Workplace Bullying Among Junior Doctors in Malaysia: A Multicentre Cross-Sectional Study

Abstract

Background: Research suggests that junior doctors often experience workplace bullying, which may have adverse impacts on medical training and delivery of quality healthcare. However, evidence among local population has not been established. The present study aims to examine the prevalence of workplace bullying among Malaysian junior doctors and explore its associated sociodemographic and employment factors.

Methods: A multicentre cross-sectional study was conducted in 12 government hospitals accredited for housemanship training within the central zone of Malaysia. The study included a total of 1,074 house officers who had been working for at least 6 months in various housemanship rotations. The Negative Acts Questionnaire-Revised (NAQ-R) was used to examine workplace bullying.

Results: The 6-month prevalence of workplace bullying among study participants was 13%. Work-related bullying such as ‘being ordered to do work below your level of competence’, person-related bullying such as ‘being humiliated or ridiculed in connection with your work’, and physically intimidating bullying such as ‘being shouted at or being the target of spontaneous anger’ were commonly reported by study participants. Medical officers were reported to be the commonest perpetrators of negative actions at the workplace. Study participants who graduated from Eastern European medical schools (adjusted odds ratio [AOR] 2.27; 95% confidence interval [CI]: 1.27, 4.07) and worked in surgical-based rotation (AOR 1.83; 95% CI: 1.13, 2.97) had higher odds of bullying compared to those who graduated from local medical schools and worked in medical-based rotation, whereas study participants with good English proficiency (AOR 0.14; 95% CI: 0.02, 0.94) had lower odds of bullying compared to those with poor English proficiency.

Conclusion: The present study shows that workplace bullying is prevalent among Malaysian junior doctors. Considering the gravity of its consequences, impactful strategies should be developed and implemented promptly in order to tackle this serious occupational hazard.

Full text

Malays J Med Sci. 2021;28(2):142–156
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This work is licensed under the terms of the Creative Commons Attribution (CC BY)
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142
To cite this article: Samsudin EZ, Isahak M, Rampal S, Rosnah I, Zakaria MI. Workplace bullying among junior
doctors in Malaysia: a multicentre cross-sectional study. Malays J Med Sci. 2021;28(2):142–156. https://doi.
org/10.21315/mjms2021.28.2.13
To link to this article: https://doi.org/10.21315/mjms2021.28.2.13
Abstract
Background: Research suggests that junior doctors often experience workplace bullying,
which may have adverse impacts on medical training and delivery of quality healthcare. However,
evidence among local population has not been established. The present study aims to examine
the prevalence of workplace bullying among Malaysian junior doctors and explore its associated
sociodemographic and employment factors.
Methods: A multicentre cross-sectional study was conducted in 12 government hospitals
accredited for housemanship training within the central zone of Malaysia. The study included a
total of 1,074 house ocers who had been working for at least 6 months in various housemanship
rotations. The Negative Acts Questionnaire-Revised (NAQ-R) was used to examine workplace
bullying.
Results: The 6-month prevalence of workplace bullying among study participants was
13%. Work-related bullying such as ‘being ordered to do work below your level of competence’,
person-related bullying such as ‘being humiliated or ridiculed in connection with your work’,
and physically intimidating bullying such as ‘being shouted at or being the target of spontaneous
anger’ were commonly reported by study participants. Medical ocers were reported to be the
commonest perpetrators of negative actions at the workplace. Study participants who graduated
from Eastern European medical schools (adjusted odds ratio [AOR] 2.27; 95% condence interval
[CI]: 1.27, 4.07) and worked in surgical-based rotation (AOR 1.83; 95% CI: 1.13, 2.97) had higher
odds of bullying compared to those who graduated from local medical schools and worked in
medical-based rotation, whereas study participants with good English prociency (AOR 0.14; 95%
CI: 0.02, 0.94) had lower odds of bullying compared to those with poor English prociency.
Conclusion: The present study shows that workplace bullying is prevalent among
Malaysian junior doctors. Considering the gravity of its consequences, impactful strategies should
be developed and implemented promptly in order to tackle this serious occupational hazard.
Keywords: workplace bullying, junior doctors, prevalence, associated factors, Occupational Safety and Health,
psychosocial hazard
Workplace Bullying Among Junior Doctors
in Malaysia: A Multicentre Cross-Sectional
Study
Ely Zarina
SamSudin
1, Marzuki
iSahak
2, Sanjay
Rampal
2,
RoSnah
Ismail3, Mohd Idzwan Zakaria4
1 Department of Public Health Medicine, Faculty of Medicine, Universiti
Teknologi MARA, Selangor, Malaysia
2 Department of Social and Preventive Medicine, Faculty of Medicine,
University of Malaya, Kuala Lumpur, Malaysia
3 Department of Community Health, Faculty of Medicine, Universiti
Kebangsaan Malaysia, Bangi, Selangor, Malaysia
4 Dean’sOce,FacultyofMedicine,UniversityofMalaya,KualaLumpur,
Malaysia
Submitted: 7 Sept 2020
Accepted: 12 Jan 2021
Online: 21 Apr 2021
Original Article

