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Bullying Within Medium, Low and Locked rehabilitation Forensic Secure Psychiatric Hospital

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A descriptive analysis of the nature and extent of bullying within medium, low and locked rehabilitation forensic secure psychiatric hospital.
SUMMARY
Purpose: The main aim of the study was to assess the nature and extent of bullying within locked rehabilitation, low and medium forensic psychiatric secure hospitals.
Method: The sample was selected from two forensic secure hospitals,
housing adult males in low, medium and locked rehabilitation wards. The
sample group consisted of seventy patients detained in the hospital and fifty
clinical staff who worked within the hospitals. Participants were asked to
complete a purpose-designed questionnaire face to face with a research
assistant. Patient’s questionnaires assessed their experiences, observations
and perceptions of bullying by other patients within the hospital. The staff
questionnaire assessed their observations and perceptions of bullying by
patients towards patients during their time working at the hospital.
Participation in the research was entirely voluntary and patients and staff were
informed that they were under no obligation to complete the questionnaire, or
any individual item within it, if they did not wish to.
Results: The results were analysed using Chi squared analysis regarding the
extent and nature of bullying within locked rehabilitation, low and medium
forensic psychiatric secure hospitals. Patients and staff on the whole were
consistent in their views regarding their awareness of the nature and extent of
bullying that takes place towards patients.
Conclusion: The present study demonstrated that over half of the sample of
both staff and patients reported eight out of the ten bullying behaviours had
been experienced by themselves often or occasionally. The most frequently
experienced forms of bullying were name-calling and taunting, threats
followed this. This was not consistent with the research that was carried out in
prisons which states that indirect forms of aggression and psychological/
1
verbal abuse are most frequently experienced among prisoners (Ireland,
2002, Ireland & Ireland, 2003).
INTRODUCTION
Research has seen an outpouring interest regarding bullying amongst
prisoners and detainees in psychiatric hospitals (Ireland, 2000; Levenson,
2000). Generally, it is assumed that bullying within prisons and psychiatric
hospitals is uncommon (Ministry of Justice, 2015) however, this opinion is not
consistent throughout research, and some evidence suggests that bullying
within such establishments is a significant problem (Woolf & Shi, 2011 ).
Following the anti bullying strategy that was implemented in 1999, it was
advocated that all prisons and forensic hospitals were required to have a
strategy in place to help manage bullying nationwide (Home Office Prison
Service, 1999). Whilst bullying within criminal justice settings is seen as a
crucial topic to be explored and has developed a breadth of literature over
time. More recently, research has raised attention towards developing an
understanding of the nature and to which extent bullying is present within
secured psychiatric hospitals.
Initial attention into investigating bullying in forensic settings originated in the
early 1990’s. During this time, Beck (1992, 1993, 1994, 1995) and McGurk &
McDougall ( 1991) circulated outcomes regarding bulling in young offenders
institutes and since then research has precipitously developed (Blaauw, 2005;
Brookes & Pratt, 2006; Ireland & Archer, 1996; Ireland, 1998; Ireland 2002;
Ireland & Ireland 2003; Power, Dyson, & Wozniak, 1997; Smith, Pendleton, &
Mitchell, 2005; Spain, 2005).
Whilst more research is now being conducted within secure psychiatric
settings regarding the levels of bullying that takes place this has been fairly
limited (Ireland & Snowden, 2003; Ireland, 2004; Ireland 2005; Ireland &
Bescoby, 2005). For example previous research into this area has
demonstrated that bullying within secure residential facilities is a problem but
the research cannot be generalised as they have not been replicated (Barter,
2
2004; Cawson, 2002;). Therefore, the aim of this study is to ascertain the
nature and extent of bullying within secure forensic psychiatric hospitals.
Additionally, it is thought necessary to develop an understanding of this issue
from both a staff and patient perspective, and ascertain if their experiences
are different. Previous research has shown that staffs perceptions of the level
of occurrence of bullying is rare when compared to patients/prisoners
perceptions (O’Donnell, 2004).
Defining bullying
Initially, research into bullying and outlining it was based on definitions from
schools (Beck, 1992; Connell & Farrington, 1996, 1997). They concluded that
in order for behaviour to be defined as bullying it needed to involve negative
actions which were physical and/or verbal with the purpose of causing harm
or suffering (Smith & Thompson, 1991 ), continued over a period of time and
involved an imbalance of power between the perpetrator and the victim
(Olweus, 1993). However, challenges have emerged when attempting to
apply this definition to secure psychiatric hospital setting (Ireland and Ireland,
2003). Research into bullying in secure psychiatric services is limited; the
majority of research that has been carried out is within prisons (Smith & Brain,
2000). However, whilst prisons and secured psychiatric hospitals are different
settings they both detain individuals who have broken the law, are detained
and part of the criminal justice system. Additionally, psychiatric hospitals often
care for individuals who have been transferred from prison to hospital.
Researchers have debated that a more current definition is needed when
explaining bullying within forensic settings (Ireland & Ireland, 2003; Ireland,
2002, 2005). They raise several flaws within the school-based definition of
bullying that may not be entirely relevant within a secure forensic population.
They argue that within secure forensic settings that the fear of bullying may be
more crucial in identifying bullies than the recurrence of negative behaviours.
Additionally, with regards to the imbalance of power, this may not be relevant
when considering behaviours such as ‘baroning’, where individuals sell goods
to one another and then demand high repayments at a later date. Due to this
relationship developing initially on a mutual balance of power where the
3
individual enters into the relationship voluntarily (Ireland, 2002). Lastly, they
suggest that not all bullying in prisons is inevitably deliberate where
individuals are trying to gain status within their peer groups (Ireland and
Archer, 1996). Moreover, the anxiety of recurrent violence may be more
significant than the actual frequency (Randall, 1997).
