The purpose of this module is to provide a detailed overview of sexual harassment, including its different forms and the appropriate actions to take if a nurse experiences or witnesses unwelcome sexual contact. Additionally, the proper method for reporting such incidents and the protections in place for whistleblowers will be discussed.
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Disclosure Statement
The purpose of this module is to provide a detailed overview of sexual harassment, including its different forms and the appropriate actions to take if a nurse experiences or witnesses unwelcome sexual contact. Additionally, the proper method for reporting such incidents and the protections in place for whistleblowers will be discussed.
Upon completion of this module, learners should be able to:
- define sexual harassment, including the different forms and effects of harassment
- discuss the current prevalence in the US and specifically in the healthcare field
- review the prevention of sexual harassment in healthcare workplaces
- describe the reporting process for someone who witnesses or experiences unwanted sexual contact
- understand the whistleblower protections in place for those who report incidents of sexual harassment
Sexual harassment within the workplace can be defined as unwanted sexual attention, which includes physical or verbal advances or assault; sexual coercion, which includes 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 a gender. This harassment can be overt or implicit (Fairchild et al., 2018). It can also be categorized as physical or nonphysical, and nonphysical harassment may be further divided into verbal or nonverbal harassment. Examples of physical harassment include groping, attempted kissing, unwanted physical contact, and assault. Verbal harassment encompasses incidents of degrading or sexualized speech, obscene language, sexual jokes or stories, sexual innuendos, sexual offers, or unwanted sexual invitations. Types of nonverbal harassment consist of advantages for sexual favors; sexual communication in the form of letters, emails, texts, or pictures; and whistling, staring, or making obscene gestures (Fairchild et al., 2018; Jenner et al., 2019).
Sexual harassment is a form of gender discrimination that violates Title VII of the Civil Rights Act of 1964 and can affect people of all genders in all work settings. The passing of this act made gender-based harassment illegal; however, an additional 6 years passed before the first sexual harassment lawsuit was filed in court. Even then, the US Supreme Court did not opine that sexual harassment was a form of sex discrimination until 1986. In 1991, Congress modified Title VII to give victims of sexual harassment the right to collect compensatory and punitive damages. Despite these modifications, the prevalence of sexual harassment was still not fully realized because of significant underreporting. Finally, in 2017, the #MeToo movement swept across the US, bringing sexual harassment to the forefront of national awareness. Following the #MeToo movement, the US Equal Employment Opportunity Commission (EEOC) saw a rise in sexual harassment claims, with 6,500 filed in 2020. Recently, several states have created additional protections beyond federal regulations to prevent workplace sexual harassment. All 50 states, plus Puerto Rico and the District of Columbia, currently prohibit sex discrimination. In addition, 12 of these states list sexual harassment as a form of workplace discrimination based on sex, and 39 states, plus Puerto Rico and the District of Columbia, explicitly state that sexual harassment is not permitted in the workplace. Eight states require employers to provide sexual harassment training in the workplace. More recently, many states are working on legislation prohibiting non-disclosure agreements that involve workplace sexual misconduct to protect individuals making accusations (EEOC, n.d.-a; Hentze & Tyus, 2021; Jenner et al., 2019).
Although sexual harassment laws do not prohibit simple teasing or offhand comments, these behaviors or actions become unlawful when they are frequent or severe, create a hostile work environment, or foster an adverse employment decision (e.g., the victim being fired or demoted). According to the EEOC, sexual harassment in the workplace is unwelcome and can occur in various ways (EEOC, n.d.-a; Hentze & Tyus, 2021; US Department of State, 2019):
- The victim and harasser can be of any gender.
- The victim does not have to be of a different sex from the harasser.
- The harasser can be a supervisor, coworker, nonemployee, vendor, or customer.
- A victim can be anyone affected by the offensive conduct.
- Sexual harassment can occur with economic injury or dismissal of the victim.
