Mediating Role of Self-Esteem and Self-Efficacy in Paths Between Covert Narcissism and Mental Wellbeing in Pakistani Doctors

Previous researches substantiate the lack of evidence pertaining to personality features influencing mental wellbeing of doctors working in stressful hospital environment. The present study highlights covert narcissism as important factor of doctors' mental wellbeing, with mediating role of self-esteem and self-efficacy. This research employed cross-sectional research design and used Purposive sampling technique to select the research participants from Rawalpindi and Islamabad, Pakistan. Sample consisted of N = 176 doctors aged between 24 to 34 years (M = 27.37, SD = 2.04). The Maladaptive Covert Narcissism Scale (MCNS), Warwick-Edinburgh Mental Well-being Scale (WEMWBS), Rosenberg Self-Esteem Scale (RSES) and General Self-efficacy Scale (GSE) were used to assess covert narcissism, mental wellbeing, self-esteem and self-efficacy respectively. Bivariate correlation revealed that covert narcissism had significant negativerelationship with self-esteem, self-efficacy, and mental wellbeing, whereas self-esteem and self-efficacy had a significant positive relationship with mental wellbeing. Multiple regression analysisfound covert narcissism as significant negative predictor of mental wellbeing, whereas self-esteem and self-efficacy were established to be significant positive predictors of mental wellbeing. Furthermore, mediation through Process Macro made it evident that self-efficacy and self-esteem significantly mediate the association between covert narcissism and mental wellbeing. This study provides the insight that interventions designed for enhancing mental wellbeing of doctors must focus on covert narcissism, self-esteem and self-efficacy in order to get therapeutic success.