Furthermore, Ireland (2002) stated that within forensic secure settings,
violence does not need to be recurring for it to be categorised as bullying.
Rather the anxiety of being exposed to violence may be more important than
the actual event itself in determining bullies. Likewise, when considering
‘intent’, indirect forms of bullying including gossiping are not always regarded
as bullying irrespective of the provocation of the perpetrator.
Notwithstanding, the current interest in bullying within prisons, the explanation
of ‘bullying’ remains varied between researchers. For example, some
academics dispute that behaviour would be considered as bullying when it is
repeated where as others state that this is not always essential or conceivable
in secure settings (Ireland & Ireland, 2003).
Ireland (2002) has proposed the following definition of bullying;
“An individual is being bullied when they are the victim of
direct and/or indirect aggression happening on a weekly
basis, by the same or different perpetrators. Single
incidences of aggression can be viewed as bullying,
particularly when they are severe and when the individual
either believes or fears that they are at risk of future
victimisation by the same perpetrator or others” (Ireland,
2002).
It is largely acknowledged that within forensic settings, bullying is expected to
include both direct and indirect behaviours. Direct bullying has been defined
as negative behaviours by the bully directed towards the victim including
physical and verbal aggression (Ireland & Archer, 1996). Whereas, indirect
bullying encompasses behaviours such as gossiping and deliberate social
4
exclusion, which are likely to result in the victim experiencing an adverse
effect (Ireland, 2000). Recent research has shown that indirect bullying is
more likely to occur in forensic secure settings (Holland, Ireland & Muncer,
2009; Ireland & Ireland, 2000). It is suggested that this behaviour is more
likely to occur as it is harder to discover and therefore reduce the likelihood of
getting caught (Ireland, 2005).
The nature of bullying
Research regarding bullying within prisons have shown statistics of over 50%
of prisoners in UK studies (Allison & Ireland, 2000; Archer & Southall, 2009;
Ireland & Ireland, 2008; South & Wood, 2006). It has been largely reported
that social hierarches, limited resources and locked environments may
contribute to the high levels of bullying is reported (Connell & Farrington,
1996; Ireland, 2000).
When considering the existence of bullying and victim groups social
hierarchies within prisons need to be taken into consideration (Beck, 1992). It
is often observed that victims of perpetrators then go on and act out similar
behaviours on others (Weisfield, 1994). Research has shown that males tend
to use physical aggression whereas females are more likely to use indirect
aggression (Bjorkvist, 1994; Bjorkvist, 1994 ). This contrast reflects the
variances in the forms of bullying behaviours shown by male and female
prisoners (Archer, 1996; Ireland, 1999, Ireland, 1999; Ireland & Ireland, 2000).
Due to the variety of bullying behaviours observed it increases the complexity
of the problem, which needs managing (Beck, 1993). When attempting to fit in
with the prison culture of survival it can lead to conformity and adaptation to
the environment they have been placed in to endorse their status (Connell &
Farrington, 1996). Subsequently, this can encourage bullying behaviours,
which then become a part of ‘normal life’ (Ireland, 1999).
This standardisation of the behaviours results in behaviours being viewed as
low level. New social norms are constructed in line with prison behaviours and
therefore only extreme behaviours are considered as bullying (Connell &
5
Farrington, 1996). Additionally, there are some behaviours that are only likely
to be observed within secure forensic settings such as “taxing” where
prisoners request for goods or money in lieu of tax from their victims (Ireland,
1997), and “baroning”, when individuals lend items to others and repayments
are at high levels of interest (Ireland, 1997). Notwithstanding these behaviours
are only likely to occur within secure forensic environments.
The extent of bullying
When considering the extent of bullying within forensic services research into
this has advanced substantially since the initial developments noted by
Olweus’ (1978). In relation to bullying among forensic service users and within
medium, low and locked rehabilitation secure psychiatric services, research
has investigated concerns such as the occurrence and cognizance of it and
characteristics of bullies and victims of bullies (Beck, 1994; Bunton, 1993;
O’Donnell and Edgar, 1996).
Within various prisons it is evident that the levels of bullying differ, however, it
is unquestionable that bullying is a problem (Beck, 1992). Previous research
looking into the level of bullying occurring in young offender institutes
established that the problem of bullying is much higher than initially
hypothesised (Beck, 1994; O’Donnell & Edgar, 1996). Overall, research has
shown that even if it takes place over diminutive phase, a sizeable fraction of
prisoners are likely to be involved in situations that encompass bullying that
includes being bullied or being a victim (Beck & Smith, 1995; Connell &
Farrington, 1996; Ireland, 1999; Livingston, 1994).
Historical research conducted by Ireland (1999) within five prisons
demonstrated that there was a high self-report nature of bullying with 70% of
young offenders reporting being bullied compared with 52% within adult
prisons. When comparing the experiences of bullying between male and
female prisons higher levels of bullying were reported by males (61 %)
compared to females (47%). This is a contrast to other pieces of research,
which have found much lower levels of bullying in prisons ranging from 3% to
62% (Brookes, 1993; Connell & Farrington, 1996; Ireland & Archer, 1996;
6
Livingston, 1994; Power, 1997). It is likely that the variations in defining
bullying could account for some of the variance.
Further research in support of bullying being a problem within prisons was
carried out in a category C prison. This research found that 51 % of prisons
reported being bullied and 76% reported observing bullying. Indirect forms of
aggression were most prevalent (Nagi, Browne & Blake, 2006).
