**4. Discussion**

The present survey showed that, according to the objective criteria of NAQ-R, prevalence of bullying at work in interns and residents attached to the faculty of Medicine of Monastir has significantly decreased between 2009 and 2016. However, according to the last item if NAQ-R about subjective criteria, the rate perception of workplace bullying was similar in 2009 and 2016, consequently, in both cohorts, young doctors do not seem to recognize themselves as victims of moral harassment.

As for the quality of life, no significant differences were found, between both cohorts concerning the mental and physical plans. However, both populations medians were below the American standard of 50 and participants' scores of mental and physical qualities of life have been significantly altered because of MHW in both cohorts.

The concept of moral harassment was gradually introduced in mid-80s by Norwegian and Swedish occupational psychologists such as Leymann and Einarsen [3, 15].

The presence of certain characteristics or criteria is required by the most researchers such as the persistence of negative acts (for at least six months), repetition (for example at least once a week) and notion of "Imbalance of power"

**199**

*Influence of Tunisian Revolution on Bullying at Work in Interns and Residents*

on victims, including psychological effects [2, 3, 10, 16–20].

residents has significantly decreased between 2009 and 2016.

R, report figures ranging from 8 to 32% [23–30].

between both cohorts of 2009 and 2016.

exposed to different types of negative behaviors and bullying.

tors not to claim their rights like vacations, maternity and sick leave.

had bad consequences on our health care system [35].

satisfaction with the work conditions is reported [36].

between the generator of harassment and the victim. Moreover, several authors have also incorporated into their definitions the adverse effects of this phenomenon

As for Mobbing, it has been defined by Leymann [21] as a process of harassment of a victim by one or more persecutors as a result of ordinary conflict. This is a repeated process over a long period based on words, gestures, writings, of such a nature as to affect the personality, dignity or the physical or psychic integrity of the other.

In the present survey, we have opted for the adoption of the same measurement tool (NAQ-R) and the same definition of MHW for both cohorts, but despite this comparability, our survey showed that prevalence of bullying at work in interns and

2011's Tunisian revolution, with the accompanying socio-cultural changes, such as freedom of expression procession, the creation of the Tunisian Association of Young doctors, a representative union organization of interns and residents founded in December 2016, the media coverage of violence against interns and residents on social networks, seem to be responsible, at least in a part, for this decline in

The same phenomenon has been observed other where, such as Europe, where

Physicians are at a high risk of workplace bullying. Indeed, they are in direct contact with the patients, with their pain, suffering and death, with their parents and families, and they assume all legal responsibility in case of safety care incident [5, 6]. Furthermore, Medicine is a very hierarchical profession where medical trainees, interns and residents are at the bottom of curriculum and represent the basis of patients' medical care especially in university hospitals. They are, therefore, more

Taking into account, the lack of staff, the lack of equipment,the lack of autonomy, the lack of teamwork, support and feedback and the dependence on seniors' opinions, it is easy understandable that all these factors of stress and frustration lead to the emergence of different negative acts of MHW [31, 32] . This can explain the high prevalence of bullying at work among young doctors and medical students in comparison with the general population and other health professions [33].

The present study showed that the most widespread negative acts were identical

However, some negative acts such as switching key activities by tasks below the skills and by mundane or unpleasant activities have significantly increased in 2016 while others have significantly decreased, such as putting pressure on young doc-

Since 2011, Tunisian country has been facing many socio-economic problems [34]. In fact, teaching hospitals are concerned with an increasing deterioration of work conditions especially perceived by young doctors. The lack of autonomy, the progressive installation of a culture of mediocrity lead, on one hand, to the proliferation of the private sector at the expense of the public one, and to a mass brain drain of Tunisian medical skills to foreign countries on the other hand; these factors

Nevertheless, even in countries where socio-economic stability is the rule, dis-

The insufficient number of doctors and staff to deal with growing number of patients and a growing demand for care, has been reported as the origin of MHW

the prevalence of MHW decreased from 30% in 2003 to 15% in 2011 [2, 22]. Despite the cultural and social evolution, moral harassment at work is still unknown in Tunisia, and up to now, there are no laws incriminating this phenomenon. In the literature, studies carried out among health personnel based on the NAQ-

*DOI: http://dx.doi.org/10.5772/intechopen.93847*

the prevalence of MHW.

