RESEARCH

 

Workplace bullying and mental health of medical interns in KwaZulu-Natal Province, South Africa

 

 

A Issak^I; V Ntlansana^I; P Mngomezulu^II; A Tomita^III; S Paruk^IV

^IMB ChB; Discipline of Psychiatry, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
^IIMMed (Psych); Discipline of Psychiatry, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
^IIIBSc, PhD; Centre for Rural Health, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
^IVMB ChB, PhD; Discipline of Psychiatry, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

Correspondence

 

 

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ABSTRACT

BACKGROUND. There is a silent epidemic of workplace bullying among medical doctors, with junior doctors being the most vulnerable. Little research has been conducted to establish the nature and extent of bullying of medical interns in KwaZulu-Natal (KZN) Province, South Africa.
OBJECTIVES. To describe the prevalence and types of workplace bullying, identify alleged perpetrators, and explore the association between bullying and the mental health and quality of life of medical interns in KZN.
METHODS. A cross-sectional online survey was conducted across all state hospitals in KZN designated for training first- and second-year medical interns, from 1 June to 31 August 2023, using snowball sampling. Participants completed a newly designed sociodemographic, clinical and bullying questionnaire, the Negative Acts Questionnaire (NAQ), the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder-7 (GAD-7) scale, and the World Health Organization Quality of Life scale.
RESULTS. Of the 270 medical interns employed in KZN, 182 responded, and 135 were included in the study. All interns were classified as having experienced bullying according to the NAQ, and 61.8% screened positive for symptoms of anxiety and/or depression on the PHQ-9 and GAD-7. The most commonly reported somatic symptoms and work-related behaviours caused by workplace bullying were recurrent headaches (42.5%), chronic lethargy (79.3%), gastrointestinal illnesses (42.7%), sleep disturbances (67.8%), loss of interest in work (81.0%) and absenteeism from work (43.5%). Most participants (61.2%) did not report the bullying to senior staff, and most of those who did report were dissatisfied with the outcome of the investigation (91.2%).
CONCLUSION. Medical interns in KZN have a high prevalence of anxiety and depressive symptoms, with a negative impact on their quality of life. Bullying by senior medical and nursing staff is pervasive. However, it was not possible to explore the associations between bullying and mental health, as all participants had high bullying scores on the NAQ.

Keywords: workplace bullying, medical interns, junior doctors, anxiety, depression, South Africa

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Bullying in the workplace is defined as 'repeated actions and practices that are directed against one or more workers that are unwanted by the worker(s), and whether carried out deliberately or unconsciously, cause humiliation, offence, and distress'.^[1] Bullying interferes with work performance and/or creates an unpleasant working environment for its targets. While the medical profession is traditionally known for its focus on compassion and improving patient care, it is increasingly acknowledged that medical professionals face significant challenges in the workplace.^[2] The World Health Organization has described workplace bullying in the medical community as a 'silent epidemic'.^[3] The lifetime prevalence of bullying among medical students and doctors is estimated to range from 10% to 98% in global studies. In the UK, junior medical doctors reported a 37% prevalence of workplace bullying,^[4] while a figure of 42% has been reported for the USA^[5] and a figure of 78% for South Africa (SA).^[6] An international systematic review and meta-analysis found that the pooled prevalence of bullying among medical registrars (residents) was 51% (95% confidence interval (CI) 36 - 66).^[5]

A survey conducted in 2019 among 70 (39.1%) of the 179 psychiatry registrars from all specialist training institutions in SA found that ~48% reported being bullied.^[7] Of this sample, 21 reported consultants as the main perpetrators, followed by patients and patients' relatives, hospital management, other registrars, nurses and university management. The most common form of abuse was belittling/humiliation, followed by threats/insults, deliberate prevention from accessing training, and other forms of bullying.^[7]

The present study aimed to describe the lifetime prevalence (using a sociodemographic questionnaire) and 6-month prevalence (using the Negative Acts Questionnaire (NAQ)) of bullying among medical interns in KwaZulu-Natal (KZN) Province, SA, types of bullying, alleged perpetrators, help-seeking behaviour, and the association between bullying and the interns' mental health and quality of life.

 

Methods

Study design

This was a cross-sectional, descriptive, quantitative study. An online survey link was distributed to medical interns and was available on the RedCap (Research Electronic Data Capture) platform hosted at the University of KwaZulu-Natal from 1 June to 31 August 2023.

