Sexual harassment within the workplace can be defined as unwanted sexual attention, which includes physical or verbal advances or assault; sexual coercion, which provides for sexual favors in exchange for rewards, advancement, job security, or grades; and gender harassment, which includes behavior that is hostile, objectifying, excluding, or otherwise demeaning to one gender. This harassment may be overt or implicit (Fairchild, Holyfield, & Byington, 2018). It may also be categorized as physical or nonphysical, and nonphysical may be further divided into instances of verbal or nonverbal harassment. Examples of physical harassment may include groping, attempted kissing, unwanted physical contact, and assault. Verbal harassment encompasses incidents of degrading or sexualized speech, obscene language, sexual jokes/stories, sexual innuendos, sexual offers, or unwanted sexual invitations. Types of nonverbal harassment include advantages for sexual favors; sexual communication in the form of letters, emails, texts, or pictures; as well as whistling, staring, or obscene gestures (Jenner, Djermester, Prugl, Kurmeyer, & Oertelt-Prigione, 2019). According to the American Nurses Association (ANA, 2019), the first step in preventing sexual harassment and other forms of workplace violence (WPV) is to establish a standard and universal definition. Only when it is clear to all of those involved what is acceptable workplace behavior and language and what is not, can we as a culture then move towards a zero-tolerance policy of enforcing that standard. The ANA sent a formal request to the Occupational Safety and Health Administration (OSHA) in 2017 to establish a universal standard for WPV prevention, which includes sexual harassment, but this has not yet been done (ANA, 2019).
Despite historical disagreements regarding the definition, the effects of sexual harassment have been well-documented. Sexual harassment decreases the “productivity, recognition, funding, advancement, earnings, retention, and continuation of women” in the workplace (Fairchild et al., 2018, p. 1). It is associated with adverse physical effects as well, worse for minorities and especially sexual minorities (Fairchild et al., 2018). A study involving more than 300 women found twice the rate of hypertension and sleep disturbance amongst women who reported a history of sexual harassment. Amongst those who reported a history of assault, there was three times the rate of depression and twice the rate of anxiety and poor sleep. The study authors proposed that this might be related to the disrupted balance between the sympathetic and parasympathetic portions of the autonomic nervous system caused by chronic stress (Thurston, Chang, Matthews, von Kanel & Koenen, 2019). WPV, including sexual harassment, can adversely affect the quality of patient care and outcomes as well as job satisfaction and organizational commitment amongst nurses (ANA, 2019).
A 2018 report by the National Academies of Sciences, Engineering, and Medicine (NASEM) on sexual harassment of women in science/engineering/medicine found that the culture or climate within an organization was the most predictive factor for sexual harassment occurrence (Fairchild et al., 2018). The actual prevalence of WPV, and specifically sexual harassment, is difficult to quantify with certainty. This is primarily due to low reporting rates for such events, which is as low as 20-60%, according to the ANA (2019). A 2019 survey of 304 women aged 40-60 found that only 19% reported a history of sexual harassment, and 22% a history of sexual assault (Thurston et al., 2019). A German study of 737 physicians in 2015 found that 70% of all participants, male and female, reported sexual misconduct in the workplace (76% of women surveyed and 62% of men). Of women who reported misconduct, 83% reported nonphysical harassment, and 37% described the perpetrators as their superiors. The perpetrators were male in 85% of the cases where women were not physically harassed and in 95% of the cases where women were physically harassed. Department and divisional hierarchy systems were associated with increased reports of harassment (Jenner et al., 2019).
According to a 2014 literature review, 28% of nurses worldwide report being sexually harassed at work at some point during their careers, but this percentage varies by region. The Anglo region, which includes the US, Canada, England, and Australia, was found to have a rate of 39%. The authors felt this was likely due to decreased cultural acceptance for sexual language or behavior in public in Asia and the Middle East, as well as reduced rates of reporting such incidents in these regions secondary to public shame (Nelson, 2018).
The NASEM report from 2018 outlines basic recommendations to prevent sexual harassment and gender discrimination. The report was based on their findings that harassment is more common in environments that ignore or support it, and less likely when consequences are apparent and forceful. These include suggestions for organizations to move beyond legal compliance to create a culture of diversity, respect, and inclusion; improve accountability and transparency; defuse hierarchical systems; address gender harassment; support the victim/survivor; encourage leadership that is strong and diverse; assess program effectiveness and progress regularly; conduct research; and reward change. From the government, NASEM recommends confronting the lack of meaningful enforcement of Title VII's sex discrimination prohibition, initiating legislative action to correct course, and collaborating the responses from federal agencies. NASEM recommends that professional organizations, like the ANA and others, become involved. They stress that responsibility for sexual harassment prevention lies with all those involved (Fairchild et al., 2018).