Additionally, exploration has taken place in psychiatric hospitals, which
investigated the nature, extent, and triggers of bullying among patients within
psychiatric secure hospitals (Ireland, 2004). One of the fundamental aims of
this research was to establish the variance in perceptions between staff and
patients regarding the issue. Results demonstrated that 20% of patients and
staff recounted that they had seen a patient being bullied that week. A further
20% self reported being bulled in the previous week and 10% of participants
reported bullying others. When considering the types of bullying that is
observed; the most frequent types were physical assaults, intimidation, theft,
verbal abuse and being forced to do chores. The outcomes from this research
demonstrated how patient on patient bullying is present within forensic secure
settings and subsequently is a problem that requires solving. When
considering these findings and comparing them against prison-based
research several similarities were identified such as the environment making
the findings more generalizable (Struckman-Johnson, 1996; Woolf 2011 ).
Additionally, previous research has shown that higher security establishments
are more likely to incur higher levels of violence (Edgar, 2003). The research
identified that physical violence was perceived to be a legitimate way to
address perceived ‘violations’ and acts of perceived ‘disrespect’.
Measuring bullying
Earlier research has used measures to assess the pervasiveness; occurrence
and nature of bullying, what the ‘hotspot’ areas and timeframes are,
perpetrators motivations behind carrying out such behaviours, and identifying
traits in victims (Beck and Ireland, 1997). Literature has suggested that the
‘hotspot’ areas and timeframes when bullying is more likely to take place is
7
during ‘handover’ meetings and medication times when the staff are busy
resulting in a lack of staff presence (Tewkesbury, 1989).
When measuring such behaviours, several different methods have been used
including self-report questionnaires, interviews, observations, incident reports
and clinical records. The most commonly used method is self-report
questionnaires (Brookes, 1993; McGurk and McDougall, 1986). However, it
was highlighted that due to the self report nature of this method it is difficult to
monitor when information is not accurately recorded (Connell and Farrington,
1996).
Research into the accuracy of data collected regarding bullying in prisons was
assessed by Connell and Farrington (1997). Staff and prisoners within prisons
were asked to record data regarding the prisoners about weather they felt
they were a bully, victim, neither or both. The results from this research were
considered to have the highest validity in identifying bullies and victims when
compared with other approaches (Ireland, 2002).
The current study
The existence of bullying within secure psychiatric hospitals can have a
substantial adverse effect both on individuals involved and the organisation as
a whole. Bullying within such environments has gained such significant
attention due to its association with increase psychological distress, increased
risk of suicide and self harm and increased risk of violence and aggression
(Biggam & Power, 1999; Blaauw, 2005).
Particularly due to the possible adverse influence that bullying can have and
the high levels thought to be occurring within secure settings it is apparent
that reducing the amount of bullying within such settings is important. It is
proposed that in order to support this a better understanding of the nature and
extent of bullying within secured psychiatric forensic services and the factors
that contribute to its occurrence is required.
With previous research in mind, the following research is designed to explore
the nature and extent of bullying in locked rehabilitation; low and medium
8
secure psychiatric hospitals. Researchers have identified a number of specific
areas in need of study, including the nature and extent of bullying in
psychiatric hospitals. The focus of the current study is on developing an
understanding of what types of bullying staff and patients are aware of within
psychiatric hospitals, how often they observe them, how often patients report
experiencing specific types of bullying and what the difference between
patients and staffs perceptions are. After drawing together the results, they
will be used to enable the unceasing monitoring of such bullying behaviours
and changes will be recommended regarding the specifically identified areas
of concern within the hospitals, in addition to stipulating communication to
appraise the strategic direction of policies.
This study will explore the level of bullying across different levels of security.
Due to the nature of patients within higher levels of security one would expect
higher levels of aggression, violence and behaviours that would constitute as
bullying (Edgar, 2003; Ireland, 2002).
The second focus of this study is to explore the perceptions of observed
bullying prevalence between staff and patient groups. The research
demonstrates that victimisation is complex, multi-faceted and rapidly evolving.
To date there has been much debate about the true prevalence of bullying
within psychiatric wards (Struckman-Johnson, 1996; Woolf 2011 ).
Although it is likely that bullying goes under reported, such bullying
behaviours are generally believed to be uncommon in British prisons and
psychiatric hospitals (Ministry of Justice, 2015). However, contrasting
research shows that patients and prisons generally believe that bullying does
occur regularly (Woolf & Shi, 2011) whereas this is different to that of staffs
perceptions of the level of occurrence of bullying where research has
suggested that staffs perceptions of victimisation within prisons and hospitals
was rare (O’Donnell, 2004) which leads us to hypothese’ that staff would
report bullying occurs less than patients do.
In addition to prevalence rates the research also aims to investigate types of
bullying that occur and where this is most likely to happen in secure services.
9
Research shows that secure services are designed to deescalate physical
violence as a result indirect forms of aggression are more prevalent (Ireland,
2002). For bullying to thrive within secure services it needs to go undetected
for that reason we would expect that bullying would occur in areas that have
the least staff supervision. This is supported in literature by Tewkesbury,
(1989) who suggests higher levels of bullying generally occur when and
where there is a lack of supervision as it decreases the chances of individuals
being caught/observed.
Hypotheses:
1. There will be a higher level of bullying found in higher levels of security
settings compared to lower levels of security settings.
2. Patients will observe higher levels of bullying when compared to staff.
3. Indirect forms of aggression will be the most prevalent type of bullying
experienced by patients than direct forms of bullying.
4. There will be higher levels of bullying observed in secure settings where the
lowest levels of supervision/observation are.
METHOD
Participants:
It was calculated that the study required a sample of 120 participants based
on an F2 of 0.15 and using an online a priori sample size calculator with
statistical power of .8, 8 predictors and probability level of p<0.05 (Soper,
2014). Subsequently, seventy adult male service users and fifty clinical staff
detained or working in medium, low and locked rehabilitation secure
psychiatric services were approached and agreed to participate in the study.
The data was collected between August 2015 and February 2016. To be
included in the study participants had to be over the age of 18, sectioned
10
under the Mental Health Act (1983) and detained as a patient or working in
medium, low and locked rehabilitation secure psychiatric services, who were
deemed to have capacity to consent to take part. As a result, the sole
exclusion criterion was those individuals who lacked capacity.
