Grounded theory study on the psychological and behavioural processes of medical nurses in response to patient incivility

Abstract

Background

Patient incivility is a significant source of work-related stress for nurses, particularly in highly interactive departments such as internal medicine. Although such behaviours are low in intensity, they occur frequently, continuously depleting nurses’ emotional and psychological resources and impacting their well-being and the safety of nursing care. Existing research predominantly focuses on the impact at an overall level, lacking in-depth understanding of nurses’ individual cognition, coping strategies, and internal psychological processes within specific situations. This study aimed to explore the psychological and behavioural processes of medical nurses when encountering uncivil behaviours from patients, and to provide a basis for clinical management and support systems.

Methods

A qualitative research method using Grounded Theory was adopted. Semi-structured in-depth interviews were conducted with 20 nurses recruited from the internal medicine department of a tertiary hospital in China. Interview data were analysed using NVivo 12 software, following the principle of constant comparison. A theoretical model was constructed through open coding, axial coding, and selective coding.

Results

The analysis generated four core themes: (1) Situational Perception and Cognitive Appraisal: Nurses distinguish between emotional dysregulation caused by illness and purely malicious intent. (2) Diverse Coping Strategies: Including relational repair, boundary setting, cognitive reappraisal, and seeking external support. (3) Internal Negotiation: Reflected in the conflict between suppressing emotional expression and adhering to professional roles, the negotiation between professional ethics and personal dignity, and the trade-off between short-term and long-term outcomes. (4) Outcomes and Reflections: Manifested as changes in nurse-patient relationship quality, the dual outcomes of professional versus psychological capital, and the perceived absence of and demands for organizational support.

Conclusion

Nurses’ responses to patient incivility constitute a dynamic, cognitively-driven psychological process. The core dilemma lies in the internal negotiation and resource depletion inherent in emotional labour. The effectiveness of individual coping strategies is limited, and systemic impact depends on the support of the organizational environment.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12912-026-05174-x.

Background

Within the medical service system, nurses, as the group with the most frequent and direct contact with patients, constitute a core element in ensuring medical quality and safety, as their positive working environment and physical and mental health are paramount [1–2]. However, studies worldwide indicate that the healthcare industry, particularly the nursing field, has become a high-prevalence area for workplace incivility [3–5]. Workplace incivility is defined as low-intensity deviant behaviour with ambiguous intent to harm that violates the norm of mutual respect, such as verbal belittlement, dismissive neglect, sarcastic remarks, and non-cooperation [1, 6]. Although not as overt as physical violence, such behaviours persistently impact nurses’ physical and mental health due to their frequency, insidious nature, and cumulative effect [7].

Medical nursing units, as a vital component of the hospital, involve work that makes nurses more susceptible to frequent and prolonged exposure to such risks [8]. Patients in internal medicine departments often suffer from chronic and complex diseases [9], with prolonged illness durations and recurrent treatment processes. Patients and their families frequently endure significant financial, physiological, and psychological stress [10], making them prone to anxiety, depression, helplessness, and anger [11–12]. These emotions can sometimes transform into uncivil behaviours towards nursing staff [13–14]. Compared to departments like surgery, nursing in internal medicine requires extensive, in-depth communication and emotional labour with patients. This high-density interaction, while reflecting high-quality care when relationships are harmonious, can become a breeding ground for conflict when tensions arise. Consequently, incivility from patients is both typical and prevalent among medical nurses [15].

Although existing research has confirmed that patient incivility leads to emotional exhaustion, decreased job satisfaction, increased turnover intention, and can even affect their clinical judgment and safety behaviours, current studies predominantly explore its incidence and macro-level impact from a quantitative perspective, presenting certain limitations [16]. First, most studies treat “workplace incivility” as a holistic concept, with sources potentially mixing colleagues, supervisors, and patients, failing to meticulously isolate the context originating solely from patients [4, 17–18]. Second, existing countermeasures are often based on managerial perspectives or theoretical deductions [19–21]. There is a lack of systematic, contextualized exploration of how individual nurses actually perceive, feel, interpret, and cope with this incivility from patients in specific clinical situations, including their internal psychological processes and strategic choices.

