Comment on: ‘Horizontal Violence or Workplace Bullying Among Intensive Care Unit Nurses: A Mixed Systematic Review’

We read with great interest the recent mixed systematic review by Zhang et al. (2025), entitled ‘Horizontal Violence or Workplace Bullying Among Intensive Care Unit Nurses: A Mixed Systematic Review’. The authors provided a valuable synthesis of evidence regarding the awareness, contributing factors, impacts, and mitigation strategies of horizontal violence or workplace bullying (HVWB) among intensive care unit nurses, thereby addressing a significant gap in the literature. We are writing to further explore a crucial point highlighted in their discussion—the role of cultural context, specifically Confucian norms, in shaping HVWB. We posit that a deeper integration of this cultural-specific perspective is imperative for developing effective, culturally adaptive interventions in global healthcare settings. The review aptly identifies cultural norms, such as collectivism and respect for hierarchy in Confucian-influenced societies, as contributors to the mistreatment of junior nurses (Cha and Sung 2020; Zhang et al. 2025). However, the influence of culture extends beyond a contributing factor to a fundamental lens through which HVWB is perceived, manifested, and addressed. In cultures characterised by high power-distance and collectivism, such as those across much of East Asia, HVWB behaviours may be subtly disguised as ‘strict mentoring’ or an unavoidable aspect of ‘team integration’, making them more insidious and less likely to be formally reported. The profound emphasis on hierarchical relationships and ‘saving face’ can discourage junior nurses from challenging authority or reporting abuses, often internalising such experiences as a necessary ‘rite of passage’ (Yang et al. 2025). Furthermore, the pervasive ‘in-group/out-group’ dynamics and the importance of personal connections (‘Guanxi’ in Chinese contexts) can intensify the formation of exclusive cliques and ostracism, as noted in the review (Bry and Wigert 2022), but with culturally specific mechanisms that are more deeply embedded in social fabric. Consequently, standard definitions and reporting tools for HVWB, often developed in Western, individualistic contexts, may lack the sensitivity to capture these culturally nuanced expressions, leading to significant under-recognition of the problem. Therefore, moving forward, we strongly advocate for a culturally adaptive approach in both research and practice to effectively mitigate HVWB in ICUs worldwide. This entails several actionable steps. Firstly, in research, we must go beyond cross-cultural comparisons of prevalence. Future studies should employ qualitative and mixed-methods designs to deeply explore the emic expressions of HVWB within specific cultural contexts. This knowledge should then inform the development and validation of culturally sensitive assessment tools that can accurately capture nuanced behaviours like passive-aggressive communication or exclusion masked as disciplinary action. Secondly, in clinical practice, intervention strategies must be localised. For instance, leadership training programs should explicitly address how to foster psychological safety while respectfully navigating hierarchical structures. Training for all staff should include modules on identifying and addressing culturally embedded bullying, empowering both victims and bystanders to speak up within a framework that acknowledges local social norms. Thirdly, at the policy level, anti-bullying policies need to be co-created with local nurses and cultural experts to ensure they are perceived as legitimate and actionable, rather than a top-down, foreign imposition. Finally, evaluating the implementation of these tailored interventions is crucial. Drawing upon implementation science frameworks (e.g., the Consolidated Framework for Implementation Research—CFIR) (Damschroder et al. 2009) can help identify the specific barriers and facilitators to deploying such culturally informed strategies in different ICU settings, ensuring they are not only effective in theory but also feasible and sustainable in practice. By systematically integrating cultural considerations into every step—from understanding the problem to evaluating the solution—we can develop more precise and powerful strategies to dismantle HVWB, ultimately fostering healthier work environments for ICU nurses across the globe. In conclusion, we sincerely appreciate the foundational work by Zhang et al. (2025), which provides a comprehensive platform for this essential discussion. By championing a culturally adaptive lens—one that meticulously considers the profound influence of norms, hierarchies, and social dynamics—we can significantly enhance the precision and impact of our efforts to combat HVWB. It is through such nuanced understanding and tailored actions that we can truly hope to cultivate inclusive and psychologically safe ICU environments globally, thereby retaining our invaluable nursing workforce and safeguarding the quality of patient care. The author has nothing to report. The author declares no conflicts of interest. The author has nothing to report.