Opportunity sampling was used in the study. Individuals were asked to take
part in the study via the research assistants attending the ward that they were
detained/working on. Chi squared was used to analyse the data because the
information collected was categorical, comparing difference between two
groups across categorical variables.
The staff who participated in the study had a mean age of 50.0 with a range of
20-67. Of the staff 42% (n= 21) were male and 58% (n = 29) were female.
34% (n = 17) of the participants were Black African ethnic origin, 6% (n = 3)
were black Caribbean, 2% (n = 1) were Chinese, 16% (n = 8) were mixed,
28% (n = 14) were white British and 14% (n = 7) considered themselves as
other ethnicity. The average number of years that staff had been working in a
hospital was 6.1 years with a range of 2-7 years. The number of years that the
staff reported working in this hospital was 5.4 years with a range of 1-7 years.
Within this sample 52% (n = 26) of individuals had working in a hospital for
over 7 years, which demonstrated an experienced sample. However, 20% (n
= 10) had worked in the hospital where the research took place for less than a
year in comparison to 28% (n = 14) who had worked in this hospital for 7
years or more. With regards to the staff’s job roles, 42% (n = 21) were nurses,
30% (n = 15) were Health Care Workers, 8% (n = 4) were psychologists, 4%
(n = 2) were Occupational Therapists, 8% (n = 4) were Medics, 4% (n = 2)
were therapy assistants and 4% (n = 2) were social workers.
Of the patients who were approached to take part in the study all were males.
The average age was 43.7 with a range of 19-87. 22.9% (n = 16) of the
sample were of Black African ethnic origin, 4.3 (n = 3) were black Caribbean,
4.3% (n = 3) were Chinese, 4.3% (n = 3) were Indian, 15. 7% (n = 11) were
mixed, 4.3% (n = 3) were Pakistani, 24.3% (n = 17) were White British, 8.6%
(n = 6) were White other and 11.4% (n = 8) considered themselves as Other
11
ethnic origin. The sample compromised of 34.3% (n = 24) of individuals from
a low secure forensic psychiatric hospital, 42.9% (n = 30) were from a
medium secure hospital and 22.9% (n = 16) were from a locked rehabilitation
unit. The mean number of years that individuals were detained in hospital was
4.8 years with a range of 1-7 years. Whereas the mean number of years that
individuals had been detained in this hospital was 3.8 years with a range of 1-
7 years. The majority of people in hospital had been for 3-6 years 28% (n =
19) where as in this current hospital 54.2% (n = 38) of sample had been in
this hospital for 3-4 years.
Materials or instruments:
A nine-item ‘Anti Social Behaviour’ questionnaire was produced for the
purpose of this study. The main themes of the research were incorporated
into the questionnaire that could be answered in a check or quantitative
format.
Three questions were used to ascertain estimates on the prevalence,
frequency and nature of bullying and where bullying was most likely to occur
within the establishment. The participants were required to indicate the
frequency of bullying from two pre-determined lists; a) types of bullying
behaviours they have been aware of or have seen happening to others b)
types of bullying behaviours they have experienced themselves. The
questionnaire did not include the term ‘bullying’ as it has been reported to lead
to an underestimation of bullying due to its emotive nature (Ireland, 2005),
rather, the questionnaire asked questions regarding various types of
behaviours defined by Ireland (1999) as indicative of bullying. The eight-item
list of bullying behaviours ranged from indirect forms of aggression which
included threats, name calling, taunting, stealing items, racial abuse and
prohibited items to direct forms of aggression which included kicking, sexual
assault and sexual horseplay. Questions were asked to distinguish if these
bullying behaviours had been observed by staff and patients. Additional
questions were asked to distinguish what bullying behaviours patients had
experienced.
12
Participants were also asked to state where they had observed, been aware
of or experienced bullying most frequently within the establishment from a
predetermined list. The response categories for each question were: never (0
times), occasionally (1-5 times) and often (over 5 times), with participants
being free to select more than one option if they wished, with a further space
being provided for comments. Each question applied to the participant’s entire
length of stay at the establishment as selected from three response
categories; ‘less than 6 months’, ‘6-12 months’ and ‘more than 12 months’.
Participants were asked how long ago they witnessed the incidents. The
response category for this question were: 1-3 months ago, 3-6 months ago, 6-
12 months ago and longer than 12 months ago.
Participants were also asked who the anti social behaviours had been carried
out by. The response categories for this question were: individual and group.
In addition to the main research questions, one question was asked regarding
the participants perceived level of safety within the hospital, response
categories for the question were ‘always’, ‘often’, ‘sometimes’ and ‘never’. An
additional question requested information regarding how ‘safe’ their hospital
was when compared to other establishments they had been detained in, with
response categories being ‘more’, ‘less’, ‘the same’ and ‘first time in hospital’.
Additionally demographic information including age, gender, ethnicity, length
of stay in hospital were included in the questionnaire.
Design:
A between subject’s cross-sectional face-to-face questionnaire of people’s
self-reported level of the nature and extent of bullying within psychiatric
services was assessed. This study was a quantitative analysis. This approach
allowed the researcher to infer a relationship and association between
variables.
All data was analysed using SPSS 19. Firstly the study used a preliminary
analysis by conducting t-tests. Hypotheses were then further tested using Chi
squared.