Therefore, this study adopted the grounded theory research method. Grounded theory excels at generating theory from practitioners’ authentic experiences and is particularly suitable for exploring social-psychological processes that have not been fully revealed [22]. Through in-depth interviews, this research aimed to explore the experiences and strategies of medical nurses in coping with patient incivility, intending to construct a relevant theoretical framework. This framework will provide a basis for supporting nurses’ psychological well-being, improving communication training, and refining institutional systems, thereby enhancing the quality and resilience of nursing services.

Research subjects

Inclusion and exclusion criteria

Between September and October 2025, participants were recruited from the internal medicine department of a Chinese tertiary hospital using a purposive sampling approach. A total of 20 registered nurses who met the inclusion criteria were enrolled in this study. The inclusion criteria were: (1) registered nurses currently working in the internal medicine department; (2) at least one year of clinical nursing experience in this department; (3) had personally encountered at least one instance of uncivil behaviour from patients within the past six months; and (4) were willing to participate and provided informed consent. Nurses who were on leave (e.g., maternity or long-term sick leave) during the data collection period were excluded.

Sampling method and sample size

This study is reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [23].

In the first phase, purposive sampling combined with a maximum differentiation strategy was employed, and 17 participants were recruited to form the initial categories. After preliminary thematic saturation was achieved, theoretical sampling was adopted in the second phase, with an additional 3 participants recruited to further refine and validate the emerging categories. Thematic saturation was considered achieved when the data collected from three consecutive interviews no longer generated new codes, categories, or theoretical insights, and the existing categories were sufficiently dense in terms of their properties and dimensions [24]. This determination was made through team consensus during regular coding meetings, and was further verified by two external qualitative research experts who independently reviewed the coding framework and confirmed that no additional categories emerged from the final interviews.

Research instruments

Sociodemographic characteristics questionnaire

Based on literature review and group discussion, a sociodemographic characteristics questionnaire was developed for the research subjects. This questionnaire included the nurses’ age, gender, marital status, educational level, total years of work experience, and years of work experience in the internal medicine department.

Interview outline

Based on the research objectives, a draft interview outline was developed through group discussion. Three nurses were invited to participate in a pilot interview. Based on the results of the pilot interview, the researchers revised the interview outline content, forming the final version of the semi-structured interview outline (Supplementary File 1).

Research team

The research team consisted of one professor with academic expertise in qualitative research and clinical practice, and two graduate students with extensive training in qualitative methodology. One professor was responsible for research design, overall quality control, and facilitating the collaborative coding process. The two graduate students were responsible for data collection and analysis.

Regarding the researchers’ relationships with participants, two team members (one professor and one graduate student) were employed at the same hospital where the interviews were conducted and had pre-existing clinical relationships with some participants through routine ward work. These relationships were professional and collegial, as the researchers held no supervisory or evaluative authority over participants. However, we recognized that some participants might have perceived the researchers as institutional insiders, potentially influencing their willingness to disclose negative experiences or sensitive emotions. To mitigate this risk, several strategies were implemented.

First, interviews were conducted by researchers who had no direct supervisory relationships with the participants, and all participants were explicitly assured that their responses would remain confidential and anonymous, and that non-participation or honest responses would have no impact on their employment or professional standing. Second, interviewers adopted a neutral, non-judgmental stance, adhered closely to the semi-structured interview guide, and refrained from expressing personal opinions. Third, reflective diaries were written after each interview to document assumptions, emotional responses, and potential influences on data collection and interpretation, and these diaries were reviewed during team meetings. Finally, multiple researchers were involved in coding, and any disagreements were resolved through consensus, ensuring that interpretations were grounded in the data rather than in individual preconceptions.

Data collection

The two graduate students conducted face-to-face semi-structured interviews in comfortable, private venues chosen according to participant preferences, typically quiet meeting rooms or empty offices within the department. Before each interview, the researchers explained the study’s purpose, sought permission to audio‑record the session, and assured participants that all recordings and transcripts would be used solely for research purposes. After obtaining written informed consent, interviews were conducted with a neutral attitude, guided by the interview outline. The interviews lasted between 35 and 55 min, with an average duration of approximately 47 min. All interviews were conducted in Mandarin Chinese, the native language of all participants. After each interview, the researchers wrote reflective diaries to document emotional responses and refine the interaction process; as noted above, these diaries were reviewed in team meetings to enhance reflexive awareness. Participant observation (e.g., observing interactions at the nurse station) was also conducted, yielding data that corroborated or complemented the interviews [25].

