Validation of an Instrument on Bullying in Older Adults

Introduction

In Spain, the population over 65 years of age at the beginning of 2022 is 19.97% of the total population (9,479,010 inhabitants) and octogenarians represent 6% of them, with women outnumbering men by 30.5%. Spain, with 9.5%, is the fourth country in the European Union with the highest number of people over 65 years of age, as indicated in the report by Pérez-Díaz et al. (2023).

The increase in life expectancy together with the fact that births have decreased has caused an aging of the population which represents a great social challenge (Office Of Science and Technology of the Congress of Deputies [Office C, 2023]). Improvements in various policies have meant that health, social, and economic conditions have translated into better lifestyles and, therefore, greater survival in old age (HelpAge International Spain Foundation, 2023). Women (85.83 years) have a longer life expectancy than men (80.27 years). Despite the health status by COVID-19, life expectancy has been increasing during the 20th century following that trend (Pérez Díaz et al., 2023). Regarding health status, it is worth mentioning that it is usually affected by socioeconomic and/or residential reasons. Thus, 50.7% of the elderly aged 65 and over perceive themselves to be in a good state of health, being higher in men (56.9%) than in women (45.8%). However, it should be noted that this perception becomes more negative as age increases (Pérez Díaz et al., 2023). Similarly, the increase in age is usually associated with an increase in limitations, both in men and women. It is usually due mainly to health conditions and to the increased probability of having a disability after the age of 60 (Pérez Díaz et al., 2023).

The green book on aging highlights the importance of promoting active and healthy aging throughout life, which requires attention to personal responsibility and the environment in which the individual lives. This has led to an increase in the demand and need for senior centers (European Commission, 2021). Institutionalized centers offer the elderly the necessary care according to their needs or disabilities in addition to alleviating feelings of unwanted loneliness (European Commission, 2021). In Spain there are 4.2 residential care places for every 100 elderly people aged 65 and over (Pérez Díaz et al., 2023).

In such environments it is essential to attend to the quality of life and well-being of the elderly person (Possenti et al., 2021; Rodríguez-Martínez et al., 2023). These are places of stay and coexistence in which a series of basic care and comprehensive care is offered to the person such as accommodation, assistance in activities of daily living, and social-health care (Huesa Andrade et al., 2020). For this reason, institutionalized centers are places that many older people consider as home (Caypa Altare & Redondo Cano, 2020). This means, therefore, that the elderly person carries out a process of adaptation to said environment. Admission to an institutionalized center can be a stressful event for the person and the loss of identity, that is, independence and control over oneself, which can cause negative emotions and can generate relational problems with other peers (Bonifas, 2016). Adapting to an institutionalized center involves new schedules, rules and routines, and even sharing services and spaces, which is why conflicts may appear in such environments as people with different opinions, beliefs, ideologies, origins, and cultural levels coexist (Brearley, 2023), among other characteristics, which can end up deteriorating the climate of the center, harming the quality of life and well-being of the person (Bonifas, 2014; Leboeuf et al., 2022). If such conflicts occur over a prolonged period of time, having consequences for the elderly who experience it, it will be alluding to bullying or harassment among the elderly (Leboeuf et al., 2022). Bullying is composed of repeated and intentional aggressive behaviors of a person or a group of people against another person who is not able to defend himself/herself and therefore there is an imbalance of power (Thornberg et al., 2020). It is repeated harassment over time that produces clear consequences in the interaction and exchange of resources in addition to impairing the quality of life of these people (Bonifas, 2016).

About 20% of older people have experienced bullying in nursing homes (Bonifas, 2016). Goodridge et al. (2017) also evidenced that 39% of people sharing a residence had had conflicts with other residents. This is therefore a global phenomenon affecting 1 in 6 older people (Hancock & Pillemer, 2022). However, hardly any studies have been carried out on bullying in older people (Hancock & Pillemer, 2022; von Humboldt et al., 2020).

