Background

School bullying is a form of interpersonal violence. It is often defined as an unwelcome aggressive behavior that is repeatedly and habitually transmitted to others in the school environment.1 School bullying is the interpersonal contradiction and conflict problem in the process of the socialisation of teenagers and is endangering the physical and mental health of teenagers across the globe.2 Bullying occurs in both developing and developed countries.3–5

According to a survey conducted by the China Youth Research Centre in 2015, 6.1% of surveyed students in primary and secondary schools were regularly bullied, while 32.5% were occasionally bullied.6 In 2017, the findings of a Chinese school bullying survey showed that all victims of school bullying were subjected to varying degrees of physical or psychological harm.7,8 Previous study reported that about 40% of students in Xi’an, Shaanxi Province participated in school bullying, of which 3.3% were bullies, 21.1% were victims, and 17.6% were bullies/victims.9 A survey in seven provinces in China shows that 25% of the 3675 urban students are victims of school bullying.10 The data only covers some provinces and cities in China, but it has been shocking and thought-provoking.

Teenagers who are bullied are more likely to suffer from psychological disorders such as social phobia. School bullying increases the risk of a range of medical conditions, including anxiety and depressive symptoms, as well as other health problems, such as suicide.11 Studies have demonstrated a significant relationship between victims of school bullying and a variety of mental health problems, including somatic symptoms such as paranoia, post-traumatic stress symptoms, anxiety and depression, suicidal ideation and suicide attempts.12 Therefore, it is more necessary to actively intervene the mental health of adolescent patients with mental disorders caused by school bullying.

Research shows that active intervention can significantly restore adolescent affective disorder, such as Action for Neutralization of Bullying Program13 and EspaiJove.net.14 These interventions were designed to promote mental health knowledge, increase help-seeking, reduce the stigma associated with mental illness, and prevent mental disorders in Spanish school settings. Psychological influence is far more serious than physiological influence.15 Bullying is a major public health problem, requiring a concerted approach by parents, educators, school administrators, health care providers, policymakers, and family members.16 The treatment of mental disorders is a long process. Nursing care is very important for the treatment of mental diseases.17 The participation of patients’ families is of great significance to nursing care.18 In China, adolescent patients with mental disorders who suffer from school bullying will receive nursing care during hospitalisation if their condition is serious. However, due to the limitations of medical resources, nursing care cannot meet the treatment needs. Current media and academic circles focus on the causes of, and solutions to, violence in school bullying, little attention is paid to its long-term impact on the physical and mental health and psychological experiences of victims.19,20

This study aimed to explore the real inner experience and nursing needs of adolescent patients who suffered from school bullying, and to develop a treatment plan to restore adolescent mental health. Based on the real experiences of adolescent patients with mental disorders caused by school bullying (including mood disorders, anxiety disorders, trauma and stress related disorders, substance related disorders, mania et al), qualitative research methods were used to study the psychological experiences and nursing requirements of adolescent patients to provide a pertinent reference and guidance for the implementation of related nursing measures.

Methods

The legal guardians provided written informed consent for participation in this study, including consent to publish anonymous responses from participants. A total of 15 patients participated in this study, from July 2016 to April 2017.

Objects

All study participants were recruited from the psychiatric outpatients of the First Hospital of Jilin University. Ethics approval was obtained from the hospital’s ethics committee. Maximum difference sampling was drawn to recruit eligible informants. After screening, we selected 15 participants from 42 patients to participate in this study. The questionnaire is only used to evaluate the degree of peer aggression, self-esteem and depression of teenagers (parents do not participate). Inclusion criteria were as follows: being within the age range of 12–18, experiencing suffering from school bullying; “The Juvenile Victimisation Questionnaire (Chinese version) ≥5 points”;21 Presence of a mental disorder, including but not limited to mood disorders, anxiety disorders, trauma and stress related disorders, substance related disorders, mania, and similar; providing informed consent and expressing willingness to participate and cooperate. Exclusion criteria included the following: suffering from a severe organic disease, having a serious communication disorder, and being unable to cooperate properly.22 Sociodemographic characteristics are listed in Table 1.

Table 1 Sociodemographic Characteristics of Interviewees

Methods Sampling

Patients were screened by “The Juvenile Victimisation Questionnaire (Chinese version)”, and they could participate in this study only after meeting the inclusion criteria. The maximum difference sampling method was used to sample informants.23 By this method, the research results produced by the selected samples cover all kinds of different situations in the research phenomenon to the greatest extent. Assuming that the internal heterogeneity of the studied phenomenon is strong, if we only select a few cases for research, it is difficult to reflect the whole picture of the phenomenon. In this case, we can find out the most heterogeneous feature of the phenomenon and then use this factor as the sampling standard to screen the phenomenon. The main purpose of this is to understand what kind of homogeneous or heterogeneous performance certain characteristics have under the condition of differential distribution.