The interviews were audio-recorded and transcribed verbatim in Chinese by the two graduate students. Transcripts were checked against the original recordings for accuracy by the lead researchers. Data were analyzed in the original Chinese to preserve the richness and nuance of participants’ expressions. For the purposes of this manuscript, representative quotations were translated into English by two bilingual researchers independently, and discrepancies were resolved through discussion. We acknowledge that some cultural and linguistic nuances may be inevitably lost or altered in translation; to minimize this risk, we prioritized conceptual equivalence over literal translation and ensured that all translated quotations were reviewed by the research team to confirm they accurately reflected the original meanings.

Data analysis

NVivo 12.0 software was used to manage, organize, and facilitate analysis of the transcripts. Following the constant comparative analysis strategy, we completed the qualitative data analysis procedure, which consisted of open coding, axial coding, and selective coding [26].

To ensure transparency and dependability of the analytical process, we maintained a comprehensive audit trail throughout the study. This included raw data (audio recordings and verbatim transcripts in Chinese), coding records (initial codes, subcategories, and categories with corresponding data excerpts), coding trees generated in NVivo 12.0, reflective diaries documenting analytical decisions, meeting minutes recording team discussions, and memos written during the constant comparison process. Table 1 provides illustrative examples of the coding process across the three levels.

Table 1.

Examples of open, axial, and selective coding

Example Quote	Open Coding (Initial Concepts)	Axial Coding (Subcategories)	Selective Coding (Category)
“I first judge whether he is speaking recklessly because he is in so much pain from terminal cancer that he’s not fully conscious, or whether he is simply ill-tempered and looks down on others. In the former case, I will be more tolerant; in the latter, I need to be more careful to protect myself.”	Attribution of behaviour to illness versus personal malice; Differentiated coping based on appraisal	Behavioural Attribution	Theme 1 Situational Perception and Cognitive Appraisal
“I don’t say anything at first, I let him finish, no matter how unpleasant what he says is. While waiting for him to catch his breath, I say: ‘Is there anything I can help you with right now?‘”	Active listening; Giving space; Offering assistance	Relational Repair	Theme 2 Diverse Coping Strategies

Two researchers independently coded all transcripts using NVivo 12.0. After each coding round, they met to compare their coding schemes and identify discrepancies. Disagreements were discussed until consensus was reached through rigorous negotiation, with reference back to the original data. When consensus could not be achieved, a third researcher was consulted to arbitrate and finalize the coding decision [27]. In the selective coding phase, the two coders further interpreted the interrelationships among key categories to form core categories. Additionally, two experts were invited to verify the theoretical saturation of the categories to ensure the completeness and reliability of the findings. Participants did not participate in data analysis; however, they reviewed the categories and their relationships to ensure they captured participants’ insights. Reflective diaries also enhanced the researchers’ theoretical sensitivity and conceptualization abilities [28].

Rigor

The rigor of this qualitative study was evaluated based on four criteria proposed by Charmaz: credibility, resonance, originality, and usefulness [29]. To ensure credibility, we employed strategies such as reflective diaries, triangulated data analysis, and a comprehensive audit trail. Regarding resonance, we established trusting relationships with participants, adopted a neutral interviewing stance, and invited participants to review the categories. Regarding originality, our study offers novel insights by integrating cognitive appraisal, emotional labour, and organisational support into a cohesive theoretical model. Regarding usefulness, the findings provide practical implications for nursing management and a theoretical framework for future research.

Results

Participants

A total of 20 interviewees were included in this study, including 2 males and 18 females. The age range was 23–54 years, with an average age of 36.2 years. Regarding marital status, 8 were unmarried and 12 were married. In terms of education level, 19 held a Bachelor’s degree and 1 held a Master’s degree. The working experience ranged from 1 to 33 years, with an average working experience of 13.55 years. See Table 2 for details.

Table 2.