13
Procedure:
Ethical approval was obtained through the Integrated Research Application
System (IRAS) and attendance to the local Research Ethics Committee
meeting. Following this approval the research began. A summary information
sheet regarding the research was given to patients and staff before they
agreed to take part in the research. Participants who wished to participate
were invited to take part in the research. Times were arranged with each of
the patients and clinical staff that fitted with their schedules to complete the
questionnaire. In order to increase patient confidentiality, patients were
encouraged to complete the questionnaire at the end of professional one to
one sessions. Once patients agreed to take part they were provided with a
copy of the research confidentiality guidelines and staff offered to read this to
them and complete a consent form. After completing the consent form they
were asked to complete the questionnaire. Each questionnaire took around
five minutes to complete. Demographic details were also collected in relation
to the length of time in hospital and the type of ward they were detained on.
Following completion of the questionnaire, participants were debriefed and
contact details of the researcher and supervisor were provided to answer any
questions regarding the research within the participation debrief sheet.
RESULTS
The results were analysed using Chi squared analysis and descriptive data to
address the research hypotheses. The results below will consider the four
research hypotheses in turn.
Hypothesis 1: There will be a higher level of bullying found in higher levels of
security settings compared to lower levels of security settings.
Bullying as described in the methods section, which includes both, direct and
indirect forms of aggression were analysed. Below details the number of staff
14
and patients who observed direct and indirect bullying in medium, low and
locked rehabilitation services.
Table 1: Levels of bullying in medium security hospitals.
Medium Indirect Direct
Staff ( n=21 ) 100% 81%
Patient (n=30) 100% 90%
Within medium secure services all of the staff and patients who were asked if
they had been observed indirect forms of bullying reported that they had. The
results for observation of direct bullying were slightly lower than indirect
bullying but still high. Overall it was evident that both the staff and patients
who were asked if they had observed direct and indirect bullying reported that
they had observed such behaviours.
Table 2: Levels of bullying in low security hospitals.
Low Indirect Direct
Staff (n=13) 100% 92%
Patient (n=24) 100% 83%
Similar results were observed when staff and patients within low secure
services were asked if they had observed indirect and direct bullying that were
observed in medium secure services. All patients and staff asked stated that
they had observed indirect bullying. One member of staff reported that they
had not observed direct bullying all others asked reported having observed
direct bullying. When patients were asked if they had observed direct bullying
four patients out of the twenty-four who were asked stated that they had not
observed direct bullying.
Table 3: Levels of bullying in locked rehabilitation security hospitals.
Locked Indirect Direct
15
Staff (n=16) 100% 75%
Patient (n=16) 100% 75%
Furthermore, all patients and staff who were asked if they had observed
indirect bullying reported that they had. The same number of staff and
patients (n=12) reported that they had observed indirect bullying meaning that
four staff and four patients who took part in the research stated that they did
not observe direct bullying.
Overall, the results did not demonstrate that higher levels of bullying would
occur in higher security settings and so the hypothesis was rejected. Instead
the levels of bullying which occurred in medium, low and locked rehabilitation
services for both direct and indirect bullying was high and consistent amongst
all settings.
Hypothesis 2: Patients will observe higher levels of bullying when compared
to staff.
Table 4: How often types of bullying are observed
Type Staff Patients
Threat
Often 28% 27.1%
Occasionally 40% 37.1%
Never 32% 35.7%
Name Calling
Often 20% 37.1%
Occasionally 64% 45.7%
Never 16% 17.1%
Taunted
Often 34% 34.3%
Occasionally 56% 54.3%
Never ‘10% 11.4%
Sexual Assault
Often 0% 4.3%
Occasionally 16% 34.1%
Never 84% 64.3%
Sexual Horseplay
Often 0% 2.9%
Occasionally 18% 21.4%
Never 82% 75.7%
Kicked
Often 8% 14.3%
Occasionally 62% 57.1%
Never 30% 28.6%
Stolen Items
Often 24% 27.1%
Occasionally 56% 60%
Never 20% 12.9%
Racially Abused
Often 30% 35.7%
Occasionally 64% 50%
Chi Square
df = 2, N=120
.118 (ns)
4.709 (ns)
.071 (ns)
1.124(ns)
1.131(ns)
3.158(ns)
16
Never 6% 14.3%
Prohibited Items 1.472(ns)
Often 34% 25.7%
Occasionally 52% 60%
Never 12% 14.3%
Other Abuse
Often 0% 6%
Occasionally 30% 38.6%
Never 70% 52.9%
*The assumptions for chi-square testing were not met in these categories due to tow numbers.
No significant results were found when using chi-squared analysis when
patients and staff were asked how often they observed different types of
bullying (threats, name calling, taunted, kicked, stolen items, racial abuse and
prohibited items).
The initial hypothesis that patients would observe higher levels of bullying
than staff was found incorrect. Patients and staff on the whole were consistent
in their views regarding their awareness of the types of bullying that took
place towards patients. However, they differed in regards to how often they
felt sexual assault towards patients by patients occurred. The descriptive data
showed that patients felt that it was more likely to occur than staff reported.
Due to low numbers in these categories (particularly the ‘often’ observed
category) chi square testing was not possible as the assumptions were not
met. As a result, the categories within this variable were collapsed to ‘having
observed this behaviour’ (16% of staff and 38.4% of patients) and ‘not having
observed this behaviour’ (84% of staff and 64.3% of patients). This was
analysed using Chi-square and a significant result was found x2 (1,N=120) =
5.686, p=0.017). The other two variables with expected counts of less than 5
(sexual horseplay and other abuse) were also analysed in this way but without
any significant result. This finding supports the need for further testing of this
matter in a larger sample.
With regards to staff and patients observing threats being made to other
patients, their responses were consistent. 40% of staff and 37 .1 % of patients
reported that they had observed this bullying behaviour occasionally. When
analyzing the results regarding kicking 62% of staff and 57 .1 % of patients
stated that they had observed this behaviour occasionally. 56% of staff and
54.3% of patients had observed taunting behaviours occasionally. These
trends demonstrate that the responses obtained from staff and patients are
17
consistent with each other.