Study setting

The study information and participation request were sent to the intern curators of the hospitals where medical interns are placed in KZN (King Edward VIII Hospital, Prince Mshiyeni Memorial Hospital, Addington Hospital, R K Khan Hospital, Mahatma Gandhi Memorial Hospital/Dr Pixley Ka Isaka Seme Memorial Hospital, the Pietermaritzburg Complex, Ladysmith Hospital, Newcastle Hospital, General Justice Gizenga Mpanza Regional Hospital and Ngwelezane Hospital). According to the Department of Health District Office, 270 first- and second-year medical interns were allocated to these hospitals during 2023, and study information was also shared via email and meetings.

To recruit participants, the study employed both convenience sampling and snowball sampling, a non-probability technique in which existing participants recruit future subjects from among their peers. Medical interns recruited other medical interns via electronic communication platforms, including WhatsApp, intern email groups, and the KZN internship Facebook page. The study link to the survey questionnaires, hosted on a secure online platform (RedCap), was circulated through these platforms.

Sample size

Based on an estimated population size of 250 interns and a bullying prevalence rate of 49% reported by Beath et al.^[7] in 2021 among psychiatry registrars, the present study aimed for a sample size of 152 participants. This sample size would provide a 95% CI with a 5% error margin.

Participants

All medical interns who were completing their internship training between January 2022 and December 2023 at a state hospital in KZN and were registered with the Health Professions Council of South Africa were eligible to participate. Participants had to be aged >18 years and engaged in medical internship. Health-related internships other than medical were excluded.

Measures

Five tools were used to collect data from participants: a newly designed sociodemographic, clinical and workplace bullying questionnaire, the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder-7 scale (GAD-7), the World Health Organization Quality of Life scale (brief version) (WHOQOL-BREF), and the NAQ.

Sociodemographic, clinical and workplace bullying questionnaire. This questionnaire recorded participants' demographic (age, gender, race, marital status) and occupational data (year of internship, rotations completed), as well as clinical data (wellbeing). Bullying-related questions assessed whether participants felt that they had ever been targeted by bullying in the workplace (lifetime bullying), the consequences (including the effect on their attitude towards work), and any help-seeking behaviour. The questionnaire was designed based on a review of the literature. The validity and reliability of the sociodemographic questionnaire were not tested, but it was piloted among medical doctors prior to its use.

NAQ. Bullying was measured using the NAQ, which consists of 29 items describing negative behaviours associated with workplace bullying over the past 6 months. It is a standardised Likert-scale questionnaire with response categories as follows: 1 = never, 2 = now and then, 3 = daily, 4 = weekly, and 5 = monthly. The aim is to measure how often participants have been exposed to negative acts during a 6-month period. Responses are summed, with a possible total score of 145. A score <33 indicates no bullying, a score between 33 and 45 suggests occasional bullying, and a score >45 indicates being a target of workplace bullying. The NAQ has demonstrated good psychometric properties, including a Cronbach's alpha of 0.90 for the 29 items.^[3]

GAD-7. The GAD-7, developed by Spitzer et al.,^[8] is a self-report questionnaire used to screen for and measure the severity of generalised anxiety disorder (GAD). It consists of 7 items rated on a 4-point scale (0 - 3), with total scores ranging from 0 to 21. Scores of 5, 10 and 15 correspond to mild, moderate and severe anxiety, respectively. A cut-off score of >10 has a sensitivity of 0.89 and a specificity of 0.82 for identifying GAD and was used to denote a positive screen. This tool has been used in the SA context.^[9]

PHQ-9. The PHQ-9 is a 9-item self-administered questionnaire used to screen for depressive symptoms over the past 2 weeks. Each item is rated on a 4-point scale based on the frequency of symptoms. Higher scores indicate greater severity of depression. The PHQ-9 is used as both a diagnostic tool and a severity measure. Scores of >10 have been found to have a sensitivity of 88% and a specificity of 88% for diagnosing depression and were used as the cut-off point for a positive screen.^[10] The PHQ-9 has been validated for use in SA.^[11,12]

WHOQOL-BREF. The WHOQOL-BREF is a 26-item quality-of-life assessment tool that measures four domains: physical health, psychological health, social relationships, and environment. The tool has been validated for use in SA.^[13] It has a sensitivity of 89% and a specificity of 82% at a cut-off score of 10.^[14]

Statistical analysis

Data were analysed using Stata version 18 software (StataCorp, USA). Descriptive analysis was conducted using frequencies, percentages, means and medians. Pearson's χ² test was used to test for associations between categorical variables, and the two-sample t-test was used to assess associations between categorical and continuous variables. The level of significance was set at p<0.05.