Demographic characteristics of participants(n = 20)

Number	Age	Gender	Marital status	Educational level	Years of working experience	Years of work experience in the internal medicine department
1	37	Female	Married	Bachelor	14	14
2	36	Female	Married	Bachelor	14	14
3	31	Male	Unmarried	Bachelor	9	9
4	48	Female	Married	Bachelor	18	12
5	29	Female	Unmarried	Bachelor	7	7
6	25	Female	Unmarried	Bachelor	2	2
7	39	Female	Married	Bachelor	15	8
8	44	Female	Married	Bachelor	22	17
9	32	Female	Married	Bachelor	10	10
10	23	Female	Unmarried	Bachelor	1	1
11	39	Female	Married	Bachelor	18	18
12	28	Female	Unmarried	Bachelor	5	5
13	36	Female	Married	Bachelor	13	6
14	30	Female	Unmarried	Bachelor	8	8
15	26	Female	Unmarried	Bachelor	4	4
16	27	Female	Unmarried	Graduate	2	2
17	49	Female	Married	Bachelor	28	20
18	51	Female	Married	Bachelor	30	27
19	40	Male	Married	Bachelor	18	18
20	54	Female	Married	Bachelor	33	25

Theme

Theme 1 situational perception and cognitive appraisal

This theme reveals the cognitive processing process of nurses at the moment of encountering uncivil behaviours, which begins with the assessment of the specific situation and rapidly transitions to defining the nature of the behaviour.

Situational triggers

Patients experience emotional outbursts triggered by specific situational factors such as pain from illness, long waiting times, dissatisfaction with treatment outcomes, and noisy environments.

N2 He was in so much pain in the middle of the night that he couldn’t bear it, and the painkillers weren’t working either. His family member shouted at us: ‘Is no one going to take care of him?’ Actually, we understood that the family member was probably worried about the patient, but his tone of voice still made us feel very uncomfortable.

N3 His family seemed to be in a difficult financial situation, and his hospitalization was prolonged. That day, when he heard that more fees needed to be paid, he said many unpleasant things. Although it had nothing to do with us, we were the ones facing him directly.

N18 A newly admitted patient was in a hurry to have blood drawn, but we were all attending to other patients. The family member got angry in the corridor, rushed over, pointed at us, and shouted, accusing us of negligence and delaying the illness. (Her speech rate accelerated, as if reliving the urgency and accusation at that moment.)

Initiation of emotional labour

Feelings of shock, grievance, anger, and helplessness arise, and professional identity is challenged.

N4 For an instant, I felt furious, blood rushing to my head. I have dignity too, why treat me like this? I really felt like quitting right there. But immediately another voice stopped me: You are a nurse, you can’t do that.

N5 Apart from feeling wronged, I was actually a bit scared. Especially when facing tall male patients or emotionally agitated family members, not knowing what they might do next.

N9 My mind went blank for a moment, I felt especially shocked and wronged. We had communicated pleasantly just yesterday, how could they change like this today?

N13 At that moment, I felt particularly helpless and disheartened. He didn’t dare to vent to the doctor, only dared to argue with me. All my hard work and dedication seemed utterly worthless in his eyes.

Behaviour attribution

Nurses distinguish between “emotional decontrol caused by illness” and “purely malicious attacks.” Different definitions influence subsequent coping strategies.

N2 I first judge whether he is speaking recklessly because he is in so much pain from terminal cancer that he’s not fully conscious, or whether he is simply ill-tempered and looks down on others. In the former case, I will be more tolerant; in the latter, I need to be more careful to protect myself.

N10 I observe whether he targets everyone. If he is equally irritable with doctors, cleaners, and even his own family, it might be a mood change caused by the illness. If he only picks on nurses, the nature is different.

N14 Family members’ behaviour especially needs to be distinguished. Is it really anxiety and loss of control because a loved one is critically ill, or are they originally unreasonable and belligerent, just looking for trouble? This is very important for deciding how we should communicate.

Theme 2 diverse coping strategies

Based on their judgment of the nature of the behaviour, nurses make choices from a range of strategies.

Relational repair

Active listening, empathic responding, explanation and clarification, temporary withdrawal for a cooling-off period.

N7 I don’t say anything at first, I let him finish, no matter how unpleasant what he says is. While waiting for him to catch his breath, I say: ‘Is there anything I can help you with right now?‘

N8 I use an empathetic tone and say: ‘I know waiting this long must be really frustrating for you, anyone would get upset with such a prolonged illness, even I might be anxious if I were in your shoes. Let’s see together how we can resolve this quickly.’

N16 If he gets angry due to a misunderstanding, like thinking we missed a medication dose, when I first started working I would feel wronged and get agitated. Now, I calmly take out my PDA scanner, point to the record, and show him: ‘Look, the 9 a.m. medication was administered on time. Maybe you were asleep and don’t remember.’