Prevalence and Effects of Sexual Harassment
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 prevalence of workplace violence (WPV), specifically sexual harassment, is difficult to quantify with certainty. This is primarily due to low reporting rates for such events, which could be as low as 20% to 60% of actual cases (ANA, 2019). A 2019 survey of 304 women aged 40 to 60 found that only 19% reported a history of sexual harassment, and 22% shared 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. Departmental and divisional hierarchy systems were associated with increased reports of harassment (Jenner et al., 2019).
Within the healthcare field, 28% of nurses worldwide report being sexually harassed at work during their careers, but this percentage varies by region. The Anglo region—which includes the US, Canada, England, and Australia—has a high rate of 39%. Researchers have hypothesized that this was likely due to cultural acceptance of sexual language or behavior in public. In contrast, in Asia and the Middle East, reduced rates of sexual harassment may be due to a decreased reporting of such incidents secondary to public shame (Nelson, 2018). Female nurses are at the highest risk of sexual harassment within the medical field. In a recent systematic review, Kahsay and colleagues (2020) found that the prevalence of sexual harassment among female nurses was 43.15%, ranging from 10% to 87.3% across studies. Of the female nurses who reported sexual harassment, 35% of cases were verbal, 32.6% were nonverbal, 31% were physical, and 40.8% were psychological. Kahsay and colleagues (2020) also found that perpetrators of sexual harassment varied, with 46.59% of harassment committed by patients, 41.10% by physicians, 27.74% by patient family members, 20% by fellow nurses, and 17.8% by other coworkers.
Despite some historical disagreements regarding its definition, the effects of sexual harassment have been well-documented. Sexual harassment decreases the productivity, recognition, funding, advancement, earnings, retention, and continuation of individuals across workplaces (Fairchild et al., 2018). It is also associated with adverse physical effects. These effects are worse for underrepresented groups, especially members of the LGBTQ+ community. Thurston and colleagues (2019) explored the relationship between sexual harassment and mental and physical health in over 300 midlife women. The researchers found that women who reported a history of sexual harassment had twice the incidence of hypertension and sleep disturbances. Among those who reported a history of assault, researchers found three times the rate of depre
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ssion and twice the rate of anxiety and poor sleep. Thurston and colleagues (2019) hypothesized that these findings might be related to the disrupted balance between the sympathetic and parasympathetic portions of the autonomic nervous system due to chronic stress.
Workplace violence, including sexual harassment, can adversely affect the quality of patient care and outcomes, job satisfaction, and organizational commitment amongst nurses (ANA, 2019). When nurses or other healthcare professionals have poor job satisfaction and organizational commitment, they are more likely to leave the industry. WPV and sexual harassment not only impact job performance, but victims can also experience physical and psychological consequences. In a systematic review, Kahsay and colleagues (2020) found that among nurses who reported sexual harassment in the workplace, 44.6% developed mental health problems, 30.19% developed physical health problems, 61.26% developed emotional problems, 51.79% had a psychological disturbance, and 16.02% reported social health problems. Nurses who have experienced sexual harassment have reported anxiety, depression, sleep disorders, headaches, weight gain or loss, nausea, low self-esteem, and sexual dysfunction. Victims of WPV and sexual harassment can also experience financial hardship due to demotion, firing, or being overlooked for advancement opportunities (Kahsay et al., 2020).
Prevention
Prevention is the best tool to combat WPV and sexual harassment. The 2018 NASEM report outlines basic recommendations to prevent sexual harassment and gender discrimination. The report noted that harassment is more common in environments that ignore or support these behaviors and less likely when consequences are apparent and forceful. It included 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 each victim/survivor; encourage leadership that is strong and diverse; assess program effectiveness and progress regularly; conduct research; and reward change. NASEM also recommends confronting the lack of meaningful enforcement of Title VII's sex discrimination prohibition, initiating legislative action to correct course, and collaborating with the responses from federal agencies. Finally, NASEM advises professional organizations, like the ANA and others, to become involved, as the responsibility for sexual harassment prevention lies with all (Fairchild et al., 2018).
