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

A descriptive analysis of the nature and extent of bullying within medium, low and locked rehabilitation forensic secure psychiatric hospital.

SUMMARY

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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

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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

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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

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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

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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

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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

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prisons which states that indirect forms of aggression and psychological/

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verbal abuse are most frequently experienced among prisoners (Ireland,

2002, Ireland & Ireland, 2003).

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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

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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

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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

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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

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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, &

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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

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demonstrated that bullying within secure residential facilities is a problem but

the research cannot be generalised as they have not been replicated (Barter,

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2004; Cawson, 2002;). Therefore, the aim of this study is to ascertain the

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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

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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

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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

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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

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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

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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

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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

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‘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

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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

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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

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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 &

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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;

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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

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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.

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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.

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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.

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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

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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.

I Locked I Indirect I 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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