N20 For those frequent flyer patients who constantly complain, I sometimes proactively ask them about personal matters, like ‘Did any family members come to visit you today?’ temporarily shifting the conversation away from the point of conflict

Boundary setting

Reiterating treatment norms, maintaining professional distance, focusing on technical procedures.

N6 When he requests something that doesn’t comply with regulations, like wanting to go home for the night, I will reiterate very clearly, firmly but politely: ‘Based on your condition and hospital regulations, going home poses risks. We must be responsible for your safety.’

N9 If the other person persists with personal attacks, I take a slight step back and stop saying anything further.

N11 No matter what he says to me, the treatment procedures I need to perform cannot be disrupted. While being scolded by him, I still have to steadily and accurately insert his IV. I respond through professional performance.

Cognitive reappraisal

Self-consolation, downward comparison, temporary emotional detachment.

N5 I silently tell myself: ‘He’s cursing my role as a nurse, not me as a person. It’s not that I performed poorly.’

N14 I tell myself internally: ‘Just have to deal with this patient today. Endure it a bit longer, and my shift will be over.’

Seeking external support

Confiding in colleagues, requesting assistance from senior nurses or the head nurse, activating safety alerts when necessary.

N10 When I can’t handle it any more, I find another senior nurse. The moment she arrives, her presence is different, and the patients or family members often back down.

N12 Back in the treatment room, I tell a close colleague: ‘I’m so furious, that patient in bed XX just now…’ After venting, I feel much more relieved.

N13 When encountering particularly difficult patients or those showing signs of potential violence, I immediately report it to the head nurse.

N19 Sometimes you need to ‘leverage’ help. For example, I say to the patient: ‘What you’re saying is very important. Let me get the attending doctor, and we can explain it clearly to you together, okay?’ Bringing the doctor into the communication loop.

N20 We discreetly remind other colleagues, like saying ‘The family member of the patient in bed XX is emotionally agitated.’ This prepares other nurses for their shift.

Theme 3 internal negotiation in the coping process

This theme captures the complex conflicts and trade-offs that nurse experience internally while implementing coping strategies, representing the core manifestation of the “internal negotiation” inherent in emotional labour.

Conflict between suppressing emotional expression and adhering to professional roles

The internal conflict between “wanting to retort” and “having to endure.”

N1 At that moment, I had a million things I wanted to say back to him, I really wanted to ask him ‘Are you being reasonable?’ But in the end, I said nothing at all.

N6 Sometimes I endure it until my shift ends, and only then do I cry in my car. All the grievance and anger during work are forcibly suppressed; I dare not get angry, dare not lose my temper.

N15 I think: My parents have never scolded me like this, why should I take this kind of treatment here? But the next second I think: Forget it, he’s a patient. If I argue back, I’ll be the one in the wrong. (Her voice choked slightly.)

Negotiation between professional ethics and personal dignity

Seeking a balance point between the “patient-entered” service philosophy and maintaining one’s fundamental personal dignity.

N4 I can be infinitely patient with nursing procedures, but regarding personal insults, I will have my stance. For example, I will look at him seriously and say: ‘Please mind your language. We can solve the problem, but we need mutual respect.’

N9 On the premise of ensuring his basic treatment and safety, I will reduce unnecessary proactive communication. Since you don’t respect me, let’s just maintain a minimal professional relationship.

N17 I’m often searching for that balance point: I need to make him feel cared for, but I can’t let him think I’m a pushover who can be vented on at will. This balance is very hard to strike.

Trade-off between short-term pacification and long-term impact

Choosing methods that can quickly resolve the immediate conflict, but potentially accumulating psychological depletion.

N10 I know that unconditionally giving in is like drinking poison to quench thirst. If I suppress it this time, he might be even worse next time. But when the end of my shift is approaching, or when there are other critically ill patients to attend to, you have to choose the fastest way to smooth things over.

N16 Now I don’t invest too much emotion in patients. I feel like my sympathy and enthusiasm for patients are being consumed bit by bit. I’m really afraid that in the end, I’ll become apathetic and insensitive.

N17 A lot of our coping, in fact, is a choice between ‘protecting the ability to continue current work’ and ‘protecting my own mental health.’ Often, we have no choice but to prioritize the former.

Theme 4 outcomes and reflections on coping behaviours

The outcomes of coping behaviours are complex and nonlinear, while simultaneously articulating clear demands regarding organizational support systems.