The doctors constitute an essential asset of the society (Bhugra et al., 2019) however; little focus is placed on their mental health. The World Health Organization has deemed health as the presence of mental, physical as well as social well-being rather than absence of illness in an individual (World Health Organization, n.d.). Empirical evidence suggests that doctors due to the nature of their job environment are more susceptible to numerous psychological ailments and suicidal risk (Devi, 2011). A study conducted in Canada regarding the mental wellbeing of doctors found that 34% of participants deemed their life stressful, 39 % reported dissatisfaction with their careers and 17% rated their mental health as poor (Cohen & Patten, 2005). Atif et al. (2016) determined the elevated risk of depression and anxiety in doctors. Doctors are also found to be at a high risk of burnout (Maslach & Leiter, 2016). Young doctors especially experience a high level of stress during their transition from a learner to healthcare provider hence the rate of distress, fatigue, anxiety, burnout, and depression are higher in them due to stressful working conditions in hospital environment (Soares & Chan, 2016). Furthermore, doctors are also found to be less likely to recognize, acknowledge (Markwell & Wainer, 2009), and discuss their mental health issues (Galbraith et al., 2020). Mental health issues are known to impact doctor’s ability to manage patients' care including medication and clinical errors (Soares & Chan, 2016).
Mental well-being is a combination of eudemonic and hedonic wellbeing and encompasses the elements of both psychological and subjective well-being (Stewart-Brown et al., 2011). The perspective of mental wellbeing, used in current research, is also used as a synonymous term for mental health. It includes a broad spectrum of traits that range from affect to psychological functioning and divides it into two perspectives i.e. the hedonia that emphasizes on life satisfaction and personal experience of happiness and eudemonia includes self-realization as well as psychological functioning (Tennant et al., 2007; Tooby & Cosmides, 1992). Mental well-being is consequence of numerous positive and negative personality traits. Covert narcissism is one of those traits and leads to poor mental well-being (Akinci, 2015; Brookes, 2015).
Wink (1991) defined covert narcissism as an inflated sense of self hidden behind a facade of introversion accompanied by recurrent neurotic feelings of depression, anxiety, and vulnerability. It was further deduced that on a grass root level, much like overt narcissism, covert narcissism also possessed a grandiose and entitled core. Similarly, previous researches have described covert narcissists as possessing a grandiose, hypersensitive, and entitled nature along with feelings of inferiority as well as a victimized mentality (Murray, 1938). Contemporary personality theorists, on the other hand, have also associated characteristics such as shyness, inhibition, avoidant behavior, and apparent empathy to covert narcissism (Hendin & Cheek, 1997). According to the psychodynamic perspective, covert narcissism is vulnerable and hypersensitive as compared to overt narcissism (Kernberg, 1985).
Generally, a covert narcissist is an individual who is passively striving for external validation as a means to regulate their self-esteem that they are unable to manage on their own (Dickinson & Pincus, 2003). Certain characteristics of a covert narcissist are highlighted in previous researches. One such quality is an excessive preoccupation with self. Like an overt narcissist, a covert narcissist also seeks admiration and validation but takes a rather passive path to achieve his goals. A covert narcissist may be found undermining their achievements as a means to extract sympathy and admiration from their social circle (Caligor et al., 2015). Apart from this covert narcissist are also found playing the blame game much like the overt narcissists, however, the covert narcissists happen to be a lot slicker in their approach i.e. victimizing themselves and explaining to other how they were not to blame (McCullough et al., 2003), another quality of a vulnerable narcissist is to try to gain control of situations and people around them through tactics such as gas lighting, shaming and dismissal and patronizing (Arabi, 2019). Covert narcissists are also found to lack empathy (Caligor et al., 2015) and are not as likely to get involved in any activity that does not benefit them (American Psychiatric Association, 2013).
According to Leape et al. (2012) a certain amount of self-interest is deemed essential to excel in the rather arduous field of medicine. When magnified such feelings of self-interest can evolve to include tendencies of entitlement and insensitivity towards others, emerging as narcissistic character traits. Due to such narcissistic arrogance researchers have found physicians to Dither when it comes to disclosing their mistakes, reporting errors. They also deemed physicians to deem their own interest prior to the concern of others in such situations as well (Moskop et al., 2006).
Self-esteem is defined by Derne (1998) as an individual’s subjective notion of self-worth. The need for self-esteem left unfulfilled could lead to many psychological disturbances. On the other hand, Self-efficacy reflects an individual’s subjective belief of his own abilities and potentials, which consequently affects their performance as well as the daily living (Maddux, 2016; Schwarzer, 2014).  Empirical evidence suggests that narcissism holds negative association with self-efficacy and self-esteem (Brookes, 2015). It has been found that narcissism is a positive predictor of distress and a negative predictor of wellbeing (Hanzec-Marković et al., 2019). Moreover, previous researches have also associated self-efficacy and self-esteem with variables such as depression (Jibeen, 2017; Santos et al., 2014; Smith & Betz, 2002).
Although the relationship between covert narcissism and wellbeing is studied, few existing researchers have tried to understand the pathways through which covert narcissism affects mental wellbeing. The mediating effect of self-esteem has been determined in studies with covert narcissism as predictor. A study conducted by Sedikides et al. (2004) found self-esteem as a mediator in the link between narcissism and mental wellbeing. Moreover, self-esteem has been identified a mediator in the relationship of covert narcissism with cyberbullying (Fan et al., 2019), body dissatisfaction (Purton et al., 2018), and emotion dysregulation (Zhang et al., 2017). Nevertheless, self-efficacy has not been studied yet as a mediator with narcissism as predictor and mental wellbeing as an outcome, to the best of our knowledge, but a study conducted by Matherne III et al. (2019) revealed that self-efficacy partially mediates the association between covert narcissism and higher amorality.
The two continuum model of mental health and illness categorizes individuals into four groups the first group comprises those who do not hold a diagnosis and are mentally healthy, the second group comprises of those individuals who hold a diagnosis but can cope with their illness and experience wellbeing, the third group comprises of those who hold a diagnosis and are unable to cope with their illness, and finally, the fourth group comprises of those who do not hold a diagnosis but still are not experiencing mental wellbeing. Moreover, according to the two continuum model of mental health no individual is restricted to a particular group. By improving their mental wellbeing or mental health individuals can move to a different group. This model points to the simultaneous occurrence of mental health and mental wellbeing (Westerhof & Keyes, 2010). According to contemporary researches, doctors experience a number of personality issues including narcissism (Moskop et al., 2006). The fourth group mentioned, while elaborating upon the two continuum model of mental health, evokes the possibility that doctors working in a hospital, regardless of their outwardly healthy appearance, may be suffering from poor mental wellbeing.
It is essential to study under-researched personality constructs, like narcissism, that may be affecting a doctor’s mental well-being. Keeping in mind the literature gaps the current research hence focuses on the impact of covert narcissism on doctor’s mental well-being, through paths of self-esteem and self-efficacy. The pathways of covert narcissism and mental wellbeing through self-esteem and self-efficacy have been less emphasized, especially in the Pakistani context. Therefore, this study is significant in identifying these pathways and paving a path towards clearer understanding of the mental wellbeing of doctors.