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Original Article | Workplace bullying among Malaysian junior doctors
Correspondingly, the present study attempts to
determine the prevalence of workplace bullying
among Malaysian junior doctors and explore
the sociodemographic and employment factors
associated with it.
Methods
Sample
The terminology for junior doctors varies
across the globe, including terms such as
‘intern’, ‘foundation doctor’, ‘resident’, ‘trainee
doctor’, ‘doctor in training’ and ‘house ocer’.
In the present study, the term house ocer
(HO) has been used to refer to junior doctor
working in the Malaysian healthcare system. A
multicentre cross-sectional study was conducted
in 12 government hospitals accredited with
housemanship training (GHAHT) within the
central zone of Malaysia. The main reason for
selecting GHAHT was to enable the sampling
of HO. Meanwhile, the central zone of Malaysia
was selected because it is the most populated
zone and houses the largest number of GHAHT,
as well as all types of GHAHT, including state,
major specialist, university and military hospitals
(22).
Following ethical approval, permission
to conduct the study was granted for 12 of
the 16 GHAHT located within the central
zone of Malaysia. HO who were working for
at least 6 months in the general medicine,
general surgery, orthopaedic, obstetrics and
gynaecology, paediatrics, emergency medicine
and anaesthesiology departments of these
hospitals were universally sampled. A 6-month
clinical experience cut-o was chosen as
workplace bullying is described to be a persisting
phenomenon in which exposure to negative
actions have had occurred for at least 6 months
(23–24). Those who declined to participate in the
study, did not return their questionnaires and
on maternity or medical leaves were excluded
from the study. A priori sample size calculation
based on an estimated 4,991 population of house
ocers in Malaysia (22) and bullying prevalence
of 14% among junior doctors identied from
previous studies (25) was determined to be 215,
using the OpenEpi calculator (version 3).
Data Collection
Data was collected in several ways. In the
rst study site, an email survey was conducted
due to its ease of administration, extensive
Introduction
Workplace bullying, a phenomenon that is
also labelled as workplace mobbing, harassment,
aggression, emotional abuse and victimisation
(1), has emerged as a signicant workplace
health and safety problem. Dened as ‘situations
where an employee is persistently exposed to
negative and aggressive behaviours at work
primarily of a psychological nature with the
eect of humiliating, intimidating, frightening
or punishing the target’ (2), it is a problem
that has been shown to exist worldwide (3–4).
Within the healthcare industry, many cases of
bullying experienced by doctors are reported to
be perpetrated by others in a pecking order of
seniority (5). Indeed, studies have demonstrated
that 30% to 95% of junior doctors across the
globe report being bullied at work (6). This
has been suggested to be due to the traditional
hierarchical structures of hospitals and gruelling
medical training, which produces a culture in
which bullying is not only unchallenged, but
perceived as a ‘functional educational tool’ (7–8).
Further compounding the problem is the culture
of silence in which only 12% of junior doctors
report experiences of abuse to a supervisor, for
fear of repercussions in reporting mistreatment
(9). Thus, such incidences are allowed to persist
and perpetuate, causing ‘bullying’ to become a
learned behaviour that gives rise to a legacy of
abuse in medicine (8–11).
In Malaysia, numerous newspaper articles
have highlighted cases of workplace bullying
among junior doctors over the past few years
(12–15). These incidences were shown to lead
to detrimental repercussions for the targets
of bullying, with some developing depression,
quitting housemanship and even considering
suicide (12–15). Indeed, a considerable body of
literature has established that junior doctors’
exposure to workplace bullying have resulted in
undesirable health and work outcomes, such as
mental strain, job dissatisfaction and burnout
(16–20). Disconcertingly, bullied junior doctors
have also been reported to be more likely to
make serious or potentially serious medical
errors and had higher frequency of accidents
compared to non-bullied peers (17, 21). These
eects may not only negatively impact their
training but may also hinder the delivery of safe
and high-quality patient care. Despite the above
concerns, to date, no studies have been published
to examine the occurrence of workplace
bullying among local junior doctor population.