Ethical considerations

Approval for the study was obtained from the University of KwaZulu-Natal Biomedical Research Ethics Committee (ref. no. BREC/00005111/2022) and the KZN Department of Health. All participants provided written informed consent, and their anonymity was maintained throughout the study. To address potential psychological distress, a mental health resource guide was displayed upon completion of the online survey. The survey also included gratitude remarks, directing participants to relevant support services. The anonymised questionnaires were uploaded to an electronic database.

 

Results

Of the 270 medical interns who were employed during the study period, 182 (67.4%) responded. Data from 135 (74.2% of those who responded) were analysed, as 47 questionnaires were excluded owing to incompleteness. For some of those that were included, the rate of responses to questions was unfortunately not optimal, so some information was missing. The data are presented according to the five data collection tools, followed by statistical analysis to establish associations.

Sociodemographic data

The mean (standard deviation) age of participants was 26.6 (2.7) years, and the majority were female (n=102; 75.6%), black (n=56; 41.8%) and single (n=105; 80.2%). Ninety-four participants (71.2%) were in their second year of internship. The sociodemographic variables are detailed in Table 1.

 

 

Prevalence and types of bullying

Table 2 summarises the prevalence of various bullying types and the alleged perpetrators, as reported in the sociodemographic questionnaire. Almost all participants (n=125; 92.6% of the total number) reported experiencing bullying during one or more clinical rotations, often by workplace personnel, including medical officers, consultants and nurses. In addition, 52 participants reported being bullied by patients or their relatives. Of the participants, 107 (79.3%) completed the NAQ. Notably, 9 (90.0%) of the 10 participants who indicated that they had not been bullied on the sociodemographic questionnaire completed the NAQ (one did not complete it), on which they all scored high and were classified as having been a target of bullying in the past 6 months. The median (interquartile range) NAQ score was 46.0 (35.0 - 58.0), and all participants who completed the tool scored high as bullying targets.

 

 

The most prevalent form of bullying as reported on the sociodemographic questionnaire was psychological bullying (n=116; 91.3%), followed by intellectual bullying (n=112; 88.2%). The least common forms were cyberbullying (n=10; 9.7%) and physical bullying (n=9; 8.7%). More than one type of bullying was commonly experienced. Most participants identified medical officers (n=99; 83.2%) as the primary perpetrators, followed by nurses (n=73; 67.6%), consultants (n=71; 65.1%), registrars (n=52; 51.0%), patients (n=43; 43.4%), patients' relatives (n=36; 37.1%), and managers (n=26, 26.5%).

Table 3 provides an overview of the somatic symptoms, work-related behaviours (such as absenteeism and loss of interest in work) and help-seeking behaviours reported by the participants.

 

 

The results of the depression and anxiety screenings using the PHQ-9 and GAD-7, as well as the physical, psychological and social relationship impairments as measured by the WHO-QOL BREF, are summarised in Table 4. Of 102 participants who completed both the PHQ-9 and GAD-7, 63 (61.8%) screened positive for depression, anxiety or both.

 

 

Table 5 shows the association of bullying with mental health and WHOQOL-BREF scores. We considered looking for associations between NAQ scores and mental health, but all the interns scored in the high target range.

 

Discussion

This study aimed to describe the prevalence and types of workplace bullying, identify alleged perpetrators, and examine the association between bullying and the mental health and quality of life of medical interns in KZN, SA. A high prevalence of lifetime workplace bullying was reported, with 92.6% of participants reporting they had experienced bullying, and all who completed the NAQ scoring positive as bullying targets. Additionally, participants reported a high prevalence of symptoms of anxiety and depression. Many participants reported somatic symptoms and loss of interest in their work, with 43.5% attributing absenteeism to workplace bullying. Furthermore, most participants (61.2%) did not report the bullying, and most of those who did report it were dissatisfied with the outcome of the investigation (91.2%).

The 6-month prevalence of bullying in this study, as measured by the NAQ, is much higher than that reported in recent studies. For example, Samsudin et al.,^[15] who conducted research among junior doctors in Malaysia, found a bullying prevalence of just 13% among the doctors. Conco et al.^[16] reported a prevalence of 58% in SA, with 44% of participants experiencing bullying and over two-thirds witnessing it. An SA study by Fakroodeen^[17] found an 81% prevalence of bullying among medical students. These studies confirm that bullying in the medical field is highly prevalent. Most participants in the present study (71.2%) were second-year medical interns who had spent time in various clinical rotations and facilities, which gave them ample opportunity to describe the extent of their bullying experiences. As the most junior members in the medical hierarchy, interns are particularly vulnerable to bullying.

