Introduction

Academic bullying, defined as behaviours that systematically erode a colleague’s confidence, reputation, or career prospects, thrives in professions marked by steep hierarchies and fierce competition, none more so than medicine [1]. Junior doctors, positioned at the base of this hierarchy, are uniquely vulnerable. Multiple studies report verbal abuse, public humiliation, exclusion from critical learning opportunities, and punitive workloads as routine features of training environments [2,3,4]. Such mistreatment is not benign: sustained exposure is associated with anxiety, depression, professional disengagement, and premature exit from the medical workforce [4, 5], while team dysfunction and impaired clinical judgment jeopardise patient safety [6,7,8].

Evidence from Africa, though limited, suggests that academic bullying is both widespread and consequential [2, 3, 9]. In Sierra Leone, where health system fragility, workforce shortages, and the legacy of post-conflict reconstruction intersect, the issue remains critically underexplored. A cross-sectional survey conducted within Sierra Leone of 126 junior doctors at the University of Sierra Leone Teaching Hospitals Complex (USLTHC) found that 68.3% had experienced academic bullying, with no statistically significant predictors identified [3]. Beyond this, comparable data exist only for in-school adolescents [10, 11], underscoring the lack of systematic inquiry within clinical training environments.

Understanding the drivers, consequences, and perceived solutions to bullying among junior doctors is needed. First, the country’s efforts to rebuild a resilient health system depend on retaining skilled and motivated early-career physicians. Second, bullying erodes the collaborative culture essential for delivering safe, high-quality care. Third, progress toward Sustainable Develoicpment Goal 3c, which calls for an expanded and well-supported health workforce, will be impeded if clinical training settings remain hostile and demoralising.

Against this backdrop, we undertook a qualitative study to illuminate the lived realities of academic bullying among junior doctors at the USLTHC, building on the recent quantitative signal [3]. By foregrounding the voices of those most affected, we aimed to explore the experiences, perceptions, and coping strategies of junior doctors subjected to academic bullying at the USLTHC.

Methods

Study site

This study was conducted across the primary referral hospitals of the USLTHC in Freetown, including Connaught Hospital (≈ 350 beds), Princess Christian Maternity Hospital (140 beds), Ola During Children’s Hospital (139 beds), and the Sierra Leone Psychiatric Teaching Hospital (159 beds). These four institutions comprise the USLTHC, the country’s largest government-run tertiary care system and the central hub for clinical training. They serve as key teaching sites for early-career physicians. Collectively, the four hospitals provide roughly 780 inpatient beds, function as the main government referral centres for the 1.35 million inhabitants of Freetown and the wider Western Area, and treat more than 10 495 patients each month. Their workforce now includes 254 specialists and junior doctors, and approximately 670 professional nurses [12].

In the Sierra Leonean context, the term “junior doctor” refers to physicians who have not yet attained consultant status. This group includes house officers (interns), who are recent medical graduates in supervised clinical practice; medical officers, who have completed internship but are not enrolled in formal residency programs; and registrars (residents), who are undertaking postgraduate specialist training but have not yet achieved full certification [3].

Study design and participants

This explorative qualitative study was conducted in compliance with the Declaration of Helsinki (http://www.wma.net/en/30publications/10policies/b3/index.html) and received approval from the College of Medicine and Allied Health Sciences Institutional Review Board (IRB review number: COMAHS/IRB/013-2024). Informed written and verbal consent was obtained from all participants prior to their participation in adherence with established ethical principles and protocols. Participants were clearly informed about the purpose and intended use of the collected data. Stringent measures were implemented to ensure proper data storage and management. All methods were carried out in accordance with the relevant norms, guidelines, and regulations of the College of Medicine and Allied Health Sciences Institutional Review Board. The study follows the Standards for Reporting Qualitative Research (SRQR) reporting guideline [13].

The multidisciplinary research team comprised medical professionals (physicians and public-health researchers) with formal training in qualitative inquiry and no supervisory relationship with participants. Additional members were brought in from different clinical specialties and academic institutions to further enrich the group’s perspective.

