The impact of nurses’ perfectionistic self-presentation and toxic leadership of nurse managers on workplace incivility: a cross-sectional study

Nurses, who account for the greatest proportion of the healthcare workforce [1], are regarded as one of the most trustworthy professional groups [2]. However, workplace incivility is a notable issue in nursing [3], negatively affecting nurses’ psychological well-being, job satisfaction, and turnover intention [3]. Furthermore, it can lead to increased medical errors [4], decreased patient satisfaction, and compromised patient safety [5]. Thus, workplace incivility is detrimental not only to nurses but also to organizational performance, highlighting the need for scholarly and practical attention as well as organizational-level interventions.

Workplace incivility encompasses mild forms of norm-violating behavior in organizations that occur without explicit intent to cause harm. Experiences of incivility can lead to uncivil behavior, and such interactions can develop into retaliatory actions and “spiral” into more serious conflicts [6]. Types of uncivil behavior in hospitals include gossip, negative remarks, hostile behavior and gaze, harsh or sarcastic tones of voice, and unequal workload and work assignment [7]. According to a systematic literature review of the predictors and triggers of incivility in healthcare teams [8], incivility is more prevalent within the same occupation (e.g., among nurses) than among different occupations.

Nurses working in hospitals face unique job demands where even minor mistakes may have fatal consequences for patients. This environment fosters heightened perfectionistic tendencies [9]. In particular, perfectionistic self-presentation—defined as the interpersonal tendency to appear flawless to others [10]—has been linked to greater occupational stress and burnout among nurses [9]. Nurses can demonstrate highly perfectionistic tendencies such as repeated checks and reviews to prevent errors [9]. Those individuals with higher perfectionistic self-presentation may hesitate to seek professional help, as it becomes more difficult to reveal their errors and incompetence [11].

The concepts of perfectionism and perfectionistic self-presentation both arise from the individual’s desire to be perfect and both are closely related to psychological issues and interpersonal difficulties [10]. On the one hand, perfectionism differs in that the tendency to pursue perfection is demonstrated by demanding high performance from oneself according to one’s own standards and displaying extreme reactions if those standards are not met [12]. On the other hand, perfectionistic self-presentation is a method of interpersonal presentation centered on the desire to appear perfect to other people rather than actually being perfect [10] and it entails promoting behaviors deemed to be perfect, while concealing those deemed to be imperfect [11].

According to a recent systematic literature review and meta-analysis, perfectionistic self-presentation was found to be a transdiagnostic factor for psychopathological results such as social anxiety, depression, and narcissism [13]. Additionally, perfectionistic self-presentation was found to affect workplace bullying in a study on intensive care unit nurses [14]. Therefore, it is important to ensure that nurses’ perfectionistic self-presentation does not harm their health or contribute to workplace incivility. A recent study highlighting different predictors of workplace bullying victimization and perpetration revealed that perfectionistic self-presentation significantly predicted perpetration but not victimization [15]. Building on these findings, we conducted this study to investigate workplace incivility from both victim and perpetrator perspectives, focusing on the distinct roles of perfectionistic self-presentation in each.

Alongside this individual factor, organizational factors such as toxic leadership also play a crucial role in exacerbating workplace incivility, with negative leadership or the absence of leadership identified as a particularly powerful antecedent [8]. Because nurse managers play a central role in shaping the work climate, modeling norms of interaction, and allocating resources, their leadership style can either buffer staff from or expose them to uncivil behavior [16, 17]. Moreover, leadership is a modifiable factor that can be directly targeted through educational and organizational policies, which makes it a meaningful focus for intervention-oriented research [18, 19]. Toxic leadership is classified as a typical form of negative leadership, which also includes abusive supervision, tyrannical leadership, destructive leadership, workplace bullying, and laissez-faire leadership [20]. Destructive leadership is characterized by greater intensity and severity in certain disciplines or groups (e.g., female workers, workers in the early stages of their careers). Toxic leadership, which comprises aspects of both negative and destructive leadership, is characterized by narcissistic and self-promoting tendencies as well as unpredictable, abusive, and authoritative behavior by leaders [21]. This form of supervision can be detrimental to the overall organization, as the leader’s destructive behaviors manifest in a persistent and organized manner [22]. Toxic leaders can demonstrate toxicity at various times and in various forms, which affects how they are perceived by subordinates [23]. This perception is primarily determined by the leader’s behavior, which is commonly characterized by bullying, denigrating, and intimidating subordinates.