Procedures

Semi-structured interview questioning is often used in the qualitative research of adolescent mental disorders17 and used to extract themes.24 Qualitative research methods and thematic analysis method were adopted. In-depth interviews were conducted to ascertain the real psychological experiences of 15 victims of school bullying, each experiencing psychological disorders at different levels.

Before each interview, participants were told the purpose of the study. If the participants permitted an interview, we determined the appropriate time for the interview with them. The interview group is led by the subject leader of this study. The interviewer(female) was asked to visit separately, usually on the nearest weekend after this contact. The interview place was the hospital conference room, and the interview was conducted in Chinese. Children participated in the interview on their own with no parents present.

Before the interview, the interviewer will start with a relaxed topic to relieve the patient’s tension and anxiety, such as stars, sports and other topics of interest to teenagers. Semi-structured interviews were used, beginning with the open question, “Can you recall the impact of bullying on you?” The complete interview comprised the following open-ended questions: (1) What impact does school bullying have on your studies and your life? (2) How do your teachers and parents react to the bullying you have suffered? (3) What do you think caused you to be a victim of school bullying? (4) What do you think about the things you are going through? The interviewer encouraged interviewees to express their inner feelings and advised that each interview should last for 45–60 minutes, with the order of the outline being adjusted according to the particular situation.

The whole process was recorded with a recording pen, and meaningful details such as changes in participants’ facial expressions and emotions were noted. The researchers repeatedly listened to the recordings and read each of the interview notes. They recorded the whole interview with a tape recorder and converted it into text data to extract the theme. Significant statements were extracted and encoded, recurring views were assembled, and memos were written. Finally, the psychological and real inner experiences of adolescent patients affected by school bullying were summarised. When the content analysis could not induct a new category, data saturation was achieved. According to the principle of voluntariness and confidentiality in this study, the interviewer did not evaluate the interview content. Another researcher evaluated it, and coding was used to represent the participants interviewed.

The themes were based on the interview. The thematic analysis method was used for analysis. A code was assigned for each meaningful sentence and then gather similar codes in overarching sub-themes. The similar sub-themes were grouped together under a main theme reflecting its sub-themes.

Quality Control

Only one interviewer was selected in this study to avoid the bias of results caused by multiple interviewers participating in the conversation. Other authors were involved in screening patients and other work. The interviewer has experience in psychology and was trained in questioning, listening, and responding skills before the interview. All authors analyzed the data and coded. Three authors performed a preliminary analysis, with the remaining authors acting as second coders for the data. Subsequently, the initial coding was reviewed and compared. Finally, a consensus was achieved among all authors, which led to three themes.

Statistical Analysis

Statistical analyses were conducted using the program R software 1.0.136 (https://www.R-project.org/). Descriptive analyses were reported as means (standard deviations) or absolute and relative frequencies.

Results

Thirteen patients came from Jilin and the other two from the Inner Mongolia Autonomous Region. All were aged 12–18 years and had suffered from school bullying for between one month and three years. The interview data were analysed through five steps: reading, analysis, reflection, classification, and extraction. Through the interviewer’s assessment of the participants’ psychological state, three themes were extracted: helplessness, severe negative emotion, and anxiety about personal growth. Among them, 12 (80%) participants felt helpless, 13 (86.7%) participants had Severe negative emotion, and 10 (66.7%) participants felt anxiety about personal growth.

Theme 1: Helplessness

Adolescents are often threatened and afraid to report their experiences to their teachers and parents. In addition, even when they do report it, most school officials and parents pay no attention. This means these adolescents must bear the burden alone, and they eventually feel helpless.

Interviewee A:When teachers meet such things, they do not concern themselves and pretend not to know. So when someone bullies me, I don’t think it’s necessary to tell the teacher. It’s useless.

Interviewee G:My junior high school is in the village, which provides mandatory accommodation. My parents are busy earning money, and no other relatives are nearby. When someone bullies me, there is no one who can help me, so I dare not say a word.

Interviewee K:I was so unlucky. I was even beaten by the girls in my class. Actually, I felt so uncomfortable, but our teacher said they were playing with me and did not punish them. Such a teacher! I was so disappointed. [Sighs].

Interviewee H:They are always scolding me in WeChat moments for fun, regardless of my feelings. I don’t know who incited whom. It feels like everyone around me is one of those people and unbelievable. They just care about their own feelings, but not mine.

Interviewee L:I thought telling our teachers could help, but they became aggravated. I also told my parents, but they said I was too weak to handle it. Then I didn’t want to tell them anymore. I really feel desperate.