Malays J Med Sci. 2021;28(2):142–156
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144
coverage and exibility in choosing when
to complete the questionnaire. The study
questionnaire was recast in Google Form
format, with a participant information sheet
and electronic consent form attached to the rst
part. It was designed to be anonymous and this
was emphasised to study participants. An email
including a condential link to the Google Form
was sent to all HOs in the mailing list retrieved
from the administration unit of the clinical
departments. A week later, reminder to complete
the study questionnaire was carried out using
email reminders, verbal reminders from group
supervisors and individual text messaging.
Though no emails were reported to bounce
back, the response rate from the email survey
was poor. Thus, for the remaining study sites,
data was collected via a self-administered paper
questionnaire. Again, the study questionnaire
was designed to be anonymous and this was
emphasised to the participants. In addition,
completed questionnaires were asked to be kept
in a brown opaque envelope and separate from
the participant information sheet and consent
form. The data collection was conducted in
two phases. For each hospital, the list of HO
was rst retrieved from the Human Resource
Department, whereas information on the date
and time of meetings involving HO was obtained
from the Occupational Safety and Health ocer.
In the rst phase, the principal investigator
invited all HOs present in the meeting to
participate in the study. Those who agreed were
asked to complete the study questionnaire and
return it by the end of the meeting. Those who
were not present in the meeting were identied
from the attendance list and later included in
a new list. In the second phase, the new list
was then given to the HO team leaders of each
department, who were asked to help distribute
the study questionnaires to their colleagues.
The principal investigator then collected
the questionnaires from the team leaders
after two weeks. The entire process of data
collection continued for almost 6 months, from
27 November 2017 to 17 May 2018.
Instruments
Single item questions were used to measure
sociodemographic characteristics such as age,
gender, ethnicity, educational background and
English prociency as well as employment
characteristics such as working duration, medical
specialty and type of hospital. In relation to
this, educational background was assessed by a
single item question asking study participants to
state which medical school they graduated from,
whereas English prociency was evaluated using
a self-reported item, “How well do you think you
speak English?”, with response options ranging
from ‘excellent’, ‘good’, ‘fair’ and ‘poor’. The
Negative Acts Questionnaire-Revised (NAQ-R)
and a stem question based on a denition
of workplace bullying were used to measure
workplace bullying. The NAQ-R is a 22-item
scale that measures study participants’ exposure
to work-related bullying, person-related bullying
and physical intimidation within the past
6 months, with study participants rating their
exposure as ‘Never’, ‘Now and then’, ‘Monthly’,
‘Weekly’ and ‘Daily’ (2). Post-hoc validation
demonstrated a one-factor solution and excellent
reliability (intraclass correlation coecient
[ICC] of 0.94 and Cronbach’s alpha of 0.97). The
NAQ-R was followed up by the stem question
asking study participants whether they perceive
being bullied at work, based on the following
denition of workplace bullying: ‘Workplace
bullying refers to situations where an employee
is persistently exposed to negative and aggressive
behaviour at work primarily of a psychological
nature with the eect of humiliating,
intimidating, frightening or punishing the target’
(2). It has the same response anchors as the
NAQ-R. Following that, the study participants
were asked to answer a single item question to
select the commonest perpetrators of negative
actions at the workplace.
Data Analysis
Statistical analyses were performed using
the Software for Statistics and Data Science
(STATA) version 14.0. Initial data analysis
included assessment of missingness and
inuential data, as well as model checking
for logistic regression. Model diagnostics
indicated that all assumptions were met as:
i) the dependent variable was binary, which was
the appropriate structure for logistic regression;
ii) multicollinearity analysis indicated that all
variables had acceptable variance ination factor
(VIF < 10) and tolerance (tolerance > 0.1) and
iii) residual-versus-tted plot showed that
linearity in the transformed expectations was
observed. In relation to missingness, results
suggested that missingness for study instrument
items was less than 5% and also missing
completely at random, and thus ignorable.
Sensitivity analysis was also conducted to
determine whether there was any dierence in

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Original Article | Workplace bullying among Malaysian junior doctors
the outcome according to study site or mode
of data collection. No signicant dierences
in prevalence of bullying according to data
collection method or hospital were observed and
thus, data was pooled together for subsequent
analyses.
Next, data were categorised. Educational
background was categorised by region, i.e.
local, Western Europe, Eastern Europe,
Australasia, Middle East, East Asia, South Asia
and Southeast Asia. Medical specialty group
was categorised according to the classication
of medical specialties, which included medical
(general medicine and paediatrics), surgical
(general surgery and orthopaedic surgery) and
mixed (obstetrics and gynaecology, emergency
medicine, and anaesthesiology) specialties (26).
Following that, to describe the characteristics
of study participants, prevalence and types
of workplace bullying experienced by study
participants, and commonest perpetrator of
negative actions, descriptive statistics was
conducted using mean and standard deviations
for continuous data and frequency and
percentage for categorical data. The prevalence
of workplace bullying was calculated using
the following methods that were derived from
literature review: i) Behavioural Experience
Method and NAQ-R cut o scores (27);
ii) Behavioural Experience Method and
Leymann’s Criterion (23, 28); iii) Behavioural
Experience Method and Mikkelsen and
Einarsen’s Criterion (29); iv) Self-labelling with
Denition Method (24) and v) Combination
Method based on Both Behavioural Experience
and Self-labelling Methods (4). In this study,
cases of bullying was operationalised as
scoring 45 or more on the NAQ-R, in line
with the recommended cut-o score proposed
by Notalaers and Einarsen (27), as well as
perceiving to be bullied weekly or daily according
to the denition of bullying given. The frequency
of negative actions experienced was categorised
into: i) never, now and then or monthly and
ii) weekly or daily, to denote infrequent and
frequent exposures respectively. To investigate
the possible association between all factors and
workplace bullying, simple logistic regression
analysis was performed and the crude odds
ratio (COR) and 95% condence interval (CI)
was estimated. Variables that were signicant
at a P-value of less than 0.25 were entered into
a multiple logistic regression analysis to predict
the nal independent factors, and the adjusted
odds ratio (AOR) and 95% CI was estimated.
Additionally, model tness was assessed using
the Hosmer-Lemeshow goodness-of-t test, with
a P-value of less than 0.05 taken as an indication
of poor t.
Results
The overall response rate of this study was
62% (n = 1,074). The characteristics of study
participants are outlined in Table 1. The study
participants had a mean age of 27.0 ± 1.5 and
were mainly composed of female participants
(65%). In terms of ethnicity, Malay participants
comprised the majority (67%) and most of the
study participants graduated from medical
schools in Malaysia (52%), followed by medical
schools in countries within the Middle East
(17%) and Eastern Europe (10%). Majority of
study participants rated their English-speaking
prociency as good (54%). The study participants
had a mean duration working of 15.5 ± 7.0
months and were evenly distributed across all
medical specialties (ranging from 31% to 35%).
Study participants from major specialist hospital
contributed to the majority of the study sample
(63%), followed by state hospital (26%) and
university hospital (11%).
The prevalence of workplace bullying
among study participants was 13% (Table 2).
The most frequent types of negative actions
reported by the study participants included
work-related bullying such as ‘being ordered to
do work below your level of competence’ (21%
weekly or daily), person-related bullying such as
‘being humiliated or ridiculed in connection with
your work’ (17% weekly or daily), and physically
intimidating bullying such as ‘being shouted at or
being target of spontaneous anger’ (16% weekly
or daily) (Table 3). The commonest perpetrators