Table 5: How long ago participants observed different types of bullying
occurring
Type
Threat
1-3
3-6
6-12
Over 12
Never
Name Calling
1-3
3-6
6-12
Over 12
Never
Taunted
1-3
3-6
. 6-12
Over 12
Never
Sexual Assault
1-3
3-6
6-12
Over 12
Never
Sexual Horseplay
. 1-3
3-6
6-12
Over 12
Never
Kicked
1-3
3-6
6-12
Over 12
Never
Stolen Items
1-3
3-6
6-12
· Over 12
Never
Racially Abused
1-3
3-6
6-12
Over 12
Never
Prohibited Items
1-3
3-6
6-12
Over12
Staff
22%
50%
12%
6%
10%
16%
48%
18%
6%
12%
54%
30%
6%
0%
10%
6%
6%
4%
0%
84%
6%
4%
4%
4%
82%
32%
18%
14%
6%
30%
32%
24%
22%
2%
20%
48%
28%
18%
0%
6%
38%
24%
22%
4%
Patients
24.3%
47.1%
10%
7.1%
11.4%
21.4%
30%
24.3%
7.1%
17.1%
24.3%
31.4%
20%
12.9%
11.4%
20%
11.4%
4.3%
0%
64.3%
8.6%
8.6%
4.3%
2.9%
75.7%
31.4%
28.6%
10%
1.4%
28.6
38.6%
32.9%
14.3%
1.4%
12.9%
42.9%
24.3%
14.3%
4.3%
14.3%
34.3%
27.1%
15.7%
8.6%
Chi Square
di= 2, N=120
.334 (ns)
4.072 (ns)
17,561 ..
6.542 (ns)
1’439 (ns)
3.601(ns)
3.125 (ns)
4.573 (ns)
1.881(ns)
18
Never
Other Abuse
1-3
3-6
6-12
Over 12
Never
12%
12%
2%
12%
4%
70%
*p=<0.05, **p=<0.01, ***p=<0.001
14.3%
12.9%
20%%
11.4%
2.9%
52.9%
9.128 (ns)
Of all of the types of bullying analysed there was one significant result
obtained when looking at how long ago both staff and patients observed
different types of bullying occurring. The majority of results demonstrated that
both staff and patients were consistent in the perceptions. When analysing the
data obtained from staff and patients perception of individuals being taunted
54% of staff stated that they had observed this occurring compared to 24.3%
of patients x2 (2,N=120) = 17.561, p=0.01 ). This suggests that staff were more
likely to perceive taunting occurring on the wards than patients. Overall, from
the results obtained the hypothesis made that patients would observe higher
levels of bullying was not met.
Hypothesis 3: Indirect forms of aggression will be the most prevalent type of
bullying experienced by patients than direct forms of bullying.
Table 6: Patients experience of bullying
Frequency (n=70)
Type
Often Occasionally Never
Threat 14 (20%) 43 (61.4%) 13 (18.6%)
Name Calling 20 (28.6%) 36 (51.4%) 14 (20%)
Taunted 19 (27.1%) 34 (48.6%) 17 (24.3%)
Sexual Assault 2 (2.9%) 12 (17.1%) 54 (80%)
Sexual Horseplay 1 (1.4%) 12 (17.1%) 57 (81.4%)
Kicked 11 (15.7%) 26 (37.1%) 33 (47.1%)
Stolen Items 18 (25.7%) 39 (55.7%) 13 (18.6%)
Racially Abused 16 (22.9%) 31 (44.3%) 23 (32.9%)
Prohibited Items 13 (18.6%) 29 (41.4%) 28 (40%)
Other Abuse 7 (10%) 30 (42.9%) 33 (47.1%)
*p=<0.05, **p=<0.01, ***p=<0.001
In line with the hypothesis made, with regards to self-report victimisation,
name calling and taunting (indirect forms of aggression) were rated as most
19
prevalent. 28.6% of patients reported that they had been a victim of name
calling often, and 27.1% reported being a victim of taunting often. Sexual
horseplay (N=1, 1.4%) and sexual assault (N=2, 2.9%) were the least
reported incidents of bullying that patients stated they were victims of often.
Hypothesis 4: There will be higher levels of bullying observed in secure
settings where the lowest levels of supervision/observation are.
Table 7: Locations of bullying being observed
Location Staff Patient
Bedroom
Often 22% 17.1%
Occasionally 68% 48.6%
Never 10% 34.3%
Corridor
Often 6% 22.9%
Occasionally 74% 52.9%
Never 20% 24.3%
Lounge
Often 50% 31.4%
Occasionally 38% 50%
Never 12% 18.6%
Courtyard
Often 4% 8.6%
Occasionally 42% 45.7%
Never 54% 45.7%
Ground Leave
Often 0% 0%
Occasionally 0% 0%
Never 100% 100%
Community Leave
Often 0% 0%
Occasionally 12% 15.7%
Never 88% 84.3%
Reception
Often 0% 0%
Occasionally 8% 21.4%
Never 92°/0 78.6%
Meal Times
Often 0% 14.3%
Occasionally 68% 65.7%
Never 32% 20%
Visits
Often 0% 0%
Occasionally 16% 1.4%
Never 84% 98.6%
*p=<0.05, **p=<0.01, ***p=<0.001
Chi Squared
df = 2, N=120
9.420**
7.587′
4.297(ns)
1.413(ns)
.331 (ns)
3.947′
8.846*
8.927***
When exploring the location of bullying behaviours within the hospital ten
different locations were listed. The results demonstrated that patients and
staff were consistent in their observations of bullying in four different locations
of the hospital. The lounge area was considered the location where bullying
20
was most likely to take place. 50% of staff and 31.4% of patients reported that
they had observed bullying ‘often’ taking place in the bedrooms. Whereas
during ground leave and community leave 0% of both staff and patients
reported observing bullying taking place in these areas. These results were
not what was hypothesised, they did not demonstrate that higher levels of
bullying occurred in secure settings where the lowest levels of
supervision/observation were.