#### *Influence of Tunisian Revolution on Bullying at Work in Interns and Residents DOI: http://dx.doi.org/10.5772/intechopen.93847*

*Occupational Wellbeing*

**3.3 Impact of MHW on the quality of life**

The median MCS was 40.3 ± 12 in 2009 and 40.61 ± 13.48 in 2016. No significant difference was recorded for the MCS. However, the majority of respondents had a mental health score below the standard of 50 in 2009 Cohort (86.1%) as well in 2016

**NAQ results 2009 Cohort 2016 cohort p**

NAQ-R Harassed 245 74 146 43.6 <10–3

Mobbing Yes 23 6.9 17 5.1 0.19

Not harassed 86 26 189 56.4

No 308 93.1 318 94.9

**N % N %**

Univariate regression showed that workplace bullying influenced the mental quality of mental life significantly in 2009 (p < 10−3, SD = [2.63; 7.06]) as well as in

The median score for the PSC was 45.6- ± 11.72009 and 45.36 ± 11.09 in 2016

In 2009 Cohort as well as in 2016 one, the majority of participants had compa-

Univariate regression showed that workplace bullying had significantly influenced the physical quality of life in 2009 (p = 0.013, SD = [0.49; 4.2]) and in 2016

The present survey showed that, according to the objective criteria of NAQ-R, prevalence of bullying at work in interns and residents attached to the faculty of Medicine of Monastir has significantly decreased between 2009 and 2016. However, according to the last item if NAQ-R about subjective criteria, the rate perception of workplace bullying was similar in 2009 and 2016, consequently, in both cohorts, young doctors do not seem to recognize themselves as victims of moral harassment. As for the quality of life, no significant differences were found, between both cohorts concerning the mental and physical plans. However, both populations medians were below the American standard of 50 and participants' scores of mental and physical qualities of life have been significantly altered because of MHW in both cohorts. The concept of moral harassment was gradually introduced in mid-80s by Norwegian and Swedish occupational psychologists such as Leymann and

The presence of certain characteristics or criteria is required by the most researchers such as the persistence of negative acts (for at least six months), repetition (for example at least once a week) and notion of "Imbalance of power"

with no statistically significant difference between both cohorts.

rable PSC < 50 (69.8%/72%) with no significant difference.

*3.3.1 Mental health score (MCS)*

*Comparison of both cohorts' NAQ-R scores.*

2016 (p < 10−3, SD = [3.14, 7.04]).

*3.3.2 Physical health score (PCS)*

(p = 0.004, SD = [0.86, 4.37]).

**4. Discussion**

Einarsen [3, 15].

Cohort (84.8%).

**Table 5.**

**198**

between the generator of harassment and the victim. Moreover, several authors have also incorporated into their definitions the adverse effects of this phenomenon on victims, including psychological effects [2, 3, 10, 16–20].

As for Mobbing, it has been defined by Leymann [21] as a process of harassment of a victim by one or more persecutors as a result of ordinary conflict. This is a repeated process over a long period based on words, gestures, writings, of such a nature as to affect the personality, dignity or the physical or psychic integrity of the other.

In the present survey, we have opted for the adoption of the same measurement tool (NAQ-R) and the same definition of MHW for both cohorts, but despite this comparability, our survey showed that prevalence of bullying at work in interns and residents has significantly decreased between 2009 and 2016.

2011's Tunisian revolution, with the accompanying socio-cultural changes, such as freedom of expression procession, the creation of the Tunisian Association of Young doctors, a representative union organization of interns and residents founded in December 2016, the media coverage of violence against interns and residents on social networks, seem to be responsible, at least in a part, for this decline in the prevalence of MHW.