Nurse-patient relationship changes

Trust may be rebuilt, or the relationship may become distant, maintaining only minimal therapeutic interaction.

N2 Some patients, after venting, actually feel embarrassed the next day. They take the initiative to greet me and have a particularly good attitude. The relationship even seemed a bit closer than before.

N5 Rebuilding trust is very difficult. Even if things seem fine on the surface, I still have a lingering unease in my heart, and maybe he does too. Whatever procedure I perform afterwards, I am extra careful to avoid giving him any chance to find fault.

N8 For those who are particularly unreasonable, our interaction is reduced to the bare minimum of therapeutic communication. I just complete the work, not staying a second longer than necessary, as long as nothing goes wrong.

N13 There are extreme cases where the family demands to have me replaced, or I proactively request not to be assigned to that patient’s care.

Professional versus psychological capital

Accumulating communication experience and enhancing coping abilities, or conversely, leading to emotional exhaustion and professional burnout.

N9 Having experienced a lot, I can spot the signs at a glance and also know which conversational techniques can stabilize the situation the fastest. I guess you could say I’ve trained myself; my adaptability and communication skills have indeed improved.

N12 Every time I deal with this kind of unpleasantness, I feel a significant internal drain. Enthusiasm and patience are limited. A little is consumed today, a little tomorrow, and I don’t know when it will be completely depleted.

N17 Now, my first reaction to a new patient is sometimes not ‘How can I help him?‘, but ‘Is he going to be a difficult person?’ This kind of defensiveness is both experience and a tragedy.

Organizational support

A strong desire for clear behavioural guidelines, psychological counselling support, and tangible backing from management.

N3 What we need most is that ‘when something happens, the leadership can stand up and speak fairly for us,’ rather than unconditionally demanding that we ‘endure’ and ‘pay attention to our service attitude‘ (She became somewhat emotional.)

N7 I hope the hospital can have clear procedures: defining the threshold at which encountering verbal abuse or threats of violence allows us to take certain measures, instead of making us judge and bear the risks ourselves.

N18 Training shouldn’t only teach us to provide enthusiastic service; it should also teach us how to protect ourselves.

Discussion

This study employed a grounded theory approach to explore the psychological and behavioural response processes of internal medicine nurses when facing patient incivility. Moving beyond the static perspective of simply categorizing nurses’ coping behaviours as “communication skills” or “emotion management,” we constructed a dynamic theoretical model encompassing four dimensions: situational perception and cognitive appraisal, diverse coping strategies, internal negotiation, and outcome reflection. The detailed theoretical model is presented in Fig. 1.

Fig. 1.

Model of the coping process of medical nurses facing patient incivility

Our findings indicate that cognitive attribution constitutes a critical juncture that can guide divergent coping pathways. Nurses do not generate coping responses immediately after encountering patient incivility; rather, they first engage in rapid attribution [30], distinguishing whether the behaviour is illness-related or stems from personal malice. This cognitive appraisal influences subsequent emotional labour strategies and outcomes. When nurses attribute the behaviour to illness, empathy is activated and deep emotional labour strategies (such as relational repair) are employed, which may positively influence patient satisfaction [31]. Conversely, when nurses attribute the behaviour to personal malice [32], psychological defence is triggered and surface emotional labour strategies (such as normative boundary-setting) are adopted [33–34]. This strategy may increase the risk of unethical behaviour [35] and elevate vulnerability to professional burnout [36]. Furthermore, our findings corroborate experimental evidence that more irritable patient behaviour generates stronger negative emotional responses in nurses, thereby affecting their professional judgment [37].

This study advances understanding of emotional labour by revealing the concrete manifestations of “internal negotiation” within the high pressure medical environment. The model demonstrates that when implementing professionally required emotional regulation, nurses continuously weigh emotional suppression, ethical dilemmas, and personal costs [38]. Specifically, nurses engage in ongoing negotiation between organizational “display rules” (e.g., maintaining calmness and caring) and their own “genuine feelings” (e.g., anger or grievance) [39]. This practice of expressing work‑required emotions through masking has become a professional norm, particularly in high‑pressure environments where nurses universally face expectations to appear competent, calm, and empathetic [40]. Within the East Asian cultural context influenced by Confucian thought, concealing genuine emotions is a prevalent professional requirement [41]. Research indicates that surface acting cannot avoid emotional dissonance, which constitutes a significant source of persistent psychological stress and may lead to anxiety, depression, and burnout [42–44]. Moderate emotional regulation or masking may help maintain professional image and potentially enhance work engagement; however, when this internal negotiation becomes excessive, prolonged emotional suppression can trigger internal depletion and feelings of self‑estrangement, thereby severely reducing work engagement [45].