According to the ANA, only nine states within the US currently have standardized processes and regulatory requirements for the reporting of WPV. Therefore, it is incumbent upon healthcare organizations and healthcare workers to be the drivers of change. Their campaign, #EndNurseAbuse, outlines four core components of change: support, educate, action, and share. Support highlights the importance of developing, improving, and supporting policies of zero-tolerance for WPV. They suggest formulating and initiating safety protocols to prevent violence and training the staff and providers (ANA, n.d.). Primary prevention techniques designed to avoid WPV include educating healthcare workers on the definition of harassment as well as other strategies to identify risks for WPV. Other techniques include increasing buffers, reducing vulnerabilities, and improving relationships amongst coworkers and colleagues to develop a robust team approach in the delivery of healthcare. The ANA encourages nurses to participate in WPV prevention programs at their organization and educate themselves and their coworkers about their institution’s policies and procedures regarding WPV and sexual harassment. For nursing schools and nurse educators, this includes preparing student nurses to identify and manage WPV correctly (ANA, 2019). To prevent acts of WPV, the ANA recommend that nurses:
- Be observant and aware of surroundings, watchful for warning signs;
- Whenever possible, use de-escalation techniques;
- When the nurse suspects potential for WPV, they should call for help;
- Nurses should use barriers to protect themselves from violence when able, and self-defense when appropriate;
- Finally, nurses should report every incident as soon as they are in a safe position to do so, as only through reporting and assessment will the full scale of the issue of WPV become clear and evident (ANA, n.d.).
The two remaining directives from the ANA are action and share. Action encourages nurses to contact their legislators and sign the ANA pledge against WPV. The share directive refers to nurses publicly speaking about their knowledge and work against WPV with their fellow nurses and their communities at large (ANA, n.d.).
Secondary prevention limits the immediate impact of WPV. For organizations, this may include data collection and assessment for quality improvement purposes; assessment of program strengths, weaknesses, and need for revisions/changes; and the full investigation and subsequent interprofessional review of each reported case or episode. For nurses, they suggest participating in comprehensive WPV programs, using crisis intervention and management strategies to handle escalating situations, and the consistent reporting of any incidents or program concerns (ANA, 2019).
Tertiary prevention techniques aim to limit the long-term effects of WPV. For organizations, this may include evaluation and constant improvement of their programs, scheduling provisions to allow nurses to leave work after an incident, support systems in place to facilitate return to work after an incident, and conducting a root cause analysis after an incident to help inform future policy. Tertiary prevention for nurses may include participation in program evaluations and post-incident meetings or debriefings, use of counseling services if needed, and the show of support to coworkers involved in an incident (ANA, 2019).
On a systems level, the ANA (2019) advocates for the development and consistent use of an electronic database for the anonymous reporting, tracking, and assessment of WPV to improve access to data and research for the future.
Reporting and Follow-up
Harassment victims may choose not to report the incident due to feelings of shame, a belief that their report will not change or improve the situation, or fear of retaliation or job loss. Union nurses, who have stronger legal support and representation within hospital leadership, report feeling more secure reporting incidents of sexual harassment due to reduced fear. The rate of sexual harassment seen in the medical field is considered a direct result of the hierarchy of administration, management, and physicians in hospital settings, which conveys with it an inherent structure of power and domination (Nelson, 2018). In addition to the reasons cited above, the ANA cites additional reasons that a nurse may not report sexual harassment when it occurs, such as:
- WPV is considered just part of the job within healthcare, and violence is routine;
- Uncertainty regarding whether or not the incident qualifies as WPV;
- Fear of being blamed or accused of poor performance; fear of reporting a supervisor;
- A lack of training, knowledge, or familiarity with the systems in place to report incidents and management techniques;
- A perception that the incident was not serious enough to warrant reporting;
- A confusion between intentional and unintentional incidents (i.e., when caring for cognitively impaired patients);
- Nonexistent or suboptimal support from administration/management or direct supervisor (ANA, 2019).
The ANA encourages institutions and organizations to take responsibility by promoting a working culture of transparency, safety, and support to encourage victims to report incidents (ANA, 2019). The acronym STOP WPV is used to help nurses who have experienced workplace violence know what and how to report the incident accurately and is outlined below:
Situation- describe the event entirely with as much detail as possible.