The same phenomenon has been observed other where, such as Europe, where the prevalence of MHW decreased from 30% in 2003 to 15% in 2011 [2, 22].

Despite the cultural and social evolution, moral harassment at work is still unknown in Tunisia, and up to now, there are no laws incriminating this phenomenon.

In the literature, studies carried out among health personnel based on the NAQ-R, report figures ranging from 8 to 32% [23–30].

Physicians are at a high risk of workplace bullying. Indeed, they are in direct contact with the patients, with their pain, suffering and death, with their parents and families, and they assume all legal responsibility in case of safety care incident [5, 6].

Furthermore, Medicine is a very hierarchical profession where medical trainees, interns and residents are at the bottom of curriculum and represent the basis of patients' medical care especially in university hospitals. They are, therefore, more exposed to different types of negative behaviors and bullying.

Taking into account, the lack of staff, the lack of equipment,the lack of autonomy, the lack of teamwork, support and feedback and the dependence on seniors' opinions, it is easy understandable that all these factors of stress and frustration lead to the emergence of different negative acts of MHW [31, 32] . This can explain the high prevalence of bullying at work among young doctors and medical students in comparison with the general population and other health professions [33].

The present study showed that the most widespread negative acts were identical between both cohorts of 2009 and 2016.

However, some negative acts such as switching key activities by tasks below the skills and by mundane or unpleasant activities have significantly increased in 2016 while others have significantly decreased, such as putting pressure on young doctors not to claim their rights like vacations, maternity and sick leave.

Since 2011, Tunisian country has been facing many socio-economic problems [34]. In fact, teaching hospitals are concerned with an increasing deterioration of work conditions especially perceived by young doctors. The lack of autonomy, the progressive installation of a culture of mediocrity lead, on one hand, to the proliferation of the private sector at the expense of the public one, and to a mass brain drain of Tunisian medical skills to foreign countries on the other hand; these factors had bad consequences on our health care system [35].

Nevertheless, even in countries where socio-economic stability is the rule, dissatisfaction with the work conditions is reported [36].

The insufficient number of doctors and staff to deal with growing number of patients and a growing demand for care, has been reported as the origin of MHW among nurses in Japan [23], South Korea [28], the United Kingdom [24] and violence in hospitals in India [37].

Excessive supervision of work was another type of negative acts, frequently reported by interns and residents in both cohorts. It was also one of the most reported negative acts by young doctors in the United States in 2015 (44%) [38].

The socio-cultural changes, arising after Tunisian revolution, allowed young people to challenge some department heads' unfair decisions and to claim their rights [39].

Besides, the negative act relating to the deliberate ignorance of opinions or points of view were common among trainee physicians [40–42] as well as among healthcare givers [43]. Such inappropriate behavior can interfere with the relationship and create a hostile environment that can negatively influence work.

A meta-analysis published in 2014, 51 studies about MHW and discrimination in medical trainees [44] has shown that the most common negative act was verbal abuse (3–28%) and racial and gender discrimination (4–19%).The same respective types of discrimination, in addition to religious one, were reported in medical students in Saudi Arabia [45].

Contrary to our study, several other studies conducted among practicing physicians and those in the process of training showed, that verbal abuse was a widespread behavior [33, 38, 42, 45–49]. This type of act could lead to depressive symptoms among medical students [50].

Even though it was rare in the present study, humiliation is a negative act of MHW and has been found to be common in multiple studies conducted among physicians in training courses and health personnel [24, 38, 41, 51–54] .

Moreover, physical violence in hospitals was the least negative act reported in some harassment investigations among young doctors [40, 44, 48] and it did not significantly increase between 2009 and 2016 in our study.