This study approached the issue of bullying among junior doctors in academic medicine through a social constructivist viewpoint. We focused on how societal structures and interpersonal interactions shape experiences rather than assuming that inherent biological differences between males and females were the primary factors. This framework allowed the team to examine how social and cultural contexts influence the way junior doctors encounter and perceive bullying in their professional environments, emphasizing the role of constructed social realities in biological determinism [14]. This epistemological orientation centers individuals’ personal interpretation of their experiences when seeking to understand social phenomena [15].

We conducted semi-structured interviews with junior doctors from July 20 to August 31, 2024. In selecting participants, we aimed for a diverse group that would provide a wide range of perspectives. We included both males and females at various stages of their medical careers, from house officers and medical officers to registrars, and from different clinical departments. Our focus was on recruiting individuals with first-hand experience of service provision within Sierra Leone's public healthcare facilities. All the participants were adults over 18 years of age.

Data collection and sampling

We conducted semi-structured interviews using an English-language interview guide developed by the research team to align with the study’s objectives (Supplement 1). The guide was informed by a review of literature on workplace bullying in medical settings and aimed to capture a broad range of experiences, with focus on power dynamics, institutional context, and coping responses. While the guide was not formally piloted, it was reviewed internally to ensure clarity, contextual relevance, and sensitivity to the topic.

Each interview was led by a team of two researchers—FJ paired with either AKB or MMJF, all of whom were medical doctors or medical students with training in qualitative interview techniques. The interviews adhered to ethical standards, and informed consent was obtained from all participants. Each interview was audio-recorded and lasted approximately 40 min.

The interview guide was developed to capture a broad range of bullying experiences. At the beginning of each interview, participants were invited to reflect on whether aspects of their personal identity may have shaped the incidents they would describe. This approach enabled a more nuanced examination of intersectionality in experiences of academic bullying.

Participants were recruited purposively using a maximum variation approach to ensure diversity across gender, clinical roles (house officers, medical officers, and registrars), and departmental affiliations. All participants had current or recent experience working in one of the four hospitals within the USLTHC.

Following the interviews, all audio recordings were transcribed verbatim and subsequently de-identified to ensure confidentiality. This process allowed for thorough and ethical analysis of the rich qualitative data collected.

Data analysis

We conducted a thematic analysis using a pragmatic approach that combined inductive insights emerging directly from the data with deductive attention to predefined focal areas aligned with the study objectives [16]. Audio recordings were transcribed verbatim into Microsoft Word and then imported into NVivo Qualitative Software (Lumivero, Denver, Colorado, United States, version 12) to aid in organizing, coding, and retrieving the data.

Two authors (FJ and MBJ) independently coded the transcripts, developing an initial framework that captured emerging themes. As analysis progressed, codes were iteratively refined through discussion, and relationships among categories were identified, allowing the analysis to evolve from descriptive coding to a more interpretive and conceptual level. This iterative process enabled the construction of a robust analytical framework and supported the identification of patterns across interviews until thematic saturation was reached [17]. To enhance credibility, we employed multiple validation strategies, including investigator triangulation and peer debriefing [17]. The evolving coding framework and preliminary findings were reviewed by the broader research team, including those involved in data collection and the lead investigator, to ensure interpretive coherence and alignment with the study’s aims.

Results

Sociodemographic profile of participants

The demographic details of the interview participants are shown in Table 1. The sex, age range, and level of training are distributed for the participants. A total of 29 doctors were interviewed. Most participants were males (51.7%), aged between 25 and 30 years (48.3%), and were house officers (48.3%).

Table 1 Characteristics of interview participants
Full size table

Thematic analysis

Overall, academic bullying at USLTHC is sustained by entrenched hierarchies and normalized by institutional culture. Overt and covert forms of bullying manifest in punishing workloads, emotional harassment, and public humiliation, leading to significant psychological distress and deterrence from certain career pathways. Junior doctors often rely on each other for emotional support in the absence of formal systems. Participants proposed targeted training in teaching methods for senior staff, enforceable anti-bullying policies, and robust mental health and reporting frameworks as pathways to a safer, more equitable learning environment.