This study reveals that the outcomes of nurses’ coping with patient incivility are nonlinear and multifaceted. The model demonstrates that coping with a single incident can yield divergent outcomes: it may be transformed into professional capital through experience accumulation, or it may continuously deplete psychological capital through emotional consumption, leading towards burnout [46]. The sustained depletion of psychological capital weakens nurses’ emotional resilience and coping abilities, threatening their mental health [47]. Therefore, organizational support is crucial in preventing nurses from falling into continued depletion. In the absence of institutional safeguards, psychological counselling, and leadership support, nurses’ individual efforts to cope with patient incivility are often limited in effectiveness and difficult to sustain [1], potentially accelerating psychological resource depletion in the long run. Research shows that authentic leadership and organizational support can enhance nurses’ work performance by boosting their psychological capital [48–49]. Meanwhile, self-regulation in emotional labour continuously consumes psychological resources, while external resources such as organizational social support can effectively replenish nurses’ emotional reserves and buffer workplace stress [50–52]. This study ultimately extends the perspective from individual capabilities to the supportive and moderating role of organizational systems, providing a more comprehensive theoretical framework for fully understanding the mechanisms of nurses’ occupational health and for designing systematic intervention programmes.

Limitations

This study has several limitations. First, the sample was recruited from a single tertiary hospital in one region, and the applicability of the findings to other healthcare settings requires cautious evaluation. Second, as a qualitative study, the results rely on participants’ subjective recall and researchers’ interpretations, introducing several specific biases. Recall bias may arise from participants recalling incidents up to six months prior, with memories potentially incomplete or reconstructed. Social desirability bias may have led participants to present coping strategies in line with professional ideals, possibly underreporting negative emotions or less adaptive behaviours. Interviewer bias may have been introduced through pre-existing clinical relationships with some participants, which could have influenced questioning, probing, or interpretation. Third, the study focused specifically on patient incivility as a particular stressor, without fully examining its interactive effects with other work-related stress factors. Fourth, although interviews were conducted and initially analysed in Mandarin Chinese to preserve the authenticity of participants’ narratives, the translation of selected quotations into English for publication may entail some loss of subtle linguistic and cultural nuances. We have taken steps to minimise this limitation through independent translation and team consensus, yet readers should interpret the findings with this consideration in mind.

Conclusion

This study constructed a theoretical model of the psychological and behavioural processes through which internal medicine nurses respond to patient incivility using a grounded theory approach. The model delineates a complete pathway from situational perception and cognitive appraisal to diverse coping strategies, internal negotiation, and outcome reflection, highlighting the critical role of cognitive attribution in initiating coping responses and the significant influence of organizational support on coping outcomes. The findings provide a process-oriented theoretical framework for understanding nurses’ workplace psychology and offer implications for nursing management practice.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

Xinyang Zhao and Tianle Wang conceived and wrote the paper; Xinyang Zhao and Tianle Wang conducted literature search; Xinyang Zhao, Tianle Wang, Yuqi Niu and Xiaochun Zhang collected and analyzed the data; Xiaochun Zhang revised the whole paper.

Funding

This study was funded by the Basic Scientific Research Projects for Colleges and Universities of Liaoning Provincial Department of Education (LJ112410159016) and the Supporting Program for National-level Research Projects of the School of Nursing, China Medical University (2024-FC4).

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Ethical approval

This study strictly adhered to the Declaration of Helsinki and received approval from the Ethics Review Committee of the First Hospital of China Medical University (No. 2024.671) before commencement. The researchers informed participants about the purpose and significance of this study and its voluntary nature. All participants signed informed consent forms before formal participation. Participants’ privacy and personal information were strictly protected throughout the research process. All audio and textual materials were used solely for this study and would not be disclosed or used for other purposes without participants’ consent. During the reporting of research results, all participant information will be anonymized to ensure adequate protection of participants’ privacy. Interview transcripts and related textual materials of respondents will be destroyed within two years after the study concludes.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.