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146
of negative actions at work were reported to be medical ocers (59%), followed by nurses and support
sta (31%) (Table 4).
Table 1. Characteristics of study participants (N = 1,074)
Variable Mean ± SD n (%)
Age (years) 27.0 ± 1.5
Gender
Male 371 (34.6%)
Female 701 (65.4%)
Ethnicity
Malay 710 (66.5%)
Chinese 159 (14.9%)
Indian 180 (16.9%)
Others 18 (1.7%)
Academic graduation by region
Local 546 (52.4%)
Western Europe 56 (5.4%)
Eastern Europe 104 (10.0%)
Australasia 14 (1.3%)
Middle East 181 (17.4%)
East Asia 2 (0.2%)
South Asia 56 (5.4%)
Southeast Asia 83 (8.0%)
English prociency
Poor 5 (0.5%)
Fair 284 (26.9%)
Good 567 (53.6%)
Excellent 201 (19.0%)
Duration working (months) 15.5 ± 7.0
Medical specialty group
Medical 356 (34.6%)
Surgical 318 (30.9%)
Mixed 354 (34.4%)
Type of hospital
State hospital 281 (26.2%)
Major specialist hospital 675 (62.9%)
University hospital 118 (11.0%)

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Original Article | Workplace bullying among Malaysian junior doctors
Table 2. Prevalence of workplace bullying among participants (N = 1,074)
Method of measuring workplace bullying Bullied
No Yes
Persistent exposure to negative actions, i.e. scoring > 45 on
NAQ-RA (n = 1,041)
644 (61.9%) 397 (38.1%)
Persistent exposure to negative actions, i.e. exposure to at
least one negative action on a weekly or daily basis for the
past 6 monthsB (n = 1,041)
588 (56.5%) 453 (43.5%)
Persistent exposure to negative actions, i.e. exposure to at
least two negative actions on a weekly or daily basis for the
past 6 monthsC (n = 1,041)
688 (66.1%) 353 (33.9%)
Perceive to be bullied according to bullying denition givenD
(n = 1,042)
878 (84.3%) 164 (15.7%)
Prevalence of workplace bullyingE (n = 1,025) 889 (86.7%) 136 (13.3%)
Notes: Abased on behavioural experience method and NAQ-R cut-o scores; Bbased on behavioural experience method and
Leymann’s criterion; Cbased on behavioural experience method and Mikkelsen and Einarsen’s criterion; Dbased on self-labelling
with denition method; Ebased on combination method (methods A and D)
Table 3. Types of workplace bullying experienced by participants (N = 1,074)
Types of negative actions
Never, now and
then or monthly
n (%)
Weekly or daily
n (%)
1. Someone withholding information which aects your performance 959 (90.8%) 97 (9.2%)
2. Being humiliated or ridiculed in connection with your work 881 (83.4%) 175 (16.6%)
3. Being ordered to do work below your level of competence 833 (79.2%) 219 (20.8%)
4. Having key areas of responsibility removed or replaced with more
trivial or unpleasant tasks
884 (84.8%) 171 (16.2%)
5. Spreading gossip about you 914 (86.6%) 141 (13.4%)
6. Being ignored or excluded 945 (89.6%) 110 (10.4%)
7. Having insulting or oensive remarks made about your person,
attitudes, or private life
942 (89.3%) 113 (10.7%)
8. Being shouted at or being target of spontaneous anger 885 (83.9%) 170 (16.1%)
9. Intimidating behaviours such as nger-pointing, invasion of
personal space, shoving, blocking your way
922 (87.5%) 132 (12.5%)
10. Hints or signals from others that you should quit your job 978 (92.5%) 79 (7.5%)
11. Repeated reminders of your errors or mistakes 926 (87.6%) 131 (12.4%)
12. Being ignored or facing a hostile reaction when you approach 946 (89.5%) 111 (10.5%)
13. Persistent criticism of your work and eort 932 (88.3%) 124 (11.7%)
14. Having your opinions ignored 939 (88.8%) 118 (11.2%)
15. Practical jokes carried out by people you do not get along with 967 (91.5%) 90 (8.5%)
16. Being given tasks with unreasonable deadlines 944 (89.3%) 113 (10.7%)
17. Having allegations made against you 986 (93.4%) 70 (6.6%)
18. Excessive monitoring of your work 947 (89.9%) 107 (10.1%)
19. Pressure to not claim something to which by right you are entitled
to
896 (85.0%) 158 (15.0%)
(continued on next page)