Themes

Through thematic analysis, eight themes emerged, providing a nuanced portrayal of academic bullying at USLTHC. The findings underscore the hierarchical nature of bullying, its profound personal and professional repercussions, as well as junior doctors’ strategies for coping and envisioning solutions.

Hierarchical nature and perpetrators of bullying

A core dynamic underlying academic bullying was the overt power imbalance between senior and junior clinicians. Most participants described senior staff,including consultants, specialists, and registrars, as key perpetrators who use their authority to demean and control. This relationship was frequently normalized, with several respondents attributing it to a historically entrenched “culture.”

“Seniors will always try to come in that direction… it is a normal practice especially in our setting and in West Africa.” – (PB010)

“The main perpetrators are usually from residents to specialists up to consultants. They generally take it as if since they have been through that before, the trend must continue.” – (PB017)

Many participants highlighted the idea that “once you have been bullied, you will bully the next generation,” reflecting a cyclical pattern.

Bullying behaviors

Bullying behaviors ranged from overt verbal abuse and public humiliation to more insidious practices such as micromanagement and withholding necessary support. Respondents noted that seniors used disparaging remarks, especially during academic or clinical rounds, to question their competency or educational background.

“He said, ‘You better go and do it, or your patient dies.’ We had to learn from YouTube to save the patient.” – (PB017)

"So, I will not use the example directly to me. I was in a team wherein a specialist was asking a house officer, where did he study? Like the university he studied, meaning that he is not capable enough or he is stupid. Especially after the house officer answered an academic question incorrectly during ward rounds in the ward in front of nurses and patients. So, it's not as if we were in in his office. No, it was outside publicly in the ward, and everybody heard him and he was like, no wonder!”– (PB014)

Some participants further described incidents where seniors demanded personal favors (e.g., greeting them in a specific way, carrying their loads), interpreting these behaviors as manifestations of domination rather than professional mentorship.

Excessive workload and long hours

Nearly all junior doctors cited excessive workload and extended shifts as central to the bullying experience. They frequently worked well beyond their scheduled hours, often performing tasks outside their job descriptions. This burden was viewed as both a stressor and a tactic of intimidation.

“I’ve been working for 72 hours plus nonstop… maybe just an hour or two of rest in 24 hours.” – (PB001)

“I was being harassed to do jobs that were beyond my reach… you have to respect that it is my off time.” – (PB030)

Participants explained that the compulsion to endure exhausting schedules made them feel undervalued and physically overextended.

Lack of institutional support and barriers to reporting

Across interviews, participants expressed frustration at the near-total absence of institutional mechanisms or formal policies to address bullying. They felt senior leadership and administration often dismissed their concerns, perpetuating a culture of silence.

“I am not aware of any institutional policies or support systems… we remain silent. Even if you say anything, who that message gets to might be the boss.” – (PB030)

“This is a country where if you voice out what is right, you will be terrorized. Complaining about a senior will only lead to being chastised or sent to remote locations.” – (PB017)

Several participants noted that even where anti-bullying protocols existed on paper, they were rarely enforced. A recurrent sentiment was that reporting harassment could lead to personal repercussions, reinforcing a sense of helplessness.

Psychological and emotional impact

The emotional toll of bullying manifested as anxiety, depression, burnout, and self-doubt. Many participants reported feeling demoralized, describing stress-related physical symptoms. They worried that perceived incompetence or hostility from seniors would further erode their confidence.

“It led me to a point wherein I developed some dyspeptic symptoms… I have to finish this before I go for lunch because if I go and then get called: why haven’t you done this or that?” – (PB030)

“It affects your self-confidence… makes you think you are not good enough, or that you chose the wrong profession entirely.” – (PB019)

Participants described feeling isolated, with some even contemplating leaving the profession. One respondent recounted a colleague who became so withdrawn that they eventually stopped coming to work.