The review carried out by Ruiz-Esteban et al. (2023) showed that this phenomenon has been studied mainly in childhood and adolescence. However, as in other developmental stages, bullying among older people usually manifests itself in several ways: a) verbal violence in a direct way through insults, nicknames, among others towards the victimized person or indirectly through actions, such as spreading pejorative rumors or slander with the aim of being ignored and limiting the person’s connections socially; b) simple physical violence of direct or indirect type, by means of weapons or objects; c) material violence in which a victim’s objects are damaged, broken, or stolen (Beaulieu et al., 2016; Bonifas & Frankel, 2012; Goodridge et al., 2017); and d) cyber-type violence that is carried out through technologies such as internet, cell phone, etc. (Bonifas, 2016; Jeffries et al., 2018). It should be noted that cyber-type violence is not unrelated to traditional violence, i.e., both types occur successively or simultaneously, since violence in real life (offline) is not detached from technologies (online) (Olweus & Limber, 2018).

Studies on older people have shown that it is mostly indirect verbal bullying with the aim of excluding the older person from social relationships in the center (Andresen & Buchanan 2017; Bonifas, 2016; National Center for Assisted Living [NCAL, 2023]; Görgen et al., 2020; VandeNest, 2016). Therefore, they are usually aggressions in their vast majority without physical contact (Andresen & Buchanan 2017; Görgen et al., 2020; VandeNest, 2016) that end up afflicting the involved person’s peer network, group coexistence, and personal adjustment (Leboeuf et al., 2022).

The various manifestations of bullying in older people are associated with psychological violence, as they involve a significant decline in mental health, causing a decrease in self-esteem, feelings of dependence and lack of autonomy, eating problems, sleep problems, depressive symptoms, anxiety, wanting to leave the school (Beaulieu et al., 2016; Bonifas & Frankel, 2012; Dong et al., 2017), chronic stress (Goodridge et al., 2017), insecurity and helplessness (Bonifas, 2016; Bonifas & Frankel, 2012; VandeNest, 2016), and even suicidal thoughts or completed suicide (Dong et al., 2017; Makara-Studzińska 2021). Sometimes, bullying often goes unnoticed by the staff of the institutionalized facility (VandeNest, 2016) which, coupled with the fact that older people do not know how or whom to ask for help (Sepe, 2015) or do not have the resources (von Humboldt et al., 2022), causes the chronification of such problems and their effects (Strandmark et al., 2019) affecting the longevity and general well-being of older people (Botngård et al., 2020). At a physical level, the authors who have inquired into the consequences of bullying in older people report a greater impact on physical health, an increase in physical pathologies (Bonifas 2016; National Center for Assisted Living, 2023; VandeNest, 2016), changes or alterations in eating and sleeping patterns, greater difficulty carrying out basic activities of daily living, greater tendency to isolation, avoidance of common places, and feelings of loneliness.

The roles of people directly involved in bullying situations among older people are: aggressor, victim, and observer. These roles influence the bullying problem, both in its configuration and in its consolidation (Bonifas, 2016). A victim’s profile is usually characterized as an older person with difficulties in social relationships (Bonifas & Frankel 2012; Makara-Studzińska, 2021), low self-esteem (Bonifas & Frankel 2012), high anxiety, and sadness (Bonifas & Frankel 2012), low perceived social support (Bonifas & Frankel 2012; Makara-Studzińska, 2021), possessing any neurodegenerative disease or disability (Andresen & Buchanan, 2017), and even having low financial resources (von Humboldt et al., 2022) or being vulnerable (Bonifas, 2016). The aggressor profile is characterized by being in a situation of physical or social superiority with respect to the peer group, having a dominant hierarchical position of asymmetric type imposing his will; he usually shows aggressive and violent behaviors that end up damaging coexistence (Bonifas & Frankel, 2012; Botngård et al., 2020), usually in small groups or with whom he has frequent contacts (Wiegand, 2019). Such actions are usually carried out through covert aggressions, so the aggressor usually goes unpunished in the face of such actions (Bonifas & Frankel, 2012).