Workplace bullying is generally more commonly experienced by female than male employees, particularly in the early stages of their careers. Conco et al.^[16] reported a predominance of female victims (70%), while Quine^[4] observed a 37% bullying prevalence among junior doctors in the UK, with almost half (49.8%) being female victims.

The most common form of bullying reported by interns in the present study was psychological, followed by intellectual bullying. Many other studies have not consistently described specific types of bullying, which are often categorised as verbal hostility, angry outbursts, unreasonable work expectations, and social exclusion.^[3] The high prevalence of intellectual bullying in the present study is consistent with other research. Quine,^[4] for example, highlighted persistent belittling and unjustified criticism as the most common forms of bullying.

In the present study, perpetrators were often fellow medical professionals, including medical officers, nurses, consultants and registrars. This finding aligns with those of other studies, emphasising the hierarchical structure of hospitals and the gruelling nature of medical training, which fosters a culture where bullying is either unchallenged or perceived as a 'functional educational tool'.^[15]

The figures for anxiety and depressive symptoms in the present study are higher than those reported in previous studies in KZN, such as a survey of doctors in rural KZN which found that 35.6% and 23.3% of participants screened positive for depression and anxiety, respectively.^[18] Another study in urban KZN reported that 20% of doctors screened positive for anxiety and 21.3% for depression.^[9] However, studies by Sansone and Sansone^[19] and Conco et al.^[16] support the 61.8% prevalence found in the present study, which may be attributed to the higher proportion of junior doctors involved.

Junior doctors may fear repercussions from reporting bullying by senior staff, which can contribute to their silence and make it difficult to address bullying in the medical field. Additionally, victims may feel that people in positions of authority are aware of the bullying but unwilling to address it,^[20] a finding consistent with the present study, in which the majority of participants did not report their experiences, and most of those who did were dissatisfied with the outcomes. This situation underscores the need for confidential reporting and investigating mechanisms to address medical bullying.

Study limitations

Limitations of the study include the cross-sectional design, which means that causation cannot be established. Additionally, selection bias may have occurred, as participants who experienced bullying may have been more likely to respond, while those who did not may have been less likely to participate. The non-probability sampling method and reliance on social media for recruitment may have excluded individuals without access to or engagement with these platforms, resulting in a potential bias. The study also relied on self-reported data, which may have introduced biases. Moreover, incomplete responses were excluded, which could have further influenced the results. Finally, the study's focus on one province (KZN) limits the generalisability of the findings, although it provides important insights into the experiences of interns in the region.

 

Conclusion

This study found that workplace bullying is highly prevalent among medical interns, who also reported elevated levels of anxiety, depression and psychosomatic symptoms. It is concerning that most participants did not report the bullying, and that those who did were dissatisfied with the responses. There is a need to raise awareness of bullying and its negative effects in medical institutions and to share these findings with hospitals that host interns. Standardised reporting procedures and clear consequences for perpetrators must be established to prevent variations in disciplinary actions across institutions. Mechanisms to address mental health challenges resulting from work-related stress should be implemented, and better reporting systems for bullying should be put in place to ensure that victims are heard and perpetrators are held accountable. Qualitative research is also recommended to give voice to the lived experiences of those in the medical workplace, particularly junior staff who often find themselves interacting with more senior members.

Data availability. The datasets generated and analysed during the present study are available from the corresponding author (AI) on reasonable request.

Declaration. The research for this study was done in partial fulfilment of the requirements for AI's MMed (Psychiatry) degree at the University of KwaZulu-Natal.

Acknowledgements. I would like to express my sincere gratitude to my supervisor, Prof. Saeeda Paruk, Dr Peacemaker Mngomezulu, Dr Vuyokazi Ntlantsana and Prof. Andrew Tomita for their invaluable guidance, support and encouragement throughout the course of this research. Their expertise and insight were instrumental in shaping the direction and depth of this study. My appreciation goes to the research participants who generously gave their time to answer the questionnaires. Special thanks to my colleagues, friends and family for their unwavering support, understanding and patience during this journey. Your encouragement made this accomplishment possible.

Author contributions. AI: conceptualised the study, conducted the literature review, collected and analysed data, and prepared the first draft of the manuscript. PM and SP: provided academic supervision, contributed to the study design, assisted with interpretation of findings, and provided critical revisions of the manuscript. VN and AT: assisted with data analysis, reviewed drafts for intellectual content, and contributed to final approval of the manuscript. All authors approved the final version of the manuscript and are accountable for all aspects of the work.

Funding. None.

Conflicts of interest. None.

 

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Correspondence:
A Issak
aakifahissak3@gmail.com

Received 30 August 2024
Accepted 16 April 2025