Career impact and high attrition risk

Bullying not only affected participants’ immediate well-being but also had long-term ramifications for career decisions. Fear of encountering the same perpetrators during specialist training or residency dissuaded junior doctors from pursuing certain fields.

“For the long-term, sometimes it affects your career growth… maybe that will affect your decision in the long run.” – (PB025)

“You might also… it might affect your interest in specializing in that particular department if you have to think that you might meet that person in that department.” – (PB027)

Several respondents mentioned the desire to leave the institution—or the country—to escape persistent mistreatment, underscoring the potential contribution of academic bullying to workforce shortages.

Coping mechanisms

Junior doctors adopted multiple strategies to navigate or buffer the bullying experience. Common approaches included relying on peer support, compartmentalizing emotions, and focusing on patient care as a personal motivator. This solidarity among junior colleagues emerged as an informal yet critical support system.

“Since all of us are frustrated together, we kind of like serve as therapists for one another.” – (PB010)

“I try to just love the job… you are doing it for yourself to gain more knowledge.” – (PB011)

Others intentionally avoided confrontation, choosing silence or detachment to preserve their mental health and professional standing.

Proposed solutions and divergent themes

A notable divergent theme focused on the urgent need for formal teacher-training programs for senior staff. Participants consistently expressed that better communication skills, respectful teaching methods, and supportive supervision could mitigate bullying.

“There should be a kind of teaching for teachers… because to teach is a skill.” – (PB026)

Finally, participants universally recommended comprehensive institutional reforms. They called for explicit anti-bullying policies, confidential reporting channels, psychological services, and structural improvements, such as workload management and competitive salaries, to address the systemic roots of academic bullying.

“We need a system to retain doctors, increase salaries, provide medical insurance, and stop academic bullying if we want to reduce burnout and shortages in our profession.” – (PB014)

“Seniors need sensitization to break the rigid, harsh system that spills over into bullying our generation. Without this, the system will never improve.” – (PB017)

Discussion

This qualitative study explored the experiences, perceptions, and coping strategies of junior doctors subjected to academic bullying at the USLTHC. The findings reveal that bullying is entrenched within rigid hierarchies and often framed by senior physicians as a “rite of passage.” Abusive behaviours commonly take the form of public humiliation, excessive workloads, and exclusion from critical learning opportunities. Weak institutional safeguards and fear of retaliation discourage formal reporting, rendering existing anti-bullying policies largely ineffective. Prolonged exposure to such environments undermines mental health, contributes to attrition through emigration or exit from the profession, and compromises patient care within an already understaffed health system.

The patterns uncovered in this study resonate strongly with a growing global evidence on academic bullying in medicine. A 2023 meta-analysis involving 44,566 participants across 19 countries reported a pooled bullying prevalence of 51%, identifying senior staff as the primary perpetrators. This pattern is consistent with our findings of persistent top-down abuse [18]. Another systematic review of 68 qualitative and quantitative studies found that excessive workloads, public humiliation, and exclusion from learning opportunities represent the core features of academic bullying, which are rarely addressed through formal reporting mechanisms [1]. Our study builds on this evidence by showing how cultural norms of deference to authority in Sierra Leone further entrench these behaviours, making them appear routine and socially acceptable.

The “rite-of-passage” narrative we documented echoes sociological models of institutionalised aggression, whereby those who were once victims deploy the same tactics as a marker of seniority, thus perpetuating a self-reinforcing cycle. Comparable mechanisms have been described in South-East Asian and sub-Saharan (SSA) teaching hospitals, where power-distance indices are likewise high [2, 19]. The persistence of bullying is further magnified by systemic stressors: chronic understaffing, equipment shortages, and extreme service demands. International surveys show that when workloads exceed residents’ perceived control, both burnout risk and bullying incidence climb steeply; the 2024 General Medical Council report, for example, found 63% of UK trainees at high or moderate risk of burnout, attributing this partly to “unsustainable workplace pressure and a blame culture [20]. Our interviews confirm a similar dynamic in Sierra Leone: excessive on-call rosters and task-shifting to juniors created ground for coercive behaviours while simultaneously undermining reporting confidence [21, 22].