Despite the seriousness of the problem of bullying in institutionalized elderly people, hardly any instruments have been found to assess bullying in this population (Ruiz-Esteban et al., 2023). Among the existing ones, instruments based on the perspective of the professional of the institutionalized elderly centers stand out (Andresen & Buchanan, 2017; Botngård et al., 2020; Görgen et al., 2020; Sepe, 2015) as opposed to instruments based directly on the perspective of the elderly person (Bonifas, 2014; Trompetter et al., 2011). The review carried out by Ruiz Esteban et al. (2023) revealed the need to validate questionnaires to obtain information on bullying in the elderly. In Spain, no validated instrument adapted to this population has been found. Therefore, the aim of the study is to validate a questionnaire to measure bullying situations among the elderly.

Method

Participants

The study included 475 elderly persons aged between 58 and 95 years belonging to institutionalized centers in a region of southeastern Spain (M = 68.48, SD = 7.11), of whom 66.9% were women. Of them, 3.8% were born outside Spain. With respect to marital status, 53.1% were married or in a domestic partnership, 18.5% were widowed, 16.4% were separated or divorced, and 12% were single. With respect to educational level, 52.6% had university studies, 34.1% had secondary studies, 6.3% had primary studies, and 6.9% had no studies at all (see Table 1). The inclusion criteria were established as follows: belonging to an institutionalized center for the elderly (criterion 1), without cognitive impairment so that they could correctly complete the questionnaires (criterion 2), and have spent at least one month residing in the center (criterion 3).

Instruments

First, a sociodemographic questionnaire was used to collect information on gender (male/female), age, origin (born in Spain/born outside Spain), marital status (married or with a partner, separated or divorced, widowed or single), and level of education (no education, primary education, intermediate education and higher education). Next, the harassment questionnaire designed in this study was applied, consisting of 22 Likert-type items with 5 categories (0 = never, 1 = every two or three months, 2 = several times a month, 3 = several times a week, and 4 = several times a day).

Procedure

The Bullying Questionnaire of Bonifas (2016) was used as a starting point. This instrument is based on questions developed by Trompetter et al. (2011) and on questions developed by Bonifas (2014). For our study, a Spanish translation of the instrument was first carried out by the members of the research team and then reviewed by a native English speaker. Similarly, it should be noted that it was necessary to adapt it to Spanish for cultural reasons (regarding some examples presented in the questions). This process was completed with a pilot test on a sample of characteristics homologous to the population under study. This validation process involved the elimination and/or modification in the wording of some items.

We then contacted the management teams of the centers for the elderly in the autonomous community of the Region of Murcia to request authorization to carry out the study. For the application, informed consent was requested from the elderly who voluntarily participated in the study, assuring that the data would be handled anonymously and confidentially. The administration of the instruments took 15-20 minutes, which could vary depending on the characteristics of the person interviewed. The study was approved by the Ethics Committee of the University of Murcia (ID: 2443/2019). The research followed an instrumental design.

Data Analysis

Descriptive statistics were calculated for the socio-demographic variables and for the total score and dimensions of the bullying questionnaire. In addition, the normality of the distributions was tested with the Shapiro-Wilk statistic. If the distributions did not follow a normal law, nonparametric tests were applied to study the significance of the results (Mann-Whitney’s U to compare two groups or Kruskal-Wallis H for more than two groups). If the result of the nonparametric ANOVA was significant, two-by-two comparisons were performed with the Dwas-Steel-Critchlow-Fligner (W) statistic. Correlation between the study variables was determined with Spearman’s rank correlation. The level of significance chosen was α = .05.

The structural validity of the bullying questionnaire was obtained with an exploratory factor analysis (EFA) using the weighted least squares method. The Pearson correlation matrix was used, since the polychoric correlation matrix did not achieve convergence. The factors were obtained using the parallel analysis method. The rotation method used was Promax, and an item was considered to load significantly on a factor if the factor loading was equal to or greater than .35. No factor could have less than three significant loadings. The internal consistency of the questionnaire dimensions and the total score was calculated with Cronbach’s alpha coefficient and McDonald’s omega coefficient (McDonald, 1999). Statistical analyses were performed with SPSS 28.0, Jamovi (v. 2.4.8) (The JAMOVI Project, 2023), and JASP (v.0.18.0.0) (JASP Team, 2023).