Patients and staff had significantly different observations in five locations of
the hospital. Several chi-squared tests were performed to examine the
relationship between staff and patients perceptions of bullying within different
locations of the hospital. The relationship between these variables within the
bedroom area was significant, x2 (2,N=120) = 9.420, p=0.009), the corridor
area, x2 (2,N=120) = 7.587, p=0.023), the reception area, x2 (2,N=120) =
3.947, p=0.047), during meal times x2 (2,N=120) = 8.846, p=0.012) and during
visits x2 (2,N=120) = 8.927, p=0.003).
DISCUSSION
Despite attempts to curb bullying in psychiatric hospitals, this study reveals it
is still a pervasive problem. Of the 120 participants who took part in this study
100% reported having observed some form of bullying. This is consistent with
previous research, which highlights that bullying within prisons/psychiatric
services remains a significant problem (Ireland, 1999).
Hypothesis 1: There will be a higher level of bullying found in higher levels of
security settings compared to lower levels of security settings.
When considering the hypothesis that there will be higher levels of bullying
found in higher levels of security settings compared to lower levels of security
settings it was alarming to note that this was not the case. Instead the levels
of bullying which occurred in medium, low and locked rehabilitation services
for both direct and indirect bullying was high and consistent amongst all
settings. Whilst historical literature suggests that this is not the case Ireland,
1999 does state that estimates of the extent of bullying does vary across
21
studies and subsequently it is difficult to generate definitive estimates of
bullying. This could be due to the self-report nature of the behaviour, the
different methods of collecting the data and the different definitions employed
by researchers. It was also highlighted that due to some of the different level
of security wards being based in the same hospitals the likelihood of policy
and procedure that takes place on the specific wards may be similar. This
could account for some of the similarities in the results obtained.
Hypothesis 2: Patients will observe higher levels of bullying when compared
to staff
A surprising finding emerged with regard to the levels of bullying observed by
patients and staff. It had been predicted that patients would observe higher
levels of bullying when compared to staff but in fact the results obtained
demonstrated that patients and staff were consistent in their views of
observations of bullying and neither party stated that they observed bullying
more than the other. One might speculate that this points to a true
representation of the bullying that is occurring in the hospitals that took part in
the study.
Hypothesis 3: Indirect forms of aggression will be the most prevalent type of
bullying experienced by patients than direct forms of bullying
Consistent with previous research it was apparent that indirect forms of
aggression were the most prevalent type of bullying experienced by patients
when compared to direct forms of bullying. The present study demonstrated
that over half of the sample reported eight out of the ten bullying behaviours
had been experienced by themselves often or occasionally. This indicated a
high self-report nature to the study. However, it should be considered that due
to the sensitivity of the topic being research this could still be being under
reported however, the level of this cannot be determined as it has not been
statistically tested. Whilst the findings confirm that bullying is a widespread
problem in hospitals the problems noted within the introduction regarding
defining bullying have proved to be important, since as Ireland (1999) noted,
22
the way in which bullying is defined may at least partly determine its recorded
frequency.
The most frequently experienced forms of bullying were name-calling and
taunting, threats followed this. This was not consistent with the research that
was carried out in prisons which states that indirect forms of aggression and
psychological/ verbal abuse are most frequently experienced among prisoners
(Ireland, 2002, Ireland and Ireland, 2003). The rate of perceived theft of items
abuse was in line with other studies, which have found this type of abuse
(Ireland and Archer, 1996, Power et al, 1997). Whilst there are difficulties in
making direct comparisons between studies due to both the different
methodologies employed for data collection and the diverse definitions of
bullying, it would seem that irrespective of the method employed, there are
similarities in the results obtained across different studies.
A large number of patients in the current study reported never having had
experienced ‘other abuse’ ( 4 7 .1 % ). Of the 10% who reported that they
experience ‘other abuse’ often and 42.9% who reported occasionally
experiencing other abuse none stated what this abuse constituted despite
having a space to specify what was meant by their response. As a result it
can neither be commented on nor discounted. In hindsight, it would have
been beneficial to ascertain from the participants what was meant by ‘other
abuse’ category. The results demonstrated that the majority of individuals had
never experienced sexual assault (80%) or sexual horseplay (81 .4%). It was
positive to identify that only a small number of respondents had been a victim
of this type of bullying. This supports the findings from other research studies,
which have found little or no evidence of this abuse among prisoners (Collin
and Farrington, Ireland, 1999, Ireland and Ireland, 2003).
Empirical research states that indirect forms of aggression and psychological/
verbal abuse are the most frequently perceived forms of aggression. The
current study however identifies little difference in the perceived frequency of
both direct and indirect aggression. This would require further exploration as it
may be that there is more opportunity for direct forms of aggression to go
unnoticed for example a low staff to patient ratio for observations, poor
23
supervision of patients, the layout of the environment enabling more direct
aggression to take place and go unnoticed.
Hypothesis 4: There will be higher levels of bullying observed in secure
settings where the lowest levels of supervision/observation are.
Secure settings can be described as a place where the risk of being bullied is
increased in comparison to other settings (Ireland, 2002) and the possibility of
being exposed to aggression is real (Edger, 2003). Historical research has
shown that individuals often feel ‘safer’ in specific places, when specific
people are around (Mccorkle, 1992). Despite this research, the current study
demonstrated a contradiction showing that both patients and staff felt that
bullying was most likely to occur in the lounge area, a place where increased
levels of supervision/observation take place. Subsequently, for the current
study this hypothesis was found to be incorrect.