The downstream effects of bullying, including mental health disorders, career attrition, and compromised clinical decision-making, are well established. Studies across multiple countries have linked exposure to workplace bullying with higher odds of depressive symptoms, increase in diagnostic errors, and a rise in turnover intention among early-career clinicians [21, 23, 24]. Our participants’ accounts of contemplating emigration or abandoning specialist training therefore portend a tangible threat to Sierra Leone’s already fragile workforce pipeline.

The present findings also add nuance to existing literature by highlighting potential resilience pathways. Informal peer support offered temporary relief, consistent with coping strategies reported among junior doctors [3]. However, such networks are insufficient without institutional accountability. Evidence supports more comprehensive interventions, such as confidential reporting systems, structured peer support groups, and mandatory “Teaching with Respect” workshops for senior staff, as potential means to reduce self-reported bullying [25,26,27]. These approaches align with participants’ own recommendations for structured teacher training and active leadership engagement as essential levers for cultural transformation within teaching hospitals.

Although some policies may exist on paper, participants reported that no enforceable anti-bullying measures are currently implemented in any of the four hospital sites. Prior studies have similarly emphasized the disconnect between written policy and actual practice, exacerbated by leadership inertia and fear of reprisal [28, 29]. In our study, junior doctors cited personal risk such as punitive reassignment to remote areas as a deterrent to formal reporting. These experiences reinforce the broader concern that hierarchical structures and resource constraints suppress the voices of vulnerable groups, perpetuating systemic injustice [28].

Work overload emerged as a theme, with junior doctors frequently exceeding their official working hours and taking on responsibilities beyond their defined roles. Participants viewed these excessive demands as both a reflection of resource constraints and a means of reinforcing hierarchical subordination. Evidence suggests that bullying can thrive in high-stress, under-resourced settings with weak organizational oversight [2]. In Sierra Leone, these pressures are further intensified by a fragile health system, heightening the risk of burnout and moral distress among early-career clinicians [21, 22].

Despite the lack of institutional recourse, junior doctors demonstrated resilience through peer support and an internalized commitment to patient care. As one participant noted, “Since all of us are frustrated together, we kind of serve as therapists for one another.” This underscores the potential of communities in mitigating stress when formal systems fail [22]. Yet, reliance on informal networks can only partially alleviate the emotional burden and does not systematically alter the conditions that allow bullying to persist. Therefore, institutional support aimed at providing mental health resources, such as counseling services and channels for peer support, is warranted. This approach aligns with the prioritization of these strategies as identified by the study participants, particularly given the psychological toll reported by the respondents.

Strengths, limitations and reflexivity

A strength of this study is the depth of qualitative insight, with the study participants being forthcoming about personal experiences and providing nuanced insights on power structures and cultural dynamics. Nonetheless, perspectives of senior physicians and allied professionals were not captured, potentially constraining the analysis of inter-professional dynamics. Moreover, our focus on a single large teaching hospital complex in Sierra Leone may limit transferability to other regions. Nevertheless, these findings are consistent with similar reports from other low-resource settings, suggesting the potential for broader applicability of our study.

Reflexivity. Five authors are practising clinicians within USLTHC. Their positionality facilitated rapport yet risked interpretive bias. To mitigate this, they maintained reflexive journals, and two external qualitative researchers independently audited the coding and theme development.

Future studies should incorporate multi-stakeholder perspectives, examine the effectiveness of faculty-development interventions, and explore organisational levers for workload reform.

Conclusion

Academic bullying at USLTHC is systemic, culturally rationalised, and exacerbated by resource constraints. It undermines junior-doctor well-being and jeopardises workforce stability. Embedding enforceable anti-bullying policies, investing in senior-staff pedagogy, and strengthening mental-health and workload supports are ethical imperatives and practical necessities for health-system resilience in Sierra Leone.