Toxic leadership behavior places unnecessary stress and pressure on subordinates, which not only diminishes their performance but also results in various other negative effects [24]. The toxic leadership of nurse managers has been reported to potentially cause depression and anxiety [25], poorer psychological well-being and lower work engagement [26, 27], and diminished confidence in the organization and greater turnover intention among nurses [28]. Considering that authority, the work environment, and managerial leadership play key roles in workplace incivility [29], examining the relationship between toxic leadership and incivility from both victim and perpetrator perspectives offers important implications for organizational management.

Based on the above, workplace incivility may be related to perfectionistic self-presentation tendencies and nurse managers’ leadership styles. Andersson and Pearson [6] used the spiral model of incivility to explain its aggressive behavioral change, noting that workplace incivility arises from the confluence of personal and organizational factors. However, most studies have focused on the consequences of workplace incivility [30], including the impacts on job satisfaction, turnover intention, and burnout [3]. Keller et al. [8] conducted a systematic review analyzing the predictors and triggers of incivility in healthcare teams but the findings on the personal characteristics of individuals subjected to incivility have been broadly inconsistent and centered on workplace bullying (i.e., the victim aspect). Further, few studies have analyzed the victim and perpetrator aspects of workplace incivility in tandem. Therefore, this study aimed to explore the impact of nurses’ perfectionistic self-presentation and nurse managers’ toxic leadership on workplace incivility, focusing on both victimization and perpetration among nurses working in general hospitals and higher-level institutions.

Based on the literature and aims of this study, we develop a theoretical model in which nurses’ perfectionistic self-presentation (individual factor) and nurse managers’ toxic leadership (organizational factor) are hypothesized to influence workplace incivility, conceptualized in terms of both victim and perpetrator aspects. Work unit characteristics (e.g., working in an intensive care unit) are also included as contextual predictors. In addition, the model assumes that experiences of workplace incivility as a victim may increase the likelihood of perpetrating incivility, reflecting the potential overlap between victim and perpetrator roles (Supplementary Fig. 1).

In this study, toxic leadership (measured using the ToxBH-NM scale) and perfectionistic self-presentation (assessed with the PSPS-K) were examined as key factors. The analysis revealed that nurse managers’ toxic leadership, nurses’ perfectionistic self-presentation, and working in intensive care units influenced the victim aspect of workplace incivility in that order. Among these, toxic leadership exerted the strongest effect. That is, the higher the level of nurse managers’ toxic leadership, the higher the likelihood that nurses would experience workplace incivility as victims. Negative leadership has been reported as a factor affecting workplace incivility [8]. In a study that explored the effect of tyrannical leadership, which is a type of negative leadership like toxic leadership, authoritative, autocratic, and derogatory tyrannical leadership types were reported to cause workplace incivility [34]. Additionally, the presence of unsupportive and autocratic leaders has been shown to increase nurses’ workplace bullying [35]. Moreover, Zhang et al. [36] found that abusive supervision induced various forms of workplace violence such as verbal and physical violence and harassment, while negative (passive-avoidant) leadership increased workplace cyberbullying [37]. Blackstock et al. [38] found that an increase in positive leadership led to a decrease in the workplace incivility (victim aspect) experienced by new nurses, while Jungert and Holm [29] showed that the leadership of managers plays a key role in workplace incivility (victim aspect).