As for the perception of workplace bullying in the present study, young doctors in both cohorts, do not seem to recognize themselves as victims of moral harassment whereas the prevalence of perceived MHW in the literature is varying from 27–52% [38, 47, 55–57].

It seems that, humiliation and offense resulting from the recognition of themselves as harassed, refer to a lower position, weakness and passivity leading to the deny of MHW by victims. Besides, victims of harassment do not want to be confronted with this truth thinking that it is their own fault [58] or that of the organization in which they work and rather than stalker's one [59]. Others believe that recognizing victim status especially during their temporary internships will call their professional future into question [46, 60, 61].

As for identified determinants of moral harassment at work in our study, the job position of intern, the deliberate choice of medical studies and the dissatisfaction with the medical practice were the common determinants in both cohorts.

Serious family problems, seniority and the lack of leisure time were also apart from the explanatory model of 2009, while the nature of specialty was an additional determinant in 2016.

Generally, young age is correlated with MHW among medical trainees because of their vulnerability to stress and their sensitivity to criticism [62].

Female gender was not a determinant of harassment in both studies, but it persisted after multiple logistic regression in 2009. It would seem therefore, that gender discrimination among young doctors decreased after the socio-cultural changes of the last 8 years.

In the literature, women in the general work field, with their tendency to vulnerability, are the most exposed to harassment [24, 26, 38, 41, 63, 64] unlike men who are predominant in management positions and consequently mostly stalkers [16, 47, 65].

**201**

*Influence of Tunisian Revolution on Bullying at Work in Interns and Residents*

shortest seniority and therefore the most vulnerable to MHW.

negative acts of harassment and explain our results.

and then the desire to leave the profession [49, 68, 69].

can explain the high level of MHW in a hospital [27, 70, 71].

factors contributing to and trivialize harassment in hospitals.

because they are more vulnerable to negative acts.

In addition, in the medical sector, women face many difficulties to reconcile

Being intern, as young trainee, was also a risk factor for bullying in both cohorts. In fact, interns are located at the bottom of the medical professional hierarchy, and are consequently exposed to a high level of stress because of a low autonomy and a high level of requirement. Thus, interns are more predisposed to

cohort while it appears to have been a confounding factor in the 2009 Cohort.

Dealing with the occupational determinants, in our study, a lower seniority was a predisposing factor to the MHW in 2009. The youngest doctors are those with

On another side, surgical specialty was a determining factor of bullying in 2016

Surgery is a specialty that requires strength and toughness, which leads to some

In the literature, some specialties with heavy workload and ubiquitous stress predispose more than others to MHW in the healthcare givers. Gynecological obstetrics specialty has been predictive of a high rate of MHW among residents in Mexico [67]. Finally, verbal aggression among doctors in the United States has been more important in the specialties of interventional radiology and in general surgery

Regarding the dissatisfaction with the work practice, it was significantly related to moral harassment score according to NAQ-R in both cohorts. Job satisfaction, as it has been defined by Locke [68], is an affective and emotional response of a person in face of a work situation resulting from the match between what the person wants (his expectations) and what he/she gets out of his/her job. Thus, dissatisfaction can contribute to emotional exhaustion, mental and physical weariness of professionals

In the literature some determinants are probably risk factors for harassment. Indeed, some changes in workplace such as diversification, staff management changes, downsizing, salary reductions or increasing working time and even the dimensions of locals can cause conflicts and influence negatively on the job which

In addition, several organizational determinants influence considerably the level of harassment in these environments, such as management of work (too authoritarian or too passive), conditions (insecurity at work) and work dynamics (workload, cognitive demand, abuse of power, interpersonal conflict), the constraints of time and cultural norms (commoditization of the bullying as a Performance tool) within

In Tunisia, the new democratic transition has contributed to the emergence of violence in the country following the appearance of religious extremists' groups, the accentuation forms of racial and sexual discrimination and violence in some protests against the government [74]. So, the mediatization of the incredible increase of violence against hospital doctors since 2011 in Tunisia could be also

The compulsory choice of Medical curriculum was another determinant factor in genesis of MHW among young doctors after logistic regression both in 2009 and 2016. Young doctors whose medical career was not initiated by a personal choice were unhappy and frustrated with their studies and more exposed to the harassment

On the other side, the satisfaction of choosing a medical career has significantly increased in 2016 compared to 2009.This could be explained a wider autonomy in the career choices for Tunisian bachelors since 2011, and by broadening the residency prospects of trainees, in fact residency positions have almost doubled since 2009.