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Types of negative actions
Never, now and
then or monthly
n (%)
Weekly or daily
n (%)
20. Being the subject of excessive teasing and sarcasm 953 (90.3%) 103 (9.7%)
21. Being exposed to unmanageable workload 904 (85.5%) 153 (14.5%)
22. Threats of violence or physical abuse or actual abuse 1,001 (94.7%) 56 (5.3%)
Table 4. Commonest perpetrator of negative actions reported by participants (N = 1,074)
Source Perpetrator of negative actions
No Yes
Consultants and specialists 782 (72.8%) 292 (27.2%)
Medical ocers 439 (40.9%) 635 (59.1%)
House ocers 890 (82.9%) 184 (17.1%)
Nurses and support sta 741 (69.0%) 333 (31.0%)
Administrative and non-clinical sta 1,030 (95.9%) 44 (4.1%)
Table 3. (continued)
In the univariate analysis, signicant
associations were observed between ethnicity,
education region, specialty group and workplace
bullying (Table 5). After controlling for potential
confounders, education region, prociency
in English and specialty group emerged as
signicant predictors of workplace bullying
among study participants. Study participants
who graduated from Eastern European medical
schools (AOR 2.27; 95% CI: 1.27, 4.07) and
worked in surgical-based rotation (AOR 1.83;
95% CI: 1.13, 2.97) had higher odds of workplace
bullying compared to those who graduated
from local medical schools and worked in
medical-based rotation. On the other hand,
study participants with good English prociency
(AOR 0.14; 95% CI: 0.02, 0.94) had lower odds
of workplace bullying compared to those with
poor English prociency. No dierences in
bullying were observed in relation to age, gender,
ethnicity, working duration and type of hospital.
Table 5. Association of sociodemographic and employment factors with workplace bullying (N = 1,025)
Variables COR (95% CI)AP-value AOR (95% CI)BP-value
Age 0.91 (0.79, 1.04) 0.156 0.91 (0.78, 1.07) 0.239
Gender n/s
Male 1.00 (ref)
Female 0.83 (0.57, 1.21) 0.344
Ethnicity
Malay 1.00 (ref) 1.00 (ref)
Chinese 1.08 (0.63, 1.85) 0.772 1.00 (0.54, 1.85) 0.996
Indian 1.72 (1.10, 2.69) 0.017 1.69 (0.97, 2.93) 0.063
Others 1.50 (0.43, 5.31) 0.526 1.76 (0.46, 6.67) 0.408
Education region
Local 1.00 (ref) 1.00 (ref)
Western Europe 1.46 (0.68, 3.13) 0.333 2.10 (0.94, 4.69) 0.069
Eastern Europe 2.04 (1.18, 3.50) 0.010 2.27 (1.27, 4.07) 0.006
Australasia 1.19 (0.26, 5.43) 0.825 1.57 (0.32, 7.69) 0.578
(continued on next page)