These findings confirm that workplace incivility is affected by managers’ leadership styles, which is consistent with the results of the current study showing that toxic leadership is a major factor affecting workplace incivility (victim aspect). Situational and cultural factors—including excessive workload, issues in communication or collaboration, and concerns about patient safety, a lack of support, and inadequate leadership—have all been found to increase the level of incivility [8]. Meanwhile, toxic leadership behavior reportedly increased with high work intensity or insufficient managerial experience [39]. Thus, to diminish workplace incivility, the work environment should be improved so that nurse managers can demonstrate leadership that positively affects the organization and its members. Additionally, senior executives should promote leadership development processes that consider managers’ years of managerial experience.

Perfectionistic self-presentation was found to affect workplace incivility (victim aspect). That is, higher levels of perfectionistic self-presentation indicated more experiences of the victim aspect of workplace incivility. Individuals with high perfectionistic self-presentation tendencies seek to conceal their errors and flaws and may refuse to acknowledge their errors in order to appear perfect to other people [10]. Thus, nurses with high levels of perfectionistic self-presentation are likely to be sensitive to evaluations from others, meaning they perceive even minor criticism or neglect as personal attacks. Jang et al.’s [14] study on intensive care unit nurses found that the higher their perfectionistic self-presentation, the higher the workplace incivility (victim aspect), consistent with the findings of the current study. Furthermore, leaders with perfectionistic tendencies affect workplace incivility (victim aspect) [40] and perfectionistic personalities affect incivility toward colleagues [41]. A study on nursing students also found that perfectionistic tendencies affect incivility (victim aspect) [42], corroborating the findings of this study. Interventions that manage perfectionistic self-presentation have been reported to mitigate vulnerability to negative evaluations and criticism in nursing practice and aid in alleviating anxiety, depression, and vulnerable narcissism [13]. Hence, providing organizational interventions for nurses and fostering psychological safety by easing the culture of perfectionistic pressure can help reduce uncivil interactions among nurses.

In this study, nurses working in intensive care units experienced a higher level of incivility than nurses working in general wards. Similarly, previous studies have reported that nurses working in special units experienced a higher level of incivility than those working in general wards [43], that intensive care unit nurses experienced greater incivility than nurses in other units [44], and that intensive care unit workers were more often victims of bullying and violence than emergency department workers [45]. These findings suggest that high-intensity and high-stress work environments can induce or reinforce uncivil interactions, indicating that workplace characteristics can affect incivility. However, the relationship between the working units and workplace incivility was not clearly identified in this study. Although operating room nurses reported the highest workplace incivility (victim aspect) scores in the Scheffè test of the differences based on working unit, the regression analysis indicated that victim incivility was higher among intensive care unit nurses than ward nurses. The findings of this study must thus be interpreted with caution, as the samples for special units such as operating rooms and intensive care units were small and the distributions of samples for each unit were uneven.

The factors that affected the perpetrator aspect of workplace incivility were the victim aspect of workplace incivility and perfectionistic self-presentation in that order. In other words, the victim aspect of workplace incivility had the greatest effect on the perpetrator aspect of workplace incivility. This suggests the potential for a vicious cycle in which being the victim of incivility can lead to becoming a perpetrator of incivility. Andersson and Pearson [6] proposed the concept of the “incivility spiral,” wherein not only can the experience of incivility lead to the perpetration of incivility but simply witnessing incivility can imbue one with the intent to be uncivil toward others and can even lead to the actual perpetration of incivility. In previous studies, increased incivility by managers was associated with an increase in incivility among colleagues six months later [46]. Further, employees who experienced incivility from patients were more likely to be uncivil not only to patients but also to their hospital colleagues [47]. In particular, those who had experienced incivility within their families were more likely to display incivility in the workplace [48, 49].

These findings are consistent with those of this study, indicating that being a victim of incivility induces the perpetration of incivility, suggesting that workplace incivility is not an individual issue but can affect and spread throughout the organization. Therefore, it is important to improve the work environment and foster a positive organizational culture to mitigate such negative effects. Furthermore, to alleviate workplace incivility and minimize its spread, human resources strategies must be developed and implemented to adequately manage the perfectionistic self-presentation tendencies of nurses and reduce the toxic leadership of nurse managers.

