Recent research suggests that bullying and unhealthy workplace environments are significantly adding to the stress many healthcare workers in South Africa already face. This is unfortunately not a new problem, but there is at least hope in some quarters that it is now slowly being addressed.

Around 58% of staff at a local university’s health science faculty, including those jointly working in public hospitals, report having been bullied more than once. 64% of respondents observed it happening to others. The research, recently published in the South African Medical Journal (SAMJ) by a team from the University of the Witwatersrand, defines bullying as unwanted actions that cause offence and distress to others.

The results suggest most bullying is linked to rank or status, as well as issues of race and gender.

While a lot of previous media coverage of the issue focuses on junior doctors, Emeritus Professor Beverley Kramer explains that the results did not highlight age or seniority as clearly as one may expect. “It wasn’t just the young people who have been bullied, there was senior staff who also said they were being bullied.”

In the same edition of the SAMJ, experts write that around half of the psychiatry registrars reported bullying and harassment, such as being belittled and threatened, deliberately prevented from accessing training, or being forced to work in an unsafe clinic.

Professor Soraya Seedat, executive head of the Department of Psychiatry at Stellenbosch University, says she was particularly concerned that this was not only having an effect on people’s ability to work but that about one in four students reported symptoms of a probable mood or anxiety disorder as a result.

While these studies were conducted in partly academic settings, it seems plausible that such toxic workplace conditions prevail throughout much of the country’s healthcare system. “This is a problem that is widespread, and it’s widespread across the world. We know that it’s not unique to South Africa,” says Seedat. “We have similar rates of bullying that have been documented among doctors and medical students.”

Contributing factors

Dr Anesu Mbizvo reflects on her time as a junior doctor at a public hospital and describes long working hours with intense emotional strain, but no room to process this. “The workplace culture was one of sacrifice,” she says. “Because of the fact that everybody was depleted and stressed — everybody was essentially emotionally empty — there was almost this unsaid rule or habit of people not talking about what they were experiencing.”

Mbizvo left full-time medicine in 2017, before the end of her internship, because of the effect the environment was having on her mental health. She says that while inside of the profession there was great pressure not to take time off work. Once she decided to leave, the reaction was somewhat the opposite. “So many of my colleagues were dying to do the same thing,” Mbizvo says, but explains many did not feel they had the freedom to do this.

Mbizvo’s story is one of many.

She was recently featured in a documentary called A Quiet Implosion that highlights the personal stories of doctors. Dr Cyan Brown produced the piece as part of her Senior Atlantic Fellowship for Health Equity at the Tekano Institute and says many conversations about healthcare workers were missing the context of what doctors were facing. She says the systemic problems often include unfair working hours, hospital safety challenges, and struggles around the availability of posts.

“The pandemic hit and exposes that healthcare workers are really struggling, but it didn’t come out of nowhere. It’s just compounded over years of these issues festering, and it’s really sad that a lot of the time they get attention only when there is a crisis,” Brown says.

Dr Adil Khan, a Public Health Masters’ candidate at the University of Cape Town, also produced a documentary about working conditions, which was released late last year, and agrees that these issues have been brought to light or even worsened during Covid.

He highlights that these are often systemic issues that then influence individual healthcare workers, then affecting the operations of the healthcare system and with it, patient care. “And if you think about it from that perspective, you realise that these aren’t actually soft issues, that these toxicities as we call them, actually have tangible impacts on how service delivery is in the country.”

Bullying, harassment, and unfair working conditions influence each other and the contributing factors are often cyclical or connected. The pressure and hierarchy of the workplace is a definite factor, and Seedat says that those who have been bullied often go on to bully. “You know, we have this hierarchy within medicine and that hierarchy has been perpetuated, and then bullying within that hierarchy has also been perpetuated across different generations of academics and students.”

Change from the bottom 

Since the problem is clearly both on a systemic and more personal level, most solutions have been a two-pronged approach. Khan explains that the bottom-up approach capacitates the individual healthcare worker and builds their resilience. This includes acknowledging the role of mental health and interpersonal challenges and training skills to handle these.

Brown adds that this should start early. “I think medical curriculums really need to include more work around tools on coping and not just from an academic point of view but from a personal point of view of this is how you debrief a colleague, this is what you do if you’re in trouble.”

Khan and Seedat explain that this should include awareness programmes around what legal and institutional recourse and support is available for those experiencing harassment, since this is often not well known and utilised.

Kramer says, “I think mentoring is extremely important for supporting the people who are experiencing bullying, but the institution needs to change the environment in which we work.”

Change from the top

Khan agrees that purely focusing on individual support is problematic. “That gives an impression that healthcare workers are the problem when clearly they are not. Clearly, they are the end result of all the toxicities and I think far more emphasis should be placed on top-down.”

Seedat agrees. “It does require an organisational shift,” she says. “I think there’s just complacency and maybe a lack of political will to really actively try and change the organisational culture.”

One clear need is improving or creating better grievance structures. Often the main port of call in hospitals is the Human Resources Department, and Khan says that these are often aligned with the bullies or the processes are not transparent and effective. “That’s often where the breakdown of trust is. I’ve had an issue, I’ve tried to make a complaint, it feels disingenuous, then I become apathetic.”

Kramer and the team’s practical recommendations address this.

“One recommendation that came through was the importance of appointing an ombudsman or facilitator, who people in the faculty could go to see when they experienced this type of bullying.” This has been brought to the faculty’s senior management, with a focus on the needed body being independent and impartial. She says that the first step should be to train individuals, particularly in management positions, who have bullied, possibly followed by disciplinary processes. The other necessary change needs to be in training and improving leadership skills, particularly of those higher up in the hierarchy.

Prof Renata Schoeman heads up the MBA in healthcare leadership at the University of Stellenbosch Business School and puts a lot of the problems down to bad leadership. She says that trying to implement a zero-tolerance approach to bullying, regardless of what level it occurs at, is important. “We leaders should be very aware of the interactions with people and also addressing uncomfortable situations in how to deal with conflict, how to deal with performance at work in a non-aggressive way, but in a constructive way,” she says.

“Leaders can be managers, but often managers are not leaders. And that is crucial in this kind of environment,” says Kramer. She says that the hiring process of senior staff should take leadership and management skills into stronger consideration and provide a mentor or coach to the new hire where needed.

Slow shifts

With this renewed studying of how bullying and toxicity in healthcare workplaces occurs, there is some hope that changes will come for those affected. Khan says he is inspired by slow shifts and by seeing more activism in the space. Seedat says that while the problems are not new, neither are the interventions and with time, the tides can turn. DM/MC

*This article was produced by Spotlight – health journalism in the public interest.