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Original Article | Workplace bullying among Malaysian junior doctors
Variables COR (95% CI)AP-value AOR (95% CI)BP-value
Middle East 0.87 (0.51, 1.50) 0.625 1.15 (0.61, 2.14) 0.670
East Asia 1.00* 1.00*
South Asia 0.89 (0.37, 2.16) 0.798 0.80 (0.30, 2.17) 0.664
Southeast Asia 0.67 (0.30, 1.53) 0.344 0.83 (0.35, 1.97) 0.680
English prociency
Poor 1.00 (ref) 1.00 (ref)
Fair 0.24 (0.04, 1.49) 0.125 0.20 (0.03, 1.37) 0.101
Good 0.19 (0.03, 1.17) 0.074 0.14 (0.02, 0.94) 0.043
Excellent 0.31 (0.05, 1.95) 0.213 0.21 (0.03, 1.44) 0.112
Duration working 0.98 (0.95, 1.01) 0.122 0.99 (0.96, 1.02) 0.606
Specialty group
Medical 1.00 (ref) 1.00 (ref)
Surgical 1.78 (1.13, 2.81) 0.012 1.83 (1.13, 2.97) 0.014
Mixed 1.00 (0.62, 1.64) 0.989 1.10 (0.64, 1.88) 0.737
Type of hospital n/s
SH 1.00 (ref)
MSH 0.82 (0.55, 1.23) 0.346
UH 0.69 (0.35, 1.37) 0.291
Notes: SH = state hospitals; MSH = major specialist hospitals; UH = university hospitals; n/s = non-signicant; ACOR estimates
from simple logistic regression; BAOR estimates from multiple logistic regression; *Insucient sample size, cell empty; Assumptions
of logistic regression have been met and the Hosmer-Lemeshow goodness-of-t test indicated good t (P = 0.558)
Table 5. (continued)
Discussion
The present study examined the prevalence
of workplace bullying among Malaysian junior
doctors and explored the sociodemographic
and employment factors associated with it.
Based on the analysis of a universal sample of
junior doctors sampled across 12 government
hospitals accredited for housemanship training
within the central zone of Malaysia (n = 1,074),
it was observed that the 6-month prevalence
of workplace bullying among junior doctors
was 13%. This is comparable to the study
published by Ling et al. (25), who reported
that 14% of junior doctors were exposed to
workplace bullying on a weekly or daily basis
for the past 12 months. The systematic review
of prior studies on the prevalence of workplace
bullying among junior doctors has suggested
that a wide range of prevalence (30%–95%) of
bullying have been reported, depending on the
study operationalisation of bullying (6). This
may be partly explained by the heterogeneity in
the terms and methodologies used to examine
workplace bullying as well as denitional
issues in relation to the persistence of negative
interactions experienced (6). Indeed, methods
used by researchers to measure workplace
bullying vary, which include the Behavioural
Experience Method using a bullying inventory
(e.g. NAQ-R) and/or the Self-labelling Method
using a bullying denition. Furthermore, even
when the same instrument is used, researchers
tend to vary in selecting the methods by
using either the Leymann criterion (23, 28),
Mikkelsen and Einarsen’s criterion (29) or the
cut-o score. As shown in the present study,
dierent methods of measuring workplace
bullying among the same study population
yielded dierent prevalence (16%–43%) and
more stringent operational denition resulted
in lower prevalence of workplace bullying.
Thus, the combination method was considered
to be the most appropriate method to measure
workplace bullying, as it could capture both the
persistency of negative actions experienced by
the study participants as well as their subjective
interpretation of being victimised (4, 24, 29).
Further, despite the combination method
being a more conservative measurement method,

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a prevalence of 13% indicated that a signicant
proportion of Malaysian junior doctors
experience bullying at work. This is evident
from the results of meta-analysis reviewing a
wide selection of studies (n = 44,878, k = 15
samples), which showed that the combination
method led to a weighted prevalence of 3.7%
bullying (4), suggesting that junior doctors were
relatively more frequent targets of bullying
compared to the general working population.
In relation to this, contextual factors which are
unique to junior doctors such as strict medical
hierarchy, especially demanding, fast-paced and
unpredictable work, and widespread custom
of ‘teaching by humiliation’ during medical
training (8, 21) may have partly contributed
to this observation. In terms of geographical
variation in the prevalence of workplace bullying
among junior doctors, no stark contrast was
observed from the ndings of Samsudin et al. (6),
though it should be noted that methodological
heterogeneity often acts as an impediment
for objective comparisons. Nonetheless, given
homogeneity in such aspects, it would have been
interesting to relate dierences in bullying to
contextual dissimilarities inherent in dierent
junior doctor populations. This is because junior
doctors in dierent parts of the world are subject
to variable resident duty hours, environment
for training and amount of clinical supervision
(30), and that there is evidence of cross-cultural
dierences between countries within and across
a region (31).
In terms of types of negative actions
experienced, the ndings of this study indicated
that junior doctors experienced all types of
bullying, including work-related, person-
related and physically intimidating bullying.
In comparison, the ndings of Ling et al. (25),
who also used the NAQ-R, indicated that
junior doctors reported higher exposure to
work-related bullying compared to person-
related and physically intimidating bullying. In
addition, contrary to this study, which reported
that medical ocers (58%) followed by nurses
and support sta (31%) were the commonest
perpetrator of negative actions at the workplace,
the commonest perpetrators reported by Ling
et al. (25) were consultants (54%), followed by
administration (28%) and fellow trainees (13%).
The ndings of this study suggested that
the probability of workplace bullying among
junior doctors was higher in certain medical
specialties, as study participants working in
surgical-based rotation had 83% higher odds of
bullying compared to those working in medical-
based rotation. Correspondingly, Dikmetas
et al. (18) and Al-Shafaee et al. (10) also reported
signicant dierences in negative interactions
experienced by junior doctors according to
medical specialties. In relation to this, Dikmetas
et al. (18) indicated that junior doctors perceived
negative interactions more frequently in
surgical medicine compared to basic medicine
and internal medicine (P = 0.001), whereas
Al-Shafaee et al. (10) reported that mistreatment
occurred more commonly during medical
rotation compared to surgical and paediatric
rotation (P = 0.005). This suggests that there
are dierences in terms of job demands and
resources and subsequent job strain between
the medical specialties, which can be explained
by the Job Demands-Resources Model (32).
Indeed, certain medical specialties have been
suggested to demand more time and provide
less emotionally and socially supportive working
environments (19), and it is evident from existing
literature that job demands relate positively
to targets’ reports of bullying, whereas job
resources relate negatively to bullying (32).
Besides that, other signicant predictors
of workplace bullying among junior doctors
include their educational background and
prociency in English language. It was observed
that study participants who graduated from
Eastern European medical schools had twice the
odds of bullying at work compared to those who
graduated from local medical schools. Although
there is no evidence to support this observation
presently, it may be postulated to be due to
the dierences in the level of condence and
preparedness for hospital work between junior
doctors graduating from traditional and non-
traditional medical programmes (33). Until now,
Eastern European medical schools have been
teaching their disciplines traditionally and have
not yet fully adopted the Integrated Pre-clinical
Medical Education Programme (34). According
to the study published by Eley (33), junior
doctors who spent undergraduate years training
at non-traditional medical schools felt more
condent and better equipped for internship.
Thus, it may be that those who graduated from
medical schools within the region were less
assured in managing daily tasks compared to
their peers, which may have led them to be
vulnerable targets for frequent bullying at the
workplace.
On the other hand, English language
prociency was shown to be a protective factor