Hypotheses

The current study hypothesizes that

1. There will be a negative relationship of covert narcissism with mental wellbeing, self-efficacy and self-esteem in doctors.
2. Self-esteem and self-efficacy will have a positive relationship with mental wellbeing in doctors.
3. Covert narcissism will likely be a negative predictor of mental wellbeing, whereas, self-esteem and self-efficacy will likely be positive predictors of mental wellbeing in doctors.
4. Self-esteem and self-efficacy are likely to mediate the relationship between covert narcissism and mental wellbeing in doctors.

Method

Research Design

The present study used cross-sectional survey based research design. It aims to examine the impact of covert narcissism on mental well-being of doctors through the paths of self-esteem and self-efficacy.

Sample and Sampling Technique

Purposive sampling technique was employed to gather the sample data for the study. The doctors who consented to participate in the research study were recruited as part of the sample group. The sample consisted of N = 176doctors. Practicing doctors between the aged 24 to 34 years were recruited, whereas, non-practicing doctors were excluded. The recruitment of participants was done from Private and government hospitals of Rawalpindi and Islamabad. A total of
N = 378 doctors were approached for the current research, of which
N = 176 completed the questionnaires, corresponds to 46% response rate. The selected sample set comprised of n = 93 males and n = 83 females having a minimum experience of 3 months. Doctors from both public as well as private institutions were included.

Procedure

Ethical approval was taken from Institutional Review Board to conduct the study. Permission to use the required questionnaires was attained from respective authors. Participants were briefed about inclusion, exclusion criteria, duration for the completion of the questionnaires and guidelines on how to completely fill each questionnaire. Once the participants consented to participate in the research they requested to sign a consent form. All queries of the participants were addressed whenever required throughout the research. Participants were acknowledged for their efforts after the completion of the research. Afterwards, data was analysed by utilizing Statistical Package for Social Sciences (SPSS) and Process Macro.

Measures

Demographics Questionnaire
The demographic scale developed by the researcher comprised of questions pertaining to doctor’s age, gender, qualification, job title, sector and approximate experience in months.

The Maladaptive Covert Narcissism Scale (MCNS)
The Maladaptive Covert Narcissism Scale (MCNS) developed by Cheek et al. (2013) was used to measure covert narcissism. It was known to have high internal consistency of α = .95 (Parton & Ent, 2018). MCNS was a 23 item self-report measure, marked on a 5 point Likert type scale i.e. 1 as very uncharacteristic and 5 as very characteristic. The score obtained on MCNS ranged from 23 to 115. The total score on MCNS was obtained by adding the score of all 23 items. Higher levels of covert narcissism corresponded with the high score on the scale and vice versa.

Warwick–Edinburgh Mental Well-being Scale (WEMWBS)
The Warwick–Edinburgh Mental Well-being Scale (WEMWBS) was used to measure mental wellbeing (Tennant et al., 2007). The scale is known to have good reliability as substantiated by previous researches is α = .90 (Blank et al., 2016). WEMWBS was a 14 item self-report survey, scored on a 5 point Likert type scale i.e. 1 as none of the time and 5 as all of the time. The score obtained on the scale ranged from 14 to 70. The total score of WEMWBS was the cumulative of all the score obtained.  The higher score indicated healthier mental wellbeing whereas lower score on the scale indicated low mental wellbeing.

Rosenberg Self–Esteem Scale (RSES)
Rosenberg Self–Esteem Scale (RSES) developed by Rosenberg (1965) was used to measure self-esteem of the doctors. RESE is attributed to have high internal consistency α = .81 (Bajaj et al., 2016). RESE was a 10 item self-report measure with a 4-point Likert type scale i.e. 1 as strongly agree and 4 as strongly disagree. The score on the scale ranged from 10 to 30.  Items 2, 5, 6, 8, 9 were reverse scored. After reverse scoring the total score is obtained by summing the score of all the items. The normal self-esteem scores ranged from 15 to 25 whereas scores below 15 pointed toward low self-esteem.

General Self-efficacy Scale (GSE) 
General self-efficacy scale (GSE) developed by Schwarzer and Jerusalem (1995) was used to measure doctor’s self-efficacy. GSE, as established by previous researches, have high internal consistency α = .91 (Brookes, 2015). It is a self-report survey comprising of 10 items, which are marked on a 4-point Likert type scale i.e. 1 as Not at all true and 4 as exactly true. The score obtained on the scale ranged from 10 to 40. The final score on GSE is obtained by combining the score of all the items. The higher levels of perceived general self-efficacy are showed by higher score on this scale whereas low perceived general self-efficacy is indicated by lower score on the scale.