*DOI: http://dx.doi.org/10.5772/intechopen.93847*

professional and private life [66].

workplace bullying [31, 41, 62].

unlike pediatrics [48].

a workplace [72, 73].

#### *Influence of Tunisian Revolution on Bullying at Work in Interns and Residents DOI: http://dx.doi.org/10.5772/intechopen.93847*

*Occupational Wellbeing*

violence in hospitals in India [37].

students in Saudi Arabia [45].

27–52% [38, 47, 55–57].

determinant in 2016.

the last 8 years.

stalkers [16, 47, 65].

symptoms among medical students [50].

among nurses in Japan [23], South Korea [28], the United Kingdom [24] and

Excessive supervision of work was another type of negative acts, frequently reported by interns and residents in both cohorts. It was also one of the most reported negative acts by young doctors in the United States in 2015 (44%) [38].

to challenge some department heads' unfair decisions and to claim their rights [39]. Besides, the negative act relating to the deliberate ignorance of opinions or points of view were common among trainee physicians [40–42] as well as among healthcare givers [43]. Such inappropriate behavior can interfere with the relation-

ship and create a hostile environment that can negatively influence work.

The socio-cultural changes, arising after Tunisian revolution, allowed young people

A meta-analysis published in 2014, 51 studies about MHW and discrimination in medical trainees [44] has shown that the most common negative act was verbal abuse (3–28%) and racial and gender discrimination (4–19%).The same respective types of discrimination, in addition to religious one, were reported in medical

Contrary to our study, several other studies conducted among practicing physicians and those in the process of training showed, that verbal abuse was a widespread behavior [33, 38, 42, 45–49]. This type of act could lead to depressive

Even though it was rare in the present study, humiliation is a negative act of MHW and has been found to be common in multiple studies conducted among

Moreover, physical violence in hospitals was the least negative act reported in some harassment investigations among young doctors [40, 44, 48] and it did not

As for the perception of workplace bullying in the present study, young doctors in both cohorts, do not seem to recognize themselves as victims of moral harassment whereas the prevalence of perceived MHW in the literature is varying from

As for identified determinants of moral harassment at work in our study, the job position of intern, the deliberate choice of medical studies and the dissatisfaction

Serious family problems, seniority and the lack of leisure time were also apart from the explanatory model of 2009, while the nature of specialty was an additional

Generally, young age is correlated with MHW among medical trainees because

Female gender was not a determinant of harassment in both studies, but it persisted after multiple logistic regression in 2009. It would seem therefore, that gender discrimination among young doctors decreased after the socio-cultural changes of

In the literature, women in the general work field, with their tendency to vulnerability, are the most exposed to harassment [24, 26, 38, 41, 63, 64] unlike men who are predominant in management positions and consequently mostly

It seems that, humiliation and offense resulting from the recognition of themselves as harassed, refer to a lower position, weakness and passivity leading to the deny of MHW by victims. Besides, victims of harassment do not want to be confronted with this truth thinking that it is their own fault [58] or that of the organization in which they work and rather than stalker's one [59]. Others believe that recognizing victim status especially during their temporary internships will

with the medical practice were the common determinants in both cohorts.

of their vulnerability to stress and their sensitivity to criticism [62].

physicians in training courses and health personnel [24, 38, 41, 51–54] .

significantly increase between 2009 and 2016 in our study.

call their professional future into question [46, 60, 61].

