Trauma-Related Symptomatology in Horizontal Nurse-to-Nurse Bullying: An Integrative Review of Direct and Indirect Exposure Pathways

24/07/2026

AI Summary

Measurement-exposure misalignment: secondary traumatic stress tools often applied to direct victims despite construct being grounded in indirect exposure.
Witnessing is under-measured despite being a plausible indirect trauma pathway that may amplify symptoms, especially when combined with direct victimisation.
Need for conceptual precision and trauma-informed leadership: distinguish direct versus indirect exposure and measure witnessing to protect nurse wellbeing and patient safety.

AI Summary

AIMS: This integrative review synthesized empirical and conceptual literature on horizontal nurse-to-nurse bullying and trauma-related symptomatology, with particular attention to how secondary traumatic stress has been theoretically conceptualized and operationalized in relation to direct versus indirect exposure pathways.

Four themes emerged: (1) measurement-exposure misalignment, with secondary traumatic stress instruments frequently applied to directly victimized nurses despite the construct's grounding in indirect exposure; (2) aggregation of horizontal bullying within broader workplace violence constructs, limiting relational specificity; (3) under-measurement of witnessing, despite its role as a plausible indirect trauma pathway that may intensify symptoms when combined with direct victimization; and (4) contextual vulnerabilities, particularly among novice and critical care nurses.

Distinguishing direct and indirect exposure pathways, explicitly measuring witnessing, and implementing trauma-informed leadership are critical to protecting nurse well-being and supporting patient safety.

Basic summary

Issues Ment Health Nurs. 2026 Jul 24:1-14. doi: 10.1080/01612840.2026.2684569. Online ahead of print.

ABSTRACT

METHODS: Guided by Whittemore and Knafl, an integrative review was conducted. Searches were completed on 6 May 2026 across three databases. Empirical and theoretical studies examining horizontal bullying and trauma-related symptoms in nurses were included. Methodological quality was appraised using Joanna Briggs Institute tools. Data were analyzed using a constant-comparative approach, with reporting aligned to PRISMA 2020.

RESULTS: The literature represented over 3,000 nurses across multiple countries. Four themes emerged: (1) measurement-exposure misalignment, with secondary traumatic stress instruments frequently applied to directly victimized nurses despite the construct’s grounding in indirect exposure; (2) aggregation of horizontal bullying within broader workplace violence constructs, limiting relational specificity; (3) under-measurement of witnessing, despite its role as a plausible indirect trauma pathway that may intensify symptoms when combined with direct victimization; and (4) contextual vulnerabilities, particularly among novice and critical care nurses. Common limitations included cross-sectional designs, reliance on self-report, and inconsistent definitions of trauma exposure.

CONCLUSIONS: Horizontal bullying is associated with trauma-consistent symptom patterns, but conceptual and measurement precision remains limited. Distinguishing direct and indirect exposure pathways, explicitly measuring witnessing, and implementing trauma-informed leadership are critical to protecting nurse well-being and supporting patient safety.

PMID:42497311 | DOI:10.1080/01612840.2026.2684569

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