51 <0.001 Stress Anxiety Depression Spearman’s ρ P value Spearman’s ρ P value Spearman’s ρ P value IWI Nurses 0.23 0.015 0.26 <0.001 0.11 0.24 Interns 0.26 0.028 0.24 0.048 0.25 0.039 Residents 0.25 0.038 0.27 0.028 0.22 0.072 GPs 0.24 0.195 0.17 0.372 0.18 0.328 Administrative staff 0.43 <0.001 0.42 <0.001 0.45 <0.001 Stress Anxiety Depression Spearman’s ρ P value Spearman’s ρ P value Spearman’s ρ P value EWB Nurses 0.49 <0.001 0.43 <0.001 0.43 <0.001 Interns 0.42 <0.001 0.47 <0.001 0.50 <0.001 Residents 0.56 <0.001 0.57 <0.001 0.59 <0.001 GPs 0.40 0.030 0.48 0.008 0.41 0.027 Administrative staff 0.48 <0.001 0.45 <0.001 0.52 <0.001 Open in a new tab Spearman’s rank-order correlations between workplace mistreatment dimensions and psychological symptoms by occupational group. EWB, experienced workplace bullying; EWI, experienced workplace incivility; GP, general practitioner; IWI, instigated workplace incivility; WWI, witnessed workplace incivility. WWI showed weaker correlations (ρ=0.21–0.50), which were statistically significant in most groups but not for anxiety and depression among interns (p=0.329 and p=0.307, respectively). IWI demonstrated the weakest and least consistent associations (ρ=0.11–0.45), with several non-significant correlations, particularly among GPs (all outcomes), as well as for depression among nurses and residents. Adjusted associations between workplace mistreatment and psychological symptoms Multivariable linear regression analyses examined associations between mistreatment dimensions and psychological symptoms after adjustment for age, gender, smoking status and occupational group ( table 7 , online supplemental table 6 ). Regression diagnostics identified one case with an extreme standardised residual in the stress model and four in the anxiety model; these cases were excluded from the final models. No cases were excluded from the depression model. No problematic multicollinearity was observed (all VIF<2.6). Table 7. Adjusted associations between workplace mistreatment and psychological symptoms. Predictor Stress B (95% CI) Stress β P value Anxiety B (95% CI) Anxiety β P value Depression B (95% CI) Depression β P value EWI 0.445 (0.240 to 0.649) 0.278 <0.001 0.299 (0.129 to 0.469) 0.223 0.001 0.460 (0.259 to 0.662) 0.291 <0.001 WWI 0.241 (0.099 to 0.383) 0.186 0.001 0.081 (−0.038 to 0.200) 0.075 0.179 0.065 (−0.075 to 0.206) 0.051 0.361 IWI 0.022 (-0.199 to 0.243) 0.010 0.844 0.097 (−0.088 to 0.282) 0.050 0.304 −0.142 (−0.361 to 0.077) −0.062 0.204 EWB 0.086 (0.018 to 0.155) 0.159 0.014 0.116 (0.059 to 0.173) 0.255 <0.001 0.152 (0.085 to 0.219) 0.283 <0.001 Smoking 3.353 (0.711 to 5.996) 0.120 0.013 5.067 (2.855 to 7.279) 0.216 <0.001 3.984 (1.363 to 6.605) 0.144 0.003 Open in a new tab Multivariable linear regression models examining adjusted associations between workplace mistreatment dimensions and psychological symptoms. Models were adjusted for age, gender, smoking status and occupational group; administrative staff served as the reference occupational group. B, unstandardised coefficient; EWB, experienced workplace bullying; EWI, experienced workplace incivility; IWI, instigated workplace incivility; WWI, witnessed workplace incivility; β, standardised coefficient. All three adjusted models were statistically significant and explained a similar proportion of variance in psychological symptoms: stress (R²=0.343, adjusted R²=0.322), anxiety (R²=0.352, adjusted R²=0.331) and depression (R²=0.341, adjusted R²=0.320; all model p<0.001). EWI remained associated with higher stress (β=0.278, p<0.001), anxiety (β=0.223, p=0.001) and depression (β=0.291, p<0.001). EWB also remained associated with higher stress (β=0.159, p=0.014), anxiety (β=0.255, p<0.001) and depression (β=0.283, p<0.001). WWI remained associated with stress only (β=0.186, p=0.001), while IWI was not associated with any psychological outcome after adjustment. Smoking remained associated with higher stress (β=0.120, p=0.013), anxiety (β=0.216, p<0.001) and depression (β=0.144, p=0.003) after adjustment. Sensitivity analyses using the full dataset showed the same overall pattern of significant associations, indicating that exclusion of cases with extreme residuals did not materially affect the findings. Interrelationships between mistreatment behaviours Spearman’s correlations revealed positive interrelationships among all mistreatment dimensions (EWI, WWI, IWI and EWB) across occupational groups ( table 8 ). The strongest associations were between EWI and EWB (ρ=0.58–0.83, all p<0.001), indicating strong to very strong correlations. EWI was also moderately to strongly correlated with WWI (ρ=0.51–0.82, all p<0.001) and IWI (ρ=0.31–0.59, all p<0.001). Associations of EWB with IWI and WWI were weaker, generally falling within the weak-to-moderate range (ρ=0.23–0.57; all p≤0.004). WWI-IWI associations varied by group and were weakest among interns (ρ=0.23, p=0.054). Table 8. Interrelationships between workplace incivility and bullying dimensions across professional groups. WWI IWI EWB Spearman’s ρ P value Spearman’s ρ P value Spearman’s ρ P value EWI Nurses 0.51 <0.001 0.43 <0.001 0.58 <0.001 Interns 0.62 <0.001 0.31 0.009 0.65 <0.001 Residents 0.61 <0.001 0.37 0.002 0.74 <0.001 GPs 0.82 <0.001 0.54 0.002 0.83 <0.001 Administrative staff 0.67 <0.001 0.59 <0.001 0.76 <0.001 WWI Nurses 0.32 0.001 0.36 <0.001 Interns 0.23 0.054 0.41 <0.001 Residents 0.57 <0.001 0.53 <0.001 GPs 0.56 0.001 0.86 <0.001 Administrative staff 0.51 <0.001 0.67 <0.001 IWI Nurses 0.30 0.002 Interns 0.35 0.003 Residents 0.40 0.001 GPs 0.51 0.004 Administrative staff 0.38 0.001 Open in a new tab Spearman’s rank-order correlations among workplace mistreatment dimensions by occupational group. EWB, experienced workplace bullying; EWI, experienced workplace incivility; GP, general practitioner; IWI, instigated workplace incivility; WWI, witnessed workplace incivility. Associations with contextual/demographic variables Spearman’s correlations between workplace incivility and bullying dimensions and continuous contextual and demographic variables (age, work experience and BMI) were mostly weak and non-significant ( online supplemental table 7 ). A small number of significant associations were observed, including age with EWB among nurses (ρ= –0.25, p=0.009), work experience with WWI among nurses (ρ= –0.22, p=0.02) and BMI with WWI among interns (ρ=0.28, p=0.017). However, no consistent patterns emerged across groups. Mann-Whitney U tests showed no significant gender differences regarding incivility and bullying scores across most groups, with small or negligible effect sizes (r=0.00–0.25) ( online supplemental table 8 ). Although males reported higher scores in 15 of 20 comparisons, only IWI among male interns reached significance (p=0.035). Mann-Whitney U analyses showed no consistent marital-status differences in mistreatment scores across occupational groups ( online supplemental table 9 ). Single participants generally reported higher mistreatment scores in several groups, but these differences were inconsistent and non-significant. The only significant differences were among nurses, where single participants reported higher EWI (p=0.005, r=0.265) and EWB (p=0.004, r=0.271) than married participants. Effect sizes were generally small, with EWI and EWB among nurses in the small-to-moderate range (r ≈ 0.27). Finally, smokers reported significantly higher scores than non-smokers across all mistreatment dimensions (EWI, WWI, IWI and EWB; all p≤0.001), with small to small-to-moderate effect sizes (r=0.18–0.22) ( online supplemental table 10 ). Discussion Overview of main findings This study found that workplace incivility and bullying are widespread across healthcare settings, with broadly comparable exposure across clinical staff, although trainee and frontline staff showed relatively higher levels. In association analyses, all mistreatment dimensions were related to psychological symptoms, but adjusted analyses identified EWI and EWB as the most consistent correlates after adjustment. The different dimensions of incivility and bullying were also closely interrelated. While most demographic and contextual variables showed limited or inconsistent associations with mistreatment, smoking was consistently associated with mistreatment dimensions. These findings suggest that workplace mistreatment operates across clinical hierarchies as a systemic and multifaceted phenomenon. Distribution and dynamics of mistreatment in clinical settings This study highlights the high prevalence of incivility and bullying across healthcare professions. Although some variation was observed across roles and specialties, these behaviours were not confined to specific groups, suggesting broader patterns within clinical environments rather than isolated role-specific issues. Incivility and bullying were reported most frequently by trainee and frontline staff (interns, nurses and residents), who face high job demands while holding limited authority—key components of the Job Demand-Control model. 29 This model has been linked to both experiencing and instigating workplace bullying 30 and incivility. 31 Bullying was more frequently reported than incivility, likely because its targeted nature makes it more recognisable, while incivility is subtler and more easily overlooked. 32 Although significant group-level differences were observed for WWI, IWI and EWB, relatively few pairwise comparisons reached significance, most involving administrative staff, who consistently reported lower levels of mistreatment. This pattern suggests that direct clinical involvement increases vulnerability, although differences in role expectations, interpersonal dynamics or reporting tendencies across professional groups may also contribute. Among clinical roles, however, the lack of consistent pairwise differences suggests that healthcare professionals—regardless of their specific roles—are exposed to broadly comparable levels of workplace incivility and bullying. This pattern challenges assumptions that nurses experience disproportionately higher mistreatment 33 and instead suggests that elevated rates reflect shared organisational and cultural stressors inherent in clinical environments rather than extreme role-specific vulnerabilities. Smaller between-role differences may also have gone undetected because of limited power for subgroup comparisons. The relatively higher WWI among interns and residents may reflect their heightened sensitivity and lower desensitisation to mistreatment, while more experienced staff may perceive such behaviours as routine. It may also relate to rotational roles that place trainees across multiple teams and expose them to a broader range of interpersonal encounters. Similarly, higher IWI among trainees may reflect social learning theory, whereby individuals adopt behaviours observed in senior colleagues and role models. 