Data Analyses
Data analyses were accomplished utilizing SPSS 21. In order to appropriately characterize the sample descriptive analysis was employed. Reliability analysis was also run to establish the adequate internal consistency of the research instruments. Moreover, Pearson Product Moment Correlation were calculated to investigate the association between covert narcissism, self-esteem, self-efficacy and mental wellbeing. Furthermore, Multiple Regression Analysis was conducted to examine covert narcissism, self-esteem and self-efficacy as predictors of mental wellbeing and finally Mediation Analyses through Process Macro (Hayes, 2013) was computed to investigate the mediating effect of self-esteem and self-efficacy in the association between covert narcissism and mental wellbeing.

Results

The reliability analysis and descriptive statistics reported in Table 1, point towards high internal consistency (.8>) of the all scales while portraying mean and standard deviations for study variables.

Table 1
Descriptive of study variables and Alpha Reliability of scales (N=176)

Note. k = No of items on the scale; α = Reliability; M = Mean; SD = Standard deviation.

Pearson correlation

A two-tailed Pearson correlation (Table 2) illustrates that covert narcissism holds negative association  with doctor’s self-esteem (r = -.26; p = .000), self-efficacy (r = -.45; p = .000) and mental wellbeing (r = -.46; p = .000) moreover self-esteem (r = .77; p = .000) and self-efficacy (r = .83; p = .000) holds positive relationship with doctors’ wellbeing. The results indicate doctors having greater covert narcissism are more likely to experience lower levels of self-esteem, self-efficacy as well as mental wellbeing whereas increased levels of self-esteem and self-efficacy are linked with improved mental wellbeing.

Table 2
Correlation between Covert Narcissism, Self-Esteem, Self-Efficacy and Mental Wellbeing in Doctors (N = 176)

Note. ***p < .001.

Multiple Regression

Multiple regression was computed to examine whether covert narcissism, self-esteem and self-efficacy are predictors of mental wellbeing of doctors (Table 3). Variance in mental wellbeing was significantly explained by covert narcissism, self-esteem and self-efficacy (R = .89; p = .000). The results further indicated that covert narcissism emerged as a significant negative predictor (b = -.05;
p = .01) whereas self-esteem (b = .91; p = .000) and self-efficacy
(b = -.05; p = .000) were established as significant positive predictors of mental wellbeing.

Table 3
Covert Narcissism, Self-Esteem and Self-Efficacy as Predictors of Mental Wellbeing in Doctors (N =176)

Note. B = Unstandardized Regression Coefficient, S.E.= standard error, β = Standardized Coefficient, CI = Confidence Interval, LL = Lower Limit, UL = Upper Limit.
*p < .05, ***p < .000.

Mediation Analysis

Process Macro was used to run mediation analysis in order to evaluate the indirect impact of covert narcissism on mental wellbeing of doctors through self-esteem and self-efficacy (Table 4). Table 4 showed that B value for indirect effect does not comprise zero, therefore the point that the confidence interval does not involve zero implies that there is likelihood of a true indirect effect. So the pathway analysis established self-esteem (b = -.14; CI = -.22 to -.06) as well as self-efficacy (b = -.28; CI = -.35 to -.21) as significant mediators in the relationship between covert narcissism and mental wellbeing. A significant direct effect was also observed between covert narcissism and mental wellbeing after subtracting indirect effects for self-esteem (b = -.22; p = .00) and self-efficacy (b = -.08; p = .00).

Table 4
Mediating Role of Self-esteem and Self-efficacy in the Relationship between Covert Narcissism and Mental Well-being (N = 176)

Note. CI: Confidence Interval; significant at ***p < .000.
a5000 samples used to calculate bias-corrected bootstrap CI.