Type- specify the type of incident (threat, harassment, assault).
Observers- list any witnesses of the incident.
People- list all people involved in the incident.
Where and when- specific details about the incident.
Preceding factors- context or prior events.
Verify-document any injuries sustained, emotional or physical (ANA, n.d.).
Regarding follow-up after an incident, the ANA recommends that the nurse who has been harassed should be given access to emotional support and referred to employee health and/or worker’s compensation services if appropriate. Nurses who have experienced harassment should be encouraged to participate fully in the investigation, and when ready, to work as a supporter and an advocate for others affected by WPV (ANA, n.d.).
According to the US Equal Employment Opportunity Commission (EEOC, n.d.), the actions to take after experiencing or witnessing sexual harassment are to tell the perpetrator to stop and to seek out the employer's policy regarding such behavior and follow it carefully. If no policy exists, the EEOC suggests reporting the incident to the direct supervisor or the perpetrator's immediate supervisor. Federal law protects those that report harassment from retaliation and allows them the right to file a report or lawsuit and participate in an investigation. If these rights are not respected, a discrimination charge can be filed with the EEOC directly (EEOC, n.d.). The 2018 NASEM report on sexual harassment advises that organizations show commitment to thorough and complete investigations as well as penalties for offenders that are escalating and punitive instead of rewarding and symbolic. Resource allocation, including training to increase awareness and familiarity with the reporting processes, is key to communicating their commitment (Fairchild et al., 2018). The EEOC defines retaliation as occurring when a supervisor or manager “fires, demotes, or harasses” an employee for “filing a complaint of discrimination, participating in a discrimination proceeding, or otherwise opposing discrimination” (El Kharzazi, Siwatu, & Brooks, 2015, para. 5). To prevent or avoid retaliation, managers should not discuss the case publicly or share information about the situation with others, isolate or threaten the employee or witnesses, respond reactively to the employee, or interfere with the investigation process. All parties should remain mindful of the importance of being accurate, open, and honest when sharing information during the investigation following an incident. They suggest that organizations provide education on retaliation included within harassment training and follow up with direct information given to supervisors/management at the outset of a complaint. Acknowledgment that retaliation and revenge are natural emotional responses that can be recognized, addressed, and overridden can help managers more effectively handle the emotional aspect and stress associated with discrimination complaints (El Kharzazi et al., 2015).
American Nurses Association. (2019). Reporting Incidents of Workplace Violence (p. 7). Retrieved from https://www.nursingworld.org/~4a4076/globalassets/practiceandpolicy/work-environment/endnurseabuse/endabuse-issue-brief-final.pdf
American Nurses Association. (n.d.). End Nurse Abuse. Retrieved November 6, 2019, from https://www.nursingworld.org/practice-policy/work-environment/end-nurse-abuse/
El Kharzazi, R. J., Siwatu, M., & Brooks, D. (2015) Retaliation: Making it Personal. The Federal Manager, (35.3), 9-13. Retrieved from https://www.flipsnack.com/kredmond/the-federal-manager-summer-2015-ftpszl5i7.html
Fairchild, A. L., Holyfield, L. J., & Byington, C. L. (2018). National Academies of Sciences, Engineering, and Medicine report on sexual harassment: Making the case for fundamental institutional change. JAMA, 320(9), 873–874. doi: 10.1001/jama.2018.10840
Jenner, S., Djermester, P., Prügl, J., Kurmeyer, C., & Oertelt-Prigione, S. (2019). Prevalence of sexual harassment in academic medicine. JAMA Internal Medicine, 179(1), 108–111. doi: 10.1001/jamainternmed.2018.4859
Nelson, R. (2018). Sexual harassment in nursing: A long-standing, but rarely studied problem. AJN The American Journal of Nursing, 118(5), 19. doi: 10.1097/01.NAJ.0000532826.47647.42
Thurston, R. C., Chang, Y., Matthews, K. A., Känel, R. von, & Koenen, K. (2019). Association of sexual harassment and sexual assault with midlife women’s mental and physical health. JAMA Internal Medicine, 179(1), 48–53. doi: 10.1001/jamainternmed.2018.4886
US Equal Employment Opportunity Employment Commission (n.d.). What You Should Know: What to do if You Have Been Harassed at Work. Retrieved on November 5, 2019 from https://www.eeoc.gov/eeoc/newsroom/wysk/harassed_at_work.cfm