Interviewee N:I am not a sensitive person, but they did make me feel humiliated and very lonely. No one can understand me. I don’t want my youth to be wasted, but I also really don’t want to go to school. I am more reluctant to stay at home. It has nothing to do with my adolescence. I am really not so rebellious or so sensitive. I just feel worn out. [Casually scratches head, with irritable expression].

Theme 2:Severe Negative Emotions

After experiencing bullying, interviewees displayed varying degrees of negative psychological conditions.

Frustration and Distrust

Interviewee B:I don’t know whom I had offended; they do this to me. I always feel upset every day, and some people are against me. You let me believe there are kind people around, but honestly, I do not know who is reliable.

Interviewee F:I was beaten during break time by my dear classmates who studied and lived together with me for a long time. All the other students pretended to be blind. No one cares about me. After that, when I get along with my classmates, I will be very contradictory. I am eager to integrate with them, but I feel I cannot trust them. My mood swings alarmingly; I can hardly get rid of it. [Frowns].

Rebellion

Interviewee C:I think they are just jealous of my high academic achievements. If I tell the teacher, and my teacher handles it, they will think the teacher was biased. To tell parents is also useless. They cannot deal with the contradictions related to my school life. Violence must be met by violence. Only fighting back can solve the situation; where there is oppression, there is resistance!

Interviewee E:Actually, I am just timid. I am afraid to tell adults, who cannot help, while I will be revenged after that. I have a bad temper at home. I lose my temper with my father because of the trivial things of life. I may be resentful because my family can t protect me. Besides, I have to give vent to it. Otherwise, I would be mad’.

Insecurity and Depression

Interviewee M:Because of my introverted personality, I am shy and reluctant to communicate with other students or teachers. Maybe because of that, I have become the object of bullying by my friend or classmate. In fact, I have always felt unsafe, not slept well, and felt blue all day. I feel life is really boring.

Interviewee O:I am afraid to remember those days. Once I think of them, my heartbeat speeds up. Unknown tension and fear made me feel like I fell into a big hole and could not get out of it. The whole world is colourless. I don t know how to describe it; I really do not know if you can understand at all. Anyway, I feel particularly uncomfortable [Repeatedly touches precordial area]’.

Theme 3: Anxiety About Personal Growth

The majority of interviewees said they had difficulty getting over the negative effects of school bullying and feared that bullying could affect their future studies and life.

Interviewee D:I thought these things had passed, but it always makes me feel quite alarmed, and I don’t like others taking the initiative to deal with it. Although I am also afraid of loneliness and poor interpersonal relationships, I really cannot control myself. I think the important key is that I cannot find a good way to solve it’.

Interviewee H:Although I use the same way as they fight back, I am no longer bullied by them. But I also become irritable, and I’m willing to deal with it in a very extreme way. I always feel that I have become someone like them. I often tell myself I did not do it intentionally, but I do not like my personality. I do not want to become an unwelcome person in the future’.

Interviewee I:I often suffer from insomnia now. I can’t afford to work all day, and my grades are going down. I am not interested in anything, and I do not feel alive. I am worried about my future life. I am afraid that I cannot live in this world.

Interviewee J:I don’t want to go to school or think about the future.

Discussion

The interview results showed that most patients felt helpless, suffered a negative psychological state and felt anxious about self-growth. Therefore, according to the interview results, we formulated specific measures to help patients recover their mental health.

Rational Use of Empathic Skills to Support and Comfort Patients

From the interview results, it is evident that most victims of school bullying experience a degree of helplessness, and their inner experiences are complex and closed. One of the main contributing factors is that when conflict happens, victims are unable to receive timely advice from their parents and teachers.25 Meanwhile, bystander of school bullying experienced cognitive dissonance, even though they believed the bullying was wrong, their intentions did not translate into action by standing up for the victim or reporting the teacher or parent because they were afraid of becoming the next victim.26 The adolescents’ negative emotions became more serious because of various forms of incorrect treatment from teachers and parents: responding indifferently, making concessions to avoid trouble, providing insincere verbal comfort, or having the opinion that violence should be met with violence.15 Therefore, to promote positive outcomes for patients, nursing staff should ensure patients are comfortable and fundamentally supported, guided to express their feelings to doctors and nurses, and taught to record their emotions in a diary, noting any abnormal emotions or feelings. A diary is not only for the medical staff to refer to but also to allow patients to vent their anger, providing the basis for the treatment of the disease.27 At the same time, when patients are emotionally unstable, upset, or anxious, nursing staff can teach patients deep breathing, meditation, and other relaxation techniques. Additional means, such as chess competitions and other entertainment, may also be used to divert attention and improve mood. Patients should be taught appropriate measures to improve their own ability to cope with stress in the face of unpleasant events.28

Carry Out Psychological Counselling Using the “Focusing on Patients and Families” Model