According to the American Nurses Association (ANA, 2019), the first step in preventing sexual harassment and other forms of WPV is to establish a standard definition. A universal standard allows everyone involved to know what is acceptable workplace behavior and language and what is not. These standards also help organizations establish a safe culture by enforcing a zero-tolerance policy. In addition, the ANA recommends a standardized process for reporting WPV and sexual harassment. According to the ANA, only 9 US states currently have standardized processes and regulatory requirements for reporting WPV. Therefore, it is incumbent upon healthcare organizations and workers to be change drivers. The ANA's #EndNurseAbuse campaign outlines four components of change: support, educate, action, and share. Support highlights the importance of developing, improving, and supporting zero-tolerance policies for WPV. The ANA suggests formulating and initiating safety protocols to prevent violence and training all staff and providers (ANA, n.d.). Primary prevention techniques designed to avoid WPV include educating healthcare workers on the definition of harassment and other strategies to identify risks for WPV. Other techniques consist of increasing buffers, reducing vulnerabilities, and improving relationships among coworkers and colleagues to develop a strong team approach to healthcare delivery. 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, these measures include preparing student nurses to identify and manage WPV correctly (ANA, n.d., 2019). To prevent acts of WPV, the ANA recommends that nurses:
- be observant, aware of their surroundings, and watchful for warning signs
- whenever possible, use de-escalation techniques
- call for help if there is the potential for WPV
- use barriers to protect themselves from violence when able and self-defense when appropriate
- 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 WPV become clear (ANA, n.d.)
The 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 working against WPV with their fellow nurses and their communities (ANA, n.d.).
Secondary prevention limits the immediate impact of WPV. For organizations, this may include data collection and assessment for quality improvement; assessment of program strengths, weaknesses, and need for revisions/changes; and the full investigation and subsequent interprofessional review of each reported case or episode of WPV or sexual harassment. The ANA advises nurses to participate in comprehensive WPV programs, use crisis intervention and management strategies to handle escalating situations, and consistently report any incidents or program concerns (ANA, 2019).
Tertiary prevention techniques aim to limit the long-term effects of WPV. For organizations, this may include evaluating and constantly improving their programs, scheduling provisions to allow nurses to leave work after an incident, creating support systems to facilitate returning to work after an incident, and conducting a root-cause analysis after an incident to help inform future policy. Tertiary prevention for nurses can consist of participation in program evaluations and post-incident meetings or debriefings, counseling services if needed, and showing support to coworkers involved in an incident. On a systems level, the ANA 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 (ANA, 2019).
Reporting and Follow-Up Measures
Harassment victims may choose not to report an incident of EPV or sexual harassment 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 with more robust legal support and representation within hospital leadership report feeling more secure when reporting incidents of sexual harassment due to reduced fear. The rate of sexual harassment in the medical field directly results from the hierarchy of administration, management, and physicians in hospital settings, which conveys an inherent structure of power and domination (Nelson, 2018). The ANA cites additional reasons that a nurse may not report sexual harassment when it occurs, such as:
- regarding WPV as just part of the job and violence as routine
- uncertainty regarding whether 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
- confusion between intentional and unintentional incidents (e.g., when caring for cognitively impaired patients)
- nonexistent or inadequate support from administration/management or direct supervisors (ANA, 2019)
The ANA encourages institutions and organizations to take responsibility by promoting a work 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:
- 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 – include context or prior events
- verify – document any injuries sustained, which can be emotional or physical (ANA, n.d.)
After an incident, the ANA recommends that any 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 EEOC (n.d.-b), 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 perpetrator's direct or immediate supervisor. Federal law protects those who report harassment from retaliation and gives them the right to file a report or lawsuit and participate in an investigation. A discrimination charge can be filed with the EEOC if these rights are not respected (EEOC, n.d.-b). The 2018 NASEM report on sexual harassment advises that organizations must be committed to thorough and complete investigations and 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 this commitment (Fairchild et al., 2018).
The EEOC defines retaliation as a supervisor or manager's act of firing, demoting, or harassing an employee for filing a complaint of discrimination, participating in a discrimination proceeding, or otherwise opposing discrimination. To prevent or avoid retaliation, managers should not discuss any 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 of an incident. Per the EEOC, organizations should provide education on harassment training, including retaliation, and follow up with direct information given to supervisors/management immediately after a complaint. Acknowledging that retaliation and revenge are natural emotional responses that can be recognized, addressed, and overridden can help managers handle the emotional stress associated with discrimination complaints (EEOC, n.d-b).