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Original Article | Workplace bullying among Malaysian junior doctors
perceive it as threatening (42). Others argue
that women are permitted narrower bands
of acceptable behaviour, and consequently,
deviations from traditional roles may submit
them to negative evaluations and increase their
risk of experiencing workplace bullying (43–
44). Finally, in relation to ethnicity, Chadaga
et al. (37) reported signicant dierences in
workplace bullying among white and non-white
participants. This dierence could perhaps
be attributed to inequalities in both personal
and social vulnerabilities among employees of
dierent ethnicities that are intrinsic in certain
cultures (45).
Though working duration was not a
signicant predictor of bullying among junior
doctors, it may inuence their exposure to
bullying because of the nature of bullying itself,
which involves a perceived power imbalance
(2). This is because those who have worked
for shorter durations are more likely to have
less knowledge and skills compared to their
seniors, making them more prone to workplace
victimisation. Furthermore, it has been
suggested that junior doctors are less skilled
and experienced in minimising and deescalating
conicts at the workplace (40), making them
more susceptible to frequent bullying, which is
a notion that is more likely for those with less
working duration.
The present study has several limitations.
The multicentre cross-sectional study design,
even though considered a cost-eective and
practical approach, is not able to establish
evidence for causality. In addition, workplace
bullying is described as a process that often
progresses and escalates over time (46); as the
study was conducted among junior doctors that
were currently employed, those who had been
severely aected by bullying to the extent that
they had resigned or developed illness requiring
long-term leave may have been excluded from
the study. As such, the prevalence of workplace
bullying may have been underestimated. Besides
that, though the generalisability of this study
was improved by applying universal sampling
as well as achieving a response rate of 62%,
which is higher than the average response rate
for surveys used in organisational research
(47), a nonresponse of approximately 40% may
have inuenced the representativeness of the
ndings. Another limitation stems from the
use of self-administered questionnaire, which
could have led to several biases, including recall
bias and social desirability bias. In this regard,
for junior doctors, as study participants who
rated their English prociency as good had 86%
lower odds of workplace bullying compared to
those who rated their English prociency as
poor. Though there are no studies to support
this nding, the underlying reason could be the
fact that those with poor English prociency may
be less adept communicators. This may have
caused them to be more frequently misconstrued
by others, generating negative reactions among
their co-workers. Indeed, in the qualitative
study conducted by Marzuki et al. (35) to assess
the congruence between language prociency
and communicative abilities, study participants
reported that those with poor communicative
abilities were those who had poor command over
the language.
The present study also demonstrated no
signicant dierences between bullied and non-
bullied participants with regards to age, gender,
ethnicity, working duration and type of hospital.
However, several studies conducted elsewhere
have indicated that age, gender and ethnicity
are signicantly associated with workplace
bullying among junior doctors. In relation to
age, Crutcher et al. (36), Chadaga et al. (37),
Bairy et al. (38), Scott et al. (39) and Hills et al.
(40) observed signicant dierences in negative
interactions experienced according to age, with
those younger than 30 years of age being more
likely to experience workplace bullying. This may
be because there is a traditional power structure
and hierarchy within the medical setting in
which junior doctors, who are typically younger,
are at the lowest end of the pecking order (36),
making them more prone to bullying. On the
other hand, it has also been postulated that
with increasing age and maturity, perceptions
and interpretations change, which may be
the reason why older doctors are less likely to
perceive bullying (36). As only House Ocers
were sampled in this study, the dierence in the
baseline age is small, which may explain the non-
signicant nding.
In terms of gender, studies published
by Chadaga et al. (37), Aykut et al. (17), Fnais
et al. (41), Ling et al. (25) and Hills et al. (40)
consistently reported that signicantly more
female junior doctors experience bullying at
work compared to their male counterparts.
This was believed by some to be due to men
and women perceiving workplace bullying
dierently, with men being more likely to
perceive bullying as a particular management
style, whereas women being more likely to