**200**

In addition, in the medical sector, women face many difficulties to reconcile professional and private life [66].

Dealing with the occupational determinants, in our study, a lower seniority was a predisposing factor to the MHW in 2009. The youngest doctors are those with shortest seniority and therefore the most vulnerable to MHW.

Being intern, as young trainee, was also a risk factor for bullying in both cohorts. In fact, interns are located at the bottom of the medical professional hierarchy, and are consequently exposed to a high level of stress because of a low autonomy and a high level of requirement. Thus, interns are more predisposed to workplace bullying [31, 41, 62].

On another side, surgical specialty was a determining factor of bullying in 2016 cohort while it appears to have been a confounding factor in the 2009 Cohort.

Surgery is a specialty that requires strength and toughness, which leads to some negative acts of harassment and explain our results.

In the literature, some specialties with heavy workload and ubiquitous stress predispose more than others to MHW in the healthcare givers. Gynecological obstetrics specialty has been predictive of a high rate of MHW among residents in Mexico [67].

Finally, verbal aggression among doctors in the United States has been more important in the specialties of interventional radiology and in general surgery unlike pediatrics [48].

Regarding the dissatisfaction with the work practice, it was significantly related to moral harassment score according to NAQ-R in both cohorts. Job satisfaction, as it has been defined by Locke [68], is an affective and emotional response of a person in face of a work situation resulting from the match between what the person wants (his expectations) and what he/she gets out of his/her job. Thus, dissatisfaction can contribute to emotional exhaustion, mental and physical weariness of professionals and then the desire to leave the profession [49, 68, 69].

In the literature some determinants are probably risk factors for harassment. Indeed, some changes in workplace such as diversification, staff management changes, downsizing, salary reductions or increasing working time and even the dimensions of locals can cause conflicts and influence negatively on the job which can explain the high level of MHW in a hospital [27, 70, 71].

In addition, several organizational determinants influence considerably the level of harassment in these environments, such as management of work (too authoritarian or too passive), conditions (insecurity at work) and work dynamics (workload, cognitive demand, abuse of power, interpersonal conflict), the constraints of time and cultural norms (commoditization of the bullying as a Performance tool) within a workplace [72, 73].

In Tunisia, the new democratic transition has contributed to the emergence of violence in the country following the appearance of religious extremists' groups, the accentuation forms of racial and sexual discrimination and violence in some protests against the government [74]. So, the mediatization of the incredible increase of violence against hospital doctors since 2011 in Tunisia could be also factors contributing to and trivialize harassment in hospitals.

The compulsory choice of Medical curriculum was another determinant factor in genesis of MHW among young doctors after logistic regression both in 2009 and 2016.

Young doctors whose medical career was not initiated by a personal choice were unhappy and frustrated with their studies and more exposed to the harassment because they are more vulnerable to negative acts.

On the other side, the satisfaction of choosing a medical career has significantly increased in 2016 compared to 2009.This could be explained a wider autonomy in the career choices for Tunisian bachelors since 2011, and by broadening the residency prospects of trainees, in fact residency positions have almost doubled since 2009.

As for the impact of bullying on participants' quality of life, it significantly influenced the quality of mental life regardless of the study cohort, but no significant difference was found between 2009 and 2016 and most of scores were below the standard average of 50.

Despite the decline in the rate of MHW in 2016, the quality of mental life did not change after the revolution. This may be related to other factors than the MHW upon which social or managerial factors, working conditions, work-family interface quality, social support, marital status and income … [75, 76].

In the latest study conducted by 'Word Happiness' in 2017 regarding the satisfaction of life and happiness based on certain criteria such as health, social support, freedom and corruption, Tunisia was among the lowest ranked countries (rank of 102 out of 155 countries) [77].

The alteration of interns and resident mental quality of life can be also attributed to the fact that the internship is a period of chronic stress for young doctors who face the challenge of learning to work as a team, to become competent, responsible and empathic doctors and at the same time ensuring the best medical benefits in a sometimes competitive and even hostile climate.