Nurses are often faced with inappropriate behaviors of harassment from patients or patients' family members. This dynamic can be challenging for nurses to navigate because they may feel pressured by their obligation to care for the patient. However, inappropriate behaviors by patients and family members should be addressed without the fear of retaliation. If a patient or family member displays inappropriate behavior, the nurse should set clear boundaries and inform them that the comments or behaviors are unwanted. These conversations can be challenging, especially for patients with mental health problems. In these situations, including a social worker or psychiatrist may be beneficial. The nurse should report the incident to organizational leadership and follow the appropriate organizational policies for reporting harassment. Nurses and other healthcare workers are at increased risk of physical violence by patients and family members. Local law enforcement may need to be involved depending on the inappropriate behaviors or violence severity (Ross et al., 2019).
Conclusion
Sexual harassment is a widespread problem across countries and occupations. Nurses are at increased risk for WPV and sexual harassment, and these incidents can impact the quality and safety of patient care. Nurses who have experienced WPV or sexual harassment can experience long-lasting physical and psychological effects, leading to job dissatisfaction and turnover. Identifying and addressing sexual harassment is a challenging task for healthcare organizations. However, healthcare organizations have an ethical and legal obligation to address WPV and sexual harassment. Creating a zero-tolerance culture is key to preventing and addressing WPV and sexual harassment effectively. In addition, healthcare organizations should provide sexual harassment education, including examples of what constitutes inappropriate behavior. Finally, healthcare organizations should have policies to protect anyone who reports WPV or sexual harassment incidents (Ross et al., 2019).
References
American Nurses Association. (n.d.). End nurse abuse. Retrieved July 20, 2022, from https://www.nursingworld.org/practice-policy/work-environment/end-nurse-abuse
American Nurses Association. (2019). Reporting incidents of workplace violence. https://www.nursingworld.org/~4a4076/globalassets/practiceandpolicy/work-environment/endnurseabuse/endabuse-issue-brief-final.pdf
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. https://doi.org/10.1001/jama.2018.10840
Hentze, I., & Tyus, R. (2021). Sexual harassment in the workplace. National Conference of State Legislatures. https://www.ncsl.org/research/labor-and-employment/sexual-harassment-in-the-workplace.aspx
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. https://doi.org/10.1001/jamainternmed.2018.4859
Kahsay, W. G., Negarandeh, R., Nayeri, N. D., & Hasanpour, M. (2020). Sexual harassment against female nurses: A systematic review. BMC Nursing, 19, 58. https://doi.org/10.1186/s12912-020-00450-w
Nelson, R. (2018). Sexual harassment in nursing: A long-standing, but rarely studied problem. AJN: The American Journal of Nursing, 118(5), 19. https://doi.org/10.1097/01.NAJ.0000532826.47647.42
Ross, S., Naumann, P., Hinds-Jackson, D. V., & Stokes, L. (2019). Sexual harassment in nursing: Ethical considerations and recommendations. The Online Journal of Issues in Nursing, 24(1). https://doi.org/10.3912/OJIN.Vol24No01Man01
Thurston, R. C., Chang, Y., Matthews, K. A., von Känel, R., & 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. https://doi.org/10.1001/jamainternmed.2018.4886
US Department of State. (2019). Sexual harassment policy. Office of Civil Rights. https://www.state.gov/key-topics-office-of-civil-rights/sexual-harassment-policy
US Equal Employment Opportunity Employment Commission. (n.d.-a). Sexual harassment. Retrieved July 20, 2022, from https://www.eeoc.gov/sexual-harassment
US Equal Employment Opportunity Employment Commission. (n.d.-b). What you should know: What to do if you have been harassed at work. Retrieved July 20, 2022, from https://www.eeoc.gov/eeoc/newsroom/wysk/harassed_at_work.cfm