The interviews showed that victims of bullying experienced negative psychological conditions to different degrees. Long term bullying made patients feel humiliated and nervous, resulting in negative emotions. Such conditions include insomnia, irritability, depression, bipolar disorder, autism, personality disorder, and post-traumatic stress disorder. These kinds of conditions repeatedly appear with environmental stimulation.21 Research shows that psychological treatment is the main treatment method for psychogenic diseases in childhood, but it cannot solve the problem of recurrence by removing the cause. Therefore, family-centred therapy can be significant. According to the modern holistic concept of “focusing on patients and families”, nursing staff should make an all-around evaluation and apply nursing procedures beginning when the patients are admitted to the hospital. First, good relationships, based on trust, should be established between nurses and patients, where nurses accept and affirm patients’ discomfort and illness. Second, the focus should be on families. The existing and potential health problems of patients and their families should be individually assessed and diagnosed. Based on the complete assessment, psychological counselling should be offered to address any incorrect behaviour, child-rearing patterns, and understanding of the disease. At the same time, a good educational environment is useful in promoting positive mental health and personal growth in adolescents. Parents can ask teachers for assistance in the following measures: to reduce the student’s academic burden, provide them with guidance and support, and give students a sense of belonging and the opportunity to integrate into the collective life of the school. Finally, follow-up visits should be strengthened. When the patient is discharged, they should be given union cards, allowing free hospital contact for them and their parents. Follow-up phone calls offering individual guidance should be made after one month, three months, six months and one year. Family visits and on-site counselling should be given if necessary.29 In this study, we took the following interventions to help patients recover.

1. Psychological education intervention: positive reinforcement was given to patients’ positive behaviour so that patients can treat irritability and social withdrawal in the best way.

2. Cognitive behaviour intervention: teaching patients to improve their behaviour, including self-monitoring, self-speech guidance, problem-solving strategies, self-assessment and self-strengthening.

3. Interpersonal psychological intervention: finding and correcting the patients’ unreasonable ideas about life, society, family and interpersonal relationships.

4. Decompression intervention: in the process of intervention, encourage parents to participate in meditation together, provide meditation learning videos for patients and parents to learn, make brochures to help patients with decompression exercises and emotional relief exercises, organise salons, and let patients and parents conduct psychological counselling in the form of groups.

Promote Health Education and Understanding of Mental Illness Within the Wider Population and Encourage Self-Growth in Patients

From the results of the interviews, it is apparent that the effects of school bullying on adolescents are long-lasting, and a person’s long-term self-development is limited, to a differing degree. Bullying made patients’ psychological status worse and their academic performance lower, which leads to their anxiety about self-growth. They were clearly aware that their academic performance was getting worse and worse, and they were very worried about that. Additionally, studies have shown that patients’ symptoms are often kept secret and mixed with rebellion30 and that the uptake of treatment is low because of shame and poor self-esteem. Therefore, school bullying, and the psychological problems caused by it, should be scientifically identified, discovered early and effectively prevented.31 Nursing staff should take a positive role in promotion and rehabilitation, carry out various forms of education, encourage the wider society to understand and support this kind of patient and create a good and relaxed environment for young students’ growth. The following measures are suggested: ① Based on the psychosomatic clinic, hold psychosomatic disease lectures, popularise disease-related knowledge, and encourage parents to identify mental disorders and seek psychological guidance early; ② Promote deeper awareness in schools by holding mental health lectures from the perspectives of cognitive psychology and rational emotive therapy, guide students in how to live in peace and teachers in how to communicate well with students and perform psychological testing and psychological counselling;32 ③ Rely on the community and teach teenagers living at home about mental health issues. Establish a good system of intervention by associating with students’ parents and other family members, mobilising family members to participate, and correct misinformation;33 ④ Make full use of new multimedia methods to promote knowledge and to provide remote psychological counselling.

This study has some limitations: First, the sample size of this study is small, which may cause bias in the results. Second, the patient’s subjective feelings may weaken the objectivity of the score. More studies can also focus on gender differences and psychological status differences among bullying victims, as well as the types of school bullying and its impact on psychological status at different ages.

Summary

In this study, we found the most common significant inner experiences of adolescent patients with mental disorders caused by school bullying were helplessness, severe negative emotion, and anxiety about personal growth, and we found some effective intervention measures. This has important guiding significance for the rehabilitation of adolescent patients with mental disorders caused by school bullying. Based on fully understanding the psychological experiences of adolescent patients with mental disorders caused by school bullying, nursing staff should take targeted measures, strengthening cooperation and communication with family, school and social circles to create an adequate environment for the healthy development of adolescents.

Ethics Approval and Consent to Participate

This study was conducted in accordance with the Declaration of Helsinki and approved by the ethics committee of The First Hospital of Jilin University.

The legal guardians provided written informed consent for participation in this study, including consent to publish anonymous responses from participants.

Disclosure

The authors report no conflicts of interest in this work.

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