The influence of MHW on the mental quality of life has been demonstrated in literature both in the general population [77, 78] and in the health caregivers [78, 79] and some authors assert that mental disorders are also predictors of harassment [79–81].

If we consider, the influence of MHW on the quality of physical life, the latter significantly altered the physical quality of life in both cohorts without significant difference between them and scores were below the American standard of 50.

In the literature, MHW has deleterious effects on physical health. It increased cardiovascular risk and caused musculoskeletal pain in addition to other medical problems [62, 73].

The new scheme of residency ship, consisting in pending months from June to December with long periods of preparation, leads to inactivity, and spending most of the day on screen and desk could explain the lack of improvement in the quality of physical life despite the significant increase in leisure time and the regression of the MHW in 2016 comparatively to 2009.

Considering the limits of our study, despite the decrease in the participation rate in 2016, the sample of the studied population remains representative of the general population. Some factors could influence the participation rate in both cohorts: some of the interns and residents were unmotivated, others could not answer our questionnaire due to lack of time and excessive workload. Many of them also found that the questionnaire was too long. The lower participation rate of residents compared to interns' one can be explained by their heavier workloads. Finally, the abstention of some participants can also be explained by the perception of MHW as a taboo subject or lack of conviction of the usefulness of such investigations.

The rate of participation in workplace bullying investigations among young physicians in literature varied between 22.1 and 72% [40, 41, 55, 63, 82].

Regarding the used tools, the NAQ and the SF8 are both validated and frequently used in different professional sectors and in various languages. But, due to the absence of a validated version in Tunisian dialect or in Arabic, we opted for the use of the French validated version which is commonly understandable by our study population because all medical studies are performed in French in Tunisia.

However, the disadvantage of the NAQ-R is that it asks a direct question at the end, about the self-perception of moral harassment. The respondents tend to deny this suffering, either out of shame or lack of motivation or unconscious denial of reality. This could be the cause of underestimation of results.

**203**

**Author details**

Imen Miled and Charfeddine Amri

Monastir, University of Monastir, Monastir, Tunisia

\*Address all correspondence to: irtyah@gmail.com

provided the original work is properly cited.

*Influence of Tunisian Revolution on Bullying at Work in Interns and Residents*

As for the quality of life, the SF8 provides a simple method for evaluating general mental and physical health; it has the advantage to be a brief and a valid questionnaire.

Health care professions, especially in young doctors, are at high-risk of moral harassment, due to required interactions with patients and their parents, requested performance of learning and the advent of violence against healthcare professionals after Tunisian revolution. The present study showed that MHW had significantly decreased in2016 according to the objective assessment by NAQ-R score. No significant difference between both cohorts perception of MHW was shown which can be explained by the lack of awareness of this phenomenon and by the absence

The determinants of the MHW in 2009 were the job position, gender, and seniority, choice of medicine satisfaction, serious family problems and leisure activities; while in 2016, they were the job position, the specialty nature, the choice of medical studies and the satisfaction of the exercise of Medicine. Finally, MHW negatively influenced the quality of mental and physical life in a comparable way in

The promulgation of a law penalizing the MHW has become urgent especially after the revisions of the post revolution law texts. Politicians should focus on this major issue because MHW has many bad effects on the personal, social and organizational level. It is also important to set up training and awareness programs about MHW to

Irtyah Merchaoui\*, Ines Rassas, Marouen Hayouni, Nidhal Mlik, Feten Mhenni,

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Department of Occupational Health and Ergonomics, Faculty of Medicine of

*DOI: http://dx.doi.org/10.5772/intechopen.93847*

of Tunisian legislation against harassment.

prevent its emergence and reduce its deleterious effects.

the two steps of investigation.

**5. Conclusion**

As for the quality of life, the SF8 provides a simple method for evaluating general mental and physical health; it has the advantage to be a brief and a valid questionnaire.