Malays J Med Sci. 2021;28(2):142–156
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152
well as organisational characteristics including
organisational climate, culture, leadership,
justice, and support, are signicant factors
of workplace bullying among junior doctors.
However, causality has not been established
for these factors. Further, variables associated
with workplace bullying such as psychological
capital (52), social, coping and problem-solving
skills (53–59), conict management styles
(57), core self-evaluations (60), organisational
change (61–63), and societal norms and culture
(64–66) have also not been examined among
junior doctors. Given the seriousness of the
consequences in relation to junior doctors’
ability to learn and provide safe patient care,
greater awareness of workplace bullying in
medicine should be given utmost importance and
healthcare policies to tackle this occupational
hazard should be developed and implemented
promptly.
Acknowledgements
We thank the Occupational Safety and
Health Unit, Medical Development Division,
Ministry of Health Malaysia for assistance
in retrieving permission to conduct the
study in government hospitals accredited
for housemanship training from the Medical
Development Division, Ministry of Health
Malaysia. We would also like to thank the
directors of the government and university
hospitals included for consenting to data
collection among junior doctors.
Ethics of Study
Ethics approval was sought from the
Medical Research and Ethics Committee via
NMRR [NMRR-17-1360-36368 (IIR)] and the
Medical Ethics Committee of university hospitals
involved.
Conict of Interest
None.
Funds
None.
social desirability bias may have been possible as
bullying often goes unreported because targets
of bullying feel ashamed (48) and may have
chosen to report otherwise to avoid perceiving
themselves as victims. However, it may have
been reduced as participant anonymity and
study condentiality were emphasised during
the recruitment process. On the other hand,
recall bias was unavoidable as the questionnaires
were anonymous and there was no method
of contacting study participants to verify any
irregular responses once they have submitted
their questionnaires.
Despite the above limitations, several steps
were taken to increase the robustness of the
present study, including sampling from multiple
study sites and applying universal sampling
procedures to increase external validity of
study ndings, conducting a priori sample size
calculation to ensure adequate study power,
and using validated instrument that was further
veried via post-hoc exploratory factor analysis
and reliability testing as well as adjusting for
potential confounders in the nal model to
improve the internal validity of study ndings.
Conclusion
The ndings of the present study indicate
that workplace bullying is a signicant issue
for Malaysian junior doctors and that at least 1
in 10 Malaysian junior doctors perceives being
bullied at work. Considering that bullying is an
underreported problem, this is worrying. The
ndings of the present study also suggest that
certain sociodemographic and employment
characteristics may be predictive of junior
doctors’ exposure to workplace bullying. This
implies a need to perform risk-stratication
to identify junior doctors who are most at risk
of experiencing bullying at work so that early,
targeted interventions can be initiated. Indeed,
the considerable costs of workplace bullying
should justify that tackling it be made a priority.
In fact, according to Sheehan (49), the costs of
workplace bullying prevention strategies are
marginal compared to the costs of workplace
bullying on organisations. To facilitate this,
future studies examining workplace bullying
among junior doctors should include prospective
studies that explore antecedents of bullying, in
order to explore remedial actions. In this regard,
studies published by Samsudin et al. (50) and
Samsudin et al. (51) have shown that individual
traits such as negative aect and neuroticism, as

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Original Article | Workplace bullying among Malaysian junior doctors
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Authors’ Contributions
Conception and design: EZS, MI, SR
Analysis and interpretation of the data: EZS, MI,
SR
Drafting of the article: EZS
Critical revision of the article for important
intellectual content: EZS, MI, SR, RI, MIZ
Final approval of the article: EZS
Provision of study materials or patients: EZS
Statistical expertise: SR
Administrative, technical, or logistic support: MI,
SR
Collection and assembly of data: EZS, RI, MIZ
Correspondence
Dr Ely Zarina Samsudin
BMBS (Nott), MPH (Malaya), DrPH (Malaya),
OHD (DOSH)
Department of Public Health Medicine,
Faculty of Medicine, Universiti Teknologi MARA,
Sungai Buloh Campus, Jalan Hospital,
47000 Sungai Buloh, Selangor, Malaysia.
Tel: +603 61265000
Fax: +603 61267073
E-mail: elyzarina07@yahoo.com
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