Bullying does not directly harm mental health in intern nursing students, but operates through a serial mediation path where bullying amplifies role stress, which fosters clinical maladjustment, which ultimately leads to poor mental health.
An overwhelming majority of Chinese intern nursing students reported experiencing bullying and poor mental health.
The direct effect of bullying on mental health was not statistically significant.
Bullying significantly increased role stress among intern nursing students.
Role stress significantly exacerbated clinical maladjustment among intern nursing students.
Clinical maladjustment was a strong, direct predictor of poorer mental health.
The full serial mediation path from bullying through role stress and clinical maladjustment to mental health was statistically significant.
This research suggests that workplace bullying harms the mental health of nursing students doing clinical internships, but not in the straightforward way most people assume. Rather than bullying directly causing psychological distress, the study found that bullying first creates feelings of role stress — confusion and conflict about one's responsibilities and identity as a new clinical worker. That role stress then leads to difficulty adjusting to the clinical environment, and it is this struggle to adapt that most strongly predicts poor mental health. Nearly all students surveyed (95%) reported being bullied, and over 83% had poor mental health, highlighting how widespread both problems are. The study was conducted among 489 final-year nursing students in Tianjin, China, who had completed at least six months of clinical internship. The researchers used a theoretical framework called Meleis's transitions theory, which focuses on how people navigate major life and role changes. By viewing the student-to-intern transition through this lens, they identified the psychological chain reaction set off by bullying: stress about one's role leads to clinical maladjustment, which then damages mental wellbeing. This research suggests that simply reducing bullying, while important, may not be sufficient on its own — interventions should also focus on helping nursing students manage role-related stress and adapt more successfully to clinical settings. Practical approaches recommended by the authors include strengthening clinical supervision, providing structured training programs, and creating more supportive workplace environments. Addressing the transition process itself — helping students feel confident and competent in their new clinical roles — may be a key lever for protecting their mental health.
Liu H, Zhang Y, Li X, Huang D, Gao Y, Fan W, et al.. (2026). Serial mediation of role stress and clinical maladjustment between bullying and mental health among Chinese intern nursing students: Model testing based on Meleis's transitions theory.. Nurse education today. https://doi.org/10.1016/j.nedt.2026.107158