Results

Factor Structure

The factor structure and factor loadings of the bullying scale are presented in Table 2. The first factor, consisting of items 1, 3, 4, 5, 10, and 14, can be referred to as victim (social exclusion). The second factor, consisting of items 11, 12, 16, and 17, refers to victim-aggressor behaviors. The third factor would be formed by items 2, 8, and 13, and refers to victim behaviors (verbal violence and aggression with weapons). Finally, the fourth factor, consisting of items 18, 19, 20, and 22, refers to aggressor behaviors. Items 6, 7, 9, 15, and 21 did not obtain sufficient factor loadings, so they were removed from the harassment questionnaire.

Table 3 presents correlations between the factors of the measurement instrument after factor analysis. The highest correlations were between factors 1 and 3 (r = .353) and factors 3 and 4 (r = .404).

Internal Consistency

Table 4 presents the internal consistency coefficients for the four dimensions and the total score. Internal consistency was relatively high for factor 1 and the total score. The lowest internal consistency was found in factor 3.

Descriptive Statistics of Dimensions and Floor and Ceiling Effect

Table 5 presents the descriptive statistics for the dimensions and total score of the bullying scale. The distributions of the dimensions and total score were highly skewed and pointed and did not follow a normal law. The means (and medians) were relatively low given that most of the scores were clustered around 0 (no bullying), as seen in the floor effect which ranged from 29.1% of factor 4 to 95.2% obtained in factor 2. The ceiling effect, however, was very low in all cases (0.2%).

Discussion

The study led to the identification of four factors in the bullying scale: the first factor deals with the forms of manifestations of bullying in the victim, especially of a relational type (social exclusion); the second factor refers to actions in which the person who is being harassed also exerts intimidation towards other peers, which is why they identify with the behaviors of the victim-aggressor profile; a third factor is characterized by the presence of verbal intimidation and indirect physical harassment behaviors through the use of objects such as a cane or a walker (verbal violence and aggression using weapons); and a fourth factor focusses on the aggressor’s behaviors characterized by the presence of behaviors in the form of both direct and indirect verbal aggression as well as indirect physical aggression.

The correlation matrix showed higher correlations between factors 1 and 3, i.e., being victimized through social exclusion is related to being victimized through other manifestations such as verbal violence and aggression through weapons. Likewise, the manifestations of victimization through verbal violence and aggression with weapons are related to aggressive behaviors.

Regarding internal consistency, it should be noted that it was relatively high for factor 1 and the total scale score. However, the lowest consistency is found in factor 3; this may be because it is a less frequent manifestation of bullying.

Regarding the descriptive statistics for the dimensions and the total score of the bullying scale, it should be noted that the distributions of the dimensions and the total score were highly skewed and pointed and did not follow a normal law. In general, the data found in the centers analyzed indicate the existence of low levels of bullying. This would be in line with previous studies that highlight that aggressions between older people tend to be mostly without physical contact (Andresen & Buchanan 2017; VandeNest, 2016), being mostly manifestations of indirect verbal type with the aim that the older person is excluded from social relationships in the center (Görgen et al., 2020; National Center for Assisted Living, 2023).

The study has made it clear that bullying among the elderly exists and that it needs not only to be evaluated, but also that it is necessary to implement measures for prevention and effective intervention. Thus, the present study allows to advance in the analysis of interpersonal relationships of the elderly through a brief and reliable scale.