Discussion

The present research intended to assess the indirect effect of covert narcissism on mental well-being through self-efficacy and self-esteem. Various hypotheses pertaining to the inter-correlational, predictive and mediatory relationship of the study variable were constructed and analyses lead to the confirmation of all hypothesis of this study. It was assumed that there will be a negative association between covert narcissism, self-esteem, self-efficacy and mental well-being in doctors. The study result indicated that mental well-being indeed had a significantly negative relationship with covert narcissism and a significantly positive relationship with self-esteem and self-efficacy. Furthermore, covert narcissism had a significantly negative association with self-esteem as well as self-efficacy.
Covert narcissism, self-esteem and self-efficacy facets explained 89% variance in mental wellbeing in doctors. When covert narcissism, self-efficacy and self-esteem were considered together, variance in mental wellbeing was best explained by self-esteem, self-efficacy and covert narcissism. Self-esteem and self-efficacy significantly mediated the link between covert narcissism and mental wellbeing in doctors. The effectiveness of interventions targeting mental wellbeing of doctors may therefore depend on covert narcissism, self-esteem and self-efficacy. A study conducted in Pakistan contributed to the understanding that narcissism can have an influence on work and the professional setting as it was considered as a dark side of personality of doctors which could be assessed in future prior to recruitment (Li et al., 2020).
Previous exploration into the association between the types of narcissism and psychological well-being found that covert narcissism had a significantly positive relationship with depression and anxiety and significantly negative relationship with life satisfaction (Akinci, 2015). A pathway analysis carried out by Smith and Betz (2002) showed that career decision self-efficacy, social self-efficacy, and self-esteem were negatively associated with shyness and carrier indecision which in turn mediated their relationship with depression. Moreover, global self-esteem was also found to be directly related to depression. Furthermore, vulnerable narcissism is found to hold a negative correlation with self-esteem and self-efficacy (Brookes, 2015). These results are backed by a study conducted by Hassnain et al. (2022) in Pakistani context suggests that doctors need to be humble in certain situations such as dealing with critical cases, as their self-esteem is low which is regulated by using various strategies (Swami et al., 2015). 
Results of the regression analysis also indicated that, as hypothesized, covert narcissism indeed negatively predicted mental well-being of doctors, whereas, self-esteem and self-efficacy positively predicted mental well-being. Empirical evidence corresponding with the results of the current study also finds covert narcissism as a negative predictor of life satisfaction (Akinci, 2015). Self-efficacy was also considered a predictor of well-being (Soysa & Wilcomb, 2015). Cheng and Furnham (2003) furthermore, deemed self-esteem as a predictor of happiness.
As hypothesized, the results further showed that self-esteem and self-efficacy indeed mediated the link of covert narcissism with mental well-being. Rice et al. (1998) established self-esteem as a buffer between maladaptive perfectionism and depression. On the other hand, Liu et al. (2017) suggested that perceived stress of doctors impacted their work well-being as mediated by self-efficacy. A study conducted in Pakistan also revealed that self-esteem is related to job satisfaction. Therefore, self-esteem is an important factor influencing the mental wellbeing along with job satisfaction of doctors in Pakistan (Maqbool et al., 2020).

Limitations and Suggestions

The current study focused on doctors hailing from the twin cities of Pakistan i.e., Rawalpindi and Islamabad; hence findings of the current research are restricted and require further exploration involving samples from other countries and professions. Secondly, the sample size of this study is small as sample was taken from only two cities. Thus, large sample size could be taken in future to increase the generalizability of the findings. The nature of the present study is cross-sectional which is although very useful in understanding the inter-correlation, prediction, and mediation between the study variables, but it does not add to the understanding how covert narcissism may have developed in doctors. Longitudinal research studies are required to understand the development and progress of covert narcissism in doctors as well as its effect on mental wellbeing in doctors. Also, this study does not emphasize on the factors associated with covert narcissism in doctors, therefore qualitative study can be conducted to explore these associated factors. Additionally, this study could not focus on prevalence of covert narcissism in doctors. Hence, this study gives direction towards the significance of personality traits and its impact on mental health of doctors as they have to take critical decisions in their profession.

Conclusion

The present research was carried out to evaluate self-esteem and self-efficacy as mediators in the link between covert narcissism and mental wellbeing in Pakistani doctors. Results of the current study add immensely to the prevailing literature and highlight the influence of covert narcissism on the mental wellbeing of doctors. The current study highlights the consequences of covert narcissism on the mental well-being of doctors and encourages Pakistan Medical and Dental Council to work on improving mental wellbeing of doctors. The findings of this study are open for use in seminars pertaining to doctor’s mental wellbeing. Furthermore, the present study establishes the need for the development of screening tests and intervention to improve doctor’s mental well-being.

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Received 16 September 2022
Revision received 17 August 2023