LIMITATIONS
There were a number of limitations to the present study. Specifically, several
methodological caveats must be considered when interpreting the data. The
sample was made up of only male patients; the patients were only collected
from two different hospitals. Despite these limitations, results from this study
demonstrate consistency between staff and patients responses, which are
positive and increase the consistency and validity of the data that has been
obtained by demonstrating that both staff and patients are reporting similar
perceptions/observations.
One main limitation with this study is in accurately measuring bullying in such
settings. Individuals may not feel that the behaviours they report are indicative
of bullying. Moreover, the way in which individuals are pigeonholed into
bullying categories using the questionnaire given may have lead to
24
misrepresentations, such as wrongly labelling people, who have acted
aggressively in self-defence, as bullies. Furthermore, it is unknown to what
extent individuals were reporting their behaviour and experiences honestly.
Additionally, the subjective nature of individual’s perception of the titles of
bullying could have clarified with those who took part in the research. This
would have resulted in no confusion between what was meant by the term
bullying and the types of bullying that were asked about in the questionnaire.
When considering the hypothesis that patients will observe higher levels of
bullying than staff, although the data obtained suggested that this was in fact
the case the results were not significant enough to discuss these trends.
Therefore, further exploration in this area with a larger sample size would help
to provide the necessary information.
The current report highlights a number of different locations around the
hospital where bullying was reported to have taken place. The most frequently
reported were the lounge and the bedroom. Additionally, the corridor and the
courtyard were reported locations for observing bullying. The findings of this
report supports suggestions made by Ireland (2002) that bullying can occur in
a number of different locations (Ireland, 2002, Home Office, 1999).
These findings demonstrate that bullying can occur in a variety of locations.
However, due to each hospital having a different layout it should be reflected
that this is likely to impact on the frequency of bullying in specific locations.
However, with the current study this was not taken into consideration.
It is also interesting to note that those within higher levels of security are more
likely to be desensitized to violence in general as it is more likely to occur in
these hospitals (Beck, 1995). Subsequently, due to the increased exposure of
general violence they may be less inclined to report indirect bullying as much.
Due to low prevalence of the bullying types of sexual offences, sexual
horseplay and other abuse, the assumptions of parametric tests were not met
as the numbers within each of these categories was too low and so it was not
possible to explore differences of staff and patients perceptions of these types
25
of bullying through a chi squared test.
However, differences can be seen in the raw data, which may suggest that
further exploration is required to see if this relationship is found in a larger
sample. Additionally, as some of the types of bullying that were questioned
regarding observation had very low base rates and subsequently low numbers
in the results response categories were collapsed merging ‘occasionally
observed’ and ‘often observed’. As a result, it gives us less information about
the prevalence of the behaviour and instead just informs us if it occurred or
not. Therefore, in it is not clear if these behaviours are occurring on a regular
basis or not. Although this causes higher heterogeneity in this group this data
does show that the behaviours are not happening often. Also, due to having to
collapse these specific behaviours it demonstrates that these behaviours are
different to that which are occurring ‘often’.
Lastly, as the questionnaire was purpose developed it has not been
standardized. As a result the quality and validity of it has been questioned.
However, during the pilot study there was some changes made that increased
the quality of it. For example, there was no “never” category for question 5.
This was an error and so was changed when conducting the main research
study. It should also be noted the information collected could include hearsay,
so individuals may have heard about others being victims of these types of
bullying. Additionally, patient’s diagnosis needs to be taken into consideration
when analyzing individual’s responses such as those with a personality
disorder or a history of pathological lying in their diagnosis may not be truthful
in their responses.
RECOMMENDATIONS
The findings from the present study have highlighted some specific areas for
consideration for future research. Should this research be replicated it would
be beneficial to consider changing the ‘other abuse’ category so that
26
individuals can elaborate on the type of abuse that they are referring to. In the
current study this category held a significant result for staff observation but
was not able to be explored further as the participants did not explain what
they meant by ‘other abuse’. Unfortunately, this means that there is abusetaking
place in the hospitals that we are not fully aware of. By further
identifying what this type of abuse is, strategies for managing this can be
considered.
Future research could consider collecting the data over a longer period of
time, additionally; it may be useful to take into consideration the different
layouts of the hospitals when recording the frequency and extent of bullying
occurring. Moreover, establishing what ‘other abuse’ is would result in
providing a more conversant understanding of the prevalence of bullying
within psychiatric hospitals.
Additionally, it would be useful to consider using a standardized and validated
measure. As standardized assessments have been normed against a
significant number of people it may increase the validity and reliability of the
results obtained.
In summary, of the four hypotheses made for the current study three were
found to be incorrect. The results did not demonstrate that higher levels of
bullying occurred in higher security hospitals instead across low, medium and
locked rehabilitation secure hospitals the responses regarding the level of
bullying which occurred was consistent. From this information it is difficult to
distinguish if this means that the frequency of bullying is high, as individuals
did not comment on the number of incidents observed. Further research into
the number of incidents would help to establish this and would in turn help to
identify the extent of the problem.
Data pertaining to the number of fights/assaults occurring within the hospital,
incidents of self-harm, the number of incident report forms indicating bullying,
unexplained / explained physical injuries could all be used to provide a more
informed picture of bullying prevalence. Additionally, it was pleasing to note
that staff and patients reported to have observed similar levels of bullying and
27
were consistent in their responses. However, this did therefore mean that the
hypothesis that patients will observe higher levels of bullying when compared
to staff was incorrect. The only hypothesis found to be correct was that
indirect forms of aggression would be the most prevalent type of bullying. This
was consistent with previous research.
When considering these results it is important to consider current implications
to practice and future clinical practice. The results from this research need to
be reflected in the current local bullying policy, which evidences the need for a
yearly bullying audit need to be implemented. Additionally, it would be
beneficial to develop an Anti Bullying Strategy within the hospital, which
outlines actions for managing bullying more rigidly within the hospital, which
all staff would be required to be trained in.
The data and results collected and analysed from the


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