34 In this context, witnessing mistreatment can reinforce and normalise such behaviours. 35 Compared with earlier international studies reporting bullying rates of 17%–48% 36 37 and incivility of 7%–76%, 8 the prevalence observed in this study (22%–38% for EWI and 22%–69% for EWB) was relatively high. This may reflect variation in organisational and sociocultural context across the participating hospitals, including leadership style, workload and behavioural norms. It may also reflect contextual features reported in Iranian healthcare settings, where hierarchical training structures, high workload and limited institutional support have been identified as factors that increase trainees’ vulnerability to mistreatment. 15 16 Methodological differences, including measurement tools and reporting thresholds, may also have contributed. Although not statistically significant, higher EWI and EWB among general surgery residents align with prior research showing minimal specialty differences overall, with surgical residents as a notable exception, likely because intense workloads, rigid hierarchies and fast-paced environments may foster a more hostile training culture. 38 However, the small sample sizes per specialty (n=13–19) likely limited our ability to detect significant effects. Psychological correlates of workplace mistreatment In unadjusted analyses, EWI and EWB showed consistent and statistically significant associations with stress, anxiety and depression across occupational groups. In contrast, associations involving WWI and IWI were weaker and less consistent, with several non-significant findings. After adjustment, EWI and EWB remained associated with all three psychological outcomes, suggesting that direct exposure represents the most robust correlate of distress. WWI remained associated only with stress, while IWI was not associated with any psychological outcome after adjustment. This pattern suggests that indirect or enacted forms of incivility may be psychologically relevant, but their associations are weaker, context-dependent and partly explained by overlap with direct exposure. Our findings align with previous research linking directly experienced mistreatment to psychological symptoms. 3637 39 , 41 While a few studies have linked indirect mistreatment with mental health symptoms, 42 43 empirical evidence, particularly in healthcare contexts, remains limited. By examining both direct and indirect forms of mistreatment, this study contributes to this area by demonstrating that indirect forms may be relevant within broader workplace dynamics, although their associations with psychological symptoms are less consistent than those of direct exposure. These findings should be interpreted cautiously, as the cross-sectional design precludes conclusions about directionality. While exposure to workplace incivility and bullying may contribute to psychological distress, it is also possible that individuals experiencing higher distress may be more likely to perceive, recall or report mistreatment. Alternatively, shared underlying factors—such as workplace stressors, personality traits or organisational conditions—may contribute to both mistreatment and psychological symptoms. The interconnected dynamics of mistreatment The significant positive associations among all dimensions of workplace incivility and bullying—EWI, WWI, IWI and EWB—suggest that these behaviours do not occur in isolation, but may reflect interconnected patterns across roles and hierarchies within clinical settings. The observed correlations between IWI and other mistreatment types—strongest with EWI, followed by EWB and WWI—may reflect a broader dynamic in which mistreatment, whether direct or indirect, may trigger reciprocal responses and spread through behavioural contagion. This pattern aligns with Andersson and Pearson 44 concept of the incivility spiral, where exposure to incivility increases the likelihood of reciprocation, creating a cycle of negative interactions. While direct experiences appear most influential, the significant WWI-IWI link suggests that witnessing incivility can lower behavioural inhibitions and foster the spread of mistreatment through secondary spirals of incivility. 44 Prior studies have similarly linked repeated exposure to later enactment of incivility. 43 45 In medical training environments, these dynamics may be reinforced through the social learning theory and the ‘hidden curriculum’—unspoken norms learnt through informal observation rather than formal instruction. 46 Repeated exposure to incivility and bullying may lead interns and residents to perceive mistreatment as acceptable and essential for professional integration, fostering its intergenerational transmission. Faculty incivility has been shown to predict uncivil behaviour among students, 47 illustrating how hierarchical exposure can legitimise mistreatment in educational contexts. However, these associations may also reflect shared underlying factors rather than direct transmission of behaviours. Individuals working in more stressful or conflict-prone environments may be more likely to experience, witness, and enact mistreatment, leading to correlated patterns between IWI and other dimensions without necessarily implying behavioural contagion or causal propagation. The significant associations between EWI/WWI and EWB suggest a potential escalation pathway, where incivility—whether directly experienced or vicariously witnessed—may precede more severe forms of mistreatment, such as bullying. This aligns with models describing workplace mistreatment as a progressive process, 48 including Anderson’s concept of intensifying incivility spirals in permissive environments, 44 and Leymann’s process model of bullying, which describes how initial work-related conflict may evolve into systematic, person-directed harassment over time. 49 Longitudinal studies support this view, indicating that early exposure to incivility may increase the risk of subsequent bullying—suggesting that incivility may function as an early warning signal, either as a causal precursor or as a marker of shared contextual vulnerabilities. 48 However, this pattern may also reflect conceptual and measurement overlap between incivility and bullying constructs, or shared exposure to adverse workplace conditions that give rise to both behaviours, rather than a direct temporal progression. Taken together, these findings are consistent with four interrelated mechanisms—reciprocity, contagion, escalation, and social learning—which help explain how mistreatment may become entrenched in clinical culture. Contextual and demographic factors Demographic and contextual variables showed no consistent associations with workplace mistreatment, in line with several previous studies. 10 38 40 41 50 Contrary to reports linking workplace mistreatment to younger age, 40 41 43 45 lower work experience, 10 38 or female gender, 40 41 no consistent patterns emerged in this study. Age, work experience, gender and BMI showed weak and inconsistent relationships with mistreatment, suggesting that workplace incivility and bullying may be shaped more by organisational, environmental and cultural factors than by individual demographic characteristics. In unadjusted analyses, smoking was the only factor consistently associated with higher levels of incivility and bullying across all dimensions. This finding is notable given the limited prior studies examining the relationship between smoking and workplace mistreatment. Smoking may represent a behavioural coping response among individuals exposed to stressful or mistreatment-prone work environments. Alternatively, reverse causality is possible, whereby individuals who smoke may be more likely to work in, remain in or perceive themselves as exposed to environments where mistreatment is more prevalent. In addition, unmeasured confounding factors—such as personality traits, coping styles or workplace characteristics—may contribute to both smoking behaviour and mistreatment exposure. In addition to its association with workplace mistreatment, smoking was also associated with higher levels of stress, anxiety and depression after adjustment. This suggests that smoking may reflect a broader vulnerability to psychological distress. The relationship may indicate maladaptive coping in response to stress, shared underlying risk factors or bidirectional influences between psychological distress and smoking behaviour. Given the cross-sectional design, the temporal relationship between smoking and workplace mistreatment cannot be determined, and no causal inferences can be made. Nevertheless, the consistency of the observed relationships highlights the need for further studies to examine the directionality and underlying mechanisms of this relationship. Implications The high prevalence, interconnected nature and potential escalation of workplace incivility and bullying underscore the need for proactive, organisation-level interventions targeting both behavioural and structural drivers of mistreatment. Given the elevated exposure among trainee and frontline staff—particularly interns, residents and nurses—interventions should prioritise these groups through structured mentorship, supervision, early support systems and integrated, destigmatised mental health services. The observed association between smoking and mistreatment further highlights the importance of addressing maladaptive coping strategies within broader psychosocial risk management frameworks. The links between different forms of mistreatment suggest that early identification and management of incivility may help prevent progression to more severe behaviours. Accordingly, strategies should move beyond isolated incidents and instead target the organisational conditions that sustain these patterns, including accessible reporting systems and low-threshold intervention mechanisms. Beyond individual-level approaches, these findings point to the need for systemic change. Training programmes should shape clinical culture by modelling clear behavioural standards, strengthening leadership accountability and embedding civility and bystander engagement into professional development. At the institutional and policy level, integrating anti-incivility standards into formal policies—supported by anonymous reporting channels, independent review processes and structured follow-up protocols—may improve the management of mistreatment. Embedding workplace civility and psychological safety into accreditation standards, training requirements and professional guidelines may support sustained cultural change across healthcare systems. Limitations This study’s cross-sectional design limits causal inference and does not capture how workplace incivility and bullying, and their effects, evolve over time. Self-reported data may introduce recall and social desirability bias, potentially leading to under- or over-reporting. Although multivariable regression analyses were performed to adjust for key demographic and occupational variables, residual confounding from unmeasured factors cannot be excluded. A small number of observations were excluded from regression models based on residual diagnostics; sensitivity analyses using the full dataset showed a similar pattern of findings. Lastly, the regional nature of the sample may limit generalisability to other healthcare systems or cultural contexts. Future research directions Future research should prioritise longitudinal designs to track the progression and outcomes of workplace incivility and bullying over time. Studies exploring instigated and witnessed incivility, along with larger and more diverse samples, will help clarify context-specific versus universal patterns. Qualitative approaches could also provide deeper insight into how mistreatment is experienced, interpreted and normalised in clinical settings. Conclusions This study provides a multidimensional examination of workplace incivility and bullying across diverse healthcare roles, demonstrating that these behaviours are widespread in clinical settings, with broadly comparable exposure across clinical staff; however, trainee and frontline staff (particularly interns and nurses) tended to show higher levels. Incivility and bullying appear to function within interconnected patterns shaped by reciprocity, contagion, escalation and social learning. While all mistreatment dimensions were correlated with psychological symptoms, adjusted analyses indicated that EWI and EWB were the most consistent correlates of stress, anxiety and depression after adjustment. Most demographic and contextual variables showed inconsistent associations, suggesting that workplace mistreatment may be shaped more by organisational structures, hierarchies and cultural norms than by individual characteristics. Smoking emerged as a consistent correlate of both mistreatment and psychological symptoms, warranting further investigation. These findings call for multi-level interventions—organisational, psychological and educational—addressing behavioural and structural drivers of mistreatment. Future longitudinal research should clarify causal pathways, underlying mechanisms and the roles of witnesses and instigators in shaping workplace dynamics. Supplementary material online supplemental file 1 bmjopen-16-5-s001.docx (30.6KB, docx) DOI: 10.1136/bmjopen-2025-109056 Footnotes Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online ( https://doi.org/10.1136/bmjopen-2025-109056 ). Provenance and peer review: Not commissioned; externally peer reviewed. Patient consent for publication: Consent obtained directly from patient(s). Ethics approval: This study was approved by the Arak University of Medical Sciences Ethics Committee, under approval code IR.ARAKMU.REC.1402.151 and was conducted in accordance with the principles of the Declaration of Helsinki. Participants gave informed consent to participate in the study before taking part. Data availability free text: The data generated or analysed during this study are available from the corresponding author on reasonable request. Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research. Data availability statement Data are available on reasonable request. References 1. Lim MC, Jeffree MS, Saupin SS, et al. Workplace violence in healthcare settings: The risk factors, implications and collaborative preventive measures. Ann Med Surg (Lond) 2022;78:103727. doi: 10.1016/j.amsu.2022.103727. 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[ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] BMJ Open. 2026 May 28. Review Process File Copyright and License information PMC Copyright notice bmjopen-2025-109056.reviewer_comments.pdf (250.4KB, pdf) Open in a new tab Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials online supplemental file 1 bmjopen-16-5-s001.docx (30.6KB, docx) DOI: 10.1136/bmjopen-2025-109056 Data Availability Statement Data are available on reasonable request. 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