Perfectionistic self-presentation was found to significantly affect both the victim and the perpetrator aspects of workplace incivility. While a higher level of perfectionistic self-presentation was associated with more experiences of workplace incivility as a victim, a lower level of perfectionistic self-presentation was associated with a higher likelihood of workplace incivility as a perpetrator. These findings are similar to those of Jang et al. [14], who analyzed the relationship between perfectionistic self-presentation and workplace bullying (victim and perpetrator aspects) among intensive care unit nurses. Considering that perfectionistic self-presentation characteristics involve being concerned about how one appears to other people and striving to maintain one’s image [10], this finding suggests that people with lower perfectionistic self-presentation are less sensitive to other people’s appraisal and less aware of social norms, making them more likely to display uncivil or aggressive behavior. Overall, our findings highlight a tension: excessive concern with appearing flawless may heighten perceived victimization, whereas too little concern for others’ views and workplace norms may increase the risk of acting uncivilly toward colleagues. Rather than treating perfectionism or non-perfectionism as inherently desirable, emotional and organizational support should help nurses distinguish healthy professional standards from rigid, defensive self-presentation and foster a balanced approach that combines high standards with self-compassion and civility. Therefore, emotional support and organizational-level support systems are needed to identify perfectionistic self-presentation tendencies in nurses and prevent them from being negatively reinforced.

This study has the following limitations. First, owing to its cross-sectional design, no causal relationships among the variables could be identified. Hence, longitudinal cohort studies that can confirm the causal relationships among the variables or intervention effect verification studies evaluating the changes in related variables are needed. Second, the representativeness of the sample may be limited, as the participants were recruited using convenience sampling and an online community for nurses. Future studies could adopt samples that include diverse characteristics in terms of region, institution, and hospital type to enhance representativeness. Third, because all the variables were assessed using self-reported questionnaires at a single time point, the findings may be subject to common method bias and the key variables may have been under- or overestimated owing to respondents’ subjective perceptions. Future studies could reduce this bias by using multiple data sources or time points and incorporating third-party observations or in-depth interviews. Fourth, this study had limitations in identifying the characteristics of workplace incivility in the healthcare setting, as the workplace incivility measurement tools used were not developed for nurses. Future studies could develop and verify incivility measurement tools that can capture the unique characteristics of healthcare organizations.

Despite these limitations, this study is significant in that it analyzed the dual structure of workplace incivility in nursing from both the victim and the perpetrator perspectives and identified key influencing factors: perfectionistic self-presentation as an individual characteristic of nurses and nurse managers’ toxic leadership as an organizational characteristic. Building on these findings, concrete steps in nursing practice could include the provision of leadership training programs for nurse managers to curb incivility and promote respectful communication, as nurse leaders play a key role in shaping a civil work climate and can be supported through targeted education and development initiatives [18]. In addition, peer support or coaching initiatives aimed at helping nurses manage perfectionistic self-presentation and work-related stress in healthier ways are consistent with emerging evidence that peer and leadership support programs enhance resilience and well-being among nurses [50]. Overall, the results of this study may serve as reliable empirical data for designing and implementing such practical interventions to reduce workplace incivility and support safer, more respectful clinical practice in healthcare settings [51].

This study identified the key predictors of workplace incivility among nurses, revealing that perfectionistic self-presentation, toxic leadership, and intensive care unit environments significantly influence victimization patterns. Notably, perfectionistic self-presentation and prior victimization were primary factors in perpetrator behaviors, suggesting a cyclical relationship between experiencing and enacting incivility. These findings underscore the multifaceted nature of workplace incivility, encompassing both individual psychological traits and organizational contextual factors. The perpetuation cycle in which victims become perpetrators highlights the critical need for comprehensive intervention strategies.

Organizations should prioritize leadership development programs targeting toxic management behaviors while implementing unit-specific interventions in high-risk environments. Individual-level support for nurses with perfectionistic tendencies is essential to disrupt the victim/perpetrator cycle. A multilayered approach combining managerial training, psychological support, and organizational culture reform is necessary to establish respectful work environments and prevent workplace incivility in nursing practice.