The harassment actions carried out by the aggressor or aggressors are unethical, so they are not only illegal, but should not be allowed. Therefore, prevention is essential from the institutional entity itself with preventive actions and the implementation of action protocols. Addressing harassment from the organizational level (Görgen et al., 2020; Hancock & Pillemer, 2022) is based, above all, on preventing these behaviors from appearing in coexistence environments, which will undoubtedly result in long-term medical costs (HelpAge International Spain Foundation, 2023). It is about creating careful communities where both users and staff take responsibility for their actions and are willing to establish a climate of respect and equality, being able to establish limits, as well as defend and report any negative or problematic behavior towards others. Likewise, it is necessary to promote policies that articulate the effective management of conflicts through mediation and the peaceful resolution of conflicts (Andresen & Buchanan, 2017), which will allow early detection of situations of risk to suicidal behavior (Makara-Studzińska, 2021). Similarly, the lack of staff preparedness to detect such bullying situations among elders is still apparent (NCAL, 2023; VandeNest, 2016). In this sense, it is necessary not only to provide awareness but also training to prevent and intervene in such situations (Andresen & Buchanan, 2017; Bonifas, 2016; Wiegand, 2019).

Intervention efforts must include all those involved, with the involvement of staff members being necessary (Andresen & Buchanan, 2017; Bonifas, 2016; Ruiz- Esteban et al., 2023). It is necessary to promote social interactions in senior centers and, therefore, coexistence (Bonifas, 2014). Undoubtedly, it is essential to promote primary prevention by acting through awareness-raising in society, such as advertising campaigns, training, conferences, lectures, round tables, etc., in order to mitigate these effects at an early stage (Wiegand, 2019), at a secondary level through strategies such as mediation, training in coping strategies and resilience, training in social skills, prosocial thinking, etc., and at a tertiary level it is necessary to implement restorative and palliative measures, etc. (Ruiz- Esteban et al., 2023). On the other hand, it is necessary to provide older people with resources to be able to defend themselves from the bullying situation, since sometimes they do not know how to find a solution and are unprotected against this problem (Sepe, 2015; von Humboldt et al., 2022), which causes the problem to accentuate and become chronic (Strandmark et al., 2019). In fact, psychological and/or psychiatric intervention would result in the improvement of the symptomatology in the mental health of the elderly directly involved (Makara-Studzińska, 2021). It is a matter of offering tools through psychoeducation that would allow adequate management of interpersonal conflicts and improvement of coexistence (Bonifas, 2016; Ruiz-Esteban et al., 2023), so that they can successfully cope with conflicts in interpersonal relationships (Andresen & Buchanan, 2017), which is why training in social skills takes on special relevance (Bonifas, 2016). Similarly, social support is key to cope with bullying situations. It is therefore essential to promote positive social support, which will cushion the negative impact of bullying in older people (Leboeuf et al., 2022).

Among the limitations of the study, it is worth mentioning that it was carried out in a region of the country. Likewise, it should be noted that no other validated instrument was available to estimate convergent validity. In addition to the existing limitations of using self-report, responses may be influenced by social desirability and feelings of fear, among others.

Among prospective studies, it would be of interest to delve into the study of bullying in the elderly by attending senior centers in which the incidence of the problem is is so high that the psychometric study of the scale can be improved. This would allow the study to be expanded to other autonomous communities to be able to carry out comparative studies. Similarly, longitudinal studies can delve into the profile of the people directly involved in bullying situations among the elderly. This would allow a more exhaustive and long-term monitoring of the consequences of bullying in the elderly, as well as greater knowledge to establish effective prevention and intervention strategies.

On the other hand, it would be interesting to study the influence of other factors, such as socioeconomic status, religion, health pathologies, or chronic diseases, and the use of technical supports for mobility, vision, or hearing. It would also be interesting to analyze the areas of the centers where more incidents of harassment occur and the time of day in which they are most common and the influence of the process of adaptation to the dynamics of the center on harassment among older people.

Highlights

Despite the seriousness of the problem of bullying in institutionalized elderly people, hardly any instruments have been found to assess bullying in this population (Ruiz-Esteban et al., 2023). Among the existing ones, instruments based on the perspective of the professional of the institutionalized elderly centers stand out (Andresen & Buchanan, 2017; Sepe, 2015), as opposed to instruments based directly on the perspective of the elderly person (Bonifas, 2014; Trompetter et al., 2011). Therefore, the aim of the study is to validate a questionnaire to measure bullying situations among the elderly. The instrument will allow to advance in